Banners and posters from a sit-in by pro-choice activists at the Ministry of Health in Rome on July 2, 2020. Organized by the Italian Abortion Contraception Network, activists and organizations called for free and accessible contraception and guaranteed access to abortion. © 2020 Matteo Nardone/Pacific Press/LightRocket via Getty Images

(London) – Government inaction has left women and girls facing avoidable obstacles to accessing legal abortion in Italy during the Covid-19 pandemic, putting their health and lives at risk, Human Rights Watch said today.

The government’s failure to ensure clear pathways to essential, time-sensitive medical care during the pandemic caused interruptions to abortion services and prevented some women from accessing abortion within the legal time limit, exacerbating longstanding barriers to safe and legal abortion in Italy.

“Women and girls in Italy have been left facing sometimes insurmountable hurdles to the sexual and reproductive health care they needed during a time of crisis,” said Hillary Margolis, senior women’s rights researcher at Human Rights Watch. “The Covid-19 pandemic only highlights Italy’s labyrinthine system to access abortion and demonstrates how the country’s outdated restrictions cause harm instead of providing protection.”

Between May and July 2020, Human Rights Watch interviewed 17 physicians, academics, and women’s rights activists, as well as 5 women who sought abortion or abortion-related care after the onset of the Covid-19 outbreak in Italy in February. In a letter to the Health Ministry, Human Rights Watch presented research findings and requested comment, but has not received a response.

Abortion is legal in Italy during the first 90 days of pregnancy for health, economic, social, or personal reasons. However, burdensome requirements and extensive use of “conscientious objection” by medical personnel to deny care leave women and girls scrambling to find services within the legal time frame, often requiring visits to multiple facilities within Italy or abroad – movement hindered by local and international travel bans to help prevent the spread of Covid-19. Some facilities suspended abortion services during the pandemic or reassigned gynecological staff to Covid-19 care.

Italy’s government did not immediately deem abortion essential health care during the pandemic. The Health Ministry clarified on March 30 that abortion services were non-deferrable, but hospitals and clinics did not always adhere to this guidance. Experts told Human Rights Watch that a lack of information about available services during the Covid-19 crisis further hindered access.

“I started panicking because I didn’t know where to go,” said a woman in her 40s who searched for a doctor to authorize and perform her abortion in mid-March in the Lombardy region, among the areas worst affected at the outset of the Italian outbreak. She said she was sent from one healthcare facility to another, as each denied her services because of the Covid-19 crisis. “The Italian state closed the door in my face,” she said. She finally got an abortion in a hospital in another town.

Unlike other European governments, Italian authorities did not take steps during the pandemic to facilitate access to medical abortion. Medical abortion is a safe and effective way to end a pregnancy using medication rather than more invasive surgical methods. The World Health Organization (WHO) recommends administration of mifeprostone followed by misoprostol for medical abortion, which it says can be safely self-managed by women up to the twelfth week of pregnancy where accurate information and support from a healthcare provider are available.

But medical abortion is only legal in Italy until the seventh week of pregnancy – when some people may not even know they are pregnant – and national guidance calls for the medications to be administered during a three-day hospitalization. While surgical abortion can be performed in an outpatient, or day, hospital, only 5 of 20 regions in Italy permit medical abortion on an outpatient basis.

Italy’s guidance on medical abortion runs counter to public health advice to minimize hospital visits during the Covid-19 crisis. People interviewed said that some facilities suspended abortion services, especially medical abortion, during the pandemic because they deemed the need for multiple clinical visits or hospitalization too high-risk or too burdensome on overstretched health facilities. They said women also feared going to hospitals because of the risk of contagion.

Restrictions on movement also inhibited access to abortion. In areas declared “red zones” during the Covid-19 outbreak, people could travel outside the home for health emergencies, but had to provide justification to authorities if stopped and could face fines for violations. Some women said the prospect of telling authorities they were seeking an abortion was itself a deterrent.

Experts, activists, and professional organizations, including the Italian Society of Gynecology and Obstetrics (SIGO), called on the government to expand access to medical abortion in response to Covid-19. In a positive move on July 2, the Health Ministry confirmed that it asked the High Council of Health (Consiglio Superiore di Sanità), a technical advisory body, to review national guidance on medical abortion.

