Opinions , knowledge , and attitudes of health professionals on induced abortion : a review of Brazilian studies ( 2001-2011 )

O objetivo deste artigo é apresentar uma revisão das pesquisas brasileiras quantitativas e qualitativas sobre opiniões, conhecimentos e atitudes de profissionais da saúde sobre o aborto induzido publicadas entre 2001 e 2011. Admitiram-se publicações com amostras compostas por profissionais com quaisquer graus de formação. Os trabalhos foram categorizados segundo características metodológicas: abordagem dos dados, técnica e instrumento para coleta de dados, categorias profissionais incluídas, local da pesquisa, tamanho amostral e técnica de amostragem. Na etapa seguinte, categorizaram-se os temas centrais das pesquisas (por exemplo, aconselhamento genético e anticoncepção de emergência). Finalmente, categorizaram-se os resultados das pesquisas: conhecimento técnico e legal, perspectiva moral, opiniões sobre a lei, opiniões sobre o Sistema Único de Saúde, e atitudes hipotéticas e concretas. As publicações identificadas sugerem ampla aprovação dos casos de aborto atualmente permitidos por lei, mas larga rejeição da criminalização em casos de malformações fetais graves. A maioria das publicações relatou ter investigado profissionais de medicina (especialmente gineco-obstetras) ou de enfermagem, sendo poucos ou inexistentes dados sobre assistentes sociais e psicólogos. Não foram identificados quaisquer instrumentos apresentando dados mínimos de validade, análise de confiabilidade ou adaptação transcultural. Acredita-se que, no futuro, o desenvolvimento de instrumentos com essas qualidades possa facilitar a realização de Denis Barbosa Cacique Master in Health Sciences, Administrative Officer at the Department of Statistics and Hospital information/Women’s Hospital, Professor José Aristodemo Pinotti Center for Integrated Women’s Healthcare University of Campinas. Address: Av. Alexander Fleming, 101, CEP 13083-881, Campinas, SP, Brazil. E-mail: denisbarbosa.c@gmail.com


Introduction
In the abortion debate, the opinions of health professionals (HPs) are of great value, because they are considered authorities on health issues, and their attitudes directly affect the availability and quality of healthcare (Yam et al., 2006).They play a central role in the context of abortion, either by inducing it in the cases specified by the law or by refusing it on the basis of legal (and ethical) recourse or conscientious objection.HPs will be the most affected professionals if the legal restrictions against abortion are relaxed.In the specific case of doctors, it is worth recalling that the proposed reform of the Penal Code, which is currently in the Senate, states that these professionals will be responsible for diagnosing not only the cases in which the pregnancy endangers the mother's life but also those in which the mother is not in a psychological state to cope with motherhood.
Even if this reform does not introduced, physicians and other HPs will be involved with abortion in one form or another, at least in the assistance of women with complications of unsafe abortion, because it is a common procedure.Often, HPs are involved in situations in which they believe the abortion is necessary even if illegal (Faúndes and Barzelatto, 2004).In such cases, the frequent public condemnation of abortion opposes its tacit approval in very personal and exceptional circumstances that affect family, friends, or certain patients (Faúndes and Barzelatto, 2004).
During the last decade, almost certainly because of the role of these professionals in the abortion scenario (second only to that of the women undergoing abortion), and also because of the interests and political disputes on the topic, there is an increasing number of publications on research conducted to investigate their opinions, knowledge, and attitudes (Yam et al., 2006).This article aims to identify and describe the main characteristics of these publications, including methods, peculiarities of samples studied, and main the outcomes.

Methods
For this study, we performed publication searches in the electronic databases Medline (via PubMed) and Lilacs (via Virtual Health Library).In Medline, the search was performed using the terms: abortion AND (Brazil OR Brasil) AND (opinions OR attitudes OR knowledge OR acceptability OR physicians OR doctors OR psychologists OR physiotherapists OR providers OR psychiatrists OR nursing).
In the Lilacs database, the following terms were searched "(miscarriage OR abortion) AND (opinions OR attitudes OR knowledge OR doctors OR psychologists OR social workers OR physiotherapists OR health professionals OR health professional OR psychiatrists OR pharmacist OR therapists OR biomedical OR speech therapists OR educator OR educators OR workers OR nursing OR nurse)." Both searches were performed using the time bracket as the period between 01-01-2001 and 11-08-2011.In both searches, publications containing the terms in any part of the text were included.The study included publications that clearly described the intention of empirically studying opinions, knowledge, or attitudes of HPs in Brazil in relation to abortion in their titles or abstracts.The samples of subjects involved in the selected publications comprised professionals with any degree of training (auxiliary, technical, or higher).Both quantitative and qualitative studies were included.Projects, theses, monographs, review articles, editorials, theoretical manuscripts, and studies conducted with samples composed exclusively of students or published in journals not indexed in the referred databases were excluded.
The publications identified were categorized according to title, year of publication, and language, as well as according to the names and gender of the authors.Subsequently, the methodological approaches were classified according to data (qualitative or quantitative), technique/instrument for data collection, sample professional categories, place, sample size, and sampling technique.In the following step, the main themes of the research were identified [e.g., abortion, genetic counseling, and emergency contraception (EC)].Finally, the results shown in this study were categorized and described according to the following standards: technical knowledge, legal knowledge, moral perspective, opinion regarding the law, opinion on the Unified Health System (SUS), hypothetical attitudes, and actual behavior.
The 16 publications described only 12 different studies because Faúndes and collaborators showed different results from the same study in 4 publications (Faúndes et al., 2004a;Faúndes et al., 2004b;Faúndes et al., 2007a;Faúndes et al., 2007b), andDiaz andcollaborators in two (2003a, b).With regard to language, 6 articles were written in English and 10 in Portuguese.In all articles, the number of female researchers was at least equal to the number of male researchers.In absolute numbers, the number of female researchers was more than twice that of male researcher in the publications (F:M = 32:14).

