In Western European countries where abortion is legal, the incidence of induced abortion varies: According to a recent evaluation, Sweden has the highest abortion rate (20.4 abortions per 1,000 women aged 15-44 in 1991) and the Netherlands the lowest rate (5.2 per 1,000 in 1990).1 Nevertheless, there are some common patterns.2 For example, in countries such as Denmark, Finland and Sweden, the ratio of legal abortions to live births increased after legalization and then diminished. In such countries as France, the Netherlands and England and Wales, on the other hand, abortion levels have not decreased, but have remained relatively stable.
In May 1978, Italian women were granted the right to terminate a pregnancy upon request during the first trimester. The law stipulates that induced abortion be confined to women whose physical and psychological health may be at risk. Although a proposal to repeal the law was considered in a 1981 national referendum, it was rejected by nearly 80% of voters. Abortion remains controversial in Italy, however, and was criticized in a recent Papal Encyclical ("Evangelium Vitae") on ethical issues.
In this article, we present information on the incidence of abortion in Italy since its legalization. These data were collected from women obtaining abortions in all public hospitals in Italy. Women were interviewed by health care providers at the time they underwent the procedure; these data were then collated and published by the National Institute of Statistics and the Ministry of Health.3
Abortion Incidence
In 1993, approximately 140,000 induced abortions were performed in Italy. In comparison, the average annual number during the period 1982-1984 was more than 230,000. Similar patterns can also be seen in abortion rates (Table 1, page 268). After legalization, abortion rates rose modestly, increasing from 13.7 abortions per 1,000 women aged 15-44 in 1979 to a peak of 16.9 per 1,000 in 1982 and 1983. During the period 1982-1984, Italian abortion rates stabilized, and this period was followed by a steady decline: By 1986, the rate had dropped to 14.0 abortions per 1,000 women, and by 1990 it had reached 11.1 per 1,000; by 1993, the abortion rate had decreased to 9.8 per 1,000.
Abortion ratios (the number of abortions per 1,000 live births) displayed a similar pattern subsequent to the 1979 law. The abortion ratio, at 280 per 1,000 in 1979, rose steadily through 1984 when it reached about 390 per 1,000 (Table 2, page 269). Since that time, the ratio has decreased continually, reaching a low of 261 per 1,000 in 1992. While abortion ratios in Italy are notably higher than those of many other Western European countries because of Italy's comparatively low fertility rates,4 these trends are similar to those of other Western European countries,5 suggesting that increase, stabilization and decline typify the pattern of abortion utilization following legalization. Indeed, when the data on induced abortion in Italy are plotted graphically, the data subsequent to 1984 approximate a straight line, with regression coefficients equal to -14.7 per year for abortion ratios and -0.7 per year for abortion rates.
Regional Differences
Twenty regions comprise the five geographical areas of Italy: four northwestern regions (Piedmont, Val D'Aosta, Lombardy and Liguria), four northeastern (Trentino, Veneto, Friuli-Venezia Giulia and Emilia-Romagna), four central (Tuscany, Umbria, Marches and Lazio), six southern (Abruzzo, Molise, Campania, Puglia, Basilicata and Calabria) and two island regions (Sicily and Sardinia).
Although total fertility rates (TFRs) are fairly consistent across these regions (ranging from 1.0 lifetime births per woman in Tuscany and Liguria to 1.8 births per woman in Campania),6 levels of abortion vary considerably (Table 1). Compared to the overall 1993 rate of 9.8 abortions per 1,000 women aged 15-44, abortion rates are relatively low in the northeastern regions such as Trentino and Veneto (rates of 6.8 and 5.3 per 1,000, respectively) and the islands of Sicily (7.4 per 1,000) and Sardinia (6.5 per 1,000). In the northwest, rates are similar to the national rate (e.g., 9.8 per 1,000 in Liguria) or moderately higher. Levels of abortion are quite disparate across the central and southern regions: Basilicata registers 6.0 abortions per 1,000 women of childbearing age, while neighboring Puglia has a rate of 16.8 per 1,000, the highest in the country. Similarly, centrally located Marches has a rate of 8.2 per 1,000, compared to a rate of 14.0 per 1,000 in neighboring Umbria.
