Services on Demand
On-line version ISSN 1982-0194
Acta paul. enferm. vol.21 no.3 São Paulo 2008
Healthcare for women in process of induced abortion: statements of nursing professionals*
Asistencia a la mujer en proceso de aborto provocado: discurso de profesionales de enfermería
Solange Maria dos Anjos GesteiraI; Normélia Maria Freire DinizII; Eleonora Menicucci de OliveiraIII
IPh.D., Researcher of Grupo de Estudos sobre Saúde da Mulher of Escola de Enfermagem at Universidade Federal da Bahia - EEUFBA - Salvador (BA), Brazil
IIPh.D., Professor; Leader of Grupo de Pesquisa Violência, Saúde e Qualidade de Vida. Researcher of Grupo de Estudos sobre Saúde da Mulher of Escola de Enfermagem at Universidade Federal da Bahia - EEUFBA - Salvador (BA), Brazil
IIIProfessor of the Preventive Medicine Department, Universidade Federal de São Paulo - UNIFESP - São Paulo (SP), Brazil
OBJECTIVE: To analyze the statements of nursing professionals regarding healthcare provided to women in process of induced abortion.
METHODS: Case study with qualitative approach, performed at a public maternity hospital in Salvador - BA; data were obtained with the focus group technique, using content analysis.
RESULTS: The nursing team professionals perceive abortion as a crime, a sin, and healthcare as discriminatory. The woman's right to speech is denied, with silence being observed along the abortion process.
CONCLUSION: The absence of dialogue at the healthcare services makes the possibility of humanized care delivery more distant, turning the implantation of healthcare humanization policies for women in the process of induced abortion a challenge.
Keywords: Abortion; Abortion, criminal; Nurses care; Women's health
OBJETIVO: Analizar el discurso de profesionales de enfermería con relación a la asistencia prestada a las mujeres en proceso de aborto provocado.
MÉTODOS: Estudio de caso, con abordaje cualitativo; realizado en una maternidad pública de Salvador - BA; los datos fueron obtenidos por medio de la técnica del Grupo Focal utilizando la técnica del análisis de contenido.
RESULTADOS: Las profesionales del equipo de enfermería perciben el aborto como crimen, pecado, y la asistencia, como discriminante. A la mujer le es negado el derecho a hablar, por lo que el silencio es observado a lo largo del proceso de aborto.
CONCLUSIÓN: La ausencia de diálogo en los servicios de atención vuelve más distante la posibilidad de asistencia humanizada, haciendo que la implantación de la política de humanización de la asistencia a las mujeres en proceso de aborto provocado sea un reto.
Descriptores: Aborto; Aborto criminal; Atención de enfermería; Salud de la mujer
Induced abortions have been mentioned as a public healthcare problem, and global estimates(1) point to the occurrence of 44 million induced abortions every year. It should also be noted that abortions are legal only in a few countries in North America, Europe and Asia. Clandestine abortions (about 15 million) occur elsewhere in the world, markedly in Latin American countries (about 4 million). They are responsible for the high maternal mortality on this continent(2-4).
Brazilian literature shows that maternal mortality due to abortion represents nearly 12.5% of total deaths, although many of them are not reported(5). Curettages are the second most common obstetric procedure performed in the internment units of the public healthcare network(6). In the city of Salvador(7), the maternal death rate is 132 for every 100,000 live births, with abortion pointed out as the main cause (37.6% of the deaths). These data are corroborated by another study, which cites abortion as the main cause of maternal death in this city(8).
This is linked to legal restrictions in some countries regarding similar practices(9), including Brazil. By this way of acting, these countries treat women perversely, especially those from lower-income social classes. As such, the illegal character of abortion favors its clandestine situation, and this is felt in the absence of service and in poor healthcare quality. For this reason, the high number of induced abortions in Brazil, especially in the capital of Bahia, is performed by women in solitude, without professional help, except in urgent cases when they present complications as a consequence of this practice.
Although the Brazilian Federal Constitution still considers induced abortion a crime, advances have been observed in its decriminalization. Therefore, after the 1st National Conference of Policies for Women, held in Brasilia in 2004, the federal government created the Tripartite Commission(10), including representatives of the Executive and Legislative powers and members of civil society. Medical and legal sectors and the feminist movement participated in this commission, aiming to review the set of laws ruling on punishments for the voluntary interruption of pregnancy. This led to the establishment of bill 1135/91. It addressed the decriminalization and legalization of abortion, with healthcare delivered by the Single Health System (SUS)(11-13).
However, the presence of institutional violence(14) is perceived through non-systematized observation of nursing professionals in practice, a discrimination made explicit in words, condemnatory and prejudiced attitudes, lack of commitment and postponement of healthcare. These aspects have been observed in public policies for women's healthcare, so that the way they are cared for can be changed, by considering them as subjects with rights and, hence, retrieving their citizenship. For this purpose, the public policies of the Ministry of Health, along with the state and city secretariats, have been making efforts in training and in the elaboration of manuals that will help to reverse this situation.
