Driving Women around the Bend: What’s Really Going on with Abortion Access in Italy?

In Italy, it has been nearly 40 years since abortion was legalized—confirmed in a referendum by the Catholic-majority populace—but the system for providing abortions has been deemed so severely flawed that both women and doctors are suffering.

“We have a problem in talking about abortion as a right,” says Elisabetta Canitano, president of Vita di Donna, a gynecologists’ organization for women’s health.

After nearly four decades of practice one would expect the rules to be implemented with few hitches, but the Council of Europe recently identified a string of problems. Nationwide, there has been a decrease in the number of healthcare facilities where abortion is available, while women face excessive waiting times. Overall, there is a shortage of doctors who do not object to abortion provision.

Conscientious Objection: Regulation and Rights

In April, the Council of Europe ruled the situation was so dire that women’s right to health was being violated in Italy. Responding to a claim brought by the country’s biggest trade union, CGIL (Confederazione Generale Italiana del Lavoro), the council’s committee of social rights also ruled that the government was violating doctors’ right to dignity at work.

The decision was a further blow to Italy, coming two years after the same committee at the Council of Europe backed International Planned Parenthood Federation’s claim that poor regulation of conscientious objectors within the healthcare system amounted to a violation of women’s rights.

Italy’s health ministry says it has taken numerous steps to improve the situation, such as setting up a training course for regional officials and establishing a crisis unit to deal with major problems that may arise in delivering healthcare services.

Counts of Legal Abortions: What’s In A Number?

In theory, women should have no difficulty in terminating a pregnancy in Italy, where abortion was legalized in 1978. But in the conservative country, attitudes remain less open than those in many northern European countries. “Abortion in Italy is not birth control, it’s the final step because of culture,” says Assuntina Morresi, an adviser to the health ministry.

Under the law, women have to receive a certificate from a doctor and wait a week, in non-urgent circumstances, to reflect upon their decision, before going ahead with the procedure within the first three months of pregnancy. Thereafter, an abortion is only allowed if there is a medical problem with the fetus or in order to protect the woman’s physical or mental health.

Campaigners, meanwhile, say the decline in abortions has little to do with improvements to education and heatlhcare, instead warning of a more alarming trend. On average, 70 percent of [gynecologists] in Italy are conscientious objectors—a steady increase from an average of 58.7 percent in 2005…

“Abortion in Italy is not a right. It’s allowed in many cases—it’s not on request—it’s in consultation with a doctor,” Morresi says.

According to official figures, the number of abortions has fallen significantly in the past few decades. In 30 years the numbers fell by more than 56 percent, from nearly 234,000 terminations in 1983 to just under 103,000 in 2013. For the state, the change in numbers means women are better informed and have greater access to contraception than ever before.

Campaigners, meanwhile, say the decline in abortions has little to do with improvements to education and healthcare, instead warning of a more alarming trend. On average, 70 percent of gynecologists in Italy are conscientious objectors—a steady increase from an average 58.7 percent in 2005—while in some regions the figure reaches more than 90 percent.

Those who disagree with the government line, such as Silvana Agatone, president of the prochoice gynecologists’ association, LAIGA, argue it can be so difficult to access an abortion that women are forced to seek risky alternatives.

“Imagine a woman in Trapani (Sicily) who goes to find a place for an abortion and doesn’t find one, so perhaps she finds an illegal one. For cultural reasons an Italian woman feels ashamed, so she hides it and doesn’t report it,” says Agatone, who performs abortions in Rome.

LAIGA argues that the Italian government’s approach is fundamentally flawed, as doctors are not required to note when they reject a woman’s request for an abortion. “The ministry only studies the abortions carried out; they don’t study the requests from women. So the ministry has no idea about abortion in Italy,” Agatone explains.

While the health ministry did not respond to questions from Conscience, Morresi says doctors are not required to write down the number of requests for medicines or other procedures that are not carried out, so it makes no sense to do so for abortion and would pose a privacy risk.

“It would be a police state,” she says. “Abortion for us is not an opportunity; it’s not a positive thing. It’s something which, unfortunately, a woman chooses.”