Methodological characteristics
The main methodological characteristics of the publications are described in Table 2.There is a balance with regard to the approach for analyzing the data, with 7 publications using quantitative methods and 9 using qualitative ones.The main technique for collecting data in the qualitative publications was semi-structured interviews (7 publications), whereas focal groups and open self--report questionnaires were used in 1 study each.All quantitative publications used closed self-report questionnaires.The researchers themselves have developed these questionnaires and there was no information regarding their validation, although it was mentioned that pretesting had been done.It should be highlighted that in the study by Salzano and Shuler-Faccini (2002) an international questionnaire translated into Portuguese was used, but no information regarding its pretesting, validation, and cultural adaptation was mentioned.
With regard to the subjects involved in the studies, there was a large predominance of physicians, with them being involved in 11 of the 16 studies.Among these 11 studies, 9 included specialists in gynecology and obstetrics, whereas the other 2 publications did not specify the specialization of the physicians.In second place were the nursing professionals, who were studied in 6 publications.Only 4 studies reported to have studied psychologists and social workers.Two studies included "possible EC providers," but the details of the participant professionals were not available.No quantitative studies involving nurses, psychologists, social workers, or other nonmedical categories were present.

Themes and categorization of results
The themes and categories of results are described in Table 3.The main topic in 4 of the publication was not induced abortion; instead, this publications were recarding EC (Díaz et al., 2003 a, b), the uses and implications of genetic engineering technologies (Salzano and Shuler-Faccini, 2002), and the genetic prenatal counseling (Corrêa and Guilam, 2006).Although abortion was not addressed as the main theme, these publications were included because they presented in the results at least 1 of the parameters that was of interest in the present study: knowledge, opinions, and attitudes of HPs on induced abortion.In the first 2 publications (Díaz et al., 2003a, b), the abortion topic emerged spontaneously in the words of some of the study subjects, for whom the use of EC, compared with abortion, was "[…] the minor of two evils."In the second case (Salzano and Shuler-Faccini, 2002), the topic represented a small part of an extensive structured questionnaire, through which it was intended to check opinions on the different implications of the use of genetic engineering technologies, including situations of diagnoses of fetal problems such as a predisposition to alcoholism and Huntington's disease.In the article about prenatal genetic counseling (Corrêa and Guilam, 2006), the abortion theme also appeared spontaneously in the conversation with the professionals.
All publications evaluated, with greater or lesser emphasis, the opinions, knowledge, or attitudes toward abortion.The results of these evaluations were categorized into 7 types: technical knowledge,     legal knowledge, moral perspective, opinions on the law, the Unified Health System (SUS), hypothetical studies, and empirical attitudes.Subsequently, each category was defined and the frequency with which each category was addressed in the publications was described.
In the 16 studies, the 2 most common categories referred to the opinions on the laws regulating abortion and the actual behavior toward it, both appearing in 10 publications each.In the first case, the objective was to assess whether the subjects agreed with the current laws regulating abortion in Brazil.In the second case, the goal was to know the real attitudes of respondents (e.g., whether they had undergone an abortion in case of unwanted pregnancy).The evaluation of hypothetical attitudes toward abortion was reported in 9 publications.In this case, the aim was to know what the subjects would do in hypothetical situations (for example, what would a doctor do if a patient solicited help to abort illegally).
Seven publications evaluated the knowledge about the laws that regulate the practice of abortion (e.g., what documents are needed to abort in cases of sexual violence).
The investigation of moral perspectives on the topic was reported in 6 publications.In these, the professionals' attitudes toward abortion and their opinions about the laws that regulate abortion along with the rationale behind these attitudes and opinions were described.That is, why do they agree or disagree with the laws?Why do they defend the right to abortion or oppose it?
The evaluation of the technical knowledge was reported in 4 publications, and these studies aimed to determine if the study subjects knew, for example, the operating mechanisms of EC, some of the medical abortion procedures, or the most important epidemiological data on abortion (Díaz et al., 2003a, b;Goldman et al., 2005;De Zordo and Mishtal, 2011).
Only 1 publication assessed opinions about the role of the SUS regarding abortion (Goldman et al., 2005).

