Introduction

Despite the greater access to sexual and reproductive health, the fertility rate fell from 3.92 to 2.90 in poor women in recent decades, which resulted in a mean of 1.7 children per woman in Brazil. ¹ However, this decrease did not reduce the number of abortions, especially among the most vulnerable women, unveiling the official registry of 24.8 thousand abortions in the Unified Health System (UHS), between the years 2010 and 2019, mostly in the Northeast, and 721 deaths in Brazil between 2009 and 2018 as a result of complications. ²

Part of this data is due to the conditions of socio-cultural, economic and political vulnerability in which women are involved, the low quality of care, the absence of empathic process and the failure of communication between health professionals and violence perpetrated by the health team, constituting the current phenomenon entitled obstetric violence. Considered as a global problem, obstetric violence can be defined as any violent act based on gender that results in mental, sexual, patrimonial or physical damage, causing the suffering of the woman, through threats, coercion or arbitrary deprivation of liberty, which may occur during prenatal, childbirth, postpartum and abortion situations. This problem affects women of different ages and can be characterized by neglect in care, physical, verbal, psychological and even sexual violence committed by health professionals, in the pregnancy-puerperal cycle and in abortion situation, the latter being the focus of this study. ³

Violence against women is socially naturalized, especially in obstetric care, where there is a greater process of expropriation of their body and suppression of their autonomy in situations of induced or provoked abortion. One of the evidences is the hostile and humiliating treatments to women in this process. ⁴

Situations of obstetric violence are also perceived at the international level, considering the use of the term Abuse in healthcare to describe negligence, psychological, verbal, physical and sexual abuse committed in the space of care for pregnant women, parturients and puerperal mothers ⁵_. In addition, a Nordic study described that approximately 13 to 18 % of women reported suffering practices belonging to obstetric violence. ⁶

It is evident that women in the process of abortion suffer abuse in public and private health institutions with some frequency, characterizing an exponential increase in obstetric violence with sequelae and death, requiring intervention with brevity. ^7,8 Brazilian research reveals that 25 % of women suffered some kind of violence during labor, childbirth, postpartum or abortion, and some of these acts or actions are naturalized by women themselves, due to the lack of adequate knowledge about the phenomenon. ⁹

Another study pointed to a high percentage of maternity hospitals that perform unnecessary interventions, characterized by: 63.5 % of use of venous catheter, 4.3 % of use of uterotonic drugs and 86.3 % of maintenance of the lithotomy position, practices clearly framed in obstetric violence and that happen in cases of abortion. ¹⁰

In Mexico, obstetric violence is discriminatory, as health professionals repress women’s cultural practices through: neglect; lack of privacy during procedures; use of unnecessary technologies; verbal and psychological abuse; and denial of female autonomy about the decision and preference about her body. ¹¹

In this sense, it is urgent to change health care practices, in order to respect the particularities, pains, vulnerabilities and subjectivities of each woman who experiences the process of abortion, without judgments and focusing on humanization and scientific evidence. ¹² The present study is justified as it intends to explore an object of great social magnitude, with high mortality rates and complications that affect the quality of life of women, especially those who abort.

Given the above, the following question arose: What are the health care practices developed in the abortion process typified as obstetric violence? Thus, the objective was: to analyze health care practices in the abortion process typified as obstetric violence. Therefore, the social and scientific relevance of the research focuses on the need for greater understanding and deepening on the subject, the improvement of health care practices for women in the process of abortion, which should be centered on humanization, quality and female protagonism.

Method

This is a qualitative and descriptive study, centered on the constructivist paradigm, which has a dynamic character, manifested through the development of concepts, from facts and opinions, enabling a format that goes beyond something predictable and measurable. ¹³

The study was conducted in a public hospital located in Brazil. This service assists the local population and neighboring municipalities, offering obstetric and pediatric care. It has 105 hospitalization beds, 10 of which are Neonatal Intensive Care Unit (NICU), 25 semi-intensive, 5 in the In-hospital Center for Normal Delivery (CND) and has a reference maternity in the region.

The study participants were the health professionals of technical and higher level, chosen by convenience sample, respecting the following inclusion criteria: being admitted or hired by the institution, having assisted women in the process of abortion. The exclusion criteria were: being in the process of illness or service leave for any other reason. It is noteworthy that the researchers did not previously know or had ties with the participants of the study. All participants who assisted women in the abortion process were invited and only 15 met the inclusion criteria, constituting the eligible population of the study.

