Health needs of women victims of sexual violence in search for legal abortion

Abstract Objective: to understand the health needs that emerge on the path followed toward legal abortion by women who have suffered sexual violence. Method: an exploratory, descriptive and qualitative study, whose theoretical framework was the conceptual field of Collective Health, based on the Marxian conception of needs. The study participants were ten women who requested legal abortion at a reference service located in São Paulo. A semi-structured interview script was used for data collection. The data were submitted to content analysis with the support of the WebQDA software. The analytical categories used were health needs and gender. Results: despite the fact that abortion was identified as a primary need, the data revealed other needs felt by women, related to the health-disease process and with an emphasis on mental health, work, financial situation, the exercise of motherhood, access to information, autonomy, sisterhood and welcoming in the health services. Conclusion: the properly human needs were in greater evidence in the study, surpassing merely biological needs. The results point to the importance of co-responsibility of the health services with women, aiming to minimize vulnerabilities and to effectively implement reproductive rights.


Introduction
The controversy surrounding the right to abortion is linked to ethical, moral, religious, social, gender and legal aspects. Since 1940, the Brazilian Penal Code, in its article 128, allows for abortions when there is a risk of death for the pregnant woman or when the pregnancy is the result of a rape (1) . In 2012, the Brazilian justice also decriminalized termination of anencephalic fetus pregnancies (2) .
Despite these legal exceptions, there are numerous obstacles faced by women to access the services that perform abortions in the country. In the case of pregnancies resulting from rapes, these obstacles become even greater due to the combination of stigmas attributed to sexual violence, women and abortion. It is known that the stigma of abortion is socially constructed and promotes judgments against women who choose to undergo such procedure, even in countries where legal restrictions do not exist, a fact directly related to the transgression of the roles assigned to women, whit motherhood as one of the pillars (3)(4) .
The stigma of abortion causes numerous barriers for women to access the services that perform legal abortion, perpetuating the silencing of accurate information about this practice (5) . The following stand out among these barriers: availability and quality of specialized services, accessibility, lack of knowledge about legality of the procedure and places for its conduction and emotional and cultural issues, as well as the health professionals' attitude in the face of this demand (5)(6)(7) .
A Brazilian study that investigated the structure and functioning of hospitals responsible for the care of women who suffered sexual violence evidenced that, among the 68 institutions listed by the Ministry of Health, only 37 performed legal abortions and, among them, four never did so. The study also found a shortage of medical professionals available to perform the procedure, in addition to the requirement of a police report, judicial authorization and report from the Legal Medical Institute by some institutions, revealing excessive bureaucratization to access the right to abortion (8) .
Faced with this scenario of difficulties and bureaucratization to the right to effectively perform an abortion, it is assumed that the obstacles experienced by the women who have suffered sexual violence in the search for legal abortion raise numerous health needs.
The term "health needs" is not only understood as a user's demand for the health service, but as an expression of socially and historically determined problems, arising from a collective structure (9) .
Health needs can be classified into visible and invisible, the former are related to the biological body and revealed through complaints, while the latter are linked to aspects that distance themselves from biological issues and demand care beyond the health services.
Invisibilized needs require a keen eye on the part of health professionals to identify them, as their identification and care are beyond pre-established clinical scripts (10) .
It is recognized that violence triggers particular needs, most of the times, made invisible, which are directly related to the historical construction of the feminine in society and to the vulnerabilities to which women are exposed throughout their lives. In the case of women who have suffered sexual violence, it is assumed that the needs raised are not only linked to the violence suffered and to the pregnancy resulting from it, but also to the responses offered by the services that comprise the network to combat violence against women.
Thus, the current study started with the following research question: Which health needs are triggered during the path followed by women who have suffered sexual violence from the moment they decide to undergo a legal abortion until it is carried out? To answer this question, the study aimed at understanding the health needs that emerge during the path followed by women who have suffered sexual violence toward legal abortion.
By answering the research question, it is expected to obtain relevant elements that may contribute to the implementation and realization of public policies in the services that comprise the Network for the Assistance to Women in Situations of Violence, especially those available for performing legal abortions

Type of study
An exploratory, descriptive and qualitative study, which adopted the conceptual field of Collective Health as a theoretical framework, based on the Marxian conception of needs (11) . In this way, historicity and dynamism were considered when analyzing individual and collective processes, determined by the economic, social, political and cultural aspects of society, allowing to understand reality and its contradictions in the structural, particular and singular dimensions, expanding the vision of a given phenomenon (12) .

