Balancing autonomy and collaboration: Acompañantes’ perspectives on health system partnerships for medication abortion care in three Mexican states

Acompañantes are feminist activists who accompany pregnant individuals through medication abortions outside of clinical settings. This model is safe, holistic, and destigmatizing. In Mexico, where abortion law varies by state and access to public services is limited, self-managed medication abortion with acompañantes is common. This study examines how acompañantes perceive their relationship with the public health system, exploring collaboration opportunities and challenges. We conducted semi-structured interviews with acompañantes from Baja California, Chiapas, and Mexico City—Mexican states with diverse abortion laws, in 2022-2023. The World Health Organization’s Health System Strengthening framework guided the analysis, focusing on stakeholder engagement and innovation. We analyzed the interviews using a qualitative, codebook thematic approach, incorporating both deductive and inductive methods. Seventeen interviews with acompañantes revealed key themes: 1) Acompañantes expressed a tension between operating autonomously and seeing value in collaboration —but not integration— with the formal system for legitimacy, validation, and to improve care experiences for people who access abortion; 2) In a health system where person-centered care is lacking, acompañantes fill this gap and feel a responsibility to do so; and 3) Knowledge gaps, trust issues, and political differences are barriers for acompañantes collaborating with the public health system. Aligning acompañante-supported self-managed abortion with institutional services presents challenges but also opportunities for enhancing care quality and accessibility. Innovative collaborations that respect acompañantes' autonomy and expertise, while addressing systemic barriers, could strengthen health systems and align with WHO guidelines for safe self-managed abortion, including health system referrals if needed or wanted.