Integrality of nursing care provided to women who have experiencing experienced an unsafe abortion

Objective: To discuss nursing care provided to women who undergo unsafe abortions from the perspective of integrality of reproductive healthcare and health promotion. Methods: Qualitative approach mediated by semi-structured interviews held with 16 young women aged from 18 to 29 years old cared for in public Family Health Care services. Results: Of 44 pregnancies, half resulted in an abortion. The results show the difficulty in accessing and using contraceptive methods and accessing reproductive planning services. Conclusion: Nurses as professionals working with health education should be responsible for preventing abortion and promoting reproductive health and integrality care, including social inclusion and support for these women.


INTRODUCTION
Integrality is a doctrinal principle of the Brazilian Unified Health System (SUS) and it is a complex and emerging multidimensional concept, characterized as one of the biggest challenges to the operationalization of the SUS.An approach that includes integral care and the promotion of health is essential for women who have experienced abortion, in order to avoid new unsafe abortions.
Currently, reproductive decisions take place in a difficult context marked by adverse financial conditions due to growing unemployment and low levels of education, especially due to unstable and conflict-filled affective relationships in situations of violence.
Studies addressing illegal abortion consider the figures representing the magnitude of abortions in Brazil, which is a challenge for studies in this field due to the difficulty in accessing reliable data and the high number of women who omit any mention of abortion on questionnaires with direct questions.The estimate for 2005 indicates that 1,054,243 abortions were performed in Brazil 1 .
Data from the SUS reveal a total of 223,350 post-abortion hospitalizations in Brazil in 2006.The SUS indicators concerning disease and death within the Women's Health sphere indicates that more than 2 million women, aged from 10 to 49 years old, were admitted in public hospitals in 2006.Of these, 233,000 were hospitalized due to abortions and 120,000 due to violence.Abortion was the third most frequent cause of hospitalization among this population in the same year.In the year before, 1,619 women aged from 10 to 49 years old died because of complications related to pregnancy, delivery, post-delivery or abortion 2 .
A 20-year study addressing abortion and public health in Brazil reports an increase in the quantity of studies on abortion and adolescence as a consequence of emerging studies addressing reproduction and sexuality among this group.The practice of abortion is concentrated among adolescents aged from 17 to 19 years old.The percentage of abortions among adolescents in this age group is between 72.5% and 78% 3 .
These figures show the need for strategic actions to ensure appropriate and safe conditions for sexual and reproductive practice among adolescents and young adults.There are many challenges concerning younger adolescents due to the need to expand and enable access to integral health services, even before their first occasion of sexual intercourse, ensuring privacy, reliability and supportive care without making judgments of value 3 .
Illegal abortions are not a rare, isolated, unknown practice considering the number of abortions performed in the country and the estimated maternal mortality due to this cause.Abortion is, however, a crime in Brazil and people who practice it are stigmatized.International studies show that unsafe abortions increase in regions where abortion is illegal 4 .
Considering that abortion is a public health problem and one of the causes of maternal mortality, nurses, as members of the Primary Health Care team, play an important role in providing guidance and supporting these women, whether during nursing consultations or in groups addressing reproductive planning.For that, this study's objective isto discuss nursing care provided to women who undergo unsafe abortions from the perspective of integral care and the promotion of reproductive health.

