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Utopia & Lost Futures: Medical and social perspectives on abortion

Updated: Jun 3

April 2024 lecture notes by Luci Lotte


Today I would like to give you a rough overview of the current regulations on abortions and how they should be implemented according to the current guidelines.


I would also like to briefly point out that I am explicitly describing how a pregnancy is terminated and also using some graphic language and medical terms, which may seem strange on the one hand and I can also understand very well if some people do not want to or cannot listen to this so explicitly. I will simply let them know shortly beforehand and they are welcome to leave the room. However, it's also important to me to describe the process as it happens and perhaps make it easier to understand.


-> Also, I sometimes talk about women who are pregnant, I only do this in the context of studies that explicitly refer to women and not to all pregnant people

 

At the end, I also want to look at the connection between psychological stress and unwanted pregnancy to see how a termination or carrying the pregnancy to term affects a person's mental health. If you have any questions, please feel free to get in touch and I look forward to a discussion afterwards.

As you may have noticed, a commission of experts convened by the governing parties has declared the current regulation of abortions in the Criminal Code as untenable under constitutional, law, international law, and European law.


The commission will also publish its findings on egg donation and surrogacy; negotiations on these issues were agreed in the coalition agreement. The commission concludes that abortions should be legalized up to the 12th week of pregnancy post conception. The obligation to provide counseling could remain in place. Politicians such as Alexander Dobrindt warned of a "polarization of society" following the commission's initial findings and Friedrich Merz spoke of the instigation of a "major social conflict". They describe the current situation as "pacified".


Many other things and I would not agree with that. I don't see the situation as pacified.

I can no longer work in Christian clinics if, for example, today's information event is found. Clinical staff at Christian-run clinics do not perform abortions and all their employees must undertake not to speak publicly on the subject of abortions.


I think I can show you why I believe that the current situation cannot be described as pacified and that considering the situation as "pacified" is cynical and ignorant of the lives of pregnant women.


Legal basis:

In Germany, abortion is generally punishable for all parties involved in accordance with Section 218 of the German Criminal Code (StGB). However, the following exceptions apply:

1. counseling in a recognized counseling center (96% of abortions) -> up to the 12th week of pregnancy p.c.

2. medical or criminological reasons à also possible as a late abortion, this applies, for example, to fetuses with congenital heart defects, but also to pregnant women with serious illnesses, such as breast cancer, which must be treated immediately. Criminological reasons include pregnancies resulting from rape, for example

 

Condition for both: abortions must be supervised by doctors, indication and execution must not be carried out by the same doctor

 

100,000 abortions per year, declining trend


Age distribution of people who terminate pregnancies:

- 3% under the age of 18 (65% become pregnant despite contraception, 35% without contraception)

 

-> Minors are assessed according to whether they are capable of giving consent, in which case parental consent is not required

 

- 70% between 18 and 34 years

- 20 % 35-39 years

- 8% over 40 years

 

-> for adults exactly the opposite 65% become pregnant without contraception and 35% with contraception

 

Quality of care:

Places where abortions are performed: medical or surgical:

Outpatient in practices and surgical centers: 81%

Clinic: 16%

 

-> People are also entitled to care from midwives after abortions, important in the case of medication abortion and the accompaniment thereof

 

Availability:

The Act on the "Prevention and Management of Pregnancy Conflicts (SchKG)" states: "The federal states shall ensure an adequate supply of outpatient and inpatient facilities for the performance of abortions."

- 30% of people had to contact more than one practice to obtain an abortion

- 20% found it difficult or very difficult to find a practice

-> many barriers, difficult process experienced causes negative well-being

Distance to the facility

15% had to travel more than 50 km

50% had to travel less than 10 km

9% state poor accessibility of the facilities

 

- Approx. 5% of the population need more than 40 minutes by car to reach the nearest facility -> accessibility criterion not met -> demand planning criterion

- Approx. half of the districts in Germany with poor accessibility are in Bavaria

- Supply density is lowest in south-western Germany, lowest in Bavaria, Saarland, Baden-Württemberg, Rhineland-Palatinate -> here there is poor accessibility on the one hand and only a few places that perform a high number of abortions -> here it is already a problem in some districts when doctors retire

 

Termination of pregnancy procedure after consultation (up to the 12th week of pregnancy):


-> Determination of the pregnancy, ultrasound to determine the date and localization of the pregnancy

Urine or blood test for ßHCG

Ultrasound -> location of the pregnancy: ectopic pregnancy (emergency), ectopic pregnancy (emergency)

- Only an intact pregnancy in the uterus is terminated, as other pregnancies are life-threatening for the pregnant woman

 

How is the gestational age determined?


