COMPREHENSIVE CARE IN ABORTION AND REPRODUCTIVE COUNSELING TO THE WOMAN WHO MISCARRIED : PERCEPTIONS OF NURSING

The aim in this study was to know how nursing professionals perceive comprehensive care delivery and reproductive counseling to women who miscarried. This exploratory and descriptive study with a qualitative approach was conducted with 19 nursing professionals who work at the maternity and birth center of a University Hospital in the South of Brazil. The data were collected through semi-structured interviews in November 2012. For data analysis, the Collective subject discourse method was applied. In the results, the central ideas gave rise to two categories: comprehensive are to women hospitalized for abortion and reproductive counseling as a strategy to promote reproductive health. In these, the subjects showed that they perceive comprehensive care as the satisfaction of biological needs and reproductive advice centered on contraception guidelines. Thus, the importance ofthe qualification of nursing professionals and other studies with different approaches is highlighted. 1 Universidade Federal do Rio Grande. Rio Grande RS, Brazil. 2 Universidade Federal do Rio Grande. Rio Grande RS, Brazil. 3 Universidade Federal do Rio Grande. Rio Grande RS, Brazil. 4 Universidade Federal de Pelotas. Pelotas RS, Brazil. 5 Universidade Federal do Rio Grande. Rio Grande RS, Brazil. 6 Universidade Federal do Rio Grande. Rio Grande RS, Brazil. RESEARCH PESQUISA INVESTIGACIÓN Cuidado integral e aconselhamento reprodutivo à mulher que abortou: percepções da enfermagem Esc Anna Nery (print)2013 Sep-Dec; 17 (4):698 704 Ivanete da Silva Santiago Strefling1, Wilson Danilo Lunardi Filho2, Nalú Pereira da Costa Kerber3, Marilu Correa Soares4, Vera Lúcia de Oliveira Gomes5, Elisa de Vargas6 Atención integral y asesoramiento reproductivo a la mujer que hizo un aborto: percepciones de la enfermería Abortion; Comprehensive health care; Health promotion; Nursing.


INTRODUCTION
In the course of the 20th century, different changes took place in the Brazilian public health context.Among these transformations, the conquests of social movements and feminist groups stand out regarding the right of women to comprehensive care and reproductive planning.In the Unified Health System (SUS), these conquests are guaranteed by programs and policies that, from a gender focus, adopt integrality and health promotion as guiding principles and aim to consolidate advances in the field of sexual and reproductive rights, with emphasis on the improvement of obstetric care, family planning and care to miscarriages 1 .
Specifically in situations of abortion, its practice is expressed through social inequality as, although the women share the same situation of illegality in most developing countries, most of the female population turns to different unsafe strategies, which frequently cause complications and entail maternal deaths 2 .
According to the Ministry of Health (MH), comprehensive care delivery in situations of abortion ranges from welcoming and the diagnosis of each user's true needs to the use of appropriate technologies for the treatment and the inclusion of orientations and clarifications about family planning, with a view to the choice and adoption of an appropriate contraceptive method in each situation 2 .
However, scientific evidence indicates that most abor tions results from unattended reproductive planning needs, involving lack of information and/or difficulties to access contraceptive methods, errors in their use, irregular or inappropriate use and lack of monitoring by health services 3,4 .These errors affect the women's personal, family and social life, put a strain on the health system and raise the costs to treat complications [5][6][7][8] .
In Brazil, according to ar t. 128 of the Penal Code issued in 1940, abor tion is only allowed in cases of risk for the mother's life and pregnancies deriving from sexual violence 2 .In 2012, the Brazilian Supreme Cour t approved the interruption of pregnancies with an anencephalous fetus.Research [3][4][5][6]9 indicates, however, that unplanned pregnancy is the main cause of abor tion.
In this perspective, in 2005, the MH issued the Technical Standard of Humanized Care Delivery to Abortion (NTAHA) 2 , offering support for health professionals to perform not only immediate care actions for complications that entail risks for the women's health and life, but also contraceptive alternatives to prevent the occurrence of unplanned pregnancies and repeated abortions 2 .This preventive measure is recommended for cases of induced and spontaneous abortion as, in both, the return to fertility is immediate and the female organism needs to reestablish before any new pregnancy.
Many women who arrive at the health service in case of abortion manifest not only physical, emotional and social needs, but also difficulties to recognize signs of possible complications which, in combination with fear, shame and care access difficulties, can make the women delay their search for care and information to guide the choice that is most appropriate to their context and moment in life 2 .In view of the above, reproductive counseling serves as a two-way communication technology that facilitates the interaction and information exchange between the professional and the woman and that can offer satisfactory results, mainly when this communication process takes place during the hospitalization period of women who miscarried 3,5,10 .
In hospital, the entire health team is responsible for identifying these women's true needs.Nursing professionals, however, who are present throughout the hospitalization period, have more opportunity to talk, listen and identify each woman's physical, mental and social needs and can modify the care model, offering a new paradigm to the women and society, which makes preventive actions safe, sustainable and effective 2 .
Never theless, studies 5,8,10 indicate that, in the Brazilian context, reproductive counseling in the post-abortion period and/or referral for continuous monitoring in the primary care network are not part of nursing care plans.Consequently, when assessing possible factors related to unplanned pregnancy, a study developed at two hospitals in Rio Grande/RS revealed that 65% of the pregnancies are not planned and happen due to lack of information and access to safe and effective methods 10 .
As the hospitalization can be many women's sole contact with the health system, and as reproductive counseling is a strategy that can be developed in all care spheres, the emphasis of actions on these aspects can contribute to bring down maternal morbidity and mortality due to avoidable causes, as well as the rates of abortionrelated complications 11 .
Therefore, due to the importance of nursing in the implementation of comprehensive care, in the provision of reproductive counseling, and with a view to transforming this reality, it is evidenced that nursing professionals need to reflect on their attitudes and commitments.In view of these considerations, this study was aimed at knowing how nursing professionals perceive comprehensive care and reproductive counseling as a reproductive health promotion strategy to women after a miscarriage.
Comprehensive care in abortion and reproductive counseling to the woman who miscarried

