Report of an experience to expand access to legal abortion for rape victims in the city of Rio de Janeiro, Brazil Relato de experiência sobre ampliação do acesso ao aborto legal por violência sexual no Município do Rio de Janeiro, Brasil Relato de una experiencia sobre la ampliación del acceso al aborto legal por violencia sexual en el Municipio de Río de Janeiro, Brasil

The article reports on an experience developed by the Rio de Janeiro Municipal Health Department (SMS-RJ) to expand the number of municipal maternity hospitals that provide legal abortion for rape victims. Brazil’s legislation allows legal abortions in three cases: risk to the woman’s life, rape, and fetal anencephaly. Given the high rate of sexual violence against Brazilian women, health professionals working in the Brazilian Unified National Health System (SUS) need to be trained for such care with abortion as the potential outcome if that is the woman’s choice. Despite the legal provisions and guidelines, Brazilian women still experience important barriers when attempting to access this right. One of the main obstacles is health professionals’ claim of conscientious objection. The study aims to present an awareness-raising methodology for health professionals to improve the care for victims of sexual violence and expand access to legal abortion in the municipal maternity hospitals. The methodology involved three stages: a workshop, awareness-raising in the maternity hospitals, and monitoring. This experience resulted in an increase in the number of maternity hospitals that perform legal abortion for rape victims, from two hospitals in 2016 to ten in 2019. The experience also strengthened the guidelines for the improvement of care, such as prioritization of cases for reception of patients and risk classification, supply of multidisciplinary care, and safeguards for the presence of an accompanying person during the patient’s hospital stay. Factors that favored this work included political determination by the administration of the SMS-RJ, the wager on decentralized activities in permanent education, and the health professionals’ direct involvement. Legal Abortion; Sex Offenses; Maternity Hospitals; Continuing Education; Unified Health System Correspondence B. C. Moraes Universidade Federal do Pará. Rua Augusto Corrêa 1, Belém, PA 68745-110, Brasil. bergson@ufpa.br 1 Secretaria Municipal de Saúde do Rio de Janeiro, Rio de Janeiro, Brasil. doi: 10.1590/0102-311X00181219 Cad. Saúde Pública 2020; 36 Sup 1:e00181219 COMUNICAÇÃO BREVE BRIEF COMMUNICATION This article is published in Open Access under the Creative Commons Attribution license, which allows use, distribution, and reproduction in any medium, without restrictions, as long as the original work is correctly cited.


Introduction
Brazil's legislation allows abortion in three circumstances: risk to the woman's life, rape 1 , and fetal anencephaly 2 . To guarantee this right, health services, especially maternity hospitals in the Brazilian Unified National Health System (SUS), need to be prepared to provide timely care to women, including prompt reception and case-resolution capacity.
Law n. 12.845/2013 3 and the Ministry of Health's Technical Standard 4 of 2012 define the health services' responsibilities to provide care to victims of sexual violence and in cases of legal abortion. However, there are persistent barriers to accessing this right. In cases of legal abortion for rape victims, the barriers include health professionals' unfamiliarity with the legislation and public policies, inadequate data on the police report of the crime, and difficulty in identifying professionals who are willing to perform the abortion as provided by law 5,6 .
Conscientious objection, when a health professional refuses to perform the procedure, is a major obstacle 7,8 . However, conscientious objection is not an absolute right, and the healthcare institution cannot claim it to refuse to perform the procedure 9 . Rather, the institution has the duty to inform the woman of her rights and to guarantee the abortion care by an alternative professional or service 4 .
Data on rape in the state and city of Rio de Janeiro point to high rates of such violence. According to the Women's Dossier 10 by the Institute of Public Security, in 2018 there were 4,543 cases of rape against women in the state of Rio de Janeiro, 1,400 of which occurred in the state capital. The official records do not include all the cases, since evidence points to underreporting because of the nature of the crime and the widespread taboo 11 . Table 1 lists the abortions allowed by law and recorded in the state and city of Rio de Janeiro in the last four years. The data were obtained from the Brazilian Hospital Information System (SIH/ SUS) with code O04 ("Abortion for medical and legal reasons") of the International Classification of Diseases, 10 th Revision (ICD-10), which includes procedures performed in the three circumstances specified in the Brazilian legislation.
The data show low numbers of procedures performed in the SUS when compared to the number of rapes and potential pregnancies. The data also fail to specify the legal grounds. In 2011, for example, an estimated 7% of rapes resulted in pregnancy 11 . If this percentage is applied to the number of rapes in the state, there would have been 318 pregnancies resulting from rape in 2018. That same year only 89 legal abortions were performed in the state of Rio de Janeiro.
This difference may signal difficulties in access to the procedure and women's lack of information on the right to abortion (under safe conditions and free of cost in the public healthcare system) in cases of rape 12,13 . There are also potential problems with coding, since there are other codes that end up being used for abortion because of some health professionals' difficulty in admitting that they perform the procedure.
Considering this scenario, the current article reports on an experience developed by the Rio de Janeiro Municipal Health Department (SMS-RJ) that aimed to implement an awareness-raising methodology for health professionals and administrators to upgrade care for rape victims and expand access to legal abortion.

