My Year As an Abortion Doula

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Welcome to Ovaries Week — the Cut's exploration of the female reproductive system, in its many confusing, intense, sometimes challenging, sometimes funny, often surprising facets. 

My first patient ever stares at me blankly when I say the doctor will see her soon. Her two small children treat the waiting room chairs like monkey bars; they’ve been sitting around for hours. Dee (some names have been changed throughout) is here to get laminaria inserted, the small seaweed sticks positioned in the cervix that expand upon contact with moisture, producing enough dilation to enable a second trimester abortion, which will happen tomorrow. I know I’m not succeeding at giving her the warm, confident assurance I’ve practiced in the mirror.

I stand by her head as she spreads her legs. She begins to moan, softly and then without control. “You’re doing great,” I tell her, clenching my jaw, smiling still. Through her moans I hear one doctor tell the other that there’s too much blood. They call for a hospital transport and tell her they’re going to do the abortion today, right now. Then we’re running across the hospital floor as the doctors yell for people to move out of the way. It’s my first day, but I know enough to know that this is serious. I keep my hand on Dee’s, murmuring words of support. Once she’s under anesthesia, I get out of the way, stand in the back, hope that I can handle this.

I’m in a large public hospital in Manhattan, volunteering as an abortion doula with an organization called the Doula Project. My role is to provide women with emotional and physical support, offer comfort or distraction, answer their questions, and, most of all, just be with them during their first or second trimester abortions. A year ago, when I was still in college, I got the idea to apply for the job when my roommate told me about her childhood friend Elise. Raised in a conservative, Catholic family in a wealthy Boston suburb, Elise had an abortion in high school and was harassed by classmates, churchgoers, and townspeople. Now she was volunteering as an abortion doula in New York. I’ve considered myself pro-choice since sixth grade when I learned the word, and I had manned the phones at the NARAL office in downtown New York when I was in high school. But I had never been anywhere near an abortion clinic. I had no idea what to expect.

The resident begins to perform the procedure as the attending barks commands. “Pull,” she says, “harder.” The body does not want to let go. The resident will not stop. It strikes me as strangely similar to birth, only the opposite word and a different outcome. Pull. Pull. Pull. What’s called the products of conception bucket is mostly filled with bloody gunk. I make out a doll-size arm, fist curled. It feels like I shouldn’t look, but I can’t turn away. 

After the abortion, the attending fishes through the bucket to make sure everything is out. The doctors finish but the bleeding doesn’t. They have to cut into Dee’s abdomen to get a clearer picture of what was going on. I watch in awe as they pull back the skin. I’ve never seen a body like this, bright and wide open. Eventually, they have to remove the uterus; there isn’t any other way.

In the hallway, I stumble a bit, groping at the wall, slide down until I’m seated. A janitor comes by and points out the nearest bathroom, which I walk to slowly. I lock the door, splash water on my face, and sit on the toilet. In the days and weeks to come, I get used to the stirrups, the anxiety, the questions, and nipples the size of dimes, clementines, Coke cans. There is a routine to the work. But this one, so rare it gets the med students keyed up, is the beginning, the first abortion I’ve ever seen.

Women have historically supported other women through the process of childbirth, so the work of birth doulas is nothing new. But when birth doulas Lauren Mitchell and Mary Mahoney sought to bring those support practices into abortion clinics, they met immediate resistance. “To imply that women getting abortions would need something as touchy-feely as support was not accepted,” Mitchell explains. Some birth doulas were reluctant to consider the needs of women terminating pregnancies as at all similar to their patients carrying them to term. And many pro-choice doulas, doctors, and nonprofits were unwilling to acknowledge how difficult and painful many women find abortion. To some on the left, drawing any more attention to the messiness of the procedure and the decisions surrounding it would mean potentially undermining the work of the political movement.

But in 2007, Mitchell and Mahoney founded the Doula Project, partnering with a clinic where women could seek low-cost, first-trimester abortions. With the help of three friends, they began taking on shifts, drawing from the skills — relaxation methods, techniques for helping women advocate for themselves — they developed as birth doulas. It made what can be a painful and nerve-wracking procedure easier for both patients and doctors. A year later, they worked out a deal with a public hospital with the facilities to provide abortions up to 24 weeks, the legal limit in New York. This hospital, which is where I often do my shifts, frequently takes on clients who are high risk or have complications. Around 80 doulas work in shifts to cover all of the first- and second-trimester abortion patients, in addition to the laminaria insertion. (Doula Project volunteers also work with low-income birth patients, adoption cases, and women who are still deciding what to do about their pregnancy.) There are now ten abortion doula organizations around the country, most of them in Southern states, where safety concerns are greater and the prevailing anti-abortion political and religious views put added pressure on women seeking abortion.

