Dr Janey Rademakers is Research Co–Ordinator for the Netherlands Institute of Social Sexological Research — NISSO. She is a recognised authority in matters relating to contraception, sexuality and abortion in the Netherlands and is one of the people visited by New Zealand's Abortion Supervisory Committee when they went to the Netherlands in 1998.
I interviewed Dr Rademakers in Utrecht on 12 April 2000 and we began by discussing the results of the survey carried out through Waikato University on contraceptive use in New Zealand. She was shown some of the tables which are set out in an earlier chapter of this report.
I pointed out that despite the high use of contraception among New Zealand women, our abortion rate is substantially higher than that for the Netherlands. I said those at Waikato University who had undertaken the research had found a surprisingly high level of contraceptive failure among women using the pill and the condom.
Having examined the tables, Dr Rademakers expressed her amazement that so many New Zealanders relied on the condom to prevent pregnancy. She said because the condom has such a high failure rate, they discourage its use in Holland as a method for avoiding pregnancy.
She showed me some 1998 research by the pharmaceutical company Organon which showed that only 4.9% of those aged 15–49 were using the condom in Holland compared with 45.9% using the pill. There is no comparable data available for New Zealand but the Waikato study showed 19% of those aged between 20 and 34 relied on the condom to avoid pregnancy — see Table 5 under section entitled “Major study on the use of contraception in New Zealand”.
In discussing the inevitability of contraception failing some of the time, Dr Rademakers explained that in the Netherlands a great deal of effort is directed towards educating women and girls on ways to minimise contraceptive failure. She said this is a very important objective in trying to keep abortion levels as low as possible.
We went on to discuss what is done in the Netherlands to encourage women to minimise contraceptive failure. The objective was to close the gap between the “theoretrical efficacy rate” and the 'use–effectiveness rate'. The theoretical efficacy rate is a measure of the effectiveness of the method when it is used perfectly every time. It results in fewer episodes of failure than the 'use–effectiveness rate' which is based on what actually happens in practice.
Table 7 of “Major study on the use of contraception in New Zealand” sets out failure rates identified by the Alan Guttmacher Institute.
Dr Rademakers explained there are all kinds of mistakes surrounding the use of contraception. “For example women think that when they miss a pill in the middle of the package it is a problem because they think they are in the middle of their cycle when ovulation occurs. The real problem is at the beginning or end of the package because then you lengthen the week without pills. The risk of ovulation is bigger than when you miss a pill in the middle. You have to teach women very carefully what to do when they miss a pill.”
She went on to discuss the morning–after pill which is used extensively in the Netherlands. In one of the books she gave me it was reported that during the decade 1987–1996, some 30,000 women a year used the morning–after pill.'
I pointed out that in N.Z. there had been moves for it to be sold over the counter in chemist shops but some doctors had expressed concern that it could be given to women who, for health reasons, should not be using use it. Dr Rademakers said: “It is only four normal contraceptive pills — regular 50 plus pills, those old fashioned kind of pills. It's not as dangerous as giving a woman with hypertension a normal package of the pill.”
I asked: “If as you say Dutch women are using contraception very effectively, how do you ensure that they do this? Are they given instructions by doctors and the Family Planning Association?”
She replied: “Everyone instructs them and that is the nice thing in the Netherlands, everyone is working on the same issue and giving the same kind of messages.
“For example a lot of attention is given in women's magazines about the correct use, and sometimes pill manufacturers collaborate with women's magazines in making little booklets about correct pill use. We have very good instruction sheets in the packages of the pill. The instructions are very clear. Now the Government has given us money for material for immigrant women who have more specific problems with contraceptive use and so we are developing resources for them.
“One resource is a brochure about using the pill which is written in a number of languages. Other material is more broadly for sex education or empowerment which can be used in groups.
“We put a lot of energy not only into educating people once when they visit the doctor but also into reinforcing those kinds of messages from different angles. That is what is often said to be one of the strengths of the Netherlands. We are a small country and professionals in our fields — most of the time — who more or less give out the same kind of messages. Some do research, some develop materials and we train GPs. In the Netherlands prescriptions are written by GPs, not by gynaecologists. We try to make the threshold as low as possible for all women."
I asked if the Family Planning Association was an important part of this educational force. “No,” said Dr Rademakers: “they used to be but their influence has diminished because a lot of their experience and knowledge has been transferred to the GPs. They still receive funding from the Government but this is more or less to address specific groups such as adolescents, migrant women, mentally and physically handicapped people and they are subsidized to do education for doctors."
“So,” I said “they don't actually work so much one to one with clients?”
“Not any more,” said Dr Rademakers. “They used to do that but now people go to general practitioners.” She said the training of GP's is an ongoing process. “One thing that's the same about sex education or information about contraceptive use is that it's an ongoing thing. We don't think that everything is going well so we don't have to think about it anymore. No, you have to reinforce the message and every year, new people are starting to become sexually active and every year new women change what they are doing.
“At different periods in your life, your options change and sometimes you want to change contraception so then you need new information. It's an ongoing process. It's not one talk from your parent or one talk from your doctor. It's something which is continuously going on. That's something we try to do as much as possible.