Methodology
The methodology ( Figure 1) was elaborated by a Working Group that was coordinated by the Division of Maternity Hospitals of the SMS-RJ and was in charge of mobilizing the awareness-raising activities with the health professionals and administrators. The Working Group consisted of ten professionals that attended the meetings regularly, including psychologists, social workers, and nurses from three of the 12 maternity hospitals in the municipal system. Mobilization of the Working Group began with participation by the SMS-RJ team in the Working Group on Abortion of the Perinatal Forum in Metropolitan Region I, a space for debate among administrators, health professionals, and social movements, addressing public policies targeted to women's and children's health 14 .
The methodology was implemented from October 2017 to October 2018 and consisted of three stages: (i) Workshop: marking the start of the process, the Workshop included directors of the maternity hospitals and the multidisciplinary teams (psychologists, social workers, physicians, and nurses) who studied and discussed the main guidelines, legislation, and data on sexual violence and legal abortion and participated in a discussion of cases of women who had sought abortion care; (ii) Awareness-

Figure 1
Awareness-raising methodology for health professionals on abortion in rape cases.
Cad. Saúde Pública 2020; 36 Sup 1:e00181219 raising in the maternity hospitals: based on the Workshop, Multiplier Groups were created in all 12 maternity hospitals to raise the awareness of the healthcare teams (both those in the routine daily rounds and on shifts), in order to disseminate the scheduled protocols and patient care flows. This process was backed by the folder Guidelines on Care for Rape Victims and Legal Abortion (Supplementary material: http://cadernos.ensp.fiocruz.br/site/public_site/arquivo/csp-1812-19-material-suplemen tar_7829.pdf) with the principal information on these lines of care, a copy of which was given to each professional. Specific awareness-raising activities were also conducted with the medical teams, which had frequently positioned themselves against performing abortion, claiming conscientious objection (as confirmed by the experience of the SMS-RJ team, corroborated by studies on the subject 8,9 ); and (iii) Monitoring: finally, the Working Group conducted visits to the maternity hospitals for an ongoing diagnosis of the abortion care. Questionnaires were applied to the Multiplier Groups (consisting of the multidisciplinary teams and directors) and to the health professionals who were working in the maternity hospitals at the time of the visits.
The questionnaires contained questions on the maternity hospital's functioning and addressed the following items: flows of care and protocols; reception of patients and risk classification; supply of tests and medications; supply of multidisciplinary care; case discussion activities; reporting of cases to the proper databases; methods for performing legal abortion; claim of conscientious objection; organization of multiplier groups; and aware-raising.
Following the visits, the consolidated data were presented to the Multiplier Groups. Monitoring of activities is scheduled to occur biannually, fostering collaboration between the management and patient care teams on these occasions. Table 2 shows the data on legal abortion for rape victims and the expansion of the number of municipal maternity hospitals that performed the procedure in the last four years. In 2016, only two maternity hospitals were performing legal abortion on grounds of rape, with a total of 53 procedures. The subsequent years witnessed an increase in the number of services and abortions, reaching 106 procedures in 2018 and ten maternity hospitals with cases as of July 2019.