After approval by the Ethics Committee of the State University of Santa Cruz, a meeting was held with the Coordinator of Permanent Education and the Nursing coordinator of the hospital, in which the responsible researcher clarified together with her team composed of two scholarship students duly trained for the collection, a professor in women’s health, a master’s student in nursing and a care nurse on the objectives of the research and how it would be performed. Then, all were presented to the hospital team, when they could explain again about the research, then occurring the first approach with the participants.

Before beginning the interview, the participant was informed in detail about the objectives of the research, with presentation and subsequent signature of the Informed Consent Form (ICF), demonstrating his/her consent to participate in the study.

Data collection was carried out in person, in November 2022, respecting the current protocols of the pandemic caused by the COVID-19 and the interest of the participant, using as an instrument a semi-structured interview script, involving open questions, such as: “Have you ever witnessed any situation of mistreatment of women in the process of abortion made by health professionals (rudeness, threat, shouting or humiliation, jokes, malicious comments, laughter for no reason)?”, “What procedures do you usually do when watching women in the process of abortion?”, “Have you ever performed or seen someone perform an unnecessary intervention to the woman in the process of abortion?”, recorded on a digital device. The interviews lasted an average of 20 minutes and the closure of the collection was by theoretical saturation of the data.

Then, all interviews were transcribed for further reading and analysis by the thematic content technique proposed by Bardin, through the phases of: pre-analysis: moment in which all interviews were transcribed and carefully read; exploration of the material: phase in which the interviews were read in depth and codified; treatment of the results and interpretation: stage that involves the categorization of the themes presented in the speeches of the participants. ¹⁴

The study followed Resolutions No. 466/2012 and No. 510/2016 of the National Health Council (NHC), which ensures the rights and duties of all participants and provides for the researcher-participant relationship. ^15,16 All participants were named by a letter "I" followed by a cardinal number to ensure anonymity. Finally, the material collected and analyzed will be archived for a period of five years, being excluded after this period.

Results and Analysis

The study included 15 health professionals, since this number corresponds to 100 % of those who assisted women in the process of abortion, 13 female and two male, the age interval ranged from 26 to 50 years. With regard to color/ethnicity, seven self-declared as brown, five black and three white. As for religion, eight called themselves Catholics, three Evangelicals, one Protestant, one Spiritist and two have no religion.

Regarding the professional profile, seven had technical level, all nursing technicians, and eight higher level, six being a nurse, a doctor and a nutritionist. The length of training ranged from two to 24 years, and the period of operation in the hospital ranged from six months to one year. After characterizing the profile, there was the attentive reading of the participants' testimonies, codification of the themes presented in the discourses in relation to the research questions and the definition of a category. This category shows that the care practices for women who have experienced the abortion process are loaded with prejudices and stigmas with value judgement by the health professional, devaluing complaints and causing devaluation of the user’s needs, as detailed below:

Discussion

It is known that obstetric violence is not perpetrated by a single type of health professional, and can be committed by any professional assisting the woman during the abortion process, including doctors, nurses, anesthetists, nursing technicians, receptionists, administrators and others, as evidenced in the results of this study. It is noted that technical-level professionals, most often defined as receptionists and health, such as nursing technicians, doctors, nurses and nutritionists were the professional categories found perpetrating obstetric violence in the abortion. ¹⁷

In this context, the way the woman who experiences the process of abortion is received in the service will affect her comfort and satisfaction, whose doubts will often not be clarified, in addition not to being welcomed and respected, resulting in the intensification of physical and psychological suffering. In addition, situations related to inadequate infrastructure of institutions impair the assistance provided to women in the process of abortion, with emphasis on sharing the environment of hospitalization with pregnant women and parturients with alive children, which tends to hinder the confrontation and overcoming. Allocating women who aborted along with pregnant women, parturients, postpartum women and their NBs is something reckless and considered obstetric violence, since such situation can cause depression, trauma and even influence these women not to seek health service. ¹⁸

