ORIGINAL ARTICLES

Profile of women who were subjected to the Abortion Established by Law: a descriptive exploratory study

Maria da Graça Camargo Neves¹, Dirce Guilhem², Suzana Gonçalves Rodrigues³

¹Health State Secretary of the Federal District
²University of Brasília
³Health Sciences College of Education

ABSTRACT
Aim: To define the profile of women undergoing pregnancy termination in the Legal Abortion program, in the Federal District.
Method: A descriptive, exploratory and documental study that defines the profile of women and adolescents between 2007 and 2013.
Results: Of the 81 women who interrupted pregnancy due to extra or intra-familial sexual violence, the majority were adolescents and young adult women with gestational age up to 12 weeks.
Discussion: There are few publications on this topic in Brazil. The survey reveals that 7.4% of gestational interruptions diverge from the prescribed protocol in the Technical Standard. When compared to another research project in Brazil, we highlight differences between religion, color and gestational age at the time of interruption.
Conclusions: To foster communication to stimulate information of individuals and self-care; to invest in the humanization of the professionals who monitor the process of women; to reformulate public policies and promote research in this area.
Descriptors: Abortion, Legal; Health Profile; Public Policies; Women's Health; Adolescent.

INTRODUCTION

Public debates, which are fruits of the feminist movement in the 1960s and the American Convention of 1995, proposed that the State should bring together certain demands claimed to be public policies. The priority was gender violence with a view to prevention, punishment and eradication, determined as a crime that is responsibility of the society as a whole and causes physical, psychological and sexual suffering as well as death^(1-2). Sexual abuse, one of the oldest and most frequent forms of violence in our society, reflects bitter expressions of gender aggression and it is characterized by its increase in the unequal power relations and it represents a brutal violation of human, sexual and reproductive rights⁽³⁾.

Each year approximately 12 million people experience different situations of sexual violence. In Brazil, data show an average of 8.7 rapes per 100,000 inhabitants; in the United States of America (USA) one case occurs every 6.4 minutes and it is considered the fastest growing violent crime in the country^(2,4,5).

As a result of sexual violence, a complexity of psychological, social and biological reactions that are considered intolerable for many women emerges. We highlight depression, bulimia, anorexia, sexual affective disorders, emotional and relationship difficulties, suicide, sexually transmitted diseases and physical injuries. The unwanted and unintended pregnancy is seen as a revictimization and it exacerbates the reactional conditions described above, concomitantly to the immediate need of coping as in the case of gestational interruption that takes time, frequency and cost to the public service^(3,4,6).

The termination of pregnancy, linked or not to sexual violence,  occupies a prominent place in contemporary societies which are characterized by a moral pluralism and the defense of a secular state, including a wide range of moral diversities⁽⁷⁾.

Countries are confronted with regard to the legislation to be adopted in cases of pregnancy termination, as a referendum in Europe in 2007 found. Among the countries with restrictive laws, we may highlight Ireland and Malta^(2,8). Debates between legal, religious and feminist bodies and scientific societies lead to reflections on the decriminalization of abortion, thus reflecting the reform of the current legislation in abortion cases provided for in the Penal Code^(4,5,6,9).

Twelve European countries, including Germany, France, Spain and Portugal, allow abortion during the first 12 weeks of pregnancy in case there is risk of death for the woman or if there is a threat to their physical or mental health, as well as in cases of rape, incest or fetal malformation^(2,3,8). In Latin and Central America, countries such as Chile, El Salvador, Nicaragua and the Dominican Republic do not interrupt the pregnancy under any circumstances. However, Argentina, Venezuela, Costa Rica, Peru and Paraguay, among others, permit abortion in some cases⁽⁸⁾.

In Brazil, in cases of pregnancy resulting from sexual violence, women and adolescents, as well as their legal representatives, have the right to be informed of the possibility of terminating pregnancy, as stated in the 1940 Criminal Code as well as their right to keep it until the end. In case they decide to keep it they can choose to donate the newborn or not and prenatal care is ensured to them. However, only in the 1980s was care officially carried out in the Brazilian healthcare public service⁽⁴⁾.

