RACIAL DISCRIMINATION IN REPRODUCTIVE HEALTH CARE FROM WOMEN ’ S PERSPECTIVE

Racial discrimination can influence the functioning of the health services and the relationships between health professionals and service users, and may be reproduced imperceptibly, through how the people in the vicinity are treated. This study aimed to describe women’s perception about racial discrimination in health care practices in reproductive health. It is an exploratory-descriptive study, with a qualitative approach. The information was collected in a Primary Health Care Center in Salvador, Bahia, Brazil in 2010, through semi-structured interviews held with 25 women. The technique of thematic analysis was used for analyzing the discourses. The analysis revealed situations of discrimination experienced or witnessed by the women in the reproductive health services and recognition of discrimination related to race/color and to social class. Despite there being perception of racial discrimination, the women had difficulty in recognizing that they suffered such practices, evidencing the naturalization of racial inequalities in reproductive health care. DESCRIPTORS: Perception. Reproductive health. Nursing. Race and health. DISCRIMINAÇÃO RACIAL NO CUIDADO EM SAÚDE REPRODUTIVA NA PERCEPÇÃO DE MULHERES RESUMO: A discriminação racial pode influenciar o funcionamento dos serviços de saúde e as relações entre profissionais e usuários(as) e pode ser reproduzida, imperceptivelmente, através do modo como as pessoas do entorno são tratadas. Este estudo teve como objetivo descrever a percepção de mulheres acerca da discriminação racial nas práticas de cuidado em saúde reprodutiva. Trata-se de um estudo exploratório-descritivo, com abordagem qualitativa. As informações foram coletadas numa Unidade Básica de Saúde de Salvador-BA, em 2010, por meio de entrevista semiestruturada, realizada com 25 mulheres. Para análise dos discursos utilizou-se a técnica de análise temática. A análise revelou situações de discriminação vivenciadas/presenciadas pelas mulheres nos serviços de saúde reprodutiva e o reconhecimento da discriminação relacionada à raça/cor e à classe social. Apesar de haver percepção da discriminação racial, as mulheres apresentaram dificuldade em reconhecer que sofriam tais práticas, evidenciando a naturalização das desigualdades raciais no cuidado em saúde reprodutiva. DESCRITORES: Percepção. Saúde reprodutiva. Enfermagem. Raça e saúde. LA DISCRIMINACIÓN RACIAL EN EL CUIDADO EN SALUD REPRODUCTIVA SEGÚN LA PERCEPCIÓN DE MUJERES RESUMEN: La discriminación racial puede afectar tanto el funcionamiento de los servicios de salud y las relaciones entre profesionales y usuarios y se puede jugar sin problemas tanto a través del trato a la persona de nuestro entorno ya nosotros mismos. El objetivo del estudio es identificar y describir la percepción de mujeres a cerca de la discriminación de raza en prácticas de cuidado en salud reproductiva. La investigación es del tipo descriptiva, exploratoria, con abordaje cualitativa. Las informaciones fueran colectadas en uma Unidad Basica de Salud em La ciudad de Salvador, Bahia, Brasil, en 2010. La información se obtuvo a través de entrevista semiestructurada, realizada con 25 mujeres, que acuden a la unidad que habías ido através de un servicio de salud reproductiva. Para el análisis de los discursos se utilizó la técnica de Análisis Temática. La análisis revela situaciones de discriminación que sufren/atestiguan las mujeres en los servicios de salud reproductiva y el reconocimiento por la misma discriminación, en relación con la raza/color y clase. Aunque no existe una percepción de la discriminación racial, las mujeres tenían dificultades para reconocer que sufre tales prácticas, evidenciando la naturalización de las desigualdades raciales en el cuidado en la salud reproductiva. DESCRIPTORES: Percepción. Salud reprocuctiva. Enfermería. Etnia y salud. 285

ABSTRACT: Racial discrimination can influence the functioning of the health services and the relationships between health professionals and service users, and may be reproduced imperceptibly, through how the people in the vicinity are treated.This study aimed to describe women's perception about racial discrimination in health care practices in reproductive health.It is an exploratory-descriptive study, with a qualitative approach.The information was collected in a Primary Health Care Center in Salvador, Bahia, Brazil in 2010, through semi-structured interviews held with 25 women.The technique of thematic analysis was used for analyzing the discourses.The analysis revealed situations of discrimination experienced or witnessed by the women in the reproductive health services and recognition of discrimination related to race/color and to social class.Despite there being perception of racial discrimination, the women had difficulty in recognizing that they suffered such practices, evidencing the naturalization of racial inequalities in reproductive health care.

