Abortion

When may you have an abortion carried out?

Abortion according to the consultation rule

Approximately 96.4 percent of abortions in Germany take place according to this regulation, the rest with regulation of indication. The following requirements must be met for an abortion according to the regulation of consultation:

• No more than twelve weeks must have elapsed since fertilisation.
• You have received the legally prescribed consultation and the corresponding consultation certificate.
• The abortion takes place at the earliest on the fourth day after the end of the consultation..
• The abortion is carried out by a doctor.

For the legally prescribed counselling, you have to contact a pregnancy conflict consultation, for example a pro familia counselling centre in your area.

The most common and most gentle method of instrumental abortion is the suction method (also called vacuum aspiration). It can be performed under local or general anaesthesia. For local anaesthesia, you will be given an injection to the right and left of the cervix, which is little or no painful. In some practices a sedative is given before the procedure, which makes you a little sleepy. In general anaesthesia, the anaesthesia is injected into the arm vein by an anaesthetist and you sleep during the procedure. You should not eat, drink or smoke for 6 hours before a general anaesthesia.
The cervical canal is widened with metal rods. A thin tube connected to a suction device is then inserted through the cervix into the uterine cavity. The mucosa and the amniotic sac are then sucked out. The procedure takes five to ten minutes. Bleeding and abdominal pain after the treatment are normal, but do not occur in all women.
In some cases, it may be necessary to have a scraping done (curretage). The mucous membrane and the amniotic sac are removed with instruments.

As a rule, an abortion is performed on an outpatient basis, i.e. you can go home 1-2 hours after the procedure. However, you will not be able to drive alone. An attendant can be with you at most facilities after the abortion. Also with this method a medical follow-up examination is necessary after approx. ten days.

Only a few women have health complications after the instrumental abortion. They are at their lowest between the 7th and 9th week of pregnancy. The first week of pregnancy (calculated from the first day of the last period). In rare cases, there may be secondary bleeding or inflammation, which can generally be treated well. If you experience heavy bleeding, pain, fever above 38.5° C or a foul smelling discharge, you should consult a doctor. If an inflammation is not cured quickly and completely, the fallopian tubes may stick together. This could affect subsequent fertility. Very rarely, the uterus is injured. In individual cases, the pregnancy may persist, which may require further intervention.

After abortion

After abortion, take care of yourself irrespective of the treatment method, as you are more susceptible to inflammation when exhausted. Many doctors recommend that nothing should be inserted in your vagina for the first few days to prevent inflammation. So, if you want to be careful:

• Do not use tampons but use sanitary pads
• Do not have sexual intercourse
• Do not swim or take a bath. Showering and washing is allowed.

Relief or sadness are normal feelings after an abortion. You also have to cope with the hormonal changes. Psychological complications, on the other hand, are very rare. Conversations with counsellors can be helpful. The pro familia counselling centres offer counselling on this subject.

What you need for abortion

If you have decided to have an abortion, there are many appointments coming your way. In order to spare you the unnecessary work, here are the formalities required by the office

• Certificate of legally required consultation
• Blood group identification, if available (e.g. old maternity passport/ blood donation card)
• Health insurance card and bank transfer
• Doctor's fee in cash (ask at registration) or in case of low income, insurance certificate of the health insurance (previously obtained)

The medical abortion with Mifegyne®

Mifegyne® (active ingredient name: mifepristone) is an artificial hormone with a structure similar to the natural hormone progesterone. Progesterone plays a crucial role in the development and maintenance of pregnancy. Mifegyne® blocks the effect of progesterone. It causes bleeding and leads to abortion. In addition, Mifegyne® causes softening and opening of the cervix.

36 to 48 hours after taking Mifegyne®, an additional prostaglandin preparation must be taken. Prostaglandins promote the expulsion of pregnancy tissue, reduce bleeding duration and increase the effectiveness of Mifegyne®.

Up to what degree is an abortion with Mifegyne® possible?

A medical abortion with Mifegyne® can only be carried out in early pregnancy, as the effectiveness of the drug decreases as the pregnancy progresses. Mifegyne® can be used until the 63rd day after the beginning of the last menstrual period .

