A mass in St. Peter's Square at the Vatican. Photo: Evandro Inetti/PA Images. All rights reserved.
Laura, from Naples, decided to terminate her pregnancy on 6 June 2008. The baby she was expecting had been diagnosed with down syndrome, she explains. “I was 21 weeks into my pregnancy, and I took this decision.”
Early one morning, Laura went on her gynecologist’s recommendation to a hospital where she was admitted and labour was induced. But, she says, “the ward for abortions was open only half-day, because there weren't enough doctors available.”
“At 1pm I was moved to the maternity ward. I stayed there for about 24 hours surrounded by women who were giving birth and doctors who were conscientious objectors and didn't take care of me,” she says.
Laura was left alone: nobody was monitoring her blood loss or her dilation, nobody was easing her physical pain or giving her information. She tells me: “I expelled the fetus at 9am [the next morning]. I was alone, with the umbilical cord still attached to my body. I had to scream to call a doctor.”
Four years later, Ilaria went to a hospital in Rome on 10 June 2012. She was 24 weeks into her pregnancy and the fetus had an extended lymphangioma (a congenital malformation of the lymphatic system). Doctors and specialists recommended an abortion; even if the baby survived, her health was endangered too.
“At 5pm a nurse gave me an intravenous catheter, then she left the room. The gynecologist came three hours later to induce labour. I was crying, but the doctor barely looked at me,” Ilaria says. Later, she discovered that this was the only gynecologist who performed abortions in the whole hospital.
Ilaria was in pain: “I screamed and threw up repeatedly, but nobody came. At 3.30am the nurses took me to the delivery room, where an obstetrician visited me without saying a word. As did everyone who came in the following hours. Meanwhile, I was still crying.”
At 6am Ilaria expelled the fetus. Like Laura, she was alone and had to ring a bell to call someone. Afterwards, Ilaria says she experienced dizziness, vertigo and difficulties breathing. But she was sent home by doctors who said “they had more serious things to manage, and they needed the bed.”
Laura wrote about her experience in a book published in Italian in 2012. She tells me: “Women need to know. When I decided to have an abortion I didn't know a lot of things. I wrote down what I'd been through and lots of women contacted me saying they had similar stories.”
Seven out of ten Italian gynecologists are conscientious objectors.
Abortion was legalised in Italy almost 40 years ago – in 1978, with a law (known by its number, 194) that allows women to terminate pregnancies during the first trimester, and after 90 days only if the mother’s life or health is at risk or if there are serious fetal pathologies.
This law was passed off the back of mass protests and a broader cultural liberation movement which saw women take to the streets to demand the right to choose. But, today, women across the country still struggle to access the abortion services they are legally entitled to.
According to the 194 law, doctors, nurses, anesthetists and other assistants can declare themselves conscientious objectors and essentially refuse to perform abortions. And many do.
In fact, data collected annually by the department of health shows that as many as seven out of ten Italian gynecologists are conscientious objectors.
In some regions, this figure is even higher. In Molise (in central Italy), for example, an astonishing 93% of gynecologists are conscientious objectors. Sicily and Lazio (where Rome is) are among other regions where this number is also over 80%.
Across the country, the department of health says that only 60% of all hospitals offer abortion services. But, despite these numbers, in late 2016 the department said, “regarding the exercise of conscientious objection...there are no critical issues in [access to] services.”
Silvana Agatone, a gynecologist and founder of the LAIGA association of non-conscientious objectors, tells me the law clearly states that hospitals must provide abortion services, both during and after the first trimester.
But, she says, “doctors who do abortions after the first trimester are very few,” giving the example of Lazio, where all seven doctors providing later-term abortions are in Rome.
“In the other cities of the region – Rieti, Frosinone, Latina, Viterbo – women don't have access to this service. And these towns are losing abortion care in the first 90 days too, due to increasing conscientious objection. This is a very serious fact,” Agatone says.
Indeed, last year the social rights committee of the Council of Europe said women’s rights were being violated in Italy as a result of widespread conscientious objection limiting access to safe abortion services.
It added that doctors who do not object also face discrimination and “various types of direct and indirect labour disadvantages.”
Here is your prenatal diagnosis. If you want an abortion, go elsewhere.
In 2013, Carla (a pseudonym) was 21 years old and didn't feel ready to be a mother. “I decided immediately,” she says, about her choice to terminate her pregnancy, in the first trimester. “But I couldn't have imagined that it would be so difficult.”