A year ago, when I was just starting out, Mitchell met with me and the other trainees to talk about the job. We sat in the park, eating pie. She gave us a sheet with situations so exaggeratedly horrible they seemed unreal: An 11-year-old in for an abortion who asks for birth control when she’s alone with the doctor. Her mother works nights; she’d been left with a friend who has a twentysomething son. She calls him her boyfriend; he will go to jail. A woman who says she’d like to do another ultrasound to see if it’s definitely a girl, because she’ll only keep it if it isn’t. A drug addict covered in track marks with two kids in the foster-care system who refuses birth control.

“What do you assume?” Mitchell asked of each case. “How can you be supportive?” We talked about what would be hard for us to overcome, things we might say or do and how we might feel. I felt embarrassed by my assumptions, and the limits of my compassion. I judged these women on the worthiness of their reasons (“Would she really only keep a boy?” I wondered) and found myself questioning why those who come in for late-term abortions had waited so long to decide. Later, I learned from Mahoney that all the examples were real cases that had come from her first six months working as an abortion doula.

In the hospital, I’m not anyone important — I don’t even know how to insert an IV — but I spend the most time with the patients, so I almost always have their trust. Before I became an abortion doula, I couldn’t imagine wanting some stranger to hold my hand or stroke my hair, but past the waiting room, it makes more sense. One day, a particularly terrified patient asks if she can ask me something. “Will they still be able to do it if my heart is beating real fast like this?” she says, watching my eyes for signs that I am lying. I tell her yes.

The pain is unbearable, or it isn’t. For a first-trimester abortion, patients are awake, with a local or moderate anesthesia. They feel everything and hear everything, but the anesthesia takes the edge off. Sometimes women forgo moderate anesthesia because they don’t have anyone whom they can ask to bring them home afterwards as the clinic mandates. Second-trimester abortions happen in an operating room, under full anesthesia. They take longer and they’re preceded by laminaria, those seaweed sticks, which often cause a lot of discomfort in the days leading up to the abortion. I meet most of my patients the day of their abortion. Some days I have just one patient; some days as many as 15. Because of shift scheduling, more than half of the women I work with are there for second-trimester abortions, but statistically they're in the vast minority. Nearly nine in ten abortions happen in the first trimester.

Some of the first-trimester patients scream and cry and shake. Others remain calm, barely seem to register any pain, are thrilled to have it over with. A Zales representative tries to sell me on their various collections. She doesn’t wince at all during the abortion. When it’s over, she thanks everyone, tells us which store she works in, and offers us all a discount. I find it hardest to tend to the patients who don’t seem to struggle. It’s not that I’m judging them: Pain breaks down barriers, and without it, I’m more hesitant to touch, less certain of my role.

Vicki Bloom, who does birth and abortion work in New York, told me that newly trained doulas are much more likely to assume certain things about how patients are feeling, but seeing tears on the table doesn’t mean the patient is having an emotional response — sometimes it just physically hurts. “There are people who can say, ‘I made this decision it was kind of tough; it was a really crappy day, but life goes on,’” Bloom explains.  Not everyone needed my help. These women reminded me what I sometimes forgot, which is that an abortion is, above all else, a medical procedure.    

Some of the doulas and some of the patients believe in astrology. Mitchell had said that it was a great thing to talk to patients about because everyone loves hearing about themselves, but I never memorized all the signs. Instead, I default to the Kardashians, whom most patients either love or hate. Waiting for the doctor, we exchange theories, discuss which sister is the most annoying, and debate whether anything on the TV show is real. We also talk about what food they will eat when they’re out, since they’ve been fasting since midnight to meet anesthesia requirements. To the morning patients, I say, “Well, at least you’re not in the afternoon.” To the afternoon patients, I just say, “You’ll be able to eat soon.” The doulas I talk to in North Carolina tell their patients the protestors will be gone by the time they leave.

Before the first-trimester procedures start, the doctor tells the patient to open her legs wide. “Let your legs fall open like a book,” they say. It usually takes two or three rounds of encouragement before their legs are spread enough to begin. One patient, just in her teens, says, “This is so awkward.” After it’s over, the patient is given a pad and transferred to a La-Z-Boy chair with wheels. When the patients stand, I see the blood stains on the white paper, a little or a lot. I step between them and the bed, to block their view of the blood.

