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Trajectory of women that performed a provoked abortion contained in the discourse of a clandestine procedure

Abstracts

OBJECTIVE: To analyze the trajectory of women that performed a provoked abortion related to a clandestine procedure. METHODS: This is a qualitative methodological approach through the Collective Subject Discourse obtained in a public maternity hospital in city of Salvador, state of Bahia, between July and September of 2008, with 17 women hospitalized for abortion; the research was carried out with semi-structured interviews. RESULTS: The synthesis of central ideas indicated that several players participated in the history of illegal abortion: laymen, professionals and friends of women; the abortion means ranged from the use of misoprostol to traditional and risky procedures, for example the insertion of probes. Women paid a high "price" for those procedures. CONCLUSION: The maintenance of the abortion as an illegality procedure favors gains obtained with the abortive maneuvers which results in increasing costs of health services with the complications provoked by those procedures.

Abortion, induced; Misoprostol; Women's health


OBJETIVO: Analisar a trajetória de mulheres em situação de aborto provocado no que diz respeito à clandestinidade. MÉTODOS: Estudo qualitativo por meio da estratégia metodológica do Discurso do Sujeito Coletivo, em uma maternidade pública de Salvador, Bahia, entre julho e setembro de 2008, com 17 mulheres internadas por aborto provocado. realizando-se entrevista semiestruturada. RESULTADOS: As ideias centrais síntese apontam que diversos atores participaram da trajetória clandestina do aborto provocado: leigos, profissionais e amigas das mulheres, os meios abortivos variaram do uso do Misoprostol até procedimentos tradicionais e arriscados, como inserção de sondas. As mulheres pagaram preços abusivos por estes. CONCLUSÃO: A manutenção da ilegalidade do aborto favorece o ganho ilícito com as manobras abortivas, aumentando os custos dos serviços de saúde com as complicações.

Aborto induzido; Misoprostol; Saúde da mulher


OBJETIVO: Analizar la trayectoria de mujeres en situación de aborto provocado en lo que se refiere a la clandestinidad. MÉTODOS: Estudio cualitativo realizado por medio de la estrategia metodológica del Discurso del Sujeto Colectivo, en una maternidad pública de Salvador, en el estado de Bahía, entre julio y septiembre de 2008, con 17 mujeres internadas por aborto provocado. Realizándose la entrevista semiestructurada. RESULTADOS: Las síntesis de las ideas centrales apuntan que diversos actores participaron de la trayectoria clandestina del aborto provocado, que fueron: legos, profesionales y amigas de las mujeres; los medios abortivos variaron del uso de Misoprostol hasta procedimientos tradicionales y arriesgados, como la inserción de sondas. Las mujeres pagaron un "precio" muy alto por esos procedimientos. CONCLUSIÓN: La manutención de la ilegalidad del aborto favorece la ganancia ilícita obtenida con las maniobras abortivas, aumentando los costos de los servicios de salud como resultado de las complicaciones provenientes de esa acción.

Aborto inducido; Misoprostol; Salud de la mujer


ORIGINAL ARTICLE

Trajectory of women that performed a provoked abortion contained in the discourse of a clandestine procedure* * The present article is part of the Master thesis "Aborto provocado no contexto da violência doméstica: o discurso das mulheres" (Induced abortion in the context of domestic violence: women's statements), presented by Zannety Conceição Silva do Nascimento Souza at the Post Graduation Program, Escola de Enfermagem da Universidade Federal da Bahia - UFBA - Salvador (BA), Brazil, 2009.

Trayectoria de mujeres en situación de aborto provocado contenidos en el discurso sobre clandestinidad

Zannety Conceição Silva do Nascimento SouzaI; Normélia Maria Freire DinizII; Telmara Menezes CoutoIII; Solange Maria dos Anjos GesteiraIV

IMaster in Nursing, Assistant Professor at Universidade Estadual de Feira de Santana - UEFS - Feira de Santana (BA), Brazil

IINursing Ph.D. Associate Professor, Universidade Federal da Bahia - UFBA - Salvador (BA), Brazil

IIIPost graduation student (Ph.D.) in Nursing at Universidade Federal da Bahia - UFBA - Salvador (BA), Brazil

IVNursing Ph.D. Associate Professor, Universidade Federal da Bahia - UFBA - Salvador (BA), Brazil

Corresponding Author Corresponding Author: Zannety Conceição Silva do Nascimento Souza R. Prof.º Fernando São Paulo, 1207 - São João Feira de Santana - BA - Brazil - Cep: 44051-544 E-mail: zannetynascimento@hotmail.com

ABSTRACT

OBJECTIVE: To analyze the trajectory of women that performed a provoked abortion related to a clandestine procedure.

