Beyond medical bureaucracy: an inquiry into the obstacles to abortion in a maternity ward in Italy

Beyond medical bureaucracy: an inquiry into the obstacles to abortion in a maternity ward in Italy Chiara Quagliariello1 Abstract Abortion experience has undergone a process of change over the past few decades, in tandem with the increasing number of doctors who refuse to perform the procedure. New actors and new practices characterise this contested procedure in Italian public hospitals. This paper analyses the health and social innovations related to abortion. I argue that even when there is no conscience-based refusal by health professionals, other obstacles hinder women’s right to access legal abortion. My study focuses on three aspects of the medical assistance offered to women: (i) the new obligation for doctors to provide information and ask for informed consent from patients before the abortion procedure can take place; (ii) the growing presence of men, such as women’s partners, during medical consultations aimed at abortion; and (iii) the growing influence of psychological consultations before and after abortion. Starting from the findings of a long-term ethnographic work, I examine to what extent these elements can be understood as new barriers to the implementation of women’s right to abortion in Italy. Keywords: abortion, informed consent, gender roles, post-traumatic stress, Italy. 1 chiaraquagliariello@yahoo.it 1 Beyond medical bureaucracy: an inquiry into the obstacles to abortion in a maternity ward in Italy Introduction Abortion, recognised as a fundamental right under Italian law (N. 194/1978), can be described as a conquest of the radical and feminist movements united in the struggle for the deconstruction of the supposed natural connection between being a woman and being a mother (Ortner 1974; Rich 1976; Tabet 1985). The idea promoted by these activists is that sexuality and reproduction have to be understood as separated spheres in women’s lives – a goal for which they have been trying to build an alliance since the 1970s with doctors as professionals able to provide contraception methods and ensure safe abortion (Libreria delle donne di Milano1987). Their aim has been to overcome the historical antagonism of these specialists, often represented by men, who consider abortion as a procedure that goes against the moral principles of the catholic religion. As several historians have pointed out, doctors were often absent during abortion. Like childbirth, until the 1960s abortion mostly occurred outside the hospital setting, and women were generally assisted by midwives (Enrenreich and English 1973). Despite the political efforts to bring doctors on the side of women and give the latter access to legal abortion, medical trends in Italy show a strong resistance to the normalisation of this procedure in a hospital setting (De Zordo 2015). The Council of Europe’s Committee of Social Rights denounced this situation in April 2016 after a complaint made in 2013 by the Italian General Confederation of Labour (CGIL, one of the most important Italian leftist trade unions) that underlined how access to legal abortion was nearly 2 impossible for Italian women, as most heath providers2 refused to carry out this procedure in hospitals. The protection of the right to life for the foetus, as well as the nexus between therapeutic abortion and eugenic practices, are some of the discourses promoted by Italian gynaecologists who refuse to perform abortion (De Zordo 2015). As evidenced by the Italian Ministry of Health, the number of health professionals defending such positions has always been relatively high (59,1 % in 1983), but it has particularly increased during the 2000s (70 %). The data published by the Italian Ministry of Health in response to European Council criticism shows how this phenomenon affects more public hospitals than private clinics, de facto restricting women’s right to free access to abortion. Furthermore, this trend is not equally distributed in Italian territories: a higher concentration of health professionals object to abortion in the southern regions (over 80%), and a lower concentration of these professionals object in the northern regions (over 60%)3. The experience of abortion has also undergone a process of change over the past few decades, in tandem with the increasing number of doctors who refuse to perform the procedure. New actors and new practices characterise this contested procedure in Italian public hospitals. This paper analyses the health and social innovations related to abortion. I argue that even when there is no conscience-based refusal by health professionals, other obstacles hinder women’s right to access legal abortion. My study focuses on three aspects of the medical assistance offered to women who desire or need to end their pregnancy. The first element is the new obligation for doctors to provide information and ask for informed 2 This category includes obstetricians-gynaecologists and anaesthesiologists but also midwives and nurses. 3 According to the statistical data of Italian Ministry of Health, in 2016, 13,3% of gynaecologists refused to perform abortions in Valle d’Aosta, 49% in Sardinia, 51,8% in Emilia-Romagna, 56,2% in Tuscany, 58,4% in Friulia Venezia Giulia, 63,6% in Lombardy, 65,4% in Liguria, 65,4% in Umbria, 67,4% in Piedmont, 68,8% in Marche, 72,9% in Calabria, 76,2% in Veneto, 80,7% in Lazio and Abruzzi, 81,8% in Campania, 86,1% in Apulia, 87,6% in Sicily, 90,2% in Basilicata, 92,9% in Trentino Alto Adige, and 93,3% in Molise. See http://www.repubblica.it/cronaca/2016/10/20/news/medici_obiettori_ecco_i_dati_r egione_per_regione-150182589/e [Retrieved 20 October 2016]. 