Netherlands: new law that allows the abortion pill by GP's, 2022

Background of Dutch abortion law

The abortion pill became available in the Netherlands for the first time in 2000. It was registered for use for the first 7 weeks of pregnancy only, which is considered an "overtime treatment" in the Netherlands. In the Netherlands, abortion is still a criminal offence, and an abortion treatment is only legal in clinics that have been granted a license by the Dutch Minister of Health, Safety and Sports, except for the "overtime treatment". This very early abortion until 17 days after the missed period or 6 and half weeks of pregnancy is not covered by the criminal code.

Legal loopholes and Women on Waves campaigns

The first campaign with the Women on Waves abortion boat took place in Ireland in 2001. On board were several abortion pills to be able to provide the "overtime treatment" in the international waters from Ireland. As the boat was registered under Dutch flag, the law of the Netherlands applied on board.  

The exception of the "overtime treatment" from the criminal code was confirmed by the Minister of Health Els Borst in 2002 during a parliamentary debate about the first campaign by abortion ship in Ireland and by the "Raad van State"(Council of State, the highest court in the Netherlands) in 2006 in response to the legal complaint of Women on Waves against the Dutch Government for refusing to provide an abortion clinic license. This "overtime treatment" was the legal loophole of all the campaigns with the abortion ship under Dutch Flag.

Advocating for the abortion pill by GP's

Already 15 years ago, in December 2007 after the Council of State's ruling in 2006, Gunilla Kleiverda , president of the board of Women on Waves, published an article called "Abortion pill in the drugstore" in Medisch Contact, a popular magazine for doctors in the Netherlands.

Even though the "overtime" treatment was legal outside the abortion clinics and hospitals, unfortunately the distributor of the abortion pill only wanted to deliver the medication to clinics or hospitals with an abortion clinic license citing an agreement with the Dutch government in 2000. It was therefor impossible for a family doctor or midwife to prescribe the medication for the overtime treatment as a woman could not get it in the pharmacy even on prescription.

However in 2015, Sun Pharma got market authorization for Medabon, the combination packet of mifepristone and misoprostol (despite attempts from Exelgyn the company with the only other market authorization to stop this). When we inquired about its availability, Sun Pharma informed us the medication would be dispensed by regular pharmacies. This meant that family doctors could start prescribing mifepristone and misoprostol for the "overtime" treatment.  

So in 2015 Women on Waves trained a group of 50 General Practitioners in early medical abortions.

Obstacles put in place by the Dutch governent

In response to the training and the media coverage, the Ministry of Health, Welfare and Sport and the Health Care Inspectorate took the position that prescribing by doctors and delivering the abortion pill by pharmacists for the treatment of "overtime treatment" is prohibited and punishable and send a warning letter to the pharmacies that they could be criminally prosecuted for aiding with an abortion if they would give out the medication on prescription. The minister of Health at that time, Edith Schippers said she was not against the idea that family doctors can provide the overtime treatment but that as it was illegal, she would propose a bill to make the "overtime treatment" with pills possible for family doctors. However this proposal did not take into account the former court decisions that the "overtime treatment" was did not fall within the scope of the Criminal Code and that her proposal actually did the opposite as it made the "overtime treatment' illegal by making it part of the criminal code.

In a reaction to this position of the State, the Royal Dutch Society of Physicians (KNMG) declared that they supported the idea to allow GP’s to prescribe the abortion pill. The Dutch Society of General Practitioners (NHG) developed then in March 2016 a Statement, based upon a scientific literature review, in which they declare that providing an abortion pill in primary care is effective and safe.

Taking the Dutch government to court

Women on Waves (WoW) and the Bureau Clara Wichmann and a group of family doctors, including Peter Leusink and Mirella Buurman, decided to sue the Dutch State for unlawfully obstructing the delivery of medicines for the overtime treatment by pharmacies on prescription from general practitioners and other authorized care providers on 2 June 2016. We requested the court to summon the state to inform GPs, pharmacists and wholesalers as soon as possible that they can legally prescribe the abortion pill (Mifepristone) and provide it to women for medication overtime treatment, until 17 days after the absence of menstruation.

On September 6, 2017 the court in The Hague ruled in favour of the State of the Netherlands that prescribing by doctors and delivering the abortion pill by pharmacists for overtime treatment is punishable and therefore prohibited. Women on Waves, the Clara Wichmann Trial Process Fund, as well as various general practitioners and other care providers who had joined the case appealed the ruling.

Civil actions and petitions

To keep the pressure on the government, a group of  Dutch women's rights organisations including Clara Wichmann Fonds, Women on Waves, The Feminist Club Amsterdam, Women's March the Netherlands, WOMEN Inc. - Vrouwennetwerk, Rutgers - Kenniscentrum op het gebied van seksualiteit, Atria -Kennisinstituut voor Emancipatie en Vrouwengeschiedenis, Emancipator, WO=MEN - Dutch Gender Platform, Platform Zijn and We Reclaim Our Pride, started a petition to demand the medical abortion provided by family doctors on November 2017.  

