Abstract:

Previous reviews on the subject of abortion in Brazil have estimated one million procedures per year but did not address legal abortion. This systematic review sought to update knowledge regarding legal abortion in terms of service and women’s profile, student and doctor knowledge, situations of anencephaly and severe malformations. We searched MEDLINE and LILACS for articles published in all languages between 2008 and 2018. Article quality was assessed using the Joanna Briggs Institute instruments. Search, selection, quality assessment and data extraction were carried out independently by two researchers. We selected 20 articles, 11 on the knowledge and opinion of medical professionals (4 articles) and students (7 articles) revealing a less-than-ideal level of knowledge and a high degree of objection of conscience. Six studies on women who use legal abortion services found that they are young, single and that the main demand was for pregnancy resulting from rape. When women were younger and single and when the aggressor was someone close to them, there were delays in seeking care. Three studies on severe malformation found around 40% of court authorizations. In cases for which no authorization was given, the evolution of pregnancies was complicated and deliveries were done through cesarean sections. Only one article addressed legal abortion services, showing that 37 of the 68 that had been registered were active, lack of services in seven states and concentration in capitals. Knowledge regarding legal abortion is still scarce, the demand for the procedure is repressed and medical training is deficient with regard to this subject.

Keywords:
Legal Abortion; Reproductive Rights; Systematic Review

Introduction

It is estimated that, worldwide, each year, there are 35 abortions for every 1,000 women aged between 15 and 44 years. In Latina America, that rate is 44/1,000 ¹1. Sedgh G, Bearak J, Singh S, Bankole A, Popinchalk A, Ganatra B, et al. Abortion incidence between 1990 and 2014: global, regional, and subregional levels and trends. Lancet 2016; 388:258-67. and most countries in the region, with the exception of Uruguay, Guyana and Cuba, have laws restricting the practice. In Brazil, abortion is allowed for women whose lives are at risk and in situations in which the pregnancy is the result of rape and, more recently, when there is fetal anencephaly. The two first exceptions are established in Article 128 of the Penal Code ²2. Código Penal Brasileiro. https://www2.camara.leg.br/legin/fed/declei/1940-1949/decreto-lei-2848-7-dezembro-1940-412868-publicacaooriginal-1-pe.html (acessado em Mar/2019).
https://www2.camara.leg.br/legin/fed/dec... . The third resulted from the Supreme Court’s ruling regarding Claim of Non-Compliance with a Fundamental Principle (ADPF, in Portuguese) n. 54, in 2012 ³3. Supremo Tribunal Federal. Acórdão sobre a Arguição de Descumprimento de Preceito Fundamental ADPF 54. Mostra-se inconstitucional a interpretação de interrupção da gravidez de feto anencéfalo ser conduta tipificada nos artigos 124, 126 e 128, incisos I e II, do Código Penal. https://www.conjur.com.br/dl/acordao-interrupcao-gravidez-anencefalo.pdf (acessado em Mar/2019).
https://www.conjur.com.br/dl/acordao-int... , which was ratified that same year in a decision by the Federal Medicine Council (CFM, in Portuguese) which authorizes doctors to interrupt pregnancies of anencephalic fetuses, at the pregnant woman’s request, at any point during the pregnancy ⁴4. Conselho Federal de Medicina. Resolução CFM nº 1.989/2012. Dispõe sobre o diagnóstico de anencefalia para a antecipação terapêutica do parto e dá outras providências. http://www.portalmedico.org.br/resolucoes/cfm/2012/1989_2012.pdf (acessado em Mar/2018).
http://www.portalmedico.org.br/resolucoe... . In addition to these situations, court authorizations for abortions in cases of anencephaly (before 2012) and other malformations have been issued in Brazil, broadening the perspectives of legal abortion ⁵5. Frigério V, Salzo I, Pimentel S, Gollop TR. Aspectos bioéticos e jurídicos do abortamento seletivo no Brasil. In: Católicas pelo Direito de Decidir, organizador. Aborto legal: implicações éticas e religiosas. São Paulo 2002. p. 77-98.^,66. Diniz D. Quem autoriza o aborto seletivo no Brasil? Médicos, promotores e juízes em cena. Physis (Rio J.) 2003; 13:13-34..

An extensive review of research on abortion, published in 2008, analyzed the scientific production in Brazil over a 20-year period ⁷7. Departamento de Ciência e Tecnologia, Secretaria de Ciência, Tecnologia e Insumos Estratégicos, Ministério da Saúde. 20 anos de pesquisas sobre aborto no Brasil. Brasília: Ministério da Saúde; 2009. (Série B. Textos Básicos de Saúde).. It included articles published in journals, theses, dissertations, books, works presented at conferences and argumentative texts. Most were opinion pieces and only 20% involved the production of primary data or the analysis of secondary data. A large part focused on public hospitals and few works addressed legal abortion. Another review, specifically of Collective Health studies, also did not address investigations of legal abortions ⁸8. Menezes M, Aquino EML. Pesquisa sobre o aborto no Brasil: avanços e desafios para o campo da saúde coletiva. Cad Saúde Pública 2009; 25 Suppl 2:S193-204..

Since these two articles were published ⁷7. Departamento de Ciência e Tecnologia, Secretaria de Ciência, Tecnologia e Insumos Estratégicos, Ministério da Saúde. 20 anos de pesquisas sobre aborto no Brasil. Brasília: Ministério da Saúde; 2009. (Série B. Textos Básicos de Saúde).^,88. Menezes M, Aquino EML. Pesquisa sobre o aborto no Brasil: avanços e desafios para o campo da saúde coletiva. Cad Saúde Pública 2009; 25 Suppl 2:S193-204., there have been few advances regarding abortion in Brazil, except for the 2011 update of the Ministry of Health’s Technical Norm (originally published in 2005) on the provision of abortion-related care ⁹9. 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). and the authorization of abortion in cases of fetal anencephaly in 2012 ⁴4. Conselho Federal de Medicina. Resolução CFM nº 1.989/2012. Dispõe sobre o diagnóstico de anencefalia para a antecipação terapêutica do parto e dá outras providências. http://www.portalmedico.org.br/resolucoes/cfm/2012/1989_2012.pdf (acessado em Mar/2018).
http://www.portalmedico.org.br/resolucoe... . It is worth noting two other Ministry of Health norms on the subjects of harms resulting from sexual violence ¹⁰10. 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. (Série A. Normas e Manuais Técnicos) (Série Direitos Sexuais e Direitos Reprodutivos; Caderno 6). and provision of care to pregnant women carrying anencephalic fetuses ¹¹11. Departamento de Ações Programáticas Estratégicas, Secretaria de Atenção à Saúde, Ministério da Saúde. Atenção às mulheres com gestação de anencéfalos: norma técnica. Brasília: Ministério da Saúde; 2014. (Série Direitos Sexuais e Direitos Reprodutivos; Caderno 11).. By reviewing articles on abortion in Brazil, this study seeks to update knowledge regarding legal abortion in terms of service and women’s profile, student/doctor knowledge, situation of anencephaly and severe malformations, in the period of 2008 to 2018.

Methods

This is a systematic review of legal abortion and unsafe abortion in Brazil, carried out according to the recommendations of the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) ¹²12. Liberati A, Altman DG, Tetzlaff J, Mulrow C, Gøtzsche P, Ioannidis JPA, et al. The PRISMA statement for reporting systematic reviews and meta-analyses of studies that evaluate health care interventions: explanation and elaboration. PLoS Med 2009; 6:e1000100. statement. All review steps were carried out independently by two researchers (S. C. F. and R. M. S. M. D.). This article refers to the subgroup of studies on legal abortion in the country. The results regarding unsafe abortion (frequency, women’s profile and complications) will be discussed in another publication.

Eligibility criteria

We included original scientific articles published between 2008 and 2018. We considered articles with a predominantly quantitative focus as eligible. We excluded studies with exclusively qualitative methods, non-systematic reviews, theoretical essays, research protocols, intervention and diagnostic studies and methodological studies. We did not include monographs, dissertations or theses.