It should be noted that even in case of a medical abortion, a legal consultation followed by a waiting period of three days is prescribed by law. Women who are considering an abortion with medication must therefore seek advice at the latest at the beginning of the ninth week after the beginning of the last menstrual period.

How is Mifegyne® used?

Three visits to a doctor or clinic are required.

During the first visit, the doctor will determine how long you have been pregnant. In a personal conversation, it is clarified whether an abortion with medication can be considered. If there is nothing to argue against an abortion with medication, take three tablets of Mifegyne® under medical supervision. You will be given detailed information on whom to contact, if you have any problems (e.g. heavy bleeding). You can then leave the clinic or doctor’s office.
Sometimes bleeding occurs as early as the following day, and in three percent of cases the pregnancy tissue is expelled before prostaglandin is taken. However, most women do not feel any physical change before taking prostaglandin.
A second visit to the clinic or doctor’s office is required 36 to 48 hours after taking Mifegyne®. During this visit the prostaglandin is given. Cytotec® is taken until the 49th day of pregnancy (7^th Week) as a tablet, until 63th day (8^th -9^th week) the tablets are inserted vaginally. You will then remain under medical observation for about three hours. Most women stop taking the tablets during this time, but every fourth woman does so after more than 24 hours. In order to increase the effectiveness of the method, a second one can take place three hours after the first prostaglandin administration, if no bleeding has started until then.
The third visit to the clinic or doctor (approx. 14 days later) serves as a follow-up examination to ensure that the abortion was complete.

How effective is Mifegyne®?

The combined use of Mifegyne® with prostaglandin leads to complete abortion in approximately 96 percent of women. A second dose of prostaglandin can increase this value. If abortion was not successful or there is residual tissue in the uterus, an additional instrumental intervention is required.

What side effects or complications may occur?

Possible side effects include abdominal pain, nausea, vomiting and circulatory problems. As with any abortion, there is bleeding, but it can last up to 12 days after taking Mifegyne®. In rare cases, these bleedings require medical treatment.

When is an abortion with Mifegyne® not safe or can only be considered with special precautions?

Mifegyne® must not be used,

• if the pregnancy has not been confirmed by a doctor,
• if the pregnancy lasts longer than 63 days (calculated from the first day of the last menstrual period),
• if there is a concrete suspicion of pregnancy outside the uterus (e.g. ectopic pregnancy),
• if there is an intolerance to prostaglandins,
• if you are allergic to the active ingredient mifepristone or another component of Mifegyne®,
• if you have chronic adrenal insufficiency,
• if you have been inadequately treated or have severe bronchial asthma.
• in case of liver and kidney failure,
• in cases of malnutrition,

Women with a blood coagulation disorder should have it clarified whether the use of Mifegyne® is safe. For women who have been treated with cortisone, the dosage of cortisone must be checked when Mifegyne® is used.

If pregnancy has occurred despite the use of a coil, it must be removed before Mifegyne® is taken.

What is the legal stand?

For a medical abortion, the same legal regulations hold applicable as for an instrumental abortion, e.g. the obligation to give a consultation at the latest on the fourth day before the abortion (e.g. consultation on Monday, abortion at the earliest on Friday).

Mifegyne® may only be given in clinics or medical practices that are entitled to carry out abortions according to § 13 of the pregnancy conflict law.

How much does an abortion with Mifegyne® cost?

The statutory regulations on the reimbursement of costs for women who have no or only a low income of their own are also valid for the treatment with Mifegyne®. The costs for private billing correspond to those for instrumental termination. In case of medical or criminological indications, the health insurance companies will cover all costs.

Which aspects can play a role in the decision for or against a medical abortion with Mifegyne®?