The new abortion bill

Finally in February 2018, the left parties submitted a bill in the parliament that should make it possible for the abortion pill to be dispensed via the general practitioner in an accessible manner. The initiators of this bill propose that all women in the Netherlands have the choice to terminate an unwanted pregnancy at an early stage. It is important that this can be done with a trusted care provider in the area. The so-called 'abortion pill' is registered for provision up to nine weeks. Also the LHV (Dutch Society of General Practitionars) released a statement in support of the bill.

Family doctors start providing the overtime treatment

On February 12 th, 2019, the Court of Appeal of The Hague ruled that the scope of the criminal law is unclear, partly because the term "pregnancy" is not defined. The decision of the court stated that it is not clear from the parliamentary history if early abortions (overtime treatment) fall under the criminal code. In addition, the Court of Appeal of The Hague reiterates that the legislator explicitly did not consider an overdue treatment to be a treatment aimed at terminating a pregnancy within the meaning of the WAZ (Termination of Pregnancy Act ).

The Netherlands is a constitutional state, and the principle of legality is an essential part of a constitutional state. That principle means that something is not punishable if there is no prior penalty provision that clearly indicates that something is punishable. Now that it is not clear whether an over-time treatment by a general practitioner can fall under the criminal law, it may not be the case that a general practitioner acts punishable by performing an over-time treatment based on the principle of legality.

Based on this court ruling, the organizations and the family doctors concluded that general practitioners and pharmacists can prescribe and provide the "overtime pill", because this treatment does not fall under the WAZ (Termination of Pregnancy Act). And after the decision of the Court of Appeal in 2019, a group of general practitioners started providing the "overtime pill" in their offices. Some had been able to obtain mifepristone for their own practice through the distributor or pharmacy.

Researching the obstacles to abortion access in the Netherlands

During the court case we learned that we could not present enough evidence to show that there are obstacles to abortion care in the Netherlands, as there had never been any study to research this so Women on Web opened the possibility for Dutch women to do the online consultation and get a referral letter, to gather data about the obstacles to abortion care in the Netherlands. In found 9 months from January 1 th till October 1 th, 2019 Women on Web received 172 help requests from women living in the Netherlands. The first research was published in 2019 and showed that there still is a substantial obstacle to access abortion care in the Netherlands for some people and that some  of these obstacles can easily be overcome by making medical abortions accessible through  GP's. 

" ...... I need certain documents when I do visit a clinic, which my mom has, and I can’t ask for without her getting suspicious. I really need your help. (teenager living in Urk)

"Well, the clinic I talked to in Eindhoven said that unless I have a BSN, I am paying for it in cash or not getting it at all. I do not have residency here and no proof of residency. I am living with a friend, and nothing is in my name."

"Please I can not go to any clinics...I have already troubles with my government... And the clinics will inform other instances then the government will pick up my child and I don’t want that. They will escalate I don’t want to become in troubles.Its complicated"

"Unfortunately I am undocumented and I don't have  Dutch insurance to take care of my bills..........."

"I have contacted some clinics for help about this but allcame back to huge amount of money (the one in Utrecht ask 700 Euro for example). I don't have the money to raise a child so to pay 700 Euro is also not a solution."

"I cannot go to a clinic as this is not allowed by Muslims. I have to do this without anyone knowing."

"I was flee from the war in my country and I’m in procedure in the Netherlands. I have a friend and got unplanned pregnant. I’m 3 days over time. I’ve a daughter and hope she can come over here when my procedure is finished. All visits to a doctor goes to the Dutch government and I don’t want to know them that I have a friend and being unplanned pregnant. I’m a shame and afraid that it will influence my procedure."

"Because I am only an international student and do not have a 'normal' health insurance, they will charge me for 465 euro, which is much higher than I can afford."

"The total cost of an abortion is 665 euros. I am a non working student and this is very, very hard for me to fund myself and would require months of saving. I just need help. This is very difficult for me and I have had to deal with this without the knowledge my family. I feel lost and alone and all I want is my life back. ..... I am really not ready to have a child. I’m only 19 and still a child myself. ........I have had to keep this a secret from my entire family because this is not accepted at all. Not only would I receive backlash but I would also be forced to keep a child I am not ready for a consequence of a broken condom."

In march 2020, the first publication about the provision of mifepristone and misoprostol for the "overtime treatment"  by Family doctors was published in Medisch Contact.

The abortion clinics started publicly objecting to the possibility that family doctors can prescribe mifepristone and misoprostol with the argument that general practitioners have too little interest in this or are unable to develop enough expertise.

Impact of COVID

In March 2020, COVID19 reached the Netherlands and restrictive measures were imposed. Immediately women affected by these restrictions reached out to Women on Web. In support of Trix (alias), one of the women with an unwanted pregnancy who could not go to an abortion clinic, Women on Waves and the Clara Wichmann bureau, requested the Minister of Health and Justice to allow for telemedical abortion services to guarantee that women in the Netherlands could access safe abortion services. Trix was a single mother with a daughter with COVID19 symptoms and therefore could not leave the house and go to an abortion clinic if she would follow the government guidelines. Through these summary proceedings, Trix wanted to make it possible for GPs and / or abortion doctors to be able to provide the abortion pill by post after a telephone consultation or to have it collected from the pharmacy. In this way she would have access to an abortion treatment.

