Abortion in Italy
Angela Spinelli e Michele Grandolfo
In 1978, a law was passed in Italy which set forth the regulations governing the procedures for obtaining an induced abortion. According to this law, all women are eligible to request an abortion during the first 90 days of gestation for health, economic, social, or familial reasons. To obtain an abortion, the woman must have a certificate attesting to the state of the pregnancy from her general practitioner, or a private physician or a public maternal-child health clinic. The abortion is performed free-of-charge at either at a health care structure in the National Health Care System or in a private structure contracted and authorized by regional health authorities.
Since 1980, the Laboratory of Epidemiology and Biostatistics at the Istituto Superiore di Sanità (ISS) in Rome has maintained a surveillance system for legal induced abortions. This system is based on quarterly reporting by the regional health authorities. A standardized form is compiled that contains aggregate data on major socio-demographic characteristics of the woman (age, residency status, marital status, reproductive history) as well as details about the procedure (weeks of gestation, whether the procedure is elective or performed on an emergency basis, where certification was issued, type of procedure and location where it was performed, duration of stay, and immediate complications. This information is then sent to the ISS, which examines data quality and performs data analysis of trends, geographic distribution, and characteristics of women undergoing abortion. These analyses are performed annually by the ISS and the Ministry of Health (MH) and presented by the Minister of Health to the Parliament; results are also published in ISTISAN reports, an official publication of the ISS. Italy is considered to have one of the most accurate and timely abortion surveillance systems in the world.
After legalization of abortion in 1978, there was an initial increase in incidence, with a peak of 234,000 abortions performed in 1982 (abortion rate = 17.2 per 1000 women ages 15-49 years, abortion ratio = 380.2 per 1000 live births). Subsequently, there has been a steady decline, with 139,000 abortions performed in 1999 (abortion rate = 9.9/1000, abortion ratio = 266.9/1000). This reduction represents a decline of 42% for the abortion rate and 30% for the abortion ratio over the past 15 years, with an estimated 100,000 fewer abortions in 1999 compared with 1982.
The incidence of abortion in Italy is similar to that of other countries in northwestern Europe (where rates range from 6.5/1000 in the Netherlands to 18.7/1000 in Sweden), but it is much lower than in Eastern Europe (where rates are in the 50/1000 range) and in the United States (22.9/1000).
As with many other health conditions, there are major differences within Italy between regions and geographic areas: in 1999, the abortion rate was 9.6/1000 in the North, 11.0/1000 in the Center, 10.5 in the South, and 7.8% in the Islands (Sardinia and Sicily). The declining rates over time were present in all areas of the country, with a trend toward convergence of the rates over time (Table) The greatest decreases have occurred in those regions where women obtain the required certification through maternal-child health clinics rather than from their general practitioner or private physician. In addition to the legal abortions described above, the ISS has estimated, using mathematical models, that illegal abortion persists, with an estimated 27,000 performed in 1998. These illegal abortions are not equally distributed throughout the country and are more common in the South. As is the case with legal abortions, illegal procedures have also decreased dramatically over time. Applying the same mathematical models, it has been estimated in 1983 that there were approximately 100,000 illegal abortions. The estimated number of illegal abortions has thus decreased by 73% since the early 1980s (1, 2).
From other studies performed in the past (3), it has been observed that in most cases, abortion is not considered to be the contraceptive method of choice but instead results from the failure to control fertility using other methods. More than 70% of women undergoing abortion were using a contraceptive method at the time of conception (primarily coitus interruptus). The finding that the number of repeat abortions is lower than that estimated by mathematical models that assume no changes in contraceptive behavior supports the hypothesis that the reduction in induced abortion is the consequence of a greater diffusion and more effective use of birth control methods (4).
There do appear to be some subpopulations in which abortion rates are higher: women with children, those with lower levels of education, and housewives. The most consistent declines in abortion rates are seen among married women, among those between 25 and 34 years of age (Figure), and in those with children (5).
A phenomenon to emerge in recent years has been an increase in the number of abortions requested by immigrant women. Among the 138,357 abortions performed in 1993, 13,826 (10%) involved foreign residents, an increase from 9,850 in 1996. This increase is most likely due to the rising number of immigrant women in Italy; the resident permits, for example, according to the data of the National Statitstics Institute (ISTAT), have increased from 678,000 in 1995 to 1,100,000 in1999. Based on estimates of the population of immigrant women 18-49 years of age, Istat has calculated that the AR for immigrant women was 28.7/1000 in 1998, approximately three times higher than that observed in Italian citizens. Indeed the increase in the numbers of immigrant women may be the main cause of the leveling-off of abortion rate in Italy. If the analysis of trends is limited to 1996-1998, years for which information is most complete on residency status, the number of abortions in Italian women declined from 127,700 in 1996 to 123,728 in 1998 (6).
In conclusion, the reduction of induced abortion appears related to improved use of fertility control methods and to the important role of maternal-child health clinics. Taking into account the social-demographic characteristics of women who are currently undergoing abortion, further reductions are undoubtedly possible, especially if maternal-child health services can be further strengthened.
Relazione del Ministro della Sanità sulla attuazione della legge contenente norme per la tutela della maternità e per l’interruzione volontaria di gravidanza (legge 194/78): Dati preliminari 1999, dati definitivi 1998. Luglio 2000
Figà Talamanca I., Spinelli A. L’aborto illegale in Italia: è ancora un problema reale? Contraccezione Fertilità Sessualità 1986; 13: 263-269
Grandolfo M.E., Spinelli A., Donati S., Pediconi M., Timperi F., Stazi M.A., Andreozzi S., Greco V., Medda E., Lauria L. Epidemiologia dell’interruzione volontaria di gravidanza in Italia e possibilità di prevenzione. Roma: Istituto Superiore di Sanità; 1991. Rapporto ISTISAN 91/25
De Blasio R., Spinelli A., Grandolfo M.E. Applicazione di un modello matematico alla stima degli aborti ripetuti in Italia. Annali dell’Istituto Superiore di Sanità 1988; 24: 331-338
Spinelli A., Boccuzzo G., Grandolfo M.E., Buratta V., Pediconi M., Donati S., Frova L., Timperi F. L’evoluzione dell’interruzione volontaria di gravidanza in Italia dalla legalizzazione ad oggi. Annali dell’Istituto Superiore di Sanità 1999; 35: 307-314
Boccuzzo G. editor. L'abortività volontaria in Italia. Tendenze e comportamente degli anni ’90. Informazioni n. 3. Roma: ISTAT; 2000