Nursing Care for Women in Situation of Unsafe Abortion *

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Introduction
Abortion, word originated from the Latin, is the early end of pregnancy, deprivation of birth.Abortion is related to the discharge of birth before its probability, in the period up to the 22 nd week of pregnancy and weighing less than 500 grams [1].
The World Health Organization (WHO) defines unsafe abortion as the procedure used to interrupt pregnancy by unfit or inadequate people [2].
It is considered a public health problem because of its relevance, bringing problems to women's life, causing damage to them and, in some cases, leading to death.Abortion is constantly practiced in an unsafe way, showing health risks and also providing eclectic suggestions, involving ethical, moral, religious, family, legal and illegal aspects [3].
All over the world, the prevalence of unsafe abortion is estimated at 19-20 million, of which 97% are in developing countries.In Brazil, it is estimated that more than one million illegal abortions occur every year, even with punitive laws for those who practice it.Nonetheless, it is, on the other hand, an isolated, rare and unknown event.It is considered a crime against life framed from article 124 to article 128 of the Brazilian Penal Code, decree -law 2,848, dated December 7 th , 1940.In particular, Article 124 says that causing abortion in itself or allowing others to cause it, should punish from one to three years of detention.Abortion is only authorized in case of rape or threat to maternal life.In the event of fetal deformities, conditions unable to get along with extrauterine life, the event is only performed after judicial authorization [2,5].
Unsafe abortion, mainly, is done under precarious conditions, without safety and hygiene, bringing risks and negative consequences to women's health.Abortion is practiced by women of low purchasing power, with low schooling and often without information about what the act practiced can cause their life, leading to increased rates of morbidity and mortality.Many women are aware about the risk they are having, and even so, they practice abortion as the "best practice" of failing family planning without the use of contraceptives, which has culminated in an unwanted pregnancy.In addition, the factors those permeate the abortion situation also known because they are present in most of the identified cases, such as fear of abandonment (by the partner), family rejection and lack of employment.Against this background, we will have the consequence of an unsafe abortion [4].
Abortion affects in women's health causing psychological, physical, reproductive and moral harms.Through the social practice of "good manners", the woman who aborts is treated disgracefully and without feeling.Religiousness also has a strong foundation under the idea that women have about abortion as a "sin".Guilt and fear consist of factors that are strongly present in the lives of women who carry out abortion, and who have a practicing religious life, since practice is disregarded by religious precepts [6].
There are several causes of abortion, but many pregnancies are interrupted by the personal determination of women against various factors, be they religious, moral, personal, financial, among others [5].
The types of abortions are: Threat of abortion, where the presence of transvaginal bleeding occurs in a period of 5 to 6 days, of moderate proportion and cervical dilation does not occur; Inevitable / incomplete abortion, where pains are much greater, bleeding very intense and cramps occur; Retained abortion causes the death of the conceptual product, retention of this in the uterine environment and a regression in the symptoms of pregnancy; Infected abortion is associated with unsafe methods and is associated with the classic symptoms of infection; Usual abortion, is defined as three or more consecutive losses in gestational ages of less than 24 weeks; Elective abortion, provided for by law, is a medical practice and is authorized only in cases of rape, when there is no other means of saving the mother's life, besides cases of anencephaly, since the fetus does not survive after giving birth [5].
In relation to health professionals, there are still various prejudices embodied by moral and religious issues that bring difficulties to understanding.These women are judged and decriminalized for practicing the act, but the protection and assistance must be presented, regardless of whatever causes the need.The search for an incomplete abortion service often ends up constituting an experience stressed by disrespect, characterizing the inhuman trajectory of women in health services [4].
Women are exposed to judgments and mistreatment by some professionals when they spend hours waiting for care; they suffer threats of police reporting and brutality in physical contact.Thus, dealing with abortion means entering a polemical field that mobilizes the most intimate feelings, shaking social norms built and rebuilt along the dynamics of society [4].
With regard to the health professionals involved in this service, the nursing professionals are present 24 hours a day in hospital care.This contact requires preparation to deal with such situations, which are becoming more and more constant, and it is often necessary to deconstruct moral, religious and personal values in daily work, thus trying to reduce the prejudices in respect of this subject.The fact that nursing professionals are sensitive, welcoming and communicative is well accepted by these women in situations of abortion, offering them comfort, enjoyment and a sense of well-being [7].
Nursing, regardless of etiology, must respect the limits of the nurse woman puts herself in the place of the woman, recognizing how to listen, respect, show confidence in the information received and give the attention needed.It is vital to renounce discrimination against women who practiced abortion, offering her quality assistance and free from any kind of judgment [8].
In order to avoid that induced abortion occurs, nurses should intervene more emphatically, adding to their approach the provision of guidelines to pregnant women, couples and adolescents, through lectures in basic care and educational interventions during the day-to-day life of hospital care as well.Health education, within the aspect turned to women's health, should encompass everything that is within the professional scope of the nurse, together with her team, seeking the prevention of abortion through an effective and necessary sexual education for the population.Investing in guidelines about the proper use of contraceptive methods and the risks of inappropriate use of contraceptive methods becomes a very effective strategy for disseminating information that culminates in social awareness of unwanted pregnancies [9].
During nursing academic training, professionals must be informed about the ethical and legal precepts that permeate practice, since abortion is not a theme widely accepted by society.Based on this information, it is necessary to build reeducation before their values and to transpass to their attendance respect and the necessary confidence to integral care given to women in situation of abortion; as a result, quality and humanization of the care.It is of vital importance that the nursing team performs a professional qualifying care in both situations of spontaneous abortion or induced / caused abortion, since abortive process is a traumatic experience for the woman [6].
This study is justified by the problematization generated after contact with various reports of women and health professionals, during a lived experience by one of the authors in the supervised nursing undergraduate stage in the health services, about how it is provided assistance to women who practiced unsafe abortion, performed most often in an inhumane way, damaging their lives.Argued abortion, despite its restriction in Brazil, is still an isolated and unknown practice.
Before this context, the following guiding question arose: "How is the problem pertinent to nur-sing care turned to women in situations of unsafe abortion worked out in the scientific literature?" Because of the importance of this issue, we sought to identify in the literature evidence concerning the peculiarities of nursing care given to women inserted in situations of unsafe abortion; and then, contributing to guidance about the different risk situations and promoting women's health as the main target.