With regard to legal abortion, which is the focus of this article, due to the small number of previous quantitative studies ⁸8. Menezes M, Aquino EML. Pesquisa sobre o aborto no Brasil: avanços e desafios para o campo da saúde coletiva. Cad Saúde Pública 2009; 25 Suppl 2:S193-204., the eligible themes were decided during the search process: (1) service profile - number and characteristics of care provision; (2) profile of women who had a legal abortion; (3) doctors/medical students’ knowledge of the situations in which abortion is legally permitted; and (4) abortion in cases of malformations other than anencephaly. We chose to address doctors exclusively because, in Brazil, only these professionals are allowed to perform abortions.

Bibliographic search strategy

We searched the electronic databases MEDLINE and LILACS. The key words we used in combination are presented in Box 1. Additionally, we included references cited in the selected articles that met inclusion criteria. Electronic searches, with no language restrictions, were carried out in late 2017 and updated in March 2019.

Study selection

After manual exclusion of repeated articles, we carried out an initial triage based on titles, eliminating all those not related to unsafe abortions or legal abortion in Brazil. After reading the abstracts, the articles that did not meet eligibility criteria were excluded. Other studies were eliminated after the full articles were read, if they were confirmed to be ineligible. Once again, the decision was made by consensus.

Study quality assessment

Article quality was assessed using instruments developed by the Joanna Briggs Institute ¹³13. Joanna Briggs Institute. Clinical Appraisal Tools. http://joannabriggs.org/research/critical-appraisal-tools.html (acessado em 10/Jan/2018).
http://joannabriggs.org/research/critica... and validated in the scientific literature. These instruments assess different types of studies (case series, cross-sectional studies and cohort studies) and, while respecting the specificities of each epidemiological design, value inclusion and population sampling criteria, variable measurement methods and statistical analysis. We did not exclude any study due to quality, but we present the methodological limitations we identified based on these criteria.

Result presentation

For each included study, we extracted the following data: authors, year of publication, year the study was conducted, study design, locality, study population, assessed outcome, methodological limitations and main results. In the tables, the studies are presented along with their themes: legal abortion service; women’s characteristics; knowledge/behavior of doctors/medical students; malformations and legal abortion.

Results

We identified 749 eligible titles after excluding duplicates and including six publications from article references. In the initial triage, we selected 233 abstracts. Of these, 140 were excluded because they were exclusively qualitative studies (30%), theoretical essays (22.1%), analyses of other aspects of abortion (18.6%), review studies (10%), other types of publication (editorials, letters, protocols, methodological articles, theses and dissertations, representing 19.3%). We then read the remaining 93 articles in full (we were unable to access one article on unsafe abortion) and, after applying the eligibility criteria, 20 studies on legal abortion were included in this analysis (Figure 1). The articles related to unsafe abortion (n = 50) are discussed in another article.

General article characteristics

Only three articles were of national scope ¹⁴14. Madeiro AP, Diniz D. Legal abortion services in Brazil-a national study. Ciênc Saúde Colet 2016; 21:563-72.^,1515. Diniz D, Penalva J, Faúndes A, Rosas C. A magnitude do aborto por anencefalia: um estudo com médicos. Ciênc Saúde Colet 2009; 14 Suppl 1:1619-24.^,1616. Diniz D, Madeiro A, Rosas C. Conscientious objection, barriers, and abortion in the case of rape: a study among physicians in Brazil. Reprod Health Matters 2014; 22:141-8.. All others were local. The region with the highest number of studies was the Southeast (11 articles, all from the State of São Paulo), followed by the Northeast (4 articles). The Central and North regions had only one article each (Table 1).

The studies encompassed data from 1994 to 2017, especially concentrated in the 2000s. Women’s and Children’s Health journals predominated (with nine articles). The remaining articles were published in Clinical Medicine, Medical Training, Collective Health and Bioethics journals (Table 1).

A single article described the results of a census of legal abortion services in the country, analyzing their structure and operations, the characteristics of the women who received care at these services and the perspective of their professionals ¹⁴14. Madeiro AP, Diniz D. Legal abortion services in Brazil-a national study. Ciênc Saúde Colet 2016; 21:563-72.; another five studies, of local scope, described the characteristics of women admitted to hospitals for abortion following a rape, the reasons for the decision to have an abortion and repercussions for personal and day-to-day relationships ¹⁷17. Drezett J, Pedroso D, Gebrim LH, Matias ML, Macedo Jr. H, Abreu LC. Motivos para interromper legalmente a gravidez decorrente de estupro e efeitos do abortamento nos relacionamentos cotidianos das mulheres. Reprod Clim 2011; 26:85-91.^,1818. Drezett J, Pedroso D, Vertamatti MA, Macedo-Júnior H, Blake MT, Gebrim LH, et al. Pregnancy resulting from sexual abuse: reasons alleged by Brazilian women for carrying out the abortion - pregnancy and violence. Health Med 2012; 6:819-25.^,1919. Blake MT, Drezett J, Machi GS, Pereira VX, Raimundo RD, Oliveira FR, et al. Factors associated with the delay in seeking legal abortion. Int Arch Med 2015; 8:1-14.^,2020. Santos J, Drezett J, Alves AL. Características sociodemográficas de migrantes bolivianas com gestação decorrente de violência sexual atendidas em serviço público de referência para abortamento legal, São Paulo, Brasil, 2002 - 2014. Reprod Clim 2015; 17:25-32.^,2121. Mutta DS, Yela DA. Sociodemographic characteristics of women in a public hospital in Campinas who underwent legal abortion due to sexual violence: cross-sectional study. São Paulo Med J 2017; 135:363-8.. Most studies investigated the behavior, knowledge and opinion of agents involved in providing legal abortion care, whether they were health professionals ¹⁶16. Diniz D, Madeiro A, Rosas C. Conscientious objection, barriers, and abortion in the case of rape: a study among physicians in Brazil. Reprod Health Matters 2014; 22:141-8.^,2222. Benute GR, Nonnenmacher D, Nomura RM, Lucia MCS, Zugab M. Influência da percepção dos profissionais quanto ao aborto provocado na atenção à saúde da mulher. Rev Bras Ginecol Obstet 2012; 34:69-73.^,2323. Ribeiro DR, Fonseca CT. Atenção humanizada ao aborto legal em um hospital público de Belém - PA. Rev Para Med 2015; 29:13-20.^,2424. Rocha WB, Silva AC, Leite SML, Cunha T. Percepção de profissionais da saúde sobre abortamento legal. Rev Bioét 2015; 23:387-99. or medical students ²⁵25. Almeida MAS, Amorim FHR, Barbosa IAF, Dias A, Morita I. Brazilian abortion law: knowledge in medical education. Rev Bras Educ Méd 2012; 36:243-8.^,2626. Medeiros RD, Azevedo GD, Oliveira EA, Araújo FA, Cavalcanti FJ, Araújo GL, et al. Opinion of medical and law students of Federal University of Rio Grande do Norte about abortion in Brazil. Rev Bras Ginecol Obstet 2012; 34:16-21.^,2727. Faúndes A, Duarte GA, de Sousa MH, Soares Camargo RP, Pacagnella RC. Brazilians have different views/abortion should be legal, but most do not agree with imprisoning women for abortion. Reprod Health Matt 2013; 21:165-73.^,2828. Darzé OISP, Azevêdo BKG. Competências adquiridas durante a formação médica e as opiniões e atitudes sobre o aborto. Rev Bras Ginecol Obstet 2014; 36:5-9.^,2929. Madeiro A, Rufino A, Santos P, Bandeira G, Freitas I. Objeção de consciência e aborto legal: atitudes de estudantes de Medicina. Rev Bras Educ Méd 2016; 40:86-92.^,3030. Motoki MS, Cabar FR, Francisco RP. Mother's freedom of choice and the rights of an unborn child: a comparison between the views of freshmen and senior medical school students. Clinics 2016; 71:570-4.^,3131. Darzé OISP, Barroso Júnior U. Prevalence, attitudes, and factors motivating conscientious objection toward reproductive health among medical students. Rev Bras Ginecol Obstet 2018; 40:599-605.. Three studies addressed the theme of malformations and court authorizations for abortion ¹⁵15. Diniz D, Penalva J, Faúndes A, Rosas C. A magnitude do aborto por anencefalia: um estudo com médicos. Ciênc Saúde Colet 2009; 14 Suppl 1:1619-24.^,3232. Nomura RM, Brizot ML, Liao AW, Hernandez WR, Zugaib M. Conjoined twins and legal authorization for abortion. Rev Assoc Med Bras 2011; 57:205-10.^,3333. Westphal F, Araujo Júnior E, Fustinoni SM, Abrahão AR. Maternal risks and predictor factors for the termination of pregnancy in fetuses with severe congenital anomaly: experience from a single reference center in Brazil. J Matern Fetal Neonatal Med 2016; 29:3762-7. (Table 2).

