NURSING CARE ACCORDING TO WOMEN IN ABORTION SITUATIONS

Estudo qualitativo que buscou compreender como mulheres em situação de abortamento vivenciam o cuidado de enfermagem que recebem. A análise dos depoimentos de 13 mulheres hospitalizadas ocorreu por meio da técnica de análise de conteúdo. Foi composta a categoria central “O cuidado de enfermagem vivenciado na situação de abortamento”, a partir de quatro subcategorias: o cuidado centrado nas necessidades físicas; o receio do julgamento na situação de abortamento; aspectos legais definindo o cuidado; a necessidade de apoio na situação de abortamento. As mulheres identificaram o cuidado de enfermagem fundado em aspectos físicos, não contemplando a individualidade e as especificidades delas. Os resultados apontaram a necessidade de criar um ambiente que propicie a escuta, ajudando essas mulheres a elaborar seus sentimentos, permitindo aos profissionais conduta mais próxima da realidade delas, de forma que seus próprios desejos e conflitos sejam menores, e que seja contemplada a integralidade da assistência.


INTRODUCTION
The illegality of abortion in Brazil has not impeded its practice in different conditions, ranging from clinics with care quality control to precarious and clandestine ones.Per year, 1.4 million abortions are performed in the country, corresponding to 23 abortions per 100 pregnancies and 50 million per year all over the world, imposing severe risks on women's health and lives (1)(2)(3) .In the context of maternal mortality, 12.5% of the total number of deaths is caused by abortion complications, occupying the third place among its causes.
An earlier phenomenological study observed that women in abortion situations should have the possibility to express their physiological and existential pain, independently of the cause of abortion, reminding that the decision to get an abortion is not individual, as it involves circumstances and life histories.Abortion revealed to be an experience that leads to a discomforting hospitalization as, although hospitalization time tends to be short, the women were very anxious to go home, out of fear that significant people would discover what had occurred.This study also identified feelings of guilt or fear, due to society's value parameters.The abortion experience also involves concern about the body and its integrity, in view of the possibility of complications and the fear of no longer being able to have children.Hence, these women revealed abortion as an experience that entails the desire to reconsider their life projects (4) .
As health professionals, we are concerned about nursing care from these women's perspective.This research aimed to understand how women hospitalized at a public hospital in abortion situations acknowledge the nursing care they received.

METHODOLOGICAL PROCEDURES
This is a qualitative research, as it attempts to focus on the individual with a view to understanding the study phenomena.This approach is characterized as a method to understand and reflect about a theme and attempt to reflect on questions of concern, based on the discourse of the subjects submitted to analysis, which presents meanings that help to understand the research problem (5) .This exploratory and descriptive study used content analysis, which is defined as: "... a research technique aimed at the objective, systematic and quantitative description of the manifest content of communication" (6) .
We studied nursing care to women in abortion situations, based on the discourse of 13 women who were hospitalized at a public hospital in São Paulo State between May and July 2003, after at least 20 hours of hospitalization.
Our concern focused on the contents of discourse, so as to guarantee that these reflected the women's experiences when receiving abortion care.
Data saturation occurred when contents became repeated, without the presence of new facts for interpretation.
All ethical procedures for health research were taken into consideration.The project was submitted to approval by the research hospital and later approved by the Research Ethics Committee at the same institution.
Important aspects for the subjects were considered, such as the interviewers' formal presentation, the subject's interest in the interview, the study objective and the guarantee of anonymity.
At the end of each interview, the women could clarify doubts about aspects related to the theme.
The meetings occurred as follows: first, the interviewer presented herself and asked the participant to sign the Free and Informed Consent Term and to authorize the recording of the interview, clarifying the possibility to turn off the recorder during the interview if this affected the woman's willingness to talk.
After these procedures, the interview started with the following questions: How do you acknowledge the nursing care you are receiving?Can you describe it?All interviews were carried out by one of the researchers.
Due to their characteristics and subjectivity, the collected data were submitted to qualitative analysis and systemized according to the content analysis technique.Data were organized through thematic analysis, with a view to analyzing the meanings of the women's discourse about the nursing care they received during hospitalization in abortion situations.
In this analysis, we attempted to identify the meaning of this care in their discourse, by looking at the care without prejudices about the theme, in order to understand it at that moment, from the perspective of the person experiencing the process of receiving care in an abortion situation.Thus, after reading the discourse, we selected the following central category: nursing care experienced in abortion situations, presented through four sub-categories, namely: care centered on physical needs; fear of judgment in abortion situations; legal aspects defining care; the need for support in abortion situations.At this moment, we highlighted significant extracts composing this category, in the form the women expressed them.To guarantee and preserve anonymity, all women were identified through fictitious names.

