My bodily autonomy

Imagine yourself being a single mother, who wants to terminate her pregnancy. Because your daughter is suffering from symptoms of COVID-19, you are unable to leave the house. Waiting a few weeks is not an option, because it would mean that you would no longer be eligible for a medical abortion. This happened to Trix (alias), a mother living in the Netherlands.

On the 10th of April the case of Trix against the State which was supported by the institute Bureau Clara Wichmann and Women on Waves was dismissed by the District Court of the Hague. Trix was pleading to legalize the abortion pill by post, with only a phone consultation. Other women have also come forward in support of her cause. One of these women is in an unsafe home environment with a partner who doesn’t know she’s pregnant. Because of the lockdown, she is unable to fabricate a cover story to leave the house. Another woman lives in the Wadden Islands and has had to travel for four hours to reach an abortion clinic. Alarmed by these cases, I wanted to explore the court's reasoning behind the dismissal of this case. Subsequently, I would like to explore the possibility of a solution for the women who are currently disadvantaged by the regulations regarding abortion.

Women from England, Scotland and Wales currently have access to a “Pills by Post” system. After a telephone consultation which takes about 40 minutes the abortion pills, consisting of two tablets of mifepristone and misoprostol, will be sent to their home.

The site of the British Pregnancy Advisory Service (one of three services that provide abortion pills through the post) seems to be very user-friendly. A video shows exactly what the package containing the pills will look like when it arrives. The site states that “This service is a safe and legal way to end a pregnancy at an early gestation without needing to attend a clinic for treatment.” The risks of the pill are also clearly stated on the website.

Could this website provide inspiration for a new and safe system for house-bound women who still want to have access to an abortion?

When I contacted Women on Waves (one of the supporters of Trix’ case), they referred me to a guide for healthcare professionals on abortion care in times of COVID-19. The guide was published by the Royal College of Obstetricians and Gynaecologists’ Faculty of Sexual and Reproductive Healthcare and the British Society of Abortion Care Providers. Women on Waves used this document building their argument for the case of Trix.

The document offers a summary of early medical abortion care management during the COVID-19 pandemic. It focuses on remote consultation, which can be done via video or phone. According to this summary, an ultrasound, which would mean that the woman will have to leave the house, is only considered necessary if it is a purely medical necessity. Medical history or symptoms that could be suggestive of high risk ectopic pregnancy are reasons for a mandatory ultrasound.

Given the impeccable reputation of the Royal college of Obstetricians and gynaecologists, the document is likely a reliable source that can be used to look at alternatives to the current abortion legislation in the Netherlands.

However, the summary is intended to be used as a resource for UK healthcare professionals and providers. If we want to introduce an appropriate system for our healthcare system, we should enter into discussions with the healthcare researchers that are part of the Dutch healthcare system.

When I contacted several abortion clinics, I received mixed responses to my question whether the current situation requires an amendment to the legislation surrounding abortion. Both the abortion clinic in The Hague and the abortion clinics in Amsterdam and Almere questioned the extent to which an abortion pill sent without a physical consultation and ultrasound is medically justified. When I mentioned a possible Pills by Post-inspired system, the receptionist interrupted me before I could finish my sentence:

“After the pregnancy is visible on the ultrasound, you get an abortion pill. Without this certainty we cannot give it. For all we know it is an ectopic pregnancy and because the pills induce a miscarriage, this could be very dangerous for the woman. So we don't send pills by post at all. That's a bad thing. They are very dangerous pills. Abortion pills are hormone pills. You create bleeding with these pills. If used incorrectly, it can be very intense, and can lead to a needed hospital visit. ” - Abortion Clinic Almere

Nina Willemse, a doctor working at Abortion Clinic Amsterdam, responded with a more open attitude with regards to a Pills by Post system.

“As a doctor you naturally want healthcare to be easily accessible. But you also want to be able to guarantee the best quality of healthcare. An abortion pill without ultrasound is ofcourse a great alternative to the people who really cannot get an ultrasound and who take the risks for granted. I would like to take that risk, but if it could be done differently in the Netherlands this would, in my opinion, be preferred (better quality of care). Especially because not all the women we speak to are fully aware of how long into their pregnancies they are. Even though it’s unlikely, a woman could be much further into her pregnancy than she thinks. If you don’t have to take these risks, I suggest you go to the clinic.

So, what are we to do about the risks involved with a Pills by Post system if we would like to implement such a system in the Netherlands, considering women aren’t able to find access to their legal right to an abortion?

I’d like to see the law amended in such a way that for each individual case an examination can be made as to whether access to care is hindered in such a way that you would rather make this choice in consultation with a doctor. I think the best option would be to do this via video call, so you can go through everything quietly with a client, explain everything and answer questions. For all the women we treat with the abortion pill we have around the clock service, which is nice. We often know more about the abortion pill than general practitioners (and many gynaecologists) and so women do not need to go to a GP at night in case of problems, because they can just use our 24hr service. - Nina Willemse, a doctor working at Abortion Clinic Amsterdam.

Having spoken to different institutions in the Netherlands and the UK, it became clear that it remains difficult to find a good solution. Still, it is important to take action. Debbie Maas, chairman of the National Safe Home Network (LNVT), expressed her concerns about vulnerable people who were already struggling before the COVID-19 crisis. According to her, it’s expected that stress at home can increase due to the risk of unemployment and fear of the virus. Let's make sure that these women aren’t disadvantaged when it comes to abortion options. Instead of taking a fear-based approach towards new abortion legislation, let's make use of the altering political landscape and have a conversation. Healthcare institutions, healthcare professionals, and especially the women who have been impacted by the current complacency of legislators with regards to abortion legislation must sit down together. Let’s look for new solutions that are both medically justified and offer a helping hand to women who are vulnerable in these times of crisis.