PERCEPTIONS OF THE MULTI-PROFESSIONAL TEAM GIVEN THE LEGAL INTERRUPTION OF PREGNANCY DUE TO SEXUAL VIOLENCE

Objective: to know the feelings and coping strategies used by the multi-professional team in relation to cases of legal interruption of pregnancy. Method: a qualitative, descriptive and exploratory study, conducted with 21 professionals in a hospital in the Southern Region of Brazil in September and October 2018. The participants were selected by the snowball technique and answered semi-structured individual interviews. The data were analyzed according to Minayo’s operative proposal. Results: two thematic categories were unveiled: feelings related to participation in the process of legal interruption of pregnancy and ways of coping and support service of the institution. The participants revealed feelings ranging from indifference to empathy, and that their main ways of coping are the search for specialized services, conversation groups, family and religion. Conclusion: it was observed that the cases assisted give rise to diverse feelings in the professionals and, according to reports, they do not receive any form of support from the institution to deal with them.


INTRODUCTION
The World Health Organization defines sexual violence as any sexual act or attempt to obtain sexual intercourse, unwelcome sexual advances or comments, or trafficking or any other form, against a person's sexuality using coercion. The impacts of sexual violence on the victim's life represent a serious violation of human rights. 1 Over the years, in Brazil there has been an improvement in legislation that guarantees constitutional rights to women, in a clear attempt to guarantee health care for victims of violence. However, there is a gap with regard to the development of studies that assess the effectiveness of the legal devices for tackling violence against women. 2 According to the Map of Violence in Brazil, in 2015 of all the reported cases of violence, 11.9% were of a sexual nature. Of these, 24.3% of the cases occurred with adolescents between 12 and 17 years old, while in young women (18 to 29 years old) the findings were 6.2% and in adult women (30 to 59 years old), 4.3%. In addition, there was predominance of domestic space in 71.9% of the cases. 3 In 2014-2015 there was a mean of 22.2 rape cases per 100,000 inhabitants in Brazil. This same survey shows that 85% of the women are afraid of being victims of a sexual assault. 4 Taking into account that in many cases the woman does not seek the health services or the police, being related to fear of reprisals, shame, feelings of guilt, among others, it is believed that these numbers may be higher than those published.
In this scenario, pregnancy resulting from sexual violence is highlighted by the high demand for psychological factors that involve women in this situation. They are no longer just people who went through such a situation, they now carry in their wombs the consequence of this violence and the pregnancies can be seen as continuous violence, causing feelings of despair and anguish. [3][4][5] A study carried out in Campinas/SP showed that the trauma caused by sexual violence compromised the ability to seek any kind of help, pretending, in case they do not tell anyone, that the situation was forgotten. 5 Another factor that leads women not to seek the health services is fear of reprisals. In the case of victims of sexual violence, respect and immediate assistance from the health professionals are essential to minimize the trauma and consequences of violence. 6 In this regard, we enter into another issue about the legal interruption of pregnancy, which is the difficulty in identifying health professionals who feel prepared to act in these cases. The absence of an institutional culture that values permanent education, preparing the teams to meet the demands of women, can impair the quality of the care provided. 7 Despite the fact that referral services in abortion are provided for by law, they are still little known and little disseminated among the population and among the health professionals themselves, as a result, the literature points to an outdated view about abortion, which ends up discriminating and making women subjected to sexual violence vulnerable. 8 In 2005, assistance for cases of legal interruption of pregnancy was initiated in Santa Catarina (SC), and the first hospital institution to perform this procedure was located in Florianópolis. However, only in 2014, through Ordinance No. 485/2014, the Comprehensive Care Network for People in Situations of Sexual Violence (Rede de Atenção Integral às Pessoas em Situação de Violência Sexual, RAIVVS) and the Assistance Protocol for Legal Interruption of Pregnancy were established. The RAIVVS is made up in Florianópolis by public hospitals and teaching centers, and interruption occurs in pregnancies of up to 19 weeks and 0 days. 9

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Legal interruption of pregnancy in situations of sexual violence is a veiled and little studied subject matter, especially from the perspective of the professionals, who seek to serve women in a humanized manner and at the same time experience many feelings and discomfort in these situations.
Given this context, this study was guided by the guiding question: what are the feelings, perceptions and coping strategies used by the multi-professional team in the face of cases of legal interruption of pregnancy due to sexual violence? The objective was outlined as follows: to know the feelings and coping strategies used by the multi-professional team in relation to cases of legal interruption of pregnancy.

