ORIGINAL RESEARCH

Women's feelings on the occurrence of induced abortion

Danyelle Leonette Araújo dos Santos^I; Rosineide Santana de Brito ^II

^I Nurse. Master in Nursing. Federal University of Rio Grande do Norte. Natal, Rio Grande do Norte, Brazil. E-mail: danyleonette@gmail.com
^II Nurse. PhD in Nursing. Full Professor. Federal University of Rio Grande do Norte. Natal, Rio Grande do Norte, Brazil. E-mail: rosineide@ufrnet.br

ABSTRACT

Objective : to analyze the feelings experienced by women on the occurrence of abortion. Method: qualitative study of 19 women undergoing abortion, admitted to a public maternity hospital in Natal, Rio Grande do Norte, Brazil. Data were collected between March and August 2013 by semi-structured interview, and analysis of the transcripts was framed theoretically and methodologically by Grounded Theory and Symbolic Interaction. The research project was approved by the Ethics Committee (CAAE 10332312.9.0000.5537). Results: when women underwent abortion, they interacted with fetus and health professionals, and experienced conflicts between moral values, making them feel they were transgressing moral codes, and causing sadness and fear of death and of giving birth to a disabled child. Conclusion: the women were found to have many different negative feelings, which emerged from the conflict they experienced, primarily with moral values that censure the practice of abortion.

Keywords : Abortion; abortion, induced; emotions; women´s health.

INTRODUCTION

Abortion is defined as the termination of pregnancy with gestational age of up to 22 weeks and with the product of conception featuring a weight lower than 500 grams or length less than 16 cm¹. Among the classification of abortions, there is the provoked abortion, which is caused by external interference before the embryo or fetus become viable to extrauterine life. When such intervention is carried out by people with no technical expertise and/or in harsh environments, it receives the name of unsafe abortion².

According to the World Health Organization (WHO), 22 million abortions are carried out unsafely worldwide every year. Among these, about five million entail physical and/or mental disorders to women who practice the abortion and approximately 47,000 culminate in maternal death³.

As for national indicators, it is estimated that approximately one million abortions occur annually in Brazil¹. According to the National Abortion Survey (NAS) carried out throughout the urban territory of the country, one in five Brazilian women aged between 18 and 39 years have interrupted at least one pregnancy throughout their reproductive life ⁴. In the face of such magnitude, induced abortion has been considered a serious public health problem. Therefore, maternal mortality and morbidity related to this event generate a notable burden to the physical and mental health of women¹.

Diseases of physical nature are easily identified and require immediate intervention to prevent serious consequences or even death. However, problems of psychological nature are more difficult to detect, because every woman expresses herself in a unique way before this circumstance. This uniqueness varies with the desire of the pregnancy, the sociocultural context and the affective relationship experienced by women with their partners. These conditions are also responsible for emotional distress and potential harm to mental health in the aftermath of abortions⁵.

Thus, it is assumed that the illegality of abortion practice, cultural and religious issues, as well as the power relations established by women in interactions with their partners, family members and even with health professionals responsible to provide them assistance in the situation post-abortion, are aspects that trigger conflicting feelings and generate psychological problems.

Thus, this study came from the following question: what are the feelings experienced by women before the completion of induced abortion? Therefore, the research aimed to analyze the feelings experienced by women in the process of completion of the abortive practice.

LITERATURE REVIEW

Induced abortion is a phenomenon that has always been present in society, but its acceptance varied depending on the cultural, political and religious contexts throughout times⁶. With the advent of Christianity, the act of abortion came to be strongly condemned, especially due to the idea of the existence of the soul in the fetus⁷. These religious dogmas surpassed times and have influenced the emergence of laws against abortion. In Brazil, the Penal Code criminalizes this event, considering it a crime against life, except in cases where the fetus is the result of rape or when the pregnant woman is at risk of death⁸.