3 consent from patients before the abortion procedure can take place. The second element is the growing presence of men, such as women’s partners, during medical consultations aimed at abortion. The third element is the growing influence of psychological consultations before and after abortion. My overarching aim is to examine to what extent these elements can be understood as new barriers to the implementation of women’s right to abortion: a trend that involves also hospitals that have historically been engaged for abortion in Italy (De Zordo 2016), such as the one where I carried out my research in Turin. Data and methods The analysis I propose is based on the findings of ethnographic work carried out in 2015 at a maternity hospital of Turin, the capital of Piedmont, in the north of Italy4. This hospital is one of the rare health facilities in Italy where women can choose how to give birth. Beyond the medical assistance provided by gynaecologists within the hospital space, women can give birth in a physiological birth centre connected to the maternity service, where midwives exclusively will assist them 5 . This hospital was also one of the first in Italy to introduce alternative abortion methods, such as pharmacological abortion instead of surgery within the second month of pregnancy and the use of local instead of general anaesthesia during abortion surgery after the second month of pregnancy. As is the case for 4 The Fundamental Rights Centre of Turin funded this research, entitled “Informed Consent, Health Democracy and Social Inequalities”. This anthropological and legal study was carried out between 2014 and 2016 by the author of this article and the jurist Camilla Fin. For more information on this study, see Quagliariello, C., Fin, C., eds., (2016), Il consenso informato in ambito medico. Un’indagine antropologica e giuridica, Bologna, Il Mulino. 5 In more than 90% of cases, birth assistance in Italy takes place in hospital. Women may choose to give birth at home or in birth centres if doctors attest there are no medical risks for the patient and the baby. Only a few hospitals, however, offer multiple choices for women’s assistance. The presence of birth centres linked to hospital services, for instance, only concerns small maternity units and not large hospitals like the one analysed in Turin where the average number of births is about 5,000 per year. 4 delivery, the idea connected to this broadened range of medical offerings is the implementation of women’s right to choose. The population of women assisted in this hospital is mixed and strongly stratified6. A first population is composed of local women from Turin who mostly belong to the upper classes. This category refers to women born in Turin, whose family has been living in Turin for more than three generations. Such a population corresponds to 25% of patients. A second population corresponding to 35% of patients belongs to the working class from southern Italian regions (especially Campania, Apulia and Sicily). This category refers both to women who were born in Turin but whose family comes from southern Italy, and to women who were not born in Turin but who have had some family members there since the 1960s. Members of this second group often choose to address northern Italian hospitals for abortion, as they cannot find gynaecologists to perform this procedure in the south7. A third population corresponding to 40% of patients is composed of international migrant women from Maghreb (Morocco and Tunisia), West Africa (Mali and Senegal), Eastern Europe (Romania, Ukraine, Russia) and South America (Mexico and Peru). This population has become increasingly numerous since the 1990s. In my research work I mostly used qualitative methodologies, such as participant observation during doctor-patient interactions. Over the course of four months I attended 25 medical consultations aimed at both non-therapeutic and therapeutic abortion. My participation in medical consultations always took place after I asked for and I received positive consent from the patients. During my research work I also made 21 interviews, 8 with health providers (gynaecologists and psychologists) and 13 with patients. The gynaecologists I interviewed were composed of four men and two women. The two psychologists were both women. The patients I 6 These data refer to the general population of women assisted in this hospital and not only to the patients who seek for abortion. 7 This presence within the maternity service is related to the migratory flows that have occurred since the 1960s from the south to the north of Italy, where people from the south became blue collar workers in the main production areas such as Turin. 5 interviewed were between 23 and 40 years old. Seven came from Turin and have a high level of education (a university degree). Four of them came from southern Italian regions and have a lower level of education (a high school diploma). Two of them were non-Italian: one was from Senegal and the other was from Morocco. Both were Muslim and had a lower level of education (middle school). Interviews with health professionals took place within the hospital space (medical rooms, meeting rooms, the canteen, or in hospital corridors), while the interviews with the women were realised outside the hospital setting (at their houses, in public bars, or at the park). During the interviews with women, partners were not included. This methodological choice aimed to make the women feel more comfortable while collecting their personal point of view on abortion. 