“We have been using commercial television for a number of years now. We have a lot of programmes in which information about sexuality is given — not porn — we do have soft porn programmes but we also have more informative programmes and series. In talk shows, people discuss such things. We are very open about this topic.”
We went on to discuss what happens in the schools. I asked if sexuality instruction is part of the school curriculum.
“Yes,” said Dr Rademakers, “but it's not so institutionalised. It's not that the government has a curriculum which must be implemented in schools. Until four years ago, sex education wasn't even obligatory but in nearly all schools sex education was provided. So it depends very much on the school whether they make it a small part of their programme only in biology or whether they have projects.
“In general, sex education is part of the programme from the last class of primary school — 10 or 11 years — until 16 or 17 and then in different forms in different subjects. We have a lot of programmes developed by specific organisations working in the field which can be used in their schools. More comprehensive programmes which include all kinds of values about sexuality skills, communication skills, contraception, AIDs, sexually transmitted disease and homosexuality are available. There are more specific programmes aimed at, for example, AIDS prevention. Most of the time it's something which comes back in the schools."
I asked how the Dutch schools compared with the Swedish schools where contraceptive sex education has been a part of their curriculum for about forty years.
Dr Rademakers replied: “We didn't have that. Let me say, we had it in practice but we didn't have it in law. And now the law lays down the topics which have to be discussed in schools. They don't state how they have to be discussed but the kind of topics that have to be discussed. These are topics relating to sexual health, attitudes towards sexuality, respect for other lifestyles, those kind of things.”
I asked: “Is there anything in the curriculums that would prepare young people for the possibility of facing an abortion decision?”
“Not in general,” said Dr Rademaker “because we have very few teenage abortions or abortions in general. Most Dutch women don't have an abortion so we don't prepare them for it. We just say that when something goes wrong with their contraception they should go to their general practitioner or go to the hospital or get emergency contraception. I think most of them know that when something goes wrong that's one of the options.”
“And do they understand what that could mean in their lives?”
“No,” she replied “We don't deal with that. It could scare them from seeking abortion. We try to have a more positive approach.”
“What about informed consent?” I asked. “To be able to make an informed decision women need to understand what the decision involves for them.”
“The decision involves not having an unplanned pregnancy,” she replied. “That's what the goal is.”
I went on to say: “Some people have emotional or physical health problems following abortion. If they are not told about this in advance, they probably are not able to make a properly informed choice.”
Dr Rademaker replied: “But that is about abortion counselling. We counsel women considering abortion and it depends very much on what kind of decision–making process she has had. In some clinics, for example, where the staff think the woman is not ready, they will refer her to a social worker to discuss what she really wants. Whether or not problems occur has a lot to do with the decision–making process in advance. We don't deal with that on a general basis because most Dutch adolescents and most Dutch women don't have abortions. Abortion is something which is commonly seen as needing to be avoided.”
“Abortion is not an option for example for family planning. It's really an emergency measure one has to take which you should avoid as a choice. Sometimes some, let me say, feminists kind of groups say why not have abortion as a kind of family planning but that's not the feeling in the Netherlands. In general people do not take abortion lightly.”
“They think it is an absolute last resort?” I said.
“Absolutely,” she replied. “And they'll do anything to stop having to make that type of a choice. A lot of government money is provided for contraception and sex education to prevent unwanted pregnancy and abortion. That's a goal which is commonly shared.”
“So they feel it is something they shouldn't have to confront. And yet, some eventually will,” I said.
“Yes,” said Dr Rademaker. “And a lot of women who have an unwanted pregnancy feel very guilty and very stupid because they have always been taught you should prevent an unwanted pregnancy.”
“But even with their best efforts to prevent an unwanted pregnancy by using contraception, some will fail, won't they?” I said. “In 1998 more than 24,000 Dutch women had abortions.”
“Yes.”
“And for those people,” I said “abortion is not necessarily the only choice they can make, is it?”
“They can keep the baby,” said Dr Rademaker “But in general giving your child away for adoption is not an option in the Netherlands. I think most of the women in an adult relationship will choose to have the baby and then it's not planned but its not so unwanted either.”
Dr Rademaker said: “Most people get married when they want to have children but a growing number of them don't. The question is whether or not you are in a committed relationship. Whether you have a basic living standard. I think the younger girl with an unplanned pregnancy, given the choice, will choose an abortion more often than women in their late twenties and thirties.”
At this stage I asked: “What is there about the Dutch mind set that makes people think abortion is such a bad thing. In general, I don't think that could be said of New Zealanders. There are many people who think it is — albeit regrettably — the best way to solve a problem associated with an unplanned pregnancy.”
Dr Rademaker said, “Its difficult to say why the Dutch are like this. That's a question that is often asked. It's not a religious thing nor is it a moralistic kind of thing. It's just that people think you can prevent pregnancy and everyone knows that when you're pregnant and you wait nine months you have a baby. Everyone knows that.”
“So,” I said “there's an instinctive recognition that it involves your child.”
“It's the stopping of the development of a child,” said Dr Rademaker, “and that is a major life decision not from a religious or moral perspective but for a natural perspective I think.”