Study locus
The study was carried out in a reference hospital

Period
The data were collected over a period of three months, between July and September 2018.

Study population
The study population consisted of women who were pregnant as a result of sexual violence and who requested legal abortions.

Selection criteria
The inclusion criteria were women aged 18 years old or over, coming from municipalities located outside

Participants
Ten women participated in the study, intentionally selected, and the sample was closed due to data saturation.

Data collection instruments
For data collection, an interview script was used, consisting of sociodemographic questions, aiming to characterize the participants, as well as guiding questions that served as a guide to understand the objective reality from the interviewees' speeches.

Data collection
Data collection took place using the in-depth interview technique. The invitation for the women to participate in the research took place after consultation with the social worker, at the time of requesting a legal abortion. It is noteworthy that no woman invited to participate in the research refused the invitation.
All participants were interviewed at two moments: at the time of requesting the abortion and after performing the procedure or after a decision against the procedure. They took place in a private room of the service, being recorded on a digital voice recorder and lasting between 30 and 65 minutes. After the interview, all participants were asked about their desire to hear their speech, aiming to evaluate it and, if they wished so, they could change or exclude excerpts. No woman wanted to use this feature.
It should be added that the audios of the interviews were stored in a password-protected folder on a personal computer of one of the researchers, who was solely responsible for handling them. In addition, in order to guarantee anonymity, the narratives of the interviewees were identified by the letter E for "Entrevistada" in Portuguese, followed by a number from 1 to 10, randomly assigned.
During the entire data collection period, the constant presence of the researcher in the reference service allowed rich records in the field diary that contributed to a better understanding of the women's experience during the process of requesting an abortion and subsequent hospitalization to carry out the procedure.

Data treatment and analysis
Data analysis took place continuously, starting from data collection. Thus, at each interview, relevant themes were highlighted to elucidate the phenomenon, and those that presented similarity were grouped. Thus, in the absence of new elements in the treated material, theoretical data saturation was considered.
For data analysis, the procedures proposed by Bardin were followed (13) , aiming at the emergence of empirical categories, which were discussed in the light of the "health needs" and "gender" analytical categories. To support data analysis, the WebQDA software was used because it allows coding the qualitative research data in a structured and interconnected way, ensuring better organization and interpretation of the information in a faster and more systematic way (14) .

Ethical aspects
The study complied with all the ethical precepts proposed by

Results
Among the study participants, five were between 20 and 29 years old and the others were between 30 and 39 years old. Most declared themselves white-skinned, with complete or ongoing higher education and with some religious belief, although not professing any specific religion. They worked in the formal and informal labor markets, with a family income varying between two and five minimum wages*. As for the cities of origin, all came from the southeastern region of the country, six living in the inland of the State of São Paulo and the others from Espírito Santo, Minas Gerais and Rio de Janeiro.
Regarding obstetric data, five participants had at least one child, while the others were experiencing their first pregnancy. Most had a gestational age ranging between nine and 13 weeks when they requested the legal abortion. Only two interviewees were in the second trimester of their pregnancies, with gestational ages of 17 and 23 weeks, respectively.
Analysis of the speeches revealed pregnancy as an extension of the sexual violence suffered, leading the participants to primarily translate their needs into the demand for abortion. Although they were not directly asked about the needs felt during the search for the abortion, emerging themes were identified in the reports that allowed for the emergence of four empirical categories.
In the first category, needs related to the healthdisease process of women in the face of unwanted pregnancies, it was found that the news of the In relation to social reproduction, the participants who stated having children mentioned that the daily care of their offspring was an additional concern in the process of seeking an abortion. In the category called needs related to welcoming in health services precarious assistance and re-victimization of women by the professionals who assisted them were detected, a fact verified in the speeches, when they reveal the exposure, the embarrassment and the slowness to meet the demand for abortion. It is noted that those surveyed who resorted to more than one service along the way were more exposed to institutional violence.