Characterization of women
The women were between 20 and 45 years old.On the occasion of the abortion, their gestational age ranged between 9 and 22 weeks.Five of them reported they were single, three married and five had a fixed partner.Education levels ranged from illiteracy to finished secondary education.As to occupation, one was a student, three were housewives, two unemployed, four domestic servants, two shop assistants and one public servant.Three participants mentioned this was their first pregnancy and, for the others, the number of children ranged from one to four.Three women revealed they had had an abortion before.Only two women had planned the pregnancy.
What the use of contraceptive methods is concerned, eight participants indicated they did not use any; three took the pill but had interrupted its use.

Nursing care experienced in abortion situations
Care should never remain restricted to health actions and interventions but, instead, should comprise the developed of attitudes and spaces for true intersubjective meetings, for the exercise of practical knowledge for health, supported but not limited to technology; an encounter between caregivers and patients should be promoted with a view to a more symmetrical relation between both (7) .
In this study, care cannot be experienced in this dimension, in accordance with the following description of subcategories.

Care centered on physical needs
In their discourse, the women perceived the meaning of nursing care as that care in which, on most occasions, the "basic" is performed.This meaning points towards compliance with physical needs and the performance of technical procedures and was revealed as "normal", highlighting attendance to needs related to the physical body.The health area still operates with an essential and biological conception of the human condition (8)   .
There is a need for a change in the care focus, making the nursing team reflect on their actions, as care should go beyond the solution of physical problems, that is, incorporate its social, psychological and spiritual dimension.
Nursing activities were perceived as meaningless action, or whose meaning workers do not know.This makes them reproduce a bureaucratized knowledge and practice.Hence, no natural gift can resist to the automatic repetition of acts and working in services structured like this usually becomes unbearable (9) .Thus, nursing competency is associated with the technical and bureaucratic side.
The women's discourse revealed and defined this way of being as "normal" and considered the world of nursing work as: ... would that be.It should be highlighted that the privilege of physical care aspects does not seem to take into account the needs these women experience, as their discourse revealed that this model is insufficient to provide integral care.The relations between professional nursing categories and clients were influenced by each person's subjective conditions and by material work conditions.Realities showed to be complex, difficult to apprehend as a whole and permeated by distinct and sometimes diverging beliefs and interests (9) .
These women, in their life contexts, histories, expectations and particularities, sometimes reveal to be disconnected from their own identity and often safeguard themselves by not establishing a relationship of confidence with professionals.
Sometimes, this is justified by their difficulty to deal with the consequences of what is considered a sinful and illegal act.