DESCRIPTORS:
Perception.Reproductive health.Nursing.Race and health.

INTRODUCTION
Studies focussing on health inequalities in Brazil have shown that black people, when compared to whites, have multiple social disadvantages, principally regarding access to and use of the health services.] Racial or gender discrimination have negative repercussions on black women's access to, and stay in, the health services, and are inserted not only in individual practices, but are part of the institutional norms and routines. 3Studies 2,4-6 have shown that black women are exposed to inadequate treatment and inadequate actions in care and prevention of harm to health, principally in the ambit of reproductive health care.
Regarding pregnancy and the parturitive process, the results of a study undertaken based on an analysis of reports from Maternal Death Committees showed that the risk of death is higher among black women.Among the causes, the study indicated complications resulting from the pregnancy or process of giving birth, due to lack of access to pre-natal care and/or poor quality pre-natal care. 4he National Demographic and Health Survey 5 showed that inequality in access to pre-natal care exists for Brazilian women, with black women who are pregnant having fewer pre-natal consultations than white women.In relation to the Papanicolaou test, it was found that here too there was a higher proportion of black women among those who had never had the above-mentioned examination.In addition to this, another study 6 showed that the prevalence and re-incidence of uterine myomas, and the undertaking of hysterectomy, is greater among black women.
These studies show that racial inequalities are perpetuated in the reproductive health services, revealing that it is fundamental to understand this process if oppression, discrimination and racial prejudice are to be overcome, along with their implications for black women's health.
Racism influences both the functioning of the health organizations and the relationships between health professionals and the health service users.It may be identified through some aspects such as: differences in access to health services; differentiated attendance for service users who are black; consultations in which the health profes-sionals inadequately examine black women; and the use of depreciative expressions in relation to black people. 7tudies addressing racism in care relationships remain few in Brazil, 8 principally in nursing, which is important in view of the fact of this being one of the areas which attends a significant part of the needs of women in reproductive health, notably in the public health services.The functioning of the nurses and nursing, generally, in reproductive health, encompasses both the levels of health promotion and control of health problems, through pre-natal health, prevention of gynecological cancer, and during birth and the post-partum period in health organizations, among others.
Racism is expressed in society through discrimination, prejudice, and racial stereotyping.Racial discrimination in particular means any distinction, exclusion, restriction, or preference based on race, color, descent, or national or ethnic origin, 9 and may be reproduced imperceptibly through how the people around one are treated.
As manifestations of discrimination do not always occur in explicit ways, identification of said practices is difficult, both by the victims and by the people who practise them.This non-perception of racial discrimination is the fruit, in part, of the ideological construction of the myth of the racial democracy, which obscures the expression of racism, showing Brazil as a country where relationships between racial groups are harmonious and, therefore, racism is inexistent, this also being an instrument of the reproduction of unequal racial relationships.
5][6] It is intended, through this study, to learn how women perceive racial discrimination in care practices in reproductive health.To respond to this question, the present study aimed to describe the women's perception about racial discrimination in reproductive health care practices.This is an excerpt from a research project entitled "Women's access to health care: determinations of gender and race/color" developed and carried out with the financial support of the National Council for Scientific and Technological Development.