Results
In 2017 and 2018 there was an increase in records on the number of legal abortions in the SIH/ SUS database and in the SMS-RJ's own recording system, when compared to 2016. A comparison of the SMS-RJ data with those extracted from the SIH/SUS database reveals a discrepancy, especially in the years 2017 and 2018. Some hypotheses for this difference are an increase in recording of pregnancy terminations on other legal grounds (besides rape) and inconsistent data feeding into the system.
In addition to the increase in the number of cases after the monitoring visits, all 12 maternity hospitals under the SMS-RJ are found to be prepared to perform legal abortion in cases of rape, strengthening the following guidelines: a) Priority for rape victims and cases of legal abortion at the ports of entry, with nurses receiving the patients and classifying the risk in 100% of the maternity hospitals; b) In rape cases, prompt patient reception, supply of rapid tests, and medications for prophylaxis of sexually transmitted infections and emergency contraception in 100% of the maternity hospitals, requiring adjustments to the flows of care in some of the services visited; d) Supply of multidisciplinary care in 100% of the maternity hospitals, with spaces for case discussions of legal abortion in 50% of the services (reported in the six maternity hospitals with cases as of October 2018); and e) Guaranteed authorization for the presence of an accompanying person during the hospital stay of women who underwent legal abortion, in 100% of the maternity hospitals. The data refer to the abortions actually performed; that is, there is no detailed record of the total number of procedures requested (including those refused). Medical (non-surgical) abortion is the first option in pregnancies up to 12 weeks in 75% of the maternity hospitals, while manual intrauterine aspiration was cited as the first method of choice in only three maternity hospitals with gestational age less than 12 weeks.
Conscientious objection was reported verbally by all the Multiplier Groups. However, when asked to provide details on its frequency and presence according to hospital shift, the local teams failed to provide consolidated data on this point. Importantly, when conscientious objection is claimed by the hospital teams in cases of legal abortion, the directors of the services take over and are responsible for seeing that the procedure is performed.
Monitoring also identified difficulties with the consolidation and improvement of care, such as: unfamiliarity with the legal provisions; flows of care as a work-in-progress and not implemented in some services; incipient mapping of conscientious objection; precarious referral of patients following the abortion; and lack of alignment in the records between the databases.

Discussion
The guarantee of legal abortion in services in Brazil's SUS allows the procedure to be performed under safe conditions, without women having to be exposed to high-risk situations that can jeopardize their health and even result in their death 15 .
The experience reported here shows that it is possible to achieve this objective in women's care, as long as there is political will by the administration and commitment by the professionals involved, as occurred in the case of Rio de Janeiro. Some key conditions also helped make this work possible: the wage on decentralized activities in continuing education; formation of the Working Group and the collaborative development of the awareness-raising methodology; follow-up of data on the care provided; and local monitoring with visits to the maternity hospitals.
The monitoring stage was essential for assessing the activities, showing that the teams at the maternity hospitals had persistent questions and faced internal resistance to incorporating the guidelines. Despite such resistance, spaces were created for dialogue and reinforcement of the institutional policies to guarantee legal abortion. Even so, it is necessary to confront the difficulties that were identified, conducting new rounds of monitoring and improving the quality of records to overcome the discrepancy between the databases.
The focus on awareness-raising of the health professionals involved in the care, including day staff and shift staff, proved to be an important strategy to deal with isolated attitudes based on individual beliefs and values. The awareness-raising activities were launched in eight of the 12 maternity hospitals and were in the process of development and updating in the other services as of 2018 and 2019. The aim is to reach all the healthcare workers in the different professions, conducting periodic monitoring of the activities' progress.
The methodology, as presented, was developed collectively, based on the underlying guidelines for the work in the SUS, and they need to be assessed and improved. The seriousness of the situations treated should be addressed, including the need to provide care with prompt reception of patients, case-resolution capacity, and respect for the women that seek these services.
The reproduction of this methodology in other states and municipalities can help expand access to legal abortion, as well as serving as support for the healthcare teams, especially in their knowledge of Cad. Saúde Pública 2020; 36 Sup 1:e00181219 the prevailing legal provisions. The proposal discussed here has the potential to improve the scenario of care for women through investment by the administration and the health professionals.
Finally, and importantly, this is an on-going experience, and considerable progress is still needed in the organization of services to adequately receive and care for women that have suffered sexual violence and that request legal abortion.