Reproductive Health Care in the Netherlands

Abstract

Since the 1994 ICPD, relatively little attention has been given to constraints in improving reproductive health programmes in industrialised countries. The Netherlands is known for its low rates of unwanted pregnancy, safe and accessible abortion services, low perinatal and maternal mortality and well-developed programmes for adolescent sexual health, but recent studies show a rising incidence of abortions and STDs, particularly among young people and immigrants. This article describes reproductive health services in the Netherlands, their historical roots and current constellation, including services for family planning, abortion, STDs, infertility, information, education and counselling on sexuality, and antenatal and delivery care, in the context of cost containment and other recent reforms. It shows that although these core components are well covered and the system of reimbursement for costs has greatly helped to increase accessibility, they are not all well integrated into the primary health care system. In some cases, they are well covered by other providers, such as midwives. Prevention and management of STDs and infertility, however, are particularly split between different providers and in some cases the extent and quality of service provision is lacking. What emerges is a still fragmented landscape–with many successes but also some significant shortcomings.

Résumé

Depuis la Conférence internationale sur la population et le développement en 1994, les obstacles à l'amélioration des programmes de santé génésique dans les pays industrialisés ont reçu peu d'attention. Les Pays-Bas sont connus pour leur faible taux de grossesses non désirées, des services d'avortement sûrs et accessibles, une mortalité périnatale et maternelle peu élevée et des programmes bien développés de santé sexuelle pour adolescents, mais de récentes études montrent un accroissement des avortements et des MST, particulièrement chez les jeunes et les immigrants. L'article décrit les services néerlandais de santé génésique, leur racines historiques et leur organisation actuelle, notamment les services de planification familiale, d'avortement, de MST, de stérilité, de conseils sur la sexualité et de soins prénatals et obstétriques, dans un contexte de limitation des coûts et autres réformes récentes. Ces éléments centraux sont bien couverts et le système de remboursement des frais les rend plus accessibles, mais ils ne sont pas bien intégrés dans le système de soins de santé primaires. Parfois, ils sont assurés par d'autres prestataires, comme les sages-femmes. Cependant, différents prestataires se partagent la prévention et le traitement des MST et de la stérilité, et les services sont quelquefois insuffisants et de qualité médiocre. Il en ressort une image encore fragmentée, avec beaucoup de réussites, mais aussi quelques lacunes importantes.

Resumen

Desde la CIPD en 1994, se ha prestado relativamente poca atención a las barreras al mejoramiento de los programas de salud reproductiva en los paı́ses industrializados. Los Paı́ses Bajos son conocidos por sus tasas bajas de embarazo no deseado, servicios de aborto seguros y accesibles, una baja mortalidad materna y perinatal, y programas de salud sexual adolescente bien desarrollados. Sin embargo, estudios recientes muestran una alza en la incidencia de abortos e ITS, especialmente entre jóvenes e inmigrantes. Este artı́culo describe los servicios reproductivos en los Paı́ses Bajos, sus raı́ces históricas y constelación actual, incluyendo la planificación familiar, el aborto, las ITS, la infecundidad, la información, educación y consejerı́a sobre sexualidad, y la atención prenatal y de parto en el contexto de reformas recientes. Aunque estos componentes centrales estén bien cubiertos, y el sistema de reembolso de costos haya ayudado a aumentar el acceso, no están bien integrados al sistema de salud primaria. En algunos casos, están bien cubiertos por otros proveedores, como las parteras. La prevención y manejo de las ITS y la infecundidad, en especial, están divididas entre distintos proveedores y en algunos casos la provisión de servicios no es completa ni de buena calidad. El panorama emergente es todavı́a fragmentado, con muchos éxitos pero también deficiencias significativas.

Key Words:

• sexual and reproductive health services
• integration of services
• health sector reforms
• Netherlands

At the International Conference on Population and Development in Cairo in 1994, more than 180 governments committed themselves to providing a comprehensive set of reproductive health services for women, men and adolescents, and arrived at a definition of “reproductive health” that has stood the test of time. They also agreed that reproductive health care should be an integral part of primary health care (PHC) and should be accessible in all countries “to all individuals of appropriate ages as soon as possible and no later than 2015”.¹

Post-Cairo there has been much debate on the problems involved in achieving reproductive health in developing countries.² Much less attention has been paid to reproductive health programmes in industrialised countries. This paper describes the provision of reproductive health services in the Netherlands, particularly the ways in which reproductive health services are integrated in the primary health care system, and the potential for and problems in achieving such integration.

The reproductive health concept emerged partly in response to the critiques of women's health advocates of the implementation of family planning and maternal and child health care (MCH) as components of primary health care. They argued that family planning focused too much on achieving fertility decline among married women, while MCH services gave attention only to mothers, thus ignoring non-mothers and unmarried women. Overall, primary health care programmes emphasised antenatal care, services for the sick child and immunisation, and in some countries the prevention of maternal mortality, largely neglecting other gynaecological, mental and emotional problems of women related to reproductive health. The main concern of women's health advocates was to redress this imbalance through a new approach–reproductive health care.³

The ICPD Programme of Action says that health care in the context of primary health care should include the following six components¹:

• family planning counselling, information, education, communication and services;

• education and services for antenatal, delivery and post-partum care, including breastfeeding support;

• prevention and treatment of infertility;

• abortion (if legal), prevention of unsafe abortion and management of complications of unsafe abortion;

• treatment of reproductive tract infections, sexually transmitted diseases and other reproductive health conditions; and

• information, education and counselling, as appropriate, on human sexuality, reproductive health and responsible parenthood.