METHOD
This is a descriptive, exploratory study with a qualitative approach, undertaken with 25 women who were using a Primary Health Care Center (UBS) located in a neighborhood which occupies a geographically privileged space in Salvador, Bahia.It is situated close to the waterfront, to large commercial centers, and borders four uppermiddle class neighborhoods -not being, therefore, on the outskirts of the city * .
The above-mentioned neighborhood is frequently associated with urban violence and the drugs trade, in which homicide is the leading cause of death affecting, mainly, young black males.It has a high population density, with a predominance of black people (approximately 90%) and women (57%); with low levels of income and schooling found in higher proportions than those observed in Salvador. 10:58 Women who were in the UBS for any reason on the interview days were invited to participate in the study.The women's participation occurred in line with the following inclusion criteria: to have received attendance in the area of reproductive health (pre-natal nursing consultation, family planning and prevention of cervical cancer; any consultation with a gynecologist/obstetrician; attendance during labor, birth, the post-partum period or for miscarriage) in any public health services in Salvador-Bahia, and to be aged 18 or over.Data was collected in a private room in the UBS itself, in the period January-February 2010, through semi-structured interviews, guided by a script which had been prepared beforehand and was made up of two parts.
The first part of the script was made up of socio-demographic data: race/color, age, years of schooling, profession/occupation, family income, marital status, and religion.The information regarding race/color was obtained by self-declaration, with the Brazilian Institute of Geography and Statistics' classification being adopted -white, black, mixed race, indigenous and yellow.
The second part of the script was made up of three questions: 1) Have you ever witnessed or been the victim of any type of discrimination during attendance in reproductive health?2) Have you ever been the victim of or witnessed racial discrimination during attendance in reproductive health?3) (If there was a positive answer) Why do you think that you did?The interview was recorded and transcribed in full.
The analysis of the reports followed the stages of the technique of thematic analysis, understood as three stages: pre-analysis, exploration of the material, and treatment of the results obtained and interpretation. 11The themes of analysis were: perceived racial discrimination; invisible racial discrimination versus discrimination on the basis of class, both of which will be addressed in this article.
The ethical legal aspects of the study were observed, in line with Resolution 196/96 of the National Health Council.All the participants signed the Terms of Free and Informed Consent, after being informed of the research's objectives and possible risks and benefits.Anonymity was guaranteed, with participants being referred to by a number followed by the self-declared color.The project was approved by the Research Ethics Committee of the Federal University of Bahia's College of Nursing, under decision n. 48/2009.

RESULTS AND DISCUSSION
About the women interviewed 25 women were interviewed, aged between 18 and 59, with the age range 18 to 35 predominating.Out of all the women interviewed, one self-identified as white.Family income was up to one minimum salary (R$ 510.00 at the time of data collection) for 18 of the women, in which what is important is the fact that they were involved in paid employment at the time of data collection.Regarding level of schooling, marital status and religion, it stands out that the women had, at the most, 11 years of education, which corresponds to junior high school; 15 were single or widowed (1)  and the others stated that they were married or in a stable relationship.One woman stated that she had no religion, and the others that they belonged to Christian denominations (Roman Catholics, Pentecostalists, and Spiritualists).
The characteristics presented by the participants indicate the profile of demand on the public * Poor neighborhoods and favelas are usually found on the outskirts of Brazilian cities. Translator's note.** Candomblé: Afro-Brazilian religion.Translator's note.health services, already indicated by other studies undertaken in Salvador-Bahia 12 and throughout Brazil, 13 which identify female users of the Unified Health System (SUS) as predominantly black and with weak social inclusion, considering professional qualifications and levels of income and schooling.
As it is subjective information, the perception of racism can vary in line with specific personal characteristics and the historical context in which the person lives.Other investigations [14][15][16] indicate that the degree of perception of racial discrimination differs according to people's sex, color, age, schooling and income.Generally, those who perceive racism with greater intensity are women, black people, young, with mid-level schooling, and low incomes.

