Why women choose abortion through telemedicine outside the formal health sector in Germany? A mixed-methods study

Introduction: In April 2019 the abortion telemedicine service Women on Web (WoW) opened their helpdesk to Germany and saw a progressive rise in consultations. Our aim was to understand the motivations, and perceived barriers to access, for women who choose telemedicine abortion outside the formal health sector in Germany. Methods: We conducted a parallel convergent mixed-methods study among 1090 women in Germany, who requested medical abortion through WoW between January 1st and December 31st, 2019. We performed a cross-sectional study of data contained in online consultations and a content analysis of 108 email texts. Analysis was done until saturation; results were merged, and triangulation was used to validate results. Results: Frequent reported reasons for choosing telemedicine abortion in the consultation forms were quote: I need to keep the abortion a secret from my partner or family (48%), and quote: I would rather keep my abortion private (48%). The content analysis developed two main themes and seven subsidiary categories: 1) internal motivations for seeking telemedicine abortion encompassing i) autonomy, ii) perception of external threat, iii) shame and stigma, and 2) external barriers to formal abortion care, encompassing : (iv) financial stress, v) logistic barriers to access vi) provider attitudes, and vii) vulnerability of foreigners). The findings in the quantitative and qualitative analysis were consistent. Conclusion: Women in Germany who choose telemedicine abortion outside the formal health sector do so both from a place of empowerment and a place of disempowerment. Numerous barriers to abortion access exist in the formal sector which are of special relevance to vulnerable groups such as adolescents and undocumented immigrants.