Emergency contraception in Italy: Utilization patterns and ecological correlation with induced abortion rates

to assess national trends in the use of emergency contraception (EC) and rates of induced abortion in Italy from 2017 to 2023, considering the impact of the COVID-19 pandemic and the 2020 AIFA decision that expanded over-the-counter access to ulipristal acetate (UPA) for minors.  Design: quasi-experimental ecological study using Interrupted Time Series (ITS) analysis of national data on EC use and induced abortion rates. Three interventions were evaluated: onset of the COVID-19 pandemic, end of the first lockdown, and the AIFA policy for minors. Hormonal contraceptive use and total fertility rates were included as control series.

monthly aggregated data from 2017 to 2023 on EC use, hormonal contraception, induced abortions, and fertility rates among the Italian resident women aged 15-49 years.

use of EC and UPA, induced abortion rates, regular hormonal contraceptive use, and total fertility rates. ITS parameters were expressed as incidence rate ratios (IRRs) with 95% confidence intervals.

between 2017 and 2023, EC use increased from approximately 3 to 5 packages dispensed per 1,000 women, with UPA use increasing approximately twofold. The COVID-19 pandemic was associated with a temporary but significant decline in EC use and induced abortions, followed by a rapid post-lockdown rebound (IRR trend UPA: 2.22; 95%CI 1.57-3.15; IRR trend induced abortion: 1.20; 95%CI 1.01-1.42). Induced abortion rates declined modestly but steadily (IVG: from 0.59 in January 2017 to 0.44 in December 2023), while fertility rates (from 3.06 in January 2017 to 3.07 in December 2022) and hormonal contraceptive (from 155.82 in January 2017 to 176.82 in December 2023) use remained stable. No ecological evidence of substitution effect following increased EC access was observed.

extending over-the-counter access to UPA for minors was associated with increased use without reducing hormonal contraceptive use. Changes observed during the COVID-19 pandemic were temporary and followed by a rapid recovery, without altering long-term trends. The modest decline in induced abortion rates is consistent with a pre-existing trend rather than a direct effect of expanded EC availability, suggesting a complementary role of EC within broader reproductive health strategies.