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As it happened: 'A woman is responsible for her own choice, ultimately she has to make the decision'

The Eighth Amendment Committee today focused on obstetric medicine in the Netherlands.

Hello and welcome to today’s liveblog of the Oireachtas Eighth Amendment Committee. It’s Órla Ryan here.

Today’s session will focus on obstetric medicine in the Netherlands. The speakers are Professor Sjef Gevers, Emeritus Professor of Health Law, University of Amsterdam; and Professor Eva Pajkrt, Professor of Obstetrics, University of Amsterdam.

You can watch proceedings below: / YouTube

bren Brendan Durkan

Deputy Bernard Durkan is filling in as chairperson today as his Fine Gael colleague Senator Catherine Noone is away, in case you were wondering.

sv Professor Sjef Gevers

Professor Sjef Gevers, Emeritus Professor of Health Law, University of Amsterdam, is now delivering his opening address:

“Terminating a pregnancy is a crime under Article 296 of the Dutch Penal Code. According to the fifth par. of that article, however, abortion will not be punished if carried out by a doctor in a hospital or abortion clinic with a license in accordance with the Termination of Pregnancy Act (in common lay terms: the Abortion Act).

“That act was adopted in 1981 (and came into force in 1984), after a long history and more than 10 years of public and political debate. The two conflicting values that had to be accommodated in it were clearly expressed by the government during parliamentary proceedings: The bill is based on the view that women, who are in a situation of emergency due to an unwanted pregnancy, should receive help. But we consider the termination of unborn human life as such a serious act, that it is only acceptable if unavoidable because of that emergency. This means that the physician, the woman and others that may be involved before the decision to terminate, need to act with utmost care and in awareness of their responsibility towards unborn human life and of the consequences for the woman.

“At the moment 93 hospitals and 15 clinics do have a license to terminate pregnancies, which means that they are allowed to induce abortions provided that the provisions of the Abortion Act are complied with. Such licences are granted by the Minister of Health to establishments that satisfy statutory requirements relating to the quality of treatment in terms of medical competence and facilities as well as psychological care. The directors of these establishments must submit periodical reports to the Health Care Inspectorate about the number and some characteristics of patients they have treated (the figures are published in the Inspectorate’s annual report).

“Abortion is not seen as a routine medical procedure but as one that may be carried out on request of the woman if her “circumstances leave her no other alternative. Basically, the Act does not provide substantive reasons or criteria for terminating a pregnancy. Instead, it sets standards in the form of a set of requirements designed to guarantee that the decision to terminate is taken with all due care.”

Professor Gevers continues: “In 2015, about 30,000 abortions were carried out in the Netherlands. This results in an abortion rate (ie the number of abortions per 1000 women within the ages of 15-44) of 8.6, which is relatively low if compared to several other European countries. The total number of 30,000 includes almost 4,000 abortions for non-residents (mostly from France and Germany; in 2015, 34 women from Ireland).

“The key provisions of the Abortion Act are those on careful decision-making. According to Article 5, termination may only take place if a situation of emergency of the woman makes that inevitable. ‘Emergency’ refers to the psychological state of mind of the woman due to the unwanted pregnancy; it does not require (the risk of) physical or mental injury. The Act does not provide substantive, general criteria for assessing whether or not the situation of the woman amounts to an emergency.

“The legislator has adopted this approach because the decision to terminate a pregnancy must be taken with due regard for the individual circumstances of each case. In establishing the existence of an emergency, the opinion of the pregnant woman is decisive, although the physician always retains a responsibility of his/her own for an abortion. In other words: both the woman and the doctor are responsible for the process of reaching a decision, although the decision as such is ultimately made by the woman. The physician shall assist the woman requesting an abortion in making up her mind.

“For that purpose, he/she must provide her with appropriate information about other solutions to her situation. Furthermore, the physician must see to it that her request is made and maintained freely and without undue pressure from other persons, and that she insists on that request only after careful consideration.