1) 14 days after the last menstrual period is day 1 of pregnancy -> ambiguities due to unclear cycle lengths, standard 28 days or irregular periods, other contraceptives, pill etc.

2) crown-rump length on ultrasound à between the 8th and 12th week of pregnancy, the growth of the embryo is independent of the genetics, e.g. how big the parents are


5mm in the 7th week of pregnancy

25 mm in the 10th week of pregnancy

50 mm in the 12th week of pregnancy


Time of the abortion:

76% up to week 8 p.c. (10th week p.m.) -> end of the embryonic period

22% up to 12 weeks p.c. -> this is already referred to as the fetal period, which lasts until the end of the pregnancy

 

-> referral by the gynecologist for interruption of the pregnancy

 

Pregnancy conflict counseling according to paragraph 218


- A certificate of counseling is issued to the pregnant woman regardless of the course of the consultation, counseling can also be refused


Information about costs should be provided


Costs are also covered for those with an income of less than €1400 and who have no short-term realizable assets (4% of abortions in Germany), costs range between €200 and €600 depending on the method, most of which is for anesthesia


-> Places where abortions are performed

-> Methods of performance, places where abortions are performed

-> Three-day waiting period

-> Termination of pregnancy possible


Guideline of the medical societies: Abortions in the 1st trimester of pregnancy

 

Methods:

Surgical suction method:52%

Curettage:11%

Medication (mifepristone): 32%


Medicinal abortion: mifepristone and prostaglandins

->up to the 63rd day of pregnancy


3 Important hormones in early pregnancy: ßHCG, progesterone and oestrogens

 


Tablets that are taken orally:

Mifegyne 600 mg (mifepristone: progesterone receptor antagonist) -> blocks the effect of the (corpus luteum) pregnancy hormone progesterone -> embryo detaches from the uterus and usually passes within 24-48h, medication often only taken after 24 hours.

Prostaglandins are taken after 24 hours (trigger contractions), are also given in late pregnancy to induce labor

- Mifegyne can only be taken in the presence of a doctor, Medicines Act, must be counted, prostaglandins can be taken at home, off-label use of a gastroprotective drug


After taking Mifegyne, the person can go home and usually has no medical supervision during the termination of pregnancy -> entitlement to midwife assistance


-> Many people feel unsure about choosing this method as they are afraid of the pain and bleeding and only receive limited care during this time

 

-> Four pads in 2 hours are considered too much

-> Painkillers can be taken

- Pain, heavy bleeding (1%)

- Continuation of the pregnancy (1%)

- Incomplete termination of pregnancy-> necessary surgical removal:3-5%

- Infections: 0.1-0.2%

- No risk of injury to the uterus or cervix

- No increased risk of infertility, subsequent premature births or miscarriages in subsequent pregnancies

 

Surgical abortion: outpatient or inpatient in practices or clinics and day clinics

Preoperative cervical priming with prostaglandins


-> loosens the tissue of the cervix and facilitates the insertion of medical instruments

 

Vacuum aspiration (according to consensus, regardless of whether under local or general anesthesia, although studies show that around 25% of people report great pain)


-> Method of first choice in the 1st trimester, before the 7th week of pregnancy the diagnostic challenge is the size of the tissue, which is why some people wait.

-> Electrical aspiration should be performed after the 9th week of pregnancy

-> 10th to 12th week of pregnancy -> after aspiration, possible residues should be removed with a clamp

 

- Combined with antibiotic therapy ("can" and consensus strength 2)


-> If the abortion is successful -> ßHCG test should drop by 50% the next day, the tissue removed should be examined to see if it was the pregnancy -> also here: pre- and postoperative ultrasound

-> After most operations, there is a routine check after 1-2 weeks for tissue residues, infections, pain, bleeding.

-> not evident for symptom-free people, but should be offered to all people

 

Curettage: Colloquially known as "scraping", mainly used for later abortions, where a medical instrument is inserted through the cervix and a blunt spoon is used to remove the implanted pregnancy from inside the uterus.