METHOD
This is a qualitative study based on the specificities inherent to social research, compatible with an approach to illegal abortion performed by young women as a complex social phenomenon.Stepping in the field of social research means entering a world where there are unresolved questions and in an ongoing and inconclusive debate 5 .
Three Family Health Units located in Cabo Frio, RJ, Brazil participated in the study.The main technique used to collect qualitative data was a semi-structured interview.Considering the ethical-professional and legal specificities of abortion, the interviews were held after free and informed consent forms were signed in accordance with Resolution 196/96, National Council of Health.Additionally, the participants provided prior authorization to audio-record the interviews and were ensured of anonymity and the confidentiality of their information.
Sixteen women aged from 18 to 29 years old were interviewed.They all had experienced an abortion at some point in their lives.The women were approached at the time of nursing consultations scheduled in the health unit.Both the invitation to participate in the study and the interviews were confidential in order to protect the interviewees.For this reason the interview was not held in the presence of companions, partners and/or other family members, patients and/or professionals, given the topic's particular sensitive nature.
Fieldwork and data collection were initiated only after approval was provided by the Institutional Review Board at Sérgio Arouca National School of Public Health (CEP/ENSP Nº 88/08).CNPq financially support this study, which addresses the third phase of a larger research project entitled "Young women and the process of illegal abortions -a sociological approach" and addresses the consequences women experience after abortion, as well as access to health services and care delivery.
Authorization was asked from the coordination of the Family Health Program at the city of Cabo Frio, RJ, Brazil, which was informed of the relevance of object of the study and the study's objectives.
The interviews were transcribed and the material was categorized using socio-historical analysis, which is one of the techniques of investigation based on in-depth hermeneutics.

Integrality of nursing care
Carvalho SM, Paes GO It has a general methodological framework, in which the object of analysis is a significant symbolic construction that requires interpretation 6 .

RESULTS
The interviewed women reported 44 pregnancies, 22 of which resulted in abortions.Some reported more than one abortion during their reproductive lives and not necessarily within the same sex-affective relationship.
Ages ranged from 18 to 29 years old at the time of the interviews and from 14 to 29 years old at the time the abortions occurred.Abortions were more frequent between the ages 18 and 25, that is, young adults.
We analyzed the 44 pregnancies and 22 cases of abortion including constraints and the social relationships of those involved while considering male participation in this decision.
Of all the 44 pregnancies, 26 pregnancies and 12 abortions occurred before the age of 20 years old.Fifteen pregnancies and six abortions occurred before the age of 18 years old.
In terms of relationships with partners at the time of pregnancy, only 19 cases occurred in contexts in which these women lived with their partners, while six abortions occurred in this situation.Twenty-five pregnancies and 16 abortions occurred in contexts in which these women did not live with their partners.The number of abortions is higher when women did not live with their partners; that is, they were in unstable relationships (dating) or had occasional partners.
In regard to economic situation, most (34) pregnancies and 19 abortions occurred at times women considered it difficult or unadvisable to have a child.
In 23 cases, the pregnancy was rejected by the partner or family, especially the mother.Of these, 11 pregnancies resulted in abortions.The situations in which these pregnancies occurred were heterogeneous and abortions were directly related to life aspects of these women, whether to the partner or family, or to unemployment, income, or marital status.

Post-abortion complications
Abortions performed in unsafe conditions are more likely to result in complications, which is the cause of death of most women who undergo illegal abortions.Of the 22 cases of abortion, 12 experienced some kind of complication, while nine occurred in the first abortion and three in subsequent abortions.The complication most frequently reported was hemorrhaging (08), cramps, fainting, fever and pain: A lot, because the child was already very big, five months, it was huge, all formed, so I had bleeding, which worsened even more in my case because I found out at the hospital that I have sickle cell anemia, with is a severe kind of anemia, so I could have died.(E1) In two cases, the interviewees found out through post-abortion hospital care that they had anemia, while one of them had sickle cell anemia caused by sickle-shaped red blood cells: I almost died because I lost too much blood and I was bleeding in the ambulance and the child was already dead.She was all formed and really red, almost purple, he wrapped the child and we went to hospital (...), they did the curettage and collected blood for exam and found out that I already had anemia so I lost a lot of blood and was really weak and dizzy.I had anemia and I guess what made me faint was the anemia, really severe anemia.I guess it happened during pregnancy; I wasn't attending prenatal care, I wasn't doing anything because I didn't even know I was pregnant (E6).
The cases of abortion performed by inept individuals resulted in more severe and dangerous complications with the risk of death: Ah, I got really sick, I thought I'd die.She put plastic on her bed and I stayed there the entire night, she used a speculum and put on a rubber, and a probe and tied it, I slept with that, only that in the morning I lost too much blood and couldn't stand up, so I stayed there yelling for someone to help me go to the bathroom (...) some blood clots came out, some plaque together with the rubber.I lost blood for a week (E10).