“A woman is not required to reach agreement with her partner or parents; the decision is hers alone. Like some other abortion laws, in order to ensure sufficient reflection, the Dutch law requires a waiting period between the first request of the woman and the eventual termination of her pregnancy; according to Article 3, termination may not take place before the 6th day after the initial request (which amounts to a lapse of five full days). An exception is possible when the health or life of the woman is at risk.”

Professor Gevers tells the committee: “The Abortion Act has several other provisions. It states for instance that health professionals (also if working in a hospital with a licence) cannot be obliged to carry out an abortion and that conscientious objections must always be respected. Furthermore, physicians carrying out abortions must keep medical records on why in each case he/she decided to terminate a pregnancy.

“If required so, he/she must give the inspectorate access to these data (in a form which cannot be related to individual patients). Finally mention should be made of the obligation to provide adequate care after the termination has been performed. This includes not only a medical check and psycho-social assistance if needed, but – even more important maybe – an obligation of the establishment where the abortion takes place, to provide for responsible information and education concerning the prevention of undesired pregnancies.

“The Dutch law is different from many other countries in Europe in that it makes no further distinction between the first and second trimester of pregnancy. There is only one exception to this: abortion clinics need special licence to perform an abortion after the 12th week of pregnancy (ie in the second trimester).

“This provision is not based on the (normative) view that in that stage of development the foetus deserves more legal protection than in the previous stage, but on the (factual) observation that after 12 weeks gestation an abortion is more invasive, both psychologically and medically, and that special skills and methods may be required to perform it safely. If this requirement is fulfilled, abortion can take place on the same basis during the first as well as the second trimester, as long as one remains within the 24 weeks limit.”

Professor Gevers continues: “As to the question how the concept of ‘emergency’ is applied, according to the women who answered the questionnaire, usually the reasons to request abortion are discussed with the physician. Those reasons are quite diverse (ranging from financial and housing constraints, to age, the fact that the family is already ‘complete’, a broken or fragile relationship, lack of possibilities to raise a child, etc).

Most often, there is more than one reason to request abortion. This picture is confirmed by a later study commissioned by the Ministry of Health and conducted in 2012: most women that were interviewed said that their final decision was the result of a number of reasons/factors and should be seen against the background of their present situation in life. All of them experienced the decision to terminate their pregnancy as a hard one, however, and some of them as the most difficult decision they had to make in their life.

He later states: “During the last few years, a new evaluation of the Abortion Act has been planned. It should have been carried out in 2017, but has been postponed in order to allow the new government (in office since end October this year) to give the ‘green light’ for it…

“Terminating a pregnancy after 24 weeks of gestation is prohibited (and a crime against life under Article 82a Penal Code). Nevertheless, in medical practice the need for third trimester abortion has made itself felt, at least in exceptional circumstances.

“In order to provide guidance with regard to good medical practice, in 1994 the Netherlands Association for Obstetrics and Gynaecology published a report which lays down certain criteria. According to that report, such a late term abortion may only be considered if a foetal abnormality is diagnosed which either excludes the possibility of survival after birth, or is so serious that postnatal life prolonging procedures will be considered futile.

“After setting up a multidisciplinary committee to advise them on how the criminal law system should deal with these cases, in 2007 the Ministers of Health and Justice established a Central Expert Committee. Cases of late abortion for very severe foetal abnormalities have to be notified to it so that – after reviewing them along the lines already set out in the 1994 report – it can offer its advice to the public attorney as to whether or not prosecution should take place. After an evaluation in 2013, this arrangement was slightly modified in the beginning of 2016, but the basic rules have remained the same.

In 2015, the Minister of Health announced that she would like to make it possible that also general practitioners could induce abortion, at least in the very first period of pregnancy (within 16 days overdue). The method of medical abortion had developed sufficiently to perform such an abortion safely outside hospitals and clinics, and – according to the Minister – it would be important to involve general practitioners since they knew their patients well and would be in the best position to talk with them and advise them in case a termination of a pregnancy was considered.