Racial discrimination in reproductive health care
The questioning on the subject of whether the interviewee had witnessed or suffered racial discrimination in a reproductive health care situation caused reactions of unease and silence in the participants, creating a certain embarrassment already reported by other researchers 14 when they studied the implantation of the question about color in health forms.
Nevertheless, as the interview progressed, the women managed to express their perceptions and ideas about racial discrimination in the health services.
The content of the interviews allowed the identification of the perception of discrimination based on people's own experiences or on the experiences of other women.In these cases, the women associated the poor quality of the care with social discrimination; they report about the attendance received and denounce, above all, a superficial care, in which the health professionals spend more time in providing care to the women who are white, when compared to those who are black; and the discrimination related to social class -some women believe that they receive unequal attendance due to their condition of poverty.Other women believe that both social class and race are determinant factors for the care received.
The analysis of the statements allowed the identification that the discrimination perceived may or may not be related to the women's personal experiences with the attendance in the health services.In some cases, the perceptions were from women who reported not having experienced or witnessed situations of racial discrimination, or who did not refer to concrete facts, but said that they knew that discrimination exists: [...] of course discrimination exists.I've never witnessed it, but I know it exists all right!I think that the treatment is not equal for a white person and a black person.It's obvious that the attendance is always better for a white person, isn't it?Blacks [...] black people are heavily discriminated against [...] (E23, mixed race).
[...] nowadays discrimination exists, doesn't it?The difference is that some darker people come to the health center to arrange appointments, not all, but some of the health professionals treat them, well, even badly, you know?[...] Now, when it's a white person, white-ish, they treat them well, differently, in a different way, much better than those people who are dark (E07, mixed race).
These women's position on discrimination may be attributed to the process of definition and discussion of racial inequalities, triggered in recent years by black movements, with consequences in the health sectors, evidencing the process of racialization *** in access to the health system and in the quality of the assistance.
This demonstrates that the perception of racial democracy in Brazil is increasingly becoming less of a consensus and that various sectors of society have begun to include debates on racism in their political agendas. 1 In Bahia, for example, the intense debate on quotas for those of African descent in universities, and the growing demands of this social movement have been reflected in the formulation of policies for the health of the black population, as in the example of the II State Plan of Policies for Women, whose construction began in the second half of 2007.:33 The subtle forms of the manifestation of racism can lead to ambiguous situations and result in racial discrimination which, frequently, are in-*** "The process by which understandings of race are used to classify individuals or groups of people.:574 visible to the person being discriminated against.In spite of this, the difficulty in measuring the perception of racial discrimination resides in the fact that, while in some cases the perception may exceed the actual proportions, in other situations the discrimination may frequently be imperceptible to the victim. 19acial discrimination was mentioned by the women among situations as leading to treatment which was differentiated based on race/color: [...] We notice that when a person with paler skin enters the room, they [the health professionals] take longer over the attendance.When a black woman goes in, she's soon out again.After all, they're not examining people all over in there, right?That's why there's this difference (E05, black).
[...] black or poorly-presented people don't get as much attention.This doesn't explain things well, but I've seen it, I've witnessed it happen to me, with them explaining the situation better to me and talking with me better.And with other people, they don't explain things very well.We notice when people stay hanging around the place, without the information which they would like a little more of (E15, white).
[...] people who are my color take longer to be seen, and people who are paler don't.There is this difference in the attendance, really it's quite large (E10, black).
Among the participants, the black women complain of a superficial care given by health professionals and a longer waiting time to be seen in comparison with other women who are white.According to academics, 14 health professionals' representations concerning people's skin color may be related to the practice of discrimination in health care, making it essential to discuss racial issues with the professionals and academics in the health area, as we are all historical subjects of a racist society.These women's perceptions translate inequalities in health attendance, revealing that the care received by black women is of inferior quality.Unequal treatment can cause, among other aspects, dissatisfaction with the attendance and delays in diagnosis and treatment of pathologies, and, consequently, increase black women's vulnerability to various threats to health.