METHODS: This is a qualitative methodological approach through the Collective Subject Discourse obtained in a public maternity hospital in city of Salvador, state of Bahia, between July and September of 2008, with 17 women hospitalized for abortion; the research was carried out with semi-structured interviews.

RESULTS: The synthesis of central ideas indicated that several players participated in the history of illegal abortion: laymen, professionals and friends of women; the abortion means ranged from the use of misoprostol to traditional and risky procedures, for example the insertion of probes. Women paid a high "price" for those procedures.

CONCLUSION: The maintenance of the abortion as an illegality procedure favors gains obtained with the abortive maneuvers which results in increasing costs of health services with the complications provoked by those procedures.

Keywords: Abortion, induced; Misoprostol, Women's health

RESUMEN

OBJETIVO: Analizar la trayectoria de mujeres en situación de aborto provocado en lo que se refiere a la clandestinidad.

MÉTODOS: Estudio cualitativo realizado por medio de la estrategia metodológica del Discurso del Sujeto Colectivo, en una maternidad pública de Salvador, en el estado de Bahía, entre julio y septiembre de 2008, con 17 mujeres internadas por aborto provocado. Realizándose la entrevista semiestructurada.

RESULTADOS: Las síntesis de las ideas centrales apuntan que diversos actores participaron de la trayectoria clandestina del aborto provocado, que fueron: legos, profesionales y amigas de las mujeres; los medios abortivos variaron del uso de Misoprostol hasta procedimientos tradicionales y arriesgados, como la inserción de sondas. Las mujeres pagaron un "precio" muy alto por esos procedimientos.

CONCLUSIÓN: La manutención de la ilegalidad del aborto favorece la ganancia ilícita obtenida con las maniobras abortivas, aumentando los costos de los servicios de salud como resultado de las complicaciones provenientes de esa acción.

Descriptores: Aborto inducido; Misoprostol, Salud de la mujer

INTRODUCTION

When one talks about induced abortion there is a reflection on the social dimension of the female role in reproduction, involving issues that have to do with the right of women to decide on their own body. Currently the theme is responsible for heated arguments worldwide; with positions that defend the right of the fetus to life and the right of women to reproductive autonomy(1).

These discussions are based on some definitions connected with abortion, such as the concept of when life starts, when the embryo or fetus starts to be considered a life and when it starts to have right as a human being.

The meaning of conception has several different interpretations; for some people, fertilization is the starting point, others consider the time of conception when the soul gets into the person (religious interpretation)(2).

In the debates on induced abortion, the pregnancy and fetal development stages are determiners, because some lines that defend decriminalization assume that abortion is a right of women: According to this theory, women have the right to use their own body. Additionally, there is the biological explanation of the fetal life. According to this line of discussion, if nervous stimuli (synapses), coming from the neural tube occur around the 3rd month or 12 weeks, pregnancy termination at that time would bring no suffering to the fetus.

When women decide to make an abortion, they go against the whole reproductive expectation that society puts on them, and they start to be seen as insensitive or even as criminals. Actually, the condition in which these women got pregnant and that the fetus was generated are not taken into account at all, and at the time abortion is induced, they are despised, seen with prejudice by health center professionals and judged by the society(3).

Thus, many women live with the imminent possibility of death when they are subjected to illegal and/or consecutive abortions. "In clandestinity, abortion is performed in poor and unsafe conditions: either in septic environment by untrained people or by the self-induction with medicines and the practice of traditional methods"(4).

Safe abortion and unsafe abortion are internationally acknowledge categories and are thus defined: safe abortion is the one that implies extremely low risk for parturients, a medical or surgical abortion carried out by trained people in the right environment and with the necessary means. As for unsafe abortion, it is a procedure to terminate undesired pregnancy, performed in environments without the minimum medical standards and/or performed by untrained people(2).

Therefore, to analyze unsafe abortion implies the reflection on the failure in ensuring female sexual and reproductive rights and the appropriation/medicalization of their bodies, as a target of health care, which is in harmony with all the limits and social charges.

Penalizing those that make the difficult decision of aborting is as much hypocritical as it is intolerant. Because no women want to abort, but when they need to, what they deserve - in addition to social, medical, legal and psychological care - is affection, solidarity, tolerance, respect and rest(5).