Knowledge regarding the laws regulating abortion in Brazil
Table 4 describes the main results of the publications.It is noted that, with respect to knowledge of the laws that regulate abortion in Brazil, most studies found that HPs had an adequate knowledge of the cases permitted and prohibited by law, but had inadequate information as to which documents are required for the procedure when there is risk of death to the mother or risk of serious fetal malformations.There was also inadequate knowledge about the need to report the case of a patient who aborted illegally and to register the suspected illegal abortion in the medical records.One study identified equivocal knowledge regarding the technical standard of the Ministry of Health pertaining to the assistance to patients who are victims of sexual violence (Brasil, 2005).

Opinions about the laws that regulate abortion in Brazil
In the studies including physicians, a high rate of favorable opinions on the relaxation of the abortion restrictions in cases of serious fetal malformations was observed, with percentages ranging between 77% and 89%, whereas the cases of risk to the woman's physical health (without risk of death) had lower acceptance, with rates of 61.4% and 47.4%; all other circumstances were associated with rates of acceptance <50% (Faúndes et al., 2004a;Faúndes et al., 2004b;Loureiro and Vieira, 2004;Goldman et al., 2005;Faúndes et al., 2007a;Faúndes et al., 2007b;De Zordo and Mishtal, 2011).
For some physicians, the criminalization of abortion in cases of fetal malformation is a factor limiting the prenatal genetic counseling; this is the reason why they state that, in such cases, abortion should be discouraged, even if there is the possibility of obtaining judicial authorization, which is difficult to obtain (Corrêa and Guilam, 2006).
The studies conducted with other HPs, especially nursing professionals, found greater opposition to the relaxation of legal restrictions, and even some opinions contrary to the currently existing possibilities.It should be stressed that, because these studies were not quantitative, it is not possible to present the ratios of opposing/favorable opinions, nor extrapolate these data to the population.

