Structural barriers to medically indicated abortion in Germany: A qualitative study of provider perspectives

In Germany, to perform an abortion after 14 weeks of gestation, physicians are legally required to provide a medical indication due to a serious risk to the pregnant person’s life or health. This study explores legal, institutional, and societal factors influencing abortion care in Germany from the perspective of abortion providers and counsellors. We conducted 42 semi-structured expert interviews with gynaecologists and abortion counsellors across Germany. Data were analysed using Mayring’s qualitative content analysis with a mixed inductive–deductive approach. In our analysis, we identified four overarching themes that influence care for medically indicated abortions in Germany: (1) Varying Availability and the Right to Refuse: Abortion services in Germany are unevenly distributed, with notable urban–rural divides. This restricts procedural options and leads to delays. The experts raised concerns over institutional refusals by entire hospital departments or publicly funded facilities. (2) Legal Regulation and Stigmatisation: Although medically indicated abortions are legal, their regulation under the Criminal Code fosters a sense of criminality among providers. Stigma can negatively affect professional support for patients in their decision either to terminate or continue a pregnancy. (3) Lack of Training and Standardisation: Abortion care is underrepresented in medical education and obstetric training, with few opportunities to acquire the necessary skills. The lack of national clinical guidelines further contributes to inconsistent interpretations of the medical indication and intransparency of processes. (4) Intersectional Aspects: Systemic inequities disproportionately affect structurally marginalised groups—including those living in rural areas, individuals with migration histories, language barriers, mental health conditions, or prior trauma. Experts described how opaque medical indication criteria, stigma, and lack of trauma-sensitive care result in delayed, inaccessible, or denied care. In Germany, abortions on medical grounds are complicated by legal ambiguities, fragmented care provision, and frequent use of the right to refuse. While the right to refuse protects providers, its opaque application can exacerbate inequalities and delay access to care. Stigma – legal, institutional, and interpersonal – remains a major barrier, reinforced by the Criminal Code, inadequate training, and generational differences among healthcare professionals. Future legal frameworks should guarantee equal access to care irrespective of social and medical factors. National clinical guidelines on abortion beyond 14 weeks’ gestation and bereavement care are urgently required.