“It was God’s will”: Continuing pregnancy after perinatal infection by Zika virus*

Objective: to understand the influence of the religious beliefs on the decision of a group of women residing in the Huila Department to continue their pregnancies despite perinatal infection by the Zika virus. Method: a focused ethnography. The participants were 21 women who had presented a perinatal infection by the Zika virus and whose babies were born with congenital microcephaly. 2 discussion groups and 6 semi-structured interviews were conducted, and thematic analysis was used for data treatment. Results: three themes emerged, namely: “God, why me?” is the initial questioning of the women to God for the prenatal diagnosis of microcephaly in their babies, “Clinging to a divine miracle” describes how the women did not lose their faith and begged for a divine miracle for their babies to be born healthy, and “It was God’s will” means acceptance, resignation, and respect for God’s will, as well as the denial to abort despite the medical recommendations. Conclusion: religiosity and religious beliefs were determinant factors in the women’s decision to continue their pregnancies. It becomes necessary to continue investigating this theme to understand their experiences and to generate follow-up and support actions from nursing care.


Introduction
In October 2015, Colombia declared an outbreak of the Zika virus disease, and the Huila Department presented the third highest accrued incidence of the country (517 per 100,000 inhabitants) and in pregnant women (333 per 100,000 inhabitants) (1) .
By January 2018, 248 cases of congenital syndrome related to perinatal infection by the Zika virus have been confirmed in the country (2) .
Perinatal infection by the Zika virus has been related to adverse pregnancy results, especially microcephaly and other severe brain anomalies like intellectual disability, ophthalmologic and auditory alterations and epilepsy (3)(4) .
A diagnosis of fetal congenital malformation means intense pain and emotional shock to the mothers due to the prenatal attachment (5) . Multiple losses and profound feelings of worry are also generated in the parents, and those who decide to continue their pregnancies not only experimented the loss of a healthy child and its anticipated future, but also that of a happy pregnancy (6) .
In the case of a pregnancy with a diagnosis of congenital malformation due to perinatal infection by the Zika virus, the parents' future becomes uncertain; with material evidence of primary reactions of anguish, guilt, indecision and shame; then to experience a negotiation, acceptance, and adaptation reaction to the new condition (7) .
In the city of Neiva, a specific fact was the decision of a group of mothers who decided not to interrupt their pregnancies, despite having been explained the conditions in which their babies would be born and the impact on the quality of life of both the infants and the families. The aforementioned is to be interpreted considering the option of legal abortion in case of fetal malformations offered by the 2006 C-355 Sentence (8) and by the World Health Organization's recommendation to provide access to a secure abortion in case of suspected or confirmed microcephaly due to perinatal infection by the Zika virus (9) .
The objective of this study is to understand the influence of religious beliefs on the decision of a group of women residing in the Huila Department to continue their pregnancies despite the perinatal infection by the Zika virus.

Method
The design chosen was that of a focused ethnography, an option through which it is sought to pay attention to the small elements and activities in which people get involved, which is particularly helpful to obtain information on a specific theme and whose object of study is limited to small social groups. Focused ethnographies are characterized by focused research questions, short-term field visits, and intensity in data collection and analysis (10) .
The study was conducted during 2018 in the city of Neiva, the capital and most important municipality of the Huila Department (Southern Colombia). Due to the geographical and climatic factors of this region, there is circulation of the Zika virus (11) . The participants were 21 women who presented perinatal infection by the Zika virus between 2015 and 2016, and whose babies were born with congenital microcephaly and other neurological alterations related to this infectious event. All the 21 participants are members of a support group and of the "Hijos del Zika: Milagro de Dios" ("Zika Children: God's Miracle") Association.
All the women were of age at the time of data collection and voluntarily wished to participate in the study. The group presented an age range between 18 and 37 years old (with a mean of 25 years old).
Only two of them had University schooling and four just elementary school; 18 declared to be unemployed since their babies had been born and six were single.
The first step of the research was contacting each of the leaders who served as field gatekeeper (12) for entering the group, the person in charge of inviting the women to participate in the study, invitation accepted by all.
Towards the middle of 2018, the research group met once a month on six occasions with the women to create and strengthen the women's support group. Through various group activities, the support group meetings focused on the women's statements about their experiences during pregnancy, birth, upbringing, and care for their children.
Thus, it turned into a personal space to express and share fears and worries with other women who were facing similar experiences; and to build a group identity which was structured around a "communion" instead of around simple understanding (13) . Not to mention establishing a strong bond between the researches and the women. In this space, data was collected between September and December 2018.
Data collection was performed by the lead researcher, and two discussion groups and six one-onone interviews were used. The first technique facilitates deep exploration of the information through perceptions, experiences, and attitudes of participants selected for sharing similar experiences or characteristics. Its conversational nature allows for a dynamic interaction and synergy among the participants, producing very rich data (14)(15) . Data collection was started with this technique to perform an initial exploration of the theme, of which there is little knowledge on the scientific literature (15) . www.eerp.usp.br/rlae Laza-Vásquez C, Cortés-Martínez KV, Cano-Rivillas JP.  Thematic analysis (17) was used for treating the data; this is a method to identify, analyze, and report patterns (themes) inside the data, and which is adapted to a wide range of research interests and theoretical perspectives. This included familiarization with the data, coding, search for themes, review of themes, and definition and naming of themes. Once the results were elaborated, the participants were invited to their review and they were accepted with no further suggestions.
During the research process, the methodological rigor criteria (18) were observed to safeguard the methodological quality of the research: credibility, auditability, and transferability. All the ethical aspects set out by the 1993 Colombian Resolution 8430 (19) were taken into account. The support of the