Previous experience with medical abortions has shown that different aspects are important for women, for example:

• Abortion is possible at a very early stage of pregnancy.
• As a rule, anaesthesia and instrumental intervention are not necessary.
• There is no risk of injury to the uterus.
• Mifegyne® must not be taken after the 63rd day .
• The medical abortion lasts longer than the instrumental intervention. The bleeding can last up to 12 days.
• There is a prolonged uncertainty as to whether and when a complete abortion will occur at all.
• A medical abortion is similar to a miscarriage.
• The aspects mentioned here and the active role of the woman (by taking medication) can lead to a different mental processing, to a more intensive examination of the abortion, for example.

Since you can become pregnant again shortly after an abortion with medication, you should use an effective contraceptive method as early as possible.

The cost of an abortion

If you are insured with a statutory health insurance company, only a small part of the costs can be settled with a sickness certificate, namely

• medical advice before abortion,
• Pre- and post-operative medical services and medicines, where health protection is a priority

The costs for the actual abortion are not covered by the health insurance. The costs to be borne by you amount to approximately 350 to 600 € depending on the practice, method and insurance. If you are admitted to hospital, you have to pay the daily rate yourself.

If you only have a small income of your own (currently €1,446 net; the limit increases by €343 for each child living in the household, as well as for rent charges of more than €405, up to a maximum of €424), you can, however, submit an application to cover the costs. The costs are borne by the federal state in which you live, but you must apply to your health insurance company.

• You must apply to your health insurance company for the costs to be covered before the abortion and have them confirmed to you in writing. You need the written consent for the doctor who is to perform the procedure.
• You do not need to justify the abortion. The company may only demand that you "credibly" prove your personal income and financial circumstances.
• Whether the company covers the costs of the surgery depends solely on the amount of your own income and assets. The income of your husband, parents or other breadwinners is irrelevant.

Even if you are not covered by a statutory health insurance company, you can still apply to a statutory company of your choice in your place of residence to cover the costs of the actual intervention. The prerequisite is that

• your income and assets are below the legal limits, or
• that you are receiving social assistance or are a person applying for asylum, for example.

More detailed information about the income limits in individual cases and about the procedure can be obtained from recognised counselling centres or from a health insurance company.

If you are put on sick leave after your abortion, you are entitled to continued payment of wages or salaries. As in other cases of sickness, you are not obligated to inform your employer of the reason for your absence.

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Termination of pregnancy with indication

An abortion with indication differs legally from an abortion according to the consultation rule. Abortions with indications
not only remain unpunished, but are also justified in the legal sense.

Abortion with medical indication

If the woman's life or physical or mental health is seriously endangered by pregnancy, an abortion with medical indication can be performed
.

A medical indication can also be considered if, after prenatal diagnostic
examinations, a considerable damage to the child's health can be expected. In this situation, it depends on whether your physical or mental health is seriously endangered by going through with the pregnancy.
The indication must be provided by a doctor. Whoever issues a medical indication is obligated to inform the woman in full details and also tell about possible offers of help
and to mediate contact with counselling centres in agreement with the pregnant woman.

If prenatal diagnostic examinations indicate damage to the child's health, the pregnant woman must also be advised on medical, psychological and social issues that may be related to the child's possible illness. In addition, the doctor must establish contact with self-help groups or associations for the specially abled persons, if the woman agrees. Consultation with the doctor is voluntary for those affected and can also be refused
.

If there is a medical indication, there is no legal deadline for the week of pregnancy. However, the doctor has to wait three days before he or she can start the treatment
. In case of prenatal diagnosis the days are counted from the date of the diagnosis; in case of other medical indications, the days are counted from the time of consultation
with the doctor who issues the indication. This period does not hold applicable, if there is an acute danger to the life of the pregnant woman.

Abortion with criminological indication

If the pregnancy is very likely due to a crime, the pregnancy can be terminated with a criminological indication.  This is the case, for example, if a woman has become pregnant through rape, or a girl who is under 14 years of age. The indication is given by a doctor - and not by the public prosecutor's office or the police. For a criminological indication, it is not necessary for the crime to be reported.

For criminological indications, there is no obligation for counselling.
However, the counselling services are also available for this indication.
In case of a criminological indication, abortion may only continue until the end of the twelfth week after fertilisation (14th week of pregnancy).