Racial discrimination and health: health professionals’ actions in providing care women in the induced abortion process

This paper aims to evaluate the racial inequalities in the care provided by health professionals concerning induced abortion. This systematic review study used the Preferred Reporting Items for Systematic Reviews and Meta-Analyzes (PRISMA) model, based on the following bases: Brazilian Virtual Health Library (BVS), Scientific Electronic Library Online (SciELO), National Library of Medicine, and National Institutes of Health (PubMed), Science Direct, Capes periodicals portal, with the descriptors: “racism OR social discrimination AND abortion, induced AND health personnel OR comprehensive health care OR delivery of health care OR human rights”, selected via the DeCS and Medical Subject Heading (MeSH). Eighteen papers published between 2005 and 2020 in national and international literature were analyzed following the inclusion and exclusion criteria. Most studies found a significant relationship between racial discrimination and institutional violence, including access and quality of care for patients undergoing an induced abortion. Racial discrimination is a significant risk factor for adverse care outcomes.


Introduction
Racism is a neglected but relevant cause of health disparities in multiethnic societies 1 . Different types of racism and other expressions of discrimination must be recognized, critically analyzed, and actively reversed. We empirically distinguish and recognize human rights omissions and violations and then analyze the sources of racism in close relation to an intersectional view of forms of discrimination based on gender, class, and ethnicity 2 . Most societies are racist, and this phenomenon is linked to racism and vulnerability, resulting in health inequalities. Nowadays, racism is identified as a relevant health concern but neglected and often ignored [3][4][5][6] .
Human rights are not data, but a construct, a human elaboration in constant construction and reconstruction 7 . As Piovesan 8 points out: "As a moral claim, human rights are born when they should and can be born". Considering the temporal perspective of these rights, it appears that the meaning of human rights signifies a multiplicity of meanings; among which we highlight the contemporary understanding characterized by the universality and indivisibility of these rights 9 , based on the Universal Declaration 10 , and subsequently confirmed in the Vienna Declaration of Human Rights 11 . Santos 12 adds: "we have the right to be equal when our difference makes us inferior; and we have the right to be different when our equality deprives us of character. Hence the need for equality that recognizes differences and a difference that does not produce, feed, or reproduce inequalities".
Several authors discuss the marginalization and coverage of health services, identifying a significant lack of access to medical coverage 13,14 , configuring itself in such a way as institutionalized racism, provided by discriminatory access to facilities, goods, and services 15 . Consequently, institutionalized racism is still evident in societies but mimicked in different social practices 16 . Personally-mediated racism is related to prejudice and discrimination based on race, which may or may not be intentional. However, it manifests itself due to disrespect, mistrust, devaluation, accusation, and dehumanization 17 .
Indeed, the human right to health, also known as the right to the highest possible health standard, comprises legally binding international components. One of the most critical components of the right to health is the International Covenant on Economic, Social, and Cultural Rights (ICESCR), especially ICESCR General Comment N° 14 18 . The right to health based on this comment encompasses essential elements assessed by the framework of four crucial indicators: availability, accessibility, acceptability, and quality (Chart 1). Availability refers to the existence and number of health facilities, goods, and services. Accessibility focuses on physical and economic access to health facilities' goods and services. Furthermore, accessibility has four dimensions: non-discrimination, physical, economic, and access to information. Acceptability is related to the sensitivity of health facilities, goods, and services to medical culture and ethics. Concerning quality health facilities, goods and services must be scientifically and medically adequate and of satisfactory quality 19 .
Previous research in first world multiethnic countries such as the U.S. 20 , United Kingdom 21 , Australia 22 , and New Zealand 23 , and multiethnic developing countries such as Brazil 24 , Mexico 25 and comparatively Brazil, Mexico, Colombia, and Peru 26 , have emphasized racism as the cause of persistent health disparities. For example, a USbased survey of health disparities by race provided evidence of significant inequalities between the African American population and the country's white population. In the U.S., African Americans have higher mortality rates than their white counterparts for most leading causes of death 27 . However, health disparities are not biologically or culturally determined; they are explained by a complex structure of social, economic, and political factors 28 . Therefore, racism-related health disparities are a crucial argument for the relevance of social determinants of health 29,30 . Regarding human rights, non-racism and other discrimination are positions worth considering 31 ; notably, accessibility to health facilities, goods, and services without discrimination is essential 32 .
Given the need to systematize the knowledge accumulated in recent years, this proposal aims to assess racial discrimination in the care of women with abortions by health professionals.

