Attitudes of Mexican physicians toward induced abortion

Iaemtioul domnl@I GYNECOLOGY &OBSTETRICS International Journal of Gynecology & Obstetrics 56 (1997) 47-52 Social issues in reproductive Attitudes medicine of Mexican physicians toward induced abortion E. Casanueva* a, R. Liskerb, A. Carnevale’, E. Alonsod “Depto de Inuestigacion en Nuhici&, Institute National de Perinatologia, M&co D.F, Mexico bTnnrtitutnNarional de la Nutricirin Salrmdor Zuhirbn, M&ico, Mexico cInstituto National de Pediahia, M&co, Mexico ‘Institute National de Neurolofl’a y Neurocimfl’a, M&co, Mexico Received 20 May 1996; revised 2 August 1996; accepted 19 August 1996 Abstract The objective of this study was to analyze physicians’ attitudes towards induced abortion with normal fetuses and fetuses known to have an abnormality in various degrees. A total of 193 physicians (internists, pediatricians, gynecologists and neurologists) answered a self-administered questionnaire. The questions were about voluntary abortion; voluntary abortion with malformed fetus; abortion because the fetus has anencephaly; and two questions were asked for the use of prenatal diagnosis and abortion in case of the fetus being the physician’s child. The majority of physicians were male, over 35 years, religious and did not have experience with genetic diseases. Few physicians approved abortion of a normal pregnancy, 6 out of 10 agreed if the fetus was malformed, and this number increased to 8 or 9 out of 10 in cases of severe or lethal genetic disease. Gynecologists and neurologists were less in agreement with abortion when pregnancy is normal than the internists and pedietricians (7% vs. 20%). In general the physicians did not have consistent answers. Agreement for abortion was influenced by religious values. 0 1997 International Federation Keywords: Abortion - of Gynecology and Obstetrics induced: Religion; Attitude to abortion; Attitude 1. Introduction Abortion in Mexico is illegal except in the case of rape or if either the fetus or mother’s life is in *Corresponding author. Instituto National de Perinatologia, Montes Urales 800, Mexico DF, Mexico CP 11000. 0020-7292/97/$17.00 PII 50020.7292(96) 0 1997 International 02787.7 Federation of health personnel; Mexico severe danger if the pregnancy continues [l], and as in many other developing countries there is little public debate on the ethical, religious or medical aspects of this procedure. An open population survey performed in Mexico City [2] showed that only 9% of the respondents approved of it in the case of unmarried pregnant mothers, but 55% of Gynecology and Obstetrics 48 E. Casanueva et al. /International Journal of Gynecology & Obstetrics 56 (1997) 47-52 were in agreement if the pregnancy was the result of rape and close to 70% if the fetus was malformed. A second more ambitious survey at the national level revealed that the majority thought that abortion should be legally available, at least in certain circumstances, such as rape, unmarried mothers and teenage pregnancy [3,4]. In the latter survey, the majority stated that the decision to abort or not should be taken by the women or the couple, but not by the physician, the church or the government. In countries where abortion is legal a determining factor for physicians in the presence of a malformed fetus is the severity of the defect [5]. A study performed with nurses showed that the acceptance of abortion was related to previous experience with abortions or the practice of obstetrics, degree of religiosity and race [6]. There is no information in Mexico on the opinions of physicians regarding abortion and the present work is an attempt to obtain such information comparing four different specialties, with variable degrees of relationship to patients with genetic diseases. The effect of age and religiosity on the answers given was evaluated, As detailed below, the physicians worked in one of four different Mexican National Institutes of Health (MNIH), which are tertiary care specialized institutions involved in teaching and research that act as consultants to the federal government in health legislation issues. 