Pro-abortion rights narratives in Brazil, 1976 to 2016

The article explores pro-abortion rights narratives in Brazil based on the narrative policy framework (NPF). I analyzed pro-abortion rights documents written by feminist activists from 1976 to 1988 and documents from feminist organizations, law proposals and policy documents regarding abortions produced between 1989 and 2016. I carried out a content analysis of both sets of documents using the OpenLogos software. Findings show that feminists made a strategic choice in favor of a public health narrative so as to expand the pro-abortion rights coalition through inclusion of actors from the health sector. The alliance with the health sector led to achievements, such as the creation of the first legal abortion services and the inclusion of anencephaly among the cases in which abortion is permitted. The public health narrative was, therefore, institutionalized, becoming both the main narrative employed by the coalition and the main narrative found in policy documents. This institutional-ization is a goal for advocacy coalitions, but also imposes limits to their future work, since abandoning an institutionalized narrative may risk the coalition, while future demands must be formulated within the already-existing public policy structure.


From the beginning of the mobilization to the 1988 Constitution
In Brazil, the mobilization for abortion rights began in the late 1970s, influenced by the return of exiled activists, and was associated with a broader mobilization, by feminist activists, in defense of redemocratization 4 . At the time, feminist activists were, largely speaking, university-educated professionals 4 , most of whom had been involved with Marxist leftist movements 5 .
A central narrative that appears in this period, which I have defined as the "autonomy narrative", affirms the right to make decisions regarding one's one body specifically against population control policies. In this narrative, which accounts for a majority of the texts (Table 1), the criminalization of abortion is defined as a violation of women's autonomy which reinforces social inequalities, since access to safe, albeit illicit, abortions is possible only for those who are able to pay a high price.
Thus, women are at once victims and protagonists of this narrative: victims, because they are the ones who suffer the consequences of efforts to control reproduction; protagonists because it is up to them to decide whether or not to carry a pregnancy to term. The villains, in turn, are the "controllers", be that the State, the Church, or any other group that intends to determine whether and how many children each woman should have.

Main narrative Documents
Autonomy 22 Public health 18 Unclassified 22 Total 60 Note: two texts were classified as containing both narratives.
The concern with autonomy in light of population control is central to this narrative. The manifesto Nosso Corpo nos Pertence ("Our Bodies Belong to Us") provides an exemplary summary of the feminist position: "However, one fact is true: both the anti-natalist and natalist policies have, historically, used women's bodies, considering them to be a social property above women's rights and their individuality. All of them manipulate our sexuality, our genitals, our reproductive function, deeply alienating us from our own bodies" (O Sexo Finalmente Explícito, n. 0, 1983, cover and p. 2. All translations are my own).
Although a comparison with the United States is beyond this article's scope, it is worth quickly contrasting the idea of autonomy defended by Brazilian feminists with the one established in the American example, because this contrast illustrates an important dimension of the Brazilian narrative. According to Ferree 6 , in the United States, abortion rights are based on the principle that the State does not have the right to intervene in women's decisions concerning their own bodies, which, in turn, also exempts the State from offering this service. Thus, American feminists, in a sense, "abandoned" poor women and women of color, who are "disproportionately among the women who do not feel that they have a choice to bear a child and who may feel instead compelled and coerced into sterilization, adoption, or abortion" 6 (p. 336). Brazilian feminism, on the other hand, with its strong ties to leftist movements, put the issue of social justice, and the State's obligation to promote it, front and center. Thus, while they affirmed, just as the Americans, a woman's right over her own body, they also sought to obligate the State to provide the necessary means for women to exercise that right.