Most studies were cross-sectional and descriptive. Six were case series and a single study was longitudinal (Table 2).

As for methodological quality, following the criteria we adopted ¹³13. Joanna Briggs Institute. Clinical Appraisal Tools. http://joannabriggs.org/research/critical-appraisal-tools.html (acessado em 10/Jan/2018).
http://joannabriggs.org/research/critica... , we found that 6 fulfilled more than 70% of the recommended items; 9 fulfilled between 50% and 60% of items; and the remaining 5 fulfilled less than half of the items. The main limitations are presented in Table 2. Items with the greatest fragility were those related to sample representativeness and statistical analysis.

Main results

The article by Madeiro & Diniz ¹⁴14. Madeiro AP, Diniz D. Legal abortion services in Brazil-a national study. Ciênc Saúde Colet 2016; 21:563-72. mapped the legal abortion services in the country and identified, in the 2013-2015 period, only 37 active services of the 68 registered with the Ministry of Health. These services are distributed across the regions as follows: 5 in the North, eleven in the Northeast, 3 in the Central, 12 in the Southeast and 6 in the South, concentrated in capitals and large urban centers. The interruption of pregnancy varied according to the situation: rape (most frequent reason for the demand), in all services; risk to the woman’s life, in 27; and anencephaly cases, in 30. All had multi-professional teams, but not specifically for this service. Documents such as forensic reports and court orders were demanded by 8% to 14% of services. The methods available in most services were: medication, curettage and manual intrauterine aspiration. Of 5,075 demands, 2,442 legal abortions were performed in the country between 1994 and 2015. Five services (not specified, one for each region) were selected for in-depth investigation, with an analysis of 1,238 charts. With regard to sociodemographic characteristics, women were, for the most part, young (15 to 29 years), single and Catholic (43%). As for educational level, 41% had ≤ 8 years of schooling, 47% had completed secondary education and 14% had completed higher education ¹⁴14. Madeiro AP, Diniz D. Legal abortion services in Brazil-a national study. Ciênc Saúde Colet 2016; 21:563-72.. Another study, focusing on Bolivian women who received care at a reference center for legal abortion in São Paulo, found that 40% had low educational levels ²⁰20. Santos J, Drezett J, Alves AL. Características sociodemográficas de migrantes bolivianas com gestação decorrente de violência sexual atendidas em serviço público de referência para abortamento legal, São Paulo, Brasil, 2002 - 2014. Reprod Clim 2015; 17:25-32..

With regard to age and marital status, the results from the national census ¹⁴14. Madeiro AP, Diniz D. Legal abortion services in Brazil-a national study. Ciênc Saúde Colet 2016; 21:563-72. were similar to those observed among 1,270 women who received care at a São Paulo hospital certified for performing legal abortions between 1994 and 2013 ¹⁹19. Blake MT, Drezett J, Machi GS, Pereira VX, Raimundo RD, Oliveira FR, et al. Factors associated with the delay in seeking legal abortion. Int Arch Med 2015; 8:1-14. , and among 131 women who had legal abortions after suffering sexual violence in Campinas, at the University Hospital, between 1994 and 2014 ²¹21. Mutta DS, Yela DA. Sociodemographic characteristics of women in a public hospital in Campinas who underwent legal abortion due to sexual violence: cross-sectional study. São Paulo Med J 2017; 135:363-8.. Considering all three studies, the percentage of adolescents who demanded a legal abortion was higher than one third of all women ¹⁴14. Madeiro AP, Diniz D. Legal abortion services in Brazil-a national study. Ciênc Saúde Colet 2016; 21:563-72.^,1919. Blake MT, Drezett J, Machi GS, Pereira VX, Raimundo RD, Oliveira FR, et al. Factors associated with the delay in seeking legal abortion. Int Arch Med 2015; 8:1-14.^,2121. Mutta DS, Yela DA. Sociodemographic characteristics of women in a public hospital in Campinas who underwent legal abortion due to sexual violence: cross-sectional study. São Paulo Med J 2017; 135:363-8.. However, with regard to educational levels, the São Paulo and Campinas studies ¹⁹19. Blake MT, Drezett J, Machi GS, Pereira VX, Raimundo RD, Oliveira FR, et al. Factors associated with the delay in seeking legal abortion. Int Arch Med 2015; 8:1-14.^,2121. Mutta DS, Yela DA. Sociodemographic characteristics of women in a public hospital in Campinas who underwent legal abortion due to sexual violence: cross-sectional study. São Paulo Med J 2017; 135:363-8. had a less favorable profile than the national study ¹⁴14. Madeiro AP, Diniz D. Legal abortion services in Brazil-a national study. Ciênc Saúde Colet 2016; 21:563-72..

In both studies, the aggressor was unknown in around 70% of cases ¹⁹19. Blake MT, Drezett J, Machi GS, Pereira VX, Raimundo RD, Oliveira FR, et al. Factors associated with the delay in seeking legal abortion. Int Arch Med 2015; 8:1-14.^,2121. Mutta DS, Yela DA. Sociodemographic characteristics of women in a public hospital in Campinas who underwent legal abortion due to sexual violence: cross-sectional study. São Paulo Med J 2017; 135:363-8.. However, the Campinas study found that, among adolescents, these percentages were inverted, with around 60% of aggressors being known to the victims ²¹21. Mutta DS, Yela DA. Sociodemographic characteristics of women in a public hospital in Campinas who underwent legal abortion due to sexual violence: cross-sectional study. São Paulo Med J 2017; 135:363-8..

With regard to characteristics of sexual activity, adolescents in Campinas ²¹21. Mutta DS, Yela DA. Sociodemographic characteristics of women in a public hospital in Campinas who underwent legal abortion due to sexual violence: cross-sectional study. São Paulo Med J 2017; 135:363-8. reported very low use (12.5%) of contraception and, for some, the violent event had been the first sexual relation. Among adults, despite most having an active sex life (91.6%), only 45.6% used contraception ²¹21. Mutta DS, Yela DA. Sociodemographic characteristics of women in a public hospital in Campinas who underwent legal abortion due to sexual violence: cross-sectional study. São Paulo Med J 2017; 135:363-8.. Gestational age at the time of the abortion was higher than 12 weeks in 43.8% of adolescents, practically double that of adult women (22.5%) ²¹21. Mutta DS, Yela DA. Sociodemographic characteristics of women in a public hospital in Campinas who underwent legal abortion due to sexual violence: cross-sectional study. São Paulo Med J 2017; 135:363-8..