2. Materials and methods 2.1. Population studied Four MNIH were surveyed. In the Instituto National de la Nutricidn Salvador Zubiran (internists) and in the Instituto National de Pediatria (pediatricians), approximately 1 out of every 3 specialists were selected at random from the payroll, because these institutions have more specialists than the other hospitals, resulting in 58 participants in both institutions. In the Instituto Nacional de Perinatologia all obstetricians (50) were invited to participate and in the Instituto Nacional de Neurologia and Neurocirugia all neurologists and psychiatrists agreed to participate (27 cases). The invitation to participate was in writing and personally delivered by the authors of the present report. Care was taken to guarantee confidentiality of the answers, but a record was kept indicating who had answered. Thus, 15 days after the initial invitation, those who had not replied were called urging them to do so. The positive response in the four institutions was 94%, 99%, 100% and 84%, respectively. 2.2. The questionnaire Two of us (RL and AC) translated into Spanish three of the questions used by Mater [7] to explore the perceived impact of science and technology in society, and was complemented by a fourth item obtained from the questionnaire of Marteau et al. [8] which deals with genetic counseling following the prenatal diagnosis (PD) of fetal abnormalities. The questionnaire inquired into some general information of the respondents such as sex, age, importance of religion in their everyday life and degree of experience with genetic diseases, 2.3. The questions Question 1, ‘voluntary abortion in the 4th month of pregnancy’ and question 2, ‘voluntary abortion of a malformed fetus, also in the 4th month’, inquire to what extent the physicians interviewed agreed with this action, and had three possible responses: (a> I agree; (b) I am not sure; and (c) I disagree. The third question refers to the ‘possibility of an abortion because the fetus has anencephaly’, the optional answers being: (a) I would advise to continue the pregnancy; (b> I would try to be neutral explaining the positive and negative aspects of the abnormality; and (cl I would advise termination of the pregnancy. Question 4 personalizes the problem by ‘supposing that the fetus is the physicians child and inquires whether they would ask for an abortion if the fetus has a severe or lethal genetic disorder’, the possible answers being (a) yes; (b) no; and cc> I am not sure. E. Casanueva et al. /International Table 1 General characteristics of the group studied, divided by specialties* Internists Gynecologists Characteristics* Males I 35 years old Religious Experience with genetic diseases 49 Journal of Gynecology & Obstetrics 56 (1997) 47-52 Pediatricians Neurologists X2 n P n P n P n P n P 43/50 20/50 41/49 S/50 0.86 0.40 0.84 0.16 50/58 17/58 34/57 6/57 0.86 0.29 0.60 0.10 23/27 7/27 22/27 11/27 0.85 0.26 0.81 0.41 36/58 26/58 42/57 32/57 0.62 0.45 0.74 0.56 13.9 4.72 6.71 36.34 < > > < 0.01 0.05 0.05 0.01 *Not all those surveyed answered all questions. creased proportion of female pediatricians and the higher experience with genetic diseases of neurologists and pediatricians as compared to internists and obstetricians. Due to the above we could not analyze the influence of these two variables regarding the attitudes towards abortion, but were able to do so in the case of age and importance of religion (mostly Catholicism) in everyday life. 2.4. Analysis The responses were analyzed according to the medical specialties of the physicians, their sex, age (I 35 years vs. more than 35 years), importance of religion in everyday life, and degree of experience in dealing with genetic diseases (frequently vs. occasionally or very rarely). For comparisons between groups we utilized the x2 tests [91. 