The social justice dimension is, therefore, central to the autonomy narrative. If, on the one hand, women as a whole are both victims and protagonists, the emphasis is placed on poor women, who are presented as the most victimized by the criminalization of abortion. At the same time, according to this narrative, autonomy is not restricted to the right to choose whether or not to terminate a pregnancy, but encompasses the conditions of possibility for exercising that choice, as expressed below: "As feminists, we demand that women have the right to control their bodies, to choose whether or not to have children, in the desired number. On the one hand, this requires them to have broad knowledge of their bodies and contraceptive methods, access to those methods and the right to an abortion as a last resort. On the other, it is also necessary that the women who desire a child have the material conditions to accomplish their motherhood. By material conditions, we understand decent salaries; public, good-quality medical care; daycare; collective equipments and the socialization of domestic work" (Letter sent to the press by Feminist Organizations on January 16, 1980 -Rio de Janeiro) Thus, the main strategic concern that guides the feminist mobilization is how to not only make abortion legal, but also guarantee that all Brazilian women, regardless of class, have access to safe abortions. This issue imposed itself in the 1980s because even for cases of rape, in which abortions were allowed under the law, there were no public abortion services, nor physicians willing to provide such services in their private practices 7 . This situation led feminists to believe that mere legalization would not guarantee accessibility of abortion services. On the other hand, there is a clear influence of socialist ideals that drove feminists, in light of the profound inequalities that exist in Brazil, to seek guarantees for the rights of the most vulnerable women.
As a result, the only way to guarantee not only the legality of abortion, but also all women's access to this service and all other means necessary to a truly free reproductive choice would be to force the Cad. Saúde Pública 2020; 36 Sup 1:e00189018 State to offer them. Therefore, this narrative's moral of the story is that abortion should not only be legalized, but also provided in the public health services, because this would be the only way to ensure that lower income women would have access to safe procedures.
Although this is the main narrative of this period, it is not the only one. A second one, which I have called the "public health" narrative, was also developed by feminist activists over the course of the 1980s. The main elements of both narratives can be found in Box 2.
As the Box 2 shows, both narratives have important similarities. The villains are largely the same, though the public health narrative does not characterize them as "controllers". The emphasis on poor women as the main victims of the abortion ban is also present in the public health narrative, as can be seen below: "Thousands turn to abortions, even if they are clandestine. Those who can afford to pay up to 60 thousand receive first-rate care, with disposable materials and medications in one of the many private clinics found in large cities. But most are left to inept abortion providers, without asepsis, and often end up in public hospitals to treat complications…" (Speech delivered by a representative of the feminist movement to members of the Constituent Assembly, 1987).
This excerpt illustrates an important, though subtle, difference between the two narratives. Just as in the autonomy narrative, the defense of social justice is central to the public health narrative. However, while the former emphasizes the conditions for exercising autonomy, and the ways in which these conditions are unequally distributed in society, in the latter, the focus is on the impact of clandestine abortion on women's health and lives, especially those who cannot afford to pay for safe clandestine abortions. Thus, statistics on morbidity and, especially, mortality resulting from abortion, along with statements from health organizations, play a central role in this narrative, and are used to present clandestine abortion as a public health problem, as in the excerpt below: "The World Health Organization, which considers abortion to be a public health problem in the countries where it is banned, ranks Brazil among the top five countries with the highest number of abortions and where the greatest number of women die as a result of this practice" (Aborto: Grande Hipocrisia Nacional [Abortion: the Great National Hypocrisy], Maria Maria, n. 0, 1984).
The most significant different between the narratives refers to the figure who holds the authority over the decision. The public health narrative also affirms that women should make decisions regarding their own bodies, but, by defining abortion in terms of its health impacts, it ultimately subordinates this decision to a medical authority who is capable of deciding what constitutes a "public health problem". Thus, we may say that the protagonists of this narrative are the doctors, who establish, if not each individual case of termination, at least the context and the circumstances in which the choice to have an abortion is possible. Both narratives converge once more in the moral of the story: not only

Box 2
Elements of the autonomy and public health narratives.

Elements
Autonomy that abortion must be legalized, but also that it should be available in the public health services so that all women will have guaranteed access to it, regardless of their income. Despite similarities, there were tensions with the public health narrative. Feminists at the time made a point of stating that abortion "is not only a public health problem", as Jacqueline Pitanguy states in her text Aborto -Direito de Opção ("Abortion -a Right to Choose", 1980). Feminists criticized the medical authority for its, in their view, sexist nature and denounced the medicalization of female bodies: in a speech at the first protest in favor of legalizing abortion in Brazil, in 1980, Mary Garcia Catro stated that "Feminism is against the power of institutions -the State, the Church, the constituted knowledge, e.g., medicine -over our bodies, our sexuality".