In Brazil there are 441 childcare services aimed at women who are victims of sexual violence. Of these, sixty three (63) carry out the abortion provided for by the law⁽⁶⁾. The service depicted in this study, consisting of a multi-professional team, is supposed to welcome, protect and care biologically, psychologically and socially for women and adolescent girls who are victims of sexual violence when there is risk of maternal death and when they opt for the legal interruption of pregnancy.

The year 2007 tallied a total of seven records of pregnancy interruptions due to sexual violence. After four years, in 2011, the records already reached 16 interruptions, referring to an upward line in terms of the amount of procedures. From the year 2007 until the second half of 2013 the number of legal interruptions reached 81.

METHOD

The characterization of the profile found and its analysis considered the following aspects: age according to adopted standardization(13-14); gestational age (older or younger than 12 weeks) when searching for the interruption of the gestational program; method used for pregnancy termination; color (self-determined); religion; place of residence (Federal District or the surroundings of the Federal District); record of the police report; forwarding of the Public Prosecutor; reason for interruption and type of violence - extra or intra-family, and in the latter case stating aggressor's tie with the victim of violence.

The standards adopted for the age groups(13-14) involved the following subdivisions:

• Adolescence: 10 to 19 years;
• Initial young adulthood (IYA): age 20-25 years;
• Complete young adulthood (CYA): between 25-35 years;
• Final young adulthood (FYA): between 35-40 years;
• Initial average adulthood (IAA): it refers to the age group of 40-50 years.

As for the place of residence, a geographical split was used to better delineate the profile, adopting the Federal District (FD) and the surroundings of the Federal District as locals, and it grows at a faster rate than the Federal District itself. According to Census data in 2010, conducted by the Brazilian Institute of Geography and Statistics (IBGE), the 22 cities in the state of Goiás and Minas Gerais that border the Federal District suffered a population increase of 27.2% between 2000 and 2010. Before there were 906,275 residents, but last year 1,152,725 residents were recorded. In the FD, population growth was 24.9% in 10 years (the national average is 12.3%).

The Federal District consists of 31 administrative regions: Águas Claras, Brasilia, Brazlândia, Candangolândia, Ceilândia, Cruzeiro, Fercal, Gama, Guará, Itapoã, Jardim Botanico, Norte Lago, Sul Lago, Núcleo Bandeirante, Paranoá, Park Way, Planaltina, Recanto das Emas, Riacho Fundo, Riacho Fundo II, Samambaia, Santa Maria, São Sebastião, SCIA/Estrutural, SIA, Sobradinho, Sobradinho II, Sudoeste/Octagonal, Taguatinga, Varjão and Vicente Pires⁽¹⁵⁾. On the other hand, the surrounding areas encompass the cities of Abadiânia, Água Fria de Goiás, Águas Lindas de Goiás, Alexânia, Cabeceiras, Cidade Ocidental, Cocalzinho de Goiás, Corumbá de Goiás, Cristalina, Formosa, Luziânia, Mimoso de Goiás, Novo Gama, Padre Bernardo, Pirenópolis, Planaltina, Santo Antônio do Descoberto, Valparaíso de Goiás and Vila Boa (in Goiás), also including Unaí, Buritis and Grande Cabeceira (Minas Gerais)⁽¹⁵⁾.

The research protocol was submitted for review by the Ethics Committee in Research of the Health State Department of the Federal District, which includes the abortion program provided by law, and obtained its approval by the 0475/2011 protocol. This study aimed to define the profile of adolescents and women who underwent pregnancy termination in an Abortion Program Established by Law in a public hospital in the FD.

As for the ethical aspects, the Resolution No. 466/2012 of the National Health Council features research involving human subjects and points out that it is necessary to establish procedures to ensure the confidentiality and privacy, protection of the image and non-stigmatization⁽¹⁶⁾.

