Professor Eva Pajkrt:

My name is Eva Pajkrt. I am a professor in obstetrics, in particular, prenatal diagnosis and obstetric ultrasound, at the academic medical centre of the University of Amsterdam. I was trained as a gynaecologist at Medical Centre Alkmaar, which is a general hospital, and afterwards in the Academic Medical Centre in Amsterdam, which is a tertiary referral centre. I was trained as a general gynaecologist in all aspects of the specialty. Before and during my residency, I did my PhD on prenatal screening for chromosome anomalies and I worked later and contributed to the national introduction of prenatal screening in the Netherlands. Following my residency, I did a two-year clinical fellowship in foetal medicine at University College London Hospital. Once I came back to the Netherlands in 2005, I started working again at the Academic Medical Centre as a consultant in foetal and maternal medicine. I have been head of the foetal medicine unit since 2010 and was appointed professor in 2016.

I am involved in numerous committees of the Dutch Society of Obstetrics and Gynaecology. Since the introduction of the prenatal screening programme, I have been a member on several working parties concerned with the quality of care of the programme and I have been advising the Ministry of Health on several abortion issues.

My presence here has been requested to answer the committee's question about Dutch abortion care. The abortion care is imbedded within the ethical framework of patient autonomy and is completely woman centred. The objective of Dutch abortion care is to have a thorough and comprehensive process without creating any obstacles.

I will briefly take the committee through the statement it has already received. I will not go through it extensively but I understand some of the people are following this online only and they do not have the statement. I will skip certain parts and if the committee cannot follow me, that is why.

Since 2016, there has been a national co-operation agreement between the Dutch Association of Abortion Specialists, the Dutch psycho-social counselling service for questions of unintended pregnancy, adoption and abortion, the Dutch Society of Obstetrics and Gynaecology and the Royal Dutch Organisation of Midwives. The Dutch College of General Practitioners, which is not listed, is also involved in this agreement. Women with an unplanned or undesirable pregnancies and doubts about continuation of their pregnancies will generally go to their general practitioners - this is about which professionals are involved.

In 56% of cases, the general practitioner will be the first contact. He or she may counsel the woman about her options and may refer her to an abortion clinic, a gynaecologist or for further psychological counselling. General practitioners have their own national guidelines. There is an English version which is available. In 25% of cases, women go directly to the abortion clinic and it is the first contact. The abortion clinic doctor may counsel the woman about her options. They may perform the procedure or they may refer the woman for further counselling. The other 25% either go to a midwife, a gynaecologist or some other professional. If the pregnant woman goes to the midwife, the midwife never will be the referring physician. The midwife is not legally a doctor and should refer the woman, and then the GP or gynaecologist has to refer the woman. The first contact may be a gynaecologist or other doctors. For example, the doctors of women with a cardiac problem in which it is unsafe to have a ongoing pregnancy may also refer them.

There are general considerations in cases of unplanned and undesirable pregnancy. One of the first questions one asks is whether there was a pregnancy test performed and whether there should be a repeat test. Then one should always ask if the pregnancy was planned or unplanned. That seems contradictory but it is, of course, not always so. A planned pregnancy may become undesirable and an unplanned pregnancy may become desirable. Ask about the circumstances leading to the pregnancy and whether or not the woman was on contraceptives. Mention there is always a choice and a dilemma in case of unplanned pregnancy. Ask about a dating with a scan. If there has not been one, please have one performed, preferably transvaginally. If the woman is determined to have an abortion, she should mention that on her request to the person performing the scan. Is the partner present at the consultation? If so, explore whether the woman was not forced by the partner or the person sitting beside her and that it is a voluntary request. Explore whether there has been any sexual abuse. Be aware of cultural and religious factors. Ask whether there would be a risk of genital tract infections, but in case of abortions on request as opposed to abortions due to prenatal diagnosis, we always test for sexually transmitted diseases in the Netherlands. We always discuss contraceptives - what kind of contraceptives the woman will use after she has had the abortion. Is the request consistent or does the woman seem to be in a state of panic and, as a result, would she potentially benefit from more time to make a decision? If so, refer woman for further counselling. When referring a woman for an abortion, always document the first date of the abortion request. Of course, there are several websites and I have included the address of one. Women can go online. There is a help choice and they can go through it.

There are also some questions one should always ask, including, "Are you certain about your decision?" It seems obvious but one has to ask. The others are: "How did you reach this decision?"; "Is this your own choice?"; "Have you considered other options?"; "Would you like me to explain the options?"; and "Do you need help to make a proper decision?"