The government adviser says the system is fair, above all because it is provided free of charge in either public hospitals or private clinics that are paid by the state to perform abortions.

“It’s not possible to go to a doctor and pay. This means that it’s not a way of making money; there aren’t economic interests at play,” Morresi says. “Women are not discriminated against on the basis of their socioeconomic status.”

Abortion in Italy—Off The Books

If women have an abortion illegally, they face hefty fines of up to €10,000 ($11,300), a sum that was raised earlier this year from a symbolic €51.

Italy estimates between 12,000 and 15,000 illegal abortions are carried out each year, based on calculations from the National Institute of Health, whose methodology, Morresi claims, has never been challenged. She asserts that some women choose to have illegal abortions because they prefer to be outside the official system.

“Not all women want to go through the health system, above all foreigners,” declares Morresi, arguing that if there were a problem with abortion access, there would be a series of legal cases against the government by individual women, which there have not been.

Speaking as an abortion provider, Agatone says women buy abortion pills online or from drug pushers at Metro stations before going to the hospital and claiming they have miscarried: “When they go to hospital, we understand, but we don’t say anything.”

There are a number of reasons women may decide to have an abortion illegally, explains Daniela Colombo, who has been a prochoice campaigner since the 1970s.

The shortage of nonobjecting doctors is a principal reason, with many women unaware there are organizations such as LAIGA that could advise them on how to obtain an abortion legally.

“There’s always the fact of wanting to keep it a secret, if you live in a small town,” says Colombo, owing to the sense of shame in Italian culture attached to abortion.

Colombo describes the government estimates of illegal abortions as “absolutely underestimated and far from reality.” In addition to Italian women not being able to find a doctor or wanting to avoid the official register, she says foreign women who do not have health cards also resort to illegal abortions.

Colombo says many such terminations are carried out by teenage girls, because there are greater restrictions on them to obtain emergency contraception or an abortion.

An unknown number of women travel abroad for an abortion: to Spain, the UK and elsewhere. Ann Furedi, chair and chief executive of the British Pregnancy Advisory Service, says they see around 100 Italian women a year. In the UK, abortion is available during the first 24 weeks of pregnancy, or later in some circumstances, and women who are not UK residents will need to fund their own procedure.

An abortion costs between £450 and £900 ($660 to $1,320), although Furedi says the service has a grant scheme for women in financial hardship: “We will never turn away a woman who is in need of services when we can lawfully treat her.”

Women who travel to the UK discuss their pregnancy before going ahead with an abortion, but Furedi explains they are not forced to wait a week as in Italy: “There’s no sense in this country that it’s a good idea for a woman to have a built-in waiting time.”

However, in the UK, two doctors must sign paperwork agreeing that continuing the pregnancy would be more damaging to the woman’s mental or physical health than an abortion.

“In practice, most doctors will agree if you don’t want to be pregnant it is almost certainly damaging to force you to have a baby,” says Furedi. “I do think that in Britain we’re a pretty secular society, and there’s probably more pressure on doctors to comply with a woman’s request than there is to deny it.”

Abortion: A Providers’ Perspective

In Italy, the Council of Europe found doctors face a range of disadvantages for their choice to perform abortions, including a burdensome workload and missing career opportunities, amounting to discrimination in the workplace.

Irene Donadio, a senior adviser at International Planned Parenthood Federation, says nonobjecting doctors face a “very hostile environment” and some young doctors are only able to get contracts if they claim to be antiabortion.

“The level of responsibility is immense. You should not have to be a hero to provide a safe service that is guaranteed under the law,” she says.

Agatone says in some instances, objecting medical staff refuse to bring patients into the procedure room and won’t help clean medical equipment after the procedure, while nonobjecting doctors often must travel to different hospitals to perform abortions.

“To object is comfortable, calm. The nonobjectors which have chosen to comply with women have a more difficult life,” she says. Agatone claims that in Rome, one doctor alone can perform 20 abortions a week or more, depending on how many appointments the hospital grants to the women who travel from all over the region.

