By Amelie Kolandt, Susanne Michl & Mirjam Faissner
In Germany, access to abortion remains legally restricted and structurally constrained. Our recent qualitative study “Understanding structural barriers to abortion care under the counselling regulation in Germany”, published in BMJ Sexual and Reproductive Health, highlights how criminalisation, stigma, and a lack of training undermine equitable, patient-centred abortion care in Germany – and why legal reform is urgently needed.
Abortions in Germany: a grey area
Abortion in Germany is generally illegal under §218 of the Criminal Code. The “counselling regulation” outlines criteria under which abortion remains exempt from punishment up to the 14th week of gestation: the person requesting the abortion must seek mandatory counselling at a state-certified counselling centre at least three days before the abortion is carried out. If these conditions are met, performing an abortion is legal for the physician – but receiving the abortion remains illegal for the patient. The German State considers abortions on demand „morally reprehensible“ but refrains from prosecuting abortion seekers. This creates a unique and contradictory framework within German law.
Our study shows that even though abortion is in principle accessible, the criminalisation of abortion leads to profound structural barriers in practice.
What providers told us
We interviewed 42 abortion providers and counsellors across Germany. They reported a stark shortage of professionals willing to provide abortion services, especially in rural areas and in the Southern part of Germany. Legal uncertainty and stigmatisation deter new doctors from entering the field. “We urgently need gynaecologists who perform abortions—many of them—and they need to be well-distributed”, one counsellor told us.
Access is fragmented and inequitable
Due to the provider shortage, patients often have to travel long distances and face long waiting times to access abortion care. This particularly affects people with limited resources, those who have care responsibilities or face language barriers. In border regions, some travel to the Netherlands or Austria, where the legal regulation of abortion is less restrictive – not out of preference, but necessity.
Medication abortion: blocked by law and training gaps
Although medication abortion is internationally recognised as safe and effective, its use remains limited in Germany. Legal constraints such as restrictions of the distribution of abortion medication regulated in §219b Criminal Code and inadequate training opportunities keep it out of reach for many patients. Only one of the 42 experts we interviewed reported routine access to home–use or telemedical abortion options.
Stigmatisation as a recurrent theme
The stigmatisation of abortion emerged as a highly relevant issue in most interviews. Patients fear judgement – not only from their social environment, but also from healthcare professionals. Some providers were reported to stigmatise abortion by refusing to provide treatment altogether. Meanwhile, doctors who offer abortion care face harassment, social ostracisation, or even death threats. Stigma, our interviewees emphasised, is built into the legal framework and reinforced by public discourse.
Undermining quality and patient-centred care
The criminalised status of abortion affects not only access but also the quality of training and care. Abortion methods are rarely taught in medical school and are no obligatory part of obstetric training. Our interviewees stressed that surgical abortions remain the norm in Germany, despite evidence supporting the efficacy and safety of medication abortion. Moreover, Dilatation & Curettage still is commonly used despite international guidelines recommending vacuum aspiration. Limited provider availability also means patients may not be able to choose their provider’s gender – a critical issue for those with histories of trauma.
What needs to change?
Our findings strongly support the recommendation by the German government’s expert commission: abortion can and should be regulated outside of the Criminal Code. Only this would remove one of the structural foundations of abortion stigma and allow for a patient-centred, human rights-oriented approach to abortion care. Legal reform must be accompanied by improved training, better access to medication abortion, and the provision of funding for structures that ensure equitable and inclusive abortion care.
Conclusion
Abortion is an essential healthcare service. In Germany, however, it is still criminalised which supports to ongoing stigmatisation of both patients and providers. Structural change is possible, but it will require the political will to finally treat abortion care as what it is: a fundamental part of reproductive health and rights.
About the authors
Amelie Kolandt is a researcher at the Institute of the History of Medicine and Ethics in Medicine, Charité – University Medicine Berlin. Her research focuses on abortion care and stigma.
Prof. Dr. Susanne Michl is a professor of ethics in medicine at the Institute of the History of Medicine and Ethics in Medicine, Charité – University Medicine Berlin, with expertise in health justice and bioethics.
Dr. Mirjam Faissner is a senior researcher in ethics at the Institute of the History of Medicine and Ethics in Medicine, Charité – University Medicine Berlin, focusing on structural discrimination in healthcare systems.