By Lisa Juanola, KIT SRHR Advisor and Irene de Vries, KIT Advisor on SRHR, Maternal and Newborn Care.

Internationally, the fight for the right to safe and legal abortion is ongoing. The Netherlands is blessed with liberal laws and good access to safe abortion care, meaning it often serves as an example. The Netherlands is also a leading country when it comes to women’s rights and reproductive health. However, things could be even better and more women-friendly. What does the Netherlands have to offer in the global fight for safe and legal abortion, and what the Netherlands can learn from international developments in this field?

The Netherlands shows the positive effects of a well-functioning law

As an evaluation shows, the Dutch ‘Termination of Pregnancy Act’ is working well. The number of terminations is stable at around 8.6 per 1,000 women aged 15 to 45, and the Netherlands has one of the lowest rates of abortion in the world. The percentage of unsafe abortions is not reported, in part because they are rarely seen in practice. The low figures are not only a consequence of liberal laws and access to safe abortion care but also the provision of comprehensive sexuality education and the widespread availability of contraception for all age groups.

It is important to emphasise these facts, especially as we observe that acquired rights are increasingly under pressure and the population seems less and less aware of the history and necessity of these rights.

In our work at the international level, we see that restrictive laws do not reduce the total number of abortions, but only increase the risk of unsafe abortion. Despite this fact, the legalisation of abortion seems unrealisable in many places. Advocacy for legal abortion is complex, partly because of safety risks. However, we must continue to gather the evidence from experts and countries that shows why legality is a necessity to promote women’s health and is a matter of human rights.

The central role of caregivers in accessing abortion care

Both in the Netherlands and in other countries, we see that liberal laws do not always guarantee access to safe abortion. One of the factors that plays a role in this is that referral to the right care does not always go as expected, partly due to ignorance, but often also because of the negative attitude towards abortion on the part of the care providers. In the Netherlands, 10 per cent of general practitioners surveyed said that they do not want to refer for abortion care as a matter of principle. The international consensus on conscientious objection prescribes that every woman has the right to unbiased and objective information, care and referral and that this right takes precedence over the objections of the care provider.

In addition, general practitioners are not always familiar with the guidelines and the system of abortion care. In the Netherlands, their role and that of other primary care providers, such as midwives, in the provision of information and referral, as well as in making the abortion pill more available could be increased. In many of our partner countries, this first-line involvement is fulfilled by providing the abortion pill, in accordance with international studies and guidelines, through specially trained midwives and other primary care providers. In the United Kingdom, they are working towards the normalisation and sustainability of abortion care by bringing it back from the private sector into the national health care system.

In the Netherlands, there is still a lot to learn in this area. By centring abortion care in abortion clinics, safe care is guaranteed, but abortion can remain invisible. Invisibility not only encourages stigma but also ensures that many primary care providers have insufficient knowledge about this care. By integrating abortion care into primary care, in addition to abortion clinics, care providers remain more involved, experienced and trained. Abortion, reproductive rights and attitude training should also play a more central role in medical curricula and general practitioner training.

Women’s freedom of choice

In many countries, additional legal obligations lead to unnecessarily complicated and lengthy procedures in order to obtain the right care, such as judicial authorisation for abortion in the case of rape or approval of a medical committee for a therapeutic abortion. In the Netherlands, a legal cooling-off period of five days is also an example of this, as was also established in the evaluation of the ‘Termination of Pregnancy Act’.

Internationally, this long cooling-off period is unique and is seen as a burden for women who have often already been through an extensive decision and/or referral process. In all countries where we work, better information on how women can access abortion care is necessary. In countries with restrictive laws, women often do not know under what circumstances abortion is allowed. In the Netherlands, many women do not realise that they can go directly to an abortion clinic without a referral.

The abortion pill makes abortion more accessible and safer for women in all countries, and they are increasingly asserting that the abortion pill is their preferred method of termination. The abortion pill also offers more autonomy in the abortion process. In an earlier blog, KIT reflected on the importance of self-regulated abortion in times of COVID-19. In countries such as South Africa, Ireland, England and France, remote consultation is allowed in the context of COVID-19. In this way, women can carry out abortions safely at home using the pill, in accordance with WHO guidelines.

The Dutch judiciary recently rejected a proposal to allow access to the abortion pill during the COVID-19 pandemic without visiting a clinic. The theme of this year’s international safe and legal abortion day is self-regulated abortion and tele-medication. These are not things for the future, they are a current global priority. These are topics that need to be discussed, debated and included in Dutch policy if the country is to remain a leader in the field of women’s rights and reproductive health.

The authors acknowledge that transgender men and non-binary people may also need abortion care.

Our Work on Sexual and Reproductive Health and Rights

KIT Royal Tropical Institute in collaboration with the International Federation for Gynecology and Obstetrics (FIGO) and gynaecology associations in Africa and Latin America, works to advocate for better access to safe abortion. Sexual and Reproductive Health and Rights (SRHR) and abortion are also central themes in our master’s programme and we work with international educational institutions to integrate SRHR – including abortion – into local medical curricula.

KIT congratulates Rebecca Gomperts who was recently named as one of the 100 most influential people of 2020 by Time Magazine. Her Dutch organisation – ‘Women on Waves’ – plays a key role in the debate over the abortion and increasing worldwide access to the abortion pill.