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.
German abortion law is backward in European comparison. Abortion is still regulated in the German Criminal Code. Threats of punishment reinforce stigmata and taboos around abortion in our society and prevent an open and well-founded discourse on sexuality and reproduction. They also make it more difficult to address abortion topics in medical education. They intimidate doctors and thus contribute to the decreasing numbers of abortion care providers in Germany. They create feelings of fear, shame and bad conscience in those people seeking abortions 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.
In accordance with the demands of the World Health Organization (WHO) and the UN Women’s Rights Convention (CEDAW), we demand: Abortion has to be decriminalized, and instead be regulated as a public health service. Many other countries have shown that abortion regulations can exist outside of the criminal code, for example in social codes or within the legal systems applicable to the health sector. Mandatory consultations and waiting times must be overcome, as they represent barriers to access and can unnecessarily delay medical procedures. Counseling can only be helpful if it is provided on a voluntary basis. A nationwide, free of charge, value-free and multilingual/-cultural counseling 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. Conscientious objection to abortion is problematic for two reasons. First, it means that abortion is not a compulsory part of gynecological 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 conscientious 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 should depend on their abilities and their own professional focus. The moral concerns of individual doctors (in leading positions) or hospital owners cannot endanger the health of unintentionally pregnant people.
For ordering abortion pills, physicians are faced with additional bureaucratic steps. The drugs are not supplied through the usual distribution channel (manufacturer – wholesaler – pharmacy), but are delivered directly from the manufacturer to the facilities that perform the abortion. This so-called special distribution channel (“Sondervertriebsweg”) is regulated in § 47a of the German Drug Law. This means that physicians cannot prescribe abortion pills like any other prescription drugs.
In addition, they have to pay in advance, store the drugs “safely”, keep records of every single pill dispensed, and keep this data for 5 years. These regulations represent a bureaucratic barrier that is completely unnecessary and unjustified from a medical point of view.
Abortion pills are prescription drugs and therefore should be treated as such. We call for the expungement of Section 47a of the German Drug Law. This would minimize barriers in obtaining access to the drugs and could thus increase the willingness of physicians, especially those in private practices, to offer medical abortion in their office.
With the current abortion law, Germany violates international human rights obligations: The United Nations Convention on the Elimination of All Forms of Discrimination against Women (CEDAW) includes provisions on abortion as part of reproductive and sexual health. It calls on member states to decriminalize abortion and eliminate mandatory waiting periods and counseling. Abortions should be considered a regular reproductive health service. Safe and legal access to abortion as a human right was also reaffirmed in the UN Human Rights Committee in 2018 and in the EU Parliament (so-called Matić Report) in 2021. On top, Germany’s current abortion law violates against World Health Organization (WHO) guidelines. In the updated directive of 2022, there are clear recommendations for action for implementing abortion care.
However, because ensuring these rights is still not guaranteed in Germany, Germany has been rebuked several times by human rights organizations.
We call on Germany to finally ensure sexual and reproductive health and rights. Consequently, Germany must recognize the international human right to legal and safe abortion and fulfill its obligations as a member of the EU and CEDAW. We also demand that the evidence-based recommendations for action on abortion set out in the WHO guidelines are implemented in law and practice in Germany.
Abortion should be classified as a component of human rights in the context of sexual and reproductive health. In addition to the definite decriminalization of abortion, access barriers that are not medically indicated (such as mandatory waiting periods and compulsory counseling), should be abolished. We further recommend including nurses and midwives in abortion care, ensuring comprehensive medical education and training on abortion, and offering telemedical care.
Sexual and contraceptive education in schools is often inadequate and/or one-sided. In some schools, religion classes even teach Christian fundamentalist content that focuses exclusively on abortion from a moralizing perspective. Understanding one’s own body, sexuality and contraceptive methods is however essential, especially for young people.
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 gynecological consultation hours, physicians 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 people are sure that they do not want to have children (anymore). Some would therefore like to choose sterilisation as a definite contraceptive method. For those under 30, especially women, it is almost impossible to find a physician, as most doctors refuse to perform the operation for that age.
On top, contraceptives are only covered by health insurance up to the age of 22. Especially for people with low income, the cost of contraception is an essential 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, ideologically neutral and gender-sensitive information on sex education and contraception must be guaranteed in school. The subject of abortion should not be excluded. Here, the health of those affected should always be emphasized, not religious and moral beliefs.
Contraceptives must be covered by the health insurance regardless of age. Sterilisation as the final contraceptive method should be available for all patients – regardless of gender – who are properly informed.
Even after the abolition of § 219a StGB (so-called “ban on advertising abortions”), there is still not sufficient, medically correct and neutral information on abortion. In contrast, there are still many websites that are run by the “Anti Choice” lobby which deliberately spread misinformation and abortion myths. Since these web pages try to keep a “neutral” first appearance, it can be very difficult for patients to differentiate, which web pages to trust.
Some counseling centers that are not recognized by the state also present themselves as neutral online, but then provide “counseling” with religious-fundamentalist motivation and do not even issue the mandatory counseling certificates. Some of these counseling centers even receive money from state funds.
The online search for abortion care providers is still difficult. Even after the abolition of §219a StGB, not all doctors publish on their website that they perform abortions, because they are afraid of the defamation by anti-choice activists. The list of the ‘Bundesärztekammer’ is not a sufficient alternative because it only lists some abortion care providers in Germany, contains incomplete information and is confusing.
On top, those websites that can be recommended are often only available in German. The lack of information therefore notably affects refugees, migrants or whose native language is not German.
In accordance with the World Health Organization (WHO) and the UN Women’s Rights Convention (CEDAW) we demand that factual information on abortion must be made available to those seeking help. An easily accessible, multilingual, free information service is essential.