In the studies carried out in the São Paulo reference hospital, the reasons for the decision to have an abortion and the delays to the procedure were investigated for rape cases ¹⁷17. Drezett J, Pedroso D, Gebrim LH, Matias ML, Macedo Jr. H, Abreu LC. Motivos para interromper legalmente a gravidez decorrente de estupro e efeitos do abortamento nos relacionamentos cotidianos das mulheres. Reprod Clim 2011; 26:85-91.^,1818. Drezett J, Pedroso D, Vertamatti MA, Macedo-Júnior H, Blake MT, Gebrim LH, et al. Pregnancy resulting from sexual abuse: reasons alleged by Brazilian women for carrying out the abortion - pregnancy and violence. Health Med 2012; 6:819-25.^,1919. Blake MT, Drezett J, Machi GS, Pereira VX, Raimundo RD, Oliveira FR, et al. Factors associated with the delay in seeking legal abortion. Int Arch Med 2015; 8:1-14.. The decision to have the procedure was mainly motivated by rejection of the pregnancy (88.4%) and its connection to the violence (86%). Two other reasons also had high percentages: violation of the right to motherhood and fear of social and psychological damage to the child’s future, 76.7% and 44.2%, respectively ¹⁷17. Drezett J, Pedroso D, Gebrim LH, Matias ML, Macedo Jr. H, Abreu LC. Motivos para interromper legalmente a gravidez decorrente de estupro e efeitos do abortamento nos relacionamentos cotidianos das mulheres. Reprod Clim 2011; 26:85-91.^,1818. Drezett J, Pedroso D, Vertamatti MA, Macedo-Júnior H, Blake MT, Gebrim LH, et al. Pregnancy resulting from sexual abuse: reasons alleged by Brazilian women for carrying out the abortion - pregnancy and violence. Health Med 2012; 6:819-25.. Delayed demand for care, that is, after 22 weeks of pregnancy, was found among 6% of the 1,270 patients ¹⁹19. Blake MT, Drezett J, Machi GS, Pereira VX, Raimundo RD, Oliveira FR, et al. Factors associated with the delay in seeking legal abortion. Int Arch Med 2015; 8:1-14. and was associated with age under 20 years, being single, rape committed by a partner or family member, and occurrence of a police report ¹⁹19. Blake MT, Drezett J, Machi GS, Pereira VX, Raimundo RD, Oliveira FR, et al. Factors associated with the delay in seeking legal abortion. Int Arch Med 2015; 8:1-14..

In Campinas, a high presence (close to 70%) of psychological conflicts with regard to the decision to terminate the pregnancy was found, regardless of age ²¹21. Mutta DS, Yela DA. Sociodemographic characteristics of women in a public hospital in Campinas who underwent legal abortion due to sexual violence: cross-sectional study. São Paulo Med J 2017; 135:363-8.. On the other hand, women who were interviewed months after the procedure at the São Paulo reference center did not report having regrets ¹⁷17. Drezett J, Pedroso D, Gebrim LH, Matias ML, Macedo Jr. H, Abreu LC. Motivos para interromper legalmente a gravidez decorrente de estupro e efeitos do abortamento nos relacionamentos cotidianos das mulheres. Reprod Clim 2011; 26:85-91.^,1818. Drezett J, Pedroso D, Vertamatti MA, Macedo-Júnior H, Blake MT, Gebrim LH, et al. Pregnancy resulting from sexual abuse: reasons alleged by Brazilian women for carrying out the abortion - pregnancy and violence. Health Med 2012; 6:819-25..

Of the studies on health professionals, three were conducted specifically in hospitals with legal abortion services ²²22. Benute GR, Nonnenmacher D, Nomura RM, Lucia MCS, Zugab M. Influência da percepção dos profissionais quanto ao aborto provocado na atenção à saúde da mulher. Rev Bras Ginecol Obstet 2012; 34:69-73.^,2323. Ribeiro DR, Fonseca CT. Atenção humanizada ao aborto legal em um hospital público de Belém - PA. Rev Para Med 2015; 29:13-20.^,2424. Rocha WB, Silva AC, Leite SML, Cunha T. Percepção de profissionais da saúde sobre abortamento legal. Rev Bioét 2015; 23:387-99. while the fourth was a online survey of all doctors in the country who are members of the Federation of Gynecology and Obstetrics ¹⁶16. Diniz D, Madeiro A, Rosas C. Conscientious objection, barriers, and abortion in the case of rape: a study among physicians in Brazil. Reprod Health Matters 2014; 22:141-8.. Despite their small number, these studies reveal a high ignorance of the fact that documents are not required (86% to 92%) and a high percentage (between 43.5% and 60%) of objection of conscience, that is, the refusal to provide or participate in the provision of abortion due to religious and/or moral reasons, especially in cases of demands for legal abortion due to rape. The study by Diniz et al. ¹⁶16. Diniz D, Madeiro A, Rosas C. Conscientious objection, barriers, and abortion in the case of rape: a study among physicians in Brazil. Reprod Health Matters 2014; 22:141-8. showed that 43.5% of interviewed doctors would not perform an abortion due to rape, only 10% because of religious reasons, and the others with no explicit justification. The study by Rocha et al. ²⁴24. Rocha WB, Silva AC, Leite SML, Cunha T. Percepção de profissionais da saúde sobre abortamento legal. Rev Bioét 2015; 23:387-99. mixed doctors and other health professionals. More than half of participants invoked the objection with no argumentative basis, while 16% claimed it for religious reasons. In that same study, one third of participants stated that the objection is a right of professionals and can be invoked in any situation, while another third was unable to define the concept ²⁴24. Rocha WB, Silva AC, Leite SML, Cunha T. Percepção de profissionais da saúde sobre abortamento legal. Rev Bioét 2015; 23:387-99..

Studies on medical students found a median knowledge of the situations for which abortions are legally permitted (around 50%) in Botucatu (São Paulo State) ²⁵25. Almeida MAS, Amorim FHR, Barbosa IAF, Dias A, Morita I. Brazilian abortion law: knowledge in medical education. Rev Bras Educ Méd 2012; 36:243-8. and in Bahia State ²⁸28. Darzé OISP, Azevêdo BKG. Competências adquiridas durante a formação médica e as opiniões e atitudes sobre o aborto. Rev Bras Ginecol Obstet 2014; 36:5-9., and a high knowledge (> 80%) in Rio Grande do Norte State ²⁶26. Medeiros RD, Azevedo GD, Oliveira EA, Araújo FA, Cavalcanti FJ, Araújo GL, et al. Opinion of medical and law students of Federal University of Rio Grande do Norte about abortion in Brazil. Rev Bras Ginecol Obstet 2012; 34:16-21. and in São Paulo State ³⁰30. Motoki MS, Cabar FR, Francisco RP. Mother's freedom of choice and the rights of an unborn child: a comparison between the views of freshmen and senior medical school students. Clinics 2016; 71:570-4.. These studies found low support for broadening legal abortion, varying between 15% and 40% for unrestricted permission ²⁶26. Medeiros RD, Azevedo GD, Oliveira EA, Araújo FA, Cavalcanti FJ, Araújo GL, et al. Opinion of medical and law students of Federal University of Rio Grande do Norte about abortion in Brazil. Rev Bras Ginecol Obstet 2012; 34:16-21.^,2727. Faúndes A, Duarte GA, de Sousa MH, Soares Camargo RP, Pacagnella RC. Brazilians have different views/abortion should be legal, but most do not agree with imprisoning women for abortion. Reprod Health Matt 2013; 21:165-73.^,2828. Darzé OISP, Azevêdo BKG. Competências adquiridas durante a formação médica e as opiniões e atitudes sobre o aborto. Rev Bras Ginecol Obstet 2014; 36:5-9.^,3030. Motoki MS, Cabar FR, Francisco RP. Mother's freedom of choice and the rights of an unborn child: a comparison between the views of freshmen and senior medical school students. Clinics 2016; 71:570-4.. Approval of current rules regarding legal abortion varied between 48% and 90% ²⁷27. Faúndes A, Duarte GA, de Sousa MH, Soares Camargo RP, Pacagnella RC. Brazilians have different views/abortion should be legal, but most do not agree with imprisoning women for abortion. Reprod Health Matt 2013; 21:165-73.^,3030. Motoki MS, Cabar FR, Francisco RP. Mother's freedom of choice and the rights of an unborn child: a comparison between the views of freshmen and senior medical school students. Clinics 2016; 71:570-4.. Objection of conscience was frequently invoked, varying between 4.1% and 71.4%, depending on reason for the abortion and religiousness ²⁹29. Madeiro A, Rufino A, Santos P, Bandeira G, Freitas I. Objeção de consciência e aborto legal: atitudes de estudantes de Medicina. Rev Bras Educ Méd 2016; 40:86-92.^,3131. Darzé OISP, Barroso Júnior U. Prevalence, attitudes, and factors motivating conscientious objection toward reproductive health among medical students. Rev Bras Ginecol Obstet 2018; 40:599-605.. It was higher for cases of rape (50.8%) ²⁹29. Madeiro A, Rufino A, Santos P, Bandeira G, Freitas I. Objeção de consciência e aborto legal: atitudes de estudantes de Medicina. Rev Bras Educ Méd 2016; 40:86-92. and among the more religious (71.4%) ³¹31. Darzé OISP, Barroso Júnior U. Prevalence, attitudes, and factors motivating conscientious objection toward reproductive health among medical students. Rev Bras Ginecol Obstet 2018; 40:599-605.. Aspects of ethical responsibilization connected to objection, such as providing guidance and referring the woman to another professional, were unknown to around 25% of students ³¹31. Darzé OISP, Barroso Júnior U. Prevalence, attitudes, and factors motivating conscientious objection toward reproductive health among medical students. Rev Bras Ginecol Obstet 2018; 40:599-605., or would be denied, depending on the reason for the abortion ²⁹29. Madeiro A, Rufino A, Santos P, Bandeira G, Freitas I. Objeção de consciência e aborto legal: atitudes de estudantes de Medicina. Rev Bras Educ Méd 2016; 40:86-92.. The refusal to provide guidance was more common for cases of rape (72.5%) than for those in which the pregnant women’s life was at risk (17.3%) ²⁹29. Madeiro A, Rufino A, Santos P, Bandeira G, Freitas I. Objeção de consciência e aborto legal: atitudes de estudantes de Medicina. Rev Bras Educ Méd 2016; 40:86-92., and more common among religious students (40.7%) ³¹31. Darzé OISP, Barroso Júnior U. Prevalence, attitudes, and factors motivating conscientious objection toward reproductive health among medical students. Rev Bras Ginecol Obstet 2018; 40:599-605..