RESULTS

The results are presented in tables for easy viewing of the data found and are discussed below.

DISCUSSION

Studies on this type of profile are scarce in Brazil. The lack of information is still the greatest weapon against the consolidation of the collective health of Brazilian women, of the realization of self-care and the search for rights under the Unified Health System (UHS).

The data presented in this study are in line with research conducted in a Reference Center in 2008 regarding  extra-familial sexual violence. Both studies reflect this predominance in more than 50% of the cases⁽²⁾.

As for the gestational age at the time of the interruption, 40 (49.3%) women/teenagers assisted by the Program in the FD had pregnancy interrupted up to 12 weeks and the same percentage after 12 weeks. These results are similar to those found in a São Paulo referral center and the percentage of women (55%) who underwent the termination beyond 12 weeks of gestation is slightly higher⁽²⁾. This is a finding that deserves attention from the departments involved in the APL programs, considering the risks (physical and/or psychological) arising from the performance of the procedure after 12 weeks.

There are differences with regard to religion: most women/teens of the FD (43), which correspond to 53.0%, belonged to the Protestant religion, while in São Paulo 45% were Catholic. As for the color, among women who have had gestational interruption resulting from sexual violence, 44 (54.3%) identified themselves as brown and in São Paulo, 60% of them regard themselves as white in the present study.

Most women/teenagers who had the legal termination of pregnancy were in the age group of adolescence and young adulthood, aged between 10 and 44 years, with an average of 21.5 years. The sample features a low average age when compared to other studies⁽²⁾.

The interruption authorization according to the established law is limited to 22 weeks of gestation and the methods set out to perform it are provided in the technical standard, which regulates actions related to this issue⁽³⁾. The classification based on the gestational age of women/teenagers when looking for the service is set as smaller or greater than 12 weeks. The appropriate method to perform the interruption is related to gestational age, so the intrauterine vacuuming is the recommended method for up to 12 weeks. Uterine curettage and medical abortion with misoprostol, which are considered valid and safe options for pregnancy termination, can also be used particularly in the first quarter^(3,16,17). For pregnancies after 12 weeks, abortion through a pharmacological process is the chosen method^(3,16,17).

Table 2 shows that six of the procedures performed (7.4%) differed from the Technical Standard by using methods that did not follow the protocol for the legal interruption of pregnancy. This situation needs to be reviewed by the health team so that the established protocols are followed⁽³⁾.

The right to the termination of pregnancy resulting from sexual violence is established by law⁽⁴⁾. The requirement for presentation of the police report or the IML Report for care in health services is incorrect and illegal⁽³⁾. It is noteworthy that the record of the police report is based on the procedure of the IML report, which provides the criminal evidence. However, health professionals accept and give credit to the reports of women without making value judgments or any inference to an investigation: "Our goal is not to say if it is true or false"⁽¹²⁾.

The highest number of police reports was made by teenagers. This fact is not consistent with the protocols provided for the performance of abortion established by law; however, it makes it easier to carry out criminal investigation through the use of DNA in the fetus⁽¹⁸⁾.

Table 4 presents data related to the aggressor. In 13 cases (16.1%) the perpetrator belonged to the family circle and 44 (54.3%) women/teenagers have mentioned that the offender was not known. Regardless of the individual who originated the violation, it is guaranteed to women/adolescents, or their legal representatives, the right to decide on carrying out the abortion established by law or not. Ignorance in terms of the author of violence is also prevalent in other published studies in which the perpetrator was not known for more than 50% of women/adolescents^(2,4). In 14 cases (17.2%) it was not possible to obtain this information.

Based on the profile outlined in this study, it is imperative that there are developments through other research on the subject. Data point to the need to redirect the management of this service for review of public policies aimed at modifying the flow chart that allows the screening of women and adolescent girls assisted by the service.

