Critical Care Obstetrics and Gynecology

Keywords

Sexual violence; Pregnancy; Legal abortion; Life experiences; Health services; Brazil

Introduction

The situation of abortion varies according to the laws and cultural context of society; and its implications for women's lives are quite linked to the social, cultural and religious representations of each country [1,2]. The experiences of unwanted pregnancy, abortion and its consequences on women's mental health have motivated studies with controversial results [3-5]. Most countries in Latin America have restrictive abortion laws except in some situations [6]. In Brazil, abortion is a crime, except for situations of risk to a woman's life, rape and/or incest permitted since the Constitution of 1940 [7] and, more recently, in pregnancies with anencephalic fetuses [8]. The Brazilian public health sector has standardized emergency care for victims of sexual violence (SV) since 1998 in order to, within the first 72 hours, provide emergency contraception and prophylaxis for viral and bacterial STDs. Public health services should also provide services that perform legal abortion (LA) for women who become pregnant as a result of the SV [9]. However, although required by law, women's access to abortion is still difficult. According to a research that sought to describe the care services for SV offer at 874 public hospitals with conditions to perform termination of pregnancy procedures, showed that 30.6% declared to provide the service for pregnancies resulting from sexual abuse and only 5.6% had received at least one procedure in a period of 14 months [10].

The restrictive laws and the sociocultural characteristics of the Latin America population, marked by religious perspectives with a Christian majority and differences in gender relations, contribute to a negative view of society on the issue of abortion and hamper the search for institutional help for women, as well as maximizing their suffering during and after the decision for the LA [11,12].

Considering the scarcity of studies in countries with restrictive laws to abortion and the necessity for information that may contribute to the care of women who are seeking institutional help for LA, this study aimed to know the experiences of women that underwent LA, and their fellings and difficulties through the process.

Methods

The study was conducted at the Department of Obstetrics and Gynaecology, School of Medical Sciences, University of Campinas (UNICAMP), Campinas, Brazil. The project was approved by the University’s Institutional Review Board, and all the women enrolled signed an informed consent form.

The Woman's Hospital Prof. Dr. Jose Aristodemo Pinotti is public and university teaching service located in southeastern São Paulo State, Brazil. The Division of Gynaecology has been dispensing care to women who became pregnant after sexual violence for 20 years with an average of 30 requests of LA annually.

A qualitative exploratory study based on semi-structured interviews was conducted. Participants were selected according to the logic of purposeful sampling and the strategy was maximum variation sampling [13]. Women who were ≥18 years of age, requested and performed LA of a pregnancy resulting from SV, with a minimum of 12 months and maximum 60 months after the procedure, were invited to participate. Women with cognitive disabilities and/or severe psychiatric history were excluded. Sample size was determined by the criteria of saturation of information [14].

For the selection of participants, 63 medical records of women who requested termination of pregnancy between 2006 and 2011 were evaluated, and 28 women met the inclusion criteria. Telephone contact was made with 17 women, of whom 14 agreed to participate. They were provided with information on the objectives of the study and on the voluntary nature of participation. The criterion of saturation of information was achieved in the first ten interviews.

The interviews were held in private, by appointment and were conducted by the same psychologist using an interview semistructured guide designed specifically for this study. Interviews were transcribed verbatim and transcripts checked for accuracy against the recordings. A thematic frame was organized based on the relevant themes regarding women’s experience with decision making of LA, emotions experienced before, during and after the procedure, and the experiences and changes reported by the women as arising, and these experiences were organized in a meaningful way. Subsequently the information was coded in the interviews with the aid of The Etnograph V 6.0. program (Qualis Research, Colorado, USA).

Results

Women aged 18-38 years old, with schooling ≥8 years, were interviewed 1-5 years after LA. The initial desire reported by women was to forget the violence suffered and silence about the episode, they belief that there would be no consequences remained. Women reported experiences of shock, fear, constant crying, despair and shame in the weeks that followed the episode of SV. These feelings combined with the lack of information for women about emergency care services hampered the search for institutional support immediately after VS.

"I came home, took a shower, I don't know how long I was in the shower, then I lay down, went to sleep, I don't know how long I slept... I went on months pretending nothing had happened until the day I discovered the pregnancy" (Emma).

"I had no information and I was too embarrassed. I felt very bad. I just wanted to get home, take a shower and thought I was going to sleep, but I don`t sleep ... I don`t do anything, don`t do anything you think you can do. But the only thing I wanted was not to tell anyone, not talk to anyone, I thought it would end there" (Mia).

The desire for the interruption of pregnancy arose immediately after the confirmation of pregnancy, and women said they would have sought illegal abortion if LA was not possible. The reasons given by women to support the LA as the only solution to the problem of unwanted pregnancy were: the inability to justify socially paternity of the child, since they wished to keep SV in secret; the impossibility of loving the fruit of such a violent experience and the fear of the child being the living memory of SV suffered.