In response to a question on whether the women had suffered some type of racial discrimination in the attendance received in the health services, one of the interviewees reported: [...] I woke up in the morning with the porter dragging me, taking the trolley to the room.I didn't like it, I hated it there.I never wanted to go back there again.Give birth there?Never again.For example, what if I had had problems after the birth, you know?I could have had a hemorrhage or something, and there I was in the early hours in the corridor, lying on the trolley, alone, abandoned.(E6, mixed race).
Although the service user considered the episode to be racial discrimination, this situation can also be compared and identified in other female users of the SUS, irrespective of their color, and cannot be characterized as essentially a practice of racial discrimination.
Situations of neglect and disregard such as that reported by this woman were also made clear in another study 20 undertaken with women who had recently given birth who complained of periods of solitude and abandonment and fragmented care.
The accounts complain not only of discriminatory attitudes, but also of the poor quality of the health services.:1143 Such aspects result in, among other indicators, high rates of maternal mortality, it being valid to highlight that this is higher among black women, 4 and in dissatisfaction with the care received.
According to the interviewees, the discriminatory treatment comes both from medical professionals and nurses, and support staff (receptionists and attendants).There is a tendency for health professionals not to notice that they reproduce inequalities in the attendance or to insist that it does not exist, thus contributing to the maintenance and extending of racist practices in the health services.This naturalization of the inequalities, reflected in the health professionals' attitudes and behaviors, results in prejudice and racial discrimination being incorporated into and reproduced in the everyday of the health services. 21t was possible to identify from the reports that the invisibility of the racial discrimination is due to the preponderance of inequalities and discrimination on the basis of class and purchasing power.The interviews' content shows that part of the participants did not perceive acts of racial discrimination directed at them in reproductive health care.However, they recognize that in some way the care given results in different treatment and restriction of access and/or use of the repro-ductive health services.These findings reveal that racial discrimination is generally manifested in a subliminal form, which favors its reproduction and maintenance in social relations.
Although it is necessary to consider that the experiences of seeking/using health care by the women are diverse, leading to different degrees of exposure to the risk of being discriminated against, the denial of discriminatory practices present in the women's discourses may be explained by the myth of the incorporation of the racial democracy by society.This myth's assimilation entails not perceiving racial inequalities and, consequently, not perceiving racial discrimination in the health services.
On studying racial and gender discrimination in the health services, authors 3 have affirmed there to exist a set of values which stimulate racial inequality in society, leading people not to perceive, or even to deny, the existence of the racism.They have also observed that the oppression suffered by women, and the internalization of the discrimination, stop women denouncing its existence.
It is worth emphasizing that even the women who did not perceive or identify racial discrimination in the care received left clues at some points in their discourses which evidenced the occurrence of bad or poor attendance.According to the interviewees, this type of treatment is explained by everyday factors affecting health professionals, such as: stress, bad moods, heavy workloads, and low salaries.
As an ideology, racism can orient discriminatory practices and behaviors, under the guise of other personal issues, as referred to in the following account: [...] I think a lot of professionals take home problems to work with them.It's to do with this [...] what also happens a lot is that they think that because the service is public, the attendance can be done any old how (E04, mixed-race).
The fact that expression of racism is prohibited by law has caused changes in how racial discrimination and prejudice circulate in Brazilian society, contributing to the construction of new representations and perceptions of the phenomenon.Subtle forms of discrimination, and its invisibility, appear as a result. 22n spite of some women denying the existence of racial discrimination in the attendance, it is explicit in the accounts that black women receive unequal treatment in comparison with white women, and reveals, indirectly, the reproduction of racial discrimination in the reproductive health services.From this perspective, one can treat the non-perception of discriminatory practices in reproductive health care as a problem to be confronted by black women, health professionals, and society in general.
Although racial discrimination was not perceived directly by all the interviewees, they recognize the existence of differentiated treatment related to social class.Hence, according to the accounts, discrimination occurs above all from the fact of a woman being poor rather than black.