Women that abort express feelings of guilty, fear of discrimination, lack of support, and loneliness in the hospital environment(6), which should be a reference of welcoming, also according to the recommendation of the Ministry of Health(7) in the Technical Rule of Humanized Care for Abortion.

Health professionals give priority to care for the physical aspects of women with sequelae of the abortion; some studies point out the need for making the health team sensible, especially the nursing team, to listen to the experience of these women in their social context (the violence, the grief and the abortion process)(8).

The clandestinity of the abortion presents aspects that are not expressed, discussed or even heard by most health professionals during care. Studies carried out with nursing professionals showed that they see abortion as a sin, a crime and because of that, care is conducted in a discriminatory way, denying women the right to speak with the silence remaining thorough the abortion process(9).

In this sense the question is: What is the speech of women about their path in induced abortion? The general objective of this article was to assess the path of women in situation of induced abortion regarding clandestinity.

METHODS

Study with a qualitative approach that used the Collective Subject Discourse Technique as a methodological strategy.

The place of the research was a public maternity in the city of Salvador (Bahia); it is a reference in the care of women during pregnancy and childbirth. We could get closer to the individuals of the research thanks to an extension project connected with the Federal University of Bahia that is called "Acolhimento de Mulheres em Situação de Violência Doméstica e Aborto Provocado" (Care for women Facing Domestic Violence and Induced Abortion), where we could be together with women who experienced induced abortion. The experience with this group, the receptive listening, the distance from social judgments and the histories shared by these women favored the preparation of the researcher.

The study population was formed by 17 women with the following inclusion criteria: to be admitted because of induced abortion, to present satisfactory physical conditions for the interview (being conscious, with no anesthetic effects, absence of pain and /or intensive bleeding); to have suffered domestic violence, to be over 18 or, if a minor, to have the consent of the guardian, to express a desire to take part in the research by giving their Written Consent. In case some of these items have not been met, the participant was excluded from the sample.

Data collection was done through semi-structured interviews carried out from July to September 2008, after approval by the Research Ethics Committee of the Escola Estadual de Saúde Pública da Bahia, under registration No 242/2008. The interviews have been carried out by the author of the dissertation with the help of a tape recorder. Each interview lasted about one hour and was completely transcribed after participants' authorization.

Organization and data tabulation were carried out based on the Collective Subject Discourse Technique (DSC), a discoursive methodological strategy that tries to "reconstruct, with parts of individuals statements, as in a puzzle, as many synthesis-discourse as it is necessary to express a certain picture or a certain thinking or social representation of a phenomenon"(10). From individual speeches, the Discourse Analysis Instrument (IAD1) was filled in through the identification of key expressions from where the central ideas emerged. These were grouped according to the convergence to the same synthesis idea with their key expressions in parallel. Last, to construct the DSC in the Discourse Analysis Instrument (IAD2), the key expressions were used, grouped according to central ideas with the use of connectives, expressing the collective discourse.

The basic ethical references for research with human beings of the National Health Council Resolution No 196, from October 10th, 1996 have been followed, by reading and giving the Written Consent and by the reinforcement that confidentiality would be insured. Additionally, the interview was carried out in a private place of the maternity.

Scientific rigor was kept by following the methodology chosen in two stages previously described and with the training of the author responsible for the interview in the Instituto de Pesquisa do Discurso do Sujeito Coletivo (Collective Subject Discourse Research Institute).

RESULTS

Mostly, the women from the present study were adolescents and young adults (23.5% and 29.4%), respectively. They had finished elementary school or had incomplete high school (52.9%), declared themselves as black and brown (47.1%), single (76.5%) and lived with the relatives (58.8%). Most had three or more kids (58,8%) and had already induced abortion, using misoprostol. Unemployed, they performed activities of small financial return, some were supported by their partners or relatives and justified induced abortion because of the fear of not being able to give another baby the basic needs, such as food and housing, alone.

The elements of the Collective Subject Discourse that were assessed in this article are described below, describing the abortion means used, the actors involved, the conditions and the costs with procedures carried out in an illegal way:

Central synthesis idea 5. C. - They were suspicious, took teas, bought misoprostol, took it and applied via vaginal; took an injection to dilate the cervix, used a catheter and went to the hospital after a hemorrhage.