The beginning of the 1980s also marked the emergence of feminist groups and collectives that sought to familiarize women with their own bodies and reduce their dependence on medical authorities on issues related to reproduction and sexuality, teaching them, for example, how to conduct a gynecological self-exam. The newspaper Mulherio discusses the experiences of these groups in the 1984 article A Invasão das Bruxas ("The invasion of the witches"), stating that "These accounts show the nature -innovative, educational, against the authoritarianism of medical power, while rescuing popular knowledge -that most of the alternative experiences represent" (Mulherio, n. 19, p. 15, emphasis mine). It is within this context that the feminist councilperson Clair Castilhos Coelho (PMDB/Florianópolis, Santa Catarina State) gave an interview to the newspaper Mulherio, in 1983, decrying the fact that the population is unable to face abortion in a "frank" manner, and that "The few who believe it should be decriminalized think so because of medical reasons, and not from the standpoint of women making decisions regarding their own bodies" (Aborto [Abortion], Mulheiro, n. 15, September/October 1983, p. 3). However, the opportunities that emerged over the 1980s and 1990s led the public health narrative to gain increasing prominence.
Over the course of the 1980s, feminists sought to influence the process of reformulating Brazilian institutions and laws, focusing especially on the constituent process. Despite many achievements, such as the creation of the National Council on Women's Rights (CNDM, in Portuguese) and the inclusion of the right to family planning in the Constitution, their abortion-related efforts were unsuccessful. Not only was there no legislative change, but their attempts to form alliances with political parties and with the Brazilian Bar Association (OAB, in Portuguese) and to organize a mass movement failed.
At the same time, there were points of convergence and cooperation with actors from the health sector, especially the health reform movement. Like the feminist movement, the health reform movement had strong connections with the left. Based on a theoretical framework that considered health and disease in terms of their political and social determinants, and therefore closely associated with the inequalities present in Brazil, the health reform movement also based its demands on a defense of social justice 8 .
On the other hand, the reproductive rights that feminists demanded, including the guaranteed access to legal abortion services, converged toward the creation of a public, high-quality health system that provided care to all citizens, as demanded by the health reform movement. As a result, both movements, which had worked together in the struggle against the dictatorship, were also allies in the construction of a new health system that contemplated women's health demands 9 .
Thus, starting in the mid-1980s, feminists sought a strategic alliance with the health sector. In 1984, the 1 st Women's Health Meeting took place. The Carta de Itapecerica ("Letter from Itapecirica"), issued at this event, stated that the right to have an abortion "is indissociable from women's health and freedom". The next year marked the first mention of a pro-abortion rights mobilization specifically organized by doctors, regarding cases of "severe genetic diseases".
In Following this strategic assessment, the public health narrative began to appear more frequently among the analyzed documents over the course of the 1980s, which may be see in Figure 1.

The new Constitution and the stronger cooperation with the health sector
The second period analyzed in this article is marked by the transformations brought about by the new Constitution and, in particular, by the creation of the Brazilian Unified National Health System (SUS, in Portuguese). This new context enabled the creation of the first legal abortion service, in 1989, in the city of São Paulo, through an ordinance issued by then-mayor Luiza Erundina (PT) and idealized by Maria José de Oliveira Araújo, a feminist doctor who was part of her administration.
Entities that formed the feminist movement also sought to act within the social participation institutions in the health sector since at least the 1980s 9 . The construction of alliances within these spaces was what enabled the expansion of legal abortion services in Brazil. Starting in the 1990s, feminists gained the support of the Brazilian Federation of Gynecology and Obstetrics (Febrasgo, in Portuguese), which also began to defend the creation of legal abortion services. In 1997, representatives of Febrasgo and of feminist organizations acted jointly in the CNS Inter-sector Women's Health Commission, leading the Council to edit a resolution demanding the implementation of abortion services for victims of sexual violence 7 .  In response, in 1999, the Brazilian Ministry of Health issued a Technical Norm (NT, in Portuguese) which described the procedures and criteria for performing abortions in SUS in cases of pregnancy resulting from rape. After the NT was edited, the number of these services increased significantly: they went from eight in 1998 to 44 in 2002 7 .
This success constitutes a new strategy for the feminists, articulated from the late 1980s onward. In the first period analyzed in this article, documents already signalled the need to put into practice the possibility of abortion in cases of rape established in the Penal Code. However, it is during this second period that this demand separates itself from the more general defense of the right to abortion and becomes the object of a specific narrative, that of sexual violence, presented in Box 3.