Feelings after abortion
When they were asked how they felt after having an abortion, in nine cases, women reported sadness, regret, despair and guilt for having taken a life:

Feeling really guilty. I took a life, and mainly because I'm from a very religious family and I still think a lot about it to this day (E14).
In 13 cases, women felt relieved, calm or indifferent because they achieved their objective, the abortion:

For the second one, I felt relieved because everything worked all right (E15).
The reports showing feelings such as sadness, regret and despair are related to the fact they took a child's life, a fact that is judged and criminalized by society, which causes these feelings to emerge.Those who report relief, indifference and calmness refer to the fact they achieved their goal; they were "free" from an unwanted pregnancy.

Integrality of nursing care
Carvalho SM, Paes GO

Access to health services and care delivery
A Brazilian study addressing the perspectives of 13 women hospitalized after an abortion on the delivery of nursing care revealed dissatisfaction on the part of these women with the strictly clinical care focused on the biological aspect disregarding the individual context, providing incomplete information and showing prejudice after seeing evidence of an induced abortion 7 .
When they were asked whether they sought health service after abortion, in ten cases women reported they sought care due to complications:

I went to a gynecologist and he gave me medication to stop the hemorrhaging; I lost blood for an entire week and had to go to the hospital (E8).
The care provided in health services was considered to be of poor or really poor quality.The health professionals showed discrimination and provided inappropriate care when they realized that abortion was induced, inferring pre-judgment.

Ah, it was the worse possible because it was an abortion, it wasn't a miscarriage, you know? So they do not treat you well. They leave you there suffering, my curettage was done with analgesia (E3).
In only two cases was care received classified as good and appropriate by the participants, though in their opinion, the professionals "pretended" they did not know it was an abortion and did not make any comments:

At the beginning I don't know whether they knew the abortion had been induced because they never mentioned it (...) I don't know, I only know that I was really scared because my boyfriend would go to jail, he accompanied me, they asked " (...) did you take any medication? (...)" then I said no, I was having cramps and I went to the bathroom and this happened (E6).
In 12 cases, the women did not seek a health service for various reasons, such as: fear and uncertainty of how they would be treated by health professionals; fear of being criminalized; and because they had no complications.

No, I was afraid, afraid they would report me and I'd be arrested, I don't know... (E2)
In regard to post-abortion guidance, we asked: "Did anyone provide you information on how to avoid a pregnancy or inform the services that would provide you with contraceptive methods?"Only five women received any type of information.They were instructed to seek a family planning service and start with oral contraceptives: Yes, family planning.I'd get medication at the health unit every month.Nowadays, my tubes are tied so I don't need it anymore (E2).
Of the five women instructed to seek a health service to receive guidance on family planning, three reported difficulties getting a spot in and/or attending the program.

Yes, but it is not easy, the meetings are during hours I can't come because of my work, but I'd go whenever I could (E15).
The following participant notes that she sought out the service, but no contraception was indicated, only condoms.It reflects a failure in guidance on contraceptive methods because she does not consider condoms to be contraceptive:

Then I sought it and they did not prescribe any contraceptive; they only indicated the use of condoms (E13).
Data from GRAVAD show changes in the use of contraceptives or the maintenance of contraception after the birth of the first child during adolescence, in which 37.6% of men and 45.6% of women started to use some contraceptive method, while 19.7% and 21.5%, respectively, continued to practice unprotected sex.The number of young individuals who got pregnant again is impressive: one in every four adolescents 8 .
Addressing the perspective of these women concerning their immediate post-abortion care raises important issues related to abortion-related healthcare, which can also affect the decision-making of these women as to whether to seek health services to receive guidance and information on family planning.

