Abstracts

Introduction

The sexual and reproductive health of female sex workers is widely unexplored by public health studies in Latin America. In the last two decades, the political and research agenda for health has been focused on the HIV/AIDS epidemic and other sexually transmitted diseases¹1 Pitpitan EV, Kalichman SC, Eaton LA, Strathdee AS, Patterson TL. HIV/AIDS risk among venue-based female sex workers across the globe: a look back and the way forward. Curr HIV/AIDS Rep 2013; 10(1):65-78.^,22 Baral S, Beyrer C, Muessig K, Poteat T, Wirtz AL, Decker MR, Sherman SG, Kerrigan D. Burden of HIV among female sex workers in low-income and middle-income countries: a systematic review and meta-analysis. Lancet Infect Dis 2012; 12(7):538-549.. There was an increase in the use of condoms among female sex workers, but international research data demonstrate that they still have high rates of unplanned pregnancies and abortions compared with other groups³3 Feldblum PJ, Nasution M, Hoke TH, van Damme K, Turner AN, Gmach R, Wong EL, Behets F. Pregnancy among sex workers participating in a condom intervention trial highlights the need for dual protection. Contraception 2007; 76(2):105-110.

4 Todd CS, Nasir A, Stanekzai MR, Scott PT, Strathdee SA, Botros BA, Tjaden J. Contraception utilization and pregnancy termination among female sex workers in Afghanistan. J Womens Health 2010; 19(11):2057-2062.^-55 Morineau G, Neilsen G, Heng S, Phimpachan C, Mustikawati DE. Falling through the cracks: contraceptive needs of female sex workers in Cambodia and Laos. Contraception 2011; 84(2):194-198.. A Canadian study found that 36% of local sex workers have had at least one abortion in their reproductive life⁶6 Duff P, Shoveller J, Zhang R, Alexson D, Montaner JSG, Shannon K. High lifetime pregnancy and low contraceptive usage among sex workers who use drug - an unmet reproductive health need. BMC Pregnancy Childbirth 2011; 11:61., while 86% of Kenyan sex workers have had at least one abortion and 50% of them have had more than one⁷7 Elmore-Meegan M, Conray RM, Agala BC. Sex workers in Kenya, numbers of clients and associated risks: on exploratory survey. Reprod Health Matters 2004; 12(23):50-57..

In Brazil abortion is forbidden by the 1940 Penal Code. There are three exceptions in which women will not be prosecuted: in the case of rape, risk to the life of the woman, and foetal anencephaly. Even in this restrictive legal frame, the magnitude of abortion is high. A 2010 national survey showed that one in five women at the age of 40 have had at least one abortion⁸8 Diniz D, Medeiros M. Aborto no Brasil: uma pesquisa domiciliar com técnica de urna. Cien Saude Colet 2010; 15(Supl. 1):959-966.. Misoprostol is widely used by women to perform an abortion, in spite of its illegal commercialization. Before its popularization in the 1990s, the most common methods were probes or perforating utensils, with high levels of morbidity⁹9 Hardy E, Alves G. Complicações pós-aborto provocado: fatores associados. Cad Saude Publica 1992; 8(2):454-458.. The popular use of illegal misoprostol has changed the levels of infectious and haemorrhagic outcomes of unsafe abortions in Brazil¹⁰10 Faúndes A, Santos LC, Carvalho M, Gras C. Post-abortion complications after interruption of pregnancy with misoprostol. Adv Contrac 1996; 12(1):1-9.; nevertheless, illegal and unsafe abortion is still a significant cause of morbidity in Brazil¹¹11 Camargo RS, Santana DS, Cecatti JG, Pacagnella RC, Tedesco RP, Melo Junior EF. Sousa MH. Severe maternal morbidity and factors associated with the ocurrence of abortion in Brazil. Int J Obstet Gynecol 2011; 112(2):88-92.^,1212 Santana DS, Cecatti JG, Parpinelli MA, Haddad SM, Costa ML, Sousa MH, Souza JP, Camargo RS, Pacagnella RC, Surita FC, Pinto e Silva JL; Brazilian Network for the Surveillance of Severe Maternal Morbidity. Severe maternal morbidity due to abortion prospectively identified in a surveillance network in Brazil. Int J Obstet Gynecol 2012; 119(1):44-48..