3.2. Voluntary abortion 3. Results Table 2 shows that there is little support for voluntary abortion, as only 15% of the total agrees with this, although the procedure is better accepted by internists and pediatricians than obstetricians and neurologists. Within group analysis revealed that except for the neurologists, the numbers of physicians accepting abortion was sta- 3.1. General characteristics Table 1 shows the general characteristics of the group studied. Significant differences between the four specialties were found regarding gender and experience with genetic diseases, due to the inTable 2 Agreement to voluntary Agreement to voluntary abortion abortion divided by specialties, religiosity Gynecologists Internists n P n Religiosity Yes No o/40 3/9 0.00** 0.33 Age years I 35 > 35 2/20 l/29 Total 3/49 *p < 0.05. **p < 0.01. ,y2 Internists + Pediatricians and age Neurologists Pediatricians P n P n 5/34 9/22 0.15* 0.41 l/21 l/5 0.05 0.20 0.10 0.03 2,‘17 12/39 0.12* 0.31 O/6 2/20 0.00 0.10 0.06 14/56 0.25 2/26 0.08 vs. Gynecologists + Neurologists = 7.43, P < 0.01. Total P n P 4/42 6/14 0.09** 0.43 10/137 19/50 0.07** 0.38 2/24 S/32 0.08 0.25 6/67 23/120 0.09 0.19 0.18 29/187 0.15 lo/56 50 E. Casanueva et al. /International Table 3 Abortion due to the presence of a malformed Malformed fetus Gynecologists Journal of Gynecology & Obstetkx 56 (1997) 47-52 fetus divided by specialist, religiosity Internists Neurologists and age Pediatricians Total n P n P n P n P Religiosity Yes No 27/40 7/9 0.67 0.78 16/34 8/22 0.47 0.36 18/22 5/s 0.82 1.00 22/42 9/15 0.52 0.60 83/138 29/51 0.60 0.57 Age years 5 35 > 35 12/20 22/29 0.60 0.76 7/17 17/39 0.41 0.43 5/7 18/20 0.71 0.90 12/25 19/32 0.48 0.59 36/69 76/120 0.52 0.63 Total 34/49 0.69 24/56 0.43 23/27 0.85 31/57 0.54 112/189 0.59 x2 Internists + Pediatricians vs. Gynecologists + Neurologists P n = 13.00, p < 0.001 tistically higher amongst the non-religious ones. In relation to age, only amongst the internists, voluntary abortion was significantly more acceptable by those older than 35 years of age. physicians were in favor of interrupting the pregnancy without any significant effect of specialty, importance of religion or age. 3.3. Abortion due to the presence of a malformed fetus 3.5. Abortion due to the physicians’ child having a severe or lethal genetic disease As can be seen in Table 3, almost 6 out of every 10 physicians agree with the interruption of pregnancy in this situation. Neither age nor religion showed statistically significant differences, although more older physicians favored abortion as did the non-religious ones, except for internists. As shown in Table 5, almost 8 out of 10 respondents agreed with abortion in this situation. There were no significant differences between specialists, but religion and age had an effect. At least 93% of non-religious individuals would agree with the abortion, the differences being significant in all, except for neurologists. Similarly, older specialists were more in agreement with abortion than the younger ones, the differences being significant only amongst the internists and neurologists. 3.4. Abortion due to an anencephalic fetus It can be seen in Table 4 that 91% of the Table 4 Abortion due to an anencephalic fetus divided by specialties, religiosity and age Pediatricians Internists P n P n P n P n P Religiosity Yes No 34/37 8/9 0.92 0.89 27/34 21/22 0.79 0.95 19/21 4/5 0.90 0.80 40/42 14/15 0.95 0.93 120/134 47/51 0.89 0.92 Age years 5 35 > 35 19/20 23/26 0.95 0.88 13/17 36/39 0.76 0.92 7/7 16/19 1.00 0.84 25/26 30/32 0.96 0.94 64/70 105/116 0.91 0.90 Total 42/46 0.91 48/56 0.86 23/26 0.88 55/58 0.95 169/186 0.91 fetus Neurologists Total Gynecologists n Anencephalic E. Casanueva et al. /International Journal of Gynecology & Obstem’cs 56 (1997) 47-52 51 Table 5 Favorable opinion towards the abortion of their own child with a lethal or severe genetic disorder divided by specialties, religiosity and age Own child with genetic disorder Religiosity Yes No Gynecologists n P Internists Pediatricians Neurologists Total n P n P n P n P 97/138 49/51 0.70** 0.96 0.68** 0.82 26/40 9/9 0.65* 1.00 21/34 21/22 0.62** 0.95 18/22 5/5 0.82 1.00 32/42 14/15 0.76** 0.93 Age years I 35 > 35 14/20 21/29 0.70 0.72 9/17 33/39 0.53** 0.85 5/7 18/20 0.71** 0.90 19/25 27/32 0.76 0.84 47/69 99/120 Total 35/49 0.71 42/56 0.75 23/27 0.85 46/57? 