Home » The forgotten role of family counseling – Jennifer Guerra

The forgotten role of family counseling – Jennifer Guerra

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The forgotten role of family counseling – Jennifer Guerra

The clinic in Stilo, in the province of Reggio Calabria, is located in an old reinforced concrete building with a sign indicating the seat of the justice of the peace. Until recently, patients queuing for a gynecological examination sat in the same waiting room as those who appealed for a no-parking fine. As the doorbell was connected to the judge’s office, now closed, someone made a hole in the door to put their hand in and open the lock from the inside.

The photos of this clinic, where the humidity has ruined the walls, where the staff is forced to bring the stoves from home, and where the toilets are dilapidated, have circulated on social networks thanks to the complaint of the network Let’s take back the clinics, a group of Calabrian activists who ask for the full application of the law 405 of 1975, which established family counseling centers.

The door, even during opening hours to the public, is closed. Only thanks to a round of phone calls it turns out that the midwife is on sick leave and there is no one who can replace her or at least put a notice on the door.

It is not the first time this has happened: Silvana, 65, has been waiting hours in the rain for a pap test with other women. “The door was closed, we waited, tried to call. Nothing, closed. Some have left, some have said: ‘I’ll go private’. I am indignant because perhaps not everyone can afford private life! ”, Silvana says. “Among these women there will be those who will not do that pap test anymore”. But it has not always been like this: “There have been years in which I was proud of such an efficient public service, then going on in time I saw it empty of services and figures”.

Here the problem is not that there is a lack of counseling centers: for 140 thousand inhabitants of Locride, on the Ionian side of Calabria, there are seven counseling centers. It is one of the regions that comes closest to the legal requirement of one clinic for every twenty thousand inhabitants, unlike, for example, Lombardy which has one every 65 thousand. But the structures are empty, without personnel and without tools. Missing are doctors, midwives, social workers, psychologists.

No clinic can guarantee the presence of all these professionals, who therefore have to travel by car between the various locations crossing the Locride, even several times a day, often carrying medicines, test tubes or laboratory results that a hospital courier should take care of.

Almost half of the certificates for voluntary termination of pregnancy are issued by the counseling centers

To meet the institutional mandate, gynecologists and psychologists should be on duty for 18 hours per week, while obstetricians and social workers for 36 hours. Although the 2018-2019 national survey on family clinics conducted by the Higher Institute of Health (Iss) found that Calabria is among the best regions for average hours worked by medical teams, in Locride the situation is particularly difficult and lack of resources is wearing down the strength of the last remaining professionals, many of them close to retirement. For 42 municipalities and a total of 140 thousand people, there is now only one gynecologist.

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For years the counseling centers have been in crisis, not only in the south. Their numbers are decreasing and the staff are working amid increasing difficulties, sometimes exceeding the hours of service. Established in 1975 after the reform of family law and the end of the prohibition of contraceptive propaganda, the counseling centers were born with the spirit of prevention and care of the person and have played a fundamental role in the emancipation of women, revolutionizing the relationship of women with their bodies, with sex and with their role in the family, spreading the use of hormonal contraception and contributing to drastically reducing the number of unwanted pregnancies and abortions, as the ISS report underlines.

The tasks provided for by law 405 (psychological assistance to maternity, paternity and the couple, responsible procreation, protection of women’s health and the product of conception, prevention of unwanted pregnancies) were extended with law 194 which in 1978 which decriminalized termination of pregnancy (Ivg) and has made the clinics more and more frequented and accessible places.

Today almost half of the certificates needed for the IVG are issued by the consultors. In the spirit of public health, proximity and freely accessible, all services provided are free and can be administered to minors (even without the presence of parents) and to foreigners.

In Italy there are 1,800 consultants, half of those required by law to serve the entire population. 622 are located in the north, 382 in the center and 531 in the south, with very different densities depending on the region: they range from Valle d’Aosta which has a clinic for every 10,500 inhabitants, to Molise which has one for every 66 thousand. The number of users is also very variable, with an average of five accesses per 100 inhabitants, a figure that doubles in Emilia-Romagna, Umbria and Abruzzo.

Since up to 2000 there was no obligation to collect data and statistics on the work of the consultants and many of them have not yet adapted, it is also difficult for the ISS to trace a history of these structures. A significant fact to understand the diffusion of this service in the population, however, is that of the number of certificates for the IVG issued by the counseling centers, which has doubled since the 1980s.

