We call on politicians, doctors and society to actively work to overcome existing barriers in the field of reproductive health. At present, we are focused primarily on access to abortion care. In this field there are particularly many barriers in Germany, which unnecessarily endanger the mental and physical health of countless people.
For other points of focus (e.g. self-determined birth process, ectopic pregnancy, miscarriage, reproductive medicine) we are waiting until joint positions within the association are developed and working groups are formed.
Our claims concerning equal rights to reproductive healthcare and abortion care result from existing grievances. We have divided our claims into three parts: legal; practical; and those in the public discourse.
Germany has one of the strictest abortion laws in Europe – not only the intervention can be punishable, but also the, mere, proliferations of factual information concerning the intervention. Threats of punishment reinforce the stigmatisation and tabooing of abortion in our society and prevent an open and well-founded discourse on sexuality and reproduction. They make it more difficult to address abortion topics in medical education. They intimidate doctors and thus contribute to an incomplete care situation. They create feelings of fear, shame and bad conscience in unintentionally pregnant people and endanger their mental health. The connection between restrictive abortion laws and increased health risks for unintentionally pregnant people is well known.
The criminal code should only be used for serious infringements. Abortion, by contrast, is a medical procedure that saves human lives and drastically reduces maternal mortality.
Regulations exist outside of the criminal code, for example in social codes or within the legal systems applicable to the health sector. Abortion should also be dealt with outside of the criminal code, and ought to be regulated as a public health service.
We support the demands of the World Health Organization (WHO) and the UN Women’s Rights Convention (CEDAW): Information bans as well as mandatory consultations and waiting times must be overcome, as they represent barriers to access and can unnecessarily delay medical procedures. Counselling can only be helpful if it is provided on a voluntary basis. A nationwide, free of charge, value-free and multilingual/cultural counselling service is therefore necessary.
Healthcare professionals are allowed to refuse to perform an abortion without justification, based on personal “reasons of conscience”. Such a conscience clause is unusual in other areas of medicine. This right of refusal on moral grounds is problematic for two reasons. First, it means that abortion is not a compulsory part of gynaecological training. Second, it contributes to the already worrying gaps in the access to abortion care in many regions of Germany. For example there are cases of entire hospitals refusing to provide abortion because of moral and religious concerns of the hospital owner or the head physician.
We demand the abolition of the conscience objection clause in the field of abortion. Doctors should not be allowed to refuse a treatment based on personal moral grounds. Whether established doctors actually offer abortions ought to depend on their abilities and their own professional focus. The moral concerns of individual doctors (in leading positions) or hospital owners ought not endanger the health of unintentionally pregnant people.
Sexual and contraceptive education in schools is often inadequate and/or one-sided. Understanding one’s own body, sexuality and contraceptive methods is essential, especially for young people. In some schools, religious instruction also teaches Christian fundamentalist content that focuses exclusively on abortion from a moralizing perspective.
But there are also too few possibilities outside of traditional schooling for adequate sex education. Reliable information on the various methods of contraception is difficult to find online on the German-language websites. In gynaecological consultation hours, doctors often do not have enough time to discuss the various contraceptive methods with their advantages and disadvantages in detail and in an understandable way. The topic affects countless people on a daily basis – the “pill” is the most prescribed drug among young women in Germany.
Some women are sure that they do not want to have children (anymore). It is almost impossible for them to choose sterilisation as most doctors refuse to perform it if the woman is still of a reproductive age.
Contraceptives are only reimbursed by health insurance up to the age of 22. Especially for women of low income, the cost of contraception is a barrier to access.
From our daily practice we know that a large proportion of unwanted pregnancies occur despite the use of contraceptives. Nevertheless, investing in better sexual and contraceptive education could help reduce the number of unwanted pregnancies.
Comprehensive and gender-sensitive information on sex education and contraception must be guaranteed in schooling. The subject of abortion should not excluded. The health of those affected should always be emphasized, nor should it be superseded by Christian moral convictions.
Statutory health insurance ought to cover the provision of a quality explanation of the advantages and disadvantages of various contraceptive methods. This service needs to be sufficiently remunerated. Sterilisation as the final contraceptive method should be available for women and men who are properly informed. Contraceptives must be covered by the health insurance regardless of age.