Italy’s government should ensure that its response to the Covid-19 pandemic and other emergencies does not unduly impede abortion access, Human Rights Watch said. To ensure safe and accessible care, it should follow medical advice, such as that in WHO guidelines, by extending the legal time frame for medical abortion to 12 weeks and eliminating requirements for hospitalization, instead providing guidance on self-management of medical abortion with in-person or telemedicine consultations.

The government should also remove burdensome requirements and address other longstanding obstacles to abortion that undermine reproductive rights. This includes eliminating a mandatory waiting period and ensuring that regions comply with obligations so that conscientious objection does not prevent abortion access. The government should ensure that conscientious objection is only invoked by individuals rather than entire facilities and that it is accompanied by appropriate referrals to alternative services.

“The Covid-19 pandemic threw a spotlight on what women and girls in Italy have known for a long time – the law says they can have safe and legal abortion, but in reality, they face obstacles at every turn,” Margolis said. “This should serve as a wake-up call that, crisis or not, protecting reproductive rights isn’t optional.”

For more information on access to abortion in Italy, see below.

Names of women who sought abortions have been changed to protect their privacy. Interviews were conducted remotely by video or telephone in English, Italian, or in Italian with an interpreter. Participants provided full informed consent at the outset of each interview.

National Legislation and Policy

Italy’s Law 194 of 1978 permits abortion for any reason during the first 90 days of pregnancy. Only three countries in Europe have a shorter legal limit for abortion on request. Many women may not realize or confirm that they are pregnant until late in the first trimester.

Law 194 contains burdensome requirements, including a 7-day waiting period and mandatory counseling “to help [a woman] overcome the factors which would lead her to have her pregnancy terminated.” The Health Ministry website notes that “the primary objective of the law [194] is the social protection of maternity and the prevention of abortion.”

Abortion can be performed at public hospitals and, in some cases, at private clinics receiving public funds. It is among guaranteed free reproductive health services for citizens, permanent residents, and irregular migrants with a special health card.

Burdensome Requirements

Accessing abortion in Italy is a protracted process that entails multiple physician visits, including for a certificate verifying the pregnancy, duration of pregnancy, and desire to terminate. Unless the doctor states an abortion is needed urgently, this is followed by a seven-day waiting period, the longest in Europe. There are also often lengthy waits for appointments for abortions. People interviewed said that such delays prohibit access to medical or surgical abortion within the legal time frames and undermine women’s reproductive choice.

After searching for a physician providing abortion care to issue her a certificate in Lombardy in March during the Covid-19 outbreak, Valentina said she went to a city hospital for an abortion:

After three weeks of feeling sick, vomiting, going to different hospitals, I went to [a] hospital and they said, ‘We will call you after [the] seven days [waiting period].’ I said, ‘I don’t need seven days to think about it. I am a mother, I work, I already have difficulty raising my two children…. But they said, ‘It’s the law.’

Valentina said she was about five or six weeks pregnant and worried about exceeding the legal time limit for medical abortion. She eventually accessed an abortion in a nearby town.

Conscientious Objection

Under Law 194, personnel at health facilities can refuse to provide abortion on grounds of “conscientious objection” unless the life of the woman is “in imminent danger.” Official statistics for 2018 show that 69 percent of gynecologists and 46 percent of anesthesiologists nationally are self-declared conscientious objectors. The same government statistics reveal that in one-quarter of the areas listed, over 80 percent of gynecologists and at least 60 percent of anesthesiologists are registered as conscientious objectors. Government data shows that general anesthesia was used in over 52 percent of abortions in Italy in 2018, making the high rate of objecting anesthesiologists a notable obstacle.

Law 194 obliges authorities to ensure that conscientious objection does not prevent fulfilment of legal requests for abortion, even if it necessitates relocating personnel. It also specifies that medical personnel cannot deny pre- or post-abortion care. However, people interviewed said that these measures are not upheld or enforced.

In mid-March “Chiara,” 24, experienced pain and symptoms of infection following an abortion several months prior. Personnel at the first family planning clinic she visited in Calabria told her their only non-objecting doctor was on vacation for an unknown period. “Then I went to a center in a nearby city and they said, ‘We don’t do visits related to abortion, not before and not after, because the head of the center is a conscientious objector,’” Chiara said. According to the March 30 Health Ministry circular, non-deferrable care during the Covid-19 pandemic includes gynecological examinations for vaginal infections.