Brazil has almost no epidemiological or qualitative data about abortion among sex workers. This solely Brazilian study was conducted in Teresina, Piauí and found that 52.6% of the local female sex workers have had at least one abortion and 16.5% of them reported three or more abortion events. Misoprostol was the most common method used among them (80%); however, half of the women had to be hospitalized to conclude the abortion¹³13 Madeiro AP, Rufino AC. Induced abortion among prostitutes: a survey using the ballot-box technique in Teresina - Piauí. Cien Saude Colet 2012; 17(7):1735-1742.. Our objective in this paper is to describe how female sex workers perform an illegal abortion and the health consequences of the methods used.

Methods and materials

We have conducted a qualitative study with 39 women who declared themselves as sex workers in the cities of Porto Alegre, Belém, and Teresina between April and November of 2012. The invitation to participate in the study was transmitted through the snowball technique and mediated by sex workers’ movements in each city. We interviewed women between 18 and 39 years old to avoid issues related to legal consent and memory errors in relation to previous reproductive events. In each city we interviewed women in different age groups (18-29; 30-39 years old) and at different levels of education (primary school, high school and university degree) aiming to analyse the abortion experiences between the different social strata.

The interviews were conducted in their places of work, such as brothels, public squares and streets at times defined by the participants. The interviews were conducted by the male author of this study to control any gender bias, and they were recorded. The interviews were guided by a semi-structured questionnaire divided into three sections: i. Socio-demographic information; ii. Methods to perform the abortion; iii. Medical complications.

The interviews were transcribed and independently analysed by the authors of this study (a physician and a social scientist). The data was codified using a 20-question instrument. The researchers compared the patterns obtained and in case of discordance they reviewed the raw data. The research proposal was reviewed and approved by the University of Brasilia Ethics Committee. All data was anonymized to avoid any identification of the participants, as abortion is illegal in the country. All participants were offered voluntary financial compensation of 8 USD to cover transportation costs. 90% of the women interviewed accepted the compensation. The Brazilian ethical review system prohibits payment for participation in academic research.

Results and Discussion

For all of the women interviewed, sex work is their main source of income and more than half of them (69.2%) indicated that they charge between R$ 20 and R$ 50 (Brazilian reais) per sexual encounter. Nearly 80% of them began sex work when they were under the age of 18, generally justifying initiating prostitution due to financial necessity. The great majority (84.6%) had more than 2 clients per day and 10% more than 5 clients per day. Over half (53.8%) did not have an intimate partner at the time of the interview and 35.9% had children. The use of alcohol before the act of sex was described as routine by all of those who worked in brothels. The demographic data, methods and medical outcomes are summarized in Table 1.

Methods to perform abortion

All women interviewed have had at least one experience performing an illegal abortion. The most common method is misoprostol, followed by traditional herbs and clandestine clinics. Six of the women (15%) have had 2 abortions, 5 (13%) have had 3 abortions, one had 5 abortions, and another one had 8 abortions. Even though the study was based on a convenience sample, we have not found any pattern relating education to recurrence of abortions. We can say that abortion is a common experience among female sex workers, but it is a solitary event for the majority of them. The same was found in other studies about the general female population¹⁴14 Diniz D, Medeiros M. Itineraries and methods of illegal abortion in five Brazilian state capitals. Cien Saude Colet 2012; 17(7):1671-1681.. In contrast with the general population, abortion is a regular reproductive experience that a sex worker will inevitably face during her professional life. 23 (59%) of them declared that the unplanned pregnancy happened as a “work accident” and not as the result of an affective-sexual relationship.