The Italian government, however, says nonobjecting doctors perform an average of 1.6 abortions a week, according to 2013 figures, with the maximum found in Rome’s Lazio region (9.4) and Sicily (9.6). The health ministry says doctors’ workloads are actually falling compared to 1983, when they carried out an average 3.3 abortions per week.

Carlo Petrini, head of the National Institute of Health’s bioethics unit, has argued that any problems in this regard come down to mismanagement on the local level rather than national policy.

“The workload required of each pro-choice doctor should neither interfere with his or her ability to perform other duties aside from abortions nor make it difficult to meet the demand for abortions,” Petrini wrote in an online note to the British Medical Journal. He told Conscience he would be unable to comment further on the matter.

The Council of Europe found doctors face a range of disadvantages for their choice to perform abortions, including a burdensome workload and missing career opportunities, amounting to discrimination in the workplace.

Benedetta Liberali, a lawyer representing the trade union CGIL in the recent European case, says in reality the current situation prompts some doctors to quit abortion services. “There are a lot of cases in which, after many years, nonobjecting doctors—even after 20 years—decide to become objectors because they aren’t able to cope with this situation,” she says. Those who remain staunchly prochoice after battling to legalize abortion now fear the increasing number of objectors means the service will stop operating once they retire.

Colombo argues this vast range of difficulties associated with being a prochoice doctor—including the heavy workload, being sidelined from promotions and surviving on short-term job contracts—pushes a disproportionate number of medics to claim they are conscientious objectors.

The majority are not motivated by religious sentiment, but rather claim to hold strict Catholic views in order to progress in their careers and avoid being marginalized.

“I do not think it’s because they’re all Catholic. They pretend. [Objecting] must be motivated by conscience, but no one goes to see if they are practicing or if they were married in church,” Colombo says.

“I do not think the number of Catholics is on the rise,” she adds, whereas the number of doctors claiming to be conscientious objectors continues to increase.

Church Influence on Italian Politics

Since the 1970s, the influence of the Catholic church in determining the choices of doctors, women and the state has been central to the abortion debate.

The Vatican remains opposed to abortion in all circumstances. Pope Francis earlier this year described the practice as a “horrendous contradiction” when “life is rejected and destroyed” within a family.

“Let us pause to think of the great value of that embryo from the moment of conception,” Francis added, writing in his apostolic exhortation on family issues, released in April under the title Amoris Laetitia (The Joy of Love).

But the Argentine pontiff has also adopted a softer tone than his predecessors, telling priests to forgive repentant women of the sin of abortion during the Vatican’s Jubilee of Mercy. Francis has broadly stayed true to Catholic teachings on social issues while not openly meddling in Italian policy.

Meanwhile, the head of the Italian bishops’ conference, Cardinal Angelo Bagnasco, has taken a more active role in voicing the church’s view on family matters. He was an outspoken critic earlier this year of the government’s effort to grant rights to same-sex couples, calling for a secret ballot and contending children should have a mother and a father. Back in 2009, Bagnasco described the abortion pill RU486 as a “crack in our civilization,” according to local media reports.

Canitano of Vita di Donna accuses the church of trying to ensure Catholic directors are installed in health facilities. “They are trying to control our health,” she says. “The problem is that the Catholic church considers Italy as its country. The Catholic church has, continuously for centuries, tried to reclaim the state and the life of citizens.”

Mirella Parachini, the Italy representative for the International Federation of Professional Abortion and Contraception Associates (FIAPAC), says the focus on religious or moral objection to abortion has left the country falling behind in its medical methods.

“I find it very important to modernize this country and make it understood that abortion is a medical procedure. As such, it’s subject to technological improvements, which requires all medical practices,” she says, asserting training of medical students is not advanced enough or else nonexistent in Italy.

But with St. Peter’s Basilica dominating the skyline of the Italian capital, the dominant debate on abortion in Italy repeatedly returns to the Catholic church. “The presence of religion—the Vatican—seeps into the mentality of the laypeople who are confronting this question,” says Parachini.