1. Informed consent and women’s right to choose The main purpose of informed consent – a procedure adopted in American hospitals since the 1960s and introduced in Italy in the early 2000s – is the implementation of the right of patients to choose (Corrigan 2003; Mol 2008; Hoeyer and Hogle 2014; Edozien 2015). Unlike in the past, under the paternalistic health model, when doctors decided on the best treatment for patients without first consulting them, doctors operating under the health democracy model have to inform patients not only about the treatment they propose to perform but also about other medical options. According to the informed consent system, the patient has the right to accept, reject or negotiate the models of care suggested by doctors. He/she becomes the first person entitled to decide how to manage personal health issues according to his/her needs, desires or individual and political beliefs. As the anthropologist Sylvie Fainzang (2006) points out, however, the concepts of health democracy, self-determination of care and patient autonomy are problematic. According to Fainzang, patients exist in the gap between the values defended by informed consent and the concrete functioning of the medical system. At the same time, beyond the increasing importance assumed by other sources of knowledge such as Internet (Hardey 2001, 2004), the information provided by doctors is still the main factor on which health choices 6 are based. These phenomena concern all medical fields, including reproductive health issues. In the case of abortion, although women have the right to decide whether or not to interrupt their pregnancy, the manner in which doctors inform them may have a big influence on their choice. In the volume Faire vivre et laisser mourir, the sociologist Dominique Memmi (2003) highlights the bio-political dimension of medical consultations on reproduction issues. In her opinion, doctors exert a form of control on patients’ behaviour via the discourses they promote, the so-called gouvernement par la parole. As I could see during my research, this form of control persists even in the era of informed consent, with direct consequences on women’s choices. An additional element that emerged from my study is the non-uniform distribution of such control over the patients. In doctor-patient interactions the information aimed to increase patients’ awareness on abortion changes according to women’s profiles. Three elements appeared particularly influential in doctor-patient interactions. The first element is social class. The doctors shared the attitude of emphasising or omitting some information according to a woman’s level of education. In most cases, the greater the asymmetry of knowledge between the doctor and the patient, the greater the use of language aimed at underlining the physical problems caused by abortion. The use of specific words and adjectives stressing the negative consequences related to abortion, such as the side effects of anaesthesia on a woman’s fertility, is an example of this. Such a tendency mostly concerns medical interactions with women who belong to the lower classes, a population doctors consider easier to persuade not to abort. Through the same technique, which we can define as a form of governance via specific health narratives, doctors can suggest women from the lower classes end their pregnancy when severe perinatal health problems have been detected during the echography. The narrative proposed by doctors this time focuses less on the risks and other negative consequences, while a greater emphasis is put on the long-term benefits related to abortion (Manaï, Burton-Jeangros and Elger 2010). Such a choice is generally justified by the assumption that, beyond the economic means, cultural background is a decisive factor in the quality of care provided to children with health problems. Most doctors I interviewed are aware 7 that the way they speak with the patients may have an impact on their choice; nevertheless, as they underline, the narrative they choose to employ refers to the sense of responsibility they feel for the future baby (Boltanski 2004; Garcia 2011). The result of this attitude is the emergence of new forms of inequality in the information process instead of the achievement of women’s universal right to be informed to increase their autonomy about abortion choice. A second influential factor is national identity and a woman’s ethnic profile. In doctor-patient interactions, the quality of information doctors provide to Italian women is not always the same as the quality of information they give to migrant patients. This phenomenon is particularly common when the latter are Muslim. On the one hand, abortion requests from migrant women make up a far smaller proportion of the total (about 5%) than requests that come from Italian patients (about 95%). On the other hand, doctors devote less time to informing migrants, even when perinatal problems are detected during the echography. The average duration of interactions with migrant women is about half the time doctors allocate to Italian patients; while medical meetings with the latter last up to 30 minutes (or even an hour when one has to discuss the possibility of undergoing a therapeutic abortion), those with migrants last up to 15 minutes. When questioned about this, doctors underline how migrant women always want to keep their babies. Some health professionals emphasise to what extent scientific explanations are not beneficial for Muslim women, as the latter explain perinatal problems as something related to God’s will. One doctor described the effort he made to inform these women as a “waste of time”: Why we have to spend our time to speak about abortion with Muslim patients? We have to inform them about abortion even if we already know what they will choose. I have been working in this hospital for 20 years and in my career, I have seen two or three Muslim women have abortions if the baby is not fine. For them, all depends on the will of God. Even if we spend our time informing them, they will follow their religion. Honestly, would it not be better to use this time to do other things, for example to inform more of the Italian patients who, facing the same problems, really