{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,9,16]],"date-time":"2026-09-16T18:05:12Z","timestamp":1789581912018,"version":"build-2803163510"},"reference-count":21,"publisher":"Public Library of Science (PLoS)","issue":"9","license":[{"start":{"date-parts":[[2026,9,16]],"date-time":"2026-09-16T00:00:00Z","timestamp":1789516800000},"content-version":"vor","delay-in-days":0,"URL":"http:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"funder":[{"DOI":"10.13039\/501100001411","name":"Indian Council of Medical Research","doi-asserted-by":"publisher","award":["5\/7\/Intramural\/Dr_Bijaya_Mishra Subject:Comprehensive Abortion Care Comprehensive Abortion Care Electronic file , with computer number 237753, with File number 5\/7\/Intramural\/Dr_Bijaya_Mishra, having subject Comprehensive Abortion Care. It has 51 notes and 11 correspondences"],"award-info":[{"award-number":["5\/7\/Intramural\/Dr_Bijaya_Mishra Subject:Comprehensive Abortion Care Comprehensive Abortion Care Electronic file , with computer number 237753, with File number 5\/7\/Intramural\/Dr_Bijaya_Mishra, having subject Comprehensive Abortion Care. It has 51 notes and 11 correspondences"]}],"id":[{"id":"10.13039\/501100001411","id-type":"DOI","asserted-by":"publisher"}]}],"content-domain":{"domain":["www.plosone.org"],"crossmark-restriction":false},"short-container-title":["PLoS One"],"abstract":"<jats:sec id=\"sec001\">\n                    <jats:title>Background<\/jats:title>\n                    <jats:p>Unsafe abortion continues to be a significant cause of avoidable maternal morbidity and mortality especially in low- and middle-income countries. Despite India\u2019s 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\u2019s 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.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec id=\"sec002\">\n                    <jats:title>Methods<\/jats:title>\n                    <jats:p>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\u201349 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\u2019s 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.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec id=\"sec003\">\n                    <jats:title>Discussion<\/jats:title>\n                    <jats:p>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 \u201cModel 0\u201d 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 (\u201cModel 0+\u201d) 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.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.1371\/journal.pone.0358274","type":"journal-article","created":{"date-parts":[[2026,9,16]],"date-time":"2026-09-16T17:52:45Z","timestamp":1789581165000},"page":"e0358274","update-policy":"https:\/\/doi.org\/10.1371\/journal.pone.corrections_policy","source":"Crossref","is-referenced-by-count":0,"title":["Status, barriers and facilitators of comprehensive abortion care services in rural India: A multicenter mixed-methods study protocol"],"prefix":"10.1371","volume":"21","author":[{"given":"Subhanwita","family":"Manna","sequence":"first","affiliation":[{"name":"ICMR","place":["New Delhi, India"],"department":["Division of Reproductive, Child Health & Nutrition"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Bijaya Kumar","family":"Mishra","sequence":"additional","affiliation":[{"name":"ICMR-National Institute of Health Research","place":["Bhubaneswar, Odisha, India"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Krishna Kant","family":"Yadav","sequence":"additional","affiliation":[{"name":"Society for Applied Studies","place":["New Delhi, Delhi, India"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0009-0005-4099-1608","authenticated-orcid":true,"given":"Pratibha","family":"Dhiman","sequence":"additional","affiliation":[{"name":"ICMR","place":["New Delhi, India"],"department":["Division of Reproductive, Child Health & Nutrition"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0009-0005-6071-7294","authenticated-orcid":true,"given":"Smiteerekha","family":"Sahoo","sequence":"additional","affiliation":[{"name":"ICMR-National Institute of Health Research","place":["Bhubaneswar, Odisha, India"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Chiranjeet","family":"Mishra","sequence":"additional","affiliation":[{"name":"ICMR-National Institute of Health Research","place":["Bhubaneswar, Odisha, India"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Tanveer","family":"Rehman","sequence":"additional","affiliation":[{"name":"ICMR-National Institute of Health Research","place":["Bhubaneswar, Odisha, India"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Ranjan Kumar","family":"Prusty","sequence":"additional","affiliation":[{"name":"ICMR-National Institute For Research in Reproductive and Child Health","place":["Mumbai, India"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Ragini","family":"Kulkarni","sequence":"additional","affiliation":[{"name":"ICMR-National