Voluntary termination of pregnancy in Italy in 2020
A report containing the final 2020 data on the implementation of Law 194 of 1978, regulating social protection of motherhood and voluntary termination of pregnancy (VTP), was submitted to the Parliament on 8 June 2022.
A total of 66,413 VTP procedures were reported in Italy in 2020. This corresponds to an abortion rate of 5.4 per 1,000 women aged 15-49 years, one of the lowest in the world.
Access to legal abortion and contraception, as well as to professional support from family planning services and healthcare facilities where abortions are performed, has helped prevent unwanted pregnancies and significantly reduce recourse to VTP, as called for by Law 194. The number of procedures reported in 2020 was 71% lower than in 1983, when the highest number of abortions was recorded in Italy (243,801). Overall, this can be regarded as one of the most successful public health interventions ever implemented in our country.
The VTP Epidemiological Surveillance System, established in 1980 and involving the Istituto Superiore di Sanità (ISS), the Ministry of Health, the National Institute of Statistics (ISTAT), as well as all the Regions and Autonomous Provinces, ensures continuous and in-depth monitoring of abortions. The resulting report is, therefore, one of the most thorough and detailed in the world. The Prime Ministerial Decree (DPCM) of 2017 recognized this surveillance as a public health priority by including it among those of national significance, and identifying the ISS as the national body responsible for its coordination.
Impact of the COVID-19 pandemic on VTP in 2020
A survey conducted among all the regional coordinators of the surveillance in May 2020 showed how the various Regions and VTP services coped with and responded to the COVID-19 emergency. More than half of the Regions stated that no issues had been reported by their facilities. Seven Regions introduced separate VTP pathways for SARS-CoV-2 positive women. In three Regions, VTP procedures were concentrated into fewer facilities, while several Regions reported a reduction in the number of weekly medical and surgical procedures. An assessment of organizational strategies and potential problems observed in 2021 will help identify the best organizational models to deal with any future pandemic, in light of the Ministry of Health’s decision to include VTP among gynaecological treatments that cannot be postponed.
Medical abortion
In the early 2000s, the World Health Organization (WHO) included mifepristone and prostaglandins, used for medical abortion since 1980, in its Model List of Essential Medicines. In Italy, in 2009, the Italian Medicines Agency (AIFA) approved the use of mifepristone for medical abortions up to 49 days of gestation and following admission to hospital; this was in line with the opinion of the Consiglio Superiore di Sanità (the senior advisory body of the Ministry of Health), which recommended a 3-day stay in hospital and a limit of 49 days of amenorrhea for the procedures to be performed. The “Guidelines on voluntary termination of pregnancy with mifepristone and prostaglandins”, issued by the Ministry of Health on 16 July 2010, confirmed those recommendations, in contrast with other European countries where medical abortions were already being carried out up to 63 days of gestation and in outpatient settings. Since it was first introduced in Italy, access to medical termination of pregnancy has varied considerably across the country and between Regions. The percentage of VTP procedures involving the combined use of mifepristone and prostaglandins rose from 3.3% in 2010 to over 10% in 2014 and over 20% in 2018. In 2019, medical procedures accounted for 24.9% of all abortions performed across the country, and in 2020 for 31.9%. On 4 August 2020, in line with technical and scientific advice from the Consiglio Superiore di Sanità, the Ministry of Health issued an update circular allowing women to access medical abortion up to 9 weeks of gestation in hospital day units, public outpatient facilities that are properly equipped, functionally linked to a hospital and authorized by the Regions, or family planning clinics. The new guidelines will probably contribute to an increase in the number of medical abortions, but an ad hoc survey conducted by the ISS in October 2020 showed that not all the Regions had taken the necessary steps to adopt such guidelines. Only Tuscany had issued specific recommendations for starting administration of mifepristone and prostaglandins in non-hospital outpatient settings in November 2020. In 2020, Region Lazio also started offering VTP services in non-hospital settings. Seven Regions had planned to introduce VTP services outside hospitals in 2021, while 11 Regions were not considering doing so until after 2021. An analysis of the 2021 data will therefore be needed to fully assess the effects of the new guidelines on the timing and procedures for providing medical abortions. In other European countries, where medical abortion was legalized many years earlier than in Italy, rates have continued to rise, exceeding 70% in France and England, and 90% in Northern Europe. The most common method of abortion in Europe, medical termination of pregnancy is associated with better use of resources, as it reduces costs and the need for surgery and anaesthesia/sedation. In Italy, reduced recourse to surgical abortion might help limit issues arising from conscientious objection.