Doctors who perform abortions, and are therefore experts in this field, are not permitted to clearly detail on their websites how they provide abortion care. Even since the reform of §219a of the penal code, they may only state that they carry out abortions. The newly introduced list of the Bundesärztekammer (German Medical Association), which lists addresses of abortion doctors nationwide, is confusing and contains only incomplete information. It does not replace the doctors’ obligations to provide medical information. Doctors should be able to inform their patients (with impunity) what type of abortion care they offer, up to which week of pregnancy this care is offered, what the respective side effects are and what they should bring with them to the procedure.
§219a of the Strafgesetzbuch (Criminal code) makes doctors the unprotected target of abortion opponents. They constantly act in fear of being penalised and threatened. In this threatening situation, many doctors have decided against carrying out abortions.
At the same time, anti-abortion activists deliberately spread false information online in order to prevent unintentionally pregnant people from carrying out abortions. Some self-avowed counselling centres, which are not recognised by the state, present themselves as neutral, but then “advise” according to Christian fundamentalist views. They do so even though they are not allowed to issue the counselling certificates that are needed to carry out an abortion.
We join the demands of the World Health Organization (WHO) and the UN Women’s Rights Convention (CEDAW): providing factual information on abortion should not be criminalised, but should be made available to those seeking help. Doctors who wish to provide qualified information should not be punished for doing so.
As in France, deliberately misleading and false information about abortion should be banned.
Counselling centres that are not state-approved for pregnancy conflict counselling must make this recognizable and should be subject to stricter controls.
The tabooing of abortion care remains prevelant in medical education in Germany. Although it is one of the most common gynaecological procedures, it is barely discussed during medical school. It is also not a compulsory part of gynaecological training. For doctors who wish to be trained in abortion care, there is no certified further training possibility. Doctors who are not gynaecologists, but have nevertheless learned how to carry out abortions (like general practitioners), must travel to the Netherlands in order to be certified.
14.3% of the abortions carried out in Germany are still carried out with curettage (scraping), a method classified as outdated and unsafe by the WHO. There are no guidelines for abortion care that guarantee patients consistent treatment according to modern standards.
We join the demands of medical students in Germany such as Medical Students for Choice Berlin: Legal and medical aspects (including procedure, side effects and contraindications) of medical and surgical abortion must be taught in medical studies. Additionally, allowance must be made for emotional, socio-political and ethical debate in this education.
Hormonal and non-hormonal contraceptive methods with their advantages and disadvantages should also be taught comprehensively in medical studies. Because doctors will need the knowledge in their daily medical practice, regardless of their eventual practiced specialty.
Gynaecological training should provide practical knowledge and skills in contraception and abortion care. These should be explicitly listed in the subject catalogue of the gynaecological specialist examination.
We continue to call for the development of certified advanced training opportunities, based on the Dutch model, which enable abortions to be carried out. These should be open to all doctors, including those in residency in general medicine, and should entitle them to carry an additional qualification (e.g. “Doctor for reproductive health”). These trained doctors should be allowed to offer abortions depending on spatial equipment of their practice. Advanced training in medical abortion, especially for general practitioners, should be promoted and supported in all federal states. The qualification of non-medical health professionals to perform abortions (task shift) is a further measure recommended by the World Health Organization to counteract critical lacks of access to abortion care. In France, for example, midwives have been successfully carrying out drug abortions for years.
Evidence-based guidelines for safe, professional and modern abortion methods must be established. The use of curettage should be strongly discouraged.
There is an acute lack of abortion care providers in many regions of Germany. The number of practices and clinics offering abortions has fallen by 40% since 2003 – from 2000 to 1200 providers. In many clinics, abortions are only carried out according to medical or criminological indications; however this affects only 4% of abortions. In some regions, unintentionally pregnant people have to travel up to 200 km to their nearest practice. Long journeys, and the additional organisational and financial costs associated with them, endanger the psychological and physical health of unwanted pregnant people. Medical procedures are unnecessarily delayed by these access barriers. Abortion is safer the earlier it is performed.
For the health of our patients, a nationwide provision of doctors who carry out abortions must be guaranteed. We need a reliable census of these current provision gaps and rapid political measures to counteract the situation. The implementation of the requirements mentioned under “German Criminal Code”, “Schwangerschaftskonfliktgesetz (Pregnancy Conflict Act)” and “Education” could be a first step: decriminalisation of abortion, abolition of conscientious objection and a better and broader medical training for abortion care. Abortion should be part of the range of services offered by a hospital, regardless of the hospital owner or denomination. At the same time, we would like to encourage our colleagues to take their medical responsibility seriously despite criminal intimidation. Because unintentionally pregnant people depend on doctors who are willing to provide abortion care.