DISCUSSION
This study revealed that after the process of undergoing an abortion, women experienced negative reactions such as remorse, regret and a sense of loss, reflecting feelings of guilt.Additionally, they are stigmatized and many fear going to health services, afraid of being criminalized.
Integrality is one of the principles of the Unified Health System that considerably contributes to the reform of the Brazilian health system, providing a broadened view of healthcare and some specificities in terms of professional practices and the organization of services 9 .
This principle is included in the Brazilian Constitution as a guideline based on integral care, giving priority to preventive Integrality of nursing care Carvalho SM, Paes GO actions without, however, losing sight of healthcare 10 .In this context, it is believed that the Brazilian Constitution proposes a professional health practice focused on the patient's needs,not restricted to compliance with protocols and routines designed to provide preventive actions or procedures.
Considering the programs directed to women's health care, we highlight the Integral Care to Women Health Program (PAISM), which was devised in 1983 and disseminated by the Ministry of Health in 1984.It is considered one of the most complex and conceptually advanced programs directed to women's health in the world.
In 1994, the Ministry of Health included the concept of reproductive health in this program, and its innovation consisted of proposing reproductive healthcare in the context of integral actions, as well as the recognition of women's reproductive rights.Therefore, the program included aspects concerning women's reproductive health from adolescence to menopause, including prenatal care, sexually transmitted diseases and integral actions for family planning.PAISM proposed to include the concept of women's integral healthcare, giving new meaning to women's bodies in the social context, expressing a change in the position of women.
The National Search for Abortion performed in 2010 infers that abortion is a common practice in Brazil and, by the age of 40 years old, more than one in every four women have already induced an abortion.Abortions occur in the middle of women's reproductive age, that is, between 18 and 29 years old.Another particularity is that abortions more frequently occur among less educated women, a fact that may be related to other social determinants 11 .
Women in a situation of abortion want to be understood in this context, since moral judgments and disapproval do not solve the problem.It is necessary for health professionals to provide support for these women so that they feel protected and safe in order to overcome this difficult time in their lives 7 .
When nurses support these women in the health services, they should pay attention to the specificities of this situation and try to provide integral care, mainly to provide and support reproductive planning guidance to prevent new episodes of abortion.
Giving support is one of the dimensions of integrality expressed by the ability of professionals to take notice of suffering, which results in spontaneous demand.Therefore, there should be a dialogical practice during care delivery to meet this demand so health professionals use their knowledge to identify the need(s) for health services and actions as presented by each individual 12 .
More than a principle related to intervention, integrality is translated into a notion of care, since in the context of its development, procedures and techniques become secondary to the relationships established with patients.Providing care requires acknowledging another, who is seen as a human dimension in the plane of intersubjectivity 12 .Nursing actions refer to integrality when these consider care beyond the objectivity of healthcare, the subjectivity of the collective experience of the individual involved 13 .
From this perspective we note that the decision to perform an abortion is not individual but it is a process that involves social factors and other participants, such as the woman's family and partner.Despite the complexity of this social phenomenon, we observe that society tends to hold the woman responsible for her reproductive choices.A study conducted with women who had induced prior abortion(s) revealed that the main interlocutor, in most of the instances, is the partner, and even when the man does not gives his opinion in regard to the decision to abort, insisting that this is the woman's responsibility, he somehow participates in this decision 14 .
In this sense, the first step for nurses to develop planning focused on health promotion in the sphere of integrality is to acknowledge the woman who experienced an unsafe abortion as an object of care.

CONCLUSIONS
In this study we worked with categories related to unsafe abortions, including healthcare delivery, recognizing the importance of the methodological interaction of the study with the complex object health-healthcare-attention, indicating the various possibilities of analysis devised from the reports and experiences of these women in the process of illegal abortions.
In regard to health services, according to the interviewees, information and guidance on contraceptive methods are seldom disseminated and when they are disseminated, they fail in terms of prevention and health promotion.This situation shows the need for strategic actions to improve conditions for sex and reproductive practices, especially of young women, including post-abortion care.
The promotion of health included in the context of integrality is intended to transform the way health is produced through a proactive attitude of those involved.We note that gender issues, as a framework that allows us to understand inequalities within the universality and integrality of services available in the field of women's health, is a challenge imposed on the promotion of integral reproductive health 15 .
Considering such aspects, integral care is an important tool for nurses to ground their practice and provide support to these women and, giving them alternatives to access reproductive planning services, including the prevention of new episodes of abortion.