Abstract

Introduction

According to estimates, from 2010 to 2014 there were 25.1 million unsafe abortions in the world, of which 24.3 million occurred in developing countries ¹1. Ganatra B, Gerdts C, Rossier C, Johnson Jr. BR, Tunçalp Ö, Assifi A, et al. Global, regional, and subregional classification of abortions by safety, 2010-14: estimates from a Bayesian hierarchical model. Lancet 2017; 390:2372-81.. In Brazil, based on the National Survey on Abortion in 2016 (PNA 2016), nearly one out of five Brazilian women had undergone an abortion by age 40 ²2. Diniz D, Medeiros M, Madeiro A. Pesquisa Nacional de Aborto 2016. Ciênc Saúde Colet 2017; 22:653-6.. In countries like Brazil with legal restrictions, clandestine abortion is practiced by women of all social and economic levels, but the consequences are most severe for those living in situations of social vulnerability (low schooling, low income, young age, and single marital status), given the precarious health conditions in which such abortions are performed ²2. Diniz D, Medeiros M, Madeiro A. Pesquisa Nacional de Aborto 2016. Ciênc Saúde Colet 2017; 22:653-6.^,33. Pacagnella RC. Novamente a questão do aborto no Brasil: ventos de mudanças? Rev Bras Ginecol Obstet 2013; 35:1-4.. The World Health Organization (WHO) classified this type as unsafe abortion ⁴4. World Health Organization. Safe abortion: technical and policy guidance for health systems. 2nd. Ed. Geneva: World Health Organization; 2012.. An assessment of the situation with unsafe abortion in Brazil from 1996 to 2012 found a slight downward trend, but with an average of close to a million unsafe abortions a year ⁵5. Martins-Melo FR, Lima MS, Alencar CH, Ramos Junior AN, Carvalho FHC, Machado MMT, et al. Tendência temporal e distribuição espacial do aborto inseguro no Brasil, 1996-2012. Rev Saúde Pública 2014; 48:508-20..

The late 20^th century witnessed the possibility of medical (non-surgical) termination of pregnancy, initially with antiprogestin alone and later in combination with a uterotonic agent or with uterotonic agents alone ⁶6. Baulieu EE. Contragestion by antiprogestin: a new approach to human fertility control. Ciba Found Symp 1985; 115:192-210.^,77. Thong KJ, Baird DT. Introduction of abortion with mifepristone and misoprostol in early pregnancy. Br J Obstet Gynaecol 1992; 99:1004-7.^,88. Blanchard K, Winikoff B, Ellertson C. Misoprostol used alone for termination of early pregnancy: a review of the evidence. Contraception 1999; 59:209-17.. Medical or drug-induced abortion has proven to be an effective means for termination of pregnancy ⁹9. von Hertzen H, Piaggio G, Huong NT, Arustamyan K, Cabezas E, Gomez M, et al. Efficacy of two intervals and two routes of administration of misoprostol for termination of early pregnancy: a randomized controlled equivalence trial. Lancet 2007; 369:1938-46.^,1010. Faúndes A, Fiala C, Tang OS, Velasco A. Misoprostol for the termination of pregnancy up to 12 completed weeks of pregnancy. Int J Gynaecol Obstet 2007; 99:172S-7S.^,1111. Morris JL, Winikoff B, Dabash R, Weeks A, Faúndes A, Gemzell-Danielsson K, et al. FIGO's updated recommendations for misoprostol used alone in gynecology and obstetrics. Int J Gynaecol Obstet 2017; 138:363-6..