If the partner is present, the partner also should be asked. In case of ambivalence, it is important that the woman understands that she is responsible for her own choice. Ultimately, she has to make the decision. Nobody is going to make that decision for her. The woman should not be forced into making a decision; rather she should be helped to make a choice. It is important not to blame the woman for being ambivalent and that the emergency situation of the woman is considered. If the woman remains ambivalent, she should be referred for further counselling. In the Netherlands women are also referred to FIOM, which is the Dutch agency that helps women who give consideration to or opt to have their child adopted.

Time is important in any case of unplanned pregnancy in view of the method of abortion. Once a woman is referred, a quick appointment is mandatory, preferably within a week or, at least, within ten days. From the moment the woman indicates she is considering an abortion and the actual treatment, a reflection time of at least five completed days is mandatory in the Netherlands. This reflection time is not mandatory until a gestational age of six weeks plus two days, which is the 44 days after the first day of the last menstrual period. However, 65% of these women do have a reflection period of more than five days.

There are several ways to terminate a pregnancy. A woman can have a surgical termination, a medical termination or a combined termination, which involves the use of medication followed by a surgical procedure. Women may choose where to have an abortion and what type of abortion they would like, although their choice is, of course, dependent on gestational age. Women over 16 years of age do not need parental consent. Women between 12 and 16 years do require parental consent but we may withhold it if we believe it is a reasonable argument.

Approximately 90% of abortions in the Netherlands are carried out in abortion clinics. The Dutch Health Care Inspectorate produces an annual report with statistical information on terminations performed in the Netherlands in the preceding year. The last report was in 2015. As the data in the report are aggregated data, it is not possible to correlate between the different components of the abortion registration. In 2015, approximately 30,000 abortions were carried out in the Netherlands, almost 4,000, 13%, of which were on behalf of women from a foreign country. Of these 30,000 abortions, 8,500, 28%, were carried out before 44 days and as such these terminations are not considered under the abortion Act. Approximately 16,000, 50%, were performed before seven weeks gestation, while almost 9,000, 29%, were performed between seven and 12 weeks gestation. Thus, 80%, of all the abortions were performed in the first trimester, before 13 weeks.

The majority of women undergoing an abortion were between 25 and 30 years of age. Only 83 pregnancies were terminated in women under 15 years. In 2015, the total number of pregnancy terminations in teenagers was 3,079. This number has been decreasing slowly over the last couple of years. This is reflected in the percentage of teenage pregnancies that go to term. This is very low in comparison with other European countries.

Since 2007, all pregnant women in the Netherlands may undergo pre-natal screening. They are offered a combined test for screening for Down's syndrome, Edward's syndrome and Patau syndrome. As of 2017, non-invasive pre-natal testing, NIPT, has been added as a first trier test to screen for the above mentioned trisomies. Moreover, every women is offered a 20 week scan. Since 2011, it is possible to address whether an abortion is the result of pre-natal diagnosis. In 2015, a little over 1,000 of all abortions were performed after pre-natal diagnosis, the majority of which were carried out in a hospital. We know from the aggregated data that more than 30% of the abortions in hospitals are due to pre-natal diagnosis, compared with only 0.5% in abortion clinics. However, we do not have any knowledge on diagnosis nor is it possible to correlate the date with gestational age. It is likely that abortion due to pre-natal diagnosis will be carried out in the second trimester due to the time it takes to get a definite diagnosis. Thus, we can assume that around 20% of the second trimester abortions is due to pre-natal diagnosis.

Of all women undergoing abortion, 75% leave the clinic or hospital with a prescription for contraceptives. Since 2012, it is mandatory to provide sexual education to all schoolgoing children. This starts in elementary school. Up to 2011, contraceptives were reimbursed for every woman. Since 2011, only women up to 21 years are reimbursed. In the Netherlands, abortion is free for everyone who is legal and has a social security number. It is subsidised care. The costs are not reimbursed by the insurance companies but are subsidised by the ministry of health. For foreigners or people living illegally in the Netherlands, the cost varies, between €380 and €940. Particular centres, such as the Academic Medical Center, are subsidised separately by the ministry of health to take care of these women. For women who are in a really difficult position and cannot afford an abortion our hospital will provide an abortion, for which the hospital receives a subsidy, although I am not sure about how reimbursement in this regard is regulated.