need to understand what to do? 8 As highlighted by these words, far from being considered as a rule applying to all, the time spent informing patients on abortion may seem to be well spent or wasted to health professionals, depending on the cultural characteristics of the patient. Another result of the information process, then, is the emergence of new forms of discrimination instead of the achievement of health democracy values (Charles, Gafni and Whelan 1999; Coulter, Entwistle and Gilbert 1999). A third factor influencing doctor-patient interactions is a woman’s life and family situation. Most doctors emphasise more the risks related to abortion when they speak with married women or patients who have a stable sentimental relationship. Working conditions also contribute to a classification of women into two main categories: those who, as doctors said, “would be better off ending their pregnancy as they could not be good mothers”, such as unemployed patients or patients not in a stable sentimental relationship; and those for whom, “it is a shame that they ask for abortion as they would be good mothers”, such as patients with a stable partner and a good job. The fact that doctors insist more on the bad sides of abortion with the second group of patients is representative of the choice to adjust medical information to a woman’s profile and personal life elements. Together with work conditions and sentimental relationships, aspects related to a previous maternity experience also play a role. Hence, the information given to women in their first pregnancy, and to women who have already had one or more children, is often not the same. Usually, the greater the number of children a woman has already had, the less doctors focus on the risks related to abortion during medical consultations. So, while other medical fields favour the modern, informed consent idea of patients as subjects able to decide what to do (or not to do) with their body and for their health, in cases of abortion, where the right for women to choose has been recognised since the 1970s, doctors’ attitudes in adjusting medical information to women’s histories and social profiles somehow limit patients’ awareness and influence their decision-making process. 9 2. The couple dimension in the abortion experience Social scientists and historians highlight how men have become crucial actors in experiences related to reproductive health since the 1980s and (more widely) the 1990s (Charrier and Clavandier 2013; Truc 2006). In many Western European and North American contexts, men are increasingly present during antenatal consultations; they attend training courses for childbirth (Ketler 2000); they are at the side of women during delivery (Quagliariello 2017); and they take part in medical meetings regarding breastfeeding (Gojard 2010). As a consequence, while in the past reproduction was understood as a sphere that mostly concerned women (Knibiehler 1997), it is now considered a domain in which men are also involved. At the same time, the male presence during medical consultations – in over 90% of the cases this presence is represented by women’s partners – has become the way couples show the solidity of their sentimental relationship to medical staff. As it emerges from abortion experiences, these historical trends have a strong impact on medical assistance, to the extent that they can turn into new emerging challenges to women’s personal rights. The common request from doctors for a couple consent to abortion is emblematic in this regard. The doctors I interviewed preferred to inform both individuals in a couple about the detection of a foetus’s physical or genetic problems. According to the doctors, the need to speak with both parents concerns both married and unmarried couples; hence, the choice is always made to include the father of the coming baby in medical consultations. The male presence is expected and required by doctors, even when abortion is not connected to any health problems. Only a few doctors prefer to interact just with women in non-therapeutic consultations. Sometimes health professionals choose to speak individually, first with the patient, and then with the partner. In this case, however, partners are also requested to give their opinion and sign the informed consent for abortion. Therefore, despite the right under Italian law to choose whether to continue the pregnancy being an individual right allowed to women, access to abortion has de facto become an experience to be shared by both members of a couple. 10 In some situations, a male presence may represent a support for women, who describe sharing medical consultations with their partner positively. Some women underline how they feel less responsible for the choice they make with their partners. Other women have the impression their partners can protect them against hostility from their own families. Other times, however, women describe a male presence as a problem or as a limit on their personal choice. This opinion especially emerged from women who preferred not to explain the reasons for their choice to the doctors, as they feared their partner reaction. The story of Maria, 34 years old, is representative of the difficulties encountered by some of the women who cannot speak with doctors because of their partner’s presence during medical consultations. The first time I met her, Maria was undergoing her first consultation. She arrived at hospital together with her partner Pietro. They had been engaged for four years but were not married. When the doctor called her, Pietro followed Maria in the corridor to enter with her into the medical room. She did not refuse his presence, but through the expression on her face she showed a discomfort the doctor did not seem to notice. During the consultation, Maria emphasised that she did not feel