“Self-managed abortion empowers people with an unwanted pregnancy”

Dinah Riese: Abortion is only permitted in Germany under very precise, narrowly defined conditions. This year’s International Safe Abortion Day on 28 September is focusing on the topic of “self-managed abortion”. What is that about?

Alicia Baier: It is about taking abortion out of that context. The state, religion and the patriarchy have always tried to exert influence over abortions. Self-manged abortion is a way of putting control in the hands of the people who are immediately affected.

What does that mean in concrete terms?

Sophie G.: Medical abortion is the best example for how a person with an unwanted pregnancy can manage their own abortion. All they need are two medications: Mifepristone causes the embryo to detach, and then misoprostol, taken within the next 48 hours, clears the uterus of foetal tissue. Once the patient has received advice and the appropriate medication, no medical personnel is required. The pregnant person can decide for themselves when and where to take the medication; they can choose the context and surroundings themselves.

How does a medical abortion compare to a surgical abortion?

Alicia Baier: Both methods are very safe. A surgical abortion takes around ten minutes, while a medical abortion is drawn out over several days. But ultimately a medical abortion is gentler, as no foreign devices are inserted into the uterus. Many patients experience worse bleeding and pain during a medical abortion. For some people that’s an argument against it, but it can help others to process the trauma of the procedure.

Self-managed abortion isn’t about making the procedure as pleasant as possible, is it?

Alicia Baier: It’s about making someone who needs to terminate their pregnancy more independent of medical personnel. One reason why that’s so important here in Germany is that increasing numbers of doctors are unwilling to carry out an abortion.

Sophie G.: And even when they are prepared to do it, the procedure often takes place within a negatively charged atmosphere. We hear reports of stigmatisation, with patients being given to understand that the medical personnel do not condone their decision. So in Germany much of it is about empowerment. In other countries it’s about much more than that – it’s about making any kind of access to abortion possible.

In countries with very restrictive laws?

Sophie G.: Precisely. If you can get hold of the medications, you can take them at home no matter what the law says. It may also be the case that although the local laws allow for abortion, there is no access to them in practical terms. That might be for geographical, social or economic reasons. Or maybe because it’s just too much of a taboo.

That brings us to the topic of Women on Web. What does your work there entail, Sophie?

Sophie G.: Women on Web provides access to information, contraceptives and abortions, independently of legal, financial or other circumstances. People can contact us in any of 22 different languages. We give them information and put them in contact with local support services. People can also request assistance on our website. They then receive online medical advice from one of our partner doctors, and the medication is sent through the post. They take the medication with remote medical supervision, supported at every step.

Is demand high?

Sophie G.: Yes. Around 1.5 million people visit our website each month. We get about one thousand requests for help from around the world every month. In 2019 we sent out around 13,000 packages. By far the highest number of packages go to two specific countries: In 2019 we sent roughly 2,500 packages to Poland, and as many as 4,000 to South Korea. Other countries with considerable demand include Chile, Thailand, Malta and Northern Ireland. And then we get requests from countries where access to abortion is legally possible, but where it’s difficult in practice.

Such as?

Sophie G.: Germany. We opened up our support service here only in 2019, primarily to find out whether there were people in Germany in need of our help, and if so for what reasons. From May 2019 to the end of the year we received around 1,200 requests for help from Germany. We advised each and every person with an unwanted pregnancy of the legal situation and told them where they could get help locally. And yet we still sent out around 20 packages each month.

How is that possible in a country like Germany, Alicia?

Alicia Baier: Many people in Germany think that the laws here are liberal. But unfortunately that’s not the case. Compared to many other European countries, the law here is strict and there are many hurdles to overcome. Abortion is still regarded as a crime, and Section 219a of the Criminal Code even forbids public dissemination of material about the methods used. In combination with the high level of stigmatisation, that has led to a massive supply gap that greatly worries us. In rural areas and very Christian areas in particular, fewer and fewer doctors are willing to perform abortions. And many of those who are willing are already of retirement age. What will happen when they stop practising? I am therefore not surprised to hear that people with unwanted pregnancies right here in Germany are seeking support from Women on Web – but it’s still shocking.

