“I was confident from the bottom of my heart that I will be fine with these medicines”: Qualitative analysis of decision-making around self-managed abortion trajectories in India

While the incidence of self-managed abortion (SMA) in India is well-documented, why the majority of abortions in India are self-managed remains largely unanswered. This qualitative study explores factors that contribute to decision-making about SMA in India. Between January and August 2022, we conducted 43 in-depth interviews with people who self-managed abortions across six Indian states, recruiting via accredited social health activists, clinic sampling frames, and social media posts. Underpinned by the Coast et al. framework, we coded and analyzed transcripts using thematic analysis and then organized factors that contributed to people's decision-making around SMA versus facility-based care. Contributing factors to people's decisions not to seek facility-based abortion care included concerns about poor treatment by providers, the unaffordability of private facility care, and fear of procedural abortion methods. Factors contributing to people's decision to seek SMA included having prior SMA experience, access to information about SMA, affordability, privacy, accessibility, and convenience. SMA is a valued option for abortion seekers in India due to perceived benefits and a desire to avoid facility-based care. Our findings highlight the need for improved person-centered abortion care at facilities and offer potential avenues for developing supportive resources for people who self-manage abortion in India.