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San Marino residents are voting on whether or not to lift the abortion ban after a tense referendum campaign.

The extremely conservative landlocked state in central Italy, which has a population of about 33,000, is one of the last places in Europe to have a total abortion ban.

People will vote if abortion is allowed up to 12 weeks of pregnancy. After the twelfth week, the procedure would only be allowed if the mother’s life was in danger or if there were fetal abnormalities.

Having an abortion in San Marino is punishable by between three and six years in prison, forcing women to terminate their pregnancies in Italy, where abortion was legalized after a referendum in 1978.

The activists have faced fierce opposition from Catholic and pro-life groups.

San Marino votes in referendum on lifting the ban on abortion |  San Marino
A nun casts her vote in Sunday’s referendum. Church bells sounded Sunday morning as a signal for the faithful to vote against lifting the ban. Photograph: Antonio Calanni / AP

San Marino is governed by the Christian Democratic Party, a political force with close ties to the Catholic Church. The party has asked people to vote against legalizing abortion. Meanwhile, Pope Francis recently reiterated that abortion was “murder.”

Church bells sounded Sunday morning as a signal for the faithful to vote against lifting the ban. Opponents of abortion have held vigils in recent days, praying that the referendum is defeated.

There was widespread condemnation, including from those opposed to lifting the ban, early in the campaign, when anti-abortion activists covered the walls of San Marino with posters depicting a child with Down syndrome. The caption read: “I am an anomaly, does that mean I have fewer rights than you?”

Other posters featured a picture of a fetus along with the message: “I am a boy even at 12 weeks, save me!”

San Marino has long lagged other European countries when it comes to women’s rights. A 1982 referendum, the first held in the state, to repeal a law removing citizenship from women who married a foreigner was defeated. The law was eventually repealed by parliament, but not until 2000.

Women were only granted the right to vote in 1964, while divorce was legalized in 1986.

The referendum comes after several attempts over the past two decades to legalize abortion were sabotaged by a succession of mostly conservative governments.

More than 3,000 signatures were collected in support of the plebiscite, more than double the legal requirement.

Pro-abortion activists are hopeful that the high level of support will translate into a victory.

The result of the referendum is expected around 10:30 p.m. CET.

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