Technical knowledge regarding abortion
Regarding the technical knowledge regarding abortion, 2 publications reported that Brazilians did Moral perspectives toward abortion: The study found a variety of opinions, many of which are contradictory.In some cases the right to abortion was defended as "a woman's right as a person and citizen."There was an identification with the feminist cause "I've always been a person concerned about the woman's point of view, if she does not want to, why have that child?"In a testimonial, the health professional, though he seemed to consider abortion as morally wrong, appeared to believe that the determinants of abortion mitigate the guilt of the woman: "I think we should look at the woman who had an abortion, and try to understand the causes.I do not know any woman who feels happy after she has had an abortion.So we cannot think that she did it because she likes to commit the crime of abortion … because when we incriminate women it is because we think she liked to do it."In other testimonials, the religious perspective of abortion was stated, according to which it is a sin.More than 50% professionals who had religious or spiritual conceptions revealed a representation of abortion more related to guilt, suffering and sin: the way we were educated, we were told that it was a sin, and the women who do it were not going to heaven.Even though I know that it is not a sin, it is hard to change my belief because it was built from the inside."Empirical attitudes toward abortion: the fact that the choice for abortion in cases of rape seemed not to be the ethical responsibility of the professionals: "the decision is made by the woman, it is her problem, not the professional's."Thus, although there were conflicting personal views among those surveyed, there was, according to the researchers, unanimity among the professionals regarding the duty to maintain a neutral and impartial position about the woman's decision: "The professional should not persuade or oppose the abortion."A possible consequence of this quest for neutrality, which can be a tacit condemnation of abortion, is an acceptable way of relating to the patient: "We are not involved in the story, about how the woman feels, and we keep ourselves distant."Legal knowledge: Approximately 93% doctors were aware that the Brazilian law does not punish abortion if the pregnancy is the result of rape, and almost 90% were aware of the same in the case of life threat for the mother.Approximately 33% incorrectly believed that the laws also did not penalize abortion in cases where the fetus has severe malformations.Less than 1% believed that the law exempts from penalty in any case.Approximately 66% physicians incorrectly believed that it a judicial order was necessary to practice abortion permitted by law, and almost 80% were aware that the permission was necessary in case of severe congenital malformations.The necessity of a report by 3 doctors in the cases provided by law was mentioned (correctly) by almost half of the respondents, by 44% in case of severe fetal malformations, and 42% answered correctly that the police report (BO) was previously required when the pregnancy resulted from rape, but that BO is no longer needed.Just >25% of physicians knew that in the 2 cases mentioned in the law, a written request of abortion by the women is necessary.And approximately 20% knew of the need for authorization from the legal representative in the case of pregnant minors.
Opinions about the laws that regulate the practice of abortion: Most of the respondents opined that the law should permit abortion in the case of a pregnancy being life threatening to the pregnant woman.Approximately 80%thought the same for severe fetal malformation and for pregnancies resulting from rape (both with percentages approximately 77%), whereas 10% said that abortion should be permitted under any circumstances.
Other circumstances: Less than 20% subjects were in favor of decriminalization in cases in which the mother did not show the psychological/emotional stability to maintain pregnancy; approximately 10% subjects were in favor for HIV+ woman or partner, whereas very few people were in favor of abortion for other causes.Less than 5% opined that abortion should not be allowed ever.About 60% answered that an increase from 2-to 5-fold in the risk of dying during pregnancy was sufficient to justify abortion.Approximately 12.5% doctors opined that abortion for a life-threatening pregnancy was never justified.
Possible changes in the Brazilian abortion law: Approximately 66% subjects responded that the circumstances in which abortion is not punishable should be broadened, and another 15% said that abortion should no longer be considered a crime in any circumstance.Less than 15% opined that the law should not be changed.Hypothetical attitudes toward abortion: Approximately 40% doctors would help a patient who consulted him for unwanted pregnancy and abortion requests, although only <2% said they would perform the abortion.Thus, the aid would consist mainly in referring patients to a reliable doctor and/or teaching the women to use misoprostol.In case of a close family member with unwanted pregnancy, the percentage of doctors who would help increased to nearly 48%, but only approximately 2% would perform the abortion in these circumstances.Empirical attitudes toward abortion: in cases where the woman herself (physician) or the man's partner (physician) found herself in the situation of an absolutely unwanted pregnancy, the percentage who practiced abortion was 77.6% and 79.9%, respectively.6 The closer you are, the better you understand: The reaction of Brazilian obstetricians and gynecologists to unwanted pregnancy Empirical attitudes toward abortion: Almost 25% female physicians and 33% male physicians reported having encountered cases of unwanted pregnancy, and 80% of them reported that such cases resulted in induced abortions.Among those for whom religion was very important, 70% opted for abortion when they were personally involved with an unwanted pregnancy.

