Understanding structural barriers to abortion care under the counselling regulation in Germany: results of a qualitative interview study.

Objective: Abortion care in Germany is under-researched. Available data show regional disparities in the availability and accessibility of abortion services, but the structural causes for this remain unclear. In Germany, abortion is technically illegal but is exempt from punishment under the counselling regulation, which means that the pregnant person has to undergo mandatory counselling and observe a 3-day waiting period. This qualitative interview study examines the perspectives of abortion care providers on the provision of abortion care under this regulation in Germany.

Design: We included 42 gynaecologists and abortion counsellors nationwide. We conducted in-depth, guideline-based interviews that explored the participants' perspectives on challenges in abortion care. The data were analysed using qualitative content analysis according to Mayring. The results were evaluated against the WHO's components of the right to sexual and reproductive health: availability, accessibility, acceptability, quality, and equity, inclusivity and patient-centredness of care.

Results: We identified various structural barriers that limit the availability, accessibility, acceptability and quality of abortion care under the counselling regulation in Germany. Interviewees named the shortage of doctors performing abortions as one structural root cause for insufficient abortion care that is exacerbated by the procedure's criminalisation. A lack of information transparency, complex legal requirements, language barriers, disinformation as well as social stigmatisation were cited as important barriers to abortion care. These barriers were described as having a particularly strong impact on patients from marginalised groups.

Conclusions: Our study indicates that structural barriers associated with the current legal regulation create significant hurdles for both patients and providers and undermine the access, availability, acceptability, quality of care, and patient-centredness of care. In this context, we strongly support the recommendation of the German government's expert commission to revise the current legal regulation of abortion in Germany.