In the corona pandemic, many countries have relaxed strict regulations on abortion. So that with restrictions on lockdowns and quarantine obligations, access to care for women with an unwanted pregnancy could be guaranteed. The strongest example of this is Francewhich from now on makes it possible for women who have an unwanted pregnancy to obtain a prescription for an abortion pill via an online consultation.
The Netherlands has always been a guide country in the legalization of abortion, but suddenly stands out conservatively. “Yes, that’s right,” says gynecologist Gunilla Kleiverda, “The Netherlands is now miles behind the others.” Until the middle of last year, Kleiverda worked as a gynecologist at the Flevoziekenhuis in Almere and is a director at Women on Waves (WoW), an organization that works internationally for free access to abortion care.
Compared to other countries, the abortion pill is rarely used in the Netherlands. Abortion here is remarkably often performed as a surgical procedure, a so-called suction curettage. An ultrasound will take place before and after the procedure to determine the status of the pregnancy and the result of the treatment.
Stigma and taboo
That big difference with most other western countries was also apparent in a review article that appeared two years ago in The BMJ Sexual & Reproductive Health† Together with Italy, Belgium and Germany, the Netherlands is an exception in the use of the abortion pill as an alternative. In most countries, more than half of the abortions are induced with drugs, in Finland and Sweden it is even 93 and 97 percent respectively. Although the share of pill abortions in the Netherlands is growing slowly, in 2020 it amounted to ‘only’ 31 percent.
Most of the abortions (90.5 percent) takes place in one of the sixteen abortion clinics in our country. The rest takes place in hospitals. What is striking in the figures of the Health and Youth Care Inspectorate: in hospitals, the vast majority of abortions are performed with the abortion pill.
An amendment to the Termination of Pregnancy Act is currently being discussed in the House of Representatives, which should also make it possible for general practitioners to prescribe an abortion pill. “That would be a big improvement,” says Lianne Holten, obstetrician and researcher at the Midwifery Academy in Amsterdam. “It is more appropriate with the GP as part of regular care than in separate clinics,” says Holten. “It can help alleviate some of the stigma and taboo surrounding abortion. Women who have to go to an abortion clinic to terminate their pregnancy often live with the fear that they will be harassed by activists. And there are also women who become unintentionally pregnant as victims of domestic violence. They are very hard to get out of. It will be easier for them to go to the GP than to an abortion clinic that sometimes requires them to travel far.”
Drug combination
GPs will be able to safely supervise abortions, says gynecologist Kleiverda. “Medically it is a very simple act, comparable to guiding a miscarriage, which is what GPs also do. If complications arise, they can quickly refer you to a hospital. In Ireland, which legalized abortion a few years ago, that care was immediately transferred to the general practitioners. In France, that also works without any problems.”
The abortion pill is not one pill, but a combination of two drugs. The standard treatment is as follows: the woman first takes a pill containing 200 milligrams of mifepristone. Mifepristone softens the cervix and stops the growth of the embryo (it works against the pregnancy hormone progesterone). It serves as ‘preparation’ for the second drug, misoprostol, to work better. Misoprostol induces contractions and ensures that the fetus is expelled. One to two days after taking mifepristone, four tablets (800 milligrams) of misoprostol should be placed deep in the vagina or in the cheek pouch to dissolve slowly. The bleeding usually starts within four hours. This can be accompanied by severe abdominal cramps, which can be relieved with painkillers (ibuprofen).
Since 2005, the drug combination for abortion has been on the rise the list of essential medicines of the World Health Organization (WHO). At the time, it was also stated that this had to be prescribed under close medical supervision, because there was still only limited insight into the effectiveness and safety of the drugs. But in 2019, the WHO dropped that condition, because there was now enough scientific evidence that there was no need for it. Routine ultrasound checks are also not necessary, writes the WHO†
A widespread misunderstanding is that the so-called morning after pill works just like the abortion pill. But it’s something completely different. The morning after pill consists of a hormone that temporarily suppresses ovulation, so that there is no egg that can be fertilized. The pill does not terminate a pregnancy, but prevents it. After unprotected sex, there is still some respite because fertilization usually only takes place in the following days.
Abortion care must become much more accessible
Gunilla Kleverda gynaecologist
Morning-after pills have been available without a prescription at drug stores or pharmacies since 2004. From a survey in the report Sexual health in the Netherlands 2017 from the Rutgers Foundation shows that one in twenty adult women had used the morning after pill at least once in the previous year.
Dutch law makes an exception for so-called ‘overtime treatments’. Until seventeen days after the absence of menstruation, the pregnancy may be terminated with medication or curettage without registration obligation. In 2020, 9,903 women received such late treatment. “So this does not fall under the abortion law, but it is exactly the same treatment as the abortion provocatus that can be performed exclusively by hospitals and clinics after 17 days past due up to nine weeks gestational age,” notes Kleiverda. “The difference is really not that big. And by the way, there are now also GPs who provide overtime treatments.”
While the Netherlands is discussing the provision of the abortion pill through the general practitioner, other countries are already daring to provide abortion pills through online consultations. And there also appear to be no special medical risks, researchers conclude in a a large-scale comparative study performed in Great Britain. Teleconsultations without ultrasound are just as safe and effective as traditional physical consultations that provide abortion pills. Nevertheless the British government decided this week to reverse this measure introduced under pandemic circumstances as of September 1. Wales chose it though to make the provision of online abortion pills permanently possible.
Teleconsultations without ultrasound
A smaller study done at the Brugmann university hospital in Brussels during the corona pandemic, the results of the British study confirmed. The abortion went even better in the home group (99 percent success, in one go) than in the hospital group (93 percent), although the participants felt on average slightly safer with treatment in hospital.
Women on Waves also has experience with thousands of women abroad who knocked on their door for help and received abortion medication by post. “With very good results,” says Kleiverda. “In most cases you can do a reliable anamnesis remotely. I estimate that in two-thirds of women, it is not necessary to physically visit a doctor and have an ultrasound done.”
Lianne Holten would like to see all three options for abortion become possible in the Netherlands: in the clinic, through the GP or online. “The latter can be a solution for women who already know for sure that they want an abortion. Going to the doctor can be difficult for women if they want to keep their pregnancy a secret from the outside world. On the other hand, there are also women who would very much like an advisory meeting with their GP about their choice. And there are women who prefer to take a sedative to terminate the pregnancy, they are best off in an abortion clinic.”
In an article in Medical Contact from 2007, Gunilla Kleiverda even argued in favor of making the abortion pill available through the drugstore, just like the morning after pill. Does she still feel that way? “Consider it a manner of speaking,” says Kleiverda. “Abortion care must become much more accessible and, as far as I am concerned, abortion should also be removed from criminal law. If it ends up with the GP, that is in any case an important step forward. In addition to general practitioners, midwives could also offer such guidance.”
#Guide #country #Netherlands #bit #abortion #pill