The meanings of moral solidarity in legal abortion
Moral perspectives toward abortion: When asked about their motivations for acting in the program legal abortion, respondents revealed, according to the authors, commitment to solidarity with women, as well as the defense of individual freedom.In the face of the woman's decision, the professionals seem to exempt themselves from ethical responsibility: "The most important is the conscious choice of the woman to continue the pregnancy or not.She is conscious, oriented, and it is hers choice alone."According to the authors, 'at no time did practitioners show frightened concerns with moral judgments opposing to the program.'"Rather, according to the authors, the moral solidarity permeates almost every speech, especially in the search for a humanized, integrated, and welcoming care "to a clientele that has always been discriminated by society and health professionals." (To be continued) Approximately 90% believe that abortion should be allowed in cases of serious fetal malformations, 31.5% in cases of risk to maternal health, 12.9% due to socioeconomic reasons, 13.3% with respect to the choice of women, and 4% opined that abortion should never be performed.Technical knowledge regarding abortion: Approximately 70% reported never having been trained to perform it.Empirical attitudes toward abortion: Approximately 33% said they had performed the procedure.Allocation of public funds to perform abortions: Approximately 95% subjects were in favor of this.
10 Reactions of the nursing team facing the possibility of participation in a legal abortion Empirical attitudes toward abortion: When questioned about their involvement in cases of legal abortion, some professionals have demonstrated a need to accept the situation and even to accommodate for the decisions made by other professionals, apparently accepting the conduct without questioning it: "I do not have to solve anything, I have to accept the decisions regarding the procedure."It is clear that some members of the nursing staff seem to still be very dependent on the actions and opinions of other professionals, subjecting themselves to behaviors that go against their values and beliefs, apparently not considering alternatives for certain situations, such as legal abortion, but submitting themselves to participate in abortions, even against their wish.Hypothetical attitudes toward abortion: a nurse stated refusal to participate in any abortion procedure, even if legal.To exemplify her attitude, the professional narrated a case in which a patient was admitted with judicial authorization for an abortion, but the whole team refused to perform the procedure.The researcher asked the nurse if her attitude would be different if the other professionals had consented to perform the procedure: "I would not participate.I would talk to the doctor, explain my position and ask for someone else to go in my place."According to the authors, by maintaining her decision the nurse demonstrated that from her values and principles, she exercises her freedom and autonomy when she makes decisions regarding to her daily professional.Knowledge of the laws regulating abortion: Some professionals seem not to know the cases in which abortion is legal and what the legal procedures for its implementation are.
Moral perspectives toward abortion: The 2 main moral perspectives on abortion were contradictory.On one side, the life of the unborn child was valued: "I used to think that in the case of rape, we had to do it.The mother could not suffer twice.Today, I do not think so; it is a life that you're taking.Just like that mother is not to blame, it is also not the child's fault.The decision to take a life is difficult.The book "Let me live" made me think a lot, and I started to see things differently."But the majority of respondents seemed to agree that the decision is solely of the mother and, if she decides to abort, her wish should be respected, "you may be experiencing a rape situation and you want to continue a pregnancy.So in reality it is an option and you, as a professional, have to respect that person's choice.Maybe I could not even live with it, but she can.So I think it varies from person to person, because in reality the decision is not mine." (To be continued) Opinions on laws regulating abortion: According to the authors, the subjects of the study point to the criminalization of abortion (in case of fetal malformation) as a limiting factor for prenatal genetic counseling.Thus, the respondents believe that abortion should be discouraged, even with the possibility of obtaining judicial authorization to carry it out, which is difficult to obtain.Therefore, 1 of the doctors interviewed said, "in the current context it is difficult to work and decide or think in prenatal genetic counseling."The doctor stated that a full review of the abortion issue, which would let the woman decide, authorize in an universal way, would bring meaning to counseling practice.Knowledge of the laws regulating abortion: Results from 2 studies were compared.The percentage of doctors who knew the circumstances under which abortion is not penalized was >80% in both cases.However, there was a decrease in the percentage of those who knew the legality of abortion due to risk of life (89.3%-82.9%).The proportion of respondents who knew that abortion for severe fetal malformation is not permitted by the current law increased by >33% (the error decreased from 31.8% to 19.6%).Opinions on laws regulating abortion: There was a consistent increase in the percentage of doctors in favor of allowing abortion in various circumstances, and the proportion of those who thought it should not be allowed under any circumstances (from 4.5% to 3 4%) decreased.
14 Assistance to women in the process of induced abortion: discourse of nursing professionals Opinions on the laws regulating abortion: Even in the cases allowed by the law, this practice continues to be regarded by the nursing professionals as a crime, "even in cases of rape or if you know that a child will be born malformed, I am not in favor of abortion.For you to take a life is a crime.Abortion is a crime.It is a wrong practice."Moral perspectives toward abortion: According to the authors, the way professionals perceive abortion brings out the doctrine of fatalism, i.e., moral or intellectual attitude according to which everything happens because it has to happen: "I am not in favor of abortion because what comes to us is what we can give support.Women who provoked abortion should be punished.I would force the use of an intrauterine devices and, if they had >4 children, ligation.I would force her to attend, during a week, the clinic that receives women who had an abortion, for her to witness the patients filling the forms, crashing, bleeding, so that she would have the opportunity to see the other side of it, see to what she was facing." The nursing professionals also perceive abortion as a sin, in the sense that no one has the right to take the life of another person, "although there is a natural law, which is the law of life, no one has the right to take their own life, nor has the right to take the life of another in any way."Another interviewee said the following: "abortion goes against both ethical and God's principles.We have to respect both the law of God and the laws of men.God does not accept such a thing.God is love.It's life."The professionals recriminate the attitude of the women who had an abortion based "both in the law of men as well as the law of God." Accordingly, they claim that "she cannot decide to abort … she made a decision, it is her fault.There are some women who later, when they see the fetus, feel guilty and cry a lot and at that time they ask for forgiveness."Empirical attitudes toward abortion: according to the authors, the nursing professionals have the perception that they discriminate against women who do abortions when assisting them, prioritizing assistance to pregnant women, lactating women and high-risk pregnancies at the expense of women who have abortions: "we start discriminating from the time we receive them." Hypothetical attitudes toward abortion: "If you have to choose between an abortion and a birth, you run to help in the birth, except if the abortion is super serious."Another professional said the following: "I do not like working with women in a process of abortion, I prefer to work with pregnant women and postpartum women who are at risk." (To be continued) Moral perspectives toward abortion: According to the authors, the answers given by professionals regarded both a biological and a moral analysis "abortion is the termination of pregnancy through bleeding," "irresponsible, wrong," "an aggressive act"; "is taking a helpless "life and" is an inhuman act."When referring to the abortion (all cases permitted by law), the professionals were against it: "because no one has the right to take a life," "Life belongs to God, only he can take it," Because the fetus is nonetheless a life," it's taking a life from the time it is induced, in this case I am against it "(P6).
Opinions on laws regulating abortion: the interviewees stated they were in favor of miscarriage and in the 2 cases allowed by law.Even so, 1 interviewee stated: "She has the right to do it.But she should not do it.According to another: "As long as the cause is rape.Otherwise, if she did not want to get pregnant she should have used contraception." not consider EC as techniques of abortion (Díaz et al., 2003a, b).In another study, 70% subjects had a good knowledge regarding abortion, but 1 in 5 physicians were unaware of important epidemiological data on the topic, particularly concerning maternal mortality (Loureiro and Vieira, 2004).The lack of epidemiological data knowledge was also observed in the study of DeZordo and Mishtal (2011).The study by Goldman and collaborators (2005) found that 68.7% physicians were never trained in the induction of abortion.