To integrate these into primary health care, cost-effective care packages needed to be developed, taking into consideration limitations on human and clinical resources.⁴ However, “integration” means different things to different people, including adding new services to existing ones, enhanced collaboration between existing vertical programmes, and a more comprehensive merging of responsibilities for implementation. For many reasons, however, evidence post-Cairo suggests that implementation of integrated reproductive health care has been slow in many countries.^{5 6 7}

This paper describes reproductive health care services in the Netherlands, which are regarded as a success story because we have low rates of unwanted pregnancy, low perinatal and maternal mortality, safe and accessible abortion services, and well-developed programmes for adolescent sexual health. The assumption among many Dutch health managers, as well as international reproductive health experts, has been that our reproductive health services function well and are effective in achieving positive health outcomes. However, in this paper, I argue that reproductive health care in the Netherlands is in fact fragmented, due to the different historical trajectories of its components. Furthermore, beliefs about good health outcomes need to be reconsidered in the light of recent data indicating an increase in STD incidence, and abortion rates. Is this new orientation also needed in an industrialised country like the Netherlands? In spite of a strong commitment to Cairo and extensive support by the Ministry for Development Cooperation for the development of such policies in low-income countries, the Netherlands Ministry of Health has not developed an integrated reproductive health policy.⁸

The changing Dutch primary health care system

Before the introduction of compulsory health insurance in 1941, there were wide geographic and class-related variations in the Netherlands in access to health care. In general, the poor were cared for out of municipal medical relief funds, while the rest of the working classes were able to participate in voluntary insurance schemes. The middle and upper classes relied on private practice. Delivery of health care was in the hands of private organisations, but municipalities paid most of the costs.⁹ Under these arrangements, the state was merely the roof that secured the Catholic, Protestant, liberal and socialist health care structures, each of which operated private voluntary associations that played an important role in primary health care and health education. Responsibility for health was defined as a collective responsibility, but the religious community and political associations took the main responsibility.¹⁰ The associations set up health education programmes and infant and child health clinics in the early 20th century, and were involved in maternal health care. As family guardians and health care providers, women were an important target group; they were taught how to feed their children properly and to practise hygiene to avoid infectious diseases.¹¹

The period since the second World War has been characterised by growing state intervention, guided by the values of primary health care, equity and solidarity. However, as a result of the introduction of market forces into health care, these values are increasingly under strain, and cost-effectiveness of health interventions, quality, freedom of choice and financial responsibility are playing an important role in Dutch health care nowadays.¹² Even so, health sector reforms have not been very successful in the Netherlands. Despite efforts to increase competition and decentralise health care, the role of government remains strong–it regulates health care supply, sets annual expenditure limits and shapes the reimbursement policies of insurance companies.^{13 14}

Health financing policies play a key role in defining which types of treatment and services are available. The Dutch system is characterised by equity of access to basic health services, with a mix of voluntary insurance from competing private insurance companies, and insurance mechanisms subsidised by the state. The 1995 reform defines the following three financing tiers, each of which covers the costs of different reproductive health services:

• long-term care and mental health care, covered by national health insurance (AWBZ);

• basic curative care financed by private insurers (for one third of the population) and the government-subsidised Ziekenfonds (Sickness Fund, for two-thirds of the population below specific income thresholds); and

• amenity care, a supplementary insurance package which people can choose to buy (covers 3% of total health care expenditure).¹⁴

An emphasis on individual responsibility and patient autonomy is also reflected in a patients' rights charter (Wet op de Geneeskundige Behandelingsovereenkomst) adopted in 1995. The ideal of the charter is that patients receive sufficiently good quality information to make informed choices in treatment, a right which underlies the Cairo definition of reproductive health. Of relevance to reproductive health care are the provisions regarding minors. Over age 16, patients are considered autonomous in decisions on health care, including contraception. Between ages 12 and 16 parental consent is needed, but if parents do not give consent and the minor wants treatment (e.g. contraception), a doctor can provide it if not doing so would have serious, negative consequences for the minor. The extent to which the Dutch respect the autonomy of minors is reflected in a recent survey in which 75% of respondents thought a doctor should prescribe contraception without parental consent if that is what the minor needed and wanted.¹⁵

Primary health care (first-line) services in the Netherlands are provided by general practitioners (GPs), who are the first point of access to the Dutch health system and act as gatekeepers for more specialised care. GPs do not provide all the components of reproductive health care in the Netherlands, however. They provide most but not all contraceptive services, conduct first-line infertility diagnosis and treatment, and STD diagnosis and treatment. Some also provide maternal health care but only in areas not covered by midwifery services. They are expected to deal with sexuality problems, though this is mostly restricted to medico-technical aspects. Psychosocial counselling related to sexual and reproductive health problems is limited, due to lack of both time and counselling training. Preventive infant and child care is not the responsibility of GPs, as it is still provided by child health centres, set up some 100 years ago.