Since the legalization of abortion in 1979, declines in abortion rates have been greatest in the north, where family planning and reproductive health services are more extensive and well-established.7 The abortion rate in Liguria, for example, dropped by more than 50%, from 20.1 abortions per 1,000 in 1979 to 9.8 per 1,000 in 1993, while the rate in Piedmont declined from 20.8 per 1,000 in 1980 to 11.5 per 1,000 in 1993.
In 1993, the abortion ratio in Italy was 262 abortions per 1,000 live births (Table 2). However, this measure also varies regionally. The central and northern regions (in particular Emilia-Romagna, Liguria and Tuscany) are characterized by relatively low TFRs (one lifetime birth per woman), high abortion rates and elevated abortion ratios. While low levels of fertility can also be found in some of the northwestern regions, abortion rates are moderate in these regions (9-12 abortions per 1,000); therefore, abortion ratios in a few of these areas are closer to the national level.
The southern and island regions, which have the highest fertility and the lowest abortion rates (Campania, Basilicata, Calabria and the island of Sicily) demonstrate the lowest abortion ratios (150 abortions per 1,000 live births in Sicily, for example). On the other hand, a low abortion rate and a low abortion ratio is a pattern also seen in the northeastern regions of Trentino and Veneto. Meanwhile, the southern regions of Puglia and Molise show a pattern more similar to those seen in central and northwestern Italy.
In the years since the enactment of the Italian abortion law, regional differences appear to have diminished. We measured regional variability in abortion levels using the coefficient of variation (the standard deviation divided by the mean, multiplied by 100). For abortion ratios, this measure has decreased from 58.8 in 1979 to 38.0 in 1991, and for abortion rates it has fallen from 34.6 in 1979 to 26.6 in 1987.
None of the data cited in this article take into account the role of clandestine abortion. In Italy, abortions performed by a physician, but not reported through the proper administrative channels, are considered illegal. The actual dimensions of this phenomenon are not known,8 but the health ministry estimates that approximately 50,000 clandestine abortions were carried out in 1993; of this number, approximately 70% occurred in the southern regions.9
Caution is therefore required in evaluating geographical differences in abortion in Italy. This is especially so for abortions obtained by women aged 15-19. Considerably lower abortion rates occurred in the south, where the role of clandestine abortion remains especially unclear.10 Nevertheless, official sources suggest that the level of clandestine abortion is decreasing in Italy, so regional variations are less likely to be influenced by this phenomenon; therefore, we believe our data provide a fairly accurate description of geographic differences in induced abortion in Italy.11
Abortion Trends: 1981-1991
Age Patterns
To examine age patterns in the occurrence of abortion in Italy, we used census data collected in 1981 and 1991 that provided specific regional information about the age structure of the population. These data enabled us to calculate the age-specific abortion rate and the total abortion rate, a standardized measure not influenced by age structure that can be used to make comparisons.
Table 3 (page 270) shows total abortion rates and age-specific abortion rates by region for 1981 and 1991. The overall total abortion rate declined by approximately one-third, from 545 lifetime abortions per 1,000 women in 1981 to 366 per 1,000 in 1991. Decreases in the total abortion rate were the least pronounced in the south, where in several regions (such as Basilicata, Campania and Molise), rates remained relatively unchanged.
Abortion rates were highest for women aged 25-29 in the 1981 cohort (25.3 per 1,000) and, not surprisingly, lowest among women aged 45-49 (0.9 per 1,000). Abortion rates among adolescent women aged 15-19 were also quite low (7.6 per 1,000). Age-specific rates varied by region. In the southern regions (with the exception of Calabria), women aged 30-34 registered the highest abortion rate (e.g., 42.7 per 1,000 in Puglia and 27.7 per 1,000 in Abruzzo). In the northeast, rates were highest among women aged 20-24 years old (35.6 per 1,000 in Emilia-Romagna and 17.4 per 1,000 in Trentino). Women aged 25-29 had the highest abortion rates in the central regions of Tuscany (31.5), Umbria (32.0) and Lazio (26.4).