METHOD
This is a qualitative, descriptive and exploratory study, carried out for the conclusion of Multiprofessional Residency in Health. The research was conducted in a medium-sized University Hospital located in a capital in the Brazilian South Region.
Twenty-one members of the multi-professional team participated in the study, foreseen in Ordinance 485/2014 of the Ministry of Health, which provides for the care service for people in situations of sexual violence within the scope of the SUS, provided for in article n.7, among them nurses, nursing technicians, physicians, social workers, psychologists and residents of these areas; pharmacists were not interviewed because, in this institution, they are not part of the multi-professional team that exclusively serves the maternity ward. 10 The criteria for inclusion were the following: professionals working in gynecological/obstetric emergency inpatient clinics, obstetric center and rooming-in, these being chosen for receiving the women who seek the service of legal interruption of pregnancy during their hospitalization, with time in the institution of at least one year, and who have provided care to women in situations of legal interruption of pregnancy due to sexual violence. The exclusion criteria were as follows: professionals who were on vacation or away from the service during data collection. The recruitment of study participants was done using the snowball method, which consists of a form of non-probabilistic sample, using chains of reference that are constructed through the indication of an interviewee who can fit the profile of the research and so on. 11 The sample was not defined, since the data saturation technique was used. 12 Data collection took place in the months of September and October 2018, through recorded interviews; for this purpose, an instrument was made to be used in the semi-structured interview, containing closed questions in order to characterize the participants, and open questions to enable further study, among these questions were: describe how you, the health professional who works directly with women in situations of sexual violence, feel when you provide assistance to women who seek the service of legal interruption of pregnancy and in case of a bad feeling that arises in the previous answer, do you, after assisting these cases, look for ways to deal with what you felt? If so, which ones?
Data analysis was based on Minayo's operative proposal, characterized by two operational moments, the exploratory phase that contains the fundamental determinations of the study and the interpretive phase. The interpretive phase involved an exhaustive reading of the transcripts of the interviews, and interrogation of the data aiming at internal coherence of the information found, allowing to apprehend the relevant structures and the central ideas. Subsequently, with the cross-reading of the interviews, it was possible to separate the themes, categories or units of meaning, separating similar parts by colors, trying to perceive the connections between them with the study object, and saving them in codes stored in tables in a text editor; in the final analysis, the data obtained were compared with the theoretical framework adopted. 12 The participants signed the Free and Informed Consent Form, informing the risks and benefits of the research, in addition to all other ethical aspects that permeate it. Anonymity of the participants

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was guaranteed by the use of the alphanumeric system to identify the research participants, with the letter P and numbering according to the order of the interviews.

Characterization of the participants
Twenty-one professionals from the multi-professional team who assist cases of legal interruption of pregnancy were interviewed, among them 15 from the nursing team, two physicians, three social workers and a psychologist. Of these, 20 were identified with the female gender, with ages varying from 24 to 60 years old. In relation to the schooling level, 10 have high school and 11 higher education, among these, five are in training (residency). Regarding the time of training, the mean was 18 years, but the answers ranged from two to 35 years and, in relation to the time working in the institution, the mean was 14 years with the answers ranging from one year and 8 months to 35 years.
The following categories were elaborated to understand the data obtained during the interviews.

Feelings related to the participation of the professional in the process of legal interruption of pregnancy
The participants of this study were approached in such a way that they could explain their feelings when assisting cases of legal interruption of pregnancy and, initially, one of those found in answers to the interview was indifference and detachment regarding the decision made by the woman who entered the protocol of legal interruption of pregnancy, as evidenced in the following report. When dealing with abortion issues, it is understood in the same way that the professionals can be faced with a reality permeated by unpleasant feelings inherent to their will, having their conducts and opinions marked based on the reality they have already experienced. Thus, conflicts or even painful personal experiences can be unconsciously projected to the user.
[ In the statements, the participants also brought the question of distrust in relation to the report made by the women in relation to the situation of sexual violence, a necessary stage to access the protocol of legal interruption of pregnancy.
[ It is possible to perceive that there is distrust on the women's report; in the following statements, it is also observed that the protocol to access the service seems to be underestimated, greater rigidity at this stage of the protocol being called into question.
But I've already heard like this 'I went to get a ride, I was taken to a beach farther away' things like that, we don't hear that anymore. Most of the reports are party reports, in the middle of parties (P12).
In addition to indifference and distrust, sadness was also obtained as a response, where the view of the procedure and expulsion of the fetus itself can be taken into account.
Look Despite the feelings described above, some people manage to express empathy for the suffering of others, trying to give a different meaning to this woman's search for the service, understanding that, in this process, it is important to respect the woman's choice, safeguarding her well-being and guaranteeing the care described in the Law, both in ethical and practical as well as legal aspects, thus avoiding individual judgment.
Feelings are diverse and often ambivalent. The impotence in front of violence situations permeates the entire service; however, at the same time, the power of listening as an intervention strategy allows the subject to be re-signified, and from there, the sensation and possibility give way to support and comfort for the women who arrive at the service (P9).
My initial concern is how she will be welcomed by the team, I always wonder if she was treated well in the emergency and in the screening. [...] I believe that the main baggage that a professional should have for these situations is knowing how to welcome and listen to her (P14).