Carla called a hospital in Rome and was told to get there “very early in the morning.” She tells me she arrived at 6am and was sent to a ward in the basement, “like there was something to hide.”
She wasn't alone: “There was a line of women waiting, some of them had been there from 4am. The ward opened at 9am, and only for five or ten of us was there the possibility to access [abortion] services that day. I had to try another hospital.”
During the first 90 days, hospitals can call outside doctors to perform abortions. But, for women seeking “therapeutic abortions” (after the first trimester, as in Laura and Ilaria’s stories), the doctor must be a member of the hospital’s medical staff as labour must be induced. Here, conscientious objection becomes a bigger problem.
Meanwhile, the number of prenatal diagnosis centres is growing, even in Catholic hospitals. “Religious structures refuse to do abortions,” Agatone explains, and so they effectively tell women: “'Here is your prenatal diagnosis. If you want to an abortion, go somewhere else.”
What do women do? Many are forced to travel around until they find a hospital where they can access the services they need. “Sometimes they have to go to another city or to another region. Sometimes they go abroad,” says Agatone.
Overall, across Italy the health department has said that the number of abortions is going down. But Agatone says this fact alone ignores crucial questions.
She explains: “How many women ask for access to abortion care? We don't know. When women fail to get abortions in Italy, they try abroad or illegally. We know of women who have used pills to provoke miscarriages.”
Why are there so many conscientious objectors?
Maurizio Silvestri is a gynecologist at a hospital in Spoleto, a small city in the central Umbria region. He was a conscientious objector for almost his entire career – but he recently changed his mind.
He tells me: “I think that the legislator in 1978 could not have foreseen this epidemic of conscientious objection.”
Silvestri explains: “In Spoleto's hospital there has always been someone available [to perform abortions]. This fact allowed me to step back. If you're not not obliged to do abortions, you do not: you stand back and just look at things through the window.”
Three months ago, he retired his objection. He says: “I am sure that when I will be called to do an abortion – it has not happened yet – I will feel bad. But I know I would feel worse if I knew that a woman had died from a clandestine abortion because she couldn't find a gynecologist available to end her pregnancy in hospital.”
“Do I think that an embryo is a life? Yes, but a woman is too. Moreover, abortion is allowed by law, and we have to respect that,” he says.
This perspective – and this change in Silvestri’s own position – isn't common, however.
The Vatican, located at the centre of Rome, has long influenced Italian politics and debates and the Catholic church’s opposition to abortion has increased stigma related to these services and women who ask for them.
In 2016, Pope Francis reaffirmed the Vatican's position and approved of conscientious objection by doctors. “The family protects life at every stage,” he said. “We remind those who work in health facilities of their moral duty to conscientious objection.”
Earlier this year, Nicola Zingaretti, governor of Lazio, advertised jobs for two gynecologists to join the staff at the San Camillo Hospital in Rome, specifying that these positions were for doctors who did not object to abortion.
This was a controversial move and it reopened debate in the media on the 194 law. The Italian Bishops' Conference said that Zingaretti’s advertisement “inhibits conscientious objection” and “distorts the structure of the 194 law that didn't aim to induce abortion but to prevent it.”
"March for Life" in Rome. Photo: Claudia Torrisi.
In 2015, an Ipsos public opinion survey found that 15% of Italian respondents agreed that abortion should never be permitted or only when the mother’s life is in danger. In contrast, that percentage was 1% in Sweden, 3% in France, 5% in the UK and 6% in Germany.
Last month, thousands of anti-abortion activists joined a "National March for Life" in Rome. Organised by a network of pro-life associations, it was the seventh Italy has seen since 2011.
Fringe Catholic organisations with names like Militia Christi and Generazione Famiglia, and right-wing political groups – including Noi con Salvini, Fratelli d’Italia, and Movimento Nazionale per la Sovranità, founded by former mayor of Rome Gianni Alemanno – took to the streets carrying signs and banners saying "Choose life" and "Stop abortion now.”
But Agatone suggests that widespread conscientious objection in Italy has little to do with religious or moral beliefs – and more to do with doctor's careers.
“Non-objector gynecologists are often seen as the 'dirty' ones, sometimes colleagues isolate them,” she says. “Moreover, they have more difficulties in advancing their career. The reason is simple: the majority of hospital directors are conscientious objectors, and they often come from religious schools. So in turn they tend to prefer doctors who are objectors.”
According to Agatone, the situation could indeed get worse. She says: “New generations feel that it is better to be objectors, that it's easier. They think that somebody else will do this 'dirty work' for them. But the risk is that soon there really will be nobody.”