METHOD
An exploratory and descriptive study with a qualitative approach was carried out, which permitted further knowledge on the study theme and revealed the research subjects' perceptions and opinions on the reality they experienced.The study context was the Maternity and Obstetric Center of a university hospital located in the South of Rio Grande do Sul, which attends to women in obstetric emergency situations, including women who are having complications in the abortion process.
The data collection technique was the semistructured interview, addressing the following questions: what do you consider as care centered on the comprehensive health needs of women hospitalized due to abortion?Do you use any reproductive health promotion strategy during care delivery to women hospitalized due to abortion?What do you think about reproductive counseling during hospitalization?
Nineteen subjects participated in the study, including seven Nurses and 12 Nursing Technicians, working in the different work journeys, who spontaneously accepted to contribute to this research, authorized the recording of the interview for further transcription and dissemination of the collected data and signed the Informed Consent Form.The interviews were held in November 2012, on dates and times previously agreed upon between the researcher and the subject.The total number of participants was determined by the number of interviews that made it possible to fully understand the study phenomenon, characterized by the repetition of the discourse.
For data analysis, the Collective Subject Discourse (CSD) technique was used, a discursive methodological strategy to reconstruct, using excerpts from distinct individual discourse, the summary discourse that is considered necessary to express the par ticipants' collective thinking about the research phenomenon 12 .Thus, three methodological figures were used to analyze the data: the Key Expressions, which revealed the essence of each testimony, the Central Ideas, which described the meaning present in the key expressions, and the CSD, which group similar key expressions, constituting a coherent discourse for each Central Idea.Therefore, connectors were used to give meaning to the CSD, without altering the structure of the phrases the subjects had elaborated though.
This study complied with the Guidelines and Standards of National Health Council Resolution 196/96.Approval for the project was obtained from the Research Ethics Committee at Universidade Federal do Rio Grande -FURG, under Opinion nº 101/2012.

RESULTS AND DISCUSSION
Among the 19 interviewees, one professional was male.The participants' age range varied between 24 and 64 years.The professional experience ranged between 6 months and 45 years.The researchers decided not to limit the work period in order to discover similarities and/or differences among discourse on the theme.
In the analysis of the testimonies, different central ideas stood out, which were organized in two categories: the first refers to comprehensive care to women hospitalized due to miscarriage, and the second addresses reproductive counseling as a reproductive health promotion strategy.

Comprehensive care delivery to women hospitalized due to abortion
Working within a comprehensive care perspective means seeking the possibility to apprehend the human being's broader needs, valuing the articulation between preventive and care perspectives that culminate in the humanization of practices 13 .According to the different realities the women who miscarried experience, humanized conducts are seen as those that demonstrate respect for the woman's option to have an abortion, consider the hospitalization period as an opportunity to listen regarding the psychosocial factors involved in this decision and promote knowledge based on exchange instead of imposition 8 .
The nursing professionals' discourse in this study indicates that care centered on comprehensive needs also includes an ethical, respectful and judgment-free approach, independent from the etiology of the disease.According to the participants, this form of care delivery grants the patients a feeling of wellbeing.