Method
This study is an integrative review of the literature about nursing care to women who were submitted to unsafe abortion.This method allows an intimate understanding regarding the subject, involving the synthesis of knowledge of teachings implied in the revision, containing systematization and publication of results, reducing doubts about practical recommendations based on previous studies.The integrative review is advantageous, as it allows experimental and quasi-experimental research, enabling to clarify the subject treated [10].
To follow up the review, six phases about integrative review of the literature were used to appropriate this study, for incorporation of this research [10]: First phase: In this phase, the guiding question is defined so that there is a well-designed integrative revision, this idealization must contain theoretical reasoning, including definitions so that the subject is understood in a clear and precise way.
Second phase: This is where the database search for recognition of the studies involved in the review takes place.The inclusion and exclusion criteria should be made in a thorough way for a better understanding of the methodology.
Third phase: This is where the data collection takes place.The purpose of this phase is to organize and extract data in a succinct manner, providing an accessible and easy to use database for handling.
Fourth phase: It is the critical analysis of included subjects, which should be studied in detail.This phase is characterized towards the application of statistical analysis, selection of studies, definition or exclusion of studies against the demarcation of the research.
Fifth phase: Where the interpretation of results occurs, making comparisons with theoretical understanding, the recognition of conclusions and implications resulting from the integrative review.
Sixth phase: It is where the synthesis of acquired knowledge happens, summarizing the available evidence, represented by documents that favor the integrative revision.
Four databases were used to identify the study, which are: Latin American Caribbean Literature in Health Sciences (LILACS), Nursing Database (BDENF-Nursing), Medical Literature Analysis and Retrieval System Online (MEDLINE) and SCOPUS through the use of a proxy licensed by the Federal University of Paraiba accessed via Capes Journal gateway.
During this search, the following descriptors were used: abortion, induced abortion, nursing care, caused abortion, nursing and nursing care, according to the Health Sciences Descriptors (DeCS) and the Medical Subject Headings (MeSH).Using the Boolean operators "AND" and "OR", as follows: abortion OR induced abortion OR caused abortion AND nursing OR nursing care, as well as the correlation between them, favoring the search performed in Portuguese and English.
Inclusion criteria were articles that met the guiding question, published between 2006 and 2016, in Portuguese, English and Spanish, available in full, online and free of charge.Dissertations and theses, letters, editorials, comments, studies with abstract summary and articles that were not available in full were excluded.The data search followed the procedures of reading titles, abstracts and articles in full, to identify if they contemplated the guiding question of the study.The collection took place from September to October 2016.
The data sampling process resulted in a total of 945 publications, of which 14 were selected to compose the review sample, as shown in Figure 1, synthesis of the data extraction process.
It should be emphasized that the commitment to ethical aspects consists in citing the articles analyzed.In order to extract the main data, an instrument was elaborated that presented information: author, title, journal, year, region/country, study approach and study scenario.The results and analyzes are presented below.
The results are presented in tables containing the information of the studies, as well as a table of the main results extracted from the articles that composed the sample, from these results, the thematic categories were elaborated and inserted in the discussion.