Regional differences occurred within age-groups as well. In the northeastern region of Emilia-Romagna, 1981 age-specific abortion rates for women younger than 40 were substantially higher than the national rate for each age-group. This was most striking among the youngest women: Women aged 15-19 in this region had an abortion rate of 15.5 per 1,000, twice the national rate of 7.6 per 1,000, while those aged 20-24 had a rate of 35.6 per 1,000, nearly 60% higher than the overall rate for this age-group. With the exception of Puglia, where abortion rates were elevated, most of Italy's southern regions had age-specific abortion rates similar to the nationwide figures. Several regions in the south, notably Calabria and Campania, had rates considerably lower than the national average, especially among women aged 15-19 and 20-24.
Age-specific abortion rates decreased between 1981 and 1991 for women of all ages, and declines appeared largest in regions with the most elevated rates in 1981, thus somewhat diminishing differences between regions. Women aged 20-24 in Emilia-Romagna, for example, registered an age-specific rate of 15.6 abortions per 1,000 in 1991, substantially closer than the 1981 cohort to that age-group's country-wide rate of 13.6 per 1,000.
The distribution of age-specific abortion rates among women in the 1991 cohort also shifted upward. The highest abortion rate occurred among women aged 30-34 (16.9 per 1,000), followed by women aged 25-29 (15.7 per 1,000). Women aged 35-39 had a higher rate of abortion (14.6 per 1,000) than did those aged 20-24 (13.6 per 1,000), the reverse of the 1981 data. Abortion rates among women aged 15-19 remained low (4.6 per 1,000). Indeed, abortion rates among Italian adolescents are considerably lower than those of other European nations. For example, in England and Wales, the abortion rate among women aged 19 or younger was 20.9 per 1,000; in Finland, the rate was 15.7 per 1,000 (1987 data).12
Legislative restrictions present barriers to legal abortion for women younger than 18 years of age. Parental consent is required for the procedure, although young women who will not (or cannot) inform their parents can seek the authorization of a judge. The proportion of abortions among teenagers that were authorized by young women's parents increased from 44% in 1981 to 47% in 1991. However, regional differences are again apparent. In the central and northern areas, this percentage increased from 42% to 52%, while in the north it rose only slightly, from 37% to 40%.
Judicial intervention may be more common in the southern regions because of more traditional values and a tendency to fear informing family members. On the islands of Sicily and Sardinia, where traditional attitudes toward adolescent sexuality and premarital pregnancy prevail, there was little change in the percentage of abortions authorized by parents.
Differences in age-specific abortion rates between the two years may be attributable to an increasing tendency by women to delay childbirth, or to changes in the pattern of contraceptive method use among younger women, particularly in the north.13 The high levels of abortion among older women (those aged 35-39) in the central and northern areas may be a consequence of continued use of traditional methods of contraception.
Social and Demographic Characteristics
Census data allow us to examine the relationship of marital status, parity and education to abortion. In Italy, abortion is more common among married than unmarried women. In 1981, single women accounted for 27% of induced abortions; this figure rose to 38% by 1991. However, unmarried women terminate their pregnancies more frequently than married women: It has been estimated that 61% of conceptions among single women are terminated, compared with only 15% of pregnancies among married women.14
Differences in abortion rates by marital status diminished considerably between 1981 and 1991, especially among women aged 25-29 (Figure 1, page 269). Declines in abortion rates over time were greatest among the youngest married women. While the abortion rate among married women aged 15-19 was 21 abortions per 1,000 women of reproductive age in 1981, the rate was 14 per 1,000 by 1991. Declines of a similar magnitude were noted among married women aged 20-24 (from 26 per 1,000 in 1981 to 17 per 1,000 in 1991) and among single women aged 25-29, whose abortion rates declined from 25 per 1,000 in 1981 to approximately 16 per 1,000 in 1991. We attribute these changes to increases in the use of modern contraceptives among these women.