On the other hand, induced abortions, considered a public healthcare problem, are also a subject for study, since their analysis may help to face this problem politically(15).
Based on these arguments, and considering the interest in the theme abortion, we sought to analyze the statements of nursing team professionals, aiming to clarify how healthcare is provided to women in process of induced abortion.
Thus, this study was conceived to answer the following question: how does the nursing team perceive the healthcare provided to women in process of induced abortion?
By observing the healthcare problem involving women in the process of induced abortion, and aiming for changes in the humanization of healthcare for these women, this study aimed to analyze the statements of nursing team professionals regarding the healthcare provided to women in the process of induced abortion at a public maternity hospital in Salvador.
This is a qualitative research study, based on detailed case studies(16).
The qualitative approach was chosen for in-depth analysis of the subjects' statements, since it "goes deeper in the world of meaning of actions and human relations, a side that is not perceived in equations, averages and statistics"(17).
The qualitative approach aims at understanding a given experience in the light of the subjects' perspective, focusing on the nature, essence, meaning and attributes of the abortion phenomenon(17-19).
The case study, in turn, not only aims to discover the situation in question, but also emphasizes the interpretation of the context. In the quest to apprehend the study object as completely as possible, we consider the healthcare provided, attaining the perceptions of nursing team professionals through their discourse(18).
The study was performed at a state maternity hospital in the city of Salvador, a healthcare reference for women in the reproductivee period in high-risk pregnancy situations, normal or cesarean delivery, besides abortions. This maternity hospital delivers care to women from different regions in the state of Bahia and several communities within the metropolitan region of Salvador.
To meet the ethical aspects, the study was approved by the Review Board of Universidade Federal de São Paulo, process No. 0604/03, complying with the standards established by Resolution 196/96 of the National Health Council, which establishes the guidelines and regulatory standards for research involving human beings(20). It was also submitted to the approval of the board of directors of the maternity where the study was performed.
Data were obtained from two focal groups(21) with five nurses and four nursing auxiliaries, after they signed the term of consent.
The focal group testimonies were recorded and transcribed, and the printed material was submitted to floating reading, referring to the recorded material when necessary. The material collected was submitted to the content analysis technique(22).
The exploration of material happened with the coding of the statements, aimed at identifying the central meanings in the text. Later, data were grouped and classified, with the selection of themes and categories.
To guarantee the anonymity of the participants, the letters (N) were used to identify nurses and (NA) to identify nursing assistants, as a convention.
Regarding age, the professionals were between 36 and 52 years old. The length of time working in Obstetrics varied from 2 to 22 years for nurses and between 16 and 29 years for nursing auxiliaries.
As for their professional education, four nurses were lato sensu graduates, three of them specializing in Obstetric Nursing and one in Neonatal Nursing. Only one had no graduate degree.
From the analysis of the data, regarding the perceptions of these nursing professionals about healthcare provided to women in process of induced abortion, the following categories were obtained: they understand abortion as a crime and a sin, a fact that drew our attention primarily, and second, that the healthcare provided is discriminatory.
In short, even in cases regarded by law, i.e. when the woman has already been through the judicial process, with a sentence in favor of the interruption of pregnancy, the nursing professionals still consider this practice as a crime.
"Even if there is a case of rape, or a pregnancy that you know will bear a malformed child, I'm not in favor of abortion" (N).
"Taking a life is a crime. Abortion is a crime, it is a wrong practice" (NA)
The way the professionals see induced abortions brings the doctrine of fatalism to light, i.e. a moral or intellectual attitude where everything happens because it has to happen, and nothing can change how events happen.
"I'm not in favor of abortion because whatever comes to us is what we can bear" (N).
Thus, these professionals clearly state that unwanted pregnancy is the only way out. In this perspective, the professionals' discourse contains the concepts of criminalization, censorship, judgment and, above all, reproach and punishment for induced abortions. This is how women inducing abortions must be chastised and punished.
"I would make her have a IUD placed, and a tubal ligation if she has more than four children. I'd make her attend the places caring for abortion women so she could see the service, fill out forms, see the cases of patients that arrive in shock, bleeding, so she can have the chance to see the other side of the thing, see what she exposed herself to". (N).
The nursing professionals also perceive induced abortions as a sin, meaning that nobody has the right to take the life of another, considering that this act is opposed to religious principles.
"Although there is a natural law that is the law of life, nobody has the right to take their own life, nor the right to take the life of another in any way". (N).
"It is against both ethical and God's principles" (NA).
We have to respect both the laws of God and of men. God does not accept something like this. God is love for life." (NA)
Thus, the professionals blame the women, reinforcing the meaning given to the criminality of abortion, both in the laws of men and in the laws of God.
"She cannot decide for abortion... she made a decision, it is her fault." (NA).
