Abstract
BACKGROUND:
Induced abortion is a medical practice that has always been much discussed all over the world. Abortion is allowed in most European countries at the request of the woman with limitations that are imposed mainly by the gestational age. However, there are legislative differences between European countries which impose stringent limits on the use of induced abortion.
OBJECTIVE:
This article analyzes the European legislation on abortion, with a particular focus on countries in which there have been recent legislative changes in recent years, and the possible consequent risk of inequality among European women.
METHODS:
Government and ministerial websites of the countries analyzed have been consulted to investigate abortion laws in Europe. In addition, the Global Abortion Policies Database of the World Health Organization was also consulted for a regulatory comparison.
RESULTS:
The differences between the various European countries are considerable. Although guaranteed by most legislation, abortion remains a fragile right in some European countries.
CONCLUSION:
Different legislation in the various countries of Europe causes difficulties for women who want to have an abortion but who reside in states where there are strict limits to abortion. In addressing the issue of induced abortion, we must not forget that the center of this practice is the woman. For this reason, it is essential to apply a reasoning based on respect for women’s rights: freedom, health, and self-determination.
Background
Abortion legislation varies considerably depending on the country of origin. Historically abortion has always been particularly debated; in fact, in the past it was considered a crime in most countries (Common Law, Civil Law, Islamic Law), therefore this medical practice was prohibited by the end of the nineteenth century [1].
Abortion has been banned in the past mainly for public health issues related to the dangerousness of this practice and for problems of a religious or ethical nature. Especially recently, the bioethical debate on abortion – often characterized by religious aspects – has increased considerably. The main problem in this area is the identification of a balance between the rights of the mother (self-determination and health) with the rights, if present, of the fetus [2].
The first International Act that could be traced back to the debate on abortion was the “Declaration of the Rights of the Child”, promulgated in 1959 by the United Nations Assembly [3].
This act protected the right to life and, by some, was used to support the thesis “pro-life”.
At the same time, in the same years, feminist movements in the United States and in Europe were spreading, advocating the right of women to self-determination, and calling for the legalization of abortion [4].
In the United States, in 1973, with abortion became legal after the Supreme Court ruling (Roe v Wade) [5]. In Europe, after World War II, many countries progressively legalized abortion.
Currently, worldwide, there are numerous states that prohibits abortion entirely or permits it only to save a woman’s life. As a result, a large percentage of women cannot freely have access to safe abortion [6].
Furthermore, there is still a considerable debate in Europe today on the right to abortion. For example, according to a recent survey, European citizens opposing the right to abortion are increasing [7]. Compared to 2014, in Germany, France, Spain and Italy there was a decrease of people in favor of abortion, respectively, of 9%, 6%, 5% and 3%.
The objective of this article is to analyze the European legal references on abortion to identify any existing inequalities - resulting in inequity and inequality - among European women.
Methods
Government and ministerial websites of the countries analyzed have been consulted to investigate abortion laws in Europe. In addition, the Global Abortion Policies Database of the World Health Organization (WHO) was also consulted for a regulatory comparison. In the research, particular attention has been paid to the limits and conditions for carrying out abortion (medical and surgical).
Results
The results refer to EU Country, law in force, gestational limits and conditions, and medical abortion conditions (with Mifepristone and Misoprostol). To facilitate the reading of the data, the results are summarized in the Supplementary Appendix.
Discussion
As our study has shown, the differences between the various European countries are considerable. In Europe, abortion is provided for and regulated by national legislation in 26 countries, the last country to have legalized it was Ireland in 2019. In Poland the possibility of performing an abortion is severely limited while Malta prohibits it completely.
Although guaranteed by most legislation, abortion remains a fragile right in some European countries. Abortion is a frequent subject of political and social debate, moreover, it is often hampered by problems of access to service. For example, the possibility of carrying out a safe abortion is also limited by waiting times, requests for unnecessary medical examinations or checks, economic costs, authorizations, and the presence of health care conscientious objectors.
In view of the continuous legislative evolution inherent in abortion, it is also important to focus on the European countries that have recently, in recent years, modified the specific legislation.
Italy
In Italy abortion is regulated by law 194/1978 which imposes the limits of abortion and the protocol to be followed for this medical practice [8,9]. The law stipulates that abortion is possible within the first 90 days of gestation for health, social, economic, or family reasons. Then the woman is allowed to abort, within the first 90 days of gestation, in case the birth of the child could cause health damage or socio-economic and family discomfort. The law requires the support of the woman who wants to have an abortion. In fact, it is the doctor must: propose alternative solutions to abortion; check whether it is possible to remove the conditions that led the woman to opt for abortion; propose to the woman to reflect for 7 days before deciding definitively to abort (except in cases of urgency). The aim of the law, which imposes this procedure, is to protect motherhood, prevent – if possible – abortion, and protect the health of women. If the woman has passed the 90 days of gestation, the law prevents abortion in the absence of specific reasons. In fact, in Italy it is possible to abort after 90 days of gestation only if there is a serious danger to the psycho-physical health of the mother. The risk to women’s health must, according to the law, be carefully assessed by the doctor and must be real and concrete. In these cases, abortion is defined as therapeutic. In addition, the law also provides specific directives for contraception [10].
In Italy, in addition to the classic surgical abortion, it is also possible to carry out medical abortion. This procedure involves the use of mifepristone. In Italy, in August 2020, following an intense debate on this issue, the Ministry of Health has released a measure called “Guidelines on voluntary termination of pregnancy with mifepristone and prostaglandin” [11]. In this document the permitted conditions for medical abortion were updated. Thanks to this measure Italian women can access the medical abortion up to 9 weeks of gestation and without the need for hospitalization. This measure was also taken to facilitate access to abortion during the COVID-19 health emergency [12,13].