The policy of successive post-war governments has been to provide care in PHC services where possible, and to offer these services outside of general practice only for those with specific needs, or to promote therapeutic innovation. In this instance, a wide range of state-subsidised reproductive health care agencies also exist, which aim to fill the gaps in, complement and strengthen first-line services. However, while first-line health services are accessible in every neighbourhood, these auxiliary services tend to be located only in the major cities

Against this background, this article reviews the following components of reproductive health care in primary health care: family planning; abortion; STD prevention and treatment; infertility diagnosis and treatment; information, education and counselling on sexuality; and antenatal and delivery care. The historical roots, the constellation of services and extent of integration in PHC of each of these components are described, with some key outcome measures over time.

Family planning services

Until as recently as the mid-1960s family planning was largely a taboo in Dutch society. The display and sale of contraceptives was legally restricted, and doctors rarely prescribed them. The Netherlands had one of the highest population growth rates in Europe, and the Central Statistical Bureau projected that the country would have a population of 21 million by the year 2000. The population problem at that time was primarily defined as lack of space and pressure on the environment. Despite these concerns, the Netherlands did not develop a fertility control-oriented population policy.¹⁶

The pill was first introduced in 1963 and was readily accepted, in part due to a strong voluntary family planning movement, active in the Netherlands since 1881 when the Dutch Neo-Malthusian League was formed. The first family planning clinic had been opened in 1882 by Aletta Jacobs, a woman doctor, immediately after the formation of the Neo-Malthusian League. By 1900 the League had established municipal departments in Amsterdam, Rotterdam, The Hague and Middelburg. Rutgers, one of the other leaders in the League, advocated women's right to decide when and how many children they want to have. He set up a programme which trained lay-women as family planning workers, who could sell (and fit) diaphragms and condoms. The League advocated responsible parenthood. In 1946 the Dutch Association for Sexual Reform (de Nederlandse Vereniging voor Sexuele Hervorming, NVSH) was formed, as a continuation of the Neo-Malthusian League. The Association aimed for a positive approach to sexuality, which was to be seen as an integral part of human existence. Membership of the Association grew rapidly, from 18,000 in 1946, to around 200,000 in 1964. At the time sales of contraceptives were forbidden, but people could get them at the NVSH if they became members.¹⁷

By the end of the 1960s the health workers involved in the sexual health reform movement had set up around 60 family planning clinics. In 1969 the NVSH decided to set up a separate organisation for these services, the Rutgers Foundation. At the time, their clinics mainly provided contraceptive services to married women. In the 1970s, the clinics broadened their services to include counselling on sexuality. Designed as conveniently located, walk-in clinics, the clinics became especially attractive to younger people.¹⁸

Pill acceptance in the Netherlands was encouraged by motivated GPs, active media involvement and a government decision in 1971 to include family planning in the national public health insurance scheme. The pill, the IUD, the diaphragm and one year later sterilisation became available free of charge, reflecting the government's policy that prevention of unwanted pregnancy was a public responsibility as well as an individual one.^{16 19} A 1977 demographic policy stressed the right of individuals and couples to decide freely the number and spacing of their children.²⁰

As a consequence of the integration of family planning into primary health care, the numbers attending Rutgers clinics began to decline. In the 1990s the government reduced its subsidies for the Rutgers clinics and by the end of the 1990s, only seven clinics remained open. In 2001 the Minister of Health announced that she intended to stop subsidies to the remaining clinics, but then agreed to a proposal that they merge with the network of abortion clinics to serve specific population groups, with an emphasis on developing innovative approaches.²¹ By the end of 2002 efforts were underway to create integrated centres for sexuality, contraception and abortion in six of the seven cities where Rutgers clinics were based and a new centre in Utrecht as well.

Health reforms aimed at containing costs also led in the mid-1990s to proposals by the Minister of Health to take the contraceptive pill out of the basic insurance package and make it available over the counter, as was already the case with condoms. The savings to the government would have been around US$45 million per year. The Minister suggested that the pill should only remain in the package for girls under the age of 18, for social reasons.²² These proposals were criticised by health professionals, who argued that they would lead to increased unwanted pregnancy rates, and women's health advocates, who stressed that the pill was a medicinal drug which required medical support, that the prevention of unwanted pregnancy was a public responsibility, and that adherence to internationally adopted reproductive rights agreements required that contraceptives be available free of charge. The policy proposals were dropped.

Contraceptive use rates have increased rapidly since the 1960s and despite health reforms have been sustained at a high level ever since (Table 1). By 1998, 70% of women of reproductive age (18–49) were using a contraceptive. Non-users were mainly women without a stable partner, pregnant women, women desiring pregnancy and infertile couples. The contraceptive pill was being used by 70% of young women (aged 18–24). The pill is more widely accepted in the Netherlands than in other countries; it has contributed to substantial reductions in unwanted pregnancies and so-called shotgun marriages, and has had far-reaching consequences for sexual behaviour and experience, as well as sexual morality in the Netherlands. Being a medical responsibility makes it respectable.²⁵ Sterilisation is the preferred method of contraception once families are completed; men are sterilised more often than women.¹⁶

Table 1 Contraceptive use rates (%) among women of reproductive age, Netherlands, 1968–98^{23 24}

Contraceptive method	1968 Women aged 21–37 (n=483)	1982 Women aged 18–37 (n=6539)	1988 Women aged 18–37 (n=5814)	1993 Women aged 18–42 (n=4512)	1998 Women aged 18–49^a(n=4932)
Hormonal pill/injectable	26%	39%	43%	47%	43%
IUD	–	8%	5%	3%	2%
Condom	9%	6%	7%	8%	6%
Sterilisation female	–	6%	3%	4%	7%
Sterilisation male	–	7%	7%	9%	8%
Other method	9%	3%	5%	3%	1%
No method	56%	30%^1	30%^1	26%	31%

a Pill use appears to be lower in 1998, but the apparent decline is due to the expansion of the age group to 18–49, compared to 1993, when it was 18–42. In the 43–49 age group, the pill is used far less.