Fear of judgment in abortion situations
Out of fear of judgment about the act they have practised, some women in self-induced abortion situations seek care because of the presence of embryo remnants.Fear of family and social censorship makes they face hospitalization alone, turning it even more painful (10) .
Cases of women experiencing spontaneous abortion should also be taken account.They are frustrated about this event and are often neglected and discriminated against, until the team becomes aware that the fetal loss was spontaneous.One of the most difficult tasks is to inform this mother about the baby's loss, and hardly anything has been done to give her psychological support.These women frequently express feelings of revolt and rejection, sometimes turning to other services to get confirmation, and express guilt because they did not avoid the loss, as well as the need to know the motive of the abortion (10)(11) .
Thus, the abortion experience is configured as a crisis and professional activities should be guided by the understanding of the feelings these women express, seeking to discern some ambivalent fears lived by these women and, mainly, avoiding legalist and moralist positions towards abortion (8,11) .
The situation is painful and complex in both spontaneous abortions and cases suggesting induction, and women need support and understanding, independently of its etiology.
However, in experiencing nursing care, the women managed to give meaning to the differentiation in the care they receive.Universal access to health and respect for each individual's singularities, without any type of discrimination, are constitutional rights.The humanization of health actions depends on the actual acknowledgement of the subject's condition as a citizen with rights, of all persons seeking any kind of health care, at public or private services.Care delivery is a political act and care is complex.Awareness of this complexity favors a critical distancing with a view to reflection, assessment and implementation of the health practices most pertinent to the situation.The humanization of health and nursing services is a continuous process and depends on the nursing team's daily reflections about care (12) .

Legal aspects defining care
The women's discourse revealed that support is essential at this moment and demonstrated that they visualize the difference in support in cases of spontaneous and "supposedly" provoked abortion.
One participant tried to show her condition by mentioning the inadequacy of Brazilian abortion laws.We need to exercise our profession, understanding the different transformations society is going through, reflecting about the phenomena that give rise to care demands.Any law facilitating this should receive our support.The illegality of abortion in Brazil has not managed to control its occurrence and these women are aware of this.Hence, they need to be guaranteed access to quality care in public and private health networks.However, care is jeopardized when health professionals appeared before these women with value judgments and prejudices.This statement points towards the fact that professionals seem to prefer to hear lies, refusing to cope with conflicting and polemic situation like abortion.
It is important for health and specifically nursing professionals to apprehend that universal access to health and respect for each person's singularities, without any kind of discrimination, are constitutional rights (12)   .
It is understandable that health professionals prefer to attend successful pregnancies, but even who is against abortion can help women at these moments and, if they do this, they will neither be committing a crime nor provoking abortion.Nursing professionals have maintained an attitude against this precept, often ignoring the woman's individuality and dignity in this condition (12) .