Misoprostol has been used in Brazil since the late 1980s ¹²12. Barbosa RM, Arilha M. A experiência brasileira com o CYTOTEC. Estudos Feministas 1993; 1:407-17., and evidence shows that its use has contributed to a reduction in the incidence of serious post-abortion complications ¹³13. Viggiano MGC, Faúndes A, Borges AL, Viggiano ABF, Souza GR, Rebello I. Disponibilidade de misoprostol e complicações de aborto provocado em Goiânia. J Bras Ginecol 1996; 106:55-61.^,1414. Faúndes A, Santos LC, Carvalho M, Gras C. Post-abortion complications after interruption of pregnancy with misoprostol. Adv Contracept 1996; 12:1-9.^,1515. Miller S, Lehman T, Campbell M, Hemmerling A, Anderson SB, Rodriguez H, et al. Misoprostol and declining abortion-related morbidity in Santo Domingo, Dominican Republic: a temporal association. Int J Gynecol Obstet 2005; 112:1291-6..

Over the course of this text, the term abortion will be used as in common practice. In Brazil, Ministry of Health technical protocol entitled Atenção Humanizada ao Abortamento¹⁶16. Departamento de Ações Programáticas Estratégicas, Secretaria de Atenção à Saúde, Ministério da Saúde. Atenção humanizada ao abortamento: norma técnica. 2ª Ed. Brasília: Ministério da Saúde; 2011. (Série A. Normas e Manuais Técnicos) (Série Direitos Sexuais e Direitos Reprodutivos; Caderno, 4). provides that women who request legal termination of pregnancy should be offered the choice between medical abortion with misoprostol or surgical abortion.

However, training of providers in the use of misoprostol has been limited. The unavailability of medical abortion is thus a relevant factor, since many Brazilian gynecologists and obstetricians who would not be willing to perform a legal termination of pregnancy by aspiration would perform the abortion if it meant prescribing misoprostol ¹⁷17. Faúndes A, Duarte GA, Andalaft Neto J, Olivatto AE, Simoneti RM. Conhecimento, opinião e conduta de ginecologistas e obstetras brasileiros sobre o aborto induzido. Rev Bras Ginecol Obstet 2004; 26:89-96..

Teaching on abortion and particularly on the various techniques for termination of pregnancy is limited or even non-existent in schools of medicine, even in developed countries like the United States or Canada ¹⁸18. Espey E, Ogburn T, Chavez A, Qualls C, Leyba M. Abortion education in medical schools: a national survey. Am J Obstet Gynecol 2005; 192:640-3.^,1919. Roy G, Parvataneni R, Friedman B, Eastwood K, Darney PD, Steinauer J. Abortion training in Canadian obstetrics and gynecology residency programs. Obstet Gynecol 2006; 108:309-14.. Residents in programs that include training on routine abortion have proven more willing than others to provide abortion. We have found no similar studies in Brazil, but there is nothing to suggest that the situation is different from that described in North America. Given this scenario, the current article aimed to identify the degree of knowledge of Brazilian medical residents in Gynecology and Obstetrics on medical abortion, since they will soon be initiating their professional practice.

Methods

A multicenter cross-sectional study was performed with residents regularly enrolled in the medical residency program in Gynecology and Obstetrics in 21 teaching hospitals in Brazil, some of which were affiliated with universities. All of the hospitals were part of the Brazilian Network of Reproductive and Perinatal Health Studies (REDE) and were tertiary services for referral of high-complexity cases and performed more than 2,000 deliveries a year. There were ten state hospitals, seven federal, two municipal, and two Mercy Hospitals. Data were collected from February 2015 to January 2016.

During the data collection at the 21 hospitals, there were 530 physicians enrolled in the medical residency in Gynecology and Obstetrics. This number represents 30.2% of the 3,018 physicians enrolled in the medical residency in this same specialty in Brazil in the year 2017 ²⁰20. Sheffer M. Demografia médica no Brasil 2018. São Paulo: Departamento de Medicina Preventiva, Faculdade de Medicina, Universidade de São Paulo/Conselho Regional de Medicina do Estado de São Paulo/Conselho Federal de Medicina; 2018..