Ways of coping and support service of the institution
From the feelings that were made explicit in the speeches, the participants were asked if they use any personal or group strategy to be able to deal with the emotions that arise, whether from a positive or negative perspective. Some professionals recognize that they seek help from professionals in order to deal with the psychological issue generated by the procedure. The only way that I find to deal with this feeling is by talking to the people I love, or even colleagues, but mainly with the family (P20). Some professionals also brought the concern with their own mental health, recognizing that the situation they assist tends to cause wear out or even loss of sensitivity to these cases.

I need to pay attention so that the ideas against abortion do not interfere with care. This contradiction generates, in most cases, an emotional strain on the professional who provides care (P11).
At the same time, I also need to protect myself, as a professional, not to be nervous, which is a situation that requires welcoming, empathy for that user, but at the same time it cannot destabilize you in terms of health mental (P18).
Some study participants pointed out the lack of support from the institution towards them, bringing at some moment the importance that this would have in their professional practice.
As a woman and as a health professional, I feel violated in some way, as meeting these situations generates emotional and psychological impacts on the professionals and, on the other hand, the institution does not offer any type of care directed to the professionals (P10).
I just think that there should be psychological support for the team. I should work with the team, before we start. That at some moment that she is uncomfortable, that she has this psychologist to assist her, it could be down there [services for workers' health in the institution]. For us to be able to vent, with a psychologist, a therapy, I think it is very interesting indeed, very valid. We don't have, for now we don't have, but I believe that in the future it will evolve (P17).
One of the participants informs in her interview that it would be of interest to the institution to support the health of employees, but they still do not offer this service as they would like, although there is a listening movement. Not

DISCUSSION
When it comes to the subject of the legal interruption of pregnancy, it is believed that it can bring even more emotional issues of confrontation, and fragility in the professionals due to the duality that this situation can possess. On one side of the situation there is the woman in a moment of fragility and, on the other, the pregnancy that is about to be interrupted and all the personal meanings that she can bring to the professionals based on her beliefs and values. By dedicating their life and training to the health area, the person assumes the commitment to heal and/or take care of others in an integral way but, when faced with taboo or difficult situations, as in the case of legal interruption of pregnancy, there may be mobilization of diverse feelings.
When dealing with health/disease and living/dying situations, the health professionals are daily exposed to situations that generate sensations and feelings of different dimensions that can clash with their personal beliefs and opinions. However, it is important to emphasize that humanized and comprehensive care is a constitutional right of women seeking health services, and the personal values of the health professional cannot overlay the Law. 13 The blaming of the victim of sexual violence, and the fear of being judged, humiliated and repudiated, are reasons that lead the woman to be silent and not to denounce or report the facts. However, when she decides to report, she has to repeat the story several times, for the family, professionals and authorities, and live with feelings, such as the indifference reported by the participants in this study. 14 Although there is a projection movement for psychological aspects and respect for the autonomy of women over the legal interruption of pregnancy, the emphasis on care is still focused on physical and reproductive recovery. Clinical knowledge, linked to the development of skills and techniques, the 8/12 maturation of personal attitudes, and ethical and professional postures, are fundamental elements for the integral care of women undergoing an abortion process. 15 The reliability of the user's report can be questioned due to personal distrust, which can directly interfere in the decision whether or not she can access this service. 6,16 Directly dealing with the legal interruption of pregnancy in the cases provided by Law, Ordinance 1508/2005, provides for the justification and authorization in cases provided for in Law 2848/40, specifically in art.128, where the four phases for accessing the protocol are described, including the detailed report of the event carried out by the woman in front of two health professionals and after issuing a technical opinion by the physician taking into account ultrasound, physical and gynecological examination, anamnesis among others, in addition to the term of responsibility, term of approval for interruption of pregnancy resulting from rape, term of free and informed consent for interruption of pregnancy resulting from sexual violence. 17 This distrust can raise questions as to whether the protocol itself should be more rigid and require legal means for its access. The fact of being in a situation of sexual violence does not guarantee the woman access to legal interruption by itself, she needs the situation to be narrated to different professionals and in different situations and, in this, way she may or may not be accepted as a victim. This search for the truth causes the woman's word to lose its legitimacy, thus putting the veracity of the facts in doubt. 18 These attitudes are closely connected with the value judgment of each professional, where in some situations the truth of the report is questioned and thus they question whether there is a need to condition the performance of the procedure before a specific occurrence report and medical report 1,15 or the need for the woman to be referred to the ethics committee to ascertain the truth of the facts. 19 Distrust is particularly directed at women with heterosexual relationships or at those who are seen as "different" by the professionals. 18 In this study, no response was obtained with these characteristics; however, statements about distrust towards the place and the circumstances of the event were observed, thus evidencing that there really is a standard for believing in the women's reports.
When it comes to bad feelings and to the professionals' explicit speech referring to the procedure itself and any question of exposure to the death of the fetus, there is the question that the health professional's mission is to be life-saving agents and, in the view of these professionals, the fetus will always be a life, regardless of its gestational age. This occurs because the maternity ward is a hospital space where death is not usually thought of. 20 The fact that the fetus seems alive at the moment of expulsion and that there is no possibility of doing anything to alleviate this moment can cause the professional to feel helpless and guilty. Given the aforementioned, it is believed that the professionals working in maternity hospitals and who are little exposed to situations and experiences like these should be better prepared, thus aiming at reducing emotional exhaustion and their difficulties in accepting finitude and the procedure of interruption itself, observing its several facets.
In this sense, there is a need for training the health professionals to deal with cases of violence. 5 The absence of training or welcoming to these professionals can result in greater emotional overload for them, as evidenced in some statements described in this study.
For the woman, this empathy is highlighted as a positive aspect of her hospitalization, as this non-condemnatory attitude makes her feel truly welcomed and not to blame for the violence suffered or the performance of the procedure itself; after all, when subjecting to it, she is running life-threatening or minimally sequelae, in addition to being at risk of triggering episodes of post-traumatic stress. 5,17 With the various repetitions of narrating what happened, this woman can have greater compromise of her emotional and psychological state, so it is necessary for the professionals of the service to carry out strategies that aim to reduce her exposure to traumatic events. 21

