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The Impact of Gynecologists' Conscientious Objection on Access

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The Impact of Gynecologists' Conscientious Objection on Access Draft for the PAA annual meeting. Please do not quote or circulate The Impact of Gynecologists’ Conscientious Objection on Access to Abortion in Italy Tommaso Autorino ∗ ,† Francesco Mattioli *,‡ Letizia Mencarini*,§ April 2018 Abstract Abortion in Italy is free of charge and legal in a broad set of circumstances, but 70.9% of gynecologists refuse to partake in procedures leading to the voluntary interruption of pregnancy on grounds of personal beliefs. We assess whether conscientious objection is linked to the inter- regional migration of women seeking an abortion. We first perform a panel data analysis at the regional level, showing that a higher prevalence of objecting professionals is associated to a higher share of women having an abortion outside the region where they reside. Secondly, analyzing individual data, we find that conscientious objection is a significant driver of the personal decision to move across regions to obtain an abortion. Overall, results suggest that conscientious objection is significantly associated to abortion-related migration. 1 Introduction Italian law permits abortion in a broad set of circumstances, while granting healthcare personnel the right to abstain from performing abortions for reasons of conscientious objection. Most European countries allow conscientious objection to abortion, but the Italian case is noteworthy for the well-documented prevalence of the phenomenon, involving more than 70% of gynecologists nationwide, with peaks above 85% in some regions. Conscientious objection is a topic of lively debate in Italy, with opponents arguing that the lack of non-objecting personnel limits access to abortion, imposing a constraint onto the individual choice of how to resolve pregnancy. On the other hand, the Italian Ministry of Health – commenting 2016 data – stated that the number of abortion providers is sufficient to grant easy access to the service and any difficulty in this respect is imputable to organizational shortcomings at the local level. Indeed, there is no ∗Carlo F. Dondena Centre for Research on Social Dynamics and Public Policy, Bocconi University - Milan, Italy †[email protected] ‡[email protected] §[email protected] 1 empirical evidence that confirms or rebuts a causal relation between conscientious objection and demand for abortions in Italy, but the high share of women obtaining an abortion outside of their region of residence suggests that abortions might be harder to obtain in certain parts of the country. Many studies that provide an economic characterization of abortion indicate the availability of providers and the costs of obtaining an abortion (including travel costs) as important drivers of abortion demand. Drawing on this literature, our study aims at assessing whether conscientious objection induces women to travel in order to find an abortion provider. We analyze data at the regional level in the period between 2002 and 2016, and find that on aggregate widespread consci- entious objection is associated with more women travelling out of their region in order to obtain an abortion. This finding is confirmed with the analysis of individual data on abortions recorded in Italy between 2002 and 2014, showing that women residing in regions where conscientious objectors are more numerous are more likely to obtain an abortion in another region. 2 Previous Research Much of the literature that aims at estimating the impact of abortion regulation on abortion rates rests on an economic model of fertility control. Within this framework, abortion is treated as a contraceptive method of last resort and the two successive decisions of whether to conceive and whether to carry a pregnancy to term respond to an array of economic variables that weigh the cost of contraception versus the opportunity cost of an additional child. The cost of obtaining an abortion encompasses the price of the medical procedure as well as indirect costs, such as the time and travel devoted to find an abortion provider, and psychic costs that may arise depending on individual and societal attitudes towards abortion. Policy that regulates abortion can affect each of these cost components, changing the terms of the individual decision on how to resolve a pregnancy, potentially resulting in large-scale impact on abortion and birth rates. Many studies look at cross-state differences in abortion regulation in the USA. Medoff (2013) provides an extensive review of this literature, while here we present only some relevant examples. Medoff (1988) finds that abortion demand is sensitive to price, restrictions of public funding of abortion1 and socioeconomic variables. The negative impact of state funding restrictions on abortion rates is confirmed by Levine, Trainor and Zimmerman (1996) and Cook, Parnell, Moore and Pagnini (1999). This strand of research shows that even minor variations in the abortion price can affect the decision of having an abortion, but such findings are hardly applicable to the case of Italy, where in 2016 94% of abortions were performed free of charge within the public healthcare system. However, price is not necessarily the most relevant determinant of the decision to seek an abortion. Gober (1994) criticizes Medoff (1988) for disregarding cross-state differences in terms of abortion regulation and availability of abortion providers, and suggests that abortion rates should be interpreted as a measure of availability of abortion, rather than a measure of demand. A number of studies evaluate the impact of provider availability in the USA, focusing on the link 1Following the liberalization of abortion in the USA, abortions were initially funded in all states under the Medicaid program. Later on, abortion was excluded from federal funding, but a number of states continued to subsidize abortions at their own expense. 2 between abortion supply, travel costs and abortion demand. Deyak and Smith (1976) study this aspect in a pre-liberalization setting2, analyzing individual data of women who travelled to New York to obtain an abortion. Results suggest that a state’s distance from New York significantly affected the likelihood that state residents would seek an abortion. Brown and Jewell (1996) and again Brown, Jewell and Rous (2001) obtained similar results with individual data from Texas, showing that women residing further away from an abortion provider were less likely to obtain an abortion. Scarce abortion supply may be associated with other inconveniences beyond travel costs, such as costs for overnight lodging, absence from work, privacy concerns and difficulty to obtain information and post-abortion care (Haas-Wilson, 1993). Provider availability may affect access to abortion also through other channels, such as signaling social acceptance of abortion and discouraging the use of other means of contraception (Brown and Jewell, 1996). To assess the impact of provider availability, some models incorporate a variable measuring abortion supply directly, rather than through travel costs. For example, Haas-Wilson (1997) finds that the number of abortion providers per 1,000 women in childbearing age is positively associated with abortion rates and concludes that women travel to obtain an abortion in states with greater supply. Matthews, Ribar and Wilhelm (1997) find that provider availability contributes to explain variations in abortion rates overtime, but conclude that the major determinant of abortion demand is the demographic structure of the population. Gius (2007) combines individual-level data on pregnancies, abortions and socioeco- nomic status with state-level data on abortion providers and legal restrictions to abortion, finding that provider availability has a statistically signicant effect on abortion rates, while legal restrictions have no significant impact. Blank, George and London (1996) make an important distinction between two alternative measures of abortion demand at the state level: the abortion rate by state of occurrence, based on the number of abortions taking place in each state, and the abortion rate by state of residence, which instead counts abortions from women residing in each state. Their results indicate that provider availability is a significant determinant of the first measure only, sug- gesting that abortion supply does not determine whether a woman will have an abortion, but where. In general, the literature supports an economic interpretation of abortion demand and indicates that direct and indirect costs of abortion, together with demographic and socioeconomic character- istics of the population, affect women’s contraceptive behaviour and abortion rates. The availability of abortion providers often appears as a major determinant of abortion use, although some studies reach different conclusions. For instance, Medoff (2002) uses an index of restrictiveness of a state’s abortion policy and finds that this measure does not contribute to explain cross-state variations in abortion rates or out-of-state abortions. Medoff (2010) examines TRAP laws – i.e. laws that impose cumbersome requirements and a licensing fee on abortion providers – and concludes that these do not affect abortion rates, despite curbing abortion supply. Importantly, a number of studies suggest that disparities across states in terms of abortion regulation and supply impact on states’ abortion rates not by preventing women from having an abortion, but inducing them to move where it is easier to obtain one. Conscientious objection to abortion is rarely mentioned in this literature. Meier, Haider-Markel,
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