Birth rates and birth points, a system reform is needed

Added to this is the progressive postponement of motherhood to a later age, a phenomenon that inevitably leads to a reduction in biological fertility. Today, Italy's fertility rate is around 1.14 children per woman, a far cry from the 2.1 needed to ensure generational replacement.

Denatality thus appears to be a structural phenomenon, closely linked to contemporary socioeconomic and cultural transformations, destined to profoundly affect the country's future demographic, political and relational dynamics. The consequences are already evident: depopulation of inland areas, the flight of qualified young people abroad and a growing shortage of specialised professionals. In the health sector alone, between 2020 and 2022, about 180 thousand professionals including doctors and nurses will choose to work outside Italia. A loss of skills that risks further compromising the health system's ability to meet future challenges. Other strategic sectors, such as engineering, also suffer from a significant shortage of highly qualified professionals; it is estimated that over seven thousand engineers are missing in Italy. This creates a paradox: at the very time when more skills, innovation and research are needed, Italia continues to lose human capital.

Making the scenario even more complex is the increase in life expectancy, which is now over 81 years for men and close to 86 for women. By 2050, some 35% of Italians could be over 65, while already today almost 40% of the population lives with at least one chronic disease.

Strategies to counteract under-natality must therefore address its root causes. Stable employment, economic security, adequate social services and a real reconciliation between work and family are essential conditions for couples to realise their desire to have children.

Among the elements considered a priority are the cost of having children - not only in economic terms but also in terms of time and opportunities - the availability of childcare and parenting support services, the possibility of reconciling motherhood, fatherhood and work, and, finally, a cultural and social context capable of supporting and enhancing those who choose to have children.

Alongside the economic and social aspects, the issue of reproductive health also emerged strongly during the conference. Many young people are still unaware of the factors that can compromise fertility and the consequences of postponing family plans. An issue that affects not only women, but also men, whose reproductive health continues to receive less attention in the public debate.

A crucial issue is the reorganisation of birth centres. In Italia there are still many facilities with activity volumes below ministerial standards. The minimum activity thresholds do not represent a bureaucratic criterion, but derive from consolidated scientific evidence demonstrating the relationship between activity volumes and clinical outcomes. Serious complications such as post-partum haemorrhage, sepsis or shoulder dystocia may be more difficult to manage in birth centres with low volumes.

The false myth that 'closer' automatically means 'safer' must be overcome. Instead, safety depends on the integration of professional skills, organisation, available technologies and the ability to deal with emergencies in a timely manner. Possible solutions include greater hospital-territory integration, enhanced assisted maternal transport, centralisation of complex cases, continuous staff training and rotation paths in high-volume facilities to maintain high clinical skills. For women who live far from the birth centres, it could also be useful to provide temporary accommodation near hospitals in the phases close to childbirth.

Due to its complexity, however, the health issue cannot be resolved with sectoral interventions alone, but requires a structural reform of the health service (which can no longer be postponed) to be tackled with a systemic approach.

During the discussion, the need to address the demographic crisis through a long-term national strategy based on scientific evidence and capable of integrating health, social and labour policies was also emphasised. Indeed, the birth rate does not only concern the number of children, but directly affects reproductive health, prevention, work organisation, welfare, maternal and child health and the quality of life of future generations.

Among the proposals that emerged was the need to consider investments in prevention, maternity support and territorial services not simply as costs, but as strategic investments in the country's future.

The point of view of the younger generations is important: Italy's low fertility rate would mainly reflect the difficulty of realising reproductive plans rather than a real reduction in the desire to have children. The gap between intentions and behaviour concerns all ages: postponement among the young, uncertainties in the transition to the first child and biological limits in older ages.
The demographic transition therefore requires not only technical and economic interventions but also a profound capacity for political, cultural and planning vision.

* Università degli Studi G. Marconi - Marconi** Azienda Tutela Salute Liguria