Since the introduction of misoprostol as the main illegal method among Brazilian women to self-induce an abortion, there was a significant decrease in the rates of mortality and near miss mortality¹¹11 Camargo RS, Santana DS, Cecatti JG, Pacagnella RC, Tedesco RP, Melo Junior EF. Sousa MH. Severe maternal morbidity and factors associated with the ocurrence of abortion in Brazil. Int J Obstet Gynecol 2011; 112(2):88-92.^,1212 Santana DS, Cecatti JG, Parpinelli MA, Haddad SM, Costa ML, Sousa MH, Souza JP, Camargo RS, Pacagnella RC, Surita FC, Pinto e Silva JL; Brazilian Network for the Surveillance of Severe Maternal Morbidity. Severe maternal morbidity due to abortion prospectively identified in a surveillance network in Brazil. Int J Obstet Gynecol 2012; 119(1):44-48.. If misoprostol empowered women to perform an abortion without exposing themselves to clandestine clinics, it also shifted the risk from clandestine medical practices to illegal drug sellers. Two Brazilian studies showed that misoprostol is sold by illegal sellers specializing in body shape medicines, such as hormone growth or loss weight¹⁵15 Diniz D, Castro R. The illegal market for gender-related drugs as portrayed in the Brazilian news media: the case of misoprostol and women. Cien Saude Colet 2011; 16(1):94-102.^,1616 Diniz D, Madeiro A. Cytotec and abortion: the police, the vendors and women. Cien Saude Colet 2012; 17(7):1795-1803.. Morbidity due to abortion was also reduced; however, some studies found that it is dependent on the safeness and precedence of the misoprostol used by the women¹⁷17 Zamberlin N, Romero M, Ramos S. Latin American women's experiences with medical abortion in settings where abortion is legally restricted. Reprod Health 2012; 9(1):34.^,1818 Arilha MM. Misoprostol: pathways, mediation and social networks for access to abortion using medication in the context of illegality of São Paulo. Cien Saude Colet 2012; 17(7):1785-1794.. The medicines are commercialized by the clandestine market, and there is some evidence that counterfeit pills are also in circulation. The main evidence that suggests the circulation of counterfeit misoprostol is the number of pills used by women to perform the abortion: the average was four, but some of them declared the use of eight pills to perform the abortion.

Considering the costs of the prostitute’s services and the education background as two indicators of income and social class, we found that the most vulnerable women are those who experienced high risks while performing an illegal abortion. Women who mentioned the use of uterine probes have the lowest educational background and income. Brazilian female sex workers are full-time professionals working in prostitution, and the vast majority of them are not included in the national social security system. The local and national organizations of female sex workers emerged in the late 1990s, but most of them are concentrated in large cities and have little political impact on national health policies. Recently, the national coordinator of the HIV/AIDS policy at the Brazilian Ministry of Health was dismissed for an educational campaign on sexually transmitted disease and prostitution¹⁹19 Ruiz E. As prostitutas não podem ser felizes. Rede HumanizaSUS. 2013. [acessado 2014 jan 14]. Disponível em: http://www.redehumanizasus.net/62924-as-prostitutas-nao-podem-ser-felizes
http://www.redehumanizasus.net/62924-as-... . Prostitution is legal in Brazil, but operating a brothel and pimping remain illegal activities. Many women interviewed in this study were independent professionals, renting their own places to attend clients, but the majority of them, 22 (56%), were attached to a brothel administrated by female and male pimps.