So-called “vigils” and demonstrations by anti-abortion activists in front of counselling centres, doctors’ practices and clinics impair the work of health care professionals. Patients seeking help feel harassed, intimidated or devalued by the demonstrators.
We demand nationwide protection zones around counselling centres, doctors’ practices and clinics so that healthcare professionals can fulfill their legal obligation to provide abortions undisturbed, and patients can seek help without harassment. Freedom of assembly and freedom of speech stop where health hazards and harassment of others begin.
At the moment there is no significant medical research on abortion in Germany. This puts us far behind countries such as England, Sweden and France. As abortion is not an object of research, it is hardly discussed at specialist congresses or in training courses.
Germany should no longer be at the bottom of the league concerning research in the field of reproductive health. Medical research on abortion should be increasingly promoted in Germany.
Scientific discourse and public discussion
Abortion is still a big taboo in our society. In our medical practice we can observe this on a daily basis: Many patients cannot talk to anyone about their unwanted pregnancy and wish for abortion, not even with close relatives or friends. At the same time, we often perceive the debate as emotionally charged, cluttered with religiously moral debates and therefore unobjective. Meanwhile we forget that it is the health of unwanted pregnant people that is at stake.
We want our society to support unintentionally pregnant people as much as possible in making a autonomous decision. The debate on abortion should be as objective and health-oriented as possible and as emotional as necessary. As a society, we should be caring and unbiased about those who had abortions – they could be a family member. The prevailing climate of supposed liberalism in Germany, which unfortunately does not match the reality of abortion care legislation and education, must be broken through and the existing problems finally must be taken seriously. We hope that abortion will be free from taboos through increasing the social debate and education. Last but not least through our work, that allows a taboo-free discussion about sexuality, reproduction and family planning.
Unfortunately, even in the medical community there are still many myths about abortion – for example the myth of the “traumatizing abortion” that leads to depression or infertility. However, a growing amount of research studies show that tthis so-called “post-abortion syndrome” does not exist. A temporary depressive mood can occur because an existentially important decision has to be made. The stress level is generally the highest before an abortion. Stigmatisation and access barriers have been shown to increase psychological stress. However, the predominant and long-term feeling after an abortion is in most cases relief. 95% of those affected do not regret an abortion even three years later. If anything, carrying out an unwanted pregnancy leads to greater psychological stress than terminating an unwanted pregnancy.
Widespread myths such as the so-called “post-abortion syndrome” make it harder to have a factual and medically correct debate. They also endanger patients who are wrongly informed and advised – knowingly or unknowingly.
We demand that the medical community finally discusses this important health issue. For an objective and sound debate, it is essential to follow the evidence-based findings of high-quality studies, international professional societies and the World Health Organization (WHO). With our association we want to contribute to this debate.
- World Health Organization (WHO), Safe abortion: technical and policy guidance for health systems, 2012, Stand: 21.08.19.
- United Nations Committee on the Elimination of Discrimination against Women (CEDAW), Concluding observations on the combined seventh and eighth periodic reports of Germany, Paragraph 38b, 2017, Retrieved 21.08.19.
- Versorgung mit Ärzt*innen – Rückmeldungen aus den Landesverbänden, pro familia Magazin 02/2019, 5-10.
- ARD Kontraste, Immer weniger Ärzte bieten Schwangerschaftsabbrüche an, 23.08.18, Retrieved 19.07.19.
- Alicia Baier, Schwangerschaftsabbruch – das Tabu in der medizinischen Ausbildung, pro familia magazin 02/2019, 20-21.
- Gabriella Zolese et al., The Psychological Complications of Therapeutic Abortion, 1992, British Journal of Psychiatry, 160 (6), 742-749.
- Brenda Major et al., Psychological responses of women after first-trimester abortion, 2000, Archives of General Psychiatry, 57 (8), 557:777–784.
- Corinne H Rocca et al., Decision Rightness and Emotional Responses to Abortion in the United States: A Longitudinal Study, 2015, PLOS ONE, 10 (7).
- American Psychological Association (APA), Task Force on Mental Health and Abortion, Report of the APA Task Force on Mental Health and Abortion, 2008.