Although the contraceptive pill enjoys wide accessibility in the Netherlands, recent studies suggest certain problems in the quality of care offered by GPs, who are now responsible for 90% of family planning consultations. In 1998, the Dutch consumer organisation studied young women's perceptions of the quality of family planning advice provided to them by GPs. The response rate was rather poor, with only 486 young women (28% of the initial sample) responding to the questionnaire (Table 2).²⁶ Although the sample may not be representative of young women on the pill and those with complaints may be over-represented, the results are still worthy of attention. Clearly, while most young women thought they had got good information on their chosen method, most were told little about other methods, side effects or protecting themselves from STDs.

Table 2 Quality of care during pill consultations, responses of 486 young women attending GPs, Netherlands, 1998

Topic	Received good information	Sufficiently informed	Topic was not discussed
Other contraceptive options	11%	35%	52%
How to use chosen contraceptive method	80%	9%	10%
Side effects	56%	7%	33%
Need to use condoms to prevent STDs	42%	27%	31%

After initial prescription, young women can phone the physician's assistant for follow-up prescriptions. A survey among health care providers, conducted in a recent situation analysis on youth and sexuality, suggests that GPs are monitoring pill use less than they used to.²⁷ Because failure to use the pill properly is considered an important cause of unwanted teenage pregnancies, more research on whether GPs could do more to reduce incorrect use is needed. Counselling should not only focus on the use of the pill and condoms, but also provide information on how to use methods properly and avoid possible problems. More information on other methods of contraception should also be provided.

An earlier exploratory study on the quality of family planning services in the Netherlands²⁸ compared quality of care in GP practices with that of the Rutgers clinics, who were responsible at the time for 10% of family planning consultations in the Netherlands. It found that the Rutgers clinics offered a greater range of contraceptives and more information than GPs, and provided more time for information provision and counselling. As well as the contraceptive pill, the Rutgers clinics offered IUDs and fit diaphragms, which many GPs do not, and were often visited for emergency contraception (which GPs also provide).

Interviews with GPs revealed that they considered the contraceptive pill the best method. Many GPs seemed not to be aware that the number of contraindications for the IUD had been reduced over time. While the costs of consultations and contraceptives prescribed by GPs (excluding condoms) continue to be reimbursed by the Dutch insurance system, this is not the case for consultations at the Rutgers clinics. The Rutgers clinics tend to be visited by relatively highly educated clients, who value the convenience of a walk-in clinic and are willing to pay for the services. The Minister of Health saw the fact that the clinics did not manage to reach out to poor, marginal and immigrant populations as a reason to diminish their subsidies. However, although this has apparently not affected contraceptive use rates in the Netherlands, it has led to a decrease in access to sexual health services.^* It is not yet clear whether the current integration of the Rutgers clinics with the abortion clinics will once more fill this gap.

Abortion services

Medically safe abortion became available in the Netherlands around 1970. Prior to that, abortion was only allowed on grounds of medical necessity under an 1881 law. The legal authorities in the Netherlands accepted, however, that the meaning of “health” had changed profoundly and referred not only to physical health but also psychological and social well-being. Groups of liberal physicians set up independent non-profit abortion services, created a national organisation for safe abortion (STIMEZO), and became allies of women's rights and health organisations who were campaigning for women to be baas in eigen buik (boss in my own belly).²⁹

After years of controversy, and by way of compromise between conservative and more liberal politicians, the Dutch abortion law was changed in 1981 to permit abortion in emergency situations, when a woman cannot cope with the pregnancy for mental, medical or social reasons. The law came into effect in 1984 but did not change practice much, except that it required a “reflection” period of five days, during which the woman together with her GP were to consider all options before a final decision for abortion was made. In practice, five days was about the length of time between making an appointment and having the abortion performed.

Abortions in the Netherlands are carried out in registered first-line clinics by GPs, generally on an out-patient basis, reimbursed by the basic health care fund. Government decided not to treat abortion as curative care because some insurance companies with religious affiliations might have objected to financing abortions. “Menstrual regulation”, a procedure done within 16 days of a missed period, does not fall under the abortion law and is done in registered clinics without legal restrictions. The Netherlands has one of the lowest abortion rates in the world.^{16 19 30}

The low abortion rate is considered one of the most important outcome measures in the Netherlands as a surrogate measure of the effectiveness of contraceptive services. However, the general picture tends to conceal the problems experienced by some population groups, particularly migrants and adolescents. A review of abortion statistics (1993–2000) revealed that the number of abortions per 1000 women of reproductive age increased from 5.2 in 1990 to 8.0 in 2000. This appears to be mainly attributable to higher numbers of abortions among immigrant women and adolescents. Two-thirds of women having abortions in 2000 were aged 20 to 35. The proportion under age 20 increased from 10.9% in 1992, to 14.2% in 2000. Rates for all major immigrant groups (Turkish, Moroccan, Antillian and Surinamese) were even higher than those for Dutch adolescents. Among Antillian women they were especially high, 86 per 1000 women of reproductive age having an abortion per year. (However, this rate could be an overestimate, because it is likely to include Antillians who are not officially registered as residents in the Netherlands and therefore not counted in the denominator).