Hypothetical attitudes
With regard to hypothetical attitudes, 49% subjects in a study said they would advise for abortion in cases of anencephaly and 40% would advise in case of risk of death of the pregnant woman (Salzano and Shuler-Faccini, 2002).The numbers are much lower for the majority of the other conditions, and zero for the case of unwanted pregnancies (Salzano and Shuler-Faccini, 2002).Only 2 other quantitative studies analyzed hypothetical attitudes.In the first study, 40% doctors said they would help a patient who solicited help to abort in case of unwanted pregnancy, but <2% stated that they would perform the abortion; therefore, the help would be mainly the referring of patients to a reliable professional or guidance on how to use misoprostol (Faúndes et al., 2004a).In case of a close family member with unwanted pregnancy, the percentage of doctors who would help increased to nearly 48%, but approximately 2% would perform the abortion under these circumstances (Faúndes et al., 2004a).The third quantitative study of this topic found that only 17.5% subjects would perform the procedure if it was decriminalized (Loureiro and Vieira, 2004).

Empirical attitudes
The empirical attitudes were assessed in 4 quantitative and 3 qualitative studies.Among the quantitative studies, 2 showed more liberal attitudes when HPs had been personally involved in cases of unwanted pregnancies, with rates of abortions performed being >75% (Faúndes et al., 2004a;Faúndes et al., 2004b).However, in the work environment, with patients who are not close relatives, this permissibility decreases dramatically.A study found that only 32.9% doctors had performed the procedure to induce abortion (Goldman et al., 2005).The results of another study showed that 12.3% doctors maintained the minimum required contact with the patient who underwent an illegal abortion, 8.8% felt anger toward the women, and 33.3% disapproved of the abortion; when requested to perform the abortion, 76.7% tried to dissuade the patient (Faúndes et al., 2004a).
One of the qualitative studies that analyzed empirical attitudes was developed exclusively with nursing staff (Lunardi and Simões, 2004).When asked about their involvement in cases of legal abortion, some professionals demonstrated a certain resignation regarding decisions made by other professionals: "[…] I do not have to solve anything, I have to accept the decisions regarding the procedure."In another study, the fact that the decision for abortion (in the case of rape) was made by the woman seemed to exempt the professionals from any ethical responsibility: "[…] it is the woman's decision, it is her problem, not that of the professional" (Soares, 2003).Thus, although the researchers in the same study revealed personal conflicts, unanimity with regard to the duty to maintain a neutral and impartial posture regarding the woman's decision was observed: "[…] the professional must not persuade the woman to have or not to have an abortion."A possible consequence of this quest for neutrality, which was sometimes a tacit condemnation of abortion, was the establishment of a distant relationship with the patient: "[…] we do not get involved with the story or the woman's feelings, and we keep a distance."Perhaps the extreme of this neutrality is indifference.In another study, HPs were found to discriminate women who had induced abortion, prioritizing pregnant women, lactating women, and high-risk pregnancies: "[…] discrimination begins from the time of attendance" (Gesteira et al., 2008).

Opinions on the role of SUS
Only 1 study addressed the opinions about the allocation of public funds to assist patients seeking abortions; the rate of approval was 95.3% (Goldman et al., 2005).