CI -Comprehensive care needs to be free from judgments
CSD: I think we have to deliver comprehensive care independently, whether it's a robber, a woman who provoked an abortion, whether it is someone who shot somebody.Sometimes, it is a baby they were expecting a lot.But we know there are other situations in which it was provoked.We are not here to judge anyone though.Here, care is centered on comprehensive needs.We aim for their wellbeing, respect them, let them cry, attempt to understand the suffering they are going through.
Although the interviewees indicate that care delivery at the research institution is not influenced by judgments about what happened to the user, other studies 5,[11][12][14][15] affirm that this posture is not unanimous, considering that "the look of nursing at women having an abortion is still Strefling ISS, Lunardi Filho WD, Kerber NPC, Soares MC, Gomes VLO, Vargas E Comprehensive care in abortion and reproductive counseling to the woman who miscarried discriminatory and predominantly technical and, when assessed from a humanization perspective, it appears as care with solidary bonding, and not as a human right" 15:140 .
Other factors are mentioned by different authors 9,11-15 which hamper comprehensive care: unavailability of time, excessive number of users at the service and the deficient physical structure.When care is planned with a focus on the subject instead of the disease though, a comprehensive and humanized approach is possible at any time during the interaction 9 .
In the context of this study, the length of professional experience was cited as a limiting factor of comprehensive care delivery.According to the interviewees, the longer the experience, the greater the professionals' lack of commitment to the subject, enhancing the gap between theory and practice and the distancing from comprehensive care in accordance with MH recommendations 2 .

CI -Comprehensive care depending on the length of professional experience
CSD: I think that care centered on the comprehensive needs depends on the experience, on the work time.Perhaps people who are starting are more patient to take care.They go there, talk, advise, already bring up contraceptive methods, adopt a broader, more comprehensive approach.More experienced professionals, on the other hand, are tired.They go there and do what they have to do and that's it.So, in general, I think we are not prepared for that.We would need more frequent training and education to be able to transmit something good and preventthe need for abortion from happening again.
As cases of abortion are common obstetric problems in health institutions, also in the present study reality, the nursing team can often see them as part of routine.Health professionals should be committed to life though, and to the guarantee of care as a human right 8 .In this perspective, nursing as a health profession, which takes care of the human being in its multiple dimensions, needs to reflect on what it means for each woman to experience an abortion and to interpret the signs and symptoms, not only as a something organic, but keeping in mind the social, economic and cultural factors, besides their subjectivity and experiences 11 .
In this study, besides some professionals' apparent lack of commitment to the effectiveness and continuity of the care process, the interviewees' discourse indicate the lack of training and awareness-raising of the professionals to incorporate welcoming and advice as complementary practices in addition to clinical actions, that is, which promote comprehensive care.Hence, impersonality in care, lack of information about the interventions that will be accomplished and neglect to consider the women's needs and ability to share decisions, in accordance with the NTAHA, can compromise the comprehensiveness of the desired care 16 .As a consequence of these aspects, the following discourse reveals that the nursing professionals perceive the care practices focused on compliance with procedures that attend to the woman's biological needs.

CI -
The perception of comprehensive care in situations of abortion is reduced to biological aspects.

CSD: I think that comprehensive care is the approach of the patient at the start of the consult. It means following the medical prescription and doing what the patient needs. If she's in pain, apply medication. If she wants to talk about something, talk, but try not to go deeper into the theme[abortion]
. Try to avoid asking many invasive questions, so as not to make her feel embarrassed.Check the vital signs and do your job.We always consider the breast issue here.Swathe the breasts, explain about the need to take the medication, because they're in a lot of pain, also because of the anxiety.
In this CSD, although the interviewees indicate some comprehensive care foci, most tasks were related to the main task, which is to respond to the clinical needs.Communicative skills, indicated in different contexts as complementary elements of the comprehensive approach, do not seem to be expressive in the research environment, considering that the subjects declare that, when theuser asks a question, they answer.If not, they remain silent and avoid a more profound dialogue.
Therefore, the view the health professionals revealed about comprehensive care does not correspond to the MH's definition of comprehensive care, as their discourse seems to be evasive and mainly focused on the biological needs.The psychoemotional and social aspects were hardly mentioned in the discourse, highlighting that the reproduction of the biomedical model remains predominant in the health service under analysis.This can affect the women's social life, limiting the exercise of their freedom, as well as in the health system itself, with new hospitalizations due to the same needs.
This reality equally seems to multiply in other health services, in accordance with a study undertaken to get to know nurses' social representations about comprehensiveness in care delivery to women in the primary health care network 16 .In that study, the nurses Comprehensive care in abortion and reproductive counseling to the woman who miscarried acknowledged the importance of comprehensive care but were unable to fit them into the professional context or in care practice.

