Abstract

This paper aims to evaluate the racial inequalities in the care provided by health professionals concerning induced abortion. This systematic review study used the Preferred Reporting Items for Systematic Reviews and Meta-Analyzes (PRISMA) model, based on the following bases: Brazilian Virtual Health Library (BVS), Scientific Electronic Library Online (SciELO), National Library of Medicine, and National Institutes of Health (PubMed), Science Direct, Capes periodicals portal, with the descriptors: “racism OR social discrimination AND abortion, induced AND health personnel OR comprehensive health care OR delivery of health care OR human rights”, selected via the DeCS and Medical Subject Heading (MeSH). Eighteen papers published between 2005 and 2020 in national and international literature were analyzed following the inclusion and exclusion criteria. Most studies found a significant relationship between racial discrimination and institutional violence, including access and quality of care for patients undergoing an induced abortion. Racial discrimination is a significant risk factor for adverse care outcomes.

Key words:
Abortion; Health professional; Racial discrimination; Emergency medical services; Human Rights

Introduction

Racism is a neglected but relevant cause of health disparities in multiethnic societies¹1 Souza J. Raça ou classe? Sobre a desigualdade brasileira. Lua Nova 2005; 65:43-69.. Different types of racism and other expressions of discrimination must be recognized, critically analyzed, and actively reversed. We empirically distinguish and recognize human rights omissions and violations and then analyze the sources of racism in close relation to an intersectional view of forms of discrimination based on gender, class, and ethnicity²2 Espósito YB. Subjetivação necropolítica e a materialidade do pós-estruturalismo. Agenda Polit 2020; 8(1):313-336.. Most societies are racist, and this phenomenon is linked to racism and vulnerability, resulting in health inequalities. Nowadays, racism is identified as a relevant health concern but neglected and often ignored³3 Williams DR, Mohammed SA. Discrimination and racial disparities in health: evidence and needed research. J Behav Med 2009; 32(1):20-47.

4 Johnstone M-J, Kanitsaki O. The neglect of racism as an ethical issue in health care. J Immigr Minor Health 2010; 12(4):489-495.

5 Horton R. Offline: Racism - the pathology we choose to ignore. Lancet 2017; 390(10089):14.^-66 Bhopal RS. Intertwining migration, ethnicity, racism, and health. Lancet 2017; 390(10098):932..

Human rights are not data, but a construct, a human elaboration in constant construction and reconstruction⁷7 Arendt H. As origens do totalitarismo. São Paulo: Cia. das Letras; 1989.. As Piovesan⁸8 Piovesan F. Direitos sociais, econômicos e culturais e direitos civis e políticos. Sur Rev Int Direitos Hum 2004; 1(1):20-47. points out: “As a moral claim, human rights are born when they should and can be born”. Considering the temporal perspective of these rights, it appears that the meaning of human rights signifies a multiplicity of meanings; among which we highlight the contemporary understanding characterized by the universality and indivisibility of these rights⁹9 Dworkin R. Levando os direitos a sério. São Paulo: Martins Fontes; 2007., based on the Universal Declaration¹⁰10 Assembleia Geral das Nações Unidas. Declaração Universal dos Direitos Humanos [internet]. [acessado 29 set 2020]. Disponível em: https://www.unidosparaosdireitoshumanos.com.pt/what-are-human-rights/universal-declaration-of-human-rights/articles-01-10.html.
https://www.unidosparaosdireitoshumanos.... , and subsequently confirmed in the Vienna Declaration of Human Rights¹¹11 Biblioteca Virtual de Direitos Humanos da USP. Declaração e Programa de Ação de Viena [Internet]. [acessado 29 set 2020]. Disponível em: http://www.direitoshumanos.usp.br/index.php/Sistema-Global.-Declara%C3%A7%C3%B5es-e-Tratados-Internacionais-de-Prote%C3%A7%C3%A3o/declaracao-e-programa-de-acao-de-viena.html.
http://www.direitoshumanos.usp.br/index.... . Santos¹²12 Santos BS. Reconhecer para libertar: Os caminhos do cosmopolitismo multicultural. Rio de Janeiro: Civilização Brasileira; 2003. adds: “we have the right to be equal when our difference makes us inferior; and we have the right to be different when our equality deprives us of character. Hence the need for equality that recognizes differences and a difference that does not produce, feed, or reproduce inequalities”.

