Healthcare experiences of homeless pregnant women

Objective: to understand healthcare experiences from the perspective of women who are or were pregnant while in homelessness. Methods: qualitative study based on Heideggerian phenomenology adapted to the field of health. There were ten participants. The technique of phenomenological interview and a semi-structured instrument were used. The comprehensive analysis methodically followed the stages of phenomenological reduction, construction, and destruction. Results: the existence of pregnant homeless women represents difficulties, discrimination, violence, prejudice, racism, and vulnerability. It is a violation of human dignity, revealing specificities and nuances of the triad women-maternity-street. Conclusion: the research made it possible to understand that healthcare, from the perspective of women who are pregnant while homeless, offers risks both to the mother and to the child. Both the self-care and the healthcare offered by health workers and services is precarious and has weaknesses, being different from any type of care that could be understood as solicitous, zealous, and concerned. Descriptors: Empathy; Women; Pregnancy; Homeless Persons. *Extraído da dissertação “Mulheres que gestam nas ruas e suas vivências de cuidado: estudo à luz da fenomenologia heideggeriana”, Universidade Estadual de Feira de Santana, 2019. 1Universidade Estadual de Feira de Santana. Feira de Santana, BA, Brasil. 2Universidade do Estado da Bahia. Salvador, BA, Brasil. Autor correspondente: Keila Cristina Costa Barros Rua Monte Verde, 76, Parque Getúlio Vargas, CEP: 440076-736. Feira de Santana, BA, Brasil. E-mail: keilaccosta@hotmail.com EDITOR CHEFE: Ana Fatima Carvalho Fernandes EDITOR ASSOCIADO: Francisca Diana da Silva Negreiros Keila Cristina Costa Barros1 Rita de Cássia Rocha Moreira1 Mariana Silveira Leal1 Tânia Christiane Ferreira Bispo2 Rosana Freitas Azevedo2 Como citar este artigo: Barros KCC, Moreira RCR, Leal MS, Bispo TCF, Azevedo RF. Healthcare experiences of homeless pregnant women. Rev Rene. 2020;21:e43686. DOI: https://doi.org/10.15253/2175-6783.20202143686 Barros KCC, Moreira RCR, Leal MS, Bispo TCF, Azevedo RF Rev Rene. 2020;21:e43686. 2 Introdução As pessoas em situação de rua são conceituadas com as características de ser heterogênea, viver em pobreza extrema; ter rompimento ou fragilidade com o vínculo familiar; ausência de moradia convencional; ocupação de espaços públicos e áreas degradadas para habitação e sustento, de forma temporária ou permanente, bem como utilizando locais de acolhimento para pernoite(1). O cuidado à saúde de gestantes em situação de rua é um fenômeno que pode ser compreendido em suas singularidades, pois olhar sensível e atentivo para esse grupo possibilita estratégias de enfrentamento e práticas de cuidado à saúde, caracterizadas por atenção, responsabilidade, zelo e desvelo, com realizações singulares, considerando tempo e espaço(2). A sobrevivência de mulheres em ruas implica o uso de práticas que extrapolam a dignidade humana, muitas realizam a troca do ato sexual por droga, de modo que o consumo de droga é uma rotina(3). Desta condição, apreende-se a possibilidade da gestação, muitas vezes, de forma não desejada. Essas gestantes, em maioria, não têm acesso ao acompanhamento pré-natal, que segundo o Ministério da Saúde do Brasil tem como principal objetivo acolher a mulher desde o início da gravidez, para assegurar, ao fim da gestação, o nascimento de uma criança saudável e o bem-estar materno e neonatal(4). Dessa forma, esta pesquisa surgiu como possibilidade de se pensar em melhorias do cuidado à saúde dessas mulheres, e se justifica por incorporar estudos que apontam para os principais fatores associados à gravidez, entre estes: estar em situação de rua, desde muito cedo, estar fora de casa por longos períodos de tempo e desistência da escola, início precoce da vida sexual e prática de sexo em troca de dinheiro, favores ou vantagens(5). Ademais, este estudo se legitima pela escassa produção acadêmica acerca desta temática e pelo reconhecimento de que gestar em situação de rua é um problema de saúde pública, bem como o baixo acesso à assistência pré-natal, já que estudo realizado apontou que 33,0% das gestantes em situação de rua realizaram o pré-natal apenas uma vez(6). Este dado corrobora com estudos realizados nos Estados Unidos da América, quando relata que o acesso ao pré-natal entre as gestantes em situação de rua é negligenciado, constituindo problema contínuo(7). Este estudo pode beneficiar e contribuir no acompanhamento e na fiscalização das políticas de direitos da mulher em situação de rua, na redução dos índices de violência, de modo a permitir o acesso universal e igualitário às ações e aos serviços de saúde, bem como colaborar positivamente na saúde sexual e reprodutiva dessas mulheres. Também, pode impactar na prevenção de morbidades e mortalidades materno-fetal e infantil e no aumento da resolubilidade e efetivação da coordenação integrada do cuidado na Atenção Básica à Saúde, para essa parcela invisível da população. Portanto, diante desse contexto existencial e de saúde pública, elaborou-se o problema de pesquisa: como mulheres em situação de rua vivenciam e/ou vivenciaram o cuidado à saúde na gestação? Com objetivo de compreender a vivência do cuidado à saúde, na ótica de mulheres que gestam e/ou gestaram em situação de rua.


Introduction
Homeless people are considered to be heterogeneous; to live in extreme poverty; to have broken or fragilized family bonds; to have no conventional housing; to occupy public and degraded spaces to live and survive, permanently or not; and to resort to shelters to spend their nights (1) .
Healthcare to pregnant homeless women is a phenomenon that can be understood in its specificities, since a sensitive and attentive look at this group makes strategies to confront the problem a possibility, as well as healthcare practices, which are characterized by attention, responsibility, zeal, and diligence, with unique actions, considering time and space (2) .
The survival of women in the streets implies the use of practices that escape human dignity. Many women exchange sexual intercourse for drugs, and drug abuse is routine (3) . Considering this situation, there is a perceptible possibility of pregnancy, oftentimes unwanted.
These pregnant women, in most cases, have no access to prenatal monitoring, which, according to the Ministry of Health, aims, especially, to embrace the women since the beginning of her pregnancy, to guarantee that, at the end of her pregnancy, a healthy child will be born, and assure maternal and neonatal wellbeing (4) .
As a result, this research emerged as a possibility of pondering on possible improvements to the healthcare offered to these women. It is justified as it incorporates studies that indicate the main factors associated to their pregnancy, among which are: being homeless since an early age, being out of home for long periods of time and abandoning school, having an early start in sexual life, trading sex for money, favors, or advantages (5) .
Additionally, this study is validated by the scarce academic production about the subject and by the recognition that being a pregnant homeless women is a public health problem, as is the low access to prenatal care, since a study pointed out that 33.0% of home-less pregnant women only went through one prenatal consultation (6) . This piece of data corroborates studies carried out in the United States, according to which the access of homeless pregnant women to the prenatal is a neglected and persistent problem (7) .
This study can benefit and contribute in the follow-up and supervision of the application of the policies of women's rights in the reduction of indexes of violence, as to make possible an equal and universal access to health services. It can also offer positive contributions to the sexual and reproductive health of these women. The study can also impact in the prevention of mother and fetus morbidity and mortality and increase the capacity of the Primary Healthcare to deal with the issue, as well as to offer an effective integral coordination of care to this invisible portion of the population.
Therefore, considering this existential and public health context, the following research question was elaborated: How do homeless women experience and/or experienced healthcare in pregnancy? The objective was to understand the healthcare experiences from the perspective of women who are or were pregnant while in homelessness.

Methods
This is a qualitative study, with an approximate axis to Heidegger's phenomenological method as adapted to the field of health. Its characteristics touches on the interpretive understanding of phenomena, and on the unveiling of meanings of daily life (8) .
In the context of a qualitative investigation, a phenomenological research means understanding the being-in-the-world, as many phenomena present themselves in the existentiality of the being, oftentimes not expressed by words, but by gestures and behaviors (9)(10) .
The research was carried out in the city of Feira de Santana, Bahia, Brazil. According to the latest Census and to the National Research on the Homeless Population, from 2007/2009, the proportion of the ho-meless, in relation to the total population of the city, was that of 237 people (11) . Currently, there is an estimated number of 300 homeless people in this location. This information has not been confirmed, despite being documented by the civil society organization National Movement of the Homeless Population, Feira de Santana Section, a group that contributed significantly for this research.
This study counted on the participation of ten women who were experiencing or had experienced pregnancy while homeless, who were 18 years old or older, and lived in public spaces of the city. The number of participants was limited to this quantity as it was enough to answer the objectives of the research. Another reason is the fact that qualitative studies can involve a small number of participants, frequently ten or less, with similar specificities. When the responses to the same question are the same for a certain period of time, and the opportunity to describe experiences is given, the numerical parameters are considered to be met (12) . The study excluded women with psychological and/or emotional disorders that prevented them from participating in the interviews.
To approach the participants of the study, at first, there were meetings with the members of the National Movement of the Homeless Population -Feira de Santana Section -Bahia, Brazil. The perspective was delimiting the places and neighborhoods in which it would be possible to meet homeless women who were pregnant or had been pregnant while homeless.
At the moment of familiarization, these women were invited to participate in the research, and the subject and objective of the study were explained. Some of them accepted answering the interview immediately, while others informed when the best moment would be. Some of them, upon being invited, denied participation, and their choice was respected.
They were guaranteed that a codename would be used and chose one among the names of the squares of the city, due to an understanding that many people in this existential situation are located and grouped in these places.
Data collection was carried out during March, April, and May 2019, by one of the authors. The technique used was the phenomenological interview, described as a way of access available to the observer to penetrate the objects experienced (8) . The interviews were recorded in a semi-structured instrument and recorded in a cellphone, after the Free and Informed Consent Form was signed. The instrument was a semi-structured script with five parts. In the first one, data to characterize the participants was recorded, including codenames and ages; in the second one, sociodemographic aspects, including race/color, marital status, educational level, city of origin, and how long does the participant live in the streets; the third stage included the collection of obstetric and gynecological data, number of pregnancies, childbirths and/or abortions, children, children with whom they have contact, whether they went through any prenatal consultations, whether they underwent any exams, whether they have diseases, and whether they participate in educational actions related to women's health.
In the fourth part, two axes to open the phenomenological interview were explored: How is it to be homeless and a woman? What about being pregnant while homeless? In the fifth part, the guiding sub--axes/open questions were addressed: Tell me about your pregnancy. What does it mean to generate/have a child while homeless? How was healthcare during your pregnancy? Did you receive any type of care from health workers during pregnancy? Do you know the Street Medical Offices? How did the Street Medical Offices contribute for the care to your pregnancy? The analytical process methodically followed certain stages (13) . The first one, the phenomenological reduction, was carried out through the transcription of the interviews and the careful reading of the statements.
The second is related to the phenomenological construction. In this stage, the understanding of meanings was sought, the perception of how being--in-the-world is, to unveil the phenomenon: experiencing healthcare in pregnancy, from the perspective of homeless women. The third and last moment, the phenomenological destruction, is the reconstruction, the moment when new knowledge emerges from the unveiling of being, of the existentiality of another, that is, of the phenomenon studied (13) .
From these methodological stages, the units of meaning, thought from the perspective of the Heideggerian phenomenology method and of other scholars of phenomenology, emerged, allowing for the construction of new knowledge. Heideggerian phenomenology is based on elements that give support to the understanding of the experiences of those who are thrown in the world. In the case of this study, the act of existing is the healthcare to pregnant homeless women. In

Results
It was found that pregnant homeless women live in a situation of social risk and vulnerability, since these circumstances and this space are not adequate for the generation of a child. Most women were black, single, from 24 to 46 years old, had elementary education, and were born in Feira de Santana, Bahia, Brazil. They live in the streets due to family problems. They lived in the streets for more than nine years, had a history of abortion, more than one child, and their children were with relatives, adopted, or they did not know where. They had no access to prenatal care, underwent no lab exams, their last gynecological examination was more than eight years ago and some of them had never had one. They mentioned to have diseases such as systemic arterial hypertension, diabetes, respiratory problems, tuberculosis, syphilis, and had no access to educational activities related to women's health.
Their statements express the reality experienced: Complicated In this world of unique experiences, women were found who did not know or did not recognize the symptoms of a pregnancy, leading them to be even more vulnerable and exposed, as suggested in the following statement: As a result, as in the following statements, most of them associated the use of drugs, in addition to the lack of care for the pregnancy, to eventual abortions and diseases of their children: The world-life of homeless pregnant women, incarnated as "naked life", is a frail and vulnerable life, exposed to all risks. It is the reduction of human life to a social condition of violence, another aspect found in the statements of the women interviewed: Being pregnant while homeless is having specific needs and means that, despite the situation being experienced, they recognize the inefficiency of public powers to offer legal means of assistance. Spaces and actions that can diminish pain, suffering, and exclusion. These women have a sensible and sensitive perspective, both for themselves and for others, that is, for those who share an existential situation with them: The narratives referred to the absence of health services and healthcare from health workers during their pregnancy: There wasn't! (care from health professionals).

According to the Nursing Protocol for Primary
Healthcare of the city in which this study took place, Street Medical Offices are part of the Primary Healthcare, as a component of the Psychosocial Healthcare Network, and should follow the standards and directives defined by the National Policy for Primary Healthcare, so it can act with those who are different, as a part of Primary Care. This program represents a huge achievement for the homeless population, and stems from demands organized by the National Movement of the Homeless Population, in the struggle for specific healthcare for this population.
Prenatal assistance to homeless pregnant women is inherent to this program, in their specific and unique demands, as stated in the Manual for the Healthcare of the Homeless Population. After all, the abuse of psychoactive substances and other comorbidities affect high numbers of pregnant homeless women, who are a high-risk population. Women presented, in their narratives, the actions of the team from this program in the city considering the care offered to them in prenatal assistance: They just arrive (the team of the Street Medical Offices) and ask: Are you feeling pain? ...They just do that, and write it in a piece of paper and leave (Kalilândia Square 1). The only thing they (the Street Medical Office team) gave me was a piece of paper to give them (the hospital) when I gave birth. It was when I got there it was a paper to say it (Kalilândia Square 3).

Discussion
There were some challenges in the trajectory followed to elaborate this study, such as locating the women, which meant that a longer time had to be spent in the interviews. Sometimes, they were in stable places, while in other cases, they moved, making it difficult to encounter them.
This study makes a contribution as it can give support to health workers and managers to rethink the care offered to these pregnant women, using Heideggerian phenomenology to unveil meanings that are veiled in the existential understanding that involves the phenomenon of being pregnant in the streets.
It makes it possible for the clinical practice to confront the condition of being pregnant on the streets, as well as it foments care that values the way in which these women exist through the implantation and implementation of healthcare practices and procedures that can be tangential to health promotion, health prevention, early diagnostic, and rehabilitation, when needed.
The pregnancy period is a moment in which women experience several feelings, such as fear and fragility, since they go through alterations in mood, body, and hormones, all of which make it possible for them to transform the way they think, act, and confront this existential moment (14) .
Pregnant homeless women live in a situation of social risk and vulnerability, since these circumstances and this space are not adequate for the generation of a child. When the woman is homeless during the pregnancy cycle, it is important to have a critical outlook, since the experience of pregnancy in this situation is considered to be a social risk factor. Therefore, the elaboration of further studies with this vulnerable population is here encouraged, as is the implementation of strategies of care, especially in the scope of public healthcare (7,15) .
Another factual experience of these women is their drug abuse during pregnancy. The addiction and the condition of being a pregnant homeless woman represented, for some of them, a challenging situation for stopping drug use (2,16) . These women understood that the use of psychoactive substances could damage the life of their children, contradicting a study carried out in São Paulo (2) , which reported that most pregnant homeless women did not know the pathogenic potential of the use of drugs during pregnancy, while the ones interviewed here did, having acquired this information from daily life experiences. However, since they are submitted to a situation of violence and submission, drugs seem to them a tool for survival, which makes their quality of life even worse (2) .
As a result, the world-life of these pregnant women, incarnated as "naked life", is a frail and vulnerable life, exposed to all risks. It is the reduction of a human life to the social condition of violence (14) . The violence and the violations also take place in the health institutions. As a result, the health services and the training of professionals to attend these women need to be rethought, since there is no professional education course whose focus is the healthcare to homeless people. This exclusion and the absence of embracing are frequent obstacles for pregnant women to seek health services, increasing their condition of vulnerability (15) .
Being pregnant while homeless is having specific needs. In this situation, the inefficiency of public powers is recognized due to the offering of legal means of assistance. Spaces and actions that can diminish pain, suffering, and exclusion. These women have a sensible and sensitive perspective, both for themselves and for others, that is, for those who share an existential situation with them (16) .
The situation demands a service with long working hours, so that homeless people can seek healthcare and be referred to it in emergency situations (17) , especially in the case of homeless pregnant women. Homeless pregnant women described a frail healthcare, with the abuse of psychoactive substances, as they lived in precarious places and were submitted to several undignified situations.
The Street Medical Offices were created to offer assistance to the specific health demands of homeless people (18) . When there is an approach involving pregnant women with many vulnerabilities, including being a woman, being pregnant, being in the streets, and abusing psychoactive substances, strategies that make it possible to offer an effective assistance to these specificities become necessary (19) . However, such care was not unveiled in the statements.
The need for comprehensive healthcare to these women can be noted when facticity is permeated by the mode of being of willing to understand, as it refers to the notion of existence, to the exercise of listening, of having the right of being, revealing the projective character that health practices may have (19) .
The unveiling of the phenomenon of healthcare to women who are and/or were pregnant while homeless showed how precarious is the setting to which they are submitted. Understanding the modes of being-in-the-world of these women is related to analysis, to zealous and attentive interventions that can bring change to their healthcare experiences. These women are thrown into vulnerability and into the fractures of being, and express, in their eyes, in their gestures, in their physical aspect, and in their statements, the daily violence and violations of human dignity.
As a result, a challenge is issued: that this study can raise the awareness of the public powers, of health entities and workers, for the inhumane condition that is being pregnant while homeless, to favor strategies to confront this existential situation.

Conclusion
Healthcare, from the perspective of women who are pregnant while homeless, was found to be precarious and to have many weaknesses, both in the case of self-care and in the attention offered by health services and professionals, which differs from the one that this research glimpses at, which is understood as solicitous, zealous, and concerned.

Acknowledgments
To the Center for the Extension and Research in Women's Health, for being so welcoming. To the homeless women, who participated in this study, for the confidence in sharing their healthcare experience as homeless. To the National Movement of the Homeless Population -Feira de Santana Section -BA, for being comrades in the struggles and the activism. To the Universidade Estadual de Feira de Santana, as it made possible and enabled part of the master's degree of the author Keila Cristina Costa Barros.

Collaborations
Barros KCC, Moreira RCR, Leal MS, Bispo TCF and Azevedo RF contributed for the conception and for the project, data analysis and interpretation, article writing, in the relevant critical review of the intellectual content and the final approval of the version to be published.