Unlike the other narratives analyzed in this article, the sexual violence narrative is based on existing Brazilian legislation. According to this narrative, there is a right to abortion in cases of rape, established in 1940 in the Penal Code, that was never enforced due to the lack of legal abortion services. Thus, the State would have an obligation to guarantee access to abortion to all women and girls who are victims of sexual violence, if they so wish. In addition to the Penal Code, the sexual violence narrative is also based on the 1988 Constitution and the creation of SUS, specifically the State duty to guarantee health to all citizens. As discussed, guaranteeing access to abortion services, and not only the legalization of abortion itself, was the key strategic concern of the feminist movement. The definition of health as a State duty become a key element of all narratives in this second period.
The victims of this narrative are the women and girls who suffer sexual violence. In the documents, they are double victims: first, of the sexual violence itself; then, of the unwanted pregnancy. According to the narrative, pregnancy resulting from rape re-victimizes these women and girls, especially when they face difficulties accessing legal abortion services. The following excerpt expresses the characterization of this double victimization: With regard to the consequences of the sexual violence committed against women, pregnancy stands out because of the complexity of psychological, social and biological reactions suffered during and after pregnancy. As a result of this violence, the unwanted or forced pregnancy is viewed as a second violence (PL 4,725/2009).
In the same way that there is a double victimization, there are also two villains in the narrative: on the one hand, the sexual aggressors, or, more generally, the structure of gender inequality that leads to sexual violence; on the other, those who seek to prevent women from accessing abortions, re-victimizing them. The focus, in this second group, are conservative lawmakers who introduce law proposals in order to restrict or eliminate the right to abortion in cases of rape.
Thus, the moral of the story is that the State must fulfill its duty to guarantee the rights both to health and to an abortion through legal abortion services in SUS. An important element of the narra-

Box 3
Elements of the sexual violence and anencephaly narratives. tive is, therefore, establishing a connection between the right to abortion in cases of rape and the right to health -of the 20 documents whose main narrative is that of sexual violence, 11 situate abortion within women's health needs, or describe the negative health impacts of unsafe abortions. The importance, for this narrative, of the connection with the health sector can also be seen by the alliances established with health actors and by the mobilization within public health institutions which led to the creation of legal abortion services, as described.

Elements
Despite the importance of health in this narrative, the protagonists are the women and girls who experience sexual violence. This protagonism is even more pointedly expressed after 2005, when the NT was re-edited, removing the demand that women present police reports in order to have an abortion in the legal abortion services. Thus, the documents emphasize that there is no authority above the woman herself, whose word is enough for the abortion to be performed.
"For the practice of legal, sentimental, ethical or humanitarian abortion, there is no need for a court decision affirming the occurrence of rape or any other crime against sexual dignity. Therefore, there is no need for a court authorization or a sentence issued against the perpetrator of the sexual crime" (Aspectos jurídicos do atendimento às vítimas de violência sexual [Legal aspects of care provision to victims of sexual violence], 2011).
If this narrative removes women from the medical authority, which is subordinated to the woman's express desire to have an abortion, it differs from the autonomy narrative due to its emphasis on the characterization of women as victims. It is true that women are the victims in all narratives discussed in this article, but there is an important distinction. While in the remaining narratives, women are the victims of the abortion ban and its consequences, in the sexual violence narrative, women are double victims: first of sexual violence, then of the lack of abortion access. The State's obligation to provide abortion services is tied to the second dimension, but the right to abortion itself is tied to the first. It is their victimization that confers the right, and the protagonism, to women and girls.
This relationship between victimization and the right to abortion is not new, nor is it specific to Brazil. As Htun 1 (p. 145) notes, in the early 20 th century, the debate regarding abortion in Brazil was influenced "by a growing international movement for 'compassionate' abortion provoked by the widespread rapes of women by invading armies during World War I". The Brazilian Penal Code was inspired by that of Argentina, the first in the region to allow abortions in these cases, with the goal of "shield[ing] women from the anguish of mothering the children of men who had sexually assaulted them" 1 (p. 145).