The unlawfulness of abortifacient practice leads many women, especially those of the lower classes, to resort to unsafe methods of abortion, making them vulnerable to various health problems. Among the methods used to terminate a pregnancy is the intake of teas, liquids and herbs; the use of abortive drugs illegally acquired and the insertion of probes into the uterine cavity by laypersons⁹. Such abortive methods can cause physical complications such as infection, bleeding and uterine perforation. However, women with higher income can afford the amounts charged to perform safe abortion in clandestine clinics. This reality points to a situation of social inequality, as women with better social status use different and less tortuous abortifacients routes compared those women of lower classes¹⁰.

Regardless of the abortive trajectory, women bear the burden of taking the difficult decision to terminate a pregnancy, experiencing many emotional conflicts, which generally are triggered by the fact that abortion is morally reproached. In this sense, the concept of having committed a moral offense causes intense guilt in these women, resulting in anxiety and depression¹¹.

These emotional conflicts can be exacerbated when women look for post-abortion care. It is also worth mentioning that some health professionals are not prepared to deal with this clientele, assigning judgment of values and reinforcing existing stereotypes in society. To change this reality, the Ministry of Health has developed a technical standard focusing on human attention to women in situations of abortion, stating that the assistance should be based on integrity and respect for individuality. This approach, when adopted by health professionals, offers women security and confidence for them to verbalize their emotions ¹

Given the above, it is necessary to implement the technical standard abovementioned in health institutions that provide post-abortion assistance to women so that they may recognize feel welcomed in these spaces. It is expected that they do not delay to search for assistance. This way, irreparable physical damage can be avoided and emotional suffering inherent to the decision made in favor of abortion minimized.

METHODOLOGY

This is part of a master's thesis whose research had qualitative approach and used the Grounded Theory (GT) and the Symbolic Interactionism as theoretical and methodological frameworks^12,13. These references were chosen because they seek the meanings derived from an interpretive process established by individuals with everything related to certain phenomenon.

The study was conducted in a tertiary maternity of the Unified Health System located in Natal, Rio Grande do Norte, Brazil. The participants were 19 women selected based on the following inclusion criteria: women aged 18 years or older; hospitalized due to an induced abortion; women that openly assumed to have induced abortion; presenting emotional and/or physical conditions favorable to answer the questions (conscious and free from effects of anesthetic drugs, lack of profuse bleeding and pain). Women were excluded when they were hospitalized for legal abortion and when they were adolescents.

Data collection occurred from March to August 2013, using a script interview consisting of socio-demographic and obstetric questions, as well as a guiding question regarding the research object: Can you tell me how it was for you to interrupt your pregnancy? The speeches were recorded on portable digital recorder and transcribed afterwards.

After this stage, there was an initial organization of data, which were treated considering the three steps of the GT: open, axial and selective coding. In the first phase, data passed through a process of microanalysis, allowing the emergence of the first category, its dimensions and properties. In axial coding, relations were established between these categories and subcategories in order to promote clearer explanations of the phenomenon. And finally, in the selective phase, categories were integrated resulting in defining a central category¹².

From this process, three categories arised, and among them, one addressed the emotions inherent in the execution of abortion discussed in this article and entitled Feelings experienced in the abortive practice. The analysis of the information was based on the foundations of Symbolic Interactionism, which aims to reveal the meaning arising from the interaction and interpretation on certain event and/or phenomenon ¹².

The study met the ethical principles of Resolution nº 466/12 of the National Health Council. The consent from the maternity where the research was conducted was obtained, as well as the approval of the Research Ethics Committee of the Federal University of Rio Grande do Norte, with Presentation Certificate for Ethics Assessment nº 10332312.9.0000.5537 and Opinion nº 218,209/2013. Furthermore, participants were requested to sign the Informed Consent form and the Authorization Term for Voice Recording. To ensure the anonymity of the interviewees, it was decided to assign them the letter I to identify them followed by a sequential number which was randomly assigned.

RESULTS AND DISCUSSION

The predominant data revealed that the interviewees were aged between 26 and 30 years, were brown skinned, Catholic, with complete high school, active in the formal labor market, with family income between one and three minimum wages, and they experienced an affective relationship with partners considered by them as stable.

