Ministry of Health REPORT OF THE MINISTER OF HEALTH ON THE IMPLEMENTATION OF THE LAW CONTAINING NORMS FOR MATERNITY PROTECTION AND FOR THE VOLUNTARY TERMINATION OF PREGNANCY (LAW 194/78) FINAL DATA 2014 and 2015 Rome, 7 December 2016 Table of contents PRESENTATIO N ............................................................................................................................................................................1 DATA COLLECTION SYSTEM .........................................................................................................................................8 FINAL DATA AND ANALYSES OF VTP PERFORMED IN 2014 AND 2015...............................................10 General trends .......................................................................................................................................................................... 10 1.1 . Absolute numbers ...................................................................................................................................................... 12 1.2 . Abortion rate............................................................................................................................................................... 13 1.3 . Abortion ratio ............................................................................................................................................................. 16 Characteristics of women who resort to VTP ...................................................................................................................16 2.1 Age classes..................................................................................................................................................................... 17 2.2 Civil status .................................................................................................................................................................... 20 2.3 Educational attainment............................................................................................................................................. 21 2.4 Employment ................................................................................................................................................................. 22 2.5 Place of residence ........................................................................................................................................................ 23 2.6 Citizenship .................................................................................................................................................................... 24 2.7 Obstetric history ......................................................................................................................................................... 27 2.7 .1 Number of live childbirths .................................................................................................................................... 27 2.7 .2 Previous s pontaneous abortions ...........................................................................................................................29 2.7 .3 Previous voluntary abortions ............................................................................................................................... 30 VTP procedures ....................................................................................................................................................................... 32 3.1 Documentation and certification .............................................................................................................................32 3.2 Urgency.......................................................................................................................................................................... 33 3.3 Gestational age ............................................................................................................................................................ 34 3.4 Waiting times between the issuing of the document/certification and the intervention.......................... 36 3.5 Facility where the abortion was performed......................................................................................................... 37 3.6 Type of anesthesia used............................................................................................................................................. 38 3.7 Type of procedure....................................................................................................................................................... 39 3.8 Duration of hospitalization....................................................................................................................................... 41 3.9 Immediate complications from VTP ......................................................................................................................42 CONSCIENTIOUS OBJECTION AND AVAILABILITY OF VTP S ERVICES (2014 data).......................... 44 1. General trends ............................................................................................................................................................... 44 2. Results of regional and sub-regional monitoring ................................................................................................. 44 PARAMETER 1: Availability in relation to the number of facilities.................................................................... 45 PARAMETER 2: Availability in relation to the female population of childbearing age and birth centres 47 PARAMETER 3: Availability in light of the right to conscientious objection in relation to the weekly number of VTP performed by each non-objecting gynecologist.................................................................... 48 3. Activity of family planning clinics for VTP ............................................................................................................54 4. Implementation of Law 194/78 and Council of Europe...................................................................................... 56 TABLES FOR 2014 ............................................................................................................................................................... 58 TABLES FOR 2015 ............................................................................................................................................................... 92 PRESENTATION Mister President, Honourable Colleagues, This Report presents and analyzes final data for 2014 and 2015 on the implementation of Law 194 of 1978, which establishes norms for the protection of maternity and for the voluntary termination of pregnancy (VTP). Since many regions had final data for 2015 available as early as June 2016, and since this data, together with preliminary data from other regions, indicated a significant drop in VTP, we decided to extend the data collection effort by two months, in order to obtain from all regions the final data for both 2014 and 2015 (the year prior to the current one). Thanks to the digitalization of information flows in many regions, the administrative sanctions introduced by ISTAT against facilities that perform VTP and do not transmit their data (Official Journal – gen. series - n. 242 of 15 October 2016), and the excellent job done by our regional liaisons, we were able to obtain complete final data on VTP for 2014 and 2015, with the exception of data on conscientious objectors for 2015. Since the beginning of my mandate, the implementation of Law 194 has been the focus of particular attention and of an extremely detailed and complex monitoring effort at the sub-regional level, which requires an ad hoc questioning of the regions every year. The survey was carried out for 2014, but it was not possible to bring it forward for 2015, as was done instead for the remaining flow of data, which was final. FINAL DATA 2014 AND 2015 The number of VTP continues to diminish; Less than 90,000 VTP were performed in 2015; a total of 87,639 VTP were notified by the regions, a drop of 9.3% compared to 2014, when 96,578 VTP were performed (itself a drop of 6.0% compared to the 102,760 cases in 2013). The number of VTP has thus more than halved compared to the record high of 234,801 cases in 1983. The significant drop observed in 2015, in particular between the second and third trimester, may at least in part be linked to the AIFA ruling of 21 April 2015 (O.J. n.105 of 8 May 2015), which eliminates, for adults, the legal requirement for a medical prescription for the use of ulipristal acetate (ellaOne), an emergency contraceptive better known as the “morning-after” pill. Indeed, data on sales of ulipristal acetate (ellaOne) show a significant increase in 2015 compared to previous years (7,796 packages in 2012, 11,915 in 2013, 16,796 in 2014 and 145,1011 in 2015). Every indicator confirms this trend: the abortion rate (number of VTP for 1,000 women between the ages of 15 and 49), the most reliable indicator for assessing trends regarding recourse to VTP, was 6.6 per 1,000 in 2015 (-8.0% compared to 2014 and - 61.2% compared to 1983); it was 7.1 in 2014. This is one of the lowest values at the international level (see par.1.2). The abortion ratio (number of VTP per 1,000 live births) in 2015 was 185.1 per 1,000, a decrease of 5.7% compared to 2014, when it was equal to 196.2 (it should be kept in mind that the number