Deliberately misleading and false information on abortion (e.g. by anti choice activists) should be banned following the French example.
Counseling centers that are not state-approved for pregnancy conflict counseling must make this very clear on their websites and counseling sessions. The should not receive funding as pregnancy conflict counseling centers.
The costs for abortions are normally not covered by health insurance. In the case of low or no income, patients are able to apply for cost coverage. This must be submitted prior to the procedure. The application procedures vary greatly depending on the federal state and health insurance company.
Overall, these rules are confusing, lead to additional bureaucratic work for pregnant people and thus to the loss of valuable time for meeting deadlines. This problem became more apparent during the Corona pandemic, where pregnant people had difficulties in obtaining coverage due to state regulations like home office and contact avoidance. Especially for socially vulnerable people, refugees or those not fluent in German, access to abortion care is made more difficult by the lack of cost coverage.
Abortion should become a public health service. The costs for abortion and contraception should be covered by public health insurance. Cost coverage must be standardized and simplified. Delays caused by the current application procedure must be avoided.
The tabooing of abortion care remains prevalent in medical education in Germany. Although it is one of the most common gynecological procedures, it is barely discussed during medical school. It is also not a compulsory part of gynecological training. The training regulations (“Muster-Weiterbildungsordnung”) do not even mention the vacuum aspiration – the method of choice for miscarriages and abortions. Similarly, the medical method of treating miscarriages and unwanted pregnancies up to the 9th week of pregnancy is not mentioned.
11.4% of the abortions carried out in Germany in 2021 were still carried out with curettage, a method classified as outdated and unsafe by the WHO. (source: German Federal Office of Statistics) We assume that a similar proportion of miscarriages are treated with said method. In many teaching hospitals, no abortions are performed at all. We know from numerous reports from our members that miscarriages are extremely rarely treated medically, and instead rather surgically, in the hospitals. This means that early medication abortions can only be trained if residents specifically spend part of their training in a medical practice where medical abortions are performed.
However, it is not only about studying the technique. They also need to learn how to deal with unwanted pregnant people in a non-judgmental and respectful manner before, during and after the procedure. Personal role models also play a role here. Physicians who do not learn about abortion as part of their own specialty during their residency and who have never come in contact with this topic will most likely not offer this procedure later when being self-employed.
For those physicians wishing to become an abortion care provider, there is no official certified training opportunities. It is even made more difficult for physicians from other specialties (e.g. general medicine). They are often forced to travel to the Netherlands, for example, to get a certificate for this.
Finally, there are no guidelines on abortion care that guarantee our patients’ consistent treatment according to modern standards.
Medical aspects (including procedure, side effects and contraindications) of medical and surgical abortion must be taught on a theoretical level in med school. Something so vital has to be taught to every med student. There should also be sufficient room for emotional, socio-political, legal and ethical discussion in small groups during the course of study.
Hormonal and non-hormonal contraceptive methods with their advantages and disadvantages should also be taught comprehensively in medical school. Future physicians will need this knowledge in their daily medical practice regardless of their future specialty.
Gynaecological residency training should provide practical knowledge and skills on contraception and abortion care. Vacuum aspiration and medical abortion should be explicitly listed in training regulations (“Muster-Weiterbildungsordnung”) for gynecology.
Financial incentives in hospitals could lead to more frequent use of vacuum aspiration as the surgical method of standard, for example by paying more for this method than for the curettage.
It is important that there is an in-house point of contact in each hospital who performs abortions and who is able to train residents. Medical practices and hospitals could be motivated to offer appropriate training rotations, e.g. through financial incentives.
Overall, it should be possible for physicians – regardless of their specialty – to become an abortion care provider. We therefore call for the development of training opportunities that enable physicians to perform abortions (e.g. through an additional qualification, based on the Dutch model). These should be open to all physicians, regardless of their specialty, and thus enable them to offer abortions. We have enough experience with this from other countries. Advanced training on 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 another 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 medical abortions for years. In New Zealand, nurses and midwives are involved in care.
Evidence-based guidelines according to WHO standards on 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 medical practices and clinics offering abortions has fallen by > 45% since 2003 – from 2000 to 1092 providers in the end of 2021. In many clinics, abortions are only carried out according to medical or criminological indications; however this affects only 4% of abortions. In some regions, unwanted pregnant people have to travel up to 200 km to their nearest abortion provider. Long journeys, and the additional organizational 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.
Due to these care gaps, the pressure on the remaining abortion care providers is growing. Especially in regions where we are the only providers in a wide area, we are forced to postpone other medical treatments in favor of abortions, or to continue practicing despite retirement.
For the health of our patients, a nationwide maintenance of abortion providers must be guaranteed. We need a reliable census of these current provision gaps and rapid political measures to counteract these. The implementation of the requirements mentioned under “German Criminal Code”, “Schwangerschaftskonfliktgesetz (Pregnancy Conflict Act)” and “Education” could be a first step: decriminalization of abortion, abolition of conscientious objection and an improved and broader medical training for abortion care – not only for gynecologists.
Abortion should be part of the range of health services offered by a gynecological hospital, regardless of denomination or hospital owner. At the same time, we would like to encourage our colleagues to take their responsibility seriously despite criminal intimidation. Because unwanted pregnant people depend on physicians who are willing to provide abortion care. This work should not rest on the shoulders of a few, but should be distributed more evenly among all colleagues. Midwives and nurses should be included in the care.
The possibility of telemedical abortion – an essential pillar of abortion care according to the WHO – should be promoted in Germany. Studies from other countries prove the safety and reliability of the method.
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 counseling centers, 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 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 an 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.
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- American Psychological Association (APA), Task Force on Mental Health and Abortion, Report of the APA Task Force on Mental Health and Abortion, 2008.