ISSN on-line: 2358-288X
Reprodução & Climatério Reprodução & Climatério
Reprod Clim 2014;29:60-5 - Vol. 29 Núm.2 DOI: 10.1016/j.recli.2014.08.003
Review article
Factors associated to late-term abortion after rape: literature review
Fatores associados ao aborto tardio após estupro: revisão de literatura
Marcia de Toledo Blakea,, , Jefferson Drezetta,b, Gilzane Santos Machia, Valdelias Xavier Pereiraa,c, Rodrigo Daminello Raimundoa,c, Fernando Rocha Oliveiraa,c, Vicente Sarubbi Juniord, Fernando Adamia, Luiz Carlos de Abreua,d
a Laboratório de Delineamento de Estudos e Escrita Científica, Faculdade de Medicina do ABC (FMABC), Santo André, SP, Brazil
b Núcleo de Programas Especiais, Hospital Pérola Byington, São Paulo, SP, Brazil
c Departamento de Medicina, Universidade Federal de São Paulo (UNIFESP), São Paulo, SP, Brazil
d Departamento de Saúde Materno-Infantil, Faculdade de Saúde Pública, Universidade de São Paulo (USP), São Paulo, SP, Brazil
Recebido 04 Julho 2014, Aceitaram 23 Julho 2014
Abstract
Introduction

The risk factors for unintended pregnancy and sexually transmitted diseases after the forced and unprotected sex are well known.

Objective

We aimed to investigate direct and indirect factors associated to the late-term abortion after rape.

Method

A search was performed in Medline, SciELO, LILACS and The Cochrane Library using the intersection between the keywords “rape or sex offenses”, “pregnancy”, “abortion”, including indexed articles published between 2009 and 2014.

Results

The selected studies demonstrated that it lacks in the literature studies which analyze factors directly related to late-term abortion in cases of rape, only indirect aspects.

Conclusion

Indirect evidences showed how different policies and proceedings can contribute to avoid a late-term and unsafe abortion: sexuality and reproductive health education, ending rape impunity and decriminalizing abortion, improving access to safe early abortions by removing unnecessary legal and regulatory restrictions, exchanging information to optimize processes and procedures, prioritizing the interests of the victim, better enabling teams in health services, and the prevention of pregnancy and STI, including HIV infection.

Resumo
Introdução

Os fatores de risco para gravidez indesejada e doenças sexualmente transmissíveis após sexo forçado e desprotegido são bem conhecidos.

Objetivo

Identificar fatores diretos e indiretos associados ao aborto tardio após estupro.

Método

Foi realizada busca nas bases Medline, SciELO, LILACS e The Cochrane Library com os descritores “rape or sex offences”, “pregnancy”, “abortion”, incluindo artigos indexados publicados entre 2009 e 2014.

Resultados

Foram selecionados sete estudos, os quais apresentam somente aspectos indiretos, ainda que atendam os critérios de inclusão.

Conclusão

Evidências indiretas mostraram como diferentes políticas e procedimentos podem contribuir para evitar aborto tardio e inseguro: educação em saúde reprodutiva e sexualidade, término da impunidade do estupro e descriminalização do aborto, melhora no acesso ao aborto precoce seguro removendo-se restrições regulatórias e legais desnecessárias, maior troca de informações para otimizar processos e procedimentos, priorizando os interesses da vítima, além de melhor capacitação das equipes nos serviços de saúde e a prevenção da gravidez e doenças sexualmente transmissíveis, incluindo a infecção por HIV.

Keywords
Rape, Sex Offenses, Pregnancy, Abortion
Palavras-chave
Estupro, Delitos sexuais, Gravidez, Aborto
Introduction

Rape is an underreported heinous crime that affects women and men around the world with physical and psychological harm, at risk of contracting infectious diseases and which may result in an unwanted pregnancy. Numerous pregnant women for rape decide late to seek their right to legal abortion up to 22 weeks of gestation.1

Besides representing a serious public health problem in developing countries, discuss the termination of unwanted pregnancy, whether as a result of rape or not, involves rethinking the legal, moral, religious, social and cultural aspects that are linked to it.2

Even nearly 7% of rape cases in Brazil result in pregnancy. Under Brazilian law, the victim of such violence has the right to abort, but 67.4% of women who have gone through this suffering had no access to legal abortion services in the public health and have just tried abortion unsafely or sought the service late.3

It is estimated that 60,000 to 70,000 women die annually from complications of unsafe abortion and hundreds of thousands suffer long-term consequences, including chronic pelvic pain and infertility. The reasons for the continuing high incidence of unwanted pregnancy leading to unsafe abortion include lack of access, misuse or failure of effective contraception, misinformation, forced sex, preventing women to protect themselves. Unsafe abortion is closely associated with restrictive legal environments and administrative and political barriers that impede access to existing services.4 In this sense, this study aimed to investigate direct and indirect factors associated to the late search for abortion after rape.

Method

Revisions were made between January 2014 and June 2014. The following database were used: Medical Literature Analysis and Retrieval Systen Online (MEDLINE), Literatura Latino-americana e do Caribe (LILACS), Scientific Eletronic Library Online (SciELO), and The Cochrane Library. We used the following keywords “rape or sex offences” and “pregnancy” and “abortion”. The keywords were defined according to the Medical Subject Headings (MeSH).

Indexed articles published between 2009 and 2014 were selected by one researcher and supervised by another senior researcher. Based on titles and abstracts, the manuscripts not clearly related to the topic were excluded. Studies that did not show summary in English between 2009 and 2014 were excluded. Inclusion criteria considered studies investigating direct and indirect factors associated to late-term abortion after rape (Fig. 1).

Figure 1.
(0.16MB).

Search and selection strategy.

All selected titles and abstracts were submitted to a final review, which considered the inclusion criteria. After reading the full texts, the inclusion criteria was reduced to include studies investigating abortion after rape due to the total lack of studies analyzing factors associated to late-term abortion after rape.

Results

The electronic search yielded a total of 54 references. Among these references, the first elimination resulted in the exclusion of 39 titles and abstracts, which were not clearly related to the subject of review. The titles of the remaining 15 abstracts were submitted to a final review, which took into account the inclusion criteria. The investigation of reference lists confirmed the absence of relevant documents directly related to late-term abortion after rape. However, summaries of 7 studies were selected for describing indirect important aspects of the termination of pregnancy after sexual assault. Table 1 shows the main findings of the studies included.

Table 1.

Major studies demonstrating different findings about factors related to abortion after rape.

Author/Year  Number of participants  Study design  Objective  Conclusion 
Mitchell et al. (2014)  378  School-based internet survey  To examine awareness of unwanted pregnancy, abortion behaviour, methods, and attitudes toward specific legal indications for abortion  Prevention of abortion morbidity and mortality among adolescents requires comprehensive sexuality and reproductive health education 
Kalonda (2012)  not apply  Qualitattive  To present three arguments which plead in favour of legalizing abortion in DRC  Ending rape impunity and decriminalizing abortion give women choice and save victims of rape and pregnant women from risks related to the pregnancy, or an eventual unsafe abortion 
Boland (2010)  not apply  Qualitattive  To review the laws of 191 countries and categorizes them by legal indications, which include preservation of the woman's life, health reasons, pregnancy due to sex offences, fetal impairment, socio-economic reasons and on request  While most countries may not decriminalize all abortions in the near future, especially second trimester abortions, less comprehensive legislative and regulatory reforms are possible. These include recommendations aimed at ensuring that abortions are carried out safely and as early as possible in pregnancy, and improving access to safe abortions by removing unnecessary legal and regulatory restrictions 
Muhlsteina et al. (2013)  not apply  Qualitattive  To summarize the main essential elements of the medical and forensic care of a pregnancy arising after a rape  The handling of a pregnant woman after rape involves several procedures of different professionals who often work in isolation. The exchange of information should ideally be able to optimize processes and procedures, prioritizing the interests of the victim 
Jakovski et al. (2011)  2 cases  Case-study  Incest discovered by examination of products of conception  Incest victims are rapidly changing physically and psychologically and may suffer serious consequences in their further development. Therefore, if an abortion is to be performed it is be best to be done in the early stage of the first trimester 
Natan (2010)  100  Descriptive  To compare the attitudes of nursing students and nurses working in maternity wards towards late abortion and to identify the factors influencing their attitudes  Personal religious beliefs, as well as the reason for the abortion, were found to be influential in determining the nursing students and nurses providing care to patients undergoing late abortions 
Cybulska (2013)  not apply  Qualitattive  Describe the factors that may affect the recovery of victims of sexual assault Immediately after the incident as prevention of unwanted pregnancy and sexually transmitted diseases including the human immunodeficiency virus  Prevention of pregnancy as well as STI, including HIV infection, offer reassurance that any potential physical damage will be prevented. Having forensic evidence gathered and aftercare facilitated may be empowering, and can assist in physical and emotional recovery from rape and sexual assault 
Discussion

When dealing with late abortion in the scenario of sexual violence, it is not possible to speak of causality narrowly because a cause is not necessarily a single factor, but comprises several components. A set of multiple causes such as environmental, cultural and social determinants, socioeconomic status, family relationships, and beliefs may suggest reasons why pregnant women seek abortion later. Hence the review aimed to seek studies which identified factors associated with the late-term abortion resulting of sexual violence.

The analysis of the texts selected for this review indicated that there are no studies directly associated to the factors which represent risk for pregnant women to search for late-term abortion after rape. However, seven studies have highlighted significant initiatives and procedures that can reduce risks and avoid late-term unsafe abortion (Table 1).

The woman who seeks deliberate abortion may consider different reasons such as economic difficulties, health problems, neglect or lack of a partner, interference on the project life, conflict with society's rules, or social vulnerability. In all cases, the common element is unwanted pregnancy, which makes the decision of abortion complex and multifactorial.5

Drezett et al. (1998)6 have assumed that the variability in gestational age of women seeking legal abortion could be related to difficulties in access to health services and barriers to the development of violence and pregnancy. However, other conditions may be associated, such as vulnerability and limiting the autonomy of people with mental illness. It is also possible that crimes in which the perpetrator threatens the physical integrity of the victim or a family member, produce a similar effect.

Mitchell et al. (2014)7 also showed that abortion knowledge and attitudes are not driven simply by age, religion or class, but rather a complex interplay that includes both social spaces and gender. Prevention of abortion morbidity and mortality among adolescents requires comprehensive sexuality and reproductive health education that includes factual distinctions between safe and unsafe abortion methods.

The difference in the legalization of abortion across countries increases the complexity of the consequences of rape. The laws of each country determine the extent of the problem and dictate the rules and procedures viable, leaving health services act within the established limits.

According to Kalonda (2012),8 from the politico-legal point of view, ending rape impunity and decriminalizing abortion are recommended. Decriminalizing abortion give women choice and save victims and pregnant women from risks related to the pregnancy, a childbirth, or an eventual unsafe abortion. These risks increase the maternal mortality already high in Congo-Kinshasa (between 950 and 3,000 for 100,000 live births).

After reviewing the laws of the 191 countries around the world for which information is available and categorizing them by legal indications, which include preservation of the woman's life, health reasons, pregnancy due to sex offences, fetal impairment, socio-economic reasons, Boland (2010)9 concluded that while most countries may not decriminalise all abortions in the near future, especially second trimester abortions, less comprehensive legislative and regulatory reforms are possible. These include recommendations aimed at ensuring that abortions are carried out safely and as early as possible in pregnancy, and improving access to safe abortions by removing unnecessary legal and regulatory restrictions.

Public policies and efforts to educate women about the seriousness of the sexual assault encourage them to notify the authorities and seek care immediately following the aggression and may reduce the complications involving such crime, including abortion.10

Such findings contrast with what was agreed in the Fourth World Conference on Women (FWCW) held in Beijing in 1995, which recognized women's right to decide freely about their fertility and sexuality, free of coercion, discrimination or violence.11 Indeed, the restriction of these rights can still be observed in almost all societies, especially those in which the woman holds position of greater submission in relation to man.12

On the other hand, almost all countries in the world have laws that allow abortion is performed to save the woman's life. In about 60% of them, the legislation also allows abortion is practiced to preserve the physical or mental health. Almost 40% of them do not punish abortion when pregnancy results from sexual violence or when courses with severe fetal anomaly. Social or economic reasons have permissive for abortion in 33% of the laws. Voluntary abortion by the woman's request is guaranteed for about 27% of the countries, the most developed.13

Based on Muhlsteina et al (2013),14 the handling of a pregnant woman after rape involves several procedures of different professionals: gynecologist, pediatrician, anesthetist, midwife, social worker, psychiatrist and psychologist, in addition to administrative and judicial personnel. Unfortunately, the various protagonists involved, often work in isolation, communicating little with each other. The exchange of information (within the limits of confidentiality and their legal exceptions) should ideally be able to optimize processes and procedures, prioritizing the interests of the victim.

Furthermore, Ben Natan and Melitz (2011)15 compared the attitudes of nursing students and nurses working in maternity wards towards late abortions performed after the 16th week of pregnancy and identified the factors influencing their attitudes. The differences in attitudes are related to their personal religious beliefs, as well as the reason for the abortion.

It was described by Cybulska (2013)16 the factors that may affect the recovery of victims of sexual assault Immediately after the incident as prevention of unwanted pregnancy and sexually transmitted diseases (STI) including the human immunodeficiency virus (HIV). Immediate medical and psychosocial care affects the well-being of the victims, and represents an important part of the beginning of the healing process. Prevention of pregnancy as well as STI, including HIV infection, offer reassurance that any potential physical damage will be prevented. Being believed, listened to and taken care of may affect reporting the crime to the police. Having forensic evidence gathered and aftercare facilitated may be empowering, and can assist in physical and emotional recovery.

These findings corroborate the evidences that the high frequency of suicidal ideation among women who experience a rape-induced pregnancy reduces significantly after the abortion.1 Undoubtedly, all care provided by a skilled and attentive staff, greatly help the recovery of the woman. Advances in public policies for women are encouraging and promising in Brazil, but the number and distribution of health services performing legal abortion is still insufficient to ensure equal opportunity for all women.17

The invisibility of sexual violence during attendance is also related to the difficulties of professionals dealing with the subject, due to a moralistic attitude of society in the face of the difficulties in handling with issues of sexuality. Often, health professionals, when in the care of women who have suffered an act of sexual violence, try to shift the “problem” to other services, the judiciary, the public safety sector or social service institution. Many of these professionals are not trained to deal with the testimonies of sexual violence of women, which reinforces the need for the guidance of legal and regulatory instruments, such as constitutional rules, code of professional ethics, federal laws, ministerial decrees, agreements and international human rights.11

Jakovski et al. (2011)18 emphasized that incest victims are rapidly changing physically and psychologically and may suffer serious consequences in their further development. Therefore, if an abortion is to be performed it is being best to be done in the early stage of the first trimester.

Incest may be the most extreme form of sexual abuse involving adult-child. Forward and Buck (1989)19 claimed that it is powerful and its devastation is greater than that of non-incestuous sexual violence against children, because it falls within the constellations of emotions and family conflicts, with an expression of complex family dynamics. The child no longer feels safe even in her own bed, being forced to learn to live with incest. The aggressor is always present and incest is a constant horror for the victim. Literature has reported different important aspects that involve an abortion procedure after rape, but there is no clear evidence of which factors are directly associated to the late search for abortion.

Conclusion

Although it is not yet clear which factors are directly associated to the late search for abortion after rape, there are different initiatives and proceedings that can contribute to avoid a late-term and unsafe abortion: comprehensive sexuality and reproductive health education, ending rape impunity and decriminalizing abortion, improving access to safe early abortions by removing unnecessary legal and regulatory restrictions, exchanging information to optimize processes and procedures, prioritizing the interests of the victim, better enabling teams in health services, and, especially, the prevention of pregnancy as well as STI, including HIV infection.

Conflicts of interest

The authors declare no conflicts of interest.

References
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Research conduced at Núcleo de Violência Sexual e Aborto Legal, Hospital Pérola Byington, São Paulo, SP, Brazil.

Corresponding author. (Marcia de Toledo Blake marciablake9@yahoo.com.br)
Copyright © 2014. Sociedade Brasileira de Reprodução Humana
Reprod Clim 2014;29:60-5 - Vol. 29 Núm.2 DOI: 10.1016/j.recli.2014.08.003