“She was totally desperate”: understanding the pathway to abortion in Germany through a qualitative study among service providers in Berlin and Brandenburg

Abstract

Access to abortion is recognised as a key component of the right to healthcare. Yet, to this day, abortion in Germany without medical or criminal indication is illegal and treated under the penal code, although not punished if taking place in the first 12 gestational weeks and following a formalised process including mandatory counselling. Our study aimed to critically examine the pathway to abortion necessitated by the current criminalising legal framework in Germany. We conducted a qualitative study between November 2023 and July 2024, using 17 interviews to capture views of abortion-related service providers on barriers and enablers to abortion in Berlin and Brandenburg, applying a thematic analysis approach using MaxQDA. Our findings point to multiple individual barriers to abortion along the pathway, whose complexity itself presents a structural barrier. Even providers were sometimes insecure about how parts of the process worked and what they were or were not allowed to do. We identified a nine-step series of actions which most individuals seeking abortion must undergo to end an unwanted pregnancy, involving multiple health service visits and the repeated need to communicate their personal situation to different authorities. Our study illustrates that the pathway to abortion in Germany produces a state-induced barrier to a fundamental reproductive health service, and in this respect can be viewed as a form of structural violence against pregnant individuals in a critically decisive situation. Our findings support existing recommendations to decriminalise abortion, which would align Germany´s abortion policy with its international commitments and with international best practices as outlined by WHO.