ready to become a mother. In her opinion it was not the right time to have a baby. From his side, Pietro highlighted to the doctor that they had not come to a final decision and were still reflecting on their choice. While Pietro was speaking with the doctor, Maria looked at the ground without saying anything. Two weeks later, the couple came back to hospital for a second medical consultation. On this occasion, they signed the informed consent for abortion to be performed after 48 hours. During the medical meeting, Maria looked quite worried. She never looked at the doctor and said only a few words. Some days after the abortion, I went to visit her at home. It was the first time we had met in a non-institutional context and without her partner. During our meeting, she told me: In the hospital I could not speak. Did you notice this? I was often silent. There was something secret I could not share. I cannot say I wanted an abortion, as I got pregnant after a relationship with another man. Could I say this in front of Pietro? I don’t think so. Could the doctor imagine something like this? I don’t know. Actually, my decision would have been the same but it would have been better for me if I could speak to the doctor without lying. 11 Women can also feel ashamed to share their thoughts with the doctors in other situations. The fear of looking like bad wives or bad mothers was described as a common feeling by patients who wanted to pursue individual projects, such as professional career, instead of investing themselves in the maternity experience. Despite these women’s lack of motivation to have a baby, they have the impression that their refusal to become mothers might hurt their sentimental relationship. Hence, some of them choose not to follow the abortion procedure after the medical consultations they underwent together with their partners. The latters exert a similar influence in women choice to undergo prenatal diagnosis (Browner 1997; Dixon-Woods et al. 2006). Alessandra, 36 years old, describes the alliance she perceived between the doctor and her partner as a contemporary paradox. As she highlights the woman’s opinion should count the most in abortion decisions: Sometimes I had the impression the partner’s will counts more than the woman’s desires in medical consultations. Doctors today use the partner’s point of view as a support to convince women to keep the baby. This is really paradoxical. According to the law, it is the woman that has to decide what to do when she is pregnant. The male presence in medical consultations looks even more problematic when partners have opposite opinions about abortion. As I could see, this situation can lead to the emergence of conflicts that force doctors to reschedule the expected medical appointment. The fact that, as doctors write in health records, the couple are still confused about their choice can endanger women’s right to access legal abortion. With the exception of therapeutic abortion, women can access abortion procedure under the Italian law not later than the third month of pregnancy. Many times, however, women do not immediately realise they are pregnant, so the time they have to ask for abortion is less than three months. Additionally, because of the small number of gynaecologists who accept to perform abortions, many professionals prefer to treat the most urgent cases first, such as women who are already in their third month of pregnancy. The result of this structural problem is that women cannot always access these professionals in the first months of their pregnancy. In many cases, 12 then, even when women are already in touch with gynaecologists, official medical consultations take place only few weeks before the delay set by the law and couples have little time in which to make their final decision. The reactions shown by health providers to women’s choice to undergo medical consultations without their partners also underline the great importance given to the couple dimension in the abortion experience. As I could see, health professionals generally question women if the male partner is absent. Through their questions, doctors try to understand to what extent a partner is aware that the woman is pregnant. Whether or not doctors discover that patients do not want to share their decision to abort with their partners, one common reaction is to emphasise to women how they might regret such an “individualistic choice”. Some doctors may also suggest that women come to see them only after they have tried to speak with their partners. This kind of attitude especially concerns doctor interactions with married women. The approach of doctors towards unmarried women appeared somehow more tolerant since, as most health providers underline, these are pregnancies that still occur beyond the social norm. Thus, in a historical moment where (and not only in Italy) one of the rules promoted in the hospital setting is privacy – such as the patients’ right to make medical choices without the obligation to inform their families – the increasing perception of male partners as being part of the abortion experience may limit women’s autonomy in the decision-making process. In this scenario a different attitude emerged between male and female gynaecologists. In the medical consultations I attended, the female doctors often showed a greater engagement to support patients who did not want to share the abortion experience with their partners. Usually, female gynaecologists spent more time to talk with women about their personal needs. Compared to consultations with male gynaecologists, medical interactions with female gynaecologists appeared more focused on the woman’s point of view on abortion, and questions about partners thoughts are less numerous. This gendered approach opens an inquiry that should be explored in future research, such as to what extent a new female alliance for abortion is emerging in Italian public hospital. 