0.81 146/189 0.77 *p < 0.05. **p < 0.01. 4. Discussion It is important to state that although the sample examined is not representative of all Mexican physicians, it reflects the point of view of a highly specialized group of MNHI who are the leaders of different specialties in Mexico. The present results do not support a previous study done in Mexico City [2], in which the people interviewed stated that the possibility of abortion should be more available when the women or the couple asked for it. In fact, only 6% of the physicians directly involved in this procedure (obstetricians) were in favor of voluntary abortion or a malformed fetus (Table 2). Of great interest are the results of Mater [7] who surveyed medical and biology students from New Zealand, Australia and Japan in which 33%, 31% and 38%, respectively agreed to the procedure. Several facts could explain this discrepancy: (a) there are age differences between Mater’s students (20-30 years old) and the physicians here reported (average age 37 years old); (bl abortion is illegal in Mexico, except in some restricted circumstances which is not the case in Australia, Japan and New Zealand; and (c) cross-cultural differences [lo]. Regarding abortion when the fetus has an abnormality, the number of physicians in agreement with the procedure increases in relation to the severity of the defect, 59% would do it in the case of a malformed fetus (Table 3), without specifying the abnormality, while 91% would if the diagnosis is anencephaly (Table 4). It should be stressed that religious beliefs were important in the acceptance of voluntary abortion (Table 2), as only 7% of religious physicians agreed to it, versus 38% of non-religious ones. However in the presence of malformed fetus (Table 3) the differences disappear, as well as when the diagnosis is anencephaly (Table 41, suggesting that in the presence of an abnormal fetus, medical rather than religious criteria prevailed in the physicians’ opinions. These results are similar to those described by Grevengood [5] and Mater [7]. Reanud [ 111generated a model in which the acceptability of abortion depends on two principal variables; severity of the malformation and degree of religiousness. It is of interest to note the results shown in Table 5, which show that when the physician’s child has a lethal genetic defect only 77% would agree with the abortion as opposed to 91% when the fetus has anencephaly (Table 4). This difference is highly significant ( x2 = 12.98, P < 0.0011, and could be explained by the fact that the decision to abort one’s own child is personal rather than medical and is more influenced by religious beliefs. We found few inter-specialty differences, regardless of the fact (Table 1) that among pediatricians females were more numerous (38%) than in the other specialties (14-15%) and that internists (10%) and gynecologists (16%) had little experience with genetic diseases,as compared to pediatricians (56%) and neurologists (41%) which may 52 E. Casanueva et al. /International Journal of Gynecology & Obstetrics 56 (1997) 47-52 mean that opinions on the legitimacy of abortion depend on the general cultural upbringing of the people, and not on technical information acquired in a professional career [12]. In this line one who could fit the fact that whenever age was statistically significant (Tables 2 and 5) it was always the older, more experienced group who favored abortion more than the other. Similarly the same tables show that religious physicians opposed abortion much more frequently than non-religious ones. References t11 Codigo Penal para el Distrito Federal en Materia comun y para toda la Republica en materia Federal. Mexico 1996 Cap&lo VI art&o 334. Mexico Editorial SISTA, 1996. El Muiioz-FemLndez L, Shrader-Cox E, Cardenas-tipez CE, Benson J. Encuesta de opinion sobre el abort0 en la Ciudad de Mexico. Salud Publica Mex 1994; 36: 35-45. 131 Frejka T, Atkin L. 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