- Brazilian obstetrician-gynecologists and abortion: a survey of knowledge, opinions and practices

In Brazil, as in most of the Latin America and Caribbean (LAC) region, abortion is highly legally restricted. The Brazilian Penal Code dating back to 1940 states that abortion is illegal except when performed to save a woman's life or in the case of rape. Although not explicitly permitted by law, abortions in the case of fetal malformation incompatible with neonatal life can be approved on a case by case basis by judicial discretion, a process that requires a lawyer's petition and statements by three physicians and a mental health professional. The law does not establish a legal gestational age limit; however, Ministry of Health guidelines recommend that abortions be conducted before 12 weeks gestation. Despite legal limitations, each year an estimated 1.4 million clandestine abortions are performed in Brazil resulting in some 300,000 hospitalizations for complications [1,2]. Unsafe abortion represents the third leading cause of maternal mortality, and deaths from unsafe abortion in Brazil comprise 12% of the maternal mortality ratio [1,3]. Brazil's abortion rate is high at 40.8 per 1,000 women, with approximately 31% of all pregnancies ending with an induced abortion [4,5].

In July 2004, a lone Brazilian federal judge issued a preliminary ruling that waived the requirement for court authorization for abortions in cases of fetuses with anencephaly (a fatal congenital defect that prevents formation of the brain), unleashing a fervent national debate that received substantial international media coverage. The Brazilian National Bishops' Conference lobbied hard for reversal of the ruling, whereas the National Confederation of Healthcare Workers (the governmental health sector union) pushed for its permanent acceptance. In October 2004, the full Brazilian Supreme Court convened and voted 7-4 to suspend the judge's solitary ruling until the full tribunal had the opportunity to deliberate and rule on the matter. As of November 2005, the issue still had not been settled and advocates continued to debate the moral, religious, and public health implications of liberalizing Brazilian abortion laws [6-8].

Although it has been the opinions of Brazilian judges and interest groups that have made headlines in this latest chapter of the country's ongoing abortion debate, physicians that play a crucial role in the accessibility and availability of safe and legal abortion. Their opinions on abortion, their willingness to perform an abortion, and their knowledge of abortion procedures directly affect whether their patients will be able to have access to safe and legal abortion. For this reason, it is important to understand their opinions and knowledge of abortion law, their knowledge of abortion procedures and their practices related to abortion.

Several studies have documented general public opinion of abortion in Brazil. A 1989 study by Meira and Ferraz examined medical and law student opinions of abortion law and found that almost half of the students surveyed thought that the law should allow for a legal abortion in more circumstances than currently permitted by Brazilian law. The majority of medical students thought that abortion should be legal in cases of rape (96%), risk to the woman's life or health (91%), congenital anomalies (86%), and mental incapacities (63%). A smaller percentage agreed with legalizing abortion in cases where the pregnant girl was less than 14 years old (36%) [9]. A survey of 1,456 women in a Southern county in Brazil revealed that 30% were in favor of legalizing abortion regardless of the circumstances, and those with higher education, higher family income and who had previously had an induced abortion were all more likely to support legalization of abortion[10]. In contrast to these women, a qualitative study of 71 Catholic, male college students in Brazil found that they generally had a negative opinion of abortion. When asked what they would do if a woman asked their advice regarding an induced abortion, 83% said they would counsel her not to abort [11].

A 2003 study in Brazil on attitudes towards abortion compared opinions of teenage women who had aborted, women who had considered abortion but ultimately did not abort, and women who did not abort. Initially, teens who had aborted and who had considered abortion were more tolerant of abortion than those who did not abort; however, their acceptance level decreased over time. Over the one-year follow-up period, the teens that did not consider abortion became more accepting of abortion. On average, across the three groups, 66% thought that an abortion was justified when the woman's life or health was in danger, 63% thought it was justified in the case of rape, and 47% felt that it was justified in the case of congenital anomalies [12].

In terms of abortion opinions of physicians, a small study conducted among 57 emergency room physicians in two São Paulo hospitals found that 31.5% demonstrated low knowledge of Brazilian abortion laws, and the vast majority were in favor of abortion in cases of rape (84%), risk to the mother's life (86%), and fetal malformation incompatible with life (82%) [13]. More recently, in 2003, Faúndes et al. surveyed a national sample of 4,261 Brazilian obstetricians-gynecologists (OB-GYNs) about abortion, asking participants whether they had helped their patients or relatives to have an abortion, and whether they themselves had had an abortion. The authors found that the respondents were progressively more accepting of legal abortion the closer they were to the person with the unwanted pregnancy: 41% of respondents had helped a patient to obtain an abortion, 49% had helped a relative to obtain an abortion, 78% of female physicians had obtained an abortion when they themselves had an unwanted pregnancy, and 80% of male physicians had helped their partners to obtain abortions. The vast majority of participants believed abortion should be legal if the woman's life is at risk (79%), if the pregnancy resulted from rape (80%), and in cases of fetal malformation (77%). Younger respondents were less supportive of abortion when confronted with unwanted pregnancies of patients or relatives, and twice as many physicians with no religious beliefs had helped patients or relatives to have an abortion compared to physicians to whom religion was very important. Nevertheless, when the physician herself or the male physician's partner had had an unwanted pregnancy, almost 70% of those to whom religion was very important had had an abortion [14,15].

The relevance of Brazilian physicians' abortion knowledge, attitudes, and practices extends far beyond the current legal limbo regarding abortion of anencephalic fetuses, and we seek to build on the Faundes et al. findings, some of which have not been published in an English-language journal [15]. We explored not only Brazilian OB-GYNs' knowledge and opinions on the legality of abortion in their country, but also their clinical experience and training (or lack thereof) in different abortion techniques [including medical abortion and manual vacuum aspiration (MVA)] and the different circumstances (e.g., in cases of risk to the woman's life or when the unwanted pregnancy is the result of a rape) under which they performed abortion. Faundes et al. documented OB-GYN abortion practices in terms of the relationship the provider held with the pregnant women, and we will expand on these findings by investigating the circumstances under which the pregnancies arose in those cases where OB-GYNs performed abortions. Finally, we will analyze the relationships between sociodemographic characteristics and experience in performing abortions on opinions on abortion law.

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