Data collection used a self-completed questionnaire with 30 closed questions, with possible responses or a Likert scale and an open question for spontaneous comments on the topic. The questionnaire contained variables on sociodemographic characteristics, opinions on situations in which abortion should be legal, whether the individual had received classes on medical abortion during undergraduate medical training and on the use of misoprostol and mifepristone during the residency, knowledge on misoprostol and mifepristone, the advantages and disadvantages for women of medical abortion versus surgical abortion, treatment practice for women who had undergone an induced or probably induced abortion, and whether the resident had participated in a legal termination of pregnancy, in addition to the residents’ willingness to perform an abortion on women under certain situations in the future.

In each of the hospitals, a local supervisor was identified who invited all the residents to participate in the study. Residents were individually or in small groups, according to the assessment of the academic and/or administrative authorities as most appropriate in each hospital. This was because the research topic is controversial and might embarrass the resident. Supervisors were asked to have a list of the residents’ names to check who had been approached and who had not, in order to invite everyone. Supervisors were also instructed to destroy the list after inviting or attempting to invite all the residents.

Supervisors were responsible for informing the residents of the study’s objectives, that their participation would be voluntary, and that they would not be identified by name, since the questionnaire did not request any such information. They were also instructed to give residents the Instructions and Responsibility Form and tell them to read it and keep this document with them, answering any questions concerning the study in case they had any doubts and explaining that the anonymous self-responded questionnaire (whether completed or not) should be deposited in a previously sealed box for this purpose The purpose of these instructions was to guarantee the residents’ privacy, so that if necessary they could decline from completing the questionnaire without any fellow resident or even the supervisor knowing.

The questionnaire was given to the residents together with the Instructions and Responsibility Form, and the supervisor informed them of the place where the box would be available for them to deposit the questionnaire, and for how long. The residents were instructed not to consult any reference materials while completing the questionnaire.

The deadline for depositing the questionnaires in the box was one to two weeks. The sealed boxes were sent to the study’s coordinating institution, and the questionnaires were numbered, reviewed, digitized, and filed.

The free and informed consent form was waived by the Institutional Review Board, considering the study topic’s characteristics and the way anonymity was guaranteed. However, in order to inform participants, the Instructions and Responsibility Form was prepared, containing the same information as a free and informed consent form, and given to the potential volunteers together with the questionnaire. The project was approved by the Institutional Review Board of the Department of Obstetrics and Gynecology of the State University of Campinas (Unicamp) and the Ethics Research Committee (CEP) of the Office of the Dean of Research of Unicamp (protocol CAAE: 21177013.3.0000.5404), besides having received approval from the CEP of the respective participating centers.

For questions on knowledge pertaining to medical abortion, participants who reported having received information on this type of abortion during their residency training were instructed to answer a question on the use of misoprostol and another on mifepristone. The resident was instructed to check the column for each statement, whether true, false, or unsure.

For the data processing, the correct responses to each of the alternatives were identified, and each phrase that the resident answered correctly was assigned a value of 1 (one), while the incorrect and “unsure” answers were assigned a value of 0 (zero). A binary response variable (≥ P70, < P70) was defined according to the 70^th percentile of the number of questions on misoprostol. The total number of questions on misoprostol was 8, and thus the 70^th percentile was 5.6. Therefore, residents that answered 6, 7, or 8 questions correctly were classified as having correct knowledge ≥ P70; otherwise, their knowledge was classified as < P70. Analysis of this variable used simple and multivariate logistic regression, presenting the odds ratios (OR) and 95% confidence intervals (95%CI).

Data were keyed in directly on electronic forms, and the data’s consistency was checked. All the digitization and verification procedures used the data entry module of the SPSS (https://www.ibm.com/). The statistical analyses used SAS (version 9.4) (https://www.sas.com/).

Results

There were 530 medical residents in Gynecology and Obstetrics in the 21 hospitals at the time of the data collection. Four hundred and forty residents were approached by their supervisors and invited to participate in the study. Of these, 407 returned the questionnaires, 404 of which were completed and three were blank. Ninety residents were not invited by their supervisors to participate in the study either because they were assigned to other health units at the time or were working on different shifts from the supervisor, and were thus not located during the data collection period.

