Although abortion is legal in Brazil to save a woman's life and in cases of rape, Brazilian women have limited access to safe abortion services. Two recent articles ascribed a portion of this limited access to legal abortion in Brazil to a lack of knowledge of abortion law in the general population [16,17]. Indeed, in our survey of Brazilian OB-GYNs, about half of the physician respondents could not correctly identify the Brazilian abortion law. Additionally, a significant number of physicians thought that abortion was legal in the case of severe fetal malformations when in fact, at the time of data collection, women were required to solicit permission from the judicial system for an abortion in these cases. The large number of physicians who were not familiar with Brazilian abortion law is alarming because these OB-GYNs will be unable to give accurate information to their patients. The participants' confusion may now be exacerbated by the recent turmoil surrounding abortion of anencephalic fetuses. Our findings are similar to those of Faundes et al., who observed that two-thirds of Brazilian OB-GYNs wrongly believed that a judicial order is required to obtain a legal abortion and only 27% knew that the woman needed to make a written request to obtain a legal abortion .
The majority of OB-GYNs surveyed reported familiarity with manual vacuum aspiration (MVA) and the dilation and curettage (D&C) procedures. Additionally, a large majority of physicians knew of the possibility of using misoprostol or other prostaglandins to induce abortion. Misoprostol, which is marketed under the name Cytotec, has received significant press coverage in Brazil as the drug's worldwide notoriety as an abortifacient first began in Brazil in 1988 . However, fewer OB-GYNs surveyed knew of the use of misoprostol in combination with either mifepristone or methotrexate, which are more successful regimens for induced abortion [19-21].
In terms of opinions on abortion law, very few physicians agreed with the current law, mostly due to the fact that an overwhelming majority thought that abortion should be legal in the case of severe fetal malformations (i.e., they felt abortion should be legal without needing judicial authorization). As an illustration of this support, out of the 188 physicians that reported having performed an abortion, over half of them said they had performed an abortion because of severe fetal malformations. In addition, there was some support for abortion being legal when the woman's health is at risk, for socioeconomic reasons, and when a woman chooses.
Overall, OB-GYNs who had correct knowledge of abortion law, who reported to be Catholic, Evangelical, or not religious (as compared to "other" religion), and who supported public funding of legal abortion services were more likely to be in favor of a more liberal abortion law. A limitation of our study in terms of this particular finding is that respondents did not specify what their religion was if it fell under the "other" category, so we cannot hypothesize about why these participants would have more conservative attitudes about abortion. Finally, contrary to a priori hypotheses, physicians who had experience in conducting abortions were not more likely to support abortion being legal under additional circumstances than those who had not performed an abortion.
About a third of OB-GYN respondents reported ever having performed an abortion. Thirty-six (19%) of those respondents who had ever performed an abortion reported doing so in the case of a rape, and 47 (25%) had performed an abortion in the case of risk to the woman's life, both of which were circumstances under which abortions were legally permitted. Nevertheless, while not specifically allowed by the law at the time of data collection, 100 (53%) of the physicians who reported ever having performed an abortion said that the abortion was a case of severe fetal malformation. It is striking that, among those respondents who had ever performed an abortion, most had done so under circumstances not explicitly permitted by law at the time of data collection.
D&C and misoprostol alone (or other prostaglandins) were the two most commonly used procedures for inducing abortion among the OB-GYNs surveyed. Very few physicians reported using MVA, despite wide recognition of its effectiveness and its increased safety and cost effectiveness over D&C [22,23]. Similarly, few physicians reported using misoprostol in combination with either mifepristone or methotrexate, even though these are more effective regimens than using misoprostol alone [19-21].