Several authors discuss the marginalization and coverage of health services, identifying a significant lack of access to medical coverage¹³13 Travassos C, Viacava F, Fernandes C, Almeida CM. Desigualdades geográficas e sociais na utilização de serviços de saúde no Brasil. Cien Saude Colet 2000; 5(1):133-149.^,1414 Viacava F, Porto SM, Carvalho CC, Bellido JG. Desigualdades regionais e sociais em saúde segundo inquéritos domiciliares (Brasil, 1998-2013). Cien Saude Colet 2019; 24(7):2745-2760., configuring itself in such a way as institutionalized racism, provided by discriminatory access to facilities, goods, and services¹⁵15 Silvério VR. Ação afirmativa e o combate ao racismo institucional no Brasil. Cad Pesqu 2002; 117:219-246.. Consequently, institutionalized racism is still evident in societies but mimicked in different social practices¹⁶16 Silva MAB. Racismo Institucional: pontos para reflexão. Laplage Rev 2017; 3(1):127-136.. Personally-mediated racism is related to prejudice and discrimination based on race, which may or may not be intentional. However, it manifests itself due to disrespect, mistrust, devaluation, accusation, and dehumanization¹⁷17 Modesto JG, Minelli AC, Fernandes MP, Rodrigues M, Bufolo R, Bitencourt R, Pilati R. Racismo e Políticas Afirmativas: Evidências do Modelo da Discriminação Justificada. Psicol Teoria Pesqu 2017; 33:e3353..

Indeed, the human right to health, also known as the right to the highest possible health standard, comprises legally binding international components. One of the most critical components of the right to health is the International Covenant on Economic, Social, and Cultural Rights (ICESCR), especially ICESCR General Comment N° 14¹⁸18 Pacto Internacional sobre Direitos Econômicos, Sociais e Culturais (PIDESC). General comment no. 14. The right to the highest attainable standard of health (article 12 of the International Covenant on Economic, Social and Cultural Rights). Genebra: ONU; 2000.. The right to health based on this comment encompasses essential elements assessed by the framework of four crucial indicators: availability, accessibility, acceptability, and quality (Chart 1). Availability refers to the existence and number of health facilities, goods, and services. Accessibility focuses on physical and economic access to health facilities’ goods and services. Furthermore, accessibility has four dimensions: non-discrimination, physical, economic, and access to information. Acceptability is related to the sensitivity of health facilities, goods, and services to medical culture and ethics. Concerning quality health facilities, goods and services must be scientifically and medically adequate and of satisfactory quality¹⁹19 Minayo MCS, Hartz ZMA, Buss PM. Qualidade de vida e saúde: um debate necessário. Cien Saude Colet 2000; 5(1):7-18..

Previous research in first world multiethnic countries such as the U.S.²⁰20 Barnes LL, De Leon CFM, Wilson RS, Bienias JL, Bennett DA, Evans DA. Racial differences in perceived discrimination in a community population of older blacks and whites. J Aging Health 2004; 16(3):315-337., United Kingdom²¹21 Karlsen S, Nazroo JY. Relation between racial discrimination, social class, and health among ethnic minority groups. Am J Public Health 2002; 92(4):624-631., Australia²²22 Larson A, Gillies M, Howard PJ, Coffin J. It's enough to make you sick: the impact of racism on the health of Aboriginal Australians. Aust N Z J Public Health 2007; 31(4):322-329., and New Zealand²³23 Harris R, Tobias M, Jeffreys M, Waldegrave K, Karlsen S, Nazroo J. Racism and health: The relationship between experience of racial discrimination and health in New Zealand. Soc Sci Med 2006; 63(6):1428-1441., and multiethnic developing countries such as Brazil²⁴24 Lemos A, Russo JA. Healthcare professionals and abortion: what is said and not said in a professional healthcare capacitation. Interface (Botucatu) 2014; 18(49):301-312., Mexico²⁵25 Bautista JER, López AO. Muerte materna en mujeres indígenas de México y racismo de Estado. Dispositivos biopolíticos en salud. Rev Salud Problema 2017; 11(21):28-53. and comparatively Brazil, Mexico, Colombia, and Peru²⁶26 Perreira KM, Telles EE. The color of health: skin color, ethnoracial classification, and discrimination in the health of Latin Americans. Soc Sci Med 2014; 116:241-250., have emphasized racism as the cause of persistent health disparities. For example, a US-based survey of health disparities by race provided evidence of significant inequalities between the African American population and the country’s white population. In the U.S., African Americans have higher mortality rates than their white counterparts for most leading causes of death²⁷27 Kung H-C, Hoyert DL, Xu J, Murphy SL. Deaths: final data for 2005. Natl Vital Stat Rep 2008; 56(10):1-120.. However, health disparities are not biologically or culturally determined; they are explained by a complex structure of social, economic, and political factors²⁸28 Smedley BD, Stith AY, Nelson AR. Unequal treatment. Confronting racial and ethnic disparities in health care. Washington, D.C.: National Academies Press; 2003.. Therefore, racism-related health disparities are a crucial argument for the relevance of social determinants of health²⁹29 Ramaswamy M, Kelly PJ. Institutional racism as a critical social determinant of health. Public Health Nurs 2015; 32(4):285-286.^,3030 Paradies Y, Ben J, Denson N, Elias A, Priest N, Pieterse A, Gupta A, Kelaher M, Gee G. Racism as a determinant of health: A systematic review and meta-analysis. PLoS One 2015; 10(9):e0138511.. Regarding human rights, non-racism and other discrimination are positions worth considering³¹31 Bazotti KDV, Stumm EMF, Kirchner RM. Ser cuidada por profissionais da saúde: Percepções e sentimentos de mulheres que sofreram abortamento. Texto Contexto Enferm 2009; 18(1):147-154.; notably, accessibility to health facilities, goods, and services without discrimination is essential³²32 Hunt P, Backman G. Health systems and the right to the highest attainable standard of health. Health Hum Rights 2008; 10(1):81-92..