Methods
This systematic review is based on the recommendations of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRIS-MA) 33  Studies published regardless of the year of publication, in English, Spanish and Portuguese, and evaluating racial discrimination in the care provided by health professionals in situations of induced abortion were included. Literature review papers, articles in the form of theses, dissertations, monographs, editorials, case reports, and those that did not meet 80% of the items required by the methodological quality assessment scales used in this study were excluded. The following data were extracted from each included study: authors, year of publication and study, study design, location, studied population, evaluated outcome, methodological limitations, and main results.
The quality of observational studies was assessed using the Strengthening the reporting of observational studies in epidemiology (STROBE) scale 34 , which proposes a list of 22 items that must be present in the body of the papers to be considered of quality. Paper quality categories were established in its version translated and validated in Brazil in 2008 35 and works meeting 80% or more of the items on the list are considered "A" category 34,35 . The Standards for Reporting Qualitative Research (SRQR) 36 was used to assess qual-itative studies. Studies with quantitative-qualitative methodology were analyzed by both quality instruments. Studies that achieved a score equal to or greater than 80% on at least one of the two scales were included in this paper. Two independent reviewers assessed the thematic eligibility of the papers, and the methodological assessment was conducted by only one of the reviewers.

Results
We identified 3,826 papers and excluded 1,135 works because they were duplicated in the databases. After analyzing the titles and abstracts, we excluded 2,477 papers as they did not meet the research eligibility criteria. The remaining 214 works were read and analyzed in full, and 182 were excluded as they did not meet the inclusion criteria. The remaining 32 papers were analyzed by the STROBE and SRQR scales, and 14 papers were excluded as they did not achieve the minimum score of 80% of the items, leaving a final sample of 18 works. Figure 1 shows the paper selection process.
Chart 2 presents the general characteristics of the selected studies with the distribution of the works by year of publication, the geographic region where they were carried out, the methodological path, sample, and objective. About In the analysis of care provided by health professionals, the perception of subjects about in-Chart 1. Structure referring to the International Covenant on Economic, Social and Cultural Rights (ICESCR).

Data Definition Availability
Must have a sufficient amount of functioning public health facilities, goods and services, and programs Accessibility Health facilities, goods, and services must be accessible (i.e., physical, financial, and information access) to everyone within the State's jurisdiction, without discrimination Acceptability The social and cultural distance between health systems and their users determines acceptability. All healthcare facilities, goods, and services must respect medical ethics and be culturally appropriate and sensitive to gender and age. They must also be designed to confidentially respect and improve the health status of the individuals involved Quality Health facilities, goods, and services must be scientifically and medically approved and of satisfactory quality Source: ICESCR 18 . duced abortion and women as potential mothers are added to the meanings attributed to the maternity hospital to negatively influence the quality of care, leading to the objectification of women undergoing abortion 45 . In general, when asked about the possible reasons that lead women to become pregnant and abort, without distinction of occupational category, the set of professionals describe the users who induced abortion, including one or more of the following characteristics: black, poor financial conditions, less educated, marital bond instability, partner abandonment, lack of family support, and irresponsible and unbridled sexuality 38,39,44,47,48,51,52 .
In some cases, a difference was observed in professionals by type of abortion, induced or not; that is, for those women who suffered a miscarriage, an image of fragility and recognition of their suffering is created, but they classify those who induced it as aggressive, aloof, relieved and indifferent. The latter are disqualified 24,29 and are assigned a state of psychic abnormality when performing an abortion.
The results show that health institutions and professionals in these hospitals include institutional violence in their practices 38,40,41,43,49,53 , especially with dehumanizing care practices 51,52 and symbolic violence 52 . Furthermore, the non-prioritization of care for women with abortions is evident in the scarce attention given to these users and the existence of racial discrimination. The articles identify the poor conditions of the health units, the deficient service infrastructure, with overcrowding in maternity wards 44,47,[51][52][53][54] .
The analysis of obstetric services identified two areas in which the literature associates the presence and reproduction of institutional violence: on the one hand, the concepts and values of the caregivers themselves regarding abortion 43,53 and the care provided in maternity wards 49,51 and,  patients admitted as emergency cases To analyze the extent and characteristics of induced abortion-related complications, including length of hospital stay, the mortality rate from induced abortion complications and its characteristics, and deaths occurring after two hospitalization days.

