Ensuring an enabling environment for abortion self-care: individuals' experiences with self-managed abortion in India

India was one of the first countries to codify the right to abortion care under specific conditions. Yet an estimated three-quarters of all abortions in India are self-managed medication abortion (SMA). We analysed individual experiences with SMA to inform programmes and policy in India.

From January to August 2022, we conducted in-depth interviews with people who had SMAs (N=43) between 2016 and 2021 and with individuals who supported someone in their family with SMA (N=11). We used community-based, facility-based and online recruitment to identify potential participants across six states in India. Interviews were conducted in English, Hindi or Tamil. Transcripts were analysed using thematic analysis. To facilitate usefulness for programme and policy-making, we mapped findings to four domains of the WHO's Enabling Environment framework for self-care: information; psychosocial support; health workforce and freedom from violence, stigma, coercion and discrimination.

Participants described information gaps on recommended medication regimens, expectations of physical symptoms and identification of abortion completion or warning signs. Misinformation about physical symptoms or the safety of abortion medication was widespread. These issues caused emotional distress and uncertainty about care-seeking. Many SMA users received highly valued psychosocial support from friends or family. Participants had positive interactions with unlicensed local providers (LPs) or accredited social health activists along their entire abortion trajectory, while experiences with pharmacists or facility-based health workers, particularly at public facilities, were described negatively. Fear of being judged by their community left many feeling isolated and inhibited in care-seeking. Stigma towards unmarried women posed barriers to receiving medication. Some participants reported reproductive coercion.

Abortion stigma in the health system, particularly within public facilities, must be addressed to create a more enabling self-care environment. Training community health workers to provide community-level comprehensive and accurate information about medication regimens, experiences and warning signs could improve abortion experiences.