Germany has seen a dramatic reduction in the number of doctors who will perform abortions. Now, a telemedicine pilot project wants to help women enact their right to reproductive self-determination.
Anna and her partner had been using a copper coil IUD as a contraceptive for two years before they found themselves staring, stunned at a positive pregnancy test. The chances of conceiving had been slim: Fewer than one in 100 women will become pregnant while using the internal contraceptive.
Anna, who was 26 at the time, and her partner didn't feel ready to start a family. Both financial constraints and a lack of support in the family played a role in their decision to terminate the pregnancy — a choice that wasn't easy to make.
Some 100,000 abortions are carried out in Germany every year. But under paragraph 218 of Germany's criminal code, abortion is illegal and carries a sentence of up to three years in prison. There are, however, exceptions for rape victims or for pregnancies that pose a risk to the woman's health. Abortion is also possible for anyone who wishes to terminate a pregnancy within the first three months — after having undergone mandatory counseling no less than three days before the procedure is carried out.
But the possibilities to do so in Germany are increasingly limited. Since 2003, the number of clinics providing abortions has halved — with women in Germany's Catholic, southern regions most affected by the shortage.
"My doctor doesn't do abortions, and the next nearest hospital has been repeatedly targeted by anti-abortion protesters," said Anna, who lives in the southern state of Bavaria. "There's a separate entrance around the back. But who wants to face extra hassle during what's already a difficult time?"
Instead of traveling several hours to a clinic, Anna opted to take part in a new pilot project offering abortions via telemedicine at home. Those who take part in the project will consult with a gynecologist via video chat, and receive the medication for an abortion at home by post.
The project is a first in Germany. It's run by the Berlin-based counseling center Pro Familia, the family planning center Balance and the organization Doctors for Choice.
Pandemic prove to be a catalyst
The need for virtual abortion consultations became urgent during the COVID-19 pandemic, said Dr. Jana Maeffert, one of four gynecologists running the project.
"One of the most common reasons given by women for using the telemedicine service during the pandemic wasn't because they actually had COVID-19 or were having to quarantine, but because of child care — or lack there of," she said.
The pandemic also left many patients without local medical services. When gynecologists fell ill, were forced to quarantine or had to close their clinics for fear of infection, women in many regions ended up without medical care.
'Procedure is just as safe as in person'
Before patients can go ahead with an abortion via telemedicine, they must first talk with a nurse about their motivations and the practicalities of going through the procedure at home. Some of the questions they're asked: Do you really want to do this? How will you be supported? Will you have the time and space to do this at home? Do you already have kids? Can you organize child care during the procedure?
If the patient ultimately decides to go ahead, she is asked to upload a number of documents, including an ultrasound scan, to a secure chat server. But it's only after the legally required counseling session that things are set in motion. Three days later, the patient will receive two pills and pain medication in the mail.
Under supervision by a gynecologist via video chat, the patient takes the first pill. She takes the second one two days later to trigger the bleeding, this time also in the company of her partner or another trusted person.
"I felt very comfortable," said Anna. "My partner was there the entire time to support me. And it was also possible to go through the procedure on a weekend. That way, I didn't have to come up with any excuses for work. My relatives didn't need to know, either."
Two-and-a-half weeks later, the patient takes a special pregnancy test to confirm that she is no longer pregnant.
"The procedure is just as safe as in person, " said Dr. Maeffert, who carries out some 100 abortions at her clinic every year. "Usually the woman takes the first pill here, and I give her the other one to take at home. The safety with telemedicine is absolutely no different from in person."
In the case of complications in either scenario, the patient would go to the nearest hospital for emergency treatment.
A similar telemedicine service in the United Kingdom acted as a blueprint for the Berlin-based medical service. Unlike in the UK, however, the German project did not require a change to existing legislation.
A report released almost a year after the UK made it possible for women to legally access early abortions at home found that the effectiveness and safety of the procedure remained the same for the telemedicine service. The report also found that the telemedicine procedure enabled women to have their abortions much earlier, reducing the risk of medical complications.
Increasing lack of expertise
In Germany, the number of gynecologists performing abortions has fallen dramatically over the past two decades, and not only in rural areas. A gap in education has also played a role.
"The younger generation of doctors simply didn't learn to perform the procedure due to the taboos that still surround the topic in teaching," said Maeffert.
Abortions are not part of the standard curriculum for gynecologists in Germany. Legal hurdles, along with the stigma still attached to advertising and performing the procedure, also contribute to the lack of training.
"Doctors who were trained in the late 1960s and who were more likely to perform abortions are slowly retiring," said Maeffert. Many of that generation, she added, were part of the student movement that rejected authority and called traditional views of politics and society into question — and they strongly believed in sexual freedom and self-determination.
Coalition government pledges legal support
The organizations behind the pilot project hope to expand the telemedicine service, as they anticipate huge changes in Germany's abortion law.
In its coalition deal, the new German government of center-left Social Democrats, Greens and neoliberal Free Democrats has pledged to abolish paragraph 219a of the criminal code, a controversial piece of Nazi-era
legislation that makes it illegal to "advertise" abortion services. Doctors should be able to provide information "without fear of prosecution," they wrote in the deal.
The parties have also pledged to ensure there is a "nationwide network of advice centers."
But a change in legislation wouldn't put an end to the harassment that many gynecologists face from a growing number of increasingly aggressive anti-abortion protesters, who rally outside hospitals and send targeted personal attacks on social media.
Christian Albring, the head of the German professional association of gynecologists, told DW that the hostility experienced by some gynecologists plays a big part in dissuading them from offering abortions.
"Nobody likes to carry out an activity for which they are publicly attacked and called a murderer," he said.