“This idea met with resistance from several sides (not only from the anti-abortion side, but also from others who felt that the delicate balance in the Abortion Act should not be disturbed), but nevertheless (in the beginning of 2017) the government (then a coalition of liberals and social democrats) submitted a bill to Parliament that was to enable general practitioners to induce medical abortion (by means of the ‘abortion pill’) within that very first period of gestation. General practitioners who wanted to do so, would need a license and basically, they would have to comply also with the other rules laid down in the Abortion Act.”

“Another important element of the bill was that abortion within the first month after conception (16 days overdue) which until then did still not fall under the Abortion Act (in spite of the recommendation resulting from the evaluation of the Act, see above), would be brought under the scope of the Act (also if taking place in a hospital or clinic). The only ‘concession’ to the procedural requirements of the Abortion Act, was that, instead of the statutory waiting time of five days, a flexible time lapse could be observed (as is already current practice in this situation).

“In the autumn of 2017 a new government coalition was formed (consisting of liberal and christian parties); in its first meeting with parliament, the new government announced that it would not proceed with the bill. So, inducing abortion (also by means of medicines) will remain limited to licensed hospitals and clinics; furthermore, the present legal situation is not likely to change in the years to come,” Professor Gevers states.

eva Professor Eva Pajkrt

Professor Eva Pajkrt, Professor of Obstetrics, University of Amsterdam, is now delivering her opening statement.

She tells the committee: “Since 2016 there has been a national cooperation agreement between the Dutch Association of Abortion Specialists (NGVA), the Dutch psychosocial counselling service for questions of unintended pregnancy, adoption and abortion (FIOM), the Dutch Society of Obstetrics and Gynaecology (NVOG) and the Royal Dutch association of Midwives (KNOV) on unplanned and unwanted pregnancy care.

“Women with an unplanned and/or undesirable pregnancy and doubts about continuation of the pregnancy will generally go to their general practitioner. Some may go to an abortion clinic, a midwife, a gynaecologist or another health care provider. To support those professional in their care and to provide for an adequate referral system, this agreement has been produced.”

Professor Pajkrt then explains the different roles in the process:

  • General practitioner: may be the first contact. Counsels the woman about her options. May refer the woman to an abortion clinic, a gynaecologist or for further (psychological) counselling. There is a national ‘Guidance for general practitioners in case on unplanned pregnancy’.
  • Abortion clinic doctor: may be the first contact. Counsels the woman about her options. May perform the procedure or may refer the woman for further counselling.
  • Midwife: may be the first contact. Counsels the woman about her options. May refer the woman to an abortion clinic, a gynaecologist or for further (psychological) counselling. However, a midwife may never be the referring physician, since legally only doctors are allowed to refer a patient for an abortion. Considering the legal framework of abortion (5 day reflection period) this is important to note.
  • Gynaecologist: may be the first contact. Counsels the woman about her options. May perform the procedure or may refer the woman to an abortion clinic or for further counselling.
  • Other professional: may be the first contact. Counsels the woman about her options. May refer the woman to the general practitioner or abortion clinic, but is never the legal referring physician.

Professor Pajkrt lists the “general considerations” in cases of “unplanned and undesirable pregnancy”:

  • Ask if the a pregnancy test has been performed and whether it would be necessary to repeat the test
  • Ask if the pregnancy is planned or unplanned
  • Ask about the circumstances leading to the pregnancy, contraceptive use
  • Mention there is always a choice and a dilemma in case of unplanned pregnancy
  • Ask if the pregnancy has been correctly dated with a scan, in case of doubt perform a scan (in early pregnancy preferably transvaginally. When referring for a scan, please mention whether it is an undesirable pregnancy
  • Is the partner present at the consultation? Explore whether the request is voluntary.
  • Explore whether there has been any sexual abuse resulting in this pregnancy
  • Be aware of cultural and religious factors
  • Ask whether there would be a risk of genital tract infections, always test for sexually transmitted diseases.
  • Always discuss contraceptives
  • Is the request consistent or does the woman seem to panic and potentially may benefit from more time to make a decision?
  • When referring a woman for an abortion always document the first date of the abortion request

General questions to ask the woman:

  • Are you certain about your descision?
  • How did you reach this descision?
  • Is this your own choice?
  • Have you considered other options?
  • Would you like me to explain the options?
  • Do you need help to make a proper descision?
  • If the partner is present:
  • What is his vision?
  • Have they considered other options?