But I can’t take away the sound. Most first-trimester abortions are vacuum aspiration. The machine sounds like a sucking through a straw when you’re at the bottom of the glass. The vacuuming is sometimes painful, but I think patients find the sound harder to bear. LiteFM stations play in the background. Most first-trimester abortions take fewer than four songs. Sitting in bars with my friends on summer nights, I hear the same songs and wonder after the women.

Honesty is a core principle of being a doula. But I quickly learn that you do whatever you need to and mostly that is to tell the truth, but sometimes you are dishonest. In the beginning, I shadow a more experienced doula as she reassures a patient that the woman in the next room screaming wildly is not here for the same procedure, though, of course, she is. Sometimes kindness is more important than truth, but if a patient wants to know how big the fetus is, I won’t lie.

For many low-income women, getting an abortion can feel like the only option. A doula tells me a story about a woman who wanted to continue the pregnancy but had lost her job, run through all her savings, and was living in a homeless shelter. “I can deal with this, but I’d never do it to a baby,” she said. Patients talk about how impossible it is to find jobs, child care, a safe place to live, health care.  (Many of my patients, in addition to being near or below the poverty line, were also minorities; women of color are more likely to face unintended pregnancies and have abortions than their white counterparts.) One patient tells me that her 10-year-old son sits inside their apartment all summer because she is working. He is bored and lonely, he begs to go to the park, but he isn’t old enough to go alone. “That must be hard to deal with,” I say. “It’s just how it is,” she answers, and shakes her head. She can’t afford another child. At first, I was afraid to ask the mothers who come in about their kids — I assumed it was the last thing they’d want to talk about in that circumstance — but they were almost always eager to share stories, how they picked names, and whether the youngest was walking, or teething, or getting into trouble.

Every abortion doula I spoke to mentioned the initial surprise of seeing so many children in the consult waiting room and women coming in for laminaria with a stroller and a sleeping toddler. So much silence surrounds that choice. In some cases, these mothers felt they had to hide the abortion from friends and family. 

Mia, in her late 20s, tells me about her son; he’s sweet but a handful. She is here for a second-trimester abortion. I learn over my months in the hospital that there are all kinds of women who find themselves waiting until the second trimester: They can’t get the funds together or the time off work. Their partner commits to raising a child and then suddenly bails. Mia had waited this long because she wasn’t sure what she wanted to do, or how the men in her life would respond: She has a boyfriend, but the baby might not be his. They decided together that they weren’t ready for another child, but that morning, he’d told her that maybe she shouldn’t do it, that they could keep it.  She looks at me and asks, “I can’t, though, right?”

“No one’s going to make you do anything you don’t want to do,” I say. “But,” she says, “what would happen?” Since she’s already done laminaria, it’s unclear what would happen if she stops at this point. I don’t know and I tell her as much.

The doctor comes with a troop of med-school students trailing behind her. She introduces herself, asks a number of routine questions, and then, “Are there any questions you have for me?” The patient shakes her head, no. They leave. I say, “I’ll be right back” and hurriedly follow to talk to her about what Mia told me.

The doctor goes back into the room to talk to Mia. “No one is going to be mad if you decide not to have it,” she says warmly. “Do you want to talk about your options?” “Yeah,” Mia says, looking a bit sheepish.

There are three possible outcomes, explains the doctor, if they remove the laminaria and she continues with the pregnancy. “The baby could be born totally normal, or with a lot of developmental delays. These could be short or long term; there’s really no way to know.” Mia nods her head and decides. “I wouldn’t want it to be born in pain or anything. I want to have the abortion.” I’m struck by how her words don’t make sense, and also do. That aborting this fetus is preventing her baby from experiencing pain. I don't know what she wants and I don't know that she does, either.

I’ve been taught to follow the patient’s lead. If she calls it her baby, then I do too. But with the next patient, just as far along, it’s fetal tissue, it’s the products of conception. One stumbles over her words, says “all the stuff inside,” and that feels right, too. 

I meet a woman with recently diagnosed fetal abnormalities for her abortion. She is devastated; her husband is impatient. Since she’ll be out for the second-trimester abortion, she’s hoping that the doctors will take some pictures of her baby. They try to remove the fetus intact, but it isn’t possible. There will be no pictures.

The doulas I talk to about their work say things like, “I’d only say this to another doula because I know you’ll understand.” I think it’s because we’ve all seen the tiny ear whorls, the patients who have second thoughts, and the ones who get abortions for reasons that make you feel uncomfortable. These images are the stuff of pro-life campaigns, the ones that try to make women change their minds.