As for the need to present legal documents, the study by Almeida et al. ²⁵25. Almeida MAS, Amorim FHR, Barbosa IAF, Dias A, Morita I. Brazilian abortion law: knowledge in medical education. Rev Bras Educ Méd 2012; 36:243-8. showed near complete unawareness (> 90%) of the fact that neither police reports nor court orders are required for the procedure. Faúndes et al. ²⁷27. Faúndes A, Duarte GA, de Sousa MH, Soares Camargo RP, Pacagnella RC. Brazilians have different views/abortion should be legal, but most do not agree with imprisoning women for abortion. Reprod Health Matt 2013; 21:165-73. explored opinions regarding the criminalization of abortion and found low approval (9.9%) for imprisoning women who have had abortions, especially among older, non-religious students. Being religious was the factor most closely associated with restrictive positions ²⁷27. Faúndes A, Duarte GA, de Sousa MH, Soares Camargo RP, Pacagnella RC. Brazilians have different views/abortion should be legal, but most do not agree with imprisoning women for abortion. Reprod Health Matt 2013; 21:165-73.^,2929. Madeiro A, Rufino A, Santos P, Bandeira G, Freitas I. Objeção de consciência e aborto legal: atitudes de estudantes de Medicina. Rev Bras Educ Méd 2016; 40:86-92.^,3131. Darzé OISP, Barroso Júnior U. Prevalence, attitudes, and factors motivating conscientious objection toward reproductive health among medical students. Rev Bras Ginecol Obstet 2018; 40:599-605..

A 2008 survey of gynecologists-obstetricians members of the Brazilian Federation of Gynecology and Obstetrics Associations (FEBRASGO, in portuguese) had a 12% response rate and showed that 83.3% of responding doctors had provided care to women pregnant with anencephalic fetuses ¹⁵15. Diniz D, Penalva J, Faúndes A, Rosas C. A magnitude do aborto por anencefalia: um estudo com médicos. Ciênc Saúde Colet 2009; 14 Suppl 1:1619-24.. According to these professionals, 85% wished to terminate the pregnancy and 43.7% obtained a court authorization ¹⁶16. Diniz D, Madeiro A, Rosas C. Conscientious objection, barriers, and abortion in the case of rape: a study among physicians in Brazil. Reprod Health Matters 2014; 22:141-8.. Two articles addressed cases of congenital malformations other than anencephaly and assessed the requests for court authorization made by women followed at reference centers for non-viable conjoined twins ³²32. Nomura RM, Brizot ML, Liao AW, Hernandez WR, Zugaib M. Conjoined twins and legal authorization for abortion. Rev Assoc Med Bras 2011; 57:205-10. and lethal fetal malformations ³³33. Westphal F, Araujo Júnior E, Fustinoni SM, Abrahão AR. Maternal risks and predictor factors for the termination of pregnancy in fetuses with severe congenital anomaly: experience from a single reference center in Brazil. J Matern Fetal Neonatal Med 2016; 29:3762-7.. Between 43% ³³33. Westphal F, Araujo Júnior E, Fustinoni SM, Abrahão AR. Maternal risks and predictor factors for the termination of pregnancy in fetuses with severe congenital anomaly: experience from a single reference center in Brazil. J Matern Fetal Neonatal Med 2016; 29:3762-7. and 63% ³²32. Nomura RM, Brizot ML, Liao AW, Hernandez WR, Zugaib M. Conjoined twins and legal authorization for abortion. Rev Assoc Med Bras 2011; 57:205-10. of pregnant women requested a termination and the factors that were positively associated with the request were an earlier gestational age ³²32. Nomura RM, Brizot ML, Liao AW, Hernandez WR, Zugaib M. Conjoined twins and legal authorization for abortion. Rev Assoc Med Bras 2011; 57:205-10. and type of malformation (especially those of the central nervous system) ³³33. Westphal F, Araujo Júnior E, Fustinoni SM, Abrahão AR. Maternal risks and predictor factors for the termination of pregnancy in fetuses with severe congenital anomaly: experience from a single reference center in Brazil. J Matern Fetal Neonatal Med 2016; 29:3762-7., while having living children reduced the probability of the request ³³33. Westphal F, Araujo Júnior E, Fustinoni SM, Abrahão AR. Maternal risks and predictor factors for the termination of pregnancy in fetuses with severe congenital anomaly: experience from a single reference center in Brazil. J Matern Fetal Neonatal Med 2016; 29:3762-7.. Authorizations were granted to 63% ³²32. Nomura RM, Brizot ML, Liao AW, Hernandez WR, Zugaib M. Conjoined twins and legal authorization for abortion. Rev Assoc Med Bras 2011; 57:205-10. to 100% ³³33. Westphal F, Araujo Júnior E, Fustinoni SM, Abrahão AR. Maternal risks and predictor factors for the termination of pregnancy in fetuses with severe congenital anomaly: experience from a single reference center in Brazil. J Matern Fetal Neonatal Med 2016; 29:3762-7. of requests. In both studies, the malformations were confirmed after birth. All women who did not terminate their pregnancies underwent cesarean sections, with a high percentage of complications (86.8%) related not only to the duration of the pregnancy, but to the malformations as well, such as polyhydramnios and dystocia ³³33. Westphal F, Araujo Júnior E, Fustinoni SM, Abrahão AR. Maternal risks and predictor factors for the termination of pregnancy in fetuses with severe congenital anomaly: experience from a single reference center in Brazil. J Matern Fetal Neonatal Med 2016; 29:3762-7..