As for obstetrical data, 13 participants had at least one living child, nine had already experienced a prior situation of abortion and seven among these reported having induced one or more of the previous abortions. On the current abortion, there was prevalence of gestational age between five and six weeks at the time of termination of pregnancy and of use of the abortifacient drug known by the trade name Cytotec®.

Feelings experienced in the abortive practice

The analysis of the narratives revealed the presence of feelings such as anguish and sorrow, especially when the participants were sure of the completion of the abortion - expulsion of the embryo or fetus.

[...] When I went to take a shower, it came down [the fetus]. In the moment you see, the first thing that comes to mind is: 'I killed my child!' [...] The visual impact is strong! (I10)

[...] I was disturbed when I saw the scene: the fetus hanging by the [umbilical] cord. I cried a lot. Because it is a living being that we are killing. (I7)

The excerpts show negative emotions among respondents who reported having seen and thus interacted with the embryo. This situation was permeated with symbolism derived from the sense of loss, as well as social condemnation of abortion. Thus, the pain of not being able to realize the dream of motherhood and not having fulfilled the socially established role of mothers, led women to experience mourning for the finitude of pregnancy.

We can say that the emotions experienced after inducing an abortion are intrinsically related to moral and religious values ​​present in society. This is evident when the participants recognized this practice as a sin and a form of murder.

This is wrong! Because, the only who have the right to take a life away is God. (I5)

For me, it will always be a crime in the eyes of God and man! A sin! (I9)

The conflict of women with their moral and religious values is noticeable in the reports, and led them to recognize that the right to interrupt a cycle of life belongs to the superior being, God. In this sense, the idea that ​​abortion is a murder is linked to the dogma of Christian doctrine, which recognizes it as a grave moral disorder, since it deliberately eliminates the life of an innocent being¹⁴. Thus, considering the religious perspective, the experience of emotions like guilt, despair, remorse and regret were detected in the study.

It is known that religion is embedded in all cultures influencing the way of thinking and acting of people, including in reproductive decisions. However, this influence does not prevent thousands of women to cause abortion. According to the NAS, the abortive practice is similar among women from different religious segments. Thus, religious background is not a relevant aspect to differentiate women who have already caused an abortion⁴.

Although the participants used religious concepts to reflect on their behavior, they pondered and gave priority to their socioeconomic condition when decided to abort. In such cases, some women understood that there is a license to perform the abortion, believing in the divine understanding of the impossibility of carrying the pregnancy to term. Corroborating this fact, different authors have shown in their studies issues related to financial conditions, marital status and number of live children as relevant factors that lead women to resort to the practice of abortion ^6,15.

Because of all aspects relating to morality and religion, the idea that ​​abortion is an act worthy of punishment was present in several reports. This may be associated with the fact that the participants bind the transgression of social rules to the compulsory need to be punished. Thus, they experienced fear of the intensity of the punishment to be imposed on them by a divine entity. The fear of death, of giving birth to a disabled child or of losing the ability to generate other children in the future were the most prominent punishments mentioned in the speeches.

I was afraid to die. [...] Taking the medicine and making the child be born sick. [...] I felt many fears [...]. (I3)

I was afraid to die. A lot! [...] I thought I could lose the uterus and never have children again. [...] It was a very great chastisement of God. [...]. (I18)

The fears reported by participants were associated with their knowledge about the risks of induced abortion and the belief that this act results in divine punishment. Thus they conceive the probability of being punished for recognizing a sinful nature in this practice^11,16.

In the case of fear about the possibility that abortifacient drugs fail, causing defects in the fetus, the authors admit that there is no scientific evidence able to correlate the use of Cytotec® with teratogenicity. Thus, research on this subject that give evidence of such association directly or indirectly reinforce the social stigma surrounding the abortive event and against women who practice it¹⁷.

Despite the fears revealed, some participants said they felt relieved after the completion of abortion.

