Amelie Kolandt¹, Mirjam Faissner¹, Susanne Michl¹

¹ Institute of History of Medicine and Medical Ethics, Charité – Universitätsmedizin Berlin

Background: Statutory deadlines, waiting periods for care and the duration of decision-making processes shape the experiences of pregnant people and those providing care.

This qualitative study examines structural barriers to access to abortion services in Germany from the perspective of experts.

Methods: Between September 2020 and May 2021, we conducted 42 guided expert interviews with gynaecologists (n=22) and pregnancy conflict counsellors (n=20) and analysed them using qualitative content analysis according to Mayring.

Results: The analysis revealed several time-critical challenges across various aspects of care.

Experts described a continuous decline in the number of providers of terminations of pregnancy, leading to longer waiting periods and greater travel distances (access). The progression of the pregnancy during the waiting period increases medical risks, limits the choice of methods and exacerbates the psychological strain on patients.

Delays in procedures following counselling requirements arise from a lack of information, mandatory counselling and waiting periods, logistical hurdles and language barriers, as well as stigmatisation.

In the case of medically indicated terminations of pregnancy, additional time-critical problems arise, such as a lack of transparency in the process of determining medical indications, fragmented care structures, institutional refusals, and the involvement of ethics committees, all of which can delay treatment.

According to the experts, marginalised groups – people in rural areas, those with a migration background, pre-existing (mental) health conditions or a history of violence – experience time-critical barriers disproportionately often, with particularly serious consequences.

Demographic change further exacerbates these healthcare challenges by creating new gaps in the system.

Discussion: In this article, we discuss how legal ambiguity, fragmented care structures and the exercise of the right to refuse treatment lead to time-critical situations. Delays can force pregnant women to exceed the 12-week deadline, meaning they are reliant on alternative care pathways abroad or the issuance of a medical certificate. This can lead to later terminations with higher risks of complications. This violates the principle of harm prevention and restricts patients’ reproductive autonomy.