The increase in abortion rates means that the Netherlands no longer has the lowest abortion rate in the world: Belgium and Germany have now overtaken us.³⁰ The Ministry of Health has recently argued that the high abortion rate among immigrant groups supports the development of specialised, integrated reproductive health clinics intended to meet the needs of groups with specific problems who are otherwise difficult to reach.

STD prevention and management

STD services find their roots in the mid-19th century, when they were mainly provided to prostitutes. Under the French legal system, prostitutes were required to register with the police and have medical examinations regularly. Those found to have an STD were not allowed to work for a period of time, depending on the severity. Progressive doctors, the so-called hygienists, pressured municipalities to institutionalise this surveillance, but towards the end of the century there was increasing resistance to the implied tolerance of prostitution. “Abolitionists” called for more attention to the victims of prostitution–married women and their children; male sexual drives needed to be curtailed.

The first outpatient STD clinic for the general public was established in Rotterdam in 1903, and treatment was free of charge. The number of clinics expanded rapidly to 68 clinics by 1925. The STD Foundation (Stichting SOA bestrijding) was formed in 1914. Promotion of STD prophylaxis was controversial; condoms were seen to promote promiscuity. The STD Foundation therefore focused in its early days on awareness of infection and treatment, and strengthening STD services. They set up a network of counselling centres in the major cities which were not supposed to provide treatment but information and diagnostic tests. Patients were referred for treatment to GPs, dermatologists or hospital outpatient STD clinics. Medical social workers were involved in case-finding and holding activities. Under the German occupation during World War II, the STD programme became more coercive; those suspected to be infected could be forced to undergo medical examinations and treatment.

After the War the number of clinics diminished rapidly, partly as a result of decreases in STD incidence. However, in the 1960s and 70s incidence figures appeared to be on the rise again. Having left STD control to the private sector before the War, the government took the initiative to re-establish the network of municipal STD clinics and gave the STD Foundation a government subsidy. Seven new hospital-based, out-patient STD clinics were set up where free treatment was available without a GP referral; at the then state-subsidised Rutgers clinics diagnosis and treatment were also available.³¹

Due to this history, STD prevention and management is perhaps the most fragmented of reproductive health services today. Today, people can also go to their GP for diagnosis, and to outpatient departments in hospitals and specialised STD clinics in most major cities, where they can receive free diagnosis and treatment. The municipal health authorities are responsible for prevention programmes among high risk groups and in schools, but prevention is also the prime responsibility of the STD Foundation. They do not provide clinical services, but aim to increase knowledge and awareness of STDs among the general public and at-risk groups, to promote safer sexual behaviour, combat the spread of STDs and improve the quality of STD management in first-line services, including those run by GPs. They also help to develop the expertise of health workers through training courses, protocols and publications. Innovations introduced by the STD Foundation have included simple diagnostic tools, more convenient treatment regimens and better partner notification guidelines. Guidelines for GPs have also been developed, but little is known about whether GPs adhere to them.³²

STDs are most common among young people who are starting sexual activity, who tend to have a succession of short-terms relationships, often without consistent use of condoms (or a contraceptive). The STD Foundation targets them with annual media campaigns, e.g. with the slogan “Safer sex or NO sex”. Surveys on knowledge, attitudes and behaviour have shown that the percentage of people who say they have done something to prevent HIV infection has increased significantly among the young and non-monogamous.³³ Each year, however, an estimated 110,000 new STDs are occurring in the Netherlands, and in 2001 data from 39 municipal health authorities revealed an alarming increase in STD incidence (Table 3).³⁴

Table 3 STD incidence in the Netherlands, 2000–2001³²

New cases	Absolute number in 2001	Overall increase over 2000 (%)	Heterosexual men	Homosexual and bisexual men	Women
HIV infection	61	+9%	−30%	+41%	0
Chlamydia	1578	+40%	+28%	+22%	+49%
Gonorrhoea	543	+32%	+30%	+33%	+60%
Syphilis	139	+22%	−14%	+130%	+15%

Though the increase is partly related to improvements in detection and recording of cases, the results suggest an increase in unsafe sexual practices.