Obstacles During the Pandemic

People interviewed said that movement restrictions, lack of information, and closure of services during the Covid-19 pandemic exacerbated delays in accessing abortion within the legal time frame.

Movement Restrictions

On February 23, the Italian government declared parts of the Lombardy and Veneto regions “red zones,” prohibiting movement into or out of designated municipalities. On March 9, the government extended these measures to all of Italy. Movement outside the home was only permitted for needed work, buying necessities, or health reasons. The regulations required people to “self-certify” the rationale for movement which, according to a government web site, could “be subject to subsequent checks” and constitute a crime if found to be false.

Women in Italy often venture outside their city or region to access abortion, but the emergency measures restricted those options. Silvana Agatone, president of Free Italian Gynecologists’ Association for the Application of Law 194 (LAIGA), said women from northern Italy began contacting her in February for help finding local services that were still operating because travel was impossible. “In nearby cities, the women were not accepted even if they came from areas that were not yet ‘red,’ because the crisis units of the hospitals did not accept people from outside the city, so they were blocked and they couldn’t move [elsewhere],” she said.

“Elisabetta,” 28, said movement restrictions compounded her difficulties in finding an abortion provider in Lombardy: “I started to feel anxiety because I was in a red zone. I didn’t know how to move around or [where to go to] get a certificate.”

Lack of Guidance and Information

People interviewed said that even after the Health Ministry confirmed that abortion services were non-deferrable, a lack of guidance on providing these services during the pandemic hindered compliance. On March 31, the ministry issued guidance for care of pregnant women, women who have recently given birth, and newborns, as well as breastfeeding, but no such guidance for abortion-related care.

“During lockdown, the gynecological societies had to interpret the government guidance, and it took time to do that,” said Dr. Suzanne Mbiye Diku, a gynecologist in Rome. “We lost weeks…. I myself had at least three or four cases where women arrived too late. They could no longer have [a legal] abortion.”

Lack of centralized information about available services led to confusion and delays. Sara Martelli, coordinator of the Safe Abortion Campaign for Italy and member of the Pro-Choice Italian Network for Contraception and Abortion (Pro-Choice/RICA), said that activists and women had to determine themselves where services were still operating. “All of this information was gathered by phone calls, word of mouth, and people who worked there,” Martelli said in June. “It is not acceptable that there is no access to this information…. [H]ere we are talking about two months [into the pandemic] and nobody knows [anything] yet.”

Lack of Available Services

Some reproductive health services were suspended or relocated to provide space for Covid-19 patients. Reassignment of medical staff to Covid-19 wards and absence of personnel due to illness or self-isolation also led to reduced services. Services in northern Italy, where the pandemic hit first and particularly hard, were especially affected.

Valentina searched for a doctor to authorize and perform her abortion in mid-March in Lombardy, among the areas worst affected at the outset of the Italian outbreak. She said: 

I went to my gynecologist – he said I can’t see you because of Covid. I went to the hospital, they said we can’t see you because of Covid. I went to another hospital – they didn’t even let me in the door because they said they were only taking urgent cases. They told me to go to the consultorio [family planning clinic]. So I called the consultorio. They said they were closed because of the pandemic.

Valentina said she felt desperate: “The Italian state closed the door in my face.” She finally accessed an abortion in a hospital in another town.

In some cases, delays in getting the necessary certificate because facilities closed or stopped providing services during the pandemic meant that women missed the legal time limit for medical or surgical abortion. People interviewed said it is impossible to know how many women turned to unsafe methods to have abortions.

Elisabetta tried to get a medical abortion in Milan when she discovered she was pregnant in early April. “I called all the hospitals of Milano province,” she said. “Some said they had suspended the service, some said they don’t do it at all…. Some said you can come and wait in line all day, but we’ll have to see if we can take you because we will only be able to see about three girls a day.” By the time Elisabetta found a hospital in a town about 60 kilometers away, the doctor said she was past the legal limit for medical abortion. Her surgical abortion was scheduled for mid-May: “I counted in my mind – it would only be about two days before the final legal date to end my pregnancy.”

A doctor at a public hospital in Rome that serves as a reference center for the Lazio region said they experienced around a 20 percent increase in women seeking abortion during the Covid-19 pandemic, which she attributed to the fact that some local facilities had closed or stopped providing certificates or performing abortions. Nongovernmental organizations facilitating access to abortion said that demand for assistance increased significantly, in part due to reduced services and movement restrictions.

