Brazil is one of the many low and middle income countries with restrictive abortion laws [1]. Current legislation in Brazil permits abortion in cases of rape, when the mother’s life is in danger and in cases of anencephaly [2]. It does not mean that women who are raped and get pregnant can easily obtain safe abortion services in public hospitals as the law allows. Until the end of the 20th? Century it was almost impossible for raped women to get legal abortion services. Since the Ministry of Health dictated the Norms for the care of women and adolescents who suffered sexual violence, in 1998, an increasing number of hospital do provide such services. However, many women meeting the conditions required to obtain a safe legal abortion are unable to access services [3].

      One of the main obstacles to obtaining access to legal abortion is the unwillingness of obstetricians - gynecologists, to provide such services [4-6]. In order to protect women’s right to safe pregnancy termination within the limits of the law it will be necessary to reduce the stigma that affect abortion, which is the main reason for the unwillingness to provide safe abortion services in public hospital, although this is disguised as conscientious objection [7].

      Most gynecologists are in favor of laws that allow abortion after rape, but that does not necessarily mean that they will be willing to provide safe abortion services within the law [8].

      In order to have better arguments to change such obstetricians - gynecologists attitude we evaluated which are the difference between opinion on abortion after rape with willingness to provide services according to the characteristics of the obstetricians - gynecologists involved, which is subject of this study.

      A KAP survey was distributed to Brazilian obstetricians - gynecologists associated with the Brazilian Federation of Societies of Gynecologists and Obstetricians (FEBRASGO), an affiliate of the International Federation of Gynecologists and Obstetricians (FIGO). A structured questionnaire for self completion was sent to all members, together with a letter explaining the purpose of the study and requesting their collaboration by responding in total confidentiality, as there was no data allowing respondents’ identification. It also included a stamped envelope for returning the questionnaire.

      Of the 3.386 questionnaires received 49 were in blank, leaving 3,337 to be included in this. The data was entered in a data bank twice by two different clerks and any inconsistency was reviewed and corrected.

      No Informed consent form was requested to be signed to prevent that a respondent could be identified. It was understood that the recipients of the questionnaire were free to respond or not, and the fact that the questionnaire was completed and returned was implicit consent after receiving the appropriate information in the letter accompanying the questionnaire.

      The research protocol was reviewed and approved by the Committee on Research Ethics of the Faculty of Medicine of the State University of Campinas (Unicamp).

      The two compared outcomes were the respondents’ opinions as to whether abortion should be legally permitted after rape and the respondents’ willingness to provide abortion services to raped women who got pregnant and requested termination in the public hospital where the respondents worked.

      The difference between opinion of abortion provision and willingness to provide abortion services in the same circumstances was evaluated according to the socio-demographic characteristics of the obstetricians - gynecologists who responded, namely age, sex, marital status, number of living children and importance given to religion.

      The characteristics of the gynecologist - obstetricians who responded the questionnaire are described in Table 1

Table 1

Table 1: Distribution of participants according to their sociodemographic characteristics.

      Missing information for 21 physicians on Age, for 10 on Marital status,for 12 on number of living children, for 59 on Importance of religion.

      The question of obstetricians - gynecologists’ opinion whether abortion should be legally permitted after rape was responded positively by 84.8% of the respondents (2,801 out of 3304)., Only 36.9% would provide abortion services to raped women requesting legal termination of pregnancy in the public hospital where they worked (Table 2). An additional 15.1% (52% in total) would be willing to prescribe medical abortion with misoprostol (Table 2).

Table 2

Table 2: Proportion of respondents who were in favor of legal abortion after rape, and who were willing to provide abortion services in general or only to prescribe misoprostol, according to respondents characteristics.

      There was not significant difference in opinion about legality of abortion after rape according to sex and age, but the proportion was significantly lower among those for whom religion was very important (p<0.001), who had three or more children (p<0.001) and who had a permanent partner (p<0.025). The greatest difference was observed in relation to importance given to religion (Table 2).

      The willingness to provide abortion services was significantly greater among those who were males (P<0.001), younger (p<0.05), with no children (p<0.001) and who did not have a religion (p<0.001). The difference according to marital status was not statistically significant (Table 2).

      Extra column for willing to provide an abortion (surgical) and also willing to prescribe to misoprostol would be helpful. Some ob/gyns may be willing to prescribe misoprostol but unwilling to perform a surgical abortion. Or Provide an extra column for each opinion category to show all p values.

      On willingness to prescribe misoprostol, the only significant difference was observed in importance given to religion (p<0.001)). The percentage willing to prescribe misoprostol was lowest among those for whom religion is very important (10.1%). It is interesting that the highest percentages of respondents who declare willingness to prescribe misoprostol, over 17% was found among those for whom religion is not very important or not important.

      More than twice as many respondents have a favorable opinion on the legality of abortion after rape than are willing to provide services (84.8% vs.36. (%). The greatest difference was observed among those for whom religion is very important, among whom the proportion willing to provide services was almost one fourth of the proportion who believed that abortion should be legal in those cases (17.5 vs 65.9).

      It should be noted that 65.9% of those who give great importance to religion agree that abortion should be permitted after rape, and 17.5% were willing to provide abortion services. If we add the 10% willing to prescribe misoprostol, we will find that more than 27.5% of the respondents for whom religion is very important, are willing to help a raped woman to terminate her pregnancy.

      On the other hand, the largest percentage of respondents willing to provide abortion services to raped women in public hospitals was found among those who declared not to profess any religion, closely followed by those for whom religion is not important.

      The results of this study confirm that less than a half of obstetricians - gynecologists are willing to provide abortion services in public hospitals, at least in this sample, although almost 85% of them agree that women who get pregnant from rape should receive such services.

      The problem seems to be that carrying out abortions in a public hospital means that everybody will know that he or she performs pregnancy terminations and his or her name will be associated with abortion provision. Given the stigma still associated to abortion, many colleagues prefer to claim conscientious objection, which in fact many times they do not have, to prevent that people in their environment identifying them as an “abortionist”, which continues to be a bad word [7].

      There may be a long way to go, before everybody recognizes that abortion is a fact of life, which cannot be fully prevented, has existed along human history and will remain with us for the foreseeable future. Currently it seems that the rejection of the concept of abortion prevails and people can change that position only when they experience the problem of unintended pregnancy and eventual abortion in their own or in persons very close to them [9].

      It is encouraging that in our results, younger doctors are more willing to provide abortion services than their older colleagues. It may mean that the younger generations have a more realistic view of abortion as an unavoidable event, and that women have the right to get safe services, more so, when they fulfill the legal requirements.

      The results also contribute to confirm the importance of the availability of medical abortion to improve access to services, noting that respondent with religion, but for whom religion was not very important or of no importance, showed the highest percentage of willingness to prescribe misoprostol, suggesting that pregnancy termination by medication appears to be seen as a less evil procedure. The important role of medical abortion to improve access to pregnancy termination has already be clearly described [10].

      Being aware that there is a long way to go before access to safe abortion is a fully recognized human right of women, we hope that the publication of this paper give at least a modest contribution to reach that ideal situation.