The morality of abortion
The morality of abortion was discussed only in qualitative studies.In 1 of these publications, the majority of subjects, including those in favor of the right to abortion in the cases currently allowed by law, expressed the preference not to perform the procedure because "[…] the mission of obstetricians should be saving lives" and "[…] the unborn child is a life."In addition, 1 of the subjects showed a fear that greater permissibility would lead to an "[…] abortion epidemic" (De Zordo and Mishtal, 2011).
Another study found a variety of opinions, many of which were contradictory (Soares, 2003).In some cases the right to abortion was supported: "[…] it is a woman's right as a person and a citizen."Some subjects identified with the feminist cause "[…] I've always been a person who is concerned about the woman's point of view: why carry that child if she does not want to?"Other subjects stated a religious perspective on abortion according to which abortion is a sin.According to the authors, >50% of the professionals who had a religious or spiritual belief revealed a representation of abortion more related to guilt, suffering and sin: "[…] the way we were educated, we were told that it was a sin, and the women who do it were not going to heaven.Even though I know that it is not a sin, it is hard to change my belief because it was built from the inside."Moreover, another study also identified contradictory perspectives (Lunardi and Simões, 2004).On the one hand, the life of the unborn child was valued: I used to think that, in the case of rape, I had to perform the abortion.The mother should not suffer twice.Today, I do not think like this, it is a life that you're taking.Just like that mother, the child is not to blame.The decision to take a life is difficult.After I read the book "Let me live," I thought about this issue a lot and I started to see things differently.
However, most respondents seemed to agree that the decision lies with the mother alone and, if she decides to abort, her decision should be respected.
A previous investigation of moral perspectives presented radical views, (Gesteira et al., 2008).According to the authors, the way professionals perceive abortion raises the doctrine of fatalism: "[…] I am not in favor of abortion because i believe that we are strong enough to handle whatever comes to us.I would force the use of intrauterine devices and with >4 children the ligation.I would force her to visit for a week the abortion clinic so that she witnessed patients filling the forms, collapsing, and bleeding, and got the opportunity to see the other side of it, see what she was facing."(p.451) Other professionals also linked abortion to the notion of sin: "God does not accept such a thing [abortion].God is love.It's life."

Discussion
Below we present, as topics, the discussion on the main findings of this review.

Subjects and methods
Despite the relative balance between the number of quantitative and qualitative surveys, it was observed that the surveys of the first type exclusively involved physicians.It should be stressed that the loss of data in this type of study, usually conducted through postal or electronic form, is not negligible.Thus, although many professionals agree to participate in the studies, the number of those who refuse to do so is almost always higher.
We were unable to identify any published quantitative studies with nurses, social workers, and psychologists.Consequently, it can be considered that there is no comprehensive information on the opinions, attitudes, and knowledge of these professionals with regard to abortion.Perhaps this is because of a possible lack of support for conducting wider studies with these nonmedical professionals, because quantitative research, when applied to large number of samples, requires significant amounts of financial and institutional support.For example, among the studies analyzed, those with larger samples were conducted with funding and logistical support from the Brazilian Federation of Gynecology and Obstetrics (Faúndes et al., 2004a;Faúndes et al., 2004b;Goldman et al., 2005;Faúndes et al., 2007a;Faúndes et al., 2007b).
Another possible factor for the lack of publications of broad studies with nonmedical HPs is the lack of standardized, validated, and reliable questionnaires that can be used for that purpose.All the included quantitative studies reported having used self-report questionnaires, some of which had been tested previously, but none of them showed information regarding validation (not even about the content), reliability analysis, and cross-cultural adaptation.The only publication of a qualitative study that reported having used a self-report questionnaire also reported not having validated the instrument.
Another result that caught our attention was the lack of data on mental health professionals.Although the technical standards of humanized abortion--related care to stipulate the multidisciplinary care of women, including mental health professionals and social service (Brazil, 2005), only 4 publications presented data on social workers and psychologists, which was meager.These data indicate that there is a possible publication bias in surveys of health professionals about abortion: almost always, only doctors are interviewed.Publication bias is the tendency of published studies to be systematically different from the set of all studies on the issue (Fletcher and Fletcher, 2006).Unsystematic searches performed on broader databases, such as Google Scholar, suggest the existence of a greater diversity of health professionals included in studies about abortion.Two examples are the studies by Lolatto (2004) and Matos (2009), both of which included social workers but were not published in scientific journals.
It is worth noting that, given the inherent difficulties in conducting empirical research on abortion in Brazil because from criminalization and social stigma associated this practice, the hospitals and maternity wards in the public health service (often universities) have been the prime locations for studies on the subject (Brasil, 2009).In these places, as medical and nursing professionals are those most directly involved in providing care to the women, it is understandable that research is more focused on their opinions than on those of other professional categories.

Disagreement between the laws and the opinions of health professionals
Most studies presented either high rates of acceptance of the inclusion of serious fetal malformations in the list of cases allowed by law or commentary advocating a change in this sense.The current situations allowed by law were almost absolutely approved in all studies, even among those HPs who considered themselves to be against abortion.On the other hand, the easing of the law in other cases, such as inadequate socioeconomic situation of the woman or the couple involved, or parents with HIV, was widely rejected by those interviewed.