Sexuality education and sexual health care

The Netherlands is known for its pragmatic approach to sex education. From the early 1960s through the mid-1970s, Dutch society underwent a “sexual revolution”, the result of a critical re-examination of socio-religious values, the efforts of the women's movement, heightened media attention and advocacy of gay rights. Citizen action, which started at the end of the 19th century, gave rise to organisations such as the Dutch Neo-Malthusian League, which later became the NVSH, one of the main groups to persuade the government to legalise contraception. By the late 1960s, family planning was accepted by the Dutch Society of Family Doctors. In the 1980s, the advent of HIV/AIDS in the Netherlands spurred a second sexual revolution, with public acceptance of wide-scale promotion of the use of condoms, directed mainly at young people. The media also played an important role in promoting the “double Dutch” method–use of condoms and the pill together. The Ministry of Health, Welfare and Support emphasised in all such activities and programmes the need for an empowering approach to sex education.^{16 27}

Schools are expected, though not required, to include sexuality education in their curricula; most secondary schools and about 50% of primary schools do so, though the focus tends to be on the biology of sex and reproduction, and contraception. In 1993 a national STD/AIDS education pack, “Long Live Love”, was developed by the STD Foundation and introduced into secondary schools (attended by youth 12–16 years of age). It was designed to advance a broader concept of sexual health, including skills such as negotiating safe sex and buying, carrying and using condoms. The “Living Together” pack was also launched in 1993 and is being used by municipal health authorities to encourage schools to introduce more comprehensive sex education. Noting the increases in STD incidence and abortion rates, reproductive health experts are now calling for a revival of sex education efforts in schools. Teaching materials suitable for multicultural use and more sensitive to gender dynamics are being developed. Special groups are being targeted, in addition to 12–16 year olds, not all of whom are sexually active, such as older youth who go to bars and clubs, and school drop-outs.³⁵

Surveys on sexuality among adolescents reveal a statistically significant increase in use of condoms during first intercourse among those younger than 18 years of age. In 1995, 58.6% of young people interviewed reported using a condom whereas in 2001 the proportion was 69%, suggesting that educational efforts have had an impact. The use of the pill at first intercourse was 20.8% in 1995 and 23% in 2001. Research suggests, however, that condoms are mainly used for contraceptive purposes.²⁷ An analysis of helpline data further suggests that despite school-based education, many 11–20 year olds have basic questions about their bodies and on contraception, specifically how to use the pill and the condom.²⁷ Adults appear to assume that young people know these things, but many do not. Declining use of Rutgers Foundation clinics, which provided anonymous counselling, has not helped. The new centres for sexuality, contraception and abortion will need to promote their services and make them known to young people.²⁵

Dutch health policy expects GPs to identify emerging sexual health problems in the general population, including in adolescents, provide psychosocial support and conduct simple diagnostic tests to identify the causes of emerging problems. GPs may also prescribe treatment and refer patients if needed. In practice, however, people resist talking to their GPs about sexual health problems, one reason being (fear of) lack of anonymity in the consultation, as the GP is the family doctor. GPs in turn often find it difficult to talk about sexuality with their patients, and with increasing workloads, lack the time to do so. First-line psychologists and first-line mental health institutions also provide sexual health services. Referral for sexual health care from specialists in sexual problems is also sometimes available in hospitals.³⁶

Antenatal and delivery care

Maternal health care in the Netherlands is well-known for its emphasis on home delivery and demedicalisation of pregnancy, and the strong professional position of midwives. An 1865 law granted midwives the right to provide support for the “natural delivery process”. The definition of “natural” was not made explicit, but the law stipulated that “…they may not use any instruments… nor shall they prescribe, advise, or offer any internal or external medicine, nor perform any bloodletting”.³⁷ During the German occupation in World War II, the law on Ziekenfonds gave the midwife primacy in safe delivery. This meant that women eligible for Ziekenfonds could not have delivery care provided by a GP reimbursed unless they lived in an area where there was no midwifery care available. This reinforced the government policy that midwives should be the childbirth experts.

Midwives' main task in addition to safe delivery has long been the prevention of unnecessary medical intervention and wherever possible, the prevention of pathology. They are required to give antenatal care and care during labour, delivery and post-partum, independent of other health professionals, and are expected to provide psychosocial support for women. Over the years they have been permitted to conduct more and more medical procedures, now including episiotomies, injections and prescriptions. A set of guidelines for referral has been drawn up which categorises pregnancies as low, medium or high risk. Women with low-risk pregnancies can give birth at home; women at high risk are referred to hospital; medium-risk women are assessed by an obstetrician, and depending on the outcome, are sent back to the midwife or to hospital. When complications occur during delivery, midwives refer the woman to hospital, which in the Netherlands is never far.

There have been a succession of debates on the exact boundaries between natural and complicated delivery and who controls delivery care in the Netherlands, with GPs the main losers. Whereas in the 1950s GPs conducted 53% of deliveries, this proportion decreased in 1970 to 30%, in 1980 to 18% and in 1993 to 9%. Only around 16% of GPs still do deliveries. Of the remaining 84%, around half are assisted by midwives and half by obstetricians.^{37 38} When assisted by a midwife, a woman can choose to deliver in hospital. At present around one-third of deliveries are home deliveries, but there is a trend towards more hospital deliveries among women who are pregnant for the first time and migrant women. Increasingly midwives are also referring women to hospital during labour; this increased from 15% in 1989 to 20% in 1993; for first pregnancies it increased from 31% in 1989 to 41% in 1993.³⁹ The increased medicalisation of pregnancy is also reflected in an increased demand for pain relief during labour, which midwives cannot administer. Feminists called for the right to pain relief, questioning the ideology of natural delivery and the positive meaning attached by midwives to women's capacity to deal with pain without pharmacological “support”.