More than half of the residents in the sample were 27 years or younger, and four-fifths were women. Slightly more than two-thirds were single (without partner) and were in the first or second year of residency at the time of the interview (Table 1). About 60% were born in the South and Southeast regions of Brazil and had done their undergraduate medical training in these same regions (Table 1).

More than two-thirds (68.3%) were doing their medical residencies in hospitals affiliated with universities (data not shown in tables).

Four out of five residents professed some religion, and for 37% of them religion was very important in their lives. Fewer than 10% of the residents stated that religion was scarcely important or unimportant (Table 1).

Just over 80% of the residents had participated in treatment of women with an induced or probably induced abortion, and just over 70% had participated in the legal termination of a pregnancy (Table 1).

As for medical abortion, 324 participants reported having received classes on the subject during their residency (80.6% of the total sample), and 70% considered this information sufficient. Slightly more than half (52.1%) reported having received classes on medical abortion during their undergraduate medical training. Only 17 residents (3%) said they had received information on the use of mifepristone for abortion (data not shown in tables).

As for correct and incorrect answers by medical residents on the use misoprostol, only 40.8% of the participants answered at least 70% of the questions correctly. The statement on the use of misoprostol and hospitalization of the woman received only a few correct answers. Slightly more than half answered correctly on the administration route, and only one third of the residents answered correctly on the dosage (Table 2).

Residents who were more than 26 years of age and those in the later years of their medical residency were significantly more likely to have better knowledge on the use of misoprostol. Fourth-year residents were nearly four times more likely to have better knowledge of medical abortion than those in their initial years (Table 3). Having participated in care for women with an induced or probably induced abortion and having participated in the legal termination of a pregnancy during medical residency were also associated with better knowledge (Table 4). In the multivariate analysis, being in the third year of residency or higher (OR = 2.18) and having participated in care for a woman with induced or probably induced abortion (OR = 4.12) remained associated with better knowledge on the subject (Table 5).

Discussion

Knowledge of medical abortion among Brazilian medical residents in Gynecology and Obstetrics is very limited. Although a large proportion of the residents (80.6%) had received information on misoprostol for abortion, when asked specifically about its use and indications in clinical practice, fewer than half answered more than 70% of the questions correctly.

As expected, the farther along in their residency, the better their knowledge on misoprostol, but fewer than 60% of fourth-year residents got more than 70% of the questions right. The progressive increase in knowledge on this subject as their medical training progresses appears to begin in undergraduate medical school, judging by the findings from a study conducted in students in their final year of school at three universities in São Paulo, in which only one out of five students displayed satisfactory knowledge on this topic ²¹21. Fernandes KG, Camargo RP, Duarte GA, Faúndes A, Sousa MH, Maia Filho NL, et al. Knowledge of medical abortion among Brazilian medical students. Int J Gynaecol Obstet 2012; 118:10S-4S..

Likewise, having participated in treatment or having performed a legal termination of a pregnancy was associated with better knowledge, corroborating findings by other authors ²²22. Holcombe SJ, Berhe A, Cherie A. Personal beliefs and professional responsibilities: Ethiopian midwives' atitudes toward providing abortion services after legal reform. Stud Fam Plann 2015; 46:73-95.. However, even in the group with this experience, only 45.4% answered more than 70% of the questions correctly, showing that even in this group with better information there were gaps in learning on medical abortion during residency in Gynecology and Obstetrics.

