Abortion, Birth Rates, The New York Times

As the Italians say, it’s been raining on wet ground. Following my recent blog entry on contraception in Italy I received several emails from readers asking whether the rock-bottom Italian birth rate might be the result of a sky-high abortion rate. By amazing coincidence, two days later the New York Times published an article about abortions in Italy and how hard it can be to get one. So the subject matter of this post is overdetermined – I get to write a wonky post about abortions in Italy at the same time as firing off a Letter to the Editor.

Amazingly, the Italian Parliament legalized first-trimester abortion in public hospitals back in 1978, making it available on demand and free of charge on the National Health Service. Three years later a nominally Catholic electorate roundly scotched a Church-promoted national referendum that tried to re-criminalize it. The Church retreated licking its wounds but eventually hit on an excellent means of sabotage: conscientious objection. The law’s option for gynecologists to refuse to participate was originally intended to remain buried in the fine print but by now 70% of all Italian gynecologists are registered as conscientious objectors. So waiting lists, despite shrinking due to the increasing use of pills rather than surgery, are still scandalously long. One out of three women seeking a legal abortion is given an appointment more than two weeks away, which drives many (20%, it’s estimated) to get one illegally instead.

As the Times article points out, it’s obvious that conscientious objection and Catholicism are related. But the Church uses stronger weapons than mere moral persuasion in its promotion. I explain in the letter I submitted (in vain) to The Times:

To The Editor,

In her otherwise excellent article, “Abortion in Italy, a Right Wronged,” Ilaria Maria Sala omits one crucial element in why so many Italian gynecologists register as conscientious objectors. In addition to the genuine religious convictions of some, and the fear of others that performing abortions would tarnish their reputation, there are more practical threats to their livelihoods. Abortions are performed only in public hospitals, by gynecologists employed by the National Health Service. Many public system gynecologists, however, want also to be able to treat their own patients, after hours, within a large network of private hospitals which in Italy are mostly owned and/or run by the Catholic Church. Any physician who performs abortions – supposedly, any physician who even just counsels patients about them – is barred from operating, delivering babies, or hospitalizing patients in any Church-run institution. Thus a gynecologist who wants to be able to work privately in Italy is virtually obliged to declare him- or herself a conscientious objector to abortion.

So to get back to our original question, do abortions have a big influence on Italian birth rates? Nope. Italy has one of the lowest abortion rates in western Europe. In proportion to the number of babies born alive Swedish women have 40% more abortions than Italians, French women 35%, English and Spanish about 18%. And only one in five abortions performed on Italian women is a repeat procedure.

Since legalization there have been fewer and fewer abortions in Italy, especially among citizens – non-Italians, many of them immigrants from developing countries, now account for one in three.

The bottom line is that the Church has indeed succeeded in mounting barriers to abortion, especially in southern Italy, but those barriers can be overcome. And women here don’t have to run the gauntlet of demonstrators you find screaming abuse outside the entrances to abortion clinics in the USA. And no one has ever shot an Italian abortionist.

Scorecard: Babies

        United States  Italy

Women age 15-44 using modern contraception          70%     36%

Birth rate per woman                                                  1.8       1.4

What’s Their Secret?

When it comes to birth control Italians have a preference for the “natural” you can trace to the Catholic Church, which long since banished the contraceptive diaphragm and persuaded most people not to use IUDs, Pills, patches, rings, implants, Depo-Provera shots, or sterilization. Condoms, which Italians usually call preservativi – watch out what word you use for jam or you’ll get snickers – are fairly popular. But what most people do to avoid pregnancy is what they call stare attenti or being careful: watching the calendar, and using withdrawal on days they think (rightly or wrongly) that they’re fertile.

Nonetheless, the Italian birth rate hovers between the lowest and the next-to-lowest on the planet. How come? The main explanation is that – contrary to what I was taught in medical school – withdrawal works. It helps that Italy has a surprising culture of shared responsibility between men and women in this particular realm, so guys are more willing to use condoms, and more skilled at pulling out.

Ripping Off The System

Fraud is a worldwide sport but in Italy, land of Verdi and Puccini, it may get embellished by melodrama. Some years back the administrators at Rome’s Jewish Hospital figured out a solution for their hospital’s unbalanced budget and their own empty pockets: soak the National Health Service. In 2014, after some 20 million dollars had been siphoned off, their scheme hit the headlines with a bang. At first the conspirators had just been overcharging dental fillings as implants, or outpatient procedures as though the patient had spent the night. Poca roba, small stuff, as the Italians say.

The Jewish Hospital staff gradually escalated to shameless double billing and to inventing “ghost operations,” until one day the authorities planned a surprise inspection. That was when the plotters found themselves having to call on their native theatrical flair. A mole inside the regional National Health Service office tipped them off about the upcoming raid, giving them time to dress up an orthopedic ward as though it belonged to dentistry (don’t ask) and a private ward as though it were public. Phony medical charts were fabricated, complete with temperature readings and lab tests, and flocks of patients were shuttled between one ward and another. One hospital chief was caught on a wire tap telling a crony: “The inspectors are coming, it’s time for us to put our little piece of Hollywood into motion. You empty out the patients on the fifth floor, and we’ll cross our fingers.”

Now don’t be shocked, but even in the USA public medicine loses billions every year to greedy cheats. There are macroscams where clinics bill for medications that were never given or buy used equipment as though it were new. Middling scams where doctors and opiate pushers collude. And microscams – the only Medicare bill I’ve happened to see with my own eyes, related to a 3-minute visit for a non-smoker’s athlete’s foot, tossed in a charge for “Tobacco counseling.” All effective in their way, but sadly lacking in pizzazz.

So who’s worse? According to reports commissioned by the European Union, 13% of all the money spent on health in Italy gets lost through corruption, whereas outright medical fraud in the US is said to add up to only 3%. But if you join me in considering obscene overpricing to be tantamount to fraud – mebendazole pills for deworming your kids, two for a buck at your local Italian pharmacy, cost $442 per pill wholesale in the USA, and many American Emergency Rooms charge patients $1000 just to walk in the door before even seeing a nurse – maybe we can charitably call the contest a draw.