Discussion

This review sought to update information regarding research on legal abortion in Brazil ⁷7. Departamento de Ciência e Tecnologia, Secretaria de Ciência, Tecnologia e Insumos Estratégicos, Ministério da Saúde. 20 anos de pesquisas sobre aborto no Brasil. Brasília: Ministério da Saúde; 2009. (Série B. Textos Básicos de Saúde).^,88. Menezes M, Aquino EML. Pesquisa sobre o aborto no Brasil: avanços e desafios para o campo da saúde coletiva. Cad Saúde Pública 2009; 25 Suppl 2:S193-204.. Despite being a regular topic of discussion in the national media ³⁴34. Fontes MLA. The stance on abortion in the Brazilian printed media ahead of the 2010 presidential elections: the exclusion of public health from the debate. Ciênc Saúde Colet 2012; 17:1805-12., we found few quantitative studies, generally restricted to the local level. Only one presented data on legal abortion services in the entire country. This study revealed few advances when compared to a report produced, over a decade earlier, by the organization Catholics for the Right to Choose, in terms of the number and concentration of services in capitals and large urban centers ³⁵35. Talib RA, Citeli MT. Serviços de aborto legal em hospitais públicos brasileiros (1989-2004): Dossiê. 2005. http://catolicas.org.br/wp-content/uploads/2005/01/Caderno-DossieAbortoLegal.pdf (acessado em 01/Mar/2018).
http://catolicas.org.br/wp-content/uploa... . The invisibility of services remains even in the hospitals where they operate. Most have equipment and professionals trained for manual intrauterine aspiration, the most recommended method; however, there is a high use of curettage and misoprostol. There is a caveat regarding gestational age, since, for terminations between 13 and 22 weeks, intrauterine aspiration is not technically applicable and the recommended method is a medication abortion using misoprostol ⁹9. 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)..

We therefore find a long-term insufficiency of the supply of legal abortion services in the country. Barriers remain to performing abortions in the (already highly-restrictive) cases established by law, with demands for unnecessary documentation in cases of pregnancy resulting from rape. The number of abortions that are performed is inferior to women’s demands. The expansion and consolidation of abortion services in the country cannot be delayed, especially in the states that still lack these services, nor can the reduction of barriers to accessing the procedure wait any longer, at least for women who fit the conditions established by law.

The women who choose to have abortions following a rape are similar in terms of educational levels, religion or race/color, but there was a high percentage of adolescents ¹⁴14. Madeiro AP, Diniz D. Legal abortion services in Brazil-a national study. Ciênc Saúde Colet 2016; 21:563-72.^,1717. Drezett J, Pedroso D, Gebrim LH, Matias ML, Macedo Jr. H, Abreu LC. Motivos para interromper legalmente a gravidez decorrente de estupro e efeitos do abortamento nos relacionamentos cotidianos das mulheres. Reprod Clim 2011; 26:85-91.^,1818. Drezett J, Pedroso D, Vertamatti MA, Macedo-Júnior H, Blake MT, Gebrim LH, et al. Pregnancy resulting from sexual abuse: reasons alleged by Brazilian women for carrying out the abortion - pregnancy and violence. Health Med 2012; 6:819-25.^,1919. Blake MT, Drezett J, Machi GS, Pereira VX, Raimundo RD, Oliveira FR, et al. Factors associated with the delay in seeking legal abortion. Int Arch Med 2015; 8:1-14.^,2020. Santos J, Drezett J, Alves AL. Características sociodemográficas de migrantes bolivianas com gestação decorrente de violência sexual atendidas em serviço público de referência para abortamento legal, São Paulo, Brasil, 2002 - 2014. Reprod Clim 2015; 17:25-32.^,2121. Mutta DS, Yela DA. Sociodemographic characteristics of women in a public hospital in Campinas who underwent legal abortion due to sexual violence: cross-sectional study. São Paulo Med J 2017; 135:363-8.. Studies from the 1990s showed a higher percentage of lower educational level among these women, compared to data from more recent years, which may reflect the change in educational profile of Brazilian women ³⁶36. Mallmann MB, Boing AF, Tomasi YT, Anjos JCD, Boing AC. Evolução das desigualdades socioeconômicas na realização de consultas de pré-natal entre parturientes brasileiras: análise do período 2000-2015. Epidemiol Serv Saúde 2018; 27:e2018022..

The rejection of pregnancies resulting from violence was nearly unanimous, as was the lack of regret following the procedure ¹⁷17. Drezett J, Pedroso D, Gebrim LH, Matias ML, Macedo Jr. H, Abreu LC. Motivos para interromper legalmente a gravidez decorrente de estupro e efeitos do abortamento nos relacionamentos cotidianos das mulheres. Reprod Clim 2011; 26:85-91.^,1818. Drezett J, Pedroso D, Vertamatti MA, Macedo-Júnior H, Blake MT, Gebrim LH, et al. Pregnancy resulting from sexual abuse: reasons alleged by Brazilian women for carrying out the abortion - pregnancy and violence. Health Med 2012; 6:819-25.. Delays in seeking care revealed vulnerabilities, especially among younger and single women and those abused by partners and/or family members ¹⁹. Despite their small number, young Bolivian migrants with low educational levels were another population vulnerable to post-rape pregnancies ²⁰20. Santos J, Drezett J, Alves AL. Características sociodemográficas de migrantes bolivianas com gestação decorrente de violência sexual atendidas em serviço público de referência para abortamento legal, São Paulo, Brasil, 2002 - 2014. Reprod Clim 2015; 17:25-32..

Studies showed lack of knowledge among both medical students and, more concerning, doctors, regarding the situations in which abortion is allowed and the ethical recommendations for handling these cases. Undue demands for police reports and other documents for accessing legal abortions persist ¹⁶16. Diniz D, Madeiro A, Rosas C. Conscientious objection, barriers, and abortion in the case of rape: a study among physicians in Brazil. Reprod Health Matters 2014; 22:141-8.^,2525. Almeida MAS, Amorim FHR, Barbosa IAF, Dias A, Morita I. Brazilian abortion law: knowledge in medical education. Rev Bras Educ Méd 2012; 36:243-8.^,3737. Zordo S. Representações e experiências sobre aborto legal e ilegal dos ginecologistas-obstetras trabalhando em dois hospitais maternidade de Salvador da Bahia. Ciênc Saúde Colet 2012; 17:1745-54.. The recent incorporation of fetal anencephaly into the list of permitted situations was little known and, although an ordinance (Ruling n. 1,145, issued on 07/Jul/2005) ³⁸38. Ministério da Saúde. Portaria nº 1145 de 07 de julho de 2005. Dispõe sobre o Procedimento de Justificação e Autorização da Interrupção da Gravidez nos casos previstos em lei, no âmbito do Sistema Único de Saúde. Diário Oficial da União 2005; 08 jul. excluded the demand for police reports when accessing legal abortion, this and other unnecessary documents are demanded from women, increasing their distress and hindering access. That is, despite being legal in only 3 instances, barriers persist and the procedures that are carried out are inferior to women’s demands. A qualitative study carried out in Campinas had already signaled low awareness among female victims of rape regarding the right to legal termination and the services for victims of sexual violence ³⁹39. Machado CL, Fernandes AMS, Osis MJD, Makuch MY. Gravidez após violência sexual: vivências de mulheres em busca da interrupção legal. Cad Saúde Pública 2015; 31:345-53..

We did not identify, in the period we analyzed, any studies on non-performance of terminations, whether due to women’s wishes or ineligibility resulting from a gestational age over 22 weeks, with the exception of an unpublished Master’s thesis. This thesis examined the profile and reasons for not having an abortion, even following authorization, in a Reference Hospital in São Paulo ⁴⁰40. Pimentel RM. Fatores associados à mudança de decisão em realizar o abortamento de gestação decorrente de violência sexual: Hospital Pérola Byington - 1994 a 2012 [Dissertação de Mestrado]. São Paulo: Universidade Federal de São Paulo; 2013.. Religiousness, among more highly educated women, and knowing the aggressor stand out as factors associated with giving up the decision to have the abortion. Knowing the aggressor had already been shown by Blake et al. ¹⁹19. Blake MT, Drezett J, Machi GS, Pereira VX, Raimundo RD, Oliveira FR, et al. Factors associated with the delay in seeking legal abortion. Int Arch Med 2015; 8:1-14. to be a reason for a delayed demand for the procedure, corroborating the relevance of this factor in women’s trajectories.