Poland
In Poland, abortion is not legal if it is a woman’s free choice. In fact, since 1993, the only cases in which Polish women can have abortions are: incest, rape, or cases in which the health of the mother could be seriously compromised by pregnancy. Until 2020, in Poland, it was also possible to abort in case of fetal abnormalities. However, in October 2020, the Polish Constitutional Court declared the unconstitutionality of abortion related to fetal abnormalities [14]. The judges said that abortion due to fetal defects corresponds to eugenic practices. As a result of this ruling, there have been numerous protests from Polish women. In fact, this decision of the Constitutional Court has been seen by many as a step backwards about women’s rights to self-determination and health [15]. The risk, which many have pointed out, is that this further legal limit of abortion in Poland induces women to choose illegal abortion with significant health risks. The alternative is that Polish women will have to go to neighboring countries like Germany to be able to abort safely [16].
Republic of Ireland
In Northern Ireland, until 2019, abortions were effectively prohibited except in cases of life-threatening women. In fact, the Criminal Justice Act from 1945 prohibited abortion even in the case of rape and incest [17]. In 2018, Irish parliament passed the Health Act [18] in which the new legal limits of abortion in Ireland were defined: legal abortion up to 12 weeks’ gestation and/or in cases of serious risk to the health of the mother and/or in case of fetal anomaly. Subsequently, in March 2019, the Northern Ireland Act entered into force. This law, passed by the British Parliament, also extended to the Republic of Ireland some civil rights, including abortion. Immediately after the entry into force of the new law, in Northern Ireland, there was a significant increase in abortions performed safely. In fact, the number of registered abortions has increased from 32 in 2018 to 6,666 in 2019 [19].
Despite this important evolutionary step in abortion legislation, in the Republic of Ireland, women who want to have an abortion still have many difficulties in specific cases. In fact, to abort, a too high risk to the health of women is still necessary. Women who have a moderate risk cannot have abortions in Ireland. Even in case of nonfatal fetal alterations it is very difficult for a woman to have access to abortion [20].
Iceland
In Iceland, abortion has been legal since 1975. In particular, it was not possible to perform an abortion on demand, but it was possible to abort in some specific cases. In fact, abortion was allowed in case of serious danger to the psychophysical health of the mother, in case the mother could not take care of the child because of age or mental disability; in case of serious fetal abnormalities. In all these cases the legal limit for abortion, until 2019, was 16 weeks of gestation [21]. In 2019, the Icelandic parliament validated a law that allows abortion up to 22 weeks of gestation [22]. This law has been much discussed as it allows abortion at a very advanced stage of pregnancy. In addition, the liberalization of abortion in Iceland has already been criticized in the past especially as regards the very high percentage of women who decide to abort in the case of a fetus with Down syndrome [23].
Risk of inequality among European women
There are still countries in Europe where there have always been significant restrictions on this medical practice [24]. It is, however, particularly important to draw attention to the recent limits imposed in an important European country: Poland. As already described, in Poland, it is considered unconstitutional to abort in case of fetal abnormalities. The Constitutional Court has stated that abortion in these cases is tantamount to eugenics. In Poland, public opinion has always been tendentially against abortion [25]. However, Poles have recently shown greater support for abortion [26].
In any case, not being able to abort in case of fetal abnormalities could cause a serious social and psychological discomfort for the woman. In fact, of course, not all women are ready to face motherhood with a child suffering from serious congenital and/or genetic diseases. Therefore, the decision to continue the pregnancy should be taken exclusively by the mother and not imposed by law. The consequences of this recent onslaught in Poland can be mainly two. The first is that the mother will give birth but will face serious social and psychological discomfort that could worsen to the point of causing a psychiatric pathology (for example depression) [27]. In this case neither the health of the mother nor, consequently, that of the child would be safeguarded. The second possible consequence is that Polish women will be forced to emigrate to other countries to have an abortion. This possibility has already been realized in the past [14]. Unfortunately, not all Polish women can afford a trip to get an abortion. Therefore, many women could take advantage of illegal abortion in the absence of health protection and with serious risks to health and life.
Even in Northern Ireland, although recent legislative changes have legalized abortion, there are still considerable limitations (not by law but in fact), as previously stated [18]. So many Irish women will still be forced to emigrate to be able to abort safely.
Therefore, looking at the recent legislative changes concerning abortion in European countries, it emerges that most of these changes are pro-abortion. However, as in the case of Poland and Northern Ireland, there are still many limitations not justified by scientific reasons but exclusively by religious and social reasons.
These limits are a serious violation of women’s rights to self-determination and health. The consequences of this violation are potentially very serious, especially during the health emergency COVID-19 [28]. Indeed, at a time when national health systems are under considerable pressure and world governments are imposing various restrictions, there is a further decrease in the protection of women’s right to abortion. Governments should therefore pay particular attention to the protection of abortion at a difficult time such as this. For example, in Italy, access to medical abortion was facilitated to continue to protect women’s rights during the pandemic [10,11]. Instead, as in certain situations in Poland and Northern Ireland, forcing a pregnant woman to change state to have an abortion, is dangerous for women’s health and creates serious inequalities between European women.
Conclusion
It is believed that the limits to be imposed for abortion should be decided by the scientific community, based on evidence-based medicine. However, unfortunately, as happened recently in Poland, it is often the judges or politicians who impose legal limits on abortion. It is very serious that these limits are not imposed for scientific reasons but exclusively for religious or social reasons.
In conclusion, it is considered that, in the matter of abortion political/social/religious opinions should not influence the limits imposed by the law. The top priority should be women’s health and their right to health and self-determination [2].
