Abortion in Italy
BEN - Notiziario ISS - Vol.14 - n.4, April 2001
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.
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