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Why women choose abortion through telemedicine outside the formal health sector in Germany: a mixed-methods study
  1. Kristina Killinger1,
  2. Sophie Günther2,
  3. Rebecca Gomperts2,
  4. Hazal Atay2,3,
  5. Margit Endler4,5
  1. 1Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
  2. 2Women on Web, Toronto, Ontario, Canada
  3. 3Centre of Political Research, Sciences Po (CEVIPOF), Paris, France
  4. 4Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden
  5. 5Women's Health Research Unit, University of Cape Town, Cape Town, South Africa
  1. Correspondence to Dr Margit Endler, Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden; margit.endler{at}


Introduction Women on Web (WoW) is a global medical abortion telemedicine service operating outside the formal health sector. In April 2019 they opened their helpdesk to Germany. 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 consulting WoW from Germany between 1 January and 31 December 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 used to validate results.

Results The quantitative analysis found that the need for secrecy (n=502, 48%) and the wish for privacy (n=500, 48%) were frequent reasons for choosing telemedicine abortion. Adolescents were more likely to report secrecy, cost, stigma and legal restrictions as reasons for using telemedicine abortion compared with older women. 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 and (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.

Conclusions 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.

  • abortion
  • induced
  • health policy
  • health services accessibility
  • qualitative research
  • reproductive health
  • reproductive rights

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  • Contributors All authors participated in the design of the study. KK performed the quantitative analysis and KK and SG performed the qualitative analysis. ME supervised the study analysis. ME and KK wrote the article manuscript. All authors participated in the discussion of the results and approved the final version of the manuscript.

  • Funding This study was funded by the Swedish Society of Medicine.

  • Competing interests Coauthors RG, SG and HA work for or are affiliated with Women on Web.

  • Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.

  • Patient consent for publication Not required.

  • Ethics approval Ethics Committee Karolinska Institutet Dnr 2009/2072-31/2 and Dnr 2020/05406

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data availability statement All original data are available upon reasonable request to the researchers.