The role of midwives has also been under attack by GPs since the 1990s. They demanded a role in delivery care and called for reversal of the policy granting primacy to midwives. One argument they used was the right of women to choose their health care provider.³⁸ They challenged the policy in court and won, forcing the government to reverse its policy. In practice, however, due to cost containment, midwifery care remains the only option for low-risk pregnant women who are insured under the Ziekenfonds.

The policy of home delivery backed up by accessible hospital referral has resulted in good health outcomes for pregnant women and their babies. Perinatal and maternal mortality rates are very low in the Netherlands and have improved greatly since World War II (Table 4).⁴⁰

Table 4 Maternal and perinatal mortality rates 1950–2000⁴⁰

	1950	1960	1970	1980	1990	2000
Perinatal mortality per 1000 live births	34.2	26.6	18.6	11.1	9.6	7.8
Maternal mortality per 100,000 live births	2.4	0.8	0.2	0.1	0.1	0.1

Prevention and treatment of infertility

Donor insemination was first introduced in the Netherlands in the 1950s. Since the first successful in-vitro fertilisation (IVF) in the Netherlands in 1983, the total number of IVF treatments has gradually grown from 2,700 in 1988, to 15,062 in 2000.⁴¹ Simple diagnostic tests are generally conducted by GPs, who can refer patients to a gynaecologist for further diagnosis and possibly IVF and other advanced reproductive technologies to treat infertility. For psychosocial support people can be referred to the FIOM, a government-subsidised organisation which focuses on problems related not only to infertility but also unwanted pregnancy, abortion and sexual violence. This organisation has 13 regional centres and offers first-line psychosocial counselling.

Infertility treatment is regulated in the Netherlands by governmental regulations, guidelines from the Netherlands Association for Obstetrics and Gynaecology, health insurance policies and hospital regulations. Governmental regulations stipulate that a maximum of three IVF treatments can be reimbursed by health insurance companies or the Ziekenfonds. Because of this, couples are inclined to opt for treatment protocols which increase the success rate, e.g. replacing more embryos, with accompanying risks of complications. Some hospitals refuse infertility treatment for lesbians and single women, others use psychosocial screening to decide who to accept for treatment. These matters have led to public and political debates about the medical imperative of the technology, health risks and ethics involved in restricting access to treatment.⁴²

Women's health centres and advocacy groups

Women's health centres were set up in the 1980s and 90s in major Dutch cities, providing a mix of information and documentation, psychosocial counselling, gender-sensitive health consultations, courses and self-help groups for women suffering from specific problems such as menopausal symptoms, endometriosis and anorexia. These centres rely heavily on volunteers. The extent to which they can provide free services is defined by the reimbursement policies of governmental and private insurance schemes and by their ability to get government subsidy for additional care. One successful centre, the Women's Health Centre Aletta, based in Utrecht, had to close down in 1999 when its government subsidy was stopped.

A wide range of patient groups advocate for better health care for women and for women's empowerment. These organisations generally provide first-line psychosocial support, and they play an important role in the provision of information and training on women's health issues. The Women's Self-Help Federation (Federatie Vrouwenzelfhulp) is an alliance of organisations which focus on health issues specific to women, including menopause, depression and gynaecological problems. The aim of this alliance is to encourage women with similar problems to interact with each other, in order to share experience and practical ideas, thus encouraging self-help. They also aim to provide information and to lobby for better quality health care.

Finally, there is the government-subsidised, national organisation Transact, which grew out of the women's health movement and focuses on sexual violence and gender-specific health care needs. It aims to contribute to a more gender-sensitive health care in the Netherlands by means of courses, training programmes for health workers and policy advocacy.

Figure 1 Sculpture on dunes, Scheveningen, Netherlands, 1998

Successes, failures and opportunities for change

This article shows that although the six core reproductive health components identified at Cairo are well covered in the Netherlands, many of their components are not well integrated into the Dutch primary health care system via GP services. In some cases, these components are covered by other service providers, such as midwives, and are highly accessible to the whole population. In others, although GPs are the main providers, the extent or quality of service provision is lacking. STD prevention and management and infertility diagnosis and treatment are particularly split among many providers. On the other hand, the system of reimbursement for the costs of PHC services by the Ziekenfonds and private insurance has greatly helped to increase their accessibility and can be described as positive.

On balance, what emerges from this overview is a still fragmented landscape–with clear evidence of many successes but also some significant shortcomings. The lack of integration is not surprising when one considers the diverse historical trajectories of the institutions. Midwives were recognised as first-line health service providers in the second half of the 19th century. STD, family planning and infant and child health clinics emerged early in the 20th century. Abortion services were set up in the 1960s–70s. Common in the historical trajectories is the strong role civil society played in organising services and acquiring municipal and later government support. The voluntary associations and Dutch Neo-Malthusian League played a key role at the end of the 19th century and the NVSH and women's health movement more recently. After World War II the role of the government in health care became stronger, and the primacy of the GP in basic health care provision was established. For antenatal and delivery care, STD treatment and abortion management, the government recognised the need for auxiliary clinics, and insurance schemes permit reimbursement of costs. Such a policy has not been applied to the Rutgers clinics or the women's health clinics, however, and reduced subsidy is resulting in declining attendance and closures.