A woman's socioeconomic status is influenced by a multitude of factors.15 Education often functions as a proxy for several of these variables, and appears to play a particularly strong role in determining abortion behavior. Level of education has a different impact according to age. Among adolescent women, abortion rates are highest for those with the most education. This is especially so for married women aged 15-19; the abortion rate among those with at most a primary education was 9 per 1,000, compared with a rate of approximately 16 per 1,000 among those with higher educational attainment. Among married women aged 20-39, abortion rates tend to decline as the level of education increases. For example, the rate among married women aged 25-29 was 24.8 per 1,000 for those with the least education, compared with 10 per 1,000 among the most educated women. Although less distinct, the trend among nonmarried women was similar. Among both married and unmarried women aged 40 and older, women with less education evidence lower abortion rates than women with higher levels of education. However, this may result from a cohort effect: We speculate that the choice to terminate the pregnancy may represent a symbol of emancipation among older women, for whom the family context has been characterized by the use of traditional contraceptive methods (e.g. withdrawal) and a traditional division of gender roles.
Repeat Abortions
Available 1991 data indicate that approximately 30% of abortions documented in Italy are repeat abortions (defined as those obtained by married women who report having had a prior pregnancy terminated through abortion).16 Table 4 indicates that the likelihood of a repeat abortion increases with parity. Among women with no children, the highest level of repeat abortion is found in the central region of Lazio, where 21% of abortions to married women were repeat procedures. The southern regions of Molise and Calabria registered the lowest level of repeat abortions, about 5% in each.
Levels of repeat abortion were slightly higher among women with one child; this proportion was lowest in the northern region of Veneto (15%) and the island of Sardinia (14%) and highest in the southern region of Puglia (29%). Among women with two or more children, repeat abortion was most frequent in the southern regions, ranging from 29% in Abruzzo to 53% in Puglia. Repeat abortion remained relatively uncommon among higher parity women in the northern region of Veneto (17%), while in other northern and central regions, this proportion ranged from 26% (in Marches) to 33% (in Tuscany).
Low levels of modern contraceptive use may contribute to elevated rates of repeat abortions among higher parity women in southern Italy. Unfortunately, data documenting the extent of induced abortion and contraceptive use are limited mostly to results from ad-hoc or irregular surveys of limited geographic scope.17 Furthermore, reliable country-wide data on levels of abortion do not include information on women's use of contraceptive methods. Data currently being analyzed from the 1996 Italian Fertility and Family Survey should be useful in further examining the links between contraception, fertility and reproductive behavior, and abortion.
Discussion
Regional differences in abortion rates in Italy are likely related to religious and cultural factors. An association between less conservative attitudes and religious beliefs and positive attitudes toward abortion is suggested by regional differences in support for the 1981 referendum. In regions where more traditional values and attitudes prevail, such as Sicily and Sardinia, the percentage of voters in favor of repeal was much higher than the national average, while voters in central and northwestern regions were mostly in favor of the existing law.18
While we cannot assume a direct causal link between abortion and political behavior, it may be that common religious and cultural factors influence the two phenomena, clustering in regions with similar patterns. For example, higher levels of abortion can generally be found in the industrialized and secularized areas of the country (the northwestern and central regions of Piedmont, Liguria, Emilia-Romagna and Tuscany), where women are more likely to participate in the work force and to have less traditional roles. The level of abortion appears to be lower in the southern part of the country (with the exception of Puglia and Molise), regions that are characterized by higher fertility and traditional family attitudes. Cultural factors may be salient in the northeastern region of Friuli, for example, where strong migration flows associated with modernization and cultural assimilation are correlated with relatively high abortion rates.
Recent attitudinal studies in Italy tend to confirm the influence of sociocultural and demographic factors on the level of abortions.19 For example, there is an inverse relationship between marital rates and abortion rates, while there is a direct relationship between the frequency of civil weddings (a proxy for low religiosity) and the level of abortions.
Despite the decrease in abortion rates during the 1980s, a continued reduction in the number of abortions among Italian women is desired. Improvements in communicating information about effective contraception and in the development of adequate reproductive health care facilities appear necessary in order to reduce the extent of abortion in Italy.