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Zika virus infection during pregnancy is a cause of congenital brain abnormalities. Its consequences to pregnancies has made governments, national and international agencies issue advices and recommendations to women. There is a clear need to investigate how the Zika outbreak affects the decisions that women take concerning their lives and the life of their families, as well as how women are psychologically and emotionally dealing with the outbreak. We conducted a qualitative study to address the impact of the Zika epidemic on the family life of women living in Brazil, Puerto Rico, and the US, who were affected by it to shed light on the social repercussions of Zika. Women were recruited through the snowball sampling technique and data was collected through semi-structured interviews. We describe the effects in mental health and the coping strategies that women use to deal with the Zika epidemic. Zika is taking a heavy toll on women’s emotional well-being. They are coping with feelings of fear, helplessness, and uncertainty by taking drastic precautions to avoid infection that affect all areas of their lives. Coping strategies pose obstacles in professional life, lead to social isolation, including from family and partner, and threaten the emotional and physical well-being of women. Our findings suggest that the impacts of the Zika epidemic on women may be universal and global. Zika infection is a silent and heavy burden on women’s shoulders. Zika


Introduction
In May 2015, the Pan American Health Organization (PAHO) issued an alert regarding the first confirmed Zika virus infection in Brazil.Subsequently, on February 1 st , 2016, the World Health Organization (WHO) declared that the Zika virus was a public health emergency of great international concern 1 .Although the WHO downgraded Zika from a public health emergency to a "common threat" in November 2016, more than 50 countries and U.S. territories continued to report active Zika virus transmissions 2,3 .
The Zika virus can cause congenital brain abnormalities during pregnancy 4,5 that led governments, national and international agencies to issue advice and recommendations to safeguard women from infection 6,7 , women's reproductive health has therefore been thrust into the limelight with the spread of Zika 8,9 .
While there has been great concern with the biomedical aspects of the disease 5,10 , little has been discussed about the psychological, social, and ethical aspects of the epidemic.Few studies were conducted to address the threatening effects of Zika in the daily lives of women worldwide or its social repercussions.Additionally, the real-life perceptions of how women are psychologically and emotionally dealing with the outbreak has to be documented yet.Therefore, we are undertaking an investigation on how the Zika outbreak affects women lives, particularly regarding their decisions on sexual behaviors and reproduction, such as their reproductive health, and their personal and family life.
In this pilot study, we analyzed the impact of the Zika epidemic on the lives of women living in Brazil, Puerto Rico, and US, who were indirectly affected by it to shed light on the social repercussions of Zika.

Methodology
This is a qualitative study that collected data through semi-structured interviews with 18 women who live in different locations of Brazil, Puerto Rico, and US, and who were from a Brazilian, Hispanic and North American ethnicity.These women were recruited through a snowball sampling.Interviewees were selected according to socioeconomic position, residence, nationality and age.Interview guides were developed including topics such as women's personal and family life, perceptions and knowledge of Zika, views on reproductive health and rights regarding the Zika syndrome.Interviews were conducted between October 2016 and June 2017 in English, Brazilian Portuguese, and Spanish.Transcripts of the interviews were analyzed for themes using the NVivo software (https://www.qsrinternational.com/nvivo/home)for qualitative data analysis.The research protocol was approved by the Institutional Review Board of the University of Massachusetts Boston under number 2016186.

Participant characteristics
Table 1 shows the sociodemographic characteristics of the sample.The ages of the women varied between 22 and 41.A total of six women had long-term partners while 12 were married.Women resided in Florida, Massachusetts, and Washington DC (USA), Puerto Rico and different localities of Brazil.Brazilian, Hispanic and North American ethnicities were represented.There were nine participants who had undergone a recent pregnancy or were pregnant at the time of the interview, while there were four that were planning to become pregnant and three that did not want to become pregnant but lived in Zika affected locations.One participant was misdiagnosed with Zika while pregnant, another had a husband diagnosed with the virus during her pregnancy, and one participant had a positive diagnosis of Zika despite not being pregnant.All participants had at least college level education.Participants religious denominations included: Catholic, Evangelist, Spiritist, Agnostic, and Atheist.

Table 1
Sociodemographic characteristics of the women interviewed.

Characteristics n
Age range (years)

Impacts
We classified the impacts that Zika has had on the interviewed women at different levels (Table 2).
The effects at personal level included the reduction of physical and emotional well-being, feelings of isolation, sadness, and uneasiness.The family life of interviewees was also affected.They repeatedly reported feeling isolated from their partners, children, parents, relatives and extended families.Elimination of leisure activities, such as social and outdoor activities, also contributed to social isolation.Reports of disruption in their social life and daily routines were common themes.
Participants started to use repellents on a constant basis and changed their dressing habits by wearing long sleeves and closed shoes, among others, which caused discomfort.At the professional level, women placed their careers at risk by giving up growth opportunities such as attending meetings and job-related travels, etc.They also felt isolated from colleagues because they tried to work from home or change occupation because of the fear of exposing themselves to Zika.Effects on the sexual and reproductive life include renouncing pregnancy or postponing their decision to motherhood, and in a few cases sexual abstinence as a form of protection.
Table 3 summarizes quotes that show the psychological stages found in the participants.All the changes and effects in varying aspects of their lives have produced consequences in their emotional health.The interviewees had a strong feeling of uncertainty and mistrust concerning unknown factors surrounding the Zika epidemic, which contributed to helplessness and distress.Fear, panic, concern, angst, and tension were also expressed.Sometimes, the women voiced feelings of sadness, responsibility, shame, failure, and even guilt because of the pressure of having a healthy child.Many participants conveyed a strong feeling loss of control of their own lives and reproductive decisions.

Table 2
Impact levels and themes from interviews.

Table 3
Quotes about emotions felt by women.

Emotions felt Quotes
Uncertainty

Discussion
Our study shows how the Zika infection is a silent and heavy burden on women's shoulders.No women are exempt from the impacts of Zika, considering that the women we interviewed have relatively comfortable socioeconomic positions.They were of diverse religious denominations, mixed nationalities and cultures, but shared similar behaviors and effects.Some studies approached the beliefs and/ or actions of pregnant women during the epidemic within a homogenous sample collected in certain Cad. Saúde Pública 2018; 34(5):e00178917 countries 9,11,12 .Our findings suggest that the impacts of the Zika epidemic on women might be universal and global -and that perhaps many important ones have been so far ignored in the literature.The coping strategies that women are adopting to live in times of Zika seem to be posing obstacles to their professional careers, isolation from their family, and harm to their emotional and physical well-being.Women's narratives indicate that they are sacrificing a lot for motherhood and to have a healthy baby.They placed their careers at risk by giving up opportunities that could involve exposure to mosquito-infested environments.They also withdrew from family, social and leisure activities to avoid exposure to the Aedes, as a result increasing the likelihood of social isolation.
The impacts on the sexual and reproductive life are concerning.Some interviewees decided to renounce or postpone their decision to become pregnant, which was also reported by women in Brazil 13,14 and in Puerto Rico 15 .Additionally, participants disclosed sexual abstinence during pregnancy, negatively affecting their emotional relationship with the partner.
All the changes in varying aspects of their daily lives have produced adverse emotional consequences for the interviewed women.For example, a change in dressing up habits resulted in women choosing to wear long sleeves in hot climates.Similar protection strategies can be seen in one study 9 , but it does not show their effect on the psychological status of women.
Thus, the Zika epidemic is taking a heavy toll on the emotional well-being of women.On the one hand, the presence of the virus created mixed and contradictory feelings of joy and sadness during pregnancy, because they could not fully enjoy their pregnancy, or had to renounce the joy of maternity.On the other hand, they felt responsible to avoid Zika contraction when, in reality, it is very difficult for them to control the mosquito.
This heavy toll is clearly and strongly stated by one woman, who complained: "...I have to plan my reproductive life according to the vital cycle of a mosquito.This is crazy, it is absurd".

Contributors
A. R. Linde contributed with the research design, implementation, analysis of the data and manuscript elaboration.C. E. Siqueira contributed with the research design and revision of the manuscript.

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of use of repellent Long sleeve clothes, etc. Changes in the home environment Reduction or elimination of social activities Elimination of leisure activities Virus Zika; Embarazo; Salud de la Mujer; Perfil de Impacto de Enfermedad Submitted on 23/Oct/2017 Final version resubmitted on 16/Feb/2018 Approved on 12/Mar/2018