[...] my period was late, I was not even 2 months when I took the tea, there are many things mixed. I bought it and made it at home, the girls taught me and the people that sell leaves on stalls, taught me how to make espinho cheiroso tea (Kanthoxilum shifolium Lam) [...] first I took the regulator Xavier then it didn't work and I took the tea which did not work either. So I bought Cytotec, from my colleague that came from Italy, four, I took two and applied two. [...] The second time I took the injection and then, after six hours, counted on the clock, I started to lose blood, to feel acute pain in the hips, contractions and then I started to bleed and lose. Because I arrived in the drugstore and asked the pharmacist if there were something to dilate the cervix because I had taken two Cytotec and it had not worked, the cervix was taking too long to dilate. I don't know the name because he didn't tell me. [...] Before that, I put a catheter. Actually, I don't even know how she does it, I know that she (person that performs the illegal abortion with a catheter) told me to lie down, I opened my legs and she put, I don't know, like a duck beak to open up the vagina, I saw that she put something there that burned. Then I started to feel pain. She said she had already worked in a hospital, but I've never heard of it. Everybody looks for her in the neighborhood; people say good things about her. She puts the catheter and tells the person to go home. She said that when the catheter went down, the fetus would come too, the catheter pulls it. It stays inside the vagina. Then the result was that the catheter went down and the fetus didn't, it stayed inside. Then I started to feel pain, to feel pain, and to bleed. She gives it twenty four hours. I started to bleed straight away, I lost too much blood, and it seemed as if I was having a hemorrhage. Then I went to the maternity. (E3;E4;E5;E6;E7;E8;E9;E10;E11;E12;E13;E14;E15;E16;E17) Collective Subject Statements, question 5, central synthesis idea 5. C

Central synthesis idea 1.J. - They had some tea, 8 days, used misoprostol, but lost the baby with the injection to dilate the cervix and the catheter.

[...] The doctor asked me what I had taken, I told him: I put a catheter. Then he asked me, is this still available? Then I said in the neighborhood nobody uses cytotec, just the catheter. Everybody looks for her (person in the neighborhood who induces abortion). And then he said: I don't understand how come she has not been arrested yet! Because first when I went to the house of that lady (that perfoms abortion) and she made a vaginal washing and it didn't come down, then she said that the only way was to put a catheter. [...] It is a fluid in the syringe. The syringe has no needle. She doesn't say what it is. It is a fluid, it looks like ether, the color is that of ether and it burns as well [...] (E8;E11;14) Collective subject statements, question 1, central synthesis idea 1. J.

Central synthesis idea 5. D - Borrowed money to abort, spent a lot of money and did everything alone

I borrowed money, I met a colleague and asked him to lend me money, he didn't want to give me, but then I asked him to lend me money for God's sake because I was in the beginning (of pregnancy). It was easier to abort. Then he lent me. Actually, it was a colleague who bought it. [...] R$ 15.00 each. I did everything myself, she just gave me the medicine, and I did everything myself, I put the applicator, I put the cream myself, I put it in the vagina, I did everything. Vaginal Cream... You have to put a vaginal cream to make it easier. [...]I sold my cell phone and then I did it with her, she made me a discount. As I was just a few months pregnant, just four weeks, she charged me R$120, 00. I spent, let me see, I spent all the money I had with me, I spent more than R$ 200.00 with the bus, more than R$ 200.00. After much cost, much cost, a lot of money, a lot of money to be able to abort this baby, I still regret it, If I had taken better care of myself I wouldn't be here. The money I had spent with it, I could have used for me in the school, I could have studied more [...] Then I borrowed money, again, to be able to do the transvaginal, and then it saw that the fetus was dead inside me, it had not left and of course I was terrified! Then I went to the maternity, and then they said they could not do that there. Then mommy brought me here to Salvador (E3; E11; E12;E13) Collective subject statements, question 5, central synthesis idea 5. D.

DISCUSSION

In the social space, women in situations of induced abortion go through a silent and confidential path, supported by friends, sellers of abortive and herbal medications, as well as people that perform illegal abortion in their houses. These illegal resources are available in the community these women live.

Thus, women who have an abortion undergo unofficial "medical practices" performed by people without the necessary academic education to provide care or, in some cases, by individuals with technical training that perform the procedure illegally.

Women use an abortive method and continue their routine activities, observing the signs and symptoms of the need for hospital services, according to their knowledge. The knowledge on abortive medications comes from the medical area, but information is conveyed to the community through mass communication. These women share their experiences.

The Collective Subject Discourse of the central synthesis idea 5.C, shows that, to terminate pregnancy successfully, women resort to several abortion methods and are exposed to risks of complications; extensive bleeding (hemorrhage) is one of them. These women wait for this sign to look for professional help in hospital because, in their perception, it means that the abortion occurred.