The 2020 data
Compared to 2019, the abortion rate and ratio continued to decline: from 5.8 to 5.4 abortions per 1,000 women aged 15-49 years and from 174.5 to 165.9 per 1,000 live births, respectively.
Characteristics of women using VTP services
In 2020, access to VTP services decreased across all age groups, especially among the youngest women. The highest rates were reported among women aged 25-34. The percentage of repeat abortions continued to fall, reaching 24.5% in 2020 (one of the lowest in the world). This is evidence of an ongoing reduction in the risk of unwanted pregnancies and the consequent reliance on VTP, probably due to increased and more effective use of alternative family planning methods, as called for by Law 194 of 1978. After a gradual levelling off, abortions among foreign-born women showed a slight decline, similar to the one observed among Italian women in previous decades. In 2020, 28.5% of all abortions were obtained by foreign-born women, and abortion rates in this population (across all age groups) were about 2-3 times higher than among Italian women.
Types of VTP procedures
Vacuum (or suction) aspiration is the most common method of surgical abortion in Italy, and accounted for 55.8% of all VTP procedures in 2020. Dilatation and curettage, another method which poses higher risks to the woman’s health, still accounted for 8.6% of all abortions; the percentage of abortions using this surgical option, however, varied significantly across the country, ranging from 0% in Molise to 30.4% in Sardinia (which may suggest inappropriate care). In 2020, medical abortions with administration of mifepristone followed by prostaglandins accounted for 31.9% of all procedures. This translated into an increase in the percentage of procedures carried out without anaesthesia (29.3% in 2020, compared to 23.9% in 2019 and 5.7% in 2012) and at an early gestational age (56% within 8 weeks of gestation in 2020), which are associated with fewer risks of complications for women.
Conscientious objection
Despite a slight decrease, the percentage of conscientious objectors remained high in 2020 (64.6% of gynaecologists, 44.6% of anaesthetists, and 36.2% of non-medical staff), with marked regional variations. The report containing the final 2020 data introduced new parameters to better analyse the impact of conscientious objection. It found that abortions were performed in 63.8% of all facilities with obstetrics and/or gynaecology departments (357/560) operating across the country, despite significant interregional variability. In addition, there were 2.9 facilities offering VTP services per 100,000 women of childbearing age, and the average weekly workload for each gynaecologist who was not a conscientious objector was similar to previous years: that said, it was particularly high in Regions Molise (2.9 abortions/week), Apulia (2) and Campania (1.9). It is to be hoped that the Regions which are currently facing the greatest challenges will explore solutions to ensure their continued compliance with Article 9 of Law 194, which reads: “All hospitals and authorized healthcare facilities shall in any case ensure the implementation of the procedures laid down in Article 7, and the performance of the required abortion procedures in accordance with the provisions of Articles 5, 7 and 8. The Regions shall monitor and guarantee the fulfilment of these requirements also through staff mobility programmes”.
The role of family planning services
Family planning clinics provide women seeking termination of pregnancy with a range of services, including pre-procedure counselling, medical checks and post-abortion contraception counselling. In 2020, VTP activities at family planning clinics were analysed through ad hoc monitoring by the Ministry of Health. Overall, 1,448 family planning services (69.9% of the total) reported offering counselling for VTP and issuing abortion certificates. Like in previous years, the number of VTP consultations was higher than the number of abortion certificates issued (45,533 consultations vs 30,522 certificates), which probably reflects the support given to “remove the causes that may lead to termination of a pregnancy” (Article 5, Law 194 of 1978). The project “Analysis of the activities of family planning services for the purpose of re-assessing their role also with regard to issues related to endometriosis”, developed by the National Centre for Disease Prevention and Control (CCM) and coordinated by the ISS, provides a snapshot of family planning services more than 40 years after their establishment, and highlights that over 95% of them offer all the services set out in Law 194 to women seeking an abortion, irrespective of geographical location: from pre-procedure consultations to post-abortion contraception counselling.