Given the need to systematize the knowledge accumulated in recent years, this proposal aims to assess racial discrimination in the care of women with abortions by health professionals.

Methods

This systematic review is based on the recommendations of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA)³³33 Liberati A, Altman DG, Tetzlaff J, Mulrow C, Gotzsche PC, Ioannidis JP, Clarke M, Devereaux PJ, Kleijnen J, Moher D. The PRISMA statement for reporting systematic reviews and meta-analyses of studies that evaluate health care interventions: explanation and elaboration. PLoS Med 2009; 6(7):e1000100.. An electronic search for papers was performed in the Virtual Health Library (BVS) databases (BDENF - Enfermagem, BINACIS, IBECS, LILACS, MEDLINE), Scientific Electronic Library Online (SciELO), National Library of Medicine, and National Institutes of Health (PUBMED), Science Direct, CAPES Journal Portal (JSTOR Archival Journals, OneFile (GALE), Science Citation Index Expanded (Web of Science), Scopus (Elsevier), Social Sciences Citation Index (Web of Science), Sociological Abstracts (ProQuest), Taylor & Francis (online - Journals), with descriptors “racism OR social discrimination AND abortion, induced AND health personnel OR comprehensive health care OR delivery of health care OR human rights”, chosen following search in Health Science Descriptors (DeCS) and Medical Subject Heading (MeSH).

Studies published regardless of the year of publication, in English, Spanish and Portuguese, and evaluating racial discrimination in the care provided by health professionals in situations of induced abortion were included. Literature review papers, articles in the form of theses, dissertations, monographs, editorials, case reports, and those that did not meet 80% of the items required by the methodological quality assessment scales used in this study were excluded. The following data were extracted from each included study: authors, year of publication and study, study design, location, studied population, evaluated outcome, methodological limitations, and main results.

The quality of observational studies was assessed using the Strengthening the reporting of observational studies in epidemiology (STROBE) scale³⁴34 Vandenbroucke JP, Von Elm E, Altman DG, Gotzsche PC, Mulrow CD, Pocock SJ, Poole C, Schlesselman JJ, Egger M, Strobe Initiative. Strengthening the reporting of observational studies in epidemiology (STROBE): explanation and elaboration. PLoS Med 2007; 4(10):e297., which proposes a list of 22 items that must be present in the body of the papers to be considered of quality. Paper quality categories were established in its version translated and validated in Brazil in 2008³⁵35 Malta M, Cardoso LO, Bastos FI, Magnanini MM, Silva CM. STROBE initiative: guidelines on reporting observational studies. Rev Saude Publica 2010; 44(3):559-565. and works meeting 80% or more of the items on the list are considered “A” category³⁴34 Vandenbroucke JP, Von Elm E, Altman DG, Gotzsche PC, Mulrow CD, Pocock SJ, Poole C, Schlesselman JJ, Egger M, Strobe Initiative. Strengthening the reporting of observational studies in epidemiology (STROBE): explanation and elaboration. PLoS Med 2007; 4(10):e297.^,3535 Malta M, Cardoso LO, Bastos FI, Magnanini MM, Silva CM. STROBE initiative: guidelines on reporting observational studies. Rev Saude Publica 2010; 44(3):559-565.. The Standards for Reporting Qualitative Research (SRQR)³⁶36 O'Brien BC, Harris IB, Beckman TJ, Reed DA, Cook DA. Standards for reporting qualitative research: a synthesis of recommendations. Academic Med 2014; 89(9):1245-1251. was used to assess qualitative studies. Studies with quantitative-qualitative methodology were analyzed by both quality instruments. Studies that achieved a score equal to or greater than 80% on at least one of the two scales were included in this paper. Two independent reviewers assessed the thematic eligibility of the papers, and the methodological assessment was conducted by only one of the reviewers.

Results

We identified 3,826 papers and excluded 1,135 works because they were duplicated in the databases. After analyzing the titles and abstracts, we excluded 2,477 papers as they did not meet the research eligibility criteria. The remaining 214 works were read and analyzed in full, and 182 were excluded as they did not meet the inclusion criteria. The remaining 32 papers were analyzed by the STROBE and SRQR scales, and 14 papers were excluded as they did not achieve the minimum score of 80% of the items, leaving a final sample of 18 works. Figure 1 shows the paper selection process.

Chart 2 presents the general characteristics of the selected studies with the distribution of the works by year of publication, the geographic region where they were carried out, the methodological path, sample, and objective. About 78% of papers were published as of 2011.

The survey of papers without time restriction provided the observation of the trend of the historical series. The first paper found is from 2005, then others are from 2007, 2008, and 2009. The theme reappears only in 2011, with publications in all subsequent years up to 2020.

In the analysis of care provided by health professionals, the perception of subjects about induced abortion and women as potential mothers are added to the meanings attributed to the maternity hospital to negatively influence the quality of care, leading to the objectification of women undergoing abortion⁴⁵45 Lemos A, Russo JA. Profissionais de saúde e o aborto: o dito e o não dito em uma capacitação profissional em saúde. Interface (Botucatu) 2014; 18(49):301-312.. In general, when asked about the possible reasons that lead women to become pregnant and abort, without distinction of occupational category, the set of professionals describe the users who induced abortion, including one or more of the following characteristics: black, poor financial conditions, less educated, marital bond instability, partner abandonment, lack of family support, and irresponsible and unbridled sexuality³⁸38 Bispo CDB, Souza VLC. Violência institucional sofrida por mulheres internadas em processo de abortamento. Rev Baiana Enferm 2007; 21(1):19-30.^,3939 Gesteira SMA, Diniz NMF, Oliveira EM. Assistência à mulher em processo de abortamento provocado: discurso de profissionais de enfermagem. Acta Paulista Enferm 2008; 21(3):449-453.^,4444 Carneiro MF, Iriart JAB, Menezes GMS. "Largada sozinha, mas tudo bem": paradoxos da experiência de mulheres na hospitalização por abortamento provocado em Salvador, Bahia, Brasil. Interface (Botucatu) 2013; 17(45):405-418.^,4747 Aniteye P, O'Brien B, Mayhew SH. Stigmatized by association: challenges for abortion service providers in Ghana. BMC Health Serv Res 2016; 16:486.^,4848 Mccallum C, Menezes G, Reis AP. O dilema de uma prática: experiências de aborto em uma maternidade pública de Salvador, Bahia. Hist Cien Saude-Manguinhos 2016; 23(1):56.^,5151 Ishoso DK, Tshefu AK, Coppieters Y. Analysis of induced abortion-related complications in women admitted to referral health facilities in Kinshasa, Democratic Republic of the Congo. PLoS One 2018; 13(8):e0203186.^,5252 Orpin J, Puthussery S, Burden B. Healthcare providers' perspectives of disrespect and abuse in maternity care facilities in Nigeria: a qualitative study. Int J Public Health 2019; 64:1291-1299..

In some cases, a difference was observed in professionals by type of abortion, induced or not; that is, for those women who suffered a miscarriage, an image of fragility and recognition of their suffering is created, but they classify those who induced it as aggressive, aloof, relieved and indifferent. The latter are disqualified²⁴24 Lemos A, Russo JA. Healthcare professionals and abortion: what is said and not said in a professional healthcare capacitation. Interface (Botucatu) 2014; 18(49):301-312.^,2929 Ramaswamy M, Kelly PJ. Institutional racism as a critical social determinant of health. Public Health Nurs 2015; 32(4):285-286. and are assigned a state of psychic abnormality when performing an abortion.

The results show that health institutions and professionals in these hospitals include institutional violence in their practices³⁸38 Bispo CDB, Souza VLC. Violência institucional sofrida por mulheres internadas em processo de abortamento. Rev Baiana Enferm 2007; 21(1):19-30.^,4040 Harries J, Stinson K, Orner P. Health care providers' attitudes towards termination of pregnancy: A qualitative study in South Africa. BMC Public Health 2009; 9:296.^,4141 Aguiar JM, d'Oliveira AFPL. Violência institucional em maternidades públicas sob a ótica das usuárias. Interface (Botucatu) 2011; 15(36):79-92.^,4343 Aguiar JM, d'Oliveira AFPL, Schraiber LB. Violência institucional, autoridade médica e poder nas maternidades sob a ótica dos profissionais de saúde. Cad Saude Publica 2013; 29(11):2287-2296.^,4949 Chavkin W, Swerdlow L, Fifield J. Regulation of conscientious objection to abortion: An international comparative multiple-case study. Health Hum Rights 2017; 19(1):55-68.^,5353 Dorr NM, Dietz G. Racism against Totonaco women in Veracruz: Intercultural competences for health professionals are necessary. PLoS One 2020; 15(1):e0227149., especially with dehumanizing care practices⁵¹51 Ishoso DK, Tshefu AK, Coppieters Y. Analysis of induced abortion-related complications in women admitted to referral health facilities in Kinshasa, Democratic Republic of the Congo. PLoS One 2018; 13(8):e0203186.^,5252 Orpin J, Puthussery S, Burden B. Healthcare providers' perspectives of disrespect and abuse in maternity care facilities in Nigeria: a qualitative study. Int J Public Health 2019; 64:1291-1299. and symbolic violence⁵²52 Orpin J, Puthussery S, Burden B. Healthcare providers' perspectives of disrespect and abuse in maternity care facilities in Nigeria: a qualitative study. Int J Public Health 2019; 64:1291-1299.. Furthermore, the non-prioritization of care for women with abortions is evident in the scarce attention given to these users and the existence of racial discrimination. The articles identify the poor conditions of the health units, the deficient service infrastructure, with overcrowding in maternity wards⁴⁴44 Carneiro MF, Iriart JAB, Menezes GMS. "Largada sozinha, mas tudo bem": paradoxos da experiência de mulheres na hospitalização por abortamento provocado em Salvador, Bahia, Brasil. Interface (Botucatu) 2013; 17(45):405-418.^,4747 Aniteye P, O'Brien B, Mayhew SH. Stigmatized by association: challenges for abortion service providers in Ghana. BMC Health Serv Res 2016; 16:486.^,5151 Ishoso DK, Tshefu AK, Coppieters Y. Analysis of induced abortion-related complications in women admitted to referral health facilities in Kinshasa, Democratic Republic of the Congo. PLoS One 2018; 13(8):e0203186.

52 Orpin J, Puthussery S, Burden B. Healthcare providers' perspectives of disrespect and abuse in maternity care facilities in Nigeria: a qualitative study. Int J Public Health 2019; 64:1291-1299.

53 Dorr NM, Dietz G. Racism against Totonaco women in Veracruz: Intercultural competences for health professionals are necessary. PLoS One 2020; 15(1):e0227149.^-5454 Goes EF, Menezes GMS, Almeida MCC, Araújo TVB, Alves SV, Alves MTSSB, Aquino EML. Vulnerabilidade racial e barreiras individuais de mulheres em busca do primeiro atendimento pós-aborto. Cad Saude Publica 2020; 36(Supl. 1):e00189618..

The analysis of obstetric services identified two areas in which the literature associates the presence and reproduction of institutional violence: on the one hand, the concepts and values of the caregivers themselves regarding abortion⁴³43 Aguiar JM, d'Oliveira AFPL, Schraiber LB. Violência institucional, autoridade médica e poder nas maternidades sob a ótica dos profissionais de saúde. Cad Saude Publica 2013; 29(11):2287-2296.^,5353 Dorr NM, Dietz G. Racism against Totonaco women in Veracruz: Intercultural competences for health professionals are necessary. PLoS One 2020; 15(1):e0227149. and the care provided in maternity wards⁴⁹49 Chavkin W, Swerdlow L, Fifield J. Regulation of conscientious objection to abortion: An international comparative multiple-case study. Health Hum Rights 2017; 19(1):55-68.^,5151 Ishoso DK, Tshefu AK, Coppieters Y. Analysis of induced abortion-related complications in women admitted to referral health facilities in Kinshasa, Democratic Republic of the Congo. PLoS One 2018; 13(8):e0203186. and, on the other hand, institutional norms and the work process³⁷37 Motta IS. A relação interpessoal entre profissionais de saúde e a mulher em abortamento incompleto: "o olhar da mulher". Rev Br Saude Materno Infantil 2005; 5(2):219-228.^,3939 Gesteira SMA, Diniz NMF, Oliveira EM. Assistência à mulher em processo de abortamento provocado: discurso de profissionais de enfermagem. Acta Paulista Enferm 2008; 21(3):449-453.^,4242 Benute GRG, Nonnenmacher D, Nomura RMY, Lucia MCS, Zugaib M. Influência da percepção dos profissionais quanto ao aborto provocado na atenção à saúde da mulher. Rev Br Ginecol Obstetr 2012; 34(2):69-73.. These factors combined show attitudes and practices that refer to institutional violence. Studies have pointed to physical violence in most cases of induced abortion by not offering medication, whether analgesics or anesthetics, to relieve pain⁵²52 Orpin J, Puthussery S, Burden B. Healthcare providers' perspectives of disrespect and abuse in maternity care facilities in Nigeria: a qualitative study. Int J Public Health 2019; 64:1291-1299.^,5353 Dorr NM, Dietz G. Racism against Totonaco women in Veracruz: Intercultural competences for health professionals are necessary. PLoS One 2020; 15(1):e0227149.. Concerning verbal violence, questioning women’s morality emerges, which is also verbally stigmatized⁴⁶46 Nieminen P, Lappalainen S, Ristimäki P, Myllykangas M, Mustonen AM. Opinions on conscientious objection to induced abortion among Finnish medical and nursing students and professionals. BMC Med Ethics 2015; 16:17.^,4747 Aniteye P, O'Brien B, Mayhew SH. Stigmatized by association: challenges for abortion service providers in Ghana. BMC Health Serv Res 2016; 16:486., with depersonalization and embarrassment⁴¹41 Aguiar JM, d'Oliveira AFPL. Violência institucional em maternidades públicas sob a ótica das usuárias. Interface (Botucatu) 2011; 15(36):79-92..

In Brazil, Gesteira et al.³⁹39 Gesteira SMA, Diniz NMF, Oliveira EM. Assistência à mulher em processo de abortamento provocado: discurso de profissionais de enfermagem. Acta Paulista Enferm 2008; 21(3):449-453. point out the influence of the context of the illegality of abortion and society’s moral values on professionals’ perceptions about the poor quality of care. However, in this study, the discussion of its results quickly addresses the broader social context elements without an in-depth analysis of institutional violence.

Some studies discuss the sociocultural conditioning that influences professionals and their care practices⁵¹51 Ishoso DK, Tshefu AK, Coppieters Y. Analysis of induced abortion-related complications in women admitted to referral health facilities in Kinshasa, Democratic Republic of the Congo. PLoS One 2018; 13(8):e0203186.

52 Orpin J, Puthussery S, Burden B. Healthcare providers' perspectives of disrespect and abuse in maternity care facilities in Nigeria: a qualitative study. Int J Public Health 2019; 64:1291-1299.^-5353 Dorr NM, Dietz G. Racism against Totonaco women in Veracruz: Intercultural competences for health professionals are necessary. PLoS One 2020; 15(1):e0227149.. The authors note pre-judgment attitudes of professionals and their difficulties in letting go of their convictions in caring for women. However, attitudes and ethical conflicts are analyzed, disregarding the immediate institutional context of motherhood and the historically constituted political processes that define the possible actions of institutions and individuals working in them.

Harries et al.⁴⁰40 Harries J, Stinson K, Orner P. Health care providers' attitudes towards termination of pregnancy: A qualitative study in South Africa. BMC Public Health 2009; 9:296. recognize the context involving institutional practices, with low investment in workers’ qualification and fragmented and verticalized work process, with implications for the relationship between workers themselves and between them and users. Thus, the insufficient training of professionals and managers to address social and subjective issues that interfere in health care practices is also admitted.

In general, the perceptions of health professionals regarding women in situations of induced abortion were marked by negative values, which influenced the senses and meanings attributed to this practice and, consequently, about the women attended, making them responsible for the pregnancy and its interruption, with naturalized discriminatory attitudes³⁹39 Gesteira SMA, Diniz NMF, Oliveira EM. Assistência à mulher em processo de abortamento provocado: discurso de profissionais de enfermagem. Acta Paulista Enferm 2008; 21(3):449-453..

Discussion

From the exposure of the main findings, we consider that the study met the proposed objectives, bringing significant results and discoveries about racial inequalities by analyzing care for abortion induced by health professionals. Studies have reported verbal and physical abuse in patients, care dehumanization, lack of privacy and confidentiality, ill-treatment, and negative and hostile attitudes of the staff as a barrier to the use of qualified services³⁹39 Gesteira SMA, Diniz NMF, Oliveira EM. Assistência à mulher em processo de abortamento provocado: discurso de profissionais de enfermagem. Acta Paulista Enferm 2008; 21(3):449-453.^,4747 Aniteye P, O'Brien B, Mayhew SH. Stigmatized by association: challenges for abortion service providers in Ghana. BMC Health Serv Res 2016; 16:486.^,5151 Ishoso DK, Tshefu AK, Coppieters Y. Analysis of induced abortion-related complications in women admitted to referral health facilities in Kinshasa, Democratic Republic of the Congo. PLoS One 2018; 13(8):e0203186.^,5252 Orpin J, Puthussery S, Burden B. Healthcare providers' perspectives of disrespect and abuse in maternity care facilities in Nigeria: a qualitative study. Int J Public Health 2019; 64:1291-1299.. Similar to the findings of this review, factors such as inadequate staff, infrastructure, equipment and supplies, and lack of supervision by health professionals were also described as important factors that contribute to disrespect and racism³⁷37 Motta IS. A relação interpessoal entre profissionais de saúde e a mulher em abortamento incompleto: "o olhar da mulher". Rev Br Saude Materno Infantil 2005; 5(2):219-228.^,3838 Bispo CDB, Souza VLC. Violência institucional sofrida por mulheres internadas em processo de abortamento. Rev Baiana Enferm 2007; 21(1):19-30.^,4747 Aniteye P, O'Brien B, Mayhew SH. Stigmatized by association: challenges for abortion service providers in Ghana. BMC Health Serv Res 2016; 16:486.^,5353 Dorr NM, Dietz G. Racism against Totonaco women in Veracruz: Intercultural competences for health professionals are necessary. PLoS One 2020; 15(1):e0227149.. Disrespect and racism were essentially defined as a hostile, inadequate, or negative attitude of the team⁴⁸48 Mccallum C, Menezes G, Reis AP. O dilema de uma prática: experiências de aborto em uma maternidade pública de Salvador, Bahia. Hist Cien Saude-Manguinhos 2016; 23(1):56.^,5353 Dorr NM, Dietz G. Racism against Totonaco women in Veracruz: Intercultural competences for health professionals are necessary. PLoS One 2020; 15(1):e0227149..

Racism occurs at multiple levels, including institutional, interpersonal, and internalized. Institutionalized racism results in differentiated access to society’s resources, services, and opportunities by ethnicity. Concerning resources, institutionalized racism includes disparities in access and quality of education, safe housing, employment, health resources, and environmental conditions. These, combined with the lack of opportunities to influence policies, limit the power of racial and ethnic minorities enforcing decisions. Interpersonal racism refers to prejudice and discrimination resulting in different assumptions about the abilities and reasons of others according to their race. Discrimination includes treating other people differently based on their race and is more commonly considered racism¹⁵15 Silvério VR. Ação afirmativa e o combate ao racismo institucional no Brasil. Cad Pesqu 2002; 117:219-246.^,1616 Silva MAB. Racismo Institucional: pontos para reflexão. Laplage Rev 2017; 3(1):127-136.. Finally, internalized racism results in accepting negative attributes, competencies, and values by members of marginalized groups. Internalized racism limits someone’s ability to reach their maximum potential⁵⁵55 Jones CP. Levels of racism: a theoretic framework and a gardener's tale. Am J Public Health 2000; 90:1212-1215..

Only three studies with a quantitative approach were identified, which has an impact since there is no comprehensive information on the opinions, attitudes, and knowledge of health professionals regarding abortion, mainly induced abortion, which was the focus of the search. Perhaps this is due to a possible lack of support for conducting more comprehensive surveys with these professionals, since quantitative surveys, generally applied to quite numerous samples, require standardized, validated, and reliable questionnaires that can be used for this purpose, besides significant amounts of financial resources and institutional support. Another result that drew attention was the lack of data on mental health professionals.

Our review results highlighted a research where racial and ethnic minority women experience greater lifetime exposure to chronic stressors, which may increase their risk of poor pregnancy outcomes⁵⁶56 Latendresse G. The interaction between chronic stress and pregnancy: preterm birth from a biobehavioral perspective. J Midwifery Womens Health 2009; 54:8-17.. The accumulation of stress throughout a woman’s life, known as allostatic load, is associated with worse health outcomes⁵⁷57 Sousa MBC, Silva HPA, Galvão-Coelho NL. Resposta ao estresse: I. omeostase e teoria da alostase. Estud Psicol 2015; 20(1):2-11.. Racial discrimination is one chronic stressor that can be a risk factor for adverse birth outcomes. The definitions of racism vary, but they all include the concept of unequal treatment due to skin color or other individual traits⁵⁵55 Jones CP. Levels of racism: a theoretic framework and a gardener's tale. Am J Public Health 2000; 90:1212-1215..

Finally, another fact that perhaps must be researched in greater depth and, if possible, in greater breadth, is the perception of racist attitudes in clinical care in abortion situations. The literature points to research suggesting a broad acceptance of abortion cases allowed by law⁵⁸58 Menezes M, Aquino EML. Pesquisa sobre o aborto no Brasil: avanços e desafios para o campo da saúde coletiva. Cad Saude Publica 2009; 25(Supl. 2):S193-S204.

59 Diniz D, Penalva J, Faúndes A, Rosas C. A magnitude do aborto por anencefalia: um estudo com médicos. Cien Saude Colet 2009; 14(Supl. 1):1619-1624.

60 Diniz D, Madeiro A, Rosas C. Conscientious objection, barriers, and abortion in the case of rape: a study among physicians in Brazil. Reprod Health Matters 2014; 22(43):141-148.^-6161 Drezett J, Pedroso D, Gebrim LH, Matias ML, Macedo Jr H, Abreu LC. Motivos para interromper legalmente a gravidez decorrente de estupro e efeitos do abortamento nos relacionamentos cotidianos das mulheres. Reprod Climatério 2011; 26:85-91., and situations of severe fetal malformation also have the approval of most health professionals⁶²62 Patrício SS, Gregório VRP, Pereira SM, Costa R. Malformação fetal com possibilidade de interrupção legal: dilemas maternos. Rev Br Enferm 2019; 72(Supl. 3):125-131..

Conclusion

Despite its limitations, this review has some critical implications for a field of research that has received little attention. Forced abortions are common, and women who have them suffer various types and degrees of stigma. Racism and other related ideologies such as sexism and classism are relevant health concerns, although application in practice seems insufficient based on the evidence of disrespect and abuse. Our data show how institutionalized racism manifests itself in the lack of qualified human resources, insufficient quantity and quality of functional health products, and income-related discrimination within medical facilities. We also highlight examples of internalization by victims of racism and reproduction of discrimination by health professionals.

Strengthening the health system’s capacity by employing an adequate number of health professionals, especially in areas with unmet needs, along with improving infrastructure facilities, will also reduce disrespect and abuse practices allegedly caused by problems such as overcrowding in facilities and lack of health professionals.

Underlying social perceptions point to the need for awareness campaigns and educational interventions at broader socio-political and community levels, including educating women and men about the rights to respectful care. Finally, racism violates the right to health in all dimensions.

Acknowledgments

We are grateful to Coordenação de Aperfeiçoamento de Pessoal de Nível Superior (CAPES) for the CST Nichele Doctoral Scholarship. Conselho Nacional de Desenvolvimento Científico e Tecnológico (CNPq) for the AP Ferreira Research Productivity Scholarship.

References

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