This justification, though progressive for the time, does not fit within the feminist defense of abortion that began to be formulated in developed countries in the 1960s. What it represents is a right based on suffering and compassion, rather than the ideas of bodily autonomy or reproductive rights developed by feminists. However, the existence of this exception in the law is also an opportunity to guarantee access to abortion. Thus, the sexual violence narrative seeks to frame abortion in cases of rape as an already-acquired right, emphasizing the women's protagonism in making this decision, without questioning the underlying logic behind this exception.
The success reached within the health sector, with the creation of legal abortion services, contrasts with feminists' loss of influence in the State over the course of the 1990s, a period when the CNDM was completely weakened, at the same time that conservative forces, especially groups opposing abortion, made important gains in National Congress 10 .
This trend seemed to reverse itself in the beginning of the Lula administration, with important gains, such as the creation of Women's Policies Secretariat. However, tensions between PT and the feminist movement, largely centered on the issue of abortion, began during Lula's first term. Amid the political crisis set in motion by accusations of a corruption scheme, the so-called "mensalão", the administration sought support from conservative groups, promising, in return, to put a stop to a proposed legalization of abortion in the first 12 weeks which had been drafted by a commission convened by Women's Policies Secretariat. A few years later, in the 2010 presidential elections, abortion was a central issue and the focus of attacks against then-candidate Dilma Rousseff, who, in response, publicly committed not to legalize abortion if elected. During her first term, abortion, along with the inclusion of gender discussions in the National Education Plan, became a focus of tensions between the feminist movement and the government, which depended on support from conservative groups in National Congress 11 . Finally, Women's Policies Secretariat, after many institutional changes, was absorbed by the Brazilian Ministry of Justice, without its original status or budget.
Cad. Saúde Pública 2020; 36 Sup 1:e00189018 The mismatch between advances in the health sector and setbacks in the relationship with the State is evident in a fact which took place in 2013, therefore, amid the tensions with the Dilma administration. That year, the Federal Medicine Council and the 27 Regional Medicine Councils publicly supported broadening the right to abortion. Among the reasons cited for this decision were "respect to women's and doctors' autonomy", the impact of clandestine abortions on public health and the "social dimension" of this impact, since if affects women differently depending on their level of income -that is, a decision justified with the public health narrative.
This narrative is not only the most common in the entire set of documents, but also dominates both the feminist documents and, especially, the government documents (Table 2). Thus, we may say that the public health narrative has been institutionalized in the sense that it has become the main narrative used by the pro-abortion rights coalition and, especially, the main narrative underlying abortion policies in Brazil.
The autonomy narrative, in turn, loses importance. Despite being the second most common narrative in the entire set of documents, it is the least represented among government documents, among which it is the main narrative of only one. Of all the narratives, therefore, that of autonomy was the least capable of subsidizing changes to abortion policies.

The anencephaly narrative and the emergence of a new type of mobilization
There is a final narrative from this period, one that focuses on abortion in cases of anencephaly, and that was developed especially after the Claim of Non-Compliance with a Fundamental Principle (ADPF, in Portuguese) n. 54 was filed with the Brazilian Supreme Court in 2004. The ADPF, which argued that banning abortions in cases of anencephaly violated women's right to dignity, health and to not be tortured, was successful: in 2012, the Supreme Court decided to authorize abortions in those cases.
The elements of the anacephaly narrative are summarized in Box 3. One important way in which this narrative differs from the others is the focus on characterizing the anecephalic fetus as not having rights due to the fact that anencephaly is a malformation that is incompatible with life. This appears in 14 of the 15 documents in which the main narrative is that of anencephaly. In contrast, only four of the 45 documents with the public health narrative, seven of the 29 with the autonomy narrative and three of the 20 with a sexual violence narrative question the fetus' status as a person endowed with rights.