Medical outcomes and number of misoprostol tablets used

The World Health Organization recommends misoprostol for medical abortion - 800mcg vaginal or sublingual every 8 hours up to three doses. It is safe when used in the first trimester of pregnancy²⁰20 World Health Organization (WHO). Safe Abortion: Technical and Policy Guidance for Health Systems. 2nd edition. Geneva: WHO; 2012.. In contrast with the results of other qualitative Brazilian studies about the use of misoprostol among the general female population, sex workers did not have difficulties or discomfort using vaginal misoprostol²¹21 Sherris J, Bingham A, Burns MA, Giroin S, Westley E, Gomez PI. Misoprostol use in developing countries: results from a multicountry study. Int J Gynecol Obstet 2005; 88(1):76-81.. The doses used were from 1 to 8 pills, vaginal and oral. After using the medicines, the vast majority of them had vaginal bleeding and/or abdominal pain. These women, who did not have previous experience with medical abortion, learned how to use the misoprostol from the drug seller or from other sex workers. The most disturbing experience for them was to understand the body signals, such as if the expulsion of the foetus (in their words, “the expulsion of the ball”) was completed. As other studies have found among the general female population, many sex workers decide to go to a hospital to check if the abortion has been successful¹⁴14 Diniz D, Medeiros M. Itineraries and methods of illegal abortion in five Brazilian state capitals. Cien Saude Colet 2012; 17(7):1671-1681.^,1717 Zamberlin N, Romero M, Ramos S. Latin American women's experiences with medical abortion in settings where abortion is legally restricted. Reprod Health 2012; 9(1):34.. Of those who were hospitalized, 63% of them did not disclose the induced abortion to the health care team.

Similar to other studies⁹9 Hardy E, Alves G. Complicações pós-aborto provocado: fatores associados. Cad Saude Publica 1992; 8(2):454-458.^,1010 Faúndes A, Santos LC, Carvalho M, Gras C. Post-abortion complications after interruption of pregnancy with misoprostol. Adv Contrac 1996; 12(1):1-9.^,2222 Harper CC, Blanchard K, Grossman D, Henderson JT, Darney PD. Reducing maternal mortality due to elective abortion: potential impact of misoprostol in low-resource setting. Int J Gynecol Obstet 2007; 98(1):66-69., intense abdominal pain and voluminous bleeding were the most common post-abortion complications described by the prostitutes. Infectious complications, requiring prolonged hospitalization and a hysterectomy in one case, were more frequently observed among those who used invasive measures. Due to the variety of means and methods used by the women, it is difficult to establish exact causes of the complications described. Nevertheless, insufficient knowledge of appropriate doses of misoprostol and, moreover, the inability to recognize the physical warning signs were frequently described by the prostitutes as post-abortion complications.

Final considerations

Female sex work provokes moral and political debates on gender justice and women’s body exploitation²³23 Mackinnon CA. Trafficking, Prostitution, and Inequality. Harvard Civil Rights - Civil Liberties Law Review 2011; 46:217-309.. We have opted not to advance in these important discussions: female sex work is an unfair reality in Brazil, not only on moral grounds related to the oppression of women, but mainly due to the public health consequences of this everyday practice. This study described one public health indicator of how risky sex work activity is in Brazil - the risk of unplanned pregnancies and consequences of unsafe abortions. This study partially fills that gap describing who they are, how they performed the abortion and the health consequences of the adopted methods.

The vast majority of the sex workers have had illegal abortions using similar means and methods that the general female population in Brazil has reported using. A typical plan is to initiate the abortion at home with illegal misoprostol and to finish it at a public hospital. The medical complications were associated with the invasive methods, such as needles and probes. In almost all sex worker narratives, the abortion was a solitary experience, performed alone without helpers, partners or other women. The prostitutes who had infectious complications as a result of the abortion more frequently indicated that they delayed going to the hospital, despite fever or persistent bleeding. The main justification given was the fear of being reported by the health team to the police.

Even though abortion is on the agenda of reproductive and sexual rights in Latin America, there is no reference to female sex workers’ vulnerability to unsafe abortion. The regular offer and use of contraceptives among female sex workers has the potential to reduce the magnitude of abortion, but the focus of the Brazilian public health policies has been the HIV/AIDS infection and the use of condoms. A national health policy on contraceptive and barrier methods targeting the sex worker population would be efficient in reducing their vulnerability to unsafe and illegal abortions.

Referências

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