Chart 2.
Descriptive characteristics of studies on racial inequalities and abortion care provided by health professionals, 2020.
it continues on the other hand, institutional norms and the work process 37,39,42 . These factors combined show attitudes and practices that refer to institutional violence. Studies have pointed to physical violence in most cases of induced abortion by not offering medication, whether analgesics or anesthetics, to relieve pain 52,53 . Concerning verbal violence, questioning women's morality emerges, which is also verbally stigmatized 46,47 , with depersonalization and embarrassment 41 . In Brazil, Gesteira et al. 39 point out the influence of the context of the illegality of abortion and society's moral values on professionals' perceptions about the poor quality of care. However, in this study, the discussion of its results quickly addresses the broader social context elements without an in-depth analysis of institutional violence.
Some studies discuss the sociocultural conditioning that influences professionals and their care practices [51][52][53] . The authors note pre-judgment attitudes of professionals and their difficulties in letting go of their convictions in caring for women. However, attitudes and ethical conflicts are analyzed, disregarding the immediate institutional context of motherhood and the historically constituted political processes that define the possible actions of institutions and individuals working in them.
Harries et al. 40 recognize the context involving institutional practices, with low investment in workers' qualification and fragmented and verticalized work process, with implications for the relationship between workers themselves and between them and users. Thus, the insufficient training of professionals and managers to address social and subjective issues that interfere in health care practices is also admitted.
In general, the perceptions of health professionals regarding women in situations of induced abortion were marked by negative values, which influenced the senses and meanings attributed to this practice and, consequently, about the women attended, making them responsible for the pregnancy and its interruption, with naturalized discriminatory attitudes 39 .

Discussion
From the exposure of the main findings, we consider that the study met the proposed objectives, bringing significant results and discoveries about racial inequalities by analyzing care for abortion induced by health professionals. Studies  reported verbal and physical abuse in patients, care dehumanization, lack of privacy and confidentiality, ill-treatment, and negative and hostile attitudes of the staff as a barrier to the use of qualified services 39,47,51,52 . Similar to the findings of this review, factors such as inadequate staff, infrastructure, equipment and supplies, and lack of supervision by health professionals were also described as important factors that contribute to disrespect and racism 37,38,47,53 . Disrespect and racism were essentially defined as a hostile, inadequate, or negative attitude of the team 48,53 . Racism occurs at multiple levels, including institutional, interpersonal, and internalized. Institutionalized racism results in differentiated access to society's resources, services, and opportunities by ethnicity. Concerning resources, institutionalized racism includes disparities in access and quality of education, safe housing, employment, health resources, and environmental conditions. These, combined with the lack of opportunities to influence policies, limit the power of racial and ethnic minorities enforcing decisions. Interpersonal racism refers to prejudice and discrimination resulting in different assumptions about the abilities and reasons of others according to their race. Discrimination includes treating other people differently based on their race and is more commonly considered racism 15,16 . Finally, internalized racism results in accepting negative attributes, competencies, and values by members of marginalized groups. Internalized racism limits someone's ability to reach their maximum potential 55 .
Only three studies with a quantitative approach were identified, which has an impact since there is no comprehensive information on the opinions, attitudes, and knowledge of health professionals regarding abortion, mainly induced abortion, which was the focus of the search. Perhaps this is due to a possible lack of support for conducting more comprehensive surveys with these professionals, since quantitative surveys, generally applied to quite numerous samples, require standardized, validated, and reliable questionnaires that can be used for this purpose, besides significant amounts of financial resources and institutional support. Another result that drew attention was the lack of data on mental health professionals.
Our review results highlighted a research where racial and ethnic minority women expe-rience greater lifetime exposure to chronic stressors, which may increase their risk of poor pregnancy outcomes 56 . The accumulation of stress throughout a woman's life, known as allostatic load, is associated with worse health outcomes 57 . Racial discrimination is one chronic stressor that can be a risk factor for adverse birth outcomes. The definitions of racism vary, but they all include the concept of unequal treatment due to skin color or other individual traits 55 .
Finally, another fact that perhaps must be researched in greater depth and, if possible, in greater breadth, is the perception of racist attitudes in clinical care in abortion situations. The literature points to research suggesting a broad acceptance of abortion cases allowed by law [58][59][60][61] , and situations of severe fetal malformation also have the approval of most health professionals 62 .

Conclusion
Despite its limitations, this review has some critical implications for a field of research that has received little attention. Forced abortions are common, and women who have them suffer various types and degrees of stigma. Racism and other related ideologies such as sexism and classism are relevant health concerns, although application in practice seems insufficient based on the evidence of disrespect and abuse. Our data show how institutionalized racism manifests itself in the lack of qualified human resources, insufficient quantity and quality of functional health products, and income-related discrimination within medical facilities. We also highlight examples of internalization by victims of racism and reproduction of discrimination by health professionals. Strengthening the health system's capacity by employing an adequate number of health professionals, especially in areas with unmet needs, along with improving infrastructure facilities, will also reduce disrespect and abuse practices allegedly caused by problems such as overcrowding in facilities and lack of health professionals.
Underlying social perceptions point to the need for awareness campaigns and educational interventions at broader socio-political and community levels, including educating women and men about the rights to respectful care. Finally, racism violates the right to health in all dimensions.

Collaborations
AP Ferreira worked on the design, research, methodology, and final writing. MR Godinho and CST Nichele worked on the research, methodology, and final writing. VR Girianelli worked on the methodology and final writing. AB Silva and GCP Cardoso worked on the conception and final writing.