In order to define the anaecephalic fetus in this manner, the documents refer to the medical literature in order to describe anencephaly and characterize it as incurable and fatal in all cases. Thus, the document Anencefalia: o Pensamento Brasileiro em sua Pluralidade ("Anencephaly: the Brazilian thinking in its Plurality", 2004), produced by Anis, states that "there is no cure for anencephaly. There is no perspective of treatment or survival for a fetus with anencephaly" (p. 18). The anencephalic fetus is described in many documents as a "cerebral stillbirth" and anencephaly is equated with brain death. As a result of this characterization, the documents state that, in these cases, what happens is not an abortion, but rather a "therapeutic anticipation of birth". The ADPF explains this difference thusly: "Abortion is described by the specialized doctrine as the "interruption of pregnancy with the subsequent death of the fetus (...)". It is worth saying: the death must be the result of the abortive means, and both the establishment of a causal relationship and the potentiality of the fetus' extra-uterine life are indispensable. This is not what happens in the anticipation of birth of an anencephalic fetus. In fact, in these cases, the fetus' death results from the congenital malformation, and is certain and inevitable even if the 9 months of normal pregnancy have passed" (ADPF 54, 2004) The central role that the discussion of the fetus' status and its impact on the characterization of abortion plays in the narrative not only differentiates it from the others, but also points to another key element in this narrative: the protagonists. As in all texts discussed int his article, those that present the anencephaly narrative state that the decision whether or not to carry a pregnancy to term should fall to women exclusively. However, the condition of possibility for this choice, as in the public health narrative, is the consent of the medical authority. It is this authority that provides the proof of the severity and incurability of anencephaly and it is the diagnosis provided by a medical authority in each specific case which grants women the legal possibility to have an abortion.
The medical authority's protagonism also appears in another way. The documents state that the possibility of abortion in cases of anencephaly was not included in the Penal Code only because the diagnosis could not be made with the technology of the time and, once this technology was developed, the legislation should necessarily be altered to reflect this advancement. This idea is clearly expressed in the excerpt below: "It should be noted that the hypothesis under examination was not expressly included in art. 128 of the Penal Code as an exemption of liability only (…) because in 1940, when the Special Part of that law was edited, the existing technology did not permit the precise diagnosis of fetal anomalies incompatible with life. We cannot permit, however, that the anachronism of the penal legislation impede the protection of fundamental rights consecrated by the Constitution, privileging exacerbated positivism to the detriment of an evolving interpretation and of the ends intended by the norm" (ADPF 54, 2004).
Comparing the four pro-abortion right narratives discussed here, we see important similarities, especially the importance of the concern with guaranteeing access to abortion services and the defense of social justice. On the other hand, the protagonists divide the narratives into two groups: on the one hand, those of public health and anencephaly, which attribute protagonism to the medical authority; on the other, those of autonomy and sexual violence, which confer this role to women. As discussed, all documents state that women, and only women, should decide whether or not to carry a pregnancy to term. However, the terms on which this choice is based in the public health and anencephaly narratives circumscribe a space of autonomy that is dictated by the medical authority's rules. Even in the case of sexual violence, in which a woman's right to choose is placed above any other consideration, this autonomy is nonetheless based on notions of suffering and compassion which do not reflect the demands for autonomy expressed in feminist texts.

Conclusions
Given the opposition of both public opinion and the majority of lawmakers, the weak institutionalization of feminist demands in the State, as well as a lack of support from other sectors, health emerged as the most receptive field to the demand for abortion rights. The construction of SUS and the consolidation of groups linked to the health reform movement within the State created opportunities for feminists and their allies. Thus, the public health narrative was institutionalized, both because it became the main narrative of the pro-abortion rights coalition, and because it is the main narrative present in abortion policy documents in Brazil. This institutionalization, in turn, restricts the coalition's possible future actions. In the same way that the sexual violence narrative must work from a logic, present in the Penal Code, which differentiates rape cases from all other unintended pregnancies based on a perspective of suffering and compassion, future efforts toward legalizing abortion will have to work from the policy documents already in place -and the narratives they contain.
Cad. Saúde Pública 2020; 36 Sup 1:e00189018 The costs of abandoning this narrative may explain, at least in part, why the public health narrative continues to be the main narrative of the pro-abortion rights coalition, despite not being able to convince public opinion or produce any gains since 2005. The adoption of the sexual violence and anencephaly narratives does not solve this impasse because they only address abortion in specific circumstances and are therefore unable to serve as the basis for a demand for its complete legalization. We must await the results of current actions, such as ADPF 442, which seeks to legalize abortion in the first 12 weeks of pregnancy, and the responses of the pro-abortion rights coalition to future changes in the abortion-related opportunity structures.