Legal abortion in Brazil: systematic review of the scientific production, 2008-2018

Reproductive health and rights, and public policies in Brazil: revisiting challenges during covid-19 pandemics

We revisit the debates on reproductive health and rights (RHR) and public policies in Brazil, with focus on contraception, abortion and maternity care. These were part of a broader political agenda for re-democratisation, and for health sector reform, with the creation of the Women's Integral Health Program (PAISM) in 1983, and of the Universal Health System (SUS) in 1988. The momentum created by ICPD in Cairo (1994) was essential to institutionalise the language of RHR. Not without resistance and organised activism, recent years of right-wing governments brought a disinvestment in most public policies for women's rights. Some components of the RHR agenda are more mainstreamed, such as fertility regulation, especially hormonal and long term-methods. The limited legal rights to abortion are poorly institutionalised and constantly threatened. Maternal care tends to be highly medicalised and frequently abusive. The covid-19 pandemic accelerated social and public health disruption. The article addresses notions such as reproductive justice and institutional violence, present in the early days of women's health movement, in order to highlight important premises that were diluted in the debate on reproductive rights and autonomy. The historical analysis of how these concepts evolved locally and globally can allow a better understanding of present challenges.

Internações por aborto no Brasil, 2008-2018: estudo ecológico de série temporal

Resumo Objetivo: Analisar a tendência temporal das internações por aborto no Brasil, de 2008 a 2018, segundo região e Unidades da Federação (UFs). Métodos: Estudo ecológico, com dados de internações por aborto de mulheres em idade fértil registrados no Sistema de Informações Hospitalares/Sistema Único de Saúde (SIH/SUS). As taxas foram calculadas segundo características da mulher; e a tendência, avaliada por regressão linear generalizada de Prais-Winsten. Resultados: As 2.258.104 internações por aborto representaram 5% de todas as internações de mulheres em idade fértil. Houve redução significativa, de 0,76 pontos percentuais ao ano, no período. Essa tendência ocorreu em 19 UFs brasileiras e em todas as regiões, exceto a Sul (estável). Houve redução significativa (p-valor<0,001) nas internações por aborto espontâneo e nas internações de mulheres de 20 a 39 anos. Conclusão: Observou-se tendência de redução das internações por aborto no país, com variações segundo características da mulher, UF e região de residência.

[What do the national data say about the supply and performance of legal abortions in Brazil in 2019?]

Abortion is supplied by the Brazilian Unified National Health System (SUS) in cases allowed under the prevailing legislation. The current study seeks to map and characterize the supply and performance of this procedure in Brazil in 2019. Data included the Referral Services for Termination of Pregnancy Authorized by Law (SRIGCPL) recorded in the National Registry of Healthcare Establishments (SCNES) and the establishments with records of abortion for medical and legal reasons in the Outpatient Information System and Hospital Information System. Establishments were characterized by type and subtype, legal status, and contractual agreements, and georeferenced according to data from the SCNES. Next, municipalities were classified as those with and without supply of the procedure in 2019 and were presented by categories of Municipal Human Development Index (HDI-M) and population size. The data were used to calculate the rates of legally authorized abortions performed in the two groups of municipalities. In all, 290 establishments supplied the service, of which 101 SRIGCPL and 251 establishments with records of the procedure. The establishments were situated in 3.6% (200) of Brazil's municipalities. The supply was mostly in hospitals (98.6%), under the public administration (62.1%), in contractual agreements with the SUS (99.7%), in municipalities in the Southeast of Brazil (40.5%), with more than 100,000 inhabitants (59.5%), and with high or very high HDI-M (77.5%). The rate of legally authorized abortions in childbearing-age residents of municipalities without supply of the service was 4.8 times lower than in municipalities with the service. The supply of legally authorized abortions in Brazil is distributed unequally across the territory, with possible negative implications for access to the service.

[Analysis of records for women that have undergone legally authorized abortions in Porto Alegre, Rio Grande do Sul State, Brazil]

