Collection of induced abortion data in Italy and its results
Angela Spinelliab, Michele Grandolfoa, Marina Pediconia, Ferdinando Timperia, Silvia Andreozzia, Mauro Bucciarellia, a Istituto Superiore di Sanità, Rome; b Agenzia di Sanità Pubblica della Regione Lazio, Rome
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, pregnant women may request an abortion during the first 90 days of gestation, for health, economic, social, or familial reasons. To obtain an abortion, the woman must first obtain a certificate attesting to the state of the pregnancy from her general practitioner, a private physician or a public maternal-child health clinic. The abortion is performed free-of-charge either at a health care structure in the National Health Care System or in a private structure with a contract from the regional health authority
Since 1980, the Istituto Superiore di Sanità (Italian National Institute of Health) has maintained a surveillance system for legal induced abortions. This system is based on quarterly reporting by the regional health authorities. For each induced abortion, a standardized form is completed in the hospital where the procedure is performed. This form contains data on major socio-demographic characteristics of the woman (age, place of birth, citizenship, education, occupation, 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 the certificate was issued, type of procedure and location where it was performed, duration of stay, and immediate complications). The Istituto Superiore di Sanità examines data quality and performs data analysis of trends, geographic distribution, and characteristics of women undergoing abortion. These analyses are performed by the ISS, in collaboration with the Ministry of Health and the National Statistics Institute (Istat), and presented annually to Parliament by the Minister of Health. Thanks to this surveillance system, Italy has very accurate and timely abortion data which is used to monitor the phenomenon and to suggest areas for research and intervention for prevention .
After the 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 130,000 abortions performed in 2002 (abortion rate=9.3/1000). This reduction represents a decline of 46% over the past 20 years, with an estimated 100,000 fewer abortions in 2002 compared with 1982.
The incidence of abortion in Italy is similar to that of other countries in north-western 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 around 50/1000) 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 2001, the abortion rate was 9.6/1000 in the North, 10.7/1000 in the Center, and 8.8 in the South. The declining rates over time have been observed in all areas of the country, with a trend toward convergence. 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 21,100 performed in 2000. 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 that in 1983 there were approximately 100,000 illegal abortions. The estimated number of illegal abortions has thus decreased by 79% since the early 1980s.
From other studies, it has been observed that in most cases, abortion is not considered to be the family planning method of choice, but instead results from the failure to control fertility using contraception. More than 70% of women who undergo abortion report that they were using some method of contraceptive 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, support the hypothesis that the observed reduction in induced abortion is the consequence of a greater diffusion and more effective use of contraception.
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 women aged between 25 and 34 years of age, and in those with children.
In recent years, there has been an increase in the number of abortions requested by immigrant women. Among the 132,234 abortions in 2001, 25,094 (19.4%) were performed on foreign citizens, a large increase from the 9,850 observed 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 Statistics Institute (Istat), have increased from 678,000 in 1995 to 1,500,000 in 2002. Based on estimates of the population of immigrant women aged 18-49, Istat has calculated that the abortion rate for immigrant women was 30/1000 in 2000, three times higher than that observed in Italian women. Indeed, the increase in the numbers of immigrant women may be the main cause of the recent leveling-off of the abortion rate in Italy. If the analysis of trends is limited to 1996-2001, years for which the information on citizenship is most complete, the number of abortions in Italian women declined from 127,700 in 1996 to 106,166 in 2001.
In conclusion, the reduction of induced abortion appears related to the improved use of contraception and to the important role of the maternal-child health clinics. The social-demographic characteristics of the women who have had abortions in recent years imply that further reductions are undoubtedly possible, especially if the maternal-child health services can be further strengthened.
Survey of immigrant women who have an induced abortion in Italy
Angela Spinellia, Michele Grandolfob, Emanuela Forcellaa, Giovanni Baglioa,
Giovanna Scassellatic, Augusto Colombod, Graziella Sacchettie, Paola Serafinif, Maria Giovanna Caccialupig, Gabriella Guasticchia
aAgenzia di Sanità Pubblica della Regione Lazio, Rome; bIstituto Superiore di Sanità, Rome; cOspedale San Camillo, Rome; d Clinica Mangiagalli, Milan; e Ospedale San Paolo, Milan; f Ospedale Sant’Anna, Turin; gCentro per la salute delle donne straniere e dei loro bambini, Bologna
The number of foreign women who have abortions in Italy is increasing; the number of induced abortions performed on foreign women has increased from 8967 in 1995 to 13826 in 1998 and to 25094 in 2001, the last being 19% of all abortions in Italy. In some regions of Italy, particularly where more immigrants have settled, this percentage is even higher. For example, in Lombardia it is 30%, while in Emilia Romagna, Lazio and Piemonte it is 26%.
The Istituto Superiore di Sanità ( the Italian National Institute of Health) which for many years has monitored induced abortion in Italy, has collaborated with the Agenzia di Sanità Pubblica (Regional Health Authority) of Lazio to launch a project in six regions of Italy to understand the rationale which leads these women to seek abortions, to identify risk factors and understand the ways and means by which these women have achieved their abortions.
The project is in two parts: the first is a quantitative survey, while the second is an in-depth interview of a smaller sample of the women. Given that the attitudes and use of contraceptives depends very much on the country of origin, it has been decided to concentrate on women from Ecuador, Peru, Nigeria, Marocco, China, Romania and the Ukraine, these being the six largest immigrant groups.
In the quantitative survey, about 600 foreign women who have had a termination of pregnancy will be questioned by interviewers who have been specifically trained, using a tailored questionnaire. The sample will be all the women from these countries who have had an abortion in one of four hospitals in the period March to June 2004. The questionnaire contains closed questions which seek information about knowledge and use of contraceptives, use of local family planning clinics, how the women discovered how to use the health services to obtain their abortions, their reproductive history and social-demographic information.
The in-depth study will be on about 50 women from the same countries, who have had a termination in the last six months, using a semi-structured questionnaire. The questions will include information on their immigration to Italy, their knowledge and use of contraceptives, the reasons why they decided to seek an abortion and the assistance they received from the local health services.
The preliminary results of this project will be presented at the conference.