The morality of abortion
Although most studies showed favorable opinions on the current legal configuration and even the inclusion of cases of serious fetal malformations, the study of the morality revealed positions radically against abortion in the majority of the studies.In some cases, this resulted in a discriminatory assistance to the women.In such cases, abortion was often described as a crime and a sin.The fear that easing the laws would lead to an epidemic of abortions was also quoted in 1 of the studies.In another publication, the notion of fatalism surfaced: " […] what comes to us is ours and we should provide support," and therefore abortion should be avoided, and women who do it should be punished.The opposition of abortion was also based on the idea that "[…] the mission of obstetricians is to save lives." Favorable moral opinions were also identified, but to a lesser extent.In these cases, access to safe abortion was defended, especially as a woman's right.In other studies, the moral posture appeared as the recognition that the choice to terminate a pregnancy is the woman's alone, so the health professional should not be entitled to judge.
No quantitative research revealed opinions on the morality of abortion, which is why it is not possible to determine the distribution of these perspectives in a larger number of samples.

The need for further investigations
Only 1 study showed the variations in personal opinions over the time.(Faúndes et al., 2004a;Faúndes et al., 2004b;Faúndes et al., 2007a;Faúndes et al., 2007b).Therefore, the development of new longitudinal studies is suggested to follow the evolution of opinions, knowledge, and attitudes over time, in order to enhance public debate and possible legal reforms on the topic.
It is believed that the diversification of occupational categories studied is also necessary.As previously stated, most studies included only physicians, although the Ministry of Health itself advocates that abortion care should be multidisciplinary.This diversification would probably be facilitated if there were questionnaires for which information on validation and reliability existed.
Another aspect that needs to be studied more comprehensively is the morality of abortion.The results of the studies analyzed here suggest broad acceptance of the cases currently allowed by law.In addition, decriminalization of cases of severe fetal malformation seems to have the approval of the majority of HPs.However, in practice, there are few professionals who are available to help women who use SUS to carry out the legal termination of pregnancy.Furthermore, studies have shown that when these same professionals are themselves involved in personal circumstances where they think the abortion (even illegal) is necessary, they will perform it.

Conclusions
The results of this research point to a widespread acceptance of the cases of abortion currently allowed by law and rejection of criminalization in cases of serious fetal malformations.With regard to the knowledge of the laws regulating abortion, it was found that there was a low level of knowledge of the detailed regulations (such as list of documents needed for the abortion procedure under specific circumstances), whereas the more general information (such as which cases are allowed by law) achieved more satisfactory levels but were still deficient.It is possible that this lack of knowledge may be endorsing the attitudes of women who have abortions.
With respect to technical knowledge, it was noted that few professionals reported having been trained to perform the abortion; moreover, the main epidemiological data on the topic are poorly known.Another important result concerns the discrepancy between the rates of professionals who would accept (or who have already accepted) to induce abortion in circumstances in which they were personally involved on the one hand and the rates of professionals who would be willing (or are willing) to assist patients who seek to undergo a legal and safe abortion on the other.Publications reporting moral perspectives radically against abortion were also observed; These views sometimes resulted in discriminatory assistance to women seeking SUS to terminate a pregnancy in a lawful and safe way.It should be noted that the professionals' position of noninvolvement, seeking an indifferent attitude, could to some extent be interpreted as a form of discrimination.This attitude harms the technical standards for abortion care, which establishes that the acceptance and guidance are important elements for a quality and humane care provided to the concerned women.
Most publications reported having only investigated the perception of physicians; therefore, we suggest a diversification of the occupational categories that are surveyed.Regarding the type of data approach, there is a lack of quantitative research with HPs other than doctors, making it impossible to determine, within the population, the opinions, knowledge, and behaviors of psychologists, social workers and others.
Regarding the tools used, some publications reported the pretesting of the questionnaires, but none mentioned any validation process.Thus, considering the period analyzed and the criteria used to identify publications, we believe that there is no questionnaire presenting validity and reliability information that can be used to assess the opinions, knowledge, and attitudes of HPs about induced abortion in Brazil.

Table 2 -Methodological Characteristics of publications (continued)
NOTE: * No data on the validation or cross-cultural adaptation of the tool.** There is no data on the professional categories of providers EC included.*** There is no data on how many among the 44 subjects were health professionals.

Table 3 -Themes and categories of results produced by surveys
(To be continued)

Table 3 -Themes and categories of results produced by surveys (continued)
NOTE: * "S" for "yes" and "N" for "no."

Table 4 -Main results
Hypothetical attitudes toward abortion: In this study, 49% subjects agreed that abortion is advisable in cases of anencephaly, 40% in cases of risk of death for pregnant women, 31% in cases of Patau Syndrome, 25% in cases of severe open spina bifida.The percentages were much lower for most other conditions, and was 0% for an embryo/fetus of unwanted gender.This indicates a consensus that even embryos or fetuses with genetic conditions considered as severe (as Hurler syndrome, cystic fibrosis, or phenylketonuria) have the right to live.Opinions regarding abortion legal setting have not been evaluated.