“I’ve had some loaded feelings,” Lauren Mitchell admitted of her seven-plus years working with women getting abortions. “People have heard me talk and said, ‘You don’t sound like you’re super pro-abortion.’ They just don’t expect a complex view.” Mary Mahoney, her co-founder, explains that such sentiments — a mix of sadness and frustration — are pretty normal given the work they do. “You see 500 abortions, a thousand abortions, of course you’re going to have a lot of feelings. That’s okay,” she says with a shrug. Symone New told me that, since she started working as an abortion doula with the Doula Project a few years ago, she’s changed the way she talks about abortion. “My political self is like, 'Yes, this is liberatory; it’s so great we have this right to make this decision,' but I’ve dropped the pro-choice, third-wave feminist diatribe when dealing with patients.” She’s seen religious patients praying on the table, pro-life women getting abortions after discovering fetal anomalies, and others who think abortion is wrong, but get one anyway. The reality of abortion isn’t as tidy as the divide surrounding it.

Like a lot of the doulas I spoke to, New is concerned that the pro-choice movement’s reliance on positive narratives about abortion, born of a sense of protection, is actually counterproductive. Necessary as it might seem in an era during which abortion rights are being severely limited in many parts of the country, sticking to an uncomplicated script isolates and silences patients who struggled with their abortions, even if they know getting an abortion was the right choice. “My most recent client wouldn’t call this liberatory and she canceled her appointment twice before coming in,” she tells me, “but she’ll be the first one to tell you that this is exactly what needed to happen.”

For the women — and girls — I work with as an abortion doula, this is what needed to happen. During her procedure, one young woman moans in pain, yells out “Mommy!” The nurse looks away; the doctor doesn’t say anything. I know she is embarrassed. Eliana is 16 and dating an older guy who’s abusive. She doesn’t tell her parents about the boyfriend or the pregnancy, and had a hard time getting the money together. In recovery, I pass her an ice pack for the cramping and ask her how she feels. "I'm so glad it's all over," she says, "I can't, I don't ... I don't know what I would have done." If she finishes school, she has a chance at a job that pays decently, at the life she wants. Another patient asks, “Do you think I’m too young for an abortion?” I tell her no; I think she’s making a really responsible choice. She looks at me, says, “Do you even know how old I am?” I shake my head no. “I’m 14,” she says.

I come in one morning looking for a patient named Princess. She labors as if giving birth; two days of laminaria have expanded her cervix. “Put your legs down,” the nurse orders. “Don’t push!” she says, as if it is easy. “Hi,” I say, still nervous around the hospital nurses. “I’m her doula.” The nurse rolls her eyes and says, “Good, she’s gonna need it.” I do deep breathing exercises with Princess for an hour, and finally she sleeps. They isolate her to another room, occasionally coming to see that she is okay. She snores lightly and I do stretches by her bedside.

She is my age, 23, and I try to imagine how I would handle cramps rippling through my body, pushing out what I couldn’t have or didn’t want. Princess wakes and the pain is worse. They’ve pushed back her second-trimester abortion because of an emergency case in front of it. She’s been here all day waiting. Soon, I keep telling her, that’s what the doctors tell me. Hours pass. Finally, we bring her to the operating floor. It is after five and nearly deserted. “It’s coming,” Princess says, “stuff is coming out.” I yell for the OR coordinator sitting behind the desk, ask her to get a doctor. She ambles away, slowly, and we’re left alone together, Princess and me.

A few minutes later, the OR coordinator returns. “She’s in surgery,” she says, looking at me coolly. “I need a doctor,” I say. “Please.” She goes off again, and the doctor sends an attending out to look at the patient. When we take her into the OR, she’s crying, fighting strong contractions. “You’ll get to go to sleep in just a minute, then it’ll all be over,” I say. “I know you’ve waited so long.” She grunts in response. She’s grown sick of me, rightfully, and resists my touch. They put her out.

The fetus comes out easily; they put it in the bucket and shove it near me. It is fully intact, curled on its left side, fists closed, knees bent up. He sleeps just like you, I think. Then, a second thought, an act of distancing: He looks more like an alien than a person.  

I have, by this point, seen lots of women and lots of fetuses, and the sight of the second doesn’t change my feelings about the first. The mourning for what could have been is countered by an appreciation for what is — a woman’s life, allowed to proceed as she wants it to. When it is over, I say, “You did great. You were so brave,” and I tell them they’re done now, because sometimes they don’t know. “It’s all finished,” I say.