I think the difference is in social class, you know?If it's a person with money, of course she'll be well attended.And poor people without money... the difference is in the social class (E25, mixed race).
According to this woman's account, the color of a person's skin is not the determinant factor in the type of treatment received, but class is.From this perspective, inequalities of social class are used by the interviewees to explain inequalities in access to and use of the health services and, consequently, mask the process of exclusion and restriction experienced by black women.
One study undertaken in Brazil showed that the influence of color on a lower probability of access to reproductive health actions disappears when social class is controlled for, suggesting that the main problem in inequality of access to the health services is related to the condition of poverty rather than the fact of being black.However, the study's author highlights that this finding -that purchasing power, more than other socio-economic characteristics, would capture this same discrimination -does not allow one to make light of the existence of racial discrimination in accessing reproductive health services. 23Added to these issues, quantitative data only evaluates questions of access to the health services, leaving gaps when one wants to discuss the topic of the quality of health attendance available to blacks and whites.Hence, qualitative research would respond better to these questions.
In contrast, other accounts showed that the condition of being a woman, coupled with the fact of being poor and black, lead to unequal and halfhearted attendance offered in the health services.
I don't think the difference is only due to color.I think it's to do with financial conditions too.When it's a white woman, more educated, better dressed, she gets more attention, sometimes she sits down, sometimes she chats... she gets more attention than me (E02, black).Sure there's a difference in the attendance.A person with less advantages, poorer, the attendance is always worse.Just because the person is like that, black and poor, has less advantages, does the attendance have to be worse?(E06, mixed race).
The reports show, therefore, that some interviewees perceive the influence of the intersectionality between race and social class on the attendance received.In this way, gender, race/ color and social class merge and lead to disadvantages for the health of black women, and should be taken into account in the analysis of this population group's health-illness process.Although these disadvantages can often be attributed to poverty alone, as the black population has a lower income, especially the women, it is admitted that institutional racism is directly related to inequalities in the provision of health care. 14he existence of racial and gender discrimination and of their impacts on black women's reproductive health needs to be recognized by health professionals and institutions.In this sense, affirmative actions -such as the insertion of the issue of racism into health institutions' discussion agendas, and the construction of networks for confronting racism with the participation of health professionals, universities and social movements, have been presented as steps for confronting racism in health. 24esides this recognition, it is necessary to put into effect a care which is sensitive to questions of gender and race 8 with a view to reducing inequalities and improving indicators in black women's reproductive health.The nurses have a fundamental role in this process, as they are responsible for meeting an important demand for reproductive health care and can contribute significantly to the development and implementation of strategic actions and mechanisms for confronting racism and empowering black women in the face of discriminatory situations.

FINAL CONSIDERATIONS
In a general way, the women's accounts were permeated by situations considered as evidence for racial discrimination.Complaints about unequal treatment, indifferent attendance, discriminatory gestures or behaviors practised by health professionals and dissatisfaction with the attendance were present in the interviewees' reports, indicating the different forms of racial discrimination perceived by the women.
Despite it being notable that the women perceive and report discriminatory situations, some of them show difficulty in perceiving and recognizing that they too are victims.This failure to recognize and perceive discrimination in the health services evidences, in a certain way, the naturalization of inequalities linked to racial conditions in Brazilian society and indicates the need to adopt political measures which combat inequalities and institutional racism in the health services and, consequently, their impacts on the health of the black and poor population.
The low number of studies on the perception of racial discrimination in the ambit of the health services denotes the naturalized way in which institutional racism is treated by researchers, which contributes to the reproduction and naturalization of discriminatory practices in these services.
Further investigations concerning this issue will contribute to shedding light on aspects surrounding this problem, favoring the access of the black population, and particularly black women, to health care.It would also contribute to quality of care, calling the health professionals' attention to racial inequalities in health care and, in contrast, would reduce the black population's vulnerability to a series of health risks and damages, as discrimination is reflected in the conducts and behaviors linked to health.