In cases where the woman seems ambivalent, Professor Pajkrt notes: “The woman is responsible for her own choice, ultimately she has to make the decision. Do not force the woman into making a decision, try to help her making a choice.

“Do not blame the woman for being ambivalent. Consider the emergency situation of the woman. If the woman remains ambivalent, refer the woman for further counselling.”

“Time is important in any case of unplanned pregnancy in view of the method of abortion. Once a woman is referred or seeks advice a quick appointment is mandatory.

“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. This reflection time is not mandatory until a gestational age of six weeks plus two days (44 days after the first day of the last menstrual period),” she states.

“The majority of women undergoing an abortion are between 25 and 30.

“Only 83 pregnancies were terminated in women <15 years of age in 2015, as opposed to 96 and 87 in 2014 and 2013 respectively.

“The total number of pregnancy terminations in teenagers (up to 19 years) was 3,079. This was 102 abortions fewer compared to 2014 (3,181 teenage abortions) and 564 fewer than in 2013 (3,643 abortions).

“In 2015 only 10% of all pregnancies was performed in teenagers, as compared to 16.8% in 2002. Since 2002 there has been a steady decrease in teenage pregnancies. This is also reflected in the number of live birth among teenagers (data from CBS). Compared to other European countries the teenage pregnancy rate is low,” Professor Pajkrt notes.

She continues: “Since 2007 all pregnant women in the Netherlands may undergo prenatal screening. They are offered the combined test for screening for Down syndrome, Edward syndrome and Patau syndrome. As of 2017, NIPT (non-invasive prenatal testing) has been added as a first tier test to screen for the above mentioned trisomies. Moreover every women is offered a 20-week structural anomaly scan.

“The majority (80%) of second trimester abortion >12 weeks gestation are still being performed in abortion clinics. However since the introduction of prenatal screening the number of second trimester abortion treated in hospital has been increasing.

Since 2011 it is possible to address whether an abortion is the result of prenatal diagnosis. Due to the manner in which the abortion are gathered, it concerns aggregated data so no correlation between the different components of the abortion registration.

“In 2015 only 1053 of all abortions (3.3%) were performed after prenatal diagnosis of which 931 had a treatment in a hospital and only 93 in an abortion clinic, thus reflecting the difference of the situation.

“We do know from the aggregated data that >32% of the abortions in hospitals is due to prenatal diagnosis compared to 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.”

Professor Pajkrt states: “Since 2012 it is mandatory to provide sexual education to all school going children. This should start in elementary school around the age of 10 years.

“Until 2011 contraceptives had always been reimbursed for every woman with insurance. Since 2011 only women up to 21 years get reimbursement.

“Abortion is free for everyone who is legal and insured in the Netherlands. It is subsidised care. The costs are not reimbursed by the insurance companies but paid for by the Ministry of Health.

“For foreigners or people living illegally in the Netherlands cost vary between €380 and €940.”

jerry Jerry Buttimer i

Responding to Senator Jerry Buttimer, Professor Pajkrt says if a woman wants prenatal screening, chromosomal screening is carried out to test for foetal trisomies. About 40% of women take up this option.

Professor Pajkrt says the uptake was less than expected when NIPT (non-invasive prenatal testing) was introduced, citing cost as a potential reason for this. About 95% of women take up the option of a 20-week scan, which is free.

There’s a vote in the Dáil, so the hearing is suspended for a few minutes.

While we wait, here’s a round-up of what happened at yesterday’s session: Representatives from the British Pregnancy Advisory Service and support group One Day More addressed the committee.


ro Rónán Mullen

Independent Senator Rónán Mullen says he’s surprised by the low number of Irish women travelling to the Netherlands for abortion (34 in 2015).

Responding to Mullen, Professor Pajkrt says 3% of all abortions in 2015 were carried out after 24 weeks, and 2% in 2016. She says this figure has “dramatically reduced” due to fatal foetal abnormalities being identified at earlier stages of pregnancy since the introduction of prenatal screening.