Unfortunately on April 10 th 2020, the District Court of The Hague dismissed the application for interim relief from Trix (alias) against the State, to make it possible to obtain the abortion pill outside the abortion clinics. The State, supported by the abortion clinics and abortion doctors who objected to the proposal to send the abortion pills to her, maintains that women have to go to an abortion clinic to pick up the medication.  

The judge argued that the women in need of abortion services did not try hard enough to access the existing abortion services even though it was impossible for them to go to a clinic.

Trix was not the only woman who would have been helped in a positive court decision. Similarly, another woman in an unsafe home situation with a partner who does not know she is pregnant and does not have a cover, such as staying away from work, to go to the clinic. Another woman lived on anIsland in the North of the Netherlands  and would have had to travel 4 hours to go to an abortion clinic. 

The judgement of the court left women deprived of necessary abortion care in times of corona, while a good alternative was within reach. Abortion clinics and doctors could just send the pills, because the termination of the pregnancy already takes place at home. The only difference would have been that women would not have to go to the clinic to pick up the pills.

Guidelines  and training for GP's

But in the mean time, Peter Leusink and Marlies Schellekens had developed a tool kit for the over time treatment for other family doctors willing to provide the medical overtime treatment.

Overtijdbehandeling door de huisarts

 Recent is er juridisch ruimte voor de huisarts om zelf de overtijdbehandeling mogelijk te maken.
Samen met abortusartsen, gynaecoloog, apotheker en kaderhuisartsen urogynaecologie hebben we een Toolkit ontwikkeld zodat de huisarts zelf aan de slag kan.

 Scholing

• • • • • CME Online scholing Zwangerschapsafbreking
        • De rol van de huisarts bij onbedoelde zwangerschap(pdf)
        • Een specifiek nascholingsartikel in Huisarts &Wetenschap is aanstaande

Patiënteninformatie

• • • • • Folder Combinatiepil voor de overtijdbehandeling(pdf)
        • nl| Ik ben onbedoeld zwanger: wat kan ik doen?

Naslag

• • • • • Leidraad Huisartsenzorg bij een onbedoelde zwangerschap
        • Overtijdbehandeling door de huisarts: lessen uit de praktijk(pdf)
        • NHG-Standpunt Medicamenteuze overtijdbehandeling

 Heeft u vragen of behoefte aan face-to-face groepsnascholing, benader ons gerust.

In response to his message the Ministry of Health again send out a threatening letter to the distributor of Mifepristone and the doctors.

Mifepristone dispatched by pharmacies

Despite the letter from the Ministry of  Health the distributor of mifepristone decided to start delivering mifepristone to pharmacies after taking with Peter Leusink, Anniek de Ruiter, professor law of University of Amsterdam and board member of Clara Wichmann Instituut who had been involved in all the court cases.  Mifepristone became available on prescription in the Dutch pharmacy without restrictions for the first time in July of 2020. This happened very silently but it made it much easier for family doctors to prescribe mifepristone and misoprostol, also silently.

The final push

In March 2021 there were new elections and the liberal and central parties won. It took almost 300 days to form a government.

In May 2021 we published another study in the restrictions of abortion care in the Netherlands.

In June 2021, the Balie, a debate center in Amsterdam organised a public debate about the abortion pill with politicians.

Almost 5 years after submitting the bill, just a few months after the new government was formed, in February 2022 the Dutch Parliament started the debate on the law proposal allowing GP's to prescribe mifepristone and misoprostol for abortion. The bill now had support from the liberal and left green parties. Women on Waves had just conducted a study into the willingness of general practitioners to prescribe Mifepristone for the termination of unwanted young pregnancies and non-intact pregnancies. An online survey was sent to 575 general practitioners across the Netherlands. 127 of them answered the survey. One or 2 GP's were selected from all the municipalities in the Netherlands.  Nearly 85% of respondents were willing to prescribe Mifepristone. A small proportion (26%) only for miscarriages, a larger proportion (58%) also for termination of pregnancy up to 9 weeks. Although this study is not representative of all more than 12,000 general practitioners in the Netherlands, it does show that some of the general practitioners are interested in medically guiding both the termination of intact and non-intact pregnancies.

On March 15 the Dutch parliament voted and adopted the bill with 106 votes for and 24 votes against.

At the end of November the Dutch Journal of Medicine published a paper which discusses the necessity of using ultrasound in general practice to determine the gestation age before starting medical termination of pregnancy. The same issue about lack of necessity of routine ultrasound had been addressed as well in Medisch Contact by Women on Waves.

December 6 th the Senate also voted on the bill. Just before the vote in the senate we shared the results of yet another study obstacles to abortion care in the Netherlands.

The Dutch Senate also voted with an overwhelming majority for the bill that allows family doctors to prescribe the abortion pill until 9 weeks. This means that at least 20.000 women will be able to get this treatment from their own doctor and won’t have to travel to an abortion clinic.

In all these years and this process, the work of 2 family doctors Peter Leusink and Mirella Buurman as well as the Groen Links parliamentarian Corrine Ellemeet have been essential.