Objection of conscience continues to be invoked by students and doctors, whether effectively due to religious reasons or, as suggested by some authors ⁴¹41. 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.^,4242. Faúndes A, Miranda L. Ethics surrounding the provision of abortion care. Best Pract Res Clin Obstet Gynaecol 2017; 43:50-7., as a subterfuge. In the latter case, the objection is invoked so doctors can excuse themselves from providing care, not due to religious or moral reasons, but for fear of suffering discrimination or as result of prejudices, since the objection is most commonly invoked in cases of rape ⁴¹41. 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.^,4242. Faúndes A, Miranda L. Ethics surrounding the provision of abortion care. Best Pract Res Clin Obstet Gynaecol 2017; 43:50-7.. Though undeclared, prejudice and lack of trust on the information provided by women permeate these opinions, reflecting an inappropriate condemnatory stance by health professionals and a reinforcement of the social stigma surrounding abortion ⁴¹41. 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.^,4343. Farias RS, Cavalcanti LF. Atuação diante das situações de aborto legal na perspectiva dos profissionais de saúde do Hospital Municipal Fernando Magalhães. Ciênc Saúde Colet 2012; 17:1755-63.^,4444. Diniz D, Dias VC, Mastrella M, Madeiro A. A verdade do estupro nos serviços de aborto legal no Brasil. Rev Bioét 2014; 22:291-8.^,4545. Adesse L, Jannotti CB, Silva KS, Fonseca VM. Aborto e estigma: uma análise da produção científica sobre a temática. Ciênc Saúde Colet 2016; 21:3819-32.^,4646. Faúndes A. The responsibility of gynecologists and obstetricians in providing safe abortion services within the limits of the law. Int J Gynaecol Obstet 2017; 139:1-3.. In the words of Diniz et al. ⁴⁴44. Diniz D, Dias VC, Mastrella M, Madeiro A. A verdade do estupro nos serviços de aborto legal no Brasil. Rev Bioét 2014; 22:291-8. (p. 293), there is a “shared regime of suspicion regarding women’s narratives of rape”. In the international literature, authors emphasize the need for more studies on stigma associated with abortion and its effects on women’s health, as well as on interventions that reduce these effects, which are even more scarce ⁴⁷47. Hanschmidt F, Linde K, Hilbert A, Riedel Heller SG, Kersting A. Abortion stigma: a systematic review. Perspect Sex Reprod Health 2016; 48:169-77.^,4848. Johnson Jr. BR, Kismödi E, Dragoman MV, Temmerman M. Conscientious objection to provision of legal abortion care. Int J Gynaecol Obstet 2013; 123 Suppl 3:S60-2..

Objection of conscience is known to be an important barrier to access to abortion, even in countries where it is legal, in the face of women’s spontaneous requests, in which pregnancies need not have been the result of rape or put the women’s lives are at risk. The result is an increase in risks to women’s health and their rights, especially for more vulnerable groups ⁴⁸48. Johnson Jr. BR, Kismödi E, Dragoman MV, Temmerman M. Conscientious objection to provision of legal abortion care. Int J Gynaecol Obstet 2013; 123 Suppl 3:S60-2.^,4949. Morrell KM, Chavkin W. Conscientious objection to abortion and reproductive healthcare: a review of recent literature and implications for adolescents. Curr Opin Obstet Gynecol 2015; 27:333-8.. Data on the average time interval between initial contact with the service and the provision of abortion in the legal abortion services are still largely unknown ¹⁴14. Madeiro AP, Diniz D. Legal abortion services in Brazil-a national study. Ciênc Saúde Colet 2016; 21:563-72.. It would be important to know what is the impact of objecting doctors’ refusal on delays to the procedure in these services. It is likely that the stigma associated with the procedure affects the provision of legal abortion care in the country, with a curtailing of women’s legal rights which, despite being restricted, have been assured for over 70 years ²2. Código Penal Brasileiro. https://www2.camara.leg.br/legin/fed/declei/1940-1949/decreto-lei-2848-7-dezembro-1940-412868-publicacaooriginal-1-pe.html (acessado em Mar/2019).
https://www2.camara.leg.br/legin/fed/dec... .

Comparing these results with a review of studies on health professionals, from 2000 to 2011, we find the continuation of lack of professional preparedness and of moralist positions, leading to discriminatory care provided to women ⁵⁰50. Cacique DB, Passini Jr. R, Osis MJMD. Opiniões, conhecimento e atitudes de profissionais da saúde sobre o aborto induzido: uma revisão das pesquisas brasileiras publicadas entre 2001 e 2011. Saúde Soc; 22:916-36.. We need investments in health professionals’ training, whether in university curricula or in continuous training for professionals already employed in health services. Uterine aspiration must be offered as a method for emptying the uterus instead of curettage, whenever pertinent. Internships in legal abortion services must be part of health professionals’ training. In this manner, we will broaden the debate on women’s sexual and reproductive rights and on good practices in abortion care.

But the context of stigma is wide-reaching and deep ⁴¹41. 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.^,4545. Adesse L, Jannotti CB, Silva KS, Fonseca VM. Aborto e estigma: uma análise da produção científica sobre a temática. Ciênc Saúde Colet 2016; 21:3819-32.. It involves not only health professionals, but society and the women who have abortions themselves, who often internalize prejudice and have difficulty making the decision and/or revealing the procedure, making this moment even more conflicted and solitary ⁴¹41. 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 study of 43 women in São Paulo showed that 42% decided to have the procedure on their own, without sharing the decision with family members, partners or friends ¹⁷17. Drezett J, Pedroso D, Gebrim LH, Matias ML, Macedo Jr. H, Abreu LC. Motivos para interromper legalmente a gravidez decorrente de estupro e efeitos do abortamento nos relacionamentos cotidianos das mulheres. Reprod Clim 2011; 26:85-91., while another study, with 1,270 participants, found that being single was strongly associated with a delay in seeking care ¹⁹19. Blake MT, Drezett J, Machi GS, Pereira VX, Raimundo RD, Oliveira FR, et al. Factors associated with the delay in seeking legal abortion. Int Arch Med 2015; 8:1-14.. Additionally, studies found that one third of women who demanded abortions in cases of rape were adolescents, corroborating the vulnerability of this age group, both for sexual violence and for the experience of abortion ⁴⁹49. Morrell KM, Chavkin W. Conscientious objection to abortion and reproductive healthcare: a review of recent literature and implications for adolescents. Curr Opin Obstet Gynecol 2015; 27:333-8.^,5151. Pilecco FB, Knauth DR, Vigo A. Aborto e coerção sexual: o contexto de vulnerabilidade entre mulheres jovens. Cad Saúde Pública 2011; 27:427-39.^,5252. Moreira GAR, Soares OS, Farias FNR, Vieira LJES. Notificações de violência sexual contra a mulher no Brasil. Rev Bras Promoç Saúde 2015; 28:327-36.. These results reinforce the need for multi-disciplinary teams that are qualified to provide care.