Mullen says Ireland cherishes people with Down syndrome more than many other countries, mentioning our participation in the Special Olympics.

Professor Pajkrt tells him many people in the Netherlands believe Down syndrome shouldn’t be screened for during pregnancy. Of the women who do screen for it, about 90% of them have an abortion if the condition is found.

Professor Pajkrt says she seriously objects to the view that women choose to have an abortion lightly, saying there are many reasons they choose this option, adding: “It’s not, ‘I’m going on a vacation and it doesn’t suit.’”

gav Paul Gavan

Replying to Sinn Féin Senator Paul Gavan, Professor Pajkrt says that while abortion can lead to complications in a small number of cases (particularly if carried out later) it is generally “a very safe procedure”.

Professor Pajkrt says contraceptives should be free, noting: “Prevention is better than to have to treat it.”

She says sexual health education is also very important, adding that children will look for information online if they don’t receive it at school or from their parents. She jokes that her own children weren’t impressed when she offered to give a talk about it at their school.

ned Ned O'Sullivan

Fianna Fáil Senator Ned O’Sullivan describes the Netherlands’ approach as “woman-centred”, saying this view is becoming more common here.

Professor Gevers says the model wasn’t voted on in a referendum in the Netherlands but he thinks it’s widely supported.

He says the law doesn’t go further in defining ‘emergency’ in order to take account of the diverse situations under which a woman may need an abortion.

Speaking about parental consent in the case of minors, Professor Gevers says a 16-year-old girl can make a decision about an abortion herself, while there’s a dual consent system in place from ages 12-16.

Professor Pajkrt says an abortion may be carried out on a girl without her parents’ consent in exceptional circumstances, but that there aren’t statistics on this.

In terms of aftercare, she says women from abroad usually just go back to the country they’re from and don’t further engage with services in the Netherlands.

peter2 Peter Fitzpatrick

Fine Gael TD Peter Fitzpatrick asks Professor Pajkrt if a woman’s right to choose is more important to her than a baby with Down syndrome’s right to life. She says it is.

She tells him the number of children with Down syndrome being born in the Netherlands – about 250 a year – has remained stable for years and has not dramatically reduced since the introduction of more prenatal screening.

She says people who have children with disabilities should be supported, adding the Netherlands is “a country where we care for everybody”.

When Fitzpatrick asks about adoption, Professor Pajkrt says doctors should listen to what a woman has requested, rather than try to give her alternative options that she has likely already considered herself.

We will be sending out an email round-up of what happened at the committee later today.

To get the weekly round-up, just enter your email in the box at the bottom of this article.

sj2 Professor Sjef Gevers

We’re back after another break for a vote in the Dáil.

Professor Sjef Gevers tells Peter Fitzpatrick there is protection and respect for the unborn in the Netherlands, but “the choice of the woman remains in the centre”.

He adds that a person only gets full rights in the Netherlands after birth.

lynn Lynn Ruane

Independent Senator Lynn Ruane thanks the speakers, saying their evidence “cancelled out yesterday’s nonsense” where it was suggested by a speaker from support group One Day More that a woman’s hormones during pregnancy may influence her decision to have an abortion.

Ruane asks if the usual five-day reflection period before an abortion is carried out in the Netherlands affects some women negatively – particularly in cases of domestic violence or where the woman may want the abortion for socio-economic reasons and may only be able to visit a clinic once.

Professor Pajkrt says 97% of women in the Netherlands who decide to have an abortion have reflection time of more than five days, not counting people before 44 days of pregnancy. About 3% of women are allowed to have an abortion without a reflection period if their circumstances require this.

She says most women appreciate the reflection period as it gives them more time to think and talk to loved ones, she says no one has ever told her: “You made me wait, that was so inhumane.”

Ruane is now bringing up the influence of the Catholic Church in terms of sexual education in Ireland.

hilde Hildegarde Naughton

Fine Gael TD Hildegarde Naughton continues the discussion about sexual education.