Reproductive counseling as a reproductive health promotion strategy
In Brazil, the reproductive health concept is implicit in health actions, since the creation of the first comprehensive women's health care programs.During different international conferences the United Nations Organization promoted in the 1990's, it was defined that reproductive health implies women and men's ability to enjoy a satisfactory and risk-free sexual life, with freedom to decide on whether to procreate or not, when and how frequently; and the right to information and access to safe, efficient and accessible family planning methods of choice and to access to pregnancy monitoring and risk-free birth services 2 .Nevertheless, access to information and to the necessary family planning services still is not exercised as a universal right by the entire population 4 .
In this study, when discussing reproductive health promotion practices for women who miscarried, the nursing professional demonstrated that they acknowledge the importance and need for a more comprehensive approach, which involves not only the means to avoid an unplanned pregnancy, but also clinical-gynecological monitoring and educative actions, so as to enable the women to make conscious choices.

CI: It is valid to develop reproductive health promotion activities, but the orientations are fragile. CSD: I think that any orientation is valid. Whenever there's acceptance, orientations should be provided [use contraception] because, often, they leave and do not think of visiting another health center, even if they do not want a new pregnancy. Then history repeats itself. That's complicated, but it's real. Most of them don't have anywhere to do cancer prevention, breast cancer control, nothing of the kind. Also, women who did not provoke the abortion and do not want a new pregnancy need to be concerned with STDs, and they don't get that orientation.
In general, they receive treatment due to the abortion, and get discharged with the contraceptive medication, but without the orientation needed.I believe that the topic should be discussed, gynecological care for women, mainly with adolescents, who have a lot to live and need to protect themselves not only against pregnancy, but also against STDs.So, besides the contraception, they need orientation to use the condom.Some of them will listen, others will ignore it and, depending on the situation they are going through, they don't even register what we say when they leave the hospital.But, independently of this posture, I think it's important to give orientations.
Even in reproductive health promotion activities, the participants considered contraception as relevant, mitigating the other aspects of women's sexual and reproductive rights.This revealed that the professionals have some difficulty to address certain themes related to sexuality and private life with women who miscarried 13 .Because it involves subjective issues of the professional and the patient, the abortion theme is perceived as an obstacle to the interaction process.This exercise is not easy, as many professionals are not prepared to deal with the feelings and social issues beyond technical-scientific practice 2 .
It is highlighted, however, that communication isa fundamental tool for nursing professionals who aim to deliver comprehensive and humanized care.In this context, reproductive counseling is highlighted as an educative strategy that helps professionals to get closer to the women, to assess their needs and feelings and to provide orientations and emotional support, helping them to make decisions 2 .
In this perspective, reproductive counseling appears as a fundamental practice for reproductive health promotion and as an essential condition for comprehensive post-abortion care delivery, with a view to reducing unplanned pregnancies and social inequalities, which can give rise to risks to the women's health and life 2 .When asked about what they think about reproductive counseling being provided during the hospitalization, the nursing professionals presented two opposite central ideas, which gave rise to the following two CSD: CI: Reproductive counseling is limited to the supply of contraceptive methods CSD: Look!I think that contraception should be in the water, because there are many adolescents and even multiparous women in their early thirties, who have an abortion, we explain everything in detail but the majority does not understand.If the really did their homework as we teach them there wouldn't be any problem, because the methods are available at primary health services, for free, but they don't take it correctly.They think they can have sex and not take it the next day.They are very resistant to other methods.In the monitoring of seropositive women, the doctor comes here and asks for samples of injectable methods and applies one on Strefling ISS, Lunardi Filho WD, Kerber NPC, Soares MC, Gomes VLO, Vargas E Comprehensive care in abortion and reproductive counseling to the woman who miscarried the way out.Here at the hospital, many methods are not available.Just when the laboratory gives samples.There used to be the placement of IUD.Not anymore.We also advise to use the condom, to avoid other problems than pregnancy.Now, in my opinion, people just don't take care if they don't want to, because there's so much information in the media.Everyone has access to the internet.But it's always good to note because, otherwise, when it comes down to it, they don't take care.
Besides reducing reproductive counseling to orientations for contraception, this CSD reveals the frailty of interpersonal relations as, when the interviewees mention that they transmit some information about counseling for contraceptive purposes to the women, there orientations are not absorbed.This indicates the need for the professionals to get closer to the social context, as it is by acknowledging the subjectivities that permeate the relationship and based on the women's perspectives that a relation of trust and knowledge exchange is established 4 .
Therefore, it is considered that the professionals' sensitivity and commitment are factors that encourage the empathy needed for reproductive counseling.As this is not very visible in the testimonies, the relationship between the professional and the patient is pictured as vertical and hardly successful, as the professionals only transmit what they "think" is necessary and do not attempt to discover the barriers that make it difficult to practice autonomy in each woman's experience of her sexual and reproductive rights.
Thus, for reproductive counseling to be efficient, nurses need to be creative, competent and attentive to the verbal and non-verbal signs of the women and other nursing team professionals.Therefore, the harsh interaction between the health team and the women needs to be ruptured, as human interaction, interpersonal contact and emotion, which naturally appear in the relations, make it possible to involve the women themselves in their recovery, through knowledge exchange, improving their understanding about their body, the way they lead their life and their relation with the social context, thus contributing for them to adopt attitudes that reduce the risks and improve their quality of life 3 .
Another central idea that stood out in the discussion about reproductive counseling to women who miscarried before they are discharged from hospital is that this activity is not part of the nursing professionals' care process at the research institution.