More than a health center

In general, the counseling centers operate in two areas that are connected but not entirely coincident: the social one and the health one. Their function is to be not only simple health aids, but also points of reference in prevention, in family difficulties or in contrasting psychological distress.

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Precisely because of their hybrid nature, the clinics were penalized by the health reforms of the nineties, which imposed a corporate and centralized vision of health, in contradiction with the idea of ​​accessible and physically present care in the area. The decline of the clinics is also due to the lack of interest on the part of the ministry of health in their development. Since 1975, the funds for the development of the counseling centers have been allocated only three times: in 1996 with a law on health and in 2007 and 2008, but only for specific projects.

For many teenagers it represents the first experience with a gynecologist

Over the years, both due to low investments and the reorganization of services, many have become mere providers of obstetric or gynecological services. In several Locride clinics, for example, often the only service provided is the pap tests required by screening for cervical cancer.

The clinic is, or should be, a free and easier to access alternative to the private practice of a specialist and for many teenagers it represents the first experience with a gynecologist. But to be such, the diagnostic or therapeutic activity must be placed side by side with that of prevention and sensitization, since it cannot be limited only to medical services as it happens more and more often.

In addition to adolescents, another group for which the clinic is a point of reference are migrant women. Since the founding of the counseling centers in 1975, the services are also free for foreigners present on the Italian territory, even if temporarily.

In areas with a high migratory presence, counseling centers are therefore essential. In Calabria, for example, the number of birth support courses activated in the region is double the national average, with almost four children for every hundred born with the assistance of the clinic. However, the participation of foreign women in the south remains difficult: only 10 per cent of the counseling centers involve a cultural mediator and only 12 per cent offer information materials in multiple languages.

The most recent and important novelty concerning family clinics is the possibility of being able to administer pharmacological abortion directly within these structures. The chemical IVG consists of taking two pills 36-48 hours apart: the first (mifepristone) inhibits the development of the embryo, while the second (prostaglandin) causes uterine contractions to favor its expulsion.

Before the update circular published by the ministry of health on 12 August 2020, it was possible to take these pills only in the hospital and with a three-day hospitalization. By adapting to the protocols followed throughout Europe for years, with the new guidelines, the intake of the two pills can take place directly in the clinic, not only eliminating the organizational problems deriving from the high percentage of objecting doctors in hospitals, but also reducing the likelihood that a woman meets one during her journey.

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For years the center-right administrations, with the support of anti-abortion groups such as the Movement for Life, have insisted that the part of law 194, relating to the protection of motherhood, is not correctly applied. Lombardy, Lazio and in more recent times Umbria and Piedmont have thus proposed various laws that allow groups opposed to abortion to promote their activities in public counseling centers.

In Italy there are several realities that testify to the desire to enhance the role of these structures. In the Saragozza district of Bologna, the counseling center in via Sant’Isaia has focused heavily on adolescents, setting up an open space every afternoon from Monday to Thursday, with a service dedicated to emergency contraception on Saturday mornings.

“It has become a point of reference for those who attend the university”, explains Giada, one of the activists of La mala educación, a help desk run by the students of the University of Bologna. The group has created a map of the counseling centers of the city and girls who need support are accompanied to visits.

Since 2018, the region has also created a hormonal contraception reimbursement program for all women under the age of 26 and for those over the age of two within two years of a termination of pregnancy in possession of an exemption. The program works well, but the waiting times were very long even before covid-19.

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The service offered by Emilia-Romagna is a rarity: there are only six regions that provide some form of reimbursement for contraception, while in all the others the cost is entirely borne by women. In fact, since 2017, there are no more loanable birth control pills, after the Italian Medicines Agency has reclassified the last ones left.

The success of the Emilian counseling centers is also due to the accessibility and transparency of online information. The region thus earned first place in the Italian Atlas on access to contraception compiled by Aidos, which awarded Emilia-Romagna 88 points out of 100. Calabria was awarded only 44.

In Locride, when Silvana remained closed outside the door of the Stilo clinic waiting for the pap test, she asked herself a question: “Why weren’t we notified? Why this disrespect? I gave myself too bad an answer: because so much is free. And my indignation has increased: it’s not free. It is a right and a right that cannot be denied ”.

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