Discussion
The analysis of the results revealed that the search for legal abortion is a path full of obstacles capable of triggering numerous health needs revealed as with potential for wear out in the women's health-disease process. These hidden needs and, sometimes, minimized due to the urgency to carry out termination of pregnancy, were expressed in several vulnerabilities on the part of those surveyed.
The health needs felt and expressed by the participants were mainly linked to properly human needs, revealing overcoming of the needs for the conservation of life, whose focus is merely biological (11) . Although biological complaints were mentioned, it is believed that the women tried to translate more complex needs triggered by the context permeated by subjectivities.
The results pointed to recognizing the need for specialized psychological assistance for the women to deal with the experience of violence and abortion. This data reproduces the idea disseminated within the scope of health services about violence being a phenomenon limited to mental health, as it escapes from the medicalizing focus, reinforcing the mind-body dichotomy (15) . Thus, the www.eerp.usp.br/rlae 6 Rev. Latino-Am. Enfermagem 2022;30:e3532.
conception that such phenomena require the action of specialized professionals as a priority can create obstacles to care integrality and to the network articulation of services.
The nonexistence of services aimed at caring for women who have suffered sexual violence in the cities where the interviewees come from emerged as a needstriggering element. The fact that most of these types of service are predominantly located in the capital cities of Brazilian states, not present in seven federative units (8) , forces women to leave their cities in search of the effective implementation of their rights.
Geographic barriers to accessing abortion services have been evidenced in several countries and related to the low availability of services and professionals, especially in countries with restrictive laws, forcing women to travel long distances to terminate a pregnancy.
These trips represent a burden, making the abortion experience more painful due to the direct and indirect costs of transportation, accommodation, food, distancing from work and/or studies and adjustments to ensure child care (16)(17)(18)(19) .
The results revealed that the logistic burdens triggered needs related to social production, linked to fear of job loss and financial difficulties. It is known that paid work empowers women in overcoming gender inequalities through financial independence, having a close relationship with women's autonomy and freedom in decision-making, thus turning to properly human needs (11,15) .
Regarding the needs related to social reproduction, linked to motherhood, a gendered view of child care was personal desires (20) . aiming at the establishment of supportive relationships that lead to female empowerment (21) .

Needs related to welcoming based on qualified
listening, professional secrecy, support and resolute assistance were also mentioned by the participants. The In the context of assistance to women in situations of violence, the health professionals' attitudes greatly influence the assistance offered. Thus, welcoming should not be summarized as a simple conversation but presuppose comprehensive care, mediated by generalized knowledge capable of responding to these women's needs.
To this end, it is fundamental to use instruments that allow for a specific approach, with qualification of listening and translation of non-verbalized needs in the services (15,22) .
In the current study, it was evidenced that the participants were attributed a position of passivity others or having their desire to terminate the contested pregnancy (16,18) .
Although confidentiality is a users' right and a duty of health professionals, the results showed that women from smaller cities feared having their privacy exposed.
The fact that their social networks intertwine with those of the professionals reinforced the idea that there is no guarantee of anonymity when it comes to morally controversial social phenomena, such as abortion. In this context, it is necessary to reflect on how this barrier can directly influence women's access to legal abortion and on how many give up on seeking this right, resorting to clandestine and unsafe procedures, risking lives.
The combination of interpersonal and logistic barriers in the search for legal abortion reveals the urgent need to rethink the care network for women in situations of violence. A number of authors highlight as fundamental in this process the organization of services that meet this demand in more distant places, acting in an articulated way with other social devices, integrated by a multidisciplinary team capable of offering safe and confidential assistance (17) .
The limitation of this study lies in the fact that the interviews were carried out in the health service where the abortion was requested and performed, which may have somehow influenced the data on access and welcoming.