Although obstetric violence is quite recurrent in Brazil, it is still a little known and discussed topic, especially when related to abortion, having been gradually incorporated into the process of formation of health professionals in the last 5 to 10 years, which can contribute to its expansion. ^17,18

Moreover, obstetric violence goes through various levels of complexity, from primary, secondary to tertiary care, not being restricted to hospital environments. This type of violence against women in the abortion process occurs in public and private spaces of assistance, requiring immediate intervention to mitigate it. ¹⁹

It is also emphasized that the practices typified as obstetric violence represent a serious violation of human rights and, therefore, should be understood as a public health problem that affects the citizenship and protagonism of women in the abortion process, demanding rapid confrontation. ^20,22

It should be noted that obstetric violence is also a worrying social phenomenon and ends up being increased when women experience abortion, often manifested through unnecessary questioning by the health team, with treatment focused purely on the procedure, with reprimand and judgments, lack of psychological support beyond organizational and structural issues such as lack of inputs or adequate beds and disproportionate number of staff to provide more adequate assistance. ⁷

There are also practices related to the delay and/or denial of care to women who miscarried with the intention of discovering the causes, whether it was intentional or not; moreover, there are also intimidation, invasive procedures without the consent of the woman, most often without anesthesia. ²³

Research carried out in an institution of reference to abortion showed the presence of institutional, psychological, religious and negligent obstetric violence, which is closely related to issues involving individual values and moral judgments of health professionals, being manifested by acts of recrimination and disrespect on their part. The use of personal values in care contributes to the naturalization of discriminatory and violent practices. Thus, it is essential to work with the conditions of vulnerability of women who are in the process of abortion, being necessary to deconstruct moral and religious values of health professionals, allowing these users to be assisted with respect and humanization. ²⁴

It is noteworthy that the care practices for women in the process of abortion that have a highly punitive character, without considering social desires and ills, are highly exclusive and inappropriate. ²⁵ Considering the typification of induced or spontaneous abortion to determine the type of care conduct is something that should be fully curbed in the care of these women. Denying analgesic and anesthetic during the procedures and minimizing complaints is unacceptable in assisting women in the process of abortion. ^26,27

Study conducted with residents in obstetric nursing of a philanthropic institution points to the presence of negligence, disrespect, imposition of values, moral judgment, breach of confidentiality, invasion of privacy and refusal to care for women in the process of abortion, demonstrating the hierarchy and authority of professionals in institutional routines as a form of threat to the right to life, health, physical and psychological integrity.²⁶

Reports of professionals who work in maternity hospitals demonstrate the difficulty they have in dealing with women in the process of abortion, as they put prejudice, discrimination and punishment as a priority in the care provided, demonstrating the need to train professionals to deal with this problem in a respectful way. ²⁸

Finally, expanding the knowledge of health professionals about forms of care for women in the process of abortion will be fundamental to overcome obstetric violence and allow care to be performed based on embracement, problem-solving, respect and fulfilled by the best scientific evidence. ^29,30 Therefore, health professionals should offer the care free of judgments to women in abortion, exercising the empathic approach, making the process less difficult and painful.

The limitation of the study focuses on the object, the process of abortion, although obstetric violence includes women during prenatal, childbirth and postpartum. In addition, the small number of participants results from the health professionals of the place chosen for the study not having assisted women during the abortion.

Conclusions

The investigation shed light on the existence of practices classified as obstetric violence, evidenced by the statements of health professionals. An important practice includes placing the woman in the abortive process in the same space as the pregnant woman, the puerperal woman and the newborn, which resulted in the exclusive treatment of users who opted for induced abortion. Moreover, these practices lead to an assistance impregnated with beliefs, prejudices, stigmas, opinions and judgments, minimizing the complaints presented by the affected women.

Therefore, it is evident the urgent need for a more solid and effective intervention by managers and coordinators of health services. It is essential to implement clear policies and protocols to prevent occurrences of obstetric violence in the daily work of health teams. Likewise, greater awareness and training of medical personnel is required to ensure respectful, compassionate and impartial treatment for all users regardless of their pregnancy decisions. The construction of a safe and empathetic care environment is essential to ensure the well-being of women in this process.

The research contributes to Women’s Science and Health, because it presents the practices of obstetric violence in women who go through the abortion process, allowing us to act on the social constructs, among health professionals, improving the care provided.