We found no previous publications presenting results of a study that specifically asked Brazilian medical residents in Gynecology and Obstetrics about their knowledge of medical abortion, beside what had already been reported on undergraduate students in their final year of medical school. Since our sample represents 30.2% of all the Brazilian medical residents in Gynecology and Obstetrics in 2017, the results strongly suggest that Brazilian medical schools have not adequately prepared residents to perform non-surgical legal termination of pregnancy, as specified in the official protocol on Prevenção e Tratamento dos Agravos Resultantes da Violência Sexual Contra Mulheres e Adolescentes²³23. Departamento de Ações Programáticas Estratégicas, Secretaria de Atenção à Saúde, Ministério da Saúde. Prevenção e tratamento dos agravos resultantes da violência sexual contra mulheres e adolescentes: norma técnica. Brasília: Ministério da Saúde; 2012., which is also a practice recommended by the WHO ⁴4. World Health Organization. Safe abortion: technical and policy guidance for health systems. 2nd. Ed. Geneva: World Health Organization; 2012. and the International Federation of Gynecology and Obstetrics (FIGO) ²⁴24. International Federation of Gynecology and Obstetrics. Ethical issues in obstetrics and gynecology; 2012. https://www.figo.org/sites/default/files/uploads/wg-publications/ethics/English%20Ethical%20Issues%20in%20Obstetrics%20and%20Gynecology.pdf (acessado em 25/Nov/2018).
https://www.figo.org/sites/default/files... and the Brazilian Ministry of Health ¹⁶16. Departamento de Ações Programáticas Estratégicas, Secretaria de Atenção à Saúde, Ministério da Saúde. Atenção humanizada ao abortamento: norma técnica. 2ª Ed. Brasília: Ministério da Saúde; 2011. (Série A. Normas e Manuais Técnicos) (Série Direitos Sexuais e Direitos Reprodutivos; Caderno, 4)..

Termination of pregnancy is authorized by Brazilian legislation in the circumstances described previously, and women who meet these conditions should receive treatment without restrictions. If there is a possible treatment for a health condition and the woman is denied access to it, her rights are being violated and the physician is failing to comply with his or her ethical and professional obligations. As the FIGO Code of Ethics states: “The primary conscientious duty of obstetrician-gynecologists is at all times to treat, or provide benefit and prevent harm to the patients for whose care they are responsible. Any conscientious objection to treating a patient is secondary to this primary duty” ²⁴24. International Federation of Gynecology and Obstetrics. Ethical issues in obstetrics and gynecology; 2012. https://www.figo.org/sites/default/files/uploads/wg-publications/ethics/English%20Ethical%20Issues%20in%20Obstetrics%20and%20Gynecology.pdf (acessado em 25/Nov/2018).
https://www.figo.org/sites/default/files... .

The main cause of the restrictions in Brazil is the stigma attached to abortion ²⁵25. Faúndes A, Duarte GA, Osis MJ. Conscientious objection or fear of social stigma and unawareness of ethical obligations. Int J Gynaecol Obstet 2013; 123 Suppl 3:S57-9., a problem that will continue unabated as long as the issue continues to receive so little attention in the country’s medical schools. Brazil’s schools of medicine need to devise ways to improve medical residents’ training in legal abortion and the use of misoprostol. This is because abortion is a common experience in the lives of childbearing-age women and is also one of the most routine surgical procedures performed by gynecologists and obstetricians ²⁶26. Steinauer J, Turk JK, Pomerantz T, Simonson K, Learman LA, Landy U. Abortion training in US obstetrics and gynecology residency programs. Am J Obstet Gynecol 2018; 219:86e1-86e6.. In addition, when this type of training is not provided to future gynecologists and obstetricians, women are deprived of their rights according to the basic principles of bioethics (autonomy, beneficence/nonmaleficence, and justice).

The standards regulating care for legal abortion in Brazil determine that the attending health professionals should provide humanized care to the woman, besides addressing the indication of misoprostol for termination of the pregnancy or uterine evacuation ¹⁶16. Departamento de Ações Programáticas Estratégicas, Secretaria de Atenção à Saúde, Ministério da Saúde. Atenção humanizada ao abortamento: norma técnica. 2ª Ed. Brasília: Ministério da Saúde; 2011. (Série A. Normas e Manuais Técnicos) (Série Direitos Sexuais e Direitos Reprodutivos; Caderno, 4).. However, the official guidelines do not suffice if the providers (gynecologists and obstetricians in Brazil’s case) are not adequately trained in the procedures.