Results
For the description of selected studies, each article received a code called letter E (study) followed by the number, as shown in Table 1.
Among the 14 articles selected, 6 (42.9%) were published in national journals and 4 (28.6%),international journals.In relation to the periodical, the Journal Text & Context of Nursing obtained 3 (21.4%) of the publications.Concerning the language of the publications, 10 (71.4%) articles in Portuguese and 6 (28.6%) in English.The year with the highest number of articles was 2015 with 4 (28.6%).It should be noted that in the years 2009, 2010, 2012 and 2014, no publications were found that met the criteria of the present study, according to Table 1.
According to the study place, Table 2, 10 (71.4%) of the studies were performed in Brazil.Among the study scenarios, 6 (42.9%) were performed in hospitals.Among the studies, 9 (64.3%) were qualitative.
In Table 3, there are some excerpts extracted from the articles that composed the sample, in relation to the way the assistance was offered to women in situations of abortion, what were the reasons pointed out for the practice of abortion and the emotional state of the women who practiced it.It is cost noting that domestic violence, inadequate use of contraceptive techniques and unplanned pregnancy are the most frequent rea-

Discussion
The analysis of the studies that comprised the review sample, made it possible to identify the scientific evidence about the reasons that led the implementation of the act of abortion and the respect of nursing care made to women in a situation of unsafe abortion, which are presented in two axes.