Sophie G.: In countries where access to safe abortion is actually possible, we do ask people why they require our help. The precise findings of the past few years are currently being compiled in a study. In Germany, it is often the case that people wish to conceal their pregnancy and the abortion from their partner or their family, perhaps because of a lack of support or out of fear of stigmatisation or even violence. Financial difficulties are a part of it, as is the shortage of willing doctors already mentioned: not everyone can afford to travel long distances or take time off work. Then, the situation is difficult for people with uncertain residency status, and there may be a lack of information for non-German speakers. During the coronavirus lockdowns, unavailability of childcare also played a role.

Medical abortion plays a less significant role in Germany. In 2019, only 25 percent of abortions were medical. Why is that?

Alicia Baier: It’s not due to a lack of demand. Studies have shown that 50 percent of people with unwanted pregnancies would opt for a medical abortion if they had the choice. But many doctors don’t even offer it. Germany is way behind other European countries in that regard. And that’s despite the fact that any licensed physician can oversee the procedure, which is not the case for surgical abortions.

So why don’t they?

Alicia Baier: Again, stigmatisation plays a role here. Doctors may damage their reputation among the medical community, or become vulnerable to attack from anti-abortionists. Apart from that, doctors barely encounter the topic during their studies and further training. Therefore many of them don’t even know how exactly a medical abortion works. That is why we at Doctors for Choice have started online training courses. Medical abortions must become a normal part of healthcare practices.

Is it really so unproblematic to perform a medical abortion at home? What if something goes wrong?

Alicia Baier: The most common complication is excessive bleeding. Patients receive precise information about that before initiating the procedure. They know how many sanitary towels it is acceptable to fill per hour, and who to turn to if the blood flow is heavier. Further treatment in hospital is only necessary in 0.1 percent of cases, and blood transfusions are only required in 0.05 percent of cases. On the other hand, it is possible that the medication does not actually terminate the pregnancy. But at 0.5 percent of cases, that is also rare. That is why follow-up checks are performed in Germany 10 to 14 days afterwards, with an ultrasound scan or pregnancy test.

How does that work for Women on Web? In countries with abortion bans, the patient cannot simply walk into a hospital and say, “My self-managed abortion went wrong.”

Sophie G.: The good thing is that medical abortion cannot be proved; it works the same as a natural miscarriage. That means that even in countries with strict laws, women can go to a hospital, say that they are worried about bleeding or have had a miscarriage, and still receive medical attention. The WHO recognises our method, with remote medical supervision, as a safe way to abort.

Alicia Baier: But in my view, ultrasound check-ups must still be carried out in Germany. We have enough doctors here who can do that. The ultrasound scan is important for increased safety and, for example, to determine the gestational week.

So you would advise pregnant people in Germany against taking the medication outside of a medical practice?

Alicia Baier: No, not at all. Home use – taking the second tablet at home – is already practised in Germany. I even think that a medical abortion with remote medical supervision – taking both tablets at home – is of interest for Germany. It would be particularly useful given the lack of willing physicians and for any future crises like the coronavirus pandemic, but is also interesting from the view of self-determination. People with unwanted pregnancies should have the option to use the method that is best for them. That is a controversial topic within Doctors for Choice – we have an ongoing internal debate on the issue. Some countries, such as the UK, introduced remote medical supervision during the coronavirus lockdown. In Germany, we need more experience of and research into this area. 

Back to the work of Women on Web: Isn’t all this simply relieving the symptoms? Surely we need to fight the root cause to ensure that people with unwanted pregnancies get legal access to abortion instead of having to order one online? 

Sophie G.: Of course. We are a sister organisation to Women on Waves, which takes a ship to countries where abortion is illegal. The ship picks up people with unwanted pregnancies and helps them carry out an abortion in international waters, under a Dutch flag. This method has directed a great deal of attention towards the issue and the related legislation. In some places it has accelerated change, such as in Spain and Portugal. But there is a limit to what you can do with a single ship. Women on Web is an interim step – while the fight for change goes on, we have to ensure that people who fall pregnant against their will are able to get a safe abortion.

So it’s mainly a pragmatic approach? 

Sophie G.: No, it’s direct action. Self-managed abortion empowers people with an unwanted pregnancy to act on their own behalf while the studies and the debates are ongoing. 

Alicia Baier: The work of Women on Web can be seen as a declaration of war on state attempts to exercise control over the uterus. It’s an act of resistance: if you block our access to abortion, then we’ll do it ourselves.

Here you can find the call to get involved in the Safe Abortion Day 2020