One proposal for educating professionals is the use of active methodologies in medical schools. This type of teaching/learning methodology is student-centered, where the professor acts as a facilitator of the knowledge. Small groups of students conduct a discussion on the knowledge to be built based on real cases. The method allows involving both basic knowledge and more advanced knowledge and promoting a critical discussion of cases. There is good experience with the use of this active methodology, especially in the improvement of skills performance and critical reasoning ²⁷27. Leon LB, Onófrio FQ. Aprendizagem baseada em problemas na graduação médica: uma revisão da literatura atual. Rev Bras Educ Méd 2015; 39:614-9.. Another technique that has been used is role-playing, which allows “switching roles” between the actors involved in the same theme so that they can perceive different points of view on one theme, that is, from different perspectives ²⁸28. Darze OISP, Barroso Júnior U. Uma proposta educativa para abordar objeção de consciência em saúde reprodutiva durante o ensino médico. Rev Bras Educ Méd 2018; 42:155-64..

Meanwhile, our results show that care for cases of legal abortion and incomplete abortion by residents was associated with better knowledge on the use of misoprostol, suggesting that if all medical schools provided services for legal termination of pregnancy, residents would be better prepared for this practice, while access to these services would be expanded in Brazil.

Using active methodologies for teaching on legal abortion and termination of pregnancy would be an important strategy, since students could be the protagonists in the discussions in the search for knowledge and case-solving. At any rate, it is important to have a space for discussion in the medical residency curriculum that involves gender issues and rights, since these health professionals will be caring for women that are experiencing abortion in the near future and will be opinion-makers on the issue.

One limitation to this study was that the question on knowledge of misoprostol was only answered by residents who reported having received classes on medical abortion. A person’s acquisition of knowledge is not associated only with didactic classes they attend, but with all kinds of information they receive through existing communications media. Students currently have easy access to books, scientific journals, bulletins, and newsletters, and interact with others on social networks. We lacked information on this point, the subject of this article, for 22.3% of the total sample.

The study’s results show that among Brazilian medical residents in Gynecology and Obstetrics, knowledge on medical abortion is very reduced and poses an obstacle to proper care in cases of legal termination of pregnancy.

Unplanned pregnancy and induced abortion have been present in all societies throughout history and have been acknowledged and addressed. The most efficient solution is legalization of abortion, which not only leads to rapid reduction of morbidity and mortality, but also contributes to the reduction of the abortion rate ²⁹29. Faúndes A, Shah IH. Evidence supporting broader access to safe legal abortion. Int J Gynaecol Obstet 2015; 131 Suppl 1:56S-9S.. Until this happens, it is up to physicians to ensure that every woman who meets the conditions allowed by law will have easy access to services for legal termination of pregnancy, particularly the poor and unprotected, who are treated at public services, because they are the ones that suffer the worst consequences of clandestine abortion ⁴4. World Health Organization. Safe abortion: technical and policy guidance for health systems. 2nd. Ed. Geneva: World Health Organization; 2012.. Physicians’ capacity to correctly provide medication for the termination of pregnancy is a factor that has proven to be of the utmost importance to facilitate access to legal abortion ³⁰30. Fiol V, Rieppi L, Aguirre R, Nozar M, Gorgoroso M, Coppola F, et al. The role of medical abortion in the implementation of the law on voluntary termination of pregnancy in Uruguay. Int J Gynaecol Obstet 2016; 134 Suppl 1:12S-5S..

We hope that the publication of these results will help call the attention of health authorities and medical societies to the need to correct this unfortunate gap in training medical residents in Gynecology and Obstetrics.

Acknowledgments

The authors wish to acknowledge the collaboration and opinions of all the residents in Gynecology and Obstetrics, the coordinators and supervisors, and the institutions that collaborated in the study’s development, as well as the São Paulo State Research Support Foundation (FAPESP) for the funding, under case review no. 2012/23129-6.

References

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History