CI: At the study institution, reproductive counseling is not part of the nursing work process.
CSD: Here at the hospital, counseling is still necessary.No specific orientation is provided to the women who miscarried.At least I don't see any of it.The women can beg for a tubal ligation and get out of here without anything.Then they may get pregnant again, try and abort, be unable, put their lives at risk and nothing happens.As it's an emergency service, however, this care could be offered too.Although the hospital follows a humanized paradigm, the women are still discharged with the mere instruction to visit the primary health service.
From a comprehensive care and reproductive health promotion perspective, this reality is a concerning situation, as any woman who receives post-abortion care is entitled to high-quality counseling and access to contraceptive methods 2 .The emphasis on the curative dimension of care, however, with total neglect of prevention and practices that reinforce the women's autonomy in the decision process about their sexual and reproductive life, seem to be reproduced in other Brazilian health services too 17 .
On the opposite, in the international context, reproductive counseling activities post-abortion are strongly stimulated educative actions, through courses, education and training for health professionals 4 .Their effect can be verified in a study that aimed to describe the impact of counseling in family planning for women undergoing post-abortion treatment 5 .According to its authors, the adoption and continuing use of contraceptive medication increased from 36.3% to 62.0% one year after the counseling had been introduced.
According to the MH, the risk of a new abortion is higher exactly among women who already had one abortion, and increases with the number of previous abortions.Therefore, the ideal situation is for orientations on planning and contraceptive methods to be available at the place where women who are aborting receive care, offering opportunities for them to make their choices and start their use before they are discharged 2 .When there are no conditions at the hospital to provide the necessary support to prevent new abortions, however, the power needs to be decentralized and the women need to be forwarded to other family planning and social inclusion services 3 .

Comprehensive care in abortion and reproductive counseling to the woman who miscarried
Hence, these study results can be related to the nursing professionals' lack of knowledge to envisage the problem in a more comprehensive way, taking into account the subject, who is permeated by individual experiences and may present specific needs.Comprehensive care is one of the landmarks of women's health policies, and particularly the NTAHA, which also recommends reproductive counseling.The practice of these policies, however, is linked to the sensitization and commitment of health and nursing professionals, among other factors.

FINAL CONSIDERATIONS
In view of the study objectives, in the discourses analyzed, the subjects indicated that care delivery to the women who miscarried cannot be influenced by personal judgments, but expressed that they see comprehensive care as the development of practices that attend to biological needs.As regards reproductive counseling, this seems to be a gap that needs to be addressed, as the professionals basically related it to orientations for contraception, while other problems the women experienced were left hidden.
Thus, as nurses are responsible for managing care while these women are hospitalized, they are able to organize the team's work and sensitize the workers to adapt the care activities to the educative activities, with a view to enabling the women to feel encouraged towards self-care.These actions are supported by public policies and appear as problem-solving strategies to reduce the demand due to sequelae caused by repeated abortion.
This research is limited by the fact that it was undertaken in a single reality, that is, exclusively involving nursing professionals who only attend to women hospitalized dueto abortion; it is known, however, that many women are victims of abortion, but end up without complications that cause hospitalizations.This underlines the relevance of further research, focusing on different approaches, contexts and subjects, in order to indicate new knowledge that contributes to the science of nursing and the qualification of care.