 

Surgical termination of pregnancy:

- Heavy bleeding (0.2%)

- Continued pregnancy (0.2%)

- Repeat operation (3%)

- Infections (1-10%) with antibiotics (2%)

- Injuries to the uterus (0.1%)

- Complications due to anesthesia (0.2%)

- Risk of premature birth and miscarriage not increased

-> If the abortion occurs after the 10th week of pregnancy, people with a blood group with a negative Rhesus factor must be vaccinated so that they do not develop antibodies against the fetal blood

-> there are no qualitative differences in the choice of methods and the person must choose a method that is suitable for them

-> the choice of method is not related to the subsequent occurrence of psychological problems

-> medical risks of abortions are very low and serious complications are very rare

-> The issue of psychological stress following abortions seems to me to be more socially discussed

 

but it is often the psychological stress of those who oppose abortion that is discussed, which is why I would like to go into this briefly

 

Life situations of people with unplanned pregnancies:

ELSA: Experiences and life situations of unplanned pregnant women

 

There is a high level of anxiety and stress before the abortion and during pregnancy conflicts, which decreases significantly immediately afterwards


-> Pregnancy hormones oestrogen and progesterone and their effects


-> Mood swings, anxiety are often reported in early pregnancy (I cannot differentiate exactly between what is social and what is biological)


Experiences after abortions:

Women experience a wide range of individually different feelings after abortions, such as relief and relief, grief and feelings of loss, feelings of guilt or, in individual cases, regret about the abortion


Feelings of guilt, shame or self-blame are an expression of the widespread stigmatization of abortion


-> Time is often characterized by unstable emotionality


Physical: feeling of tension in the breasts, blood loss can have an impact, lower abdominal pain, first menstruation usually after 4-6 weeks -> here too: Entitlement to midwife help

The most important factor for the occurrence of psychological problems after an abortion is pre-existing psychological problems, and: People with mental illnesses are more likely to become pregnant unintentionally, which is mainly due to their living conditions

circumstances


Other factors:

Pressure from the environment to terminate the pregnancy

Stigmatization of abortions (also internal stigmatization)


Internalized stigma: Adoption of negative stereotypes about oneself and the assumption that these apply to oneǹ Guilt or feelings of shame


-> 30% of people state that they feel strong self-blame and guilt and shame, approx. 23% experience no self-blame or guilt and shame at all -> the rest are somewhere in between

-> the higher the level of internalized stigma, the lower the well-being after 3 months, regardless of the internalized stigma, everyone has the same well-being after 12 months as before SS


Need to keep secrets

Partnership conflicts and separations


-> Psychological impact on partners in heteronormative relationships: the psychological impact is usually less on partners than on the pregnant woman, although there is little data on this

Lack of social support leads to greater psychological stress

 

Involvement of the social environment:

-> approx. 1⁄4 of people have not talked about it with anyone close to them

-> 70% did not talk about it with family, 65% did not talk about it with friends and only involved their partner

-> 55% felt alone with abortion.

 

Satisfaction with the decision:

Freiburg study: survey of 2000 people who were unintentionally pregnant between 1995 and 2020 - on average, 5 years have passed since the pregnancy

-> One year after unintended pregnancy: no difference in psychological well-being regardless of whether the pregnancy was terminated or carried to term

-> At the time of the survey, 95% of people rated their decision as correct, regardless of whether they had carried unwanted pregnancies to term or terminated them

 

Post Abortion Syndrome:

Rhetoric often cited by abortion opponents as a consequence of abortions, not recognized medically or psychiatrically, unlike postpartum depression for example, there is no evidence for such a phenomenon (Turnaway Study)

-> what I perceive as intimidation of unintentionally pregnant people and a stigma of abortion wrapped in medical vocabulary

-> there is no evidence that abortion has a negative impact on long-term mental health

-> for unintended pregnant people, there is no difference in the incidence of subsequent mental illness if they carry the pregnancy to term or terminate it

 

Risks of pregnancies carried to term?

- Pregnant teenagers had an increased risk of psychiatric illness in adulthood, regardless of whether the pregnancy was carried to term or terminated

- Individual studies show over the long term that young women who carried pregnancies to term achieved a poorer educational status and were more often dependent on

social benefits, while the young women who opted for an abortion later had better educational qualifications and higher self-esteem

 

-> Unintended pregnant women are more likely to have mental health problems compared to the general female population, but it is assumed that people with mental health problems have a higher risk of unintended pregnancies

 

-> These factors that negatively influence the mental well-being of unintended pregnant women and also young mothers are social and therefore changeable, I do not want to assume at this point that the figures collected must necessarily be so and see here above all the potential for a positive change, which is strongly related to political struggles and the need for which still exists, as the current situation is not yet clear.

 

Where can I find the latest information?

ELSA

Profamilia

ProChoice

Familienplanung.de (BZGA), help hotline 0800 40 40 020

Guidelines of the medical associations

 

 

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