“Our 24-hour emergency phone line went from 2 to 3 requests for help per month to 5 to 6 requests a day,” said Eleonora Mizzoni of Obiezione Respinta, a group that maps and provides information about abortion services. She said searches and requests via social media also increased.

Dr. Abigail Aiken of the University of Texas at Austin is researching access to abortion in Europe during Covid-19 with data from Women on Web, which provides medication for abortion by mail in areas with limited access. Dr. Aiken said that based on historical data analysis, research shows a 40 percent increase in contacts from Italy to Women on Web in the period beginning March 10, compared to what would have been expected prior to the pandemic.

Access to Medical Abortion During Covid-19

Italy’s Law 194 is among the European Union’s most restrictive for medical abortion, with a legal limit of seven weeks. At least 16 countries allow medical abortion at 9 weeks or beyond.

Government guidance calling for a three-day hospitalization for medical abortion cites concern about death from bleeding, though the WHO has found no increased risk for at-home management of medical abortion and found it can help combat the risks associated with unsafe abortion. People interviewed said there is no scientific basis for the three-day guideline and point to other EU countries and even areas of Italy that have successfully implemented less restrictive measures. Regional authorities have discretion in local implementation of protocols, but only 5 of 20 regions allow medical abortion in outpatient hospitals rather than requiring the 3-day hospitalization.

“The three days is absolutely crazy,” said a doctor in a public hospital in Rome, noting that medical abortion takes place in outpatient hospitals in the Lazio region. “We know there is a different reality in some regions.”

Even if done in outpatient hospitals, medical abortion in Italy requires three visits for consultation and echography, administration of medications, and follow-up. People interviewed said that the multiple medical visits and three-day hospitalization contributed to suspension of medical abortion during the Covid-19 crisis. “[Doctors] were saying this is too much, three visits [during the pandemic] – so they just cut the service,” said Dr. Marina Toschi, a gynecologist and member of Pro-Choice/RICA.

National guidance also ran counter to public health measures during the crisis. “Many structures have reacted by stopping the medical abortion as absurdly – the [national] guidelines call for a three-day hospitalization for medical abortion, while the Covid-19 [public health] guidelines call for a reduction in hospital admissions,” Martelli said.

Dr. Toschi, who works in Umbria and Marche regions, said that even prior to the Covid-19 pandemic, only around 20 percent of hospitals in Italy provided medical abortions. She said that all medical abortion services ceased in Marche region during the pandemic, and many did not reopen until after July 7. Similarly in Catania, family planning centers reportedly remained closed in mid-June with no indication of when they might reopen, although ophthalmology and other medical services were operating.

In Umbria, medical abortion services continued during the pandemic, but only 3 of 11 hospitals provide them, Dr. Toschi said. Official statistics show that medical abortion using the combination of mifepristone and prostaglandins comprised less than 21 percent of abortions in Italy in 2018. In many European countries, over half of abortions are medical, and in some cases, over 80 or even 90 percent.

Efforts to Change Requirements

European governments, including in France, England, Wales, Scotland, Ireland, Spain, and Germany, took measures to facilitate access to medical abortion during the Covid-19 pandemic, including by extending legal time limits, permitting self-management of medical abortion at home, and conducting consultations via telemedicine.

In early April, nongovernmental groups, including LAIGA, Pro-Choice/RICA, the Italian Doctors’ Contraception and Abortion Association (AMICA), and Associazione Luca Coscioni, wrote to the Italian authorities calling for extension of the legal time limit for medical abortion and elimination of the three-day hospitalization, as well as use of telemedicine to allow remote access to medical abortion during the pandemic. They reiterated their request on June 8, noting “the difficulties and risks to access to abortion that persist.”

In June, Tuscany became the first region to permit medical abortion outside of hospitals, in designated clinics. On May 14, Tuscan authorities adopted a resolution extending the time limit for medical abortion up to nine weeks, noting that the Covid-19 crisis had brought to light concerns about abortion access.

By contrast, in mid-June the newly elected Umbrian government, led by the right-wing Northern League party, reversed a policy permitting medical abortion in outpatient hospitals, reverting to the three-day hospitalization.