13 3. The control of psychologists over the abortion experience Along with partners and gynaecologists, a third group of actors – psychologists – takes part in the abortion experience. According to the hospital rules, these professionals are entitled to supervise the psycho-emotional sustainability of abortion as well as the woman’s wellbeing in the different stages of the procedure. According to these aims, the first psychological counselling session usually takes place the same day the woman (and her partner) meets the gynaecologist. This encounter has one main purpose, which is to assess the reasons for which the woman (or the couple) is asking for abortion. Despite the fact that the meeting with the psychologists occurs only after the woman has already met the gynaecologists, the function assigned to psychologists cannot be described as a complementary role. The two psychologists I interviewed underlined how the acceptability of an abortion request depends on their professional role. This opinion is based on the fact that psychologists – and not doctors – are entitled to write the hospital report that formally authorises women to access legal abortion. Unlike other medical fields, where psychologists offer a supportive function to patients, in the abortion experience women’s rights are subjected to the power exercised by these health professionals. The fear psychologists might not take their abortion request seriously appeared as a common sentiment among the women I met. Many of them highlight the need to reflect in advance on the elements of their life story to share with psychologists. The likelihood of making some “mistakes” in their narrative was always prominent in their minds. One of the difficulties related to these dialogic efforts has to do with the fact that psychological consultations are usually quite long. As I could see, the average duration of these meetings is at least one hour. The themes explored focus on women life dimension and the way they are living their pregnancy. Some of the questions addressed to the patients involve how long they have been in a stable sentimental relationship; at what stage of their life they think they will become mothers (or have other children); whether they use contraceptive methods to avoid pregnancies; to what extent this pregnancy is something that happened by chance; and whether the women have already had other abortion experiences. These elements, together with general 14 information on the women’s profile, are the main issues psychologists highlight in the hospital reports they write after the consultations. Such reports are a key moment in women’s assistance, as they prove abortion requests are not related to any psychiatric problems but depend on reasonable motivations linked to a woman’s story and personal life. According to the findings that emerged from my research, a woman’s need to demonstrate the rationale of their abortion request to psychologists is easier to accomplish when patients are somehow victims of their pregnancy, such as when there are risks to their health, when they are less than 16 years old, or if the pregnancy is the result of sexual violence. Another condition that allows women to give few explanations to psychologists is therapeutic abortion suggested by doctors. In other situations, women’s effort to look for the right answers to justify their choice appeared to be a common matter. Eleonora, 31 years old, stressed: “Even if you just do not want the baby, it is better to tell the psychologists there are some problems in your life. Nowadays it seems as though if you have no problems, you are less entitled to access abortion.” These strategies, which can be understood as a form of resistance to the system of control exerted on women’s lives, are not always possible to adopt. The difficulties women have to deal with when an abortion decision depends on their personal wishes look even greater for those who have already had a previous abortion. Camilla, 35 years old, explains: Doctors often define women who ask for abortion more than once as patients who have a chronic problem. During my consultations with the psychologist, he asked me if I were aware of the existence of contraception methods, as I have already had one abortion. His impression was that I use abortion as a contraceptive method! The sensation of being judged, as well as the need to convince psychologists about the legitimacy of their choice, are feelings women also highlight in the meetings following the first consultations. Generally, the number of meetings proposed to women is linked to the supposed uncertainty psychologists perceive during conversations: the more women look worried about their choice, the greater the number of meetings organised to speak with them. 15 Vulnerability is another element that counts in psychological assistance. For instance, psychologists try to speak more with women who have suffered sexual violence or with women who have to undergo a therapeutic abortion. Meetings with psychologists continue after the abortion has been performed. According to the hospital rules, these consultations have a preventive function, to avoid the risk of unsafe behaviour in women who might feel particularly sad or confused after abortion. In this case, also, the number of meetings proposed to women – the socalled psychological follow-up – changes according to the positive or negative impressions psychologists have during the conversations with the patients. Some of the elements stressed during these meetings are how often women still speak about their pregnancy, how often they have dreams related to their pregnancy, and to what extent it is difficult for them to start their daily life again. Psychologists I