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The feelings experienced by the participants in this study can reflect the emotional overload of the professionals in the face of situations of legal interruption of pregnancy that occur in their work environment, leading them to seek help outside the institution. It is understood from this that the stress of the situation and all the facts that permeate the consultations arouse in the professional the need for external support. This can be found as previously mentioned in terms of looking for a trained professional, in a work/colleagues/friends cycle, religion and in their own family. The professional support offered by the institution is non-existent, as found in the reports. The absence of such support can result in workers' lack of motivation. 21 The psychological distress of the employees is a problem that the institution should address and thus promote the appropriate means to preserve their health and enable the treatment of internal conditions, understanding that the work performed depends deeply on the mental health of the worker. 21 In 2017, the project for Improvement and Innovation in Care and Education in Obstetrics and Neonatology (Aprimoramento e Inovação no Cuidado e Ensino em Obstetrícia e Neonatologia, Apice On) was created, an initiative of the Ministry of Health in partnership with educational and training institutions that aims to contribute to the implementation of care and assistance practices in obstetric and neonatal areas based on scientific evidence, strengthening of sexual and reproductive health actions, and implementation of humanized care for women in situations of abortion and legal abortion. In this sense, among its objectives are the implementation of humanized care in situations of sexual violence and legal abortion and encouraging the development of research studies related to this theme. 22 It is believed that initiatives like this can contribute to minimizing the suffering and distress of the professionals in the face of cases of legal interruption of pregnancy and encourage the institutions to develop permanent education actions to qualify assistance to women in situations of violence and legal abortion.

CONCLUSION
This study aimed to highlight the feelings and ways of coping of the multi-professional team that works with cases of legal interruption of pregnancy; it evidenced that a large part of the health professionals who assist these cases of legal interruption of pregnancy is not prepared to experience the aspects that this process unleashes in themselves. The expression of the meanings that the interruption causes by itself allows for the view of opposite and often conflicting dimensions coexisting in the same person. Reports of sadness and empathy were obtained, which brings a rich insight into the subjectivity of the person in their professional environment, in cases also influenced by the personal side. The question of distrust found in the participants' speeches also brings with it the reflection of how these cases are approached and of how there is personal judgment regarding the speech of the woman in a situation of sexual violence.
Based on the analysis of the data, it was noticed that the professionals tend to assist women in the best possible manner, within the guidelines of the humanization policy, not allowing their personal perspectives to influence their assistance, but it is undeniable that it can bring feelings not favorable to their mental health. The ways of coping found were searching for professional support outside the institution, family, informal conversations and religion. It was also observed that the need for institutional support to these professionals would be necessary.
It is believed that the study achieved the proposed objectives and the following recommendations can be made: inclusion of the theme in the training of health professionals or a better approach to it, training for the professionals who work with these types of situations, but mainly the creation of a service that offers/enables psychological support to them.