"Because I could not carry for the rest of my life something I did not want to have happened. Every time I would look at the child I would remember everything" (Lily).

"… then I thought I was not going to be able to like it, in case it would happen to go on with it, not to like it, even mistreat it. And for me, the option of interruption was, at that time, the solution" (Amy).

On arrival at the referral service, the predominant experiences were of expectation and hope. The women reported that they dreaded their request be denied because they would not know what to do from that moment on. The possibility of performing the LA was felt as an opportunity to solve the problem of pregnancy and definitely forget the SV. The affirmative answer to LA brought a sense of support and relief.

"It took a weight off my shoulders. It was as if I was locked in a place without air and suddenly a window was opened and I could breathe. When I was told that the answer was positive I breathed" (Ana).

All women interviewed reported having religion; six were Evangelical, three Catholic and one Spiritist. For none of them was religion a crucial factor to the decision for the LA. However, the religious issue weighed on the elaboration of LA experience after the procedure, with references to feelings of “guilt before God for the choice of abortion”.

"Oh, I feel... is, it is difficult, because even today I can’t find a justification in religion for what I did, you know? …I guess I'll still be really punished for it" (Chloe-Catholic).

"I'm a Catholic and this was what weighed the most. Because that's where it generated more conflict in my head ... I barely go anymore (to the church). I went once after what happened and didn`t go back, I don't feel good in there" (Lily- Catholic).

Seeing the fetus or fetal parts at the moment of the expulsion was reported as a deeply striking experience. Women reported that this was the most difficult moment of the whole process, surpassed in intensity only by the experience of the SV.

"... And I saw the body as soon as, I felt something coming out, and as soon as I looked, there it was. Then I started screaming, people came to help me, then I remember the body perfectly. It hurts me so much to remember that I had killed that child. It was a child and I had killed a life, but ... you can with it and you can't live with it" (Chloe).

A woman with gestation of 18 weeks reported "... my baby died in my arms. I could not let an innocent little baby die in a tray, alone" (Emma). The viewing and contact with the fetus at the time of abortion seemed to increase the feeling of being responsible for the death of a baby, comment that appears frequently with interviewed women.

Women also reported as a problem during LA the negative reactions from some health professionals, when they expressed personal and religious opinions. These reactions triggered feelings of guilt and shame, and a sensation that they might be doing something wrong. When asked about the experiences immediately after the LA, women showed feelings of sadness and emptiness.

“…it is like, kind of an emptiness a bad thing, painful, because after all, it is a life, you know? But ... it's sad. I got a little messed up ..." (Ana).

"Because it's not easy, you come out of there feeling like crap. Until the moment you are confident, you want to reach your goal and then you reach it, but you leave the place feeling empty, mainly because you are in the middle of other mothers who are there, women who are leaving with their babies in their bundles, you know what I mean? And you leave with nothing, it`s your own choice. You killed a life, you interrupted it" (Chloe).

The reports make it clear that there was no regret for the decision of LA. Nevertheless, painful feelings of this experience were not suppressed. Women reported as a positive element of LA, to be able to have restarted their lives and, as a negative, live with the pain of the memory of SV and LA for the rest of their lives.

“I think it’ll never heal. It has been about two years or so... and to me it’s still very recent. …I think it is a wound that will never heal completed” (Amy).

In long-term the experiences of SV and LA brought consequences for women's lives. Despite the time elapsed, women still living with feelings of guilt. The guilt appeared more frequently in those with feelings of deeper religiosity, for which there was persistence of the idea of "killing a child". Women reported changed their religious practices after the experience of the LA, They experienced fear of being punished by God for the decision of abortion and the loss of faith in God.

“I think what I did was a crime…. …It is my fault for having aborted. … I'm just supported by the law, I am free, for example, from prison, and the law is on my side to protect me from this. But there is divine law, isn't there?” (Sophie).

Three women got pregnant sometime after the LA; only one of them already had a child prior to the SV. The stories of these women showed that the new pregnancy was permeated by memories of the previous one, which had been interrupted. One woman described she had faced, and still faced many emotional difficulties in the relationship with her desired baby, awakened by memories and associations with the LA; the second reported having experienced feelings of intense fear of losing the desired baby throughout pregnancy and after childbirth; and third had molar pregnancy, condition in which the fetal tissues degenerate and abortion occurs. The three experiences were identified by the women as punishment the decision of having performed LA.

“… So much that my son now was planned, which was to see if I could get all of this out of my head" (Lily).

"I remembered during pregnancy that other one. Even when he was born, he was born at eight months because my water broke and he was born with a very strong moaning, the pediatrician who received him told me not to have hope, at that time I thought – God will take this boy from me because I took the other one. It was what came to mind" (Sophie).

Three other women reported feeling the desire to get pregnant again in the future, making it clear that the experience of the interruption of pregnancy had not eliminated from them the desire to be mothers.