Need for support in abortion situations
Creating an environment that benefits listening can help these women elaborate their feelings, allowing these professionals to behave in a way closer to their reality, so as to reduce the projections of their own feelings and conflicts (13) .
Nursing service humanization implies organizing services whose environment is welcoming and comfortable, but mainly offering qualified professionals who are committed to care quality.These women's discourse evidences a more humanized attitude, in which professionals can be with these women and help them, when they mention the importance of talk and support at this moment.
... this is care, I think they have to talk, calm the person... no matter who the patient is (Maria Aparecida).
They talk to us, yes, they do everything right, but I went through a lot and I feel this lack of support.They talk like, you know?What happens?They ask if everything is ok?If you feel pain, but I miss information... and really talking about my problems...it's all very superficial, automatic (Vânia).These women's discourse shows their conformism about care, but the superficial and automatic way nursing professionals appear to them also stands out.
New relations between the caregiver and the person receiving care are needed, treating them as subjects in this process and including a commitment to the articulation of new care strategies for suffering people.
The desire to have a child, the fact of having provoked an abortion or not, the family's economic situation and gestational age do not interfere by mitigating or intensifying the pain of this loss (14)   .The way this mourning is expressed is extremely personal.Thus, when approaching women who are experiencing an abortion situation and are participating in this world, the free manifestation of their mourning, through gestures, words and silences, should be permitted and facilitated (4) .
Therefore, care implies that professionals develop relations with these women, respecting them as subjects with frustrations, expectations and dreams.These professionals should also be able to identify the moments of introspection needed to elaborate the experienced situation.
...it's good when they talk to us...it's good, we feel better...., but sometimes we don't even want to talk.For example, I would like to talk now, I like this part, the talking, you can let off steam and suffer a bit less, I think it's good, like, but sometimes it isn't.You want to stay quiet, think, relax (Renata).
This discourse points towards the need for professionals to acknowledge the moment these women are going through and support implies knowing how to share, being present at that moment.These statements showed that the women perceive the care they are receiving and not only this, but also the way it is put in practice, whether automatically, as a part of routine, or whether the interest in helping and sharing that moment with them is real, moving beyond the physical aspect of care.
Hence, listening, something apparently simple, reveals to be an extremely complex phenomenon in practice, demanding an articulation among the possible and multiple senses of each statement, and also among knowledge from different areas.Thus, listening can contribute to decrease the occurrence of prejudiced behaviors and the judgments generally made about these women (12) .
Nursing professionals at the study institution have not reached this dimension of care yet, and the women seek explanations, such as the nursing team's lack of respect, lack of consideration for their needs, lack of information, justifying these deficiencies through their perception about an insufficient number of professionals to attend to their demands and, hence, lack of time.
Some statements described these problems related to the nursing team as insufficient staff and lack of time.As the women feel weakened by the abortion situation, they attempt to justify the care merely based on physical needs, as they hold minimal care expectations.
Some of these women's statements also indicated moments they considered as a lack of respect for their needs and moments of thoughtlessness by the team.This statement shows the team's lack of respect for the women's needs and moments of thoughtlessness that may be used, in a hidden way, as a punishment for the abortion, revealing the fact that professionals are not free from value judgments and, sometimes, prioritizes care in other hospitalization situations.
In their reports, some women described the care as taking a long time and very slow in their opinion.
Ahhh Women in abortion situations without a companion perceive that care takes a long time even more intensely.In their statements, they revealed a delayed care, in which they have to wait silently while feeling pain, besides a lack of information about their condition, about the procedures that will be performed, treatments and conducts.The women reported a lack of information and thoughtlessness, and these factors create fears Nursing care according to women... Mariutti MG, Almeida AM, Panobianco MS.
Anticipating or informing means breaking the unknown, saving these women from the shock of new things and sharing the feeling of solitude, trying to minimize psychological problems (13) .

FINAL CONSIDERATIONS
Abortion is characterized as a polemic issue and a public health problem, whose morbidity and mortality should be taken into account, and whose illegal nature does not impede its occurrence.
Health practice based on the biological model has revealed to be insufficient to attend to these women's needs.In acting, it is important to understand their specificities integrally and respect their autonomy.The aim is to provide quality care to these women, raising their awareness, informing them and helping them in a situation that has no return.
We understand that professionals should reflect on their practice and get genuinely involved.Physical needs must be attended to, without forgetting to contemplate women as a whole.This implies understanding abortion in the women's existential context, detached from its illegal or criminal character.
No situation is isolated in itself.Human beings live in a context, have habits, values, socioeconomic conditions, ways of being that interfere in their life, in their existence.
Besides having professionals reflect in the search to transform current care models, it is fundamental for these women to change in the search for greater autonomy, knowledge of their own body, development of empowerment, prevention when they do not want to have children and a search for their rights as health service users.
Health and mainly nursing professionals working in this field should be aware of their role in exercising social control and in guaranteeing their clients' rights, independently of the situation, as it are the subjects who put in practice, grant meaning, body and quality to health policies.They need to understand that universal access to health and respect for each person's singularities, without any kind of discrimination, are constitutional rights.
...it's much better when you're able to tell the truth, but there's fear...I, as I never hid anything from anybody, I really didn't, ...they though I should lie, hide, they're even astonished, because they're used to lies, they want to hear the truth, but there's no way of doing that in this situation.Many times, I've left the hospital without receiving care, because I arrived and said what my problem was and they wouldn't attend me...they left me there... (Adelaide).