"There are some who, even later, when they see the fetus, have a feeling of guilt, cry a lot and ask for forgiveness at that moment." (NA).
Another remarkable aspect is that the nursing professionals perceive that they discriminate women who induce abortions when they provide healthcare, i.e. they declare that they prioritize healthcare to parturients, puerperal and high-risk pregnant women, to the detriment of care delivery to women who induced abortion.
"We start discrimination at the very beginning of the service. There is a delivery and there is an abortion, and you race to assist the delivery, unless that abortion is super grave". (N)
"I do not like to work with women in the abortion process; I prefer to work with parturients, puerperal women and high-risk pregnancies". (N)
When the nursing team professionals deliver care to women in the process of induced abortion, they bring along the idea that these women committed a crime before the law and are also sinners before the laws of God. In this sense, the professionals act and think according to their beliefs and values, making their perspective of the world clear in how they perceive the woman who aborts.
This perception is associated to the Brazilian society's tendency to attach itself to moral standards that stem from religion. By considering that an abortion is a sin, the woman, when inducing it, goes against religious dogmas(23).
Thus, the religious aspect stated by each individual emerges and can cause conflicts when the woman receives care in this process. Actually, this situation reveals a stereotyped perspective about the topic, going against the attitude of the Brazilian State, which, according to its Federal Constitution, is configured as a Lay State(23).
This conflict may be present among nursing team professionals, even though it is not exclusively theirs. Nevertheless, the Nursing Code of Ethics states that, during the process of caring for women, the professionals' religious and philosophical issues should not interfere in healthcare. About this issue, article #23 states that they should "provide nursing healthcare to the clientele without any sort of discrimination"(24).
When the nursing team professionals verbalize that women who induce abortions are sinners and criminals, they deny the reproductive rights of these women, which have been defended in society through the feminist movement and discussed by international and national organisms through public policies. The non-punishment of women who induce abortions is being studied, and this is why the Brazilian government created the Tripartite Commission. The creation of this Commission constitutes the breaking of a silence that has lasted for a long time. When the silence was over, the government admitted the existence and complexity of the problems that induced abortions caused in the life of women, as well as their public health character(25).
Regarding women's healthcare, although the professionals are aware of the discrimination, their discourse shows that they prioritize healthcare for women in labor, not considering humanitarian and risk aspects involving the health of women who induced abortions. They do not realize that the process of abortion induction can trigger post-traumatic stress(26), a frequent episode, especially in cases of induced abortions. Besides, they do not realize that they affront the ethical precepts ruling the profession.
The perception and attitude of nursing team professionals about induced abortion prominently influence the way of delivering care and relating to the women who induced an abortion. Institutional violence(14) in healthcare is a consequence of this reality.
Exposing healthcare for women in the process of inducted abortion in the institution turns induced abortion public, an element that had been repressed until then, remaining confined to the domestic space. Therefore, healthcare for women in the process of inducted abortion has been denied, excluded and postponed by healthcare professionals because of its illegality, consequently leading to social condemnation.
Thus, the history of women and inducted abortions are still considered repressed elements, which prevent the rupture of forbidden dialogues(27) in healthcare services, making the possibility of humanized, non-discriminatory healthcare seem even more distant.
In the perception of the nursing team professionals, induced abortion is a crime according to the laws of men. According to the laws of God, it is a sin. The nursing healthcare provided to women is discriminatory. Institutional violence can be observed at the moment of care delivery.
These women do not receive the right of verbalization, even though they experience the process of abortion by themselves, oppressed and fearful of death. At the moment of healthcare, she is neglected, which increases the risk of aggravation, to the extent of possibly leading to post-traumatic stress, a frequent situation in abortion cases.
This shows that the perspective of the nursing team professionals regarding the repression of induced abortions prevents the rupture of forbidden dialogues in the healthcare services, making the possibility of humanized, non-discriminatory healthcare seem even more distant, as well as advances in the decriminalization of abortions.
This study points to the dimension of induced abortion, leading to the need to implant public policies related to women's healthcare, emphasizing the dialogic relation between the professional and the client. This relation is one of the elements that turns the implantation of healthcare humanization policies for women in the process of induced abortion a challenge. Therefore, behavioral changes are necessary for professionals who deliver care to women, with the internalization of the humanization proposal, especially regarding the relational aspects between professionals and clients.
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Solange Maria dos Anjos Gesteira
R. Tenente Valmir Alcântara, s/n. - Chopm-I - Bl. 742A - Apto 302
Cabula - Salvador - BA - CEP. 41150-520
Received article 11/10/2007 and accepted 18/12/2008
* This article is part of the Doctoral dissertation called "Healthcare for women in process of induced abortion: speeches from women and nursing professionals", presented to the Graduate Program of the Nursing Department at Universidade Federal de São Paulo - UNIFESP - São Paulo (SP), Brazil.