Abortion as allowed by law in Brazil is a right that is rarely enforced, due to the multiple barriers to access. Another troublesome issue related to the health system's organization is the difficulty in obtaining reliable and easily accessible records to back monitoring and evaluation of legally authorized abortion. The current study thus aimed to analyze the patient records of women that had undergone legal abortion in the city of Porto Alegre, Rio Grande do Sul State, from 2013 to 2018 and to identify the procedure's prevalence in the Hospital Information System (SIH). The study analyzed on site the patient files for legally permitted abortions performed in the four referral services in the city. The authors cross-analyzed the data with the database of the SIH under the Brazilian Unified National Health System (SUS). Prevalence ratio was estimated with a Poisson regression model with robust variance. Examination of the patient files identified 236 cases of legal abortion, of which 95 (40.3%) were recorded in the SIH. The cases in which the patient files contained ICD O04 (medical abortion) identified in their internal records had 3.02 times higher prevalence (95%CI: 1.83-4.98) of being recorded in the SIH than those without the ICD code. The number of records of legal abortions in the SIH differed according to the hospital. However, independently of the hospital, the fact that the internal record listed ICD O04 increased the prevalence of records in the SIH. In conclusion, the lack of standardization and under-recording hindered the collection of trustworthy information in the national database of the SUS, further increasing the invisibility of legal abortion in Brazil.

Factors Associated with Abortion Complications after the Implementation of a Surveillance Network (MUSA Network) in a University Hospital

OBJECTIVE

 To evaluate the factors associated with abortion complications following the implementation of the good-practice surveillance network Mujeres en Situación de Aborto (Women Undergoing Abortion, MUSA, in Spanish).

METHODS

 A cross-sectional study with women who underwent abortion due to any cause and in any age group at UNICAMP Women's Hospital (part of MUSA network), Campinas, Brazil, between July 2017 and Agust 2019. The dependent variable was the presence of any abortion-related complications during hospitalization. The independent variables were clinical and sociodemographic data. The Chi-square test, the Mann-Whitney test, and multiple logistic regression were used for the statistical analysis.

RESULTS

 Overall, 305 women were enrolled (mean ± standard deviation [SD] for age: 29.79 ± 7.54 years). The mean gestational age was 11.17 (±3.63) weeks. Accidental pregnancy occurred in 196 (64.5%) cases, 91 (29.8%) due to contraception failure. At least 1 complication was observed in 23 (7.54%) women, and 8 (34.8%) of them had more than 1. The most frequent complications were excessive bleeding and infection. The factors independently associated with a higher prevalence of complications were higher gestational ages (odds ratio [OR]: 1.22; 95% confidence interval [95%CI]: 1.09 to 1.37) and contraceptive failure (OR: 3.4; 95%CI: 1.32 to 8.71).

CONCLUSION

 Higher gestational age and contraceptive failure were associated with a higher prevalence of complications. This information obtained through the surveillance network can be used to improve care, particularly in women more susceptible to unfavorable outcomes.

Oferta de aborto legal na atenção primária à saúde

O acesso ao aborto legal foi dificultado em várias partes do mundo em decorrência da pandemia por SARS-CoV-2. No Brasil, a legislação e regulamentação referentes ao aborto configuram um campo em disputa, fortemente marcado na atualidade por iniciativas conservadoras que visam suprimir este direito reprodutivo. Neste artigo, são apresentados argumentos em defesa da oferta de aborto legal em serviços de atenção primária à saúde como mecanismo de facilitação do acesso ao procedimento e preservação dos direitos das mulheres. Apesar de ser recomendada pela Organização Mundial de Saúde e já estar estabelecida em outros países, a participação da atenção primária ainda é incipiente no cenário nacional neste debate. Espera-se sensibilizar médicos de família e comunidade e demais atores relevantes para o potencial deste nível de atenção no provimento do aborto legal.

Barriers in Accessing Care for Consequence of Unsafe Abortion by Black Women: Evidence of Institutional Racism in Brazil

Women face difficulties in accessing post-abortion care, as hierarchical care operates under discrimination mechanisms that condemn women in abortion. In addition, it is the Black and Brown women who are more subject to unsafe abortions and need hospitalization to complete the termination of pregnancy or treat associated complications. This study aimed at identifying factors associated with the institutional barriers in access to health services for women who underwent abortion by race/color. The survey encompassed 2640 users admitted to public hospitals in Salvador, Recife, and São Luís. Differences among covariables according to race/color (Black, Brown, and White women) were analyzed and tested for statistical significance using Pearson's χ² test. The regression analysis initially included variables that may express the technical criteria of priority in care (time of pregnancy when abortion occurred and conditions of arrival), then the sociodemographic characteristics, and, lastly, the type of abortion declared. Black women faced more institutional difficulties (27.7% vs 19.5% in White women and 18.7% in Brown women), such as waiting to be attended and getting a bed. The association between being Black women and institutional barriers remained, even after adjustments in the regression model. Institutional racism limits access to health services and timely care for Black women, acting as a performative mechanism, legitimizing and generating exclusionary behaviors. The results demonstrate that the intersection between racial discrimination and abortion stigma redouble institutional barriers that are denominated intersectional discrimination.