Professor Pajkrt says “talking about sex has become a very natural, normal thing” in recent years, giving how it’s more openly talked about on TV as an example. She says it’s a natural thing to discuss with family and friends, and no longer “a taboo”.

In relation to Irish women travelling to the Netherlands for abortion, Professor Pajkrt says the five-day waiting period includes the time from which a woman makes an appointment – not the first time she walks into the clinic.

kate Kate O'Connell

Fine Gael TD Kate O’Connell brings up “the hold of the Catholic Church on our ovaries and all things sexual related”, mentioning Ireland’s “damning history” in terms of incarcerating pregnant women and forced adoption, among other things.

Speaking about the approach in the Netherlands, she says: “I think if I went to the Minister for Health and said, ‘I need a team of sexologists’, I think he’d say, ‘Lord, I don’t know how to deal with that.’”

She says there is a difficulty in separating the moral from the medical in Ireland, saying some people seem to believe that if we repeal the Eighth Amendment women might suddenly decide at 36 weeks of pregnancy that they don’t actually want a child.

Professor Pajkrt says there will always be people who question the morals of abortion, but says this doesn’t stop women from needed and getting them – sometimes illegally.

louise Louise O'Reilly

Professor Pajkrt tells Sinn Féin TD Louise O’Reilly abortion counselling isn’t mandatory in the Netherlands but many women take it up.

Referencing a comment by Rónán Mullen earlier, O’Reilly notes that the Special Olympics is an international event that the Netherlands also take part in.

cath Catherine Murphy

Replying to Social Democrats TD Catherine Murphy, Professor Pajkrt says abortion law in the Netherlands falls under criminal law but that many healthcare regulations also apply.

She says it may be dealt with under criminal law but women aren’t criminalised, adding that she hasn’t seen a protest outside an abortion clinic in a long time.

clare Clare Daly

Replying to Independents 4 Change TD Clare Daly, Professor Pajkrt says an uptake in late second-term abortions in the Netherlands may be due to more 20-week scans taking place.

Professor Pajkrt says abortion law there falls under criminal law in order to protect pregnant women from potential malpractice by doctors, not to criminalise the women themselves.

brid Bríd Smith

People Before Profit TD Bríd Smith notes that the speakers haven’t focused on abortions in the cases of rape or incest, two arguments that regularly feature in the debate in Ireland. She says relatively few abortions would actually be for these reasons, saying socio-economic circumstances would be a much more common reason.

Professor Pajkrt says women in such situations (rape and incest) would be strongly advised to get counselling and extra support, adding there is no question that they would be granted a termination.

She says there are many reasons why women choose to have an abortion, many of them “desperate stories”, and it’s unfair to say which reasons are better than others.

sj Professor Sjef Gevers

Professor Gevers says Ireland’s abortion law is “very restrictive” compared to other European countries, noting United Nations Human Rights Committee criticisms of the situation here.

When Smith asks Professor Pajkrt what she thinks of Ireland’s abortion laws, she tells her: “I think I don’t have to say that out loud, I think you probably know how I feel about it. I’m a very strong believer in women’s choice and women’s reproductive choice.”

She adds that’s she not trying to disrespect men, but ultimately it’s “a female thing”.

anne Anne Rabbitte

Fianna Fáil TD Anne Rabbitte says, in Ireland, courts have to make a decision in cases where a girl in foster or social care requests an abortion.

She says she finds it “shocking” that 12-year-old girls could be able to get an abortion without their parents’ consent. Professor Pajkrt says parents are usually involved in cases like this, but their consent may not be sought in a case where it could endanger the girl’s life – something that could happen in cases of rape or incest.

Responding to Fianna Fáil TD Lisa Chambers, Professor Gevers says he doesn’t agree with the position in Ireland where the life of the foetus is given equal status to the life of the mother (under the Eighth Amendment).

He reiterates an earlier point he made, saying that, while the foetus is valued in the Netherlands, it doesn’t have full legal rights until it’s born.

And that’s a wrap. We’ll be sending out an email round-up of what happened at the committee later today.

To get the weekly round-up, just enter your email in the box at the bottom of this article.

Thanks for staying with us so far, we’ll be back next Wednesday.

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