Another aspect is that the look for hospital care at the onset of abortion signs is followed by fear of abortion failure and that the professionals try to keep the pregnancy.

Medical action is based on the diagnoses obtained, that is, if there is fetal vitality and symptoms that show a threaten to their lives, the role of health professionals is to establish management based on urgency and emergency protocols of the Ministry of Health, to correct the maternal symptoms that threaten fetal life. In the absence of fetal vitality, measures are taken to empty the cervix, prevent hemorrhage and infections to reestablish maternal health, regardless of spontaneous or induced abortion.

DSC of the central synthesis idea 1.J demonstrates that in the places these women live there are people who are reference in illegal abortion and use invasive methods such as the catheter. This confirms that the illegal and indiscriminated use of misoprostol did not prevent these women from looking for traditional methods that are considered higher risk even though it presents a 90% rate of success in abortion(3).

Induced abortion is one of the greatest risk for women with lower purchasing power since, "the worst the conditions and techniques used for abortion, and the lower the qualification of people performing it, the greater the likelihood of complications and the worst the outcomes for women undergoing it"(11). The desire to terminate an unwanted pregnancy is so strong in the life of these women that they don't think about the consequences and they risk their own lives, looking for places with poor conditions, as demonstrated in DSCs of the central synthesis idea 5.C and 1. J.

As abortion is considered a crime by the Brazilian law, women cannot buy abortive medications. The study shows that establishments or people that do that illegally take financial benefits from the clandestinity. Thus, women who undergo illegal abortion are submitted to abusive prices in the informal and illegal trade as demonstrated by DSCs 5.C and 5.D.

Thus, induced abortion has a high price for women, not only because of the price of medications and abortive methods but also because of the private expenses with transport at each visit to the maternity and the performance of exams, such as ultrasounds, in clinics. Women who abort are vulnerable both physically and emotionally (guilt, shame, and fear of death), they need to undergo an ordeal to be cared for, to have the diagnoses and they have to pay for the image service which should be offered by the State regardless if the abortion was induced or not.

Health care centers also increase their costs with admissions due to complications from induced abortion. The question is: Who is gaining with the illegality of the abortion? The study shows that there is an illegal trading of medications such as misoprostol, with no taxes being paid and no requirement for prescription that is controlled by the Brazilian national surveillance agency, and it is not difficult to purchase these medications in the illegal trading.

Thus, illegality of the abortion favors illegal gain with abortion and the society remains strong in ideological conceptions that favor criminalization only of women without assessing in these discussions that these people are the risk of morbidity and mortality when performing the abortion, the efficiency of the programs, and the inequalities of the social context they belong to.

CONCLUSION

In the process of abortion, the path of women regarding illegality starts with the use of teas followed by medications illegally purchased and the use of catheters inserted by lay people that tell them to go to a maternity when bleeding starts. This is a lonely path and women assume the costs of abortion because health services do not respond to diagnostic procedures such as examinations and do not value the female emotional vulnerability during care.

Illegal abortion favors the profit of informal "trade and medical practices", but the social penalty is geared to women both physically and legally. What they actually need is a place where their demands are listened to and met by the health services regarding the subjective and biological aspects of an undesired pregnancy.

REFERENCES

Received article 05/11/2009 and accepted 04/06/2010

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  • Corresponding Author:
    Zannety Conceição Silva do Nascimento Souza
    R. Prof.º Fernando São Paulo, 1207 - São João
    Feira de Santana - BA - Brazil - Cep: 44051-544
    E-mail:
  • *
    The present article is part of the Master thesis "Aborto provocado no contexto da violência doméstica: o discurso das mulheres" (Induced abortion in the context of domestic violence: women's statements), presented by Zannety Conceição Silva do Nascimento Souza at the Post Graduation Program, Escola de Enfermagem da Universidade Federal da Bahia - UFBA - Salvador (BA), Brazil, 2009.
  • Publication Dates

    • Publication in this collection
      13 Jan 2011
    • Date of issue
      2010

    History

    • Accepted
      04 June 2010
    • Received
      05 Nov 2009
    Escola Paulista de Enfermagem, Universidade Federal de São Paulo R. Napoleão de Barros, 754, 04024-002 São Paulo - SP/Brasil, Tel./Fax: (55 11) 5576 4430 - São Paulo - SP - Brazil
    E-mail: actapaulista@unifesp.br