“I'm not sure that's true of New Zealand,” I said. “It seems to me that in New Zealand those advocating abortion take the view that what is growing within the womb is something of limited value. Attempts to acknowledge the existence of the unborn child are often treated with derision and scorn.”
“Oh no,” said Dr Rademakers “that is not the common idea in the Netherlands. Of course you might have some individuals who take it more lightly than others. The general view is that when you don't want to be pregnant, you have to prevent it. If you become pregnant, it's better to have an abortion than to have a really unwanted child but people always consider it the best of two bad things. But it is a bad thing. People don't take it lightly.
“That's why I think it's very common for women to have ambivalent feelings both before and after the abortion,” she went on to say. “The ambivalence is an essential part of the decision they have to take. Sometimes they are really sure of the decision but some ambivalence always lingers.”
“I think that's true,” I said. “Work I've been involved with over recent times has focused on the emotional pain some women experience following abortion. Many have deep regrets or ongoing problems. I've been involved with setting up a project for the healing of these women. But I think the young girl in New Zealand, with an unplanned pregnancy, is not encouraged to give the reality that it's a child too much thought. That's something I suspect may be different in Holland?”
“I think,” she replied, “it depends what reference frame you have. I think abortion clients in the Netherlands have very few emotional problems afterwards but that's because I think a little ambivalent and a little remorse or thinking about it after a longer period is a normal coping step. That's not always a bad thing. It's a kind of mourning — a grief. When you have taken the decision correctly and know this was the best option for you, it's not something you're glad about. It's a real dilemma.
“You don't have a good choice. You only have bad options and a real dilemma and you have to choose what is the best of two or three options. But then you might think it over afterwards and have some grief feelings, that's normal. In general, most women who come to abortion clinics have already been through a lot of decision making with their partner or their general practitioner or sometimes in the clinic with a social worker. I am sure that most of the women think it over very carefully and they get help if they need it.”
I said “When I went to see VBOK they said a lot of women come to them in that part of the process of working through their decision. I was impressed to find they employ professional social workers to assist in that work.”
“And,” said Dr Rademaker, “even when it seems clear that abortion is the best option for that woman, they will not condemn her.”
“No and I don't think you can do that,” I replied “What they do tell the woman is that should she experience emotional difficulties later, they will welcome her back. I think that is important.”
“But,” said Dr Rademaker, “there are more, let me say, of the general social workers and organisations working in all kinds of communities who do abortion counselling as well.”
I told her, “There is a tendency for some who work as counsellors in New Zealand's abortion clinics, and believe abortion is the way to deal with an unplanned pregnancy, to have a narrow perspective. In counselling women or girls they tend to focus on facilitating their access to abortion. Even where a woman may be displaying ambivalence about having an abortion, some fail to pick it up.
“Among those who later seek post abortion counselling, some will say they did not think they had been provided with the information they needed to explore their decision properly.
“Because our clinic counsellors are generally supportive of the abortion option, they are, for instance, reluctant to give the woman information on the growth and development of the child. They consider that this information should be withheld from the woman or girl.
“I am convinced that having access to such information is part of the woman's right to be properly informed. It is well documented in New Zealand that those employed as counsellors in our abortion clinics would prefer that woman did not have access to such information.”
“But it's not their choice,” said Dr Rademaker. “It is not in my interests that a woman has an abortion. It's not my choice. It's her choice. I would however be very hesitant to give a woman with an unwanted pregnancy who is thinking about abortion all kind of photographs about babies.”
“I don't think you need to give them all sorts,” I replied. “The informed consent booklet published by New Zealand's Minister of Health in 1998 included three photos by the Swedish medical photographer, Lennart Nilsson. They showed the unborn child at the 7th, 11th and 12th week after conception.”
Dr Rademakers said “Sometimes pro–lifers outside the clinics show pictures of grown fetuses. We have a high percentage of women coming during the first six weeks of pregnancy and they don't have full grown fetuses. But it is the start of a process and when you wait, it will be a baby.
“It is very important to Dutch women to come as early as possible. They know that the longer you wait, the more difficult it is to perform an abortion.”
In 1998, 18% of abortions in the Netherlands were performed during the second trimester.
Dr Rademakers went on to say that women can arrange an appointment fairly quickly at an abortion clinic or hospital once they have discovered they are pregnant. She said, “There is a five day waiting period between the first visit to a doctor and the treatment itself but they can come in earlier to see whether this is the best option for them.”
She went on to say “In other countries they regard the Netherlands as a very loose country with respect to sexuality and drugs. But when it comes to adolescent sexuality, we try to teach people a lot of things about respect for themselves, respect for their partners, respect for life in general therefore prevention of abortions.
“We try to give them the skills that will empower them to set their own boundaries and not doing something because someone else wants them to. We try to give them the skills to be in control of their own lives. These kind of things are essential. So the more I talk to people from other countries the more I think we are liberal but we have all kinds of boundaries.”
1. Ketting, E; Abortion Matters, Is the Dutch abortion rate really that low?, Stimezo, 1996, p.ll
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