On July 2, pro-choice activists protested outside the Health Ministry calling for expanded access to medical abortion and free contraception. At a meeting that day, Ministry representatives confirmed that they had asked the High Council of Health to review national guidance on medical abortion.

Access to Later Abortion During Covid-19

Beyond 90 days, abortion is legal in Italy if there is a serious threat to a woman’s life. It may be legal if there is a serious threat to her physical or mental health, including due to diagnosis of severe fetal anomalies, but the law requires doctors to “take any appropriate action to save the life of the fetus.” People interviewed said delays in testing and diagnosis during pregnancy mean women are not always aware of fetal anomalies during the first trimester, and some anomalies cannot be identified until later in pregnancy.

People also said that few doctors in Italy are willing to perform abortions after the 90-day limit. “Most doctors say, ‘It is not my problem, go somewhere else,’” said Dr. Toschi. Most people travel outside the country for later abortion, made more difficult by travel bans during the pandemic.

“Martina,” 30, a physician, said doctors first alerted her to a potential problem with her pregnancy in January. “I asked a lot of times to get the genetic testing, but they said the problem wasn’t serious enough,” Martina said. “When you are in such a situation, you are dependent on the doctors. You have no choice.”

When testing confirmed an anomaly causing serious bone problems, Martina was 28 weeks pregnant. Hospital staff told her she could seek an abortion outside of Italy but gave no further information: “They are afraid of even telling you where you can go because they worry about legal problems.”

Martina said she searched frantically online for information and contacted hospitals abroad, but several said they would not accept patients from Italy due to the Covid-19 crisis. Worried about border closures, Martina left for France in late February and eventually found a hospital where she had the abortion. She said she felt lucky to have made it out before the borders closed and to have had the necessary financial resources around €2,000 for the procedure and travel expenses.

There is no available information on how many women were unable to access later abortion, despite a serious risk to their health or lives, due to Covid-19-related travel restrictions.

While Law 194 requires annual reports on its implementation, no data is available regarding denial of abortion service, so it is impossible to know how many people were unable to get a medical or surgical abortion within the legal time limits or were denied services multiple times before finding an abortion provider.

Access to Contraception

People interviewed said that obstacles to abortion access should be considered in conjunction with lack of access to birth control in Italy. Free contraception through the national health service stopped in 2016, and only six regions now provide free hormonal birth control. Experts noted the cost of contraception in Italy can be prohibitive for poor women and adolescents. Birth control pills cost around €150 to €200 a year, and an intra-uterine device (IUD) around €250 to €300. Eleonora Mizzoni of Obezione Respinta said this creates “discrimination in access” to contraception.

In their June 8 letter to the health minister, nongovernmental organizations called for urgent measures during the Covid-19 pandemic to include free contraception in family planning centers, noting that the economic fallout of the pandemic may affect people’s capacity to purchase contraception.

Human Rights Obligations

Italy has obligations to uphold the right to the highest standard of health, including sexual and reproductive health, under international treaties to which it is a party, including the International Covenant on Economic, Social, and Cultural Rights (ICESCR), the Convention on the Elimination of All Forms of Discrimination against Women (CEDAW), and the European Social Charter.

United Nations treaty bodies have found denial of access to abortion can amount to violations of the rights to health, privacy, and freedom from cruel and inhumane treatment. The UN committee that monitors compliance with the ICESCR has noted that women’s access to comprehensive sexual and reproductive health is “essential to the realization of the full range of their human rights,” and said that countries should remove all barriers. In 2017, the UN Human Rights Committee and the committee that oversees implementation of CEDAW (CEDAW Committee) both raised concerns about persistent barriers to abortion in Italy and said that the government should ensure access to abortion services nationwide. The CEDAW Committee specifically said that Italy should ensure that conscientious objection “does not pose an obstacle for women who wish to terminate a pregnancy.” UN treaty bodies have noted that mandatory waiting periods constitute barriers to abortion access and called for their removal.

The European Committee on Social Rights ruled in 2013 and 2015 that Italy’s failure to ensure consistent access to abortion, including the overly broad practice of invoking conscientious objection, constitutes a failure to uphold the right to protection of health and nondiscrimination in violation of the European Social Charter.

The Council of Europe has said that all member states must ensure full access to reproductive health care, including abortion, in their responses to the Covid-19 pandemic and called on member states to “urgently remove all residual barriers preventing access to safe abortion.”