Recent health reforms, guided by the need to limit expenditure, mean that some conspicuous problems are being overlooked. The reportedly high incidence of teenage pregnancy and abortions among young immigrant women, for whom the Dutch “pill culture” may not be appropriate, are a case in point, as is the apparent increase in the incidence of STDs. Some basic needs are clearly not being met, and specific initiatives will be needed just to sustain performance at present levels.

Would greater integration of all the components of sexual and reproductive health care improve outcomes and benefit users in the Netherlands, i.e. would it improve efficiency and quality of care and better serve patients' needs? For example, should certain existing services be merged, and should health workers work together in teams (e.g. GPs and midwives) to decide the best way to provide more comprehensive care? In my view, comprehensive integration of all reproductive health services into one-stop, multi-service reproductive health centres does not seem appropriate in the Dutch health care context. In any case, the historical differences, current organisational culture and diversity in patient population would likely constrain such efforts.

Midwifery and preventive infant and child services have been provided since the beginning of the 20th century as separate services and their effectiveness is unquestionable. Though very little is known about women's views on the quality of these services, there appears to be no rationale for integrating them into GP services, when GPs already complain of far too heavy workloads, nor into the network of specialised sexual health clinics.

The limitations of GP care might be resolved by better collaboration and links with the newly formed centres for contraception, abortion and sexuality. However, such collaboration would be constrained by current reimbursement policies, being based on the primacy of GPs in providing contraception. In the newly formed centres, the cost of abortion can be reimbursed but not of contraception. It is remarkable that the government has been reluctant to finance contraceptive services in sexual health clinics when it does support auxiliary services for delivery care, abortion and STD management.

The proposed multifaceted centres for contraception, abortion and sexuality do represent an integration of some reproductive health services. Will these centres contribute to better reproductive health, and will they better meet needs? It is too early to tell. The former abortion clinics were attended largely by less educated and immigrant women. By integrating these services it may be possible to improve effective contraceptive use among immigrant groups. On the other hand, unless the costs of contraceptive services are reimbursed, use of these new centres may be limited to the better-off.

Meanwhile, other possibilities for integration appear to have been overlooked. STD diagnosis and treatment costs were not reimbursed in the past if carried out in abortion clinics. This problem was resolved by providing every abortion patient with a low-dose antibiotic, which reduced complications related to existing STD and other infections. However, it would be better if STD prevention and treatment were an integral part of the new centres' services. Furthermore, both female and male condoms could be made reimbursable. At present, abortion clinic attenders have to buy condoms themselves as these are not reimbursed by private insurance, unlike the contraceptive pill.

Integration of STD care in the new multifaceted clinics does not necessarily mean that existing municipal STD clinics would become superfluous. To better prevent and treat STDs, and to increase coverage, it is good to have a variety of services which meet the needs of different population groups. The objective should be not to miss opportunities to prevent and treat STDs or provide contraception, given the recent deterioration in these reproductive health outcomes.

Acknowledging the need for innovation, the Dutch Health Research Foundation (ZON/MW) organised a seminar in 2002 on integrated sexual health care, funded by the Ministry of Health. In one of the workshops, priorities and criteria for integrated care were discussed. The participants, mainly service providers, agreed that the anonymity and walk-in nature of the former Rutgers clinics were fundamental to good quality of care, and recommended that the new centres make better use of new information technology and the internet. The need to direct programmes more towards immigrant populations, using translation services and other methods to encourage participation, was also recognised. The participants agreed that ideally a broad range of reproductive health services should be offered in such centres.⁴³

Surprisingly, assessments of quality and appropriateness of services from users' perspectives have not informed recent reforms. Yet many women's health organisations take women's health needs as a point of departure for self-help activities and for advocacy of improvements in policy and quality of care. Their greater involvement could support the development of innovative models for service delivery, provision of a wider range of services and better coverage of population groups with specific needs. In turn, this would contribute to a more comprehensive reproductive and sexual health policy, and guide the Netherlands government in decisions on provision and financing of reproductive and sexual health services in future.

Acknowledgements

I wish to thank Charles Medawar for very useful comments on an earlier version of this paper. Nicole Schulp assisted in the literature review. This article is based on “Seksuele en reproductieve gezondheid: internationale uitgangspunten en opties voor een geintegreerd aanbod in de eerstelijns gezondheidszorg in Nederland”, presented at the Dutch Health Research Foundation conference on first-line sexual health services (Seksualiteitshulpverlening in de eerste lijn), Den Haag, 31 May 2002.

Notes

* At the individual level the term “sexual health” refers to the ability to enjoy sex and sexuality, free from risks of sexually transmitted diseases, unwanted pregnancy and unsafe abortion. Sexual health includes the concept of sexual rights, i.e. the ability to choose freely when and with whom to have sex, free from stigma and force. Sexual health overlaps with reproductive health, which includes the six components outlined in the ICPD Programme of Action. In the Netherlands, historically, the term “sexual health” has been used much more than the term “reproductive health”. Sexual health services typically refer to STDs, family planning, abortion services and counselling on sexuality, i.e. less comprehensive than reproductive health services, with more emphasis on sexuality and sexual rights.