Results
Three themes emerged from the statements, through which the women accounted for their decision to continue their pregnancies: "God, why me?", "Clinging to a divine miracle", and "It was God's will".
"God, why me?" The initial diagnosis became a painful and disturbing news which the women asserted they were not prepared for. Hearing the term "microcephaly" for the first time disconcerted Despite the aforementioned, the health professionals who cared for them insisted on several occasions on the option to interrupt their pregnancies. In fact, many of the women stated that they felt they were questioning their decision to continue their pregnancies.  The decision to continue their pregnancies despite the suggestions not to do so also responded to the women's argument that this was a decision incumbent only to them, to their partners, and to God. For two of them, another reason was feeling that the pregnancy was an answer from God to their asking for forgiveness for past mistakes, like a previous abortion or not wishing to have a baby.
Finally, they considered that, just as God sent them their children with that condition, He would also send them the economic, emotional, and human means for their care and support. For this reason, the women were willing to make any kind of sacrifice for the child that God was giving them.

Discussion
For most of the couples, pregnancy is a happy experience for waiting a healthy child. A late diagnosis of a fetal anomaly is infrequent, something Religion allows people to assign a meaning to their beliefs, experiences, and practices in different life situations (27) and religiosity is a means for the individuals to express their spirituality through the adoption of values, beliefs, and ritual practices which answer the main questions about life and death (28) . On their own, religious beliefs can help people to come to an agreement on the different problems in their lives and, frequently, they entail accepting adversity with the guidance of a bigger force which directs life itself (29) .
Several authors explain that, although they are difficult for people to define, the meanings of religiosity and of religious beliefs are necessary, help to understand the meaning of life and to find a balance in it, and that they are a strength and resource to face crisis (28) . Thus, these two aspects are configured as strong determinants to continue the pregnancy despite the results of a diagnosis of a prenatal congenital malformation, given the religious prohibition to interrupt pregnancies, religious fatalism as a reason to continue them, and the sensation of help which religious beliefs offer to the women to stay optimistic with respect to their pregnancies and to the health of their child to be born (30) .
A scarce number of studies have documented religiosity and religious beliefs as determinants in women and their partners to continue their pregnancies despite a diagnosis of fetal congenital malformations. This is influenced by the religious prohibition to interrupt pregnancies, as a synonym of killing and as a generator of guilt in women; the belief of children as a gift from God, the conviction that the child to be born's death must be natural and not provoked, the recognition of the fetus as a person, and the hope for a cure of the anomaly (5,20,30) . In Colombia, the abortion option generates conflicts in women because of the worries about the destiny of the souls of embryo/fetus and of the women, turning it into a synonym of killing, of sin, of condemnation to hell, and of stigma (31) .
In turn, religiosity and religious beliefs turn into a coping mechanism in the face of difficult situations and soften the effects of stress on life, increasing selfesteem or the sense of self-efficacy and openness to social support (32) .
Despite the limitations of this study lying on the size of the sample, on the non-inclusion of the women's partners and of the health professionals in the sample, and on the fact that the results are circumscribed to a region of Colombia, as far as we know, it is the first one that incorporates the voices of the women who decided to continue their pregnancies when faced with a diagnosis of congenital microcephaly related to perinatal infection by the Zika virus, thus helping to understand the complexity and the challenges faced by the women.
It also helps to understand the weight of religiosity and of religious beliefs on the decision making of people with respect to the processes related to health, disease, and care practices. This knowledge is indispensable for the nurses to provide care from a holistic perspective of the care subjects. It is also indispensable that this knowledge implies greater understanding of the spiritual dimension and its importance for health. In this sense, they draw the attention to the need of considering these two categories in the educational, investigative, and assistential work in Nursing.

Conclusion
This study shows that religiosity and religious