Considering the repercussions for women’s reproductive health, two situations stand out. The first refers to the higher number of complications among women whose fetuses had malformations and who did not have abortions, either due to religious reasons or because their demands were rejected. These complications are, in part, to be expected due to the exposure to longer gestational periods. However, other complications are associated with the congenital malformation itself, such as the occurrence of polyhydramnios and dystocia, which increase maternal morbidity. As for the form of delivery, among women who terminated their pregnancies, there was a high proportion of vaginal resolution, while 100% of those who did not terminate required cesarean sections ³³33. Westphal F, Araujo Júnior E, Fustinoni SM, Abrahão AR. Maternal risks and predictor factors for the termination of pregnancy in fetuses with severe congenital anomaly: experience from a single reference center in Brazil. J Matern Fetal Neonatal Med 2016; 29:3762-7.. Brazil is one of the countries with the highest proportion of these surgeries, with an estimated one million unnecessary cesarean sections taking place each year ⁵³53. Barros FC, Matijasevich A, Maranhão AGK, Escalante JJ, Rabello Neto DL, Fernandes RM, et al. Cesarean sections in Brazil: will they ever stop increasing? Rev Panam Salud Pública 2015; 38:217-25.^,5454. Gibbons L, Belizan JM, Lauer JS, Betrán AP, Merialdi M, Althabe F. The global numbers and costs of additionally needed and unnecessary caesarean sections performed per year: overuse as a barrier to universal coverage. Geneva: World Health Organization; 2010. (World Health Report).. Carrying the pregnancy to term, with a mandatory cesarean section, exposes women to risks associated with this procedure, with no benefits to their health or the health of their babies, since the malformations were incompatible with life. In addition, it increases the probability of obstetric complications in future pregnancies, as well the repetition of a cesarean section, compromising these women’s reproductive future ⁵⁵55. Mascarello KC, Matijasevich A, Barros AJD, Santos IS, Zandonade E, Silveira MF. Repeat cesarean section in subsequent gestation of women from a birth cohort in Brazil. Reprod Health 2017; 14:102..

Another situation is the use of uterine curettage as a method for emptying the uterus, even among those who had previously used misoprostol, something that goes against studies on the medication’s effectiveness ⁵⁶56. Whaley NS, Burke AE. Update on medical abortion: simplifying the process for women. Curr Opin Obstet Gynecol 2015; 27:476-81.^,5757. Kapp N, Baldwin MK, Rodriguez MI. Efficacy of medical abortion prior to 6 gestational weeks: a systematic review. Contraception 2018; 97:90-9., as well as against World Health Organization recommendations ⁵⁸58. Organização Mundial da Saúde. Abortamento seguro: orientação técnica e de políticas para sistemas de saúde. http://apps.who.int/iris/bitstream/10665/70914/7/9789248548437_por.pdf (acessado em Jan/2018).
http://apps.who.int/iris/bitstream/10665... . The high frequency of curettage in Latin America had been found in a study of medication provision through telemedicine in the entire world ⁵⁹59. Gomperts R, Petow SA, Jelinska K, Steen L, Gemzell-Danielsson K, Kleiverda G. Regional differences in surgical intervention following medical termination of pregnancy provided by telemedicine. Acta Obstet Gynecol Scand 2012; 91:226-31.. It is also worth encouraging a reflection regarding the inclusion of mifepristone in the list of medications available in Brazil, considering the greater efficacy and safety of the combined use of this medication with misoprostol in the initial phase of inducing abortions ⁶⁰60. Perehudoff K, Berro Pizzarossa L, Stekelenburg J. Realising the right to sexual and reproductive health: access to essential medicines for medical abortion as a core obligation. BMC Int Health Hum Rights 2018; 18:8..

A gap results from the near non-existence of investigations into care provision for the other two exceptions established by law, besides pregnancies resulting from rape. In this review, only three studies assessed terminations due to fetal malformation, one on anencephaly and the others, of local scope, on severe malformations incompatible with life for which there is no jurisprudence. Little is known about the country as whole or about the itineraries women follow, from diagnosis to termination. For anencephaly, termination can occur at any gestational age, but for other malformations, gestational age may weigh on court decisions and/or those of pregnant women.

We did not find studies evaluating the provision of care to women whose lives are at risk. Although one of studies which assessed professionals’ knowledge and perception verified a greater response regarding ethical responsibilization and less objection of conscience in cases in which the pregnant woman’s life is at risk ²⁹29. Madeiro A, Rufino A, Santos P, Bandeira G, Freitas I. Objeção de consciência e aborto legal: atitudes de estudantes de Medicina. Rev Bras Educ Méd 2016; 40:86-92., we found no studies calling into question what doctors have interpreted as “risk to life”, nor on women’s and doctors’ position regarding the decision to terminate a pregnancy. It is likely that a minority of cases of imminent risk during pregnancy and delivery are being resolved in an adequate and timely manner, with no dissent regarding the termination of pregnancy. However, in other cases, this may not be so clear. Given the importance of indirect causes in maternal mortality, it is worth questioning how professionals deal with cases of women with previous morbid conditions who are left in a gray zone: these are not cases with immediate or imminent risk to life, but can the pregnancy expose them to risks to their lives? These aspects have not been called into question in studies, though they may be documented in discussions of maternal mortality committees. Only in the study with members of the FEBRASGO do the authors discuss how the decision to terminate a pregnancy is ultimately an exclusive responsibility of doctors, who define at which level of risk of death women are entitled to an abortion, without this being discussed with the women themselves or their family members ⁶¹61. 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..

Studies that seek to gauge attitudes toward expanding the cases in which abortion is legal show that results depend on how questions are formulated. For example, when asked directly, the percentage of individuals who would accept severe malformations or women’s socioeconomic and emotional conditions are reasons for abortions is low, whether among students and health professionals or laypeople, although most oppose imprisoning women ²⁷27. Faúndes A, Duarte GA, de Sousa MH, Soares Camargo RP, Pacagnella RC. Brazilians have different views/abortion should be legal, but most do not agree with imprisoning women for abortion. Reprod Health Matt 2013; 21:165-73.. However, in a study of judges and prosecutors in 2005-2006, 78% of interviewees were in favor of expanding the cases in which abortion is legal or even decriminalizing abortion, and opinions were frequently associated with variables related to religion ⁶²62. Duarte GA, Osis MJD, Faúndes A, Sousa MH. Aborto e legislação: opinião de magistrados e promotores de justiça brasileiros. Rev Saúde Pública 2010; 44:406-20.. Religion was also a factor associated with more restrictive positions among students ²⁷27. Faúndes A, Duarte GA, de Sousa MH, Soares Camargo RP, Pacagnella RC. Brazilians have different views/abortion should be legal, but most do not agree with imprisoning women for abortion. Reprod Health Matt 2013; 21:165-73.^,2929. Madeiro A, Rufino A, Santos P, Bandeira G, Freitas I. Objeção de consciência e aborto legal: atitudes de estudantes de Medicina. Rev Bras Educ Méd 2016; 40:86-92.^,3131. Darzé OISP, Barroso Júnior U. Prevalence, attitudes, and factors motivating conscientious objection toward reproductive health among medical students. Rev Bras Ginecol Obstet 2018; 40:599-605.. However, an opinion poll carried out 2005 showed broad support among Brazilians, especially those who are Catholic, to the public provision of care in the legal abortion services and the offer of emergency contraception in health services, in clear opposition to the Catholic hierarchy in Brazil ³⁵35. Talib RA, Citeli MT. Serviços de aborto legal em hospitais públicos brasileiros (1989-2004): Dossiê. 2005. http://catolicas.org.br/wp-content/uploads/2005/01/Caderno-DossieAbortoLegal.pdf (acessado em 01/Mar/2018).
http://catolicas.org.br/wp-content/uploa... .

Lastly, it is worth discussing this study’s limitations. We did not register the review protocol. As with any work based on bibliographical search, we cannot dismiss the possibility of a publishing bias. The search was limited to electronic sources, MEDLINE and LILACS, and to references of the identified articles. In this review, predominantly-quantitative works that are accessible through traditional bases are represented. Although we used many combinations and key words, related articles, indexed with a different terminology, may have escaped the search. One conditioning factor is related to the profile of the instruments we used (checklists), which had strengths and weaknesses, as any quality assessment instrument. The independent assessment, reviewed by consensus, sought to minimize common biases in this type of assessment. Several studies had small samples and, therefore, are limited in terms of the generalization of their findings because they refer to very specific populations ⁶³63. Menezes G, Aquino EML, Fonseca SC, Domingues RMSM. Aborto e saúde no Brasil: desafios para a pesquisa sobre o tema em um contexto de ilegalidade. Cad Saúde Pública 2020; 36 Suppl 1:e00197918..

Despite these limitations, we believe the production of knowledge qualifies the debate and the political struggle for women’s reproductive rights.

Acknowledgment

To Global Health Strategies, Rio de Janeiro, Brazil.

References

Publication Dates

History