Institute For Research in Reproductive and Child Health","place":["Mumbai, India"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Mahadev","family":"Bhise","sequence":"additional","affiliation":[{"name":"ICMR-National Institute For Research in Reproductive and Child Health","place":["Mumbai, India"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Ashok Kumar","family":"Pandey","sequence":"additional","affiliation":[{"name":"ICMR-National Institute of Health Research","place":["Gorakhpur, Uttar Pradesh, India"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-0971-5067","authenticated-orcid":true,"given":"Ravikumar","family":"B. S.","sequence":"additional","affiliation":[{"name":"ICMR \u2013 National Institute of Traditional Medicine","place":["Belagavi, Karnataka, India"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Ipsita Pal","family":"Bhowmick","sequence":"additional","affiliation":[{"name":"ICMR-Regional Medical Research Centre","place":["Dibrugarh, Assam, India"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Subrata Kumar","family":"Palo","sequence":"additional","affiliation":[{"name":"ICMR-National Institute of Health Research","place":["Bhubaneswar, Odisha, India"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-7763-1685","authenticated-orcid":true,"given":"Narayana Swamy","family":"D. M.","sequence":"additional","affiliation":[{"name":"ICMR-National Institute of Health Research","place":["Bhubaneswar, Odisha, India"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Neha","family":"Srivastava","sequence":"additional","affiliation":[{"name":"ICMR-National Institute of Health Research","place":["Gorakhpur, Uttar Pradesh, India"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Umaer","family":"Alam","sequence":"additional","affiliation":[{"name":"ICMR-National Institute of Health Research","place":["Gorakhpur, Uttar Pradesh, India"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Reeta","family":"Singh","sequence":"additional","affiliation":[{"name":"ICMR-National Institute of Health Research","place":["Gorakhpur, Uttar Pradesh, India"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Manish","family":"Barvaliya","sequence":"additional","affiliation":[{"name":"ICMR \u2013 National Institute of Traditional Medicine","place":["Belagavi, Karnataka, India"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Vani","family":"Kandpal","sequence":"additional","affiliation":[{"name":"ICMR","place":["New Delhi, India"],"department":["Division of Reproductive, Child Health & Nutrition"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-4574-580X","authenticated-orcid":true,"given":"Barsha","family":"Gadapani Pathak","sequence":"additional","affiliation":[{"name":"Society for Applied Studies","place":["New Delhi, Delhi, India"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-9754-5637","authenticated-orcid":true,"given":"Reema","family":"Mukherjee","sequence":"additional","affiliation":[{"name":"ICMR","place":["New Delhi, India"],"department":["Division of Reproductive, Child Health & Nutrition"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Sanghamitra","family":"Pati","sequence":"additional","affiliation":[{"name":"ICMR-National Institute of Health Research","place":["Bhubaneswar, Odisha, India"]}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"340","published-online":{"date-parts":[[2026,9,16]]},"reference":[{"issue":"2","key":"pone.0358274.ref001","first-page":"122","article-title":"Unsafe abortion: unnecessary maternal mortality","volume":"2","author":"LB Haddad","year":"2009","journal-title":"Rev Obstet Gynecol"},{"issue":"6","key":"pone.0358274.ref002","article-title":"Global causes of maternal death: a WHO systematic analysis","volume":"2","author":"L Say","year":"2014","journal-title":"Lancet Glob Health"},{"key":"pone.0358274.ref003","unstructured":"WHO WHO. 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[cited 2026 Jan 16]. https:\/\/www.google.com\/search?q=Medical+Termination+of+Pregnancy+Act%2C+No.+34+of+1971.+Govt.+of+India%3B+10+Aug+1971.+Available+from%3A+https%3A%2F%2Fwww.indiacode.nic.in%2Fbitstream%2F123456789%2F6832%2F1%2Fmtp-act-1971.pdf+&rlz=1C1GCEA_en-GBIN1163IN116"},{"key":"pone.0358274.ref007","unstructured":"Govt. of India. Medical Termination of Pregnancy (Amendment) Act, No. 8 of 2021. 2021. https:\/\/prsindia.org\/files\/bills_acts\/acts_parliament\/2021\/Medical%20Termination%20of%20Pregnancy%20Amendment%20Act%202021.pdf"},{"key":"pone.0358274.ref008","unstructured":"Health Division MOHFW G of I. Comprehensive Abortion Care- Training and Service Delivery Guidelines. 2018. https:\/\/nhm.gov.in\/New_Updates_2018\/NHM_Components\/RMNCHA\/MH\/Guidelines\/CAC_Training_and_Service_Delivery_Guideline.pdf"},{"key":"pone.0358274.ref009","unstructured":"Health Division MOHFW G of I. 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