Reasons that led the implementation of the act of abortion
Recognizing and reflecting about the reasons that led to the act of abortion is important so that the health professional, especially the nurse, sensitizes himself and understands the women in the context in which they are inserted.To think in this way, it is to contribute to make health professionals better able to deal with abortion care, considering the care directed to women.The review articles that address this theme were composed of the discourses of women, who often do not seek health care out of fear or even fear of being judged, even keeping silent because they do not feel comfortable speaking about the subject.
A study showed that the daily life of many women who caused abortion is permeated by domestic violence and, during the phase of childhood and adolescence, stressed by abandonment and rejection by relatives [11].This context contributes to encourage an unprotected early sexuality, which can result in pregnancy and consequently abortion.In addition, marital violence is also pointed out in the study as a reason for the practice of abortion.In agreement with this study, a study carried out in a public maternity center in northeastern Brazil, with 17 women hospitalized due to induced abortion, also showed that the family relations were surrounded by the abandonment experienced since childhood, contributing to a process of vulnerability intrinsic to the social context in which they are inserted [12].Confirming this reality, other authors made the same notes in their research [4,13,14].
Other studies about the review have listed as reasons that led to abortion rejection by pregnancy, lack of support from the partner, fear of parents and low financial income [12,15,16,17,18].About this research, a survey exposed and discussed that abortion was being performed by women with high family income, which facilitated the occurrence because they had the resources to perform the practice.For these women, pregnancy was not desired and would hinder a professional future at that time [19].If in the review articles the lack of financial conditions was considered one of the reasons for abortion, in this study of women of high purchasing power, the opposite is true, which is shown to be an agent that facilitates the act.However, in all studies, pregnancy has always been undesirable.It is important that the nursing professional reflects about this entire socioeconomic context that involves women in situations of abortion, with an open look at change and totally free of preconceived judgments [19].The respect of nursing care made to women in a situation of unsafe abortion The Code of Ethics of nursing professionals comprises norms, principles, rights and duties pertinent to professional practice.In it, it is evident that nursing care must be quality, risk-free, accessible to the entire population, without beliefs and discrimination of any kind [20].
With regard to nursing care performed on women in situations of unsafe abortion, a study brings as a discussion discriminatory nursing care, treating the woman as a criminal, even in cases where abortion was provided by law [21].This discussion is in line with other studies [22,23].To think about the woman who practices abortion as a criminal is to allow beliefs and values to permeate professional practice, when one really expects the professional to remain neutral in the face of events.Professional conduct conditioned to cultural values, causes unnecessary suffering, increased anxiety and complications for assisted women [4].Against this background, such studies contradict the Code of Ethics of the profession that must be guided by the understanding, without judgments of values in relation to what happened.
With respect to nursing care focused primarily on the mechanical form, centered on the techniques and hard technology, we find that it consists of a reality observed in three studies [1,18,24].
In the first, it is an integrative review that sought to identify how nursing practice occurs in a situation of induced abortion [18].In this review, the care centered on the technique was very widespread and reflected, aiming at the change of the professional stance and the incorporation of pillars that support nursing assistance centered on humanization in health.The Ministry of Health, through a Technical Standard, guarantees that humanization in situations of abortion is a woman's right and a duty of the health professional and services, which must commit to actions that aim to receive, listen and advise, respecting women in their needs and uniqueness [5].
The National Policy on Women's Health Care, in its guidelines and principles, covers women in the face of gender, health, social and moral aspects, reinforcing humanized and quality assistance for women in situations of induced abortion [25].In the second study, the issue of mechanistic practice is approached through the statements of women in abortion who underwent this type of care, where they visualize a professional commitment with a care permeated by delay in the care and assessment of the physical, extirpating from reality the concept of totality [24].
A study about women's reproductive rights in pregnancy-puerperal care at a Maternity Public in Paraiba, Brazil, showed the predominance of the technocratic assistance model, explaining that it is not a reality only from the context of abortion [26].Nursing must be aware of its role as caregiver, assume a clear, empowered and willingness to go beyond biologic practice.In the third study, the nursing care centered on the techniques is reflected through the perceptions of nursing professionals working in an obstetric center in the South of Brazil [1].For them, this behavior reflects a professional who does not feel capable of attending to women in situations of induced abortion.Many authors stress that unpreparedness may interfere with the quality of care provided to women who are being aborted, both in hospitals and other health services [27,28].
For professionals who are obliged to assist women in situations of abortion, who do not agree to the act by expressing preformed opinions and judgments of their own, the feelings that prevail during the care actions are of anger, anguish and stress clearly reflected in the care provided [29,30].A study further says that the care provided and the feelings of the team are directly linked to the motives that led to the practice of the act [15].In another study in Taiwan, nurses are required to participate with the doctor in the practice of abortion.This obligation is one of the reasons that can compromise care and incorporate technical acts, thus making a practice that should necessarily be holistic, and technical-reductionist [29].
Nursing care should be thought of as a whole, the need to participate in the procedure or the care that is highly needed before and after the act.It is important for the woman to always feel the support of the nursing team at all times.In a systematic review, the need to think, rethink, construct and reconstruct the health practices that are being offered to people in post-abortion situations is clear [31].
In the study about nursing perceptions about abortion management and care, the idea is to provide a humane, quiet assistance with a decent and humane service to women in situations of abortion, recognizing the need for a separate environment in the maternity ward, in which the women who suffered abortion are separated from those who are in the puerperium [14].Already in a study of mourning in the abortion process, the nurse assumes a willingness to listen, not to judge, to criticize, and to provide clear and accurate information during abortion care for women [32].
Nursing needs to reflect on the care provided in abortion situations, focusing its actions on the singularity of the subject.A better preparation of undergraduate students to raise awareness about the subject, as well as ongoing and ongoing education activities for workers, may favor changes in paradigms and sensitize those involved and involved in the transformation to a humanized care [14].

Conclusion
Abortion is defined to be a matter quite controversial and an imperfection of public health, subject to mortality and morbidity of the woman who needs to be observed, where its illegality does not prevent its occurrence.
Studies have shown that nursing care is carried out in a manner more inhuman, so technicist and without quality service from the health service that involves the unsafe abortion, where the absence of communication complicates the care offered, the same way that the judgments, prejudices, religion, moral values, bring difficulties for understanding about the subject leaving to provide the quality assistance to these women.
The human look to women in abortion will reveal lives penetrated by sadness, pain, repentance and guilt, mainly because they consider them criminals.However, it is basic a change in nursing care that offers care to women in situations of abortion, where this nursing care must be a holistic care and free of judgment of values, there must also be a reform in the lives of women in the demand for independence, Knowledge about their body, methods of prevention as to his will to not have children and greater search for his direct.
This study offers nursing assistance, encouragement regarding the reflection about nursing assistance to women in situations of unsafe abortion, since the understanding about the subject has influence in the care, in the life of the professionals and especially in women's lives; contributing also to reflection and discussion about this care in the formation of nursing higher education.

Figure 1 :
Figure 1: Distribution of the publications found according to inclusion and exclusion criteria and databases.João Pessoa, Paraiba, Brazil, 2006-2016.

Table 3 .
Features extracted from studies on unsafe abortion, offered assistance, reasons for the second practice, feelings of women.Joao Pessoa,Paraiba, Brazil, 2006-2016.