Supporting self-managed abortion care in "practice not premise": provider perspectives, roles, and referral pathways in india

We aimed to describe provider beliefs, opinions, and roles in self-managed abortion (SMA) provision and identify referral pathways to facility- and self-managed abortion care in India. We analyzed 33 semi-structured interviews with healthcare providers: pharmacy workers, unlicensed local providers, accredited social health activists (ASHAs), auxiliary nurse midwives (ANMs), and registered medical providers (RMPs) in India. We coded transcripts, conducted a thematic analysis, and identified mentions of referrals including the type of provider, the abortion care modality (facility- or self-managed), and the reason. Providers’ perception of SMA safety and liability concerns resulted in discouraging clients from seeking an SMA, instead promoting the use of contraceptives or facility-managed abortion. Nonetheless, participants acknowledged three areas were providers played a role in SMA provision: describing usage and potential side effects, dispensing medication, and managing pain. LPs and pharmacy workers described usage and dispensed medications, while LPs and ASHAs described potential side effects and managed pain. ANMs and RMPs did not provide direct care to SMA clients in the community. All provider types described referrals pathways to a facility-managed abortion. Despite provider concerns, SMA care and referrals occur in India. Understanding the complex dynamics of provider roles, opinions, and referral practices can inform comprehensive reproductive health policies and interventions that promote client-centered abortion care—including SMA—and address provider concerns. These findings have implications in the US as legal restrictions increase and there is a need for synergies between the health system and SMA care networks.