Conscientious objection and voluntary abortion in Italy: what has changed in the last two decades?

Background: Italian Law 194/1978 allows voluntary termination of pregnancy within the first 90 days and guarantees healthcare professionals the right to conscientious objection (CO). However, concerns have been raised internationally regarding potential barriers to access due to the high prevalence of objecting providers. This study investigates trends in voluntary abortion in Italy over the past two decades, focusing on whether the additional workload for non-objecting gynaecologists is associated with delays in access and later gestational age at the time of abortion, and on the possible role of medication abortion in improving timeliness. Methods: An ecological study was conducted using official data from the Italian Ministry of Health on voluntary terminations of pregnancy between 1997 and 2022. Indicators included the extra workload of non-objecting gynaecologists, the proportion of abortions performed within 14 days of request, gestational age at abortion, and use of medication abortion. Spearman's rank correlation coefficients were calculated at both the national and regional levels. Results: Marked regional variability emerged across Italy. In 13 out of 21 regions, an increased workload for non-objecting gynaecologists was associated with a lower proportion of abortions performed within 14 days and with procedures occurring at later gestational ages. Conversely, the use of medication abortion showed a strong and statistically significant positive correlation with both timely access and earlier gestational age at termination. These patterns were consistent in both regional and national analyses. Conclusions: The findings suggest that increased workload for non-objectors may be associated with delays in accessing voluntary abortion services in Italy. Expanding the use of medication abortion may help mitigate some CO-related barriers by enabling earlier and less resource-intensive care. However, this potential benefit depends on adequate service organisation, sufficient non-objecting providers, clear referral pathways, and systematic monitoring, all of which are essential to support the equitable implementation of a legally guaranteed service.