[...] the embryo was thrown out when I was at home. [...] I felt a monster at that time, because the feeling was total relief. I was happy! (I2)

[...] I was quite nervous [...], afraid to die. [...] I was afraid to bleed until death. It was a relief when it came down all at home. (I6)

The feeling of relief after abortion has been linked to two main factors: the disappearance of the physical pain caused by uterine contractions and the effectiveness of the abortive practice without serious physical consequences¹⁶. The latter symbolized, in the view of the interviewed women, the resolution of something they considered a problem. For this reason, it is understandable that the abortion cause a sense of relief, so intense as to make some of these women feel happy to see the expulsion of the embryo.

It can be said that the finitude of pregnancy represented for the interviewed women a kind of freedom from the distressing feeling experienced since the discovery of pregnancy. However, this led to an ambiguity of emotions, because in spite of feeling relieved, some berated themselves for such a feeling, going to the experience of guilt and remorse. Such sentiments emerged from the conflict arising from their moral values, which led them to omit the feeling of relief to people close to them, for fear of being stigmatized. For this reason, it is believed that just a small number of respondents openly exposed the experience of relief post-abortion, but throughout the narrative, that feeling was evidenced in a veiled way in the statements of more participants.

It is important to note that the fear to report the abortion to others was significant when the participants felt the need to seek health services to carry out the evacuation.

[...] there are doctors who do not miss the chance to call attention because the person committed that mistake... I was afraid to be called to attention. (I9)

I felt very scared to tell anyone. [...] Because, people have prejudice against this. Everyone will judge you badly for this [...] they will always look at you and think that you are a monster . (I13)

The statements show the fear of the interviewees to reveal the abortion in order to seek obstetric care. This fear stemmed, in general, from information passed on by friends about women who were mistreated in the institutions for assuming to have caused the abortion. Thus, they recognized that, by making public something particular, they could become the target of criticism and prejudiced attitudes coming from the health professionals responsible to provide them care.

This fear tends to make women postpone as much as possible the search for obstetric care, and when they do this, they avoid informing the actual circumstances that led them to the abortion¹⁸. Although the Ministry of Health has incentivated a humane and ethical post-abortion care, based on integrity and respect for the human person¹, there seem to be barriers for health professionals incorporate these principles and implement a more welcoming care practice. This is because professionals suffer influence of moral conceptions of society, which lead to a discriminatory assistance, without focusing on reproductive rights or social issues. This reality creates anxiety and insecurity in women, especially regarding the procedures they will have to undertake ^16,18.

In order to avoid embarrassment, women bear the pain arising from induced abortion as far as they can, leaving hospital assistance as the last option. While they wait for the completion of abortion, they tend to make use of household measures to clean the uterus, using teas and English water. The use of such substances is intended to dissolve the abortifacient drug on the cervix, erasing remnants that can make the induction of abortion detectable⁹.

Finally, it is understood that the delay to seek obstetric care associated with the use of popular strategies to circumvent the reproach from health professionals can result in damage to the women's health. Thus, it is imperative that healthcare workers be sensitive while providing assistance to post-abortion situations, reducing prejudices and moral judgments in order to receive these women ina comprehensive manner, recognizing them as subjects with rights and worthy of care¹⁹.

CONCLUSION

Although this study has as limitation the fact that it was developed shortly after the abortive practice, when the interviewees sought for obstetric care and their feelings were possibly exacerbated, it was possible to understand relevant aspects that triggered the conflicting emotions in this process.

Thus, the analysis of the feelings of the participants revealed the presence of numerous emotions. These emerged from the moral issues involved in the phenomenon of inducing abortion. When carrying out the abortion, they went against the morality and social symbolisms attributed to life, pregnancy and maternity. This made them experience emotional pain and assign negative meanings to themselves for transgressing their own convictions.

Therefore, the importance to understand the human action as the product of an ongoing interactive process between individuals and their surroundings is recognized. In the case of abortion, this understanding is critical to know the interactions established by women, along the abortive journey, with theirs partners and/or families, the providers of the abortive method, the fetus, and the health professionals, considering the moral values inserted in their process of socialization.

By extending the look to the phenomenon of abortion, it is possible to reduce the social stereotypes about women who interrupt a pregnancy. For health professionals, the expanded understanding of this event is essential to provide a more welcoming and comprehensive care, based on qualified listening and respect for the particularities of each woman.

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