In 2021, Kiernan Cobb was the only registered nurse working at a reproductive and sexual health clinic in Oklahoma City. It meant that when they had to be away (often at the clinic’s other branch in Kansas), they had to bring on a temporary nurse. That was never ideal because it not only involved orienting someone new every time but was also occasionally catastrophic—like the day the temp nurse walked off the job, abandoning patients and grinding the clinic to a halt.

Despite the fact that nurses are the largest group of health-care providers and abortion is one of the most common health-care procedures, nurses’ crucial role in abortion care has often been overlooked and underleveraged. When you need an abortion, a physician or other advanced practice provider (like a midwife) can empty your uterus with a procedure or prescribe abortion pills. But experts say that is often only a fraction—albeit a crucial one—of the care you may need.

What if, for instance, you are not sure what kind of abortion you want and need someone to talk you through the pros and cons of each? Who will answer your questions about pain management and medication interactions? If you need sedation, who will start your IV, provide the medications, and monitor your vital signs throughout? Who is ready with rescue meds if you have an allergic reaction? Who will hold your hand? Who will explain your options for contraception or fertility going forward?

This kind of care is provided by nurses and other health-care professionals, and it is essential to abortion access—without it, clinics can’t function. But often, conversations about access center on the number of providers who can themselves perform or prescribe abortions.

That singular focus misses a simple truth: Without a full team, particularly nurses, high-quality abortion care doesn’t exist. The problem—one that has only gotten worse with the fall of Roe v. Wade—is that there are not enough of them.

The shortage reflects a perfect storm of problems. Generally, adequate nurse staffing is an issue in many settings nationwide. And specifically, nurse education and training on abortion is extremely hard to come by.

“We haven’t optimized the workforce,” Monica McLemore, a registered nurse and professor at the University of Washington who studies reproductive health, rights, and justice. “What we teach is driven by exams and employers, as opposed to by what society needs.”

McLemore said nursing education centers the needs of acute care hospitals, where a small majority of nurses are employed. This neglects other kinds of outpatient community care, particularly abortion care, which has been stigmatized and siloed.

But it’s not just a practical function of employment. Most nurse education also tends toward conservatism, and in interviews, multiple nurses said abortion was barely mentioned in nursing school.

“Most nurses are not trained in abortion care,” Cobb said. “When I was in nursing school, we got zero training on abortion. I really pushed for it.”

The result is that even nurses like Cobb who are interested in reproductive care may not understand that nurses are needed in abortion or see a way to develop a career in that field. In other words, silence on abortion in nursing education creates a negative workforce loop. This is a longstanding problem.

“Nurses were far more likely to regard abortion as part of routine health care if it was part of the curriculum and if they had opportunities to work through their feelings about the procedure,” said Karissa A. Haugeberg, a history professor at Tulane University who has studied nurses’ attitudes toward abortion through time.

By contrast, McLemore pointed out that anti-abortion groups have both been strategic in outreach to nurses and sought to weaponize the close nurse-patient relationship—to the point that nurses have turned patients in when they suspect an illegal abortion.

“Nursing is ground zero,” McLemore said. “Nurses have been long identified by the Charlotte Lozier Institute and the Susan B. Anthony group and all the anti-abortion people as the discipline to be able to operationalize anti-abortion rhetoric. So you’ve got nurses calling CPS [Child Protective Services] and the police on our patients. And they think that is our job.”

In fact, McLemore said actions like these violate nursing ethics.

The nurse-staffing bottleneck is a major contributor to lack of abortion access. It has become only more pressing in states where abortion is legal, as those states see an influx of out-of-state patients, resulting in more volume and, later, more complicated procedures at clinics, necessitating more staffing.

Filling a gap with more nurses

Last fall, California Gov. Gavin Newsom took the first large-scale step in addressing this issue when he launched a statewide program called the Reproductive Health Services Corps, a $20 million effort that will increase abortion training opportunities for all health-care workers, including nurses, pharmacists, physicians, physician and medical assistants, doulas, and EMTs.

One of the program’s partners is Nurses for Sexual and Reproductive Health (NSRH), a nationwide education and advocacy organization, founded in its current form in 2018 but already a leader in training nurses in abortion care.

In the last two years, the group has developed two programs aimed at improving abortion nurse staffing. One is a training in abortion care residency, a six-month hands-on program for nurses to gain clinical abortion skills. The other is an abortion nursing corps, a short-term travel program that places expert abortion nurses in clinics that need them.

“We knew that there is a huge gap for nurses, specifically registered nurses, to get training in abortion care,” said Anna Brown, a registered nurse and NSRH’s deputy director of programs. “And we also knew that our organization was specifically prepped to fill that gap because we’d already been creating online education and doing group learning with our nursing members on comprehensive sexual and reproductive health care, including abortion.”

Cassandra Durian is a registered nurse who went into the profession because she was interested in trauma-informed community and reproductive care. In nursing school, she quickly felt alienated by the culture.

“I felt very out of place,” Durian said. “I was questioning if nursing was for me. I was like, ‘Is this what nursing is?’ I wasn’t getting to the depths that I thought I would in terms of health and support of communities.”

As a new nurse, she was working in inpatient critical care, and that’s when she came across NSRH’s training in abortion care residency.

Durian enrolled in the residency and completed 80 hours of training at the Partners in Abortion Care clinic in College Park, Maryland plus a complementary online course developed by NSRH that included modules and seminars on both abortion nursing skills and the broader context of abortion care: how abortion funds work, what state laws require, how and when to disclