ABSTRACT

OBJECTIVES: to identify elements that influence and contribute to the social vulnerability experienced by women who gave birth on the streets, according to their perceptions.
METHOD: a qualitative study using Thematic Oral History, developed in a shelter for homeless women. The population included mothers who gave birth on the streets. The interviews were processed in three phases, as recommended by Meihy and Ribeiro: transcription, textualization, and transcreation. The data were analyzed in light of the theory of thematic analysis proposed by Braun and Clarke.
RESULTS: the following thematic axes emerged from the interviewees' discourses: Thematic Axis 1: Drug addiction as an escape from the reality they live in; Thematic Axis 2: Immersed in violence; Thematic Axis 3: The lack of health care; Thematic Axis 4: The rupture of family ties; Thematic Axis 5: Invisibility to society.
CONCLUSION: women who experience pregnancies in the context of the streets are immersed in conditions that generate and/or enhance social vulnerability, which permeates the specific needs of the gestation process, the obstacles inherent to living on the streets, as well as the deprivation of rights.

Keywords: Homeless population, Pregnancy, Social vulnerability, Vulnerable population, Oral history as topic

RESUMO

OBJETIVOS: identificar elementos que influenciam e agregam na vulnerabilidade social vivenciada por mulheres que gestaram no contexto das ruas, segundo suas percepções.
MÉTODOS: estudo de abordagem qualitativa, mediante uso da História Oral Temática, desenvolvido em uma casa de acolhimento para mulheres em situação de rua. A população envolveu mães que gestaram no contexto das ruas. O tratamento das entrevistas ocorreu em três fases, preconizadas por Meihy e Ribeiro: transcrição, textualização e transcriação. Os dados foram analisados à luz da teoria da análise temática proposta por Braun e Clarke.
RESULTADOS: os seguintes eixos temáticos emergiram dos discursos das entrevistadas: Eixo temático 1: A dependência das drogas como escape da realidade vivida; Eixo temático 2: Imersas na violência; Eixo temático 3: A invisibilidade perante a sociedade; Eixo temático 4: A carência de uma assistência em saúde; Eixo temático 5: A ruptura dos laços familiares.
CONCLUSÃO: mulheres que vivenciam gestações no contexto das ruas estão imersas em condições geradoras e/ou potencializadoras de vulnerabilidade social, a qual perpassa as necessidades específicas ao processo de gestar, os percalços inerentes à habitação rua, bem como a privação de direitos.

Palavras-chave: População em situação de rua, Gravidez, Vulnerabilidade social, Populações vulneráveis, História oral como assunto

Introduction

The População em Situação de Rua (PSR) (Homeless Population) is characterized as a heterogeneous group that shares conditions that aggregate vulnerabilities, such as extreme poverty; broken or weakened family ties; and lack of decent housing, which leads them to use public places as a place to live and make a living. This social segment is exposed to invisibility and social exclusion, and is commonly referred to with pejorative terms such as beggars, wanderers, vagrants, drug addicts and outcasts.^1,2

According to estimates by the Instituto de Pesquisa Econômica Aplicada (IPEA) for (Applied Economic Research) in March 2020, the number of homeless people in the country was 221,869, with a higher concentration in the capitals and large cities. In Rio Grande do Norte, the Secretaria do Estado de Trabalho, Habitação e Assistência Social (Sethas), (State Department of Labor, Housing and Social Assistance) estimated the street population at around 2,200 in 2022, with Natal as a city with the highest number, totaling approximately 1,500.⁴

Comparing data from March 2015 and the same month in 2020 on the size of the homeless population, there has been a considerable increase of more than 100,000 people. This may be associated with factors such as the economic crisis, rising unemployment and extreme poverty, which have been intensified during the COVID-19 pandemic.³

In the context of the streets, although women are quantitatively a minority compared to men, they become more vulnerable as a result of the prejudices and gender inequality present in society. That said, these women are susceptible to various types of physical, psychological and sexual violence, among other mishaps.⁵

In view of this, homeless women are twice as likely to become pregnant, have a higher risk of obstetric complications and receive less health care than those with access to housing. One of the causes of street pregnancies, most of which are unwanted, is prostitution, which is one of the main sources of income on the streets. This practice has historically permeated the daily lives of women who face poverty, misery and dehumanization.^6-7

It is worth noting that experiencing a pregnancy on the street is closely linked to negative health outcomes for the mother and baby, such as premature birth; low birth weight; increased risk of complications related to substance use, including neonatal alcohol syndrome; infection by blood-borne viruses and delayed development. In addition, street pregnant women face difficulties in accessing health services, which increases the factors that add to vulnerability.^5,8

Although vulnerability is widely expressed, it is still not fully understood. However, Ayres et al.⁹ refer to the concept of vulnerability as being closely linked to the weakening of the promotion, protection and/or guarantee of citizenship of populations, legally or politically, from the perspective of human rights.

The importance of this study to complement scientific knowledge in the area of maternal and child health is emphasized, more precisely to improve the evidence on the real needs of homeless pregnant women, in order to give them visibility. As such, this study asks “What factors add to the vulnerability of pregnant women in the streets context?”, with a view in creating and implementing assertive public policies based on scientific evidence.

Therefore, this study aims to identify elements that influence and add to the social vulnerability experienced by women who have given birth on the streets, according to their perceptions.

Methods

This is a qualitative study using História Oral (HO) Temática Thematic Oral History (TH), developed from a research project entitled “Análise da implantação das ações de saúde na gestação e parto de mulheres em situação de rua”(Analysis of the implementation of health actions in the pregnancy and childbirth of homeless women), a Health Evaluation research of the Normative Evaluation and Evaluative Research type.

Qualitative research can involve different methods that determine its course; such as thematic HO, which acts as an opportune tool for discriminated minorities to find space to validate their experiences, through oralization, giving social meaning to the context lived under different circumstances. This methodology therefore allows interviewees the freedom to express themselves with the capacity for argument and will, with facts, chronological advances and retreats, fantasies, omissions and even in silence.^10,11.

Thematic HO was used, which starts with the investigation and clarification of a specific and previously established theme.¹² In this sense, thematic HO, proposed by Meihy and Holanda,¹⁰ is an organized and rigid procedure for investigating the vulnerabilities that permeate the homeless population, by obtaining interviews, which become the epicentre of the research.

During the research, stimuli were valued over direct questions, so that the subject could assume the role of narrator and holder of their own story. In addition, other questions were used to encourage the participants to speak during the interview, namely: “Tell me if your pregnancy was wanted”, “What is the meaning of having a pregnancy on the streets?”, “Tell me about your care on the streets”, and “Tell me about your care (reception) by health professionals during your prenatal care”.

The universe of the study was made up of two participants who, during the data collection period, lived in the shelter where the research was carried out, but experienced their pregnancies in the streets context. Contact was made with women who lived on the streets, but they did not take part in the study, both because of obstacles related to the use of psychoactive substances and because it was difficult to find them to validate their reports.

The selection of participants was based on the following concepts defined by Meihy and Holanda¹⁰: target Community which represents the group qualified by a common experience; colony, the portion of the target community that facilitates the understanding of collective phenomena that would be lost in the scope; network formation, the portion interviewed according to the eligibility criteria; and point zero, the initial interview from which the other contacts for the formation of the network start.

The setting for the study was a shelter for homeless women founded in 2019 by a Catholic community. The shelter has six places for permanent housing and is located in the city of Natal, State of Rio Grande do Norte (RN), Brazil, more precisely in the neighborhood of Capim Macio, in the South Administrative Region of Natal.

After learning about the home, a preliminary visit was made to find out about the voluntary initiative to provide shelter for these women, as well as getting to know their responsible,space and possible participants in the study according to the eligibility criteria.

The inclusion criteria were: women over the age of 18, who lived in the shelter, but who had been on the streets during their pregnancy for no more than five years, avoiding memory bias in data collection. The exclusion criteria involved women who were not emotionally or cognitively able to take part in the study.

Data collection took place between September 2021 and January 2022, using semi-structured interviews based on Thematic Oral History. The initial contact with the interviewees included an introduction process, in which the parties were briefly introduced to each other, the purpose of the study was explained and they were asked about their desire to contribute. The interviews then began, with no time restrictions, so that each participant could feel free in their account. Each interview lasted around 40 minutes.

The following initial stimulus was used: “Tell me how was your pregnancy story while you were on the streets”, as well as the following phrases to continue the interview when necessary: “Tell me, was your pregnancy wanted”, “What does it mean to experience a pregnancy on the streets?”, “Tell me, how was your care on the streets”, and “Tell me how was your care (reception) by health professionals during your prenatal care”.

In addition, a field diary was created with records of non-verbal language and other conditions perceived during the interview. The interviewees’ speeches were recorded using a mobile phone application, with their prior authorization.

The interviews were then carefully processed using three different phases, as recommended by Meihy and Ribeiro¹³: transcription, the stage to convert the oral recording, which is faithful based on what women said, into a raw written text; textualization, which consists of corrections to make the narrative clearer; and, finally, transcreation, the stage in which the non-verbal language recorded in the field diary was incorporated to make the accounts clearer.

The interviewees were also coded according to pseudonyms they had chosen. In addition, the interviewees were returned to validate the material and sign the consent letter.

The data was analyzed precisely in the light of theory of thematic analysis proposed by Braun and Clarke,¹⁴ whose aim is to identify, analyze and report patterns (themes) in the study data, allowing for careful organization and description. It was suggested to follow the concept of inductive thematic analysis, a process of coding data without fitting it into a pre-existing structure or the researcher’s analytical perceptions, so the themes identified and discussed emerge from the data collected.¹⁴

Braun and Clarke¹⁴ also define six main stages: familiarization with the results, generation of initial codes, search for themes, review of themes, definition and naming of themes and, finally, production of the report.These were necessarily followed in order to obtain a reliable and well-structured analysis.

With regard to ethical aspects, the research project was submitted to the Research Ethics Committee of the Universidade Federal do Rio Grande do Norte (UFRN), receiving approval under opinion number 4.908.889 and CAAE 48035521.3.0000.5568.

Results and Discussion

The complexity of the inferential analysis in this research lies in the depth and richness of the data collected through Thematic Oral History, which enabled a detailed immersion in the experience and perspectives of the research participants, providing significant insights into the phenomenon studied, as well as inferences about the complexities of the social, cultural and historical context in which the experiences took place.

Two women took part in the study, who were living in a foster home at the time the data was collected, and were given the pseudonyms “Faith” and “Desire to Change”. The first was 31 years old, had lived on the streets for 13 years, and had last given birth two years ago. The second, was 49 years old, had lived on the streets for 15 years and gave birth to her last child four years ago while still living on the streets.

This age profile among the women taking part in the study corroborates a study carried out in Santa Catarina (Brazil), which found an association between the likelihood of experiencing pregnancy and older age, given the longer time they have been exposed to the elements that involve vulnerability. In addition, the longer the time on the streets, the greater the likelihood of having experienced pregnancy, which corroborates the data in this study.¹⁵

In addition, Faith has incomplete primary education and has mixed color skin, while Desire to Change has complete primary education and is black. It is also noteworthy that both were single; and both had, including the last pregnancy, four or more children, only the last was born on the streets and lived with them in the foster home. Of these, when questioned, Faith reported having lost custody of at least one child, as well as having voluntarily given at least one up for adoption or raised by the family.

In this sense, it is notorious that the female figure as a mother, especially in the Western region, is linked to the one who takes care of her children and the house; however, when she finds herself on the street, she is related to prostitution, drug use, crime and the danger these can cause to her children. This contributes to a distorted view of these mothers in society, which wrongly judges them as unfit for motherhood.¹⁶

As for how they became pregnant, it is worth noting that it was unexpected. For Faith, it was unwanted, since she got pregnant through prostitution - a means of livelihood used on the streets - so she attributed getting pregnant on the street as a difficult and painful process; for Desire to Change, although she said she wanted to get pregnant, she thought it was impossible because of her age.

In this way, a systematic review also demonstrates, from the perspective of pregnant women living on the streets, the unintentional nature of pregnancy and its occurrence, for most, an unwanted way. Pregnancy in these cases is therefore linked to an increase in risky sexual behavior, forced sexual activity or even the use of sex for survival.¹⁷

Based on the transcribed interviews, the women’s narratives was presented regarding to their perception of the problems they experienced during their pregnancy on the streets, which placed them in a condition of social vulnerability. The following thematic axes emerged from the speeches:

Thematic axis 1: Drug addiction as an escape from reality they live in

Living on the streets brings with it various obstacles, such as lack of support, a breakdown in bonds and social roles, the lack of hope, poverty and hunger, among others. As a result, the PSR appeals to means of coping in order to feel distanced from the problem, one of which is drug use and abuse. In line with this, one study points to depression, anxiety, suicidal ideation, food insecurity, interpersonal violence, relationship dynamics and previous mental health problems as the main predictors of alcohol and other drug (AOD) use.¹⁸

However, it should be noted that the effects of AOD use during pregnancy, for the baby includes, prematurity, low birth weight, sudden infant death syndrome, malformations, among others. The impacts on maternal health include placental vasoconstriction, premature detachment of the placenta, spontaneous abortion, premature labor, as well as psychosocial effects such as stress and mental health conditions.^18,19

He was born on drugs, in a totally unworthy life, and I used drugs, lots of drugs [nervous and ashamed]. I used a lot of stones, a lot, a lot of drugs... only hard drugs [...] which were crack, cocaine, marijuana. [...] They were the heaviest drugs when I was pregnant. [...] At five months my belly was small because the drugs wouldn’t let me give birth. [...] At first I was worried about myself, not the baby, because when you live on the street you don’t worry about pregnancy, you’re really thinking about drugs, so you don’t have time to worry about your belly (baby). (Faith)

I wanted to get off drugs, I wanted to get out of the streets, but I couldn’t, because the addiction was stonger than the desire to get off. [...] When my daughter was five months old I stopped using drugs [tears], but the doctors didn’t hide it from me that I could make my daughter sick or I could get sick. [...] And today I’m very happy to have managed to get off drugs, to get out of the streets, because the street is the worst addiction [speaks sadly]. You have the street as your trading point for drugs. (Desire to Change)

Based on the experiences reported and considering the literature, it can be seen that experiencing adversity on the streets makes women susceptible to look for ways to cope, which are often related to negative effects, especially in the pregnancy cycle. As observed in this study, a common strategy for these women is to abuse of drugs such as alcohol, marijuana, cocaine and crack. This use brings with it a consequent dilemma, because on the one hand there is the awareness that drug use can be harmful to pregnancy; and on the other there is the effort and difficulty in stopping the use.¹

In addition, higher rates of drug use among homeless women are correlated with substance abuse by partners, as well as suffering various forms of abuse at childhood and adulthood; subsequently post-traumatic stress disorder; or living in social environments that portrays substance use as “normal”.¹⁷

Thematic axis 2: Immersed in violence

Exposure to violence is common for those living on the streets. There are various types of violence present in the daily lives of homeless people, such as their proximity to crime, which makes them susceptible to violence; the precariousness of basic needs, which leads these people to crime and, consequently, to violence; as well as the sexual abuse that women in particular are exposed to. The interviewees refer to this context in their accounts:

And on the streets I was beaten, I was beaten a lot, I was beaten twice. The first time I was beaten I remember that [...] I lost a lot of blood, I felt a lot of pain and I thought I was having a miscarriage, [...] because the baby didn’t move in my belly for three days. It didn’t move, so I thought ‘my God, I need a curettage. I can’t die with this child. This fetus is dead [...] I need to get it out of me’. (Faith)

God was very good to me [...] that I was never abused on the streets... They tried, but I always woke up and started using violence, so a lot of people didn’t want to do anything with me, because I had a totally unruly life. (Desire to Change)

It was clear from the interviews that all the women had already been in contact with various forms of violence, because the street environment uncovers these women from protection. These forms are associated with psychological violence, expressed through prejudice against their situation; social violence, through lack of access to social facilities; and physical violence, which often comes from intolerant individuals or groups; from homeless people themselves, through debts of drug dealers, thefts, betrayals, disagreements, among others; from people who feel harmed or bothered by homeless people in the vicinity of their homes and establishments; and even from police and public agents, through physical and verbal aggression and the destruction of personal objects.^20,21

In addition, one study shows that participants reported continuous drug use in order not to feel sleepy, as this reduced the risk of rape and aggression.²¹ Another point to note is that the main perpetrators of violence against street women are men, a relationship that is the result of patriarchy, a structure characterized by a social organization that allows men to have authority over women.²⁰

Thematic axis 3: The lack of health care

When it comes to the health care provided for pregnant women living on the streets, there is a clear deficit in public policies aimed at resolving the needs for this population. One of the participants said she was dissatisfied with some of the services she came into contact with during her pregnancy, due to the violence she had experienced. On the other hand, as soon as they receive even the slightest bit of attention that solves some individual demand, they express intense gratitude, as explained below.

And I went to a maternity hospital because I was in a lot of pain, I was under the influence of drugs [...] and they treated me badly. They didn’t want to welcome me, because I was dirty, I was on the streets, like a homeless person. [...] The girl told me to wait outside. I took a piece of cardboard and lay there with pain in my stomach.(Faith)

[...] The only thing I remember was that I held on to her shoulders a lot so she wouldn’t fall, because I had her standing up, like this legs opened, and when I returned to myself I was already in the hospital [...] They helped me a lot and finished my delivery after they took me. [...] To this day I’m very grateful (Desire to Change).

These reports reveal that violence and violations against this group also happen in health institutions. As the interviewees in this study pointed out, when they go to a health service, they are often met with mistreatment, a lack of welcome and exclusion, establishing an obstacle to their adherence to health services and thus increasing the conditions of vulnerability.¹ This scenario stems both from factors such as a lack of knowledge on the behalf of the professionals about the specific needs of pregnant women living on the streets, and from the inefficiency of the public authorities in offering legal means of assistance to homeless women.¹

On the other hand, a study points to other barriers for women to seek health services, such as: lack of awareness; fear of stigma and discrimination; lack of a permanent location; poor previous experience of maternity care services.²² This results in higher rates of poor health, mental illness, poor birth outcomes and maternal mortality.²³

Thematic axis 4: The rupture of family ties

Family support, various everyday situations and is often the main means of overcoming adversity, through care, support, help, etc. One of the challenges that the women said they faced during their pregnancy on the streets was the lack of support from their families, or even facing criticism, which led to a setback in disengaging from the streets, as they say below:

So, when I was discharged, I went to my grandmother’s, overjoyed to tell her the news. ‘Grandma, I’m pregnant again’ And all I got was criticism from the family. It broke my heart and I went back to the streets. (Faith)

And I had other children, but because I lived on the streets my family didn’t give me much access to them and I became desperate. (Desire to Change)

Considering the words and expressions of the women, we can see the negative influence of the lack of a family support. Thus, finding themselves with damaged mental health, as a result of conflictual situations with family members, as well as domestic abuse, is a conditioning factor for women to take to the streets. This creates a feeling of family helplessness, leading them to lack personal and financial resources.^24-25 In addition, one study shows that the breakdown of the family system tends to increase the risk of developing unwanted pregnancies due to the factors already mentioned, such as increased exposure to risky behavior on the streets, which can result in a pregnancy.¹⁵

Thematic axis 5: Invisibility to society

Another challenge for homeless people is to deal with society’s rejection and judgment on a daily basis, in all sectors of society. From this perspective, there are countless stigmas created about this population, creating a culture of fear and discredit towards individuals who live on the streets. As well as oppressing and developing prejudice, this scenario prevents women from having voice and/or guaranteed rights. This is what the interviewees said:

Many times people say ‘yeah, living on the street is a life for naughty people’, but it’s not. It’s a disease. [...] Often we are welcomed, but there are also times when you don’t exist. People pass you by and pretend you’re not people [speaks sadly]. [...] There was one (health professional) who [...] brought me some things from her cousin’s baby, and she hurt me, you know? [...] because as soon as she gave them to me, she looked at me and said ‘I don’t know if I’m really going to give you these things or not because you’re going to sell them to use drugs’. And I told her, ‘J., I’m not using drugs anymore’ [...]. It’s something you just have to live to believe. (Desire to Change)

Considering the interviewee’s comments, it is worth highlighting the recurrence of the PSR having to deal with socially established invisibility in their experiences, caused mainly by stigmatization and prejudice on the part of the population, who often associate these people with violence and view them with fear. Another contributing factor is the lack of a dignified life due to the withdrawal of their rights to exist, causing them to occupy segregated spaces on the social scene and increasingly marginalizing this vulnerable section of the population.²⁶

Compared to more economically developed societies, homeless people are at the bottom of social exclusion. This is because not only do they live in extreme poverty, but they also have to deal with a number of impasses inherent to the circumstances of the streets, such as high levels of family and social disengagement, difficulty in achieving social reintegration/employment, as well as mental and/or physical health problems.²⁷

Given this situation, it can be seen that the street population is immersed in conditions that are incompatible with a dignified life, that is, in conditions of vulnerability, perceived by the weakening of the promotion, protection and/or guarantee of human rights, as proposed by Ayres et al.⁹ In this context, women who have experienced a pregnancy have mainly manifested the following elements: drug abuse, exposure to situations of violence, social invisibility, lack of health care, as well as family distancing.

Thus, experiencing a pregnancy living on the street is an event that goes beyond physiological/biological risks, but is, beyond the health factor, a construction of social vulnerability. This includes the insertion of pregnant women in “unfavorable conditions” which, in turn, expose them to greater risks, situations of lack of power or control, impossibility of changing their circumstances and, therefore, lack of protection.²⁸

This experience is therefore associated with social vulnerability, as proposed by the Política Nacional de Assistência Social (National Social Assistance Policy), which refers to the fragility caused by exposure to scenarios of poverty, deprivation or precariousness of public services, as well as difficulty in accessing work/income, weakening of affective and relational bonds and social belonging.²⁹

Ayres et al.⁹ also point out that, in terms of health, the conceptual approach of vulnerability arose out of a need to understand the impact of different social contexts as determinants of various susceptibilities. In this sense, the aim was to discriminate between more exposed segments of the population, not because of an individual trait, but because of the position that some occupy in relationships and situations of social responsibility.⁹

From the perspective of pregnant women living on the street, despite being in a common condition, it was possible to see the plurality of situations that make them vulnerable, showing different needs, susceptibilities and exposures. At the same time, Ayres et al.⁹ infer that vulnerability is multidimensional, since individuals in the same situation may be vulnerable to some factors and not others; it is gradual, since people are at different levels of vulnerability; and it is unstable, due to constant change over time.

This being said, pregnant women living on the streets can face dilemmas inherent to this circumstance, relating both to basic needs, such as access to food, drinking water and toilets; and to obstacles such as unprotected exposure to climate change, such as cold and rain; experiencing prejudice; physical and sexual violence; difficulties in attending some social spaces and maintaining health treatments.²⁰

As far as the development of this study is concerned, there were impasses involving data collection. As this is a group with migratory characteristics, it was difficult to find women who could take part in the research or to find interviewees who would sign the consent letter, which is why this study was conducted with two respondents.

In addition, as this was a topic that aroused emotions previously experienced on the streets, the participants expressed feelings such as sadness, fear, mistrust and shame, which created a challenge at this stage of the research. Thus, interviewing this population had an impact on recognizing and reaffirming situations of vulnerability, even causing a feeling of powerlessness in the face of real needs that are not met by the health services.

Despite the obstacles, the study has made a significant contribution to identifying/characterizing a vulnerable population that is poorly assisted by public policies and little seen by society. The methodological process of Thematic Oral History stands out as the main differential in this research, as it translates particular visions of collective phenomena, since the themes addressed follow the point of view of the subject who experiences them.

In this sense, the development of this research allowed us to see that women who experience pregnancies in the street contexts are immersed in conditions that generate and/or enhance social vulnerability. In this way, the specific needs of the gestational period became apparent, as did the difficulties inherent in living on the streets, and the deprivation of rights that permeates such vulnerability.

It is hoped that this will help to promote public policies and raise awareness of the need for health care and professional training to address the vulnerabilities of homeless pregnant women and, consequently, to reduce social inequalities and strengthen social justice.

Acknowledgements

We would like to thank the shelter for homeless women called Casa Lumen São Felipe Neri (CSFN), as well as the collaborators who took part in the study for their contribution to scientific progress.

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Authors’ contribution

Santos NAP: conception of the topic, structuring of the study, data collection, analysis and interpretation, writing of the manuscript. Silva SBL: conception of the topic, structuring of the study, data collection, analysis and interpretation, writing of the manuscript. Mota ABO: conception of the theme, structuring of the study, collection, analysis and interpretation of data, writing of the manuscript. Estevam MH: conception of the theme, structuring of the study, collection, analysis and interpretation of data, writing of the manuscript. Pinto ESG: conception of the theme, structuring of the study, analysis and interpretation of data, writing of the manuscript. Souza NL: conception of the topic, structuring of the study, analysis and interpretation of the data, writing of the manuscript. All the authors have approved the final version of the article and declare no conflicts of interest.

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Received on September 25, 2023
Final version presented on August 31, 2024
Approved on September 3, 2024

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Associate Editor: Aline Brilhante