Addressing unsafe abortion in India: A mixed-methods systematic review protocol

Unsafe abortion remains a critical public health challenge globally and in India, despite the legal provision under the Medical Termination of Pregnancy (MTP) Act for over 50 years. Multiple barriers -including limited access to trained providers, inequities in health facility readiness, stigma, poor awareness of legal entitlements, and widespread reliance on self-managed medical abortion- contribute to unsafe practices, which result in preventable maternal morbidity and mortality. Evidence on hazardous abortion in India is fragmented across facility-based studies, community surveys, and qualitative research. This protocol outlines methods for a mixed-methods systematic review integrating quantitative and qualitative data to comprehensively assess the prevalence of unsafe abortion, its determinants, associated morbidities, decision-making pathways, and the role of providers, methods, and settings.

The review will include quantitative, qualitative, and mixed-methods studies conducted in India and published from 1972 onwards. Eligible quantitative designs include surveys, cross-sectional, cohort, case-control, quasi-experimental studies, randomised controlled trials, and hospital series with at least ten instances. Qualitative designs will include studies using interviews, focus groups, ethnography, or participatory approaches. Mixed-methods studies will be eligible if India-specific results can be extracted. The electronic databases to be searched include PubMed/MEDLINE, Embase, Scopus, Web of Science, CINAHL supplemented by grey literature from WHO, UNFPA, the Ministry of Health and Family Welfare, and other national sources. Two reviewers will independently screen studies, extract data, and appraise quality. The Newcastle - Ottawa Scale will be used for observational studies, the Cochrane RoB 2 tool for trials, the Critical Appraisal Skills Programme (CASP) or Joanna Briggs Institute (JBI) checklists for qualitative studies, and the Mixed Methods Appraisal Tool (MMAT) for mixed-methods studies. Quantitative data will be synthesised using random-effects meta-analysis, while qualitative findings will be analysed through thematic synthesis guided by abortion decision-making trajectories. Integration will follow a convergent segregated design.

This review will generate an integrated synthesis of unsafe abortion in India, including prevalence, morbidities, determinants, women's decision-making, and the contextual role of providers and settings. Findings may inform national policy, programmatic interventions, and strategies to strengthen Comprehensive Abortion Care under the National Health Mission. Anticipated challenges include heterogeneity in definitions of "unsafe abortion," variation in outcome measures, and gaps in subnational data. Despite these limitations, the review will provide essential evidence to guide policy and improve women's health outcomes.

This protocol is reported in accordance with PRISMA-2020 guidelines and has been registered with the Open Science Framework (OSF). [https://doi.org/10.17605/OSF.IO/R4JPT].