Status, barriers and facilitators of comprehensive abortion care services in rural India: A multicenter mixed-methods study protocol.

BACKGROUND: Unsafe abortion continues to be a significant cause of avoidable maternal morbidity and mortality especially in low- and middle-income countries. Despite India's permissive Medical Termination of Pregnancy (MTP) Act, operational gaps continue to prevent women from accessing safe abortion services. There is still a dearth of multi-centric mixed-methods research from rural areas on women's experiences, provider perspectives, and facility readiness. This study aims to assess the status of comprehensive abortion care (CAC) in rural India by evaluating public-sector facility preparedness, provider experiences, care-seeking pathways, and identifying key barriers and facilitators as per CAC guidelines (2023). The findings will guide the development of a preliminary implementation approach (Model 0+) as well as future phases focused on testing, adaptation, and scale up to strengthen CAC availability, quality, and uptake.

METHODS: This study employs a convergent mixed-methods design across six geographically varied rural blocks in India (North, South, East, West, Central, and Northeast). There will be two participant groups: married women aged 18-49 years who are current, previous, or potential abortion service users, and public health system stakeholders involved in Comprehensive Abortion Care (CAC). A multistage cluster survey will enroll approximately 854 married women per site across 20 clusters. The qualitative component will comprise interviews with women who have had abortions in the last two years and healthcare practitioners, for a total of around 240 interviews. Additionally, 18 focus group discussions with Accredited Social Health Activists and Anganwadi Workers (three per site), will capture frontline worker's perspectives. Quantitative data will be collected using KoboCollect and analysed using STATA (or an equivalent statistical software). Qualitative data will undergo combined phenomenological and thematic analysis using NVivo or equivalent software.

DISCUSSION: This study constitutes the first phase of a multi-stage implementation research programme. The study builds upon national CAC guidelines as a foundation of implementation of "Model 0" for abortion care and assesses their functioning in routine public-sector settings. Insights from women, frontline workers, and providers will inform development of a refined implementation strategy ("Model 0+") grounded in real-world contexts. This evidence-driven approach is expected to yield a practical, acceptable, and scalable model for subsequent piloting, adaptation, and wider health system uptake.