Discussion

The experiences of the women who got pregnant as a consequence of SV who performed LA were marked by different emotions over time, and included feelings of distress and despair at the discovery of the gestation; feelings of ambivalence, hope and emptiness during the procedure; and guilt and difficulty of religious reintegration in the long-term. In addition, women reported the entire journey of these experiences in a very solitary way: SV and pregnancy were silenced, the decision for the interruption was made without help from anyone, and after some time passed, women chose to continue carrying, lonely, their stories and feelings. Among the experiences described by the interviewees as a painful during the LA process, the visualization of the fetus at the time of expulsion and negative reactions by the professional team was relevant. These two factors can be controlled by health professionals who provide assistance to LA.

The choice of silence is probably associated with stigmatization of abortion in society. A qualitative study in Mexico found that abortion stigma was attached to the high valuation of motherhood and the Catholic conservative discourse; the woman undergoing the procedure takes itself an "indelible mark" and may suffer "divine punishment" [15], similar expressions referred to by the participants in our study. The choice of women by silence and secrecy on abortion may be related to the fear of being stigmatized, which increases the suffering and the difficulty to seek help [16-18].

Research on stigmatization of abortion reported that it exists both in social contexts in which is released legally as in restrictive settings, being more evident in countries where abortion is highly restricted [18]. People who feel stigmatized can change behaviors and decisions, and suffer influences that impact their physical, mental health, and personal and professional welfare [19].

Women denied having regret after the decision and stated feelings of relief with the approval of the request for the LA. These results were similar to a study conducted in California, United States of America, where abortion is permitted at the request of a woman in any situation. Through questionnaires given to 5190 women, results showed that the most recurrent feeling after abortion was relief, and that two of every five women experienced negative emotions of sadness and guilt [20]. The authors reported that women who internalize the discrediting social attitudes surrounding abortion, which is highly linked to stigmatization, commonly report feelings of shame, judgment, sadness, and guilt [20].

In our study, women reported feelings of ambivalence and guilt after LA, initially motivated by conflict between the rational desire to not want that child and the emotional weight of the decision to end a life. This result was similar to that found in a qualitative study with North American women who described the conflict reason/emotion as one of the major emotional difficulties of the abortion experience, besides the social disapproval and loss of an important emotional relationship [21].

In the long term, feelings of ambivalence were more commonly reported by women with greater religious bond, mainly Catholic. These results agree with studies that described the greatest fear of judgment by peers as the most frequent cause of following the isolation and greater selfjudgment for women with higher religiosity, compared to nonreligious [22]. However, even women with higher religiosity denied having feelings of regret for the decision of abortion and reinforced that they would have the same attitude if they could relive the situation. This finding was similar to that observed in previous studies [23].

Previous studies have highlighted the importance of welcoming and non-judgmental attitude of the care team so that women victims of violence can feel safe to reveal their experiences [24]. The World Health Organization advises the inclusion of the issue of violence against women in the curricula of medical, nursing and public health professionals, and the constant training and supervision of these, so they know effectively and appropriately respond to cases of violence, ensuring the ability to identify and render first aid to women victims of violence, including empathic listening, emotional support and appropriate referrals [25].

The possibility of a new pregnancy came as a way to overcome the experience of LA for three respondents. These results provide reflections on facing the conflicts generated by the LA decision, not because women did not want motherhood, but due to the actual experience of SV, that the real motivation of the decision to interrupt the pregnancy. We can assume the need to "replace" the unwanted pregnancy for another, now desired and planned. Another possibility would be to assign to the new pregnancy the power to fill the void left by the experience of the LA, as a substitution of that which was lost [26]. The report of women who decided to get pregnant again showed experiences of feelings of guilt and fear of "punishment from God" during the course of the new experience and regardless of its outcome. These feelings were assigned, by themselves, for having opted for discontinuation of previous pregnancy.

The complexity of the experiences of women who have suffered SV and had to resort to LA was evident. In this study women victims of sexual violence who need gestation LA are in emotional distress and need care to avoid being revictimized both in their social contexts as by health professionals and the police team. Health services, particularly in countries with restrictive abortion laws, must provide health professionals trained to deal with legal abortion and implement internal processes facilitate the recovery of women undergoing the procedure. Besides the impact of the sustained aggression and its result, achieved through the pregnancy and the need to stop it, the women revealed the impact of moral and religious sanctions absorbed internally and translated in the impossibility of sharing the guilt and the emptiness. In Brazil, there is need for the establishment of support services which are not directly linked to referral services for LA, in order to support the emotional needs of women and offer the possibility of emotional and psychosocial restructuring. On the other hand, the support to women in situations of violence and unwanted pregnancy also requires the promotion of reflections in the health, human rights and social protection field.

Acknowledgments

The authors are grateful for the financial support of the São Paulo State Foundation for the Support of Research (FAPESP) under award #2009/18226-0. The authors gratefully acknowledge the financial support of CAPES (Coordination for the Improvement of Higher Education Personnel) through a grant conceded to CLM.

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