CONCLUSION

In the period from 2007 to 2013, ninety-six (96) women were treated in the service. Of these women, eighty-one (81) carried out the interruption management, and among these, 57 (70% approximately) were proven to be victims of sexual violence. However, the exact number of women/teenagers who suffer sexual violence is difficult to estimate, since many of them do not report it to health services or public security for fear or shame and for this reason they become vulnerable in terms of unwanted pregnancy, sexually transmitted diseases and the acquired human immunodeficiency virus (AIDS). These situations are preventable through emergency contraception and prophylaxis against STD and AIDS available in most public hospitals in the Federal District.

After pregnancy interruption, women/teenagers remain resistant to the monitoring by the multidisciplinary team, even in the presence of signs of depression and suicidal ideation that arise with some frequency. When there is an active search for these patients by the multidisciplinary team, they claim religious issues for Follow-up interruption by opting for silence and denial. This is an important vulnerability on the part of the service that deserves attention in order to be modified.

The humanization of the service still shows important deficits with regard to the relations between professionals and users, often creating asymmetrical relationships resulting from inter-professional and gender inequalities. Professionals are considered as technically holders of knowledge and they expect that women, who are conceived as an application object of this knowledge, act in a passive and inert form, alienated and without the power to choose. In this context, it is important to review the management process.

Performing other studies relating to the profile of women and adolescents who use the legal interruption of pregnancy services is necessary. The development of standard operating procedures (SOP)⁽¹⁹⁾ is an important element to achieve greater uniformity in terms of the actions taken, greater diligence and qualification as the biopsychosocial care of women victims of the violence so prevalent today. However, these strategies must be accompanied by reformulation of public policies for effective prevention of sexual violence.

Research related to the effectiveness and availability of emergency contraception is needed in the public services, since the number of pregnancies has increased, even amongst those women who used the chemical treatment in time for its action. Other aspects that need to be investigated are those related to the control of STDs and HIV serology for these women, as provided for in the protocols. In this context, there is a long way to go.

REFERENCES

1.  Rocha MIB, Barbosa R (Org.). Aborto no Brasil e países do Cone Sul: panorama da situação e dos estudos acadêmicos. Campinas: Núcleo de Estudos de População – Nepo. Unicamp; 2009.

2.  Ministério da Saúde (Brasil). Secretaria de Atenção à Saúde. Magnitude do Aborto no Brasil. Aspectos Epidemiológicos e Sócio-Culturais. Abortamento Previsto em lei em situações de violência sexual. Brasília: Ministério da Saúse; 2008.

3. Ministério da Saúde (Brasil). Secretaria de Atenção à Saúde. Prevenção e tratamento dos agravos resultantes da violência sexual contra mulheres e adolescentes: Norma Técnica. 3. ed. Brasília: Ministério da Saúde; 2012.

4. Souza CM, Adesse L (org.). Violência sexual no Brasil: perspectivas e desafios. Brasília: Secretaria Especial de Políticas para as Mulheres. 2005; 188p.

5. Drezett J, Pedroso D. Aborto e violência sexual. Cienc. Cult.  [ Internet ]. 2012 June [ cited 2013 Dec 09 ] 64(2): 35-38. Available from: http://cienciaecultura.bvs.br/scielo.php?script=sci_arttext&pid=S0009-67252012000200015&lng=en.

6. Secretaria de Políticas para as Mulheres. Rede de Enfrentamento à Violência contra as Mulheres. Secretaria Nacional de Enfrentamento à Violência contra as Mulheres. Brasília: [ s.e. ] 2012.

7. Camargo MG, Guilhem DB. Abortion procedures provided by law - repercussions for the health service: an exploratory study. Online braz j nurs [ periodic online ].2012 Oct [ cited 2013 Dec 09 ] 11 Suppl 1: 475-8. Available from: http://www.objnursing.uff.br/index.php/nursing/article/view/3942

8. Rodrigues TJH. Aborto e legislação comparada. Cienc. Cult.  [ Internet ]. 2012 June [ cited 2013 Dec 09 ] 64(2): 40-44. Available from: http://cienciaecultura.bvs.br/scielo.php?script=sci_arttext&pid=S0009-67252012000200017&lng=en.

9. Aldana M, Winckler S. Direitos reprodutivos: debates e disputas sobre o direito ao aborto no contexto da redemocratização do Brasil. Revista Sequência [ internet ]. 2009 July [ cited 2013 Dec 09 ] 58: 167-183. Available from: https://www.journal.ufsc.br/index.php/sequencia/article/view/2177-7055.2009v30n58p167/13611

10. Gil AC. Métodos e técnicas de pesquisa social. 6ª ed. São Paulo: Atlas, 2008.

11. Prodanov CC, Freitas EC. Metodologia do trabalho Científico: Métodos e Técnicas da Pesquisa e do Trabalho Acadêmico. 2. ed. Rio Grande do Sul: Universidade Feevale; 2013.

12. De Zordo S. Representations and experiences of obstetrician/gynecologists with legal and illegal abortion in two maternity-hospitals in Salvador da Bahia. Ciênc. saúde coletiva  [ Internet ]. 2012  July [ cited  2013  Dec  09 ]  17(7):1745-1754. Available from: http://www.scielo.br/scielo.php?script=sci_arttext&pid=S1413-81232012000700013&lng=en.

13. Ministério da Saúde (Brasil). Secretaria de Atenção em Saúde. Diretrizes nacionais para atenção integral à saúde de adolescentes e jovens na promoção, proteção e recuperação da saúde. Brasília: Ministério da Saúde; 2010.

14. Santos BS, Antunes DD. Adult life, motivational processes and diversity. Educação [ serial on the internet ] 2007 Jan/July [ cited 2013 Dec 09 ] 1(61), p. 149-164. Available from: http://revistaseletronicas.pucrs.br/ojs/index.php/faced/article/view/544/380

15. Anuário do Distrito Federal. Regiões Administrativas. 2012. Available from: http://www.anuariododf.com.br/regioes-administrativas/

16. Ministério da Saúde (Brasil). Conselho Nacional de Saúde. Comissão Nacional de Ética em Pesquisa. Resolução 466/2012 de 13 de Junho de 2012.

17. World Health Organization. Safe abortion: technical and policy guidance for health systems. 2nd ed. 2012.

18. Barbosa AH, Reggiane C, Drezett J, Neto JA. Abortamento legal – Guideline. Sociedade Brasileira de Reprodução Humana. [ s.d ].

19. Barbosa CN, Mauro MFZ, Cristovão SAB, Mangione JA. The importance of standard operating procedures (SOPs) for clinical research centers. Rev Assoc Med Bras [ serial on the internet ] 2011 [ cited 2013 Dec 09 ] 57(2):134-135. Available from: http://www.scielo.br/pdf/ramb/v57n2/en_v57n2a07.pdf

All authors participated in the phases of this publication in one or more of the following steps, in According to the recommendations of the International Committee of Medical Journal Editors (ICMJE, 2013): (a) substantial involvement in the planning or preparation of the manuscript or in the collection, analysis or interpretation of data; (b) preparation of the manuscript or conducting critical revision of intellectual content; (c) approval of the versión submitted of this manuscript. All authors declare for the appropriate purposes that the responsibilities related to all aspects of the manuscript submitted to OBJN are yours. They ensure that issues related to the accuracy or integrity of any part of the article were properly investigated and resolved. Therefore, they exempt the OBJN of any participation whatsoever in any imbroglios concerning the content under consideration. All authors declare that they have no conflict of interest of financial or personal nature concerning this manuscript which may influence the writing and/or interpretation of the findings. This statement has been digitally signed by all authors as recommended by the ICMJE, whose model is available in http://www.objnursing.uff.br/normas/DUDE_eng_13-06-2013.pdf

Received: 12/19/2013
Revised: 12/21/2014
Approved: 01/06/2015