interviewed underlined how these elements let them understand the way women react to abortion. Woman progression in post-traumatic stress, as they call it, or the evolution of the feelings women experience after abortion, is summarised in the hospital reports psychologists write at the end of each meeting. This longterm assistance requires women to continue attending hospital after an abortion. As some women emphasise, being in such a place constantly reminds them how their need for care is not yet over. Usually, such assistance ends when health providers declare women have overcome the abortion experience without any trauma or negative consequences for their future life. Apart from women who show signs of severe depression, posttraumatic psychological meetings are not mandatory for all patients. Despite this, many women who do not have any negative symptoms agree to meet psychologists at least once, as they want their good health to be confirmed. This attitude shows how hospital care programmes intended for exceptions can generate health needs that may become the norm. Dominique Memmi’s theories are, again, a suitable tool to analyse such a situation. In her most recent book La revanche de la chair (2014), she underlines how a new bio-political apparatus has emerged within the hospital space over the last few years. This is no longer based on the gouvernement par la parole that I have described in the first part of the article, and which is still 16 exerted by gynaecologists. A more complex system has replaced it: the so-called gouvernement par la chair, la parole et la psychologie, which is centred on doctors’ suggestions and narratives but also on psychologists’ counselling and advice (Memmi 2014: 261). The main distinguishing element of this new mechanism of control is the increasing attention to the psychological aspects connected to the physical experiences of the patients. The growing importance of the role assigned to psychologists in the abortion experience can be understood as an example of this innovative system of control on women’s individual life and health. In this regard, women who choose not to attend the psychological follow-up programme contest this form of control on their lives. Michela, 37 years old, describes the psychological meetings after abortion as a way to keep women in the role of patients, by making them feel sick from a physical and mental point of view: These meetings with psychologists give women the idea that they need to be helped after abortion. In my opinion, women do not need to meet any specialist after abortion, since they are not sick. It would be better to make us feel like people who have made a personal choice, and not as people who run the risk of having a personal crisis or some psychiatric problems because of abortion. Finally, such a sur-medicalisation (Illich 1975) of the moments proceeding and following abortion does not equally involve both members of the couple. Partners are generally included in the meetings with psychologists before the abortion decision. They can be part of the psychological counselling together with their female partner, but they can also attend the counselling alone. For instance, psychologists suggest individual consultations when the partners have to face a therapeutic abortion. By contrast, psychological meetings following the abortion procedure mainly focus on women. In most cases, the male presence is neither expected nor required. As health professionals explained to me, this choice results from the idea that the physical and psychological consequences of abortion affect more women than men; hence the greater assistance offered to women patients, which implicitly turns into a greater form of control on their lives and behaviour before and after the abortion procedure. 17 Conclusion The analysis I propose in this article shows how, even when there is no conscience-based refusal by healthcare providers, many obstacles for women to access legal abortion emerge in Italian public hospitals. More particularly, new practices that characterise doctor-patient interactions (such as the information process required for informed consent), the gender balance during medical consultations (or the growing importance given to partners’ opinion on issues relating to reproduction), and the fundamental role played by psychologists in hospital care programmes, all seem to work as potential barriers to the implementation of women’s right to abortion. As highlighted by the findings of my case study, such right is subjected to a number of external factors (cf. the figure below), which represent a global domination system to which women are still subjected: At the same time, women’s social profiles, class and ethnic relationships, as well as gender relations and power relationships between healthcare providers and patients, can be described as complementary elements that contribute to limit the autonomy of women and their right to choose abortion. If abortion as a medical procedure is being questioned more and more in Italy, the abortion crises I have discussed in this article involve public hospitals of the 18 northern regions, which have historically been more supportive of women’s reproductive rights than the hospitals of the southern regions (De Zordo 2016). If we add to this the low substitution rate of the few physicians engaged in this cause by a new generation of militant doctors, the destiny of the right to abortion in Italy appears an even more urgent question to address at both a political and a cultural level. References Boltanski, L., (2004), La condition foetale: une sociologie de l’avortement et de l’engendrement, Paris, Gallimard. Browner, C.H., (1997), Why do women say yes to prenatal diagnosis?, Social Science and Medicine, 45, pp. 979-989. 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