In this country, most abortions are not performed in clinics by vacuum aspiration, but are induced by misoprostol, a drug that causes strong contractions, said Dr. Guido Parra Anaya, the director of the Procrear assisted fertility clinic in Barranquilla.
Any doctor can prescribe the drug, and none are legally obligated to report it.
Misoprostol also is commonly given out by illegal providers here, according to the Guttmacher Institute. Frequently, women are told to take the pills and go to a hospital when heavy bleeding starts, as if they had had a miscarriage. Colombian hospitals treat an estimated 93,000 women a year for postabortion complications.
In July, Dr. Martha Lucia Ospina, the director of Colombia’s National Institutes of Health, reported that fetal deaths reported as miscarriages on death certificates had increased by 8 percent. The numbers have begun returning to normal only recently.
In Brazil, by contrast, abortion is permitted only in cases of rape or incest or to save the mother’s life, and illegal abortions are hard to get because the police, under pressure from evangelical Christians in Brazil’s Congress, began cracking down on clandestine clinics a decade ago.
Also, because the microcephaly surge in Brazil appeared with no warning, even women who might have risked illegal abortions had no time to receive ultrasounds.
In Colombia, women now normally have three ultrasounds during a pregnancy. The increased screening has made for hard choices.
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Microcephaly can also be caused by other viruses or genetic mutations, but the Zika virus causes unprecedented levels of brain damage.
“In my 22 years as an ultrasound physician, I have never seen microcephaly like this,” Dr. Parra-Saavedra said. “The heads are much smaller, to a severe degree.”
Although pockets of dead cells that foreshadow microcephaly may appear earlier, fetal heads do not become unmistakably small until early in the third trimester.
Health insurers, financially struggling here, are reluctant to approve late abortions because they must pay for neonatal intensive care if the child is born alive.
For mothers, the diagnosis is understandably difficult. By the third trimester, fetuses on ultrasounds look much like newborn babies, not like embryos.
The first scans of Kiara Munoz’s son, Juan Diego, were normal. By the time his microcephaly was evident, she was in her seventh month and could see his face clearly.
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“The gynecologist said I could terminate, and I cried,” said Ms. Munoz, who is 18 but looks 15. “It was very hard because the baby was so big. My husband and I decided to keep him. I am hoping for a miracle.”
Colombia’s Zika epidemic peaked in February and was declared over in late July. Many women who became pregnant during that time are still due to give birth, so more microcephaly cases may appear.
But they will still be far fewer than originally predicted.
Dr. Ruiz said that based on Brazil’s experience, he had expected to see 700 cases of Zika-related microcephaly this year. Now, he expects 100 to 250 at most.
In December, Dr. Ruiz asked women in Colombia to delay pregnancies, and he says he believes many did so, although he cannot prove it yet.
A drop in the birthrate would indicate that many women heeded the advice, but the national health statistics office takes 18 months to tally up each year’s birthrate.
In some Latin American countries, suggestions from health ministers that women delay pregnancy met harsh resistance — both from the Roman Catholic Church and from women’s groups complaining that there was too little access to contraception.
El Salvador faced a backlash when it asked women to stop having children for two years. But Colombia’s health ministry asked women to delay for only six to eight months while officials watched how the epidemic unfolded. Some women found that sensible.
As her husband, Gustavo, a police officer, and her young son Sebastian watched, Madis Dominquez, 27, explained how she happened to be getting a four-month ultrasound in September.
She originally planned to become pregnant last December, she said, “but they said, ‘Please wait six months.’ So I waited till May, when they said it looked safe again.”
How many women followed her example will not be known for some time.
The epidemic appears to be winding down in much of Latin America as the hottest, rainiest months end and as more people, having been bitten, develop immunity.
Some experts thought it might have been premature to declare the epidemic over in Colombia, because the virus had infected less than 1 percent of the population. In French Polynesia, it infected more than 60 percent before cases disappeared.
A study done by scientists at London’s Imperial College estimated that across Latin America, where the geography is far more diverse than on Pacific islands, it may be two to three years before widespread immunity stops the epidemic.
In places like Puerto Rico, where the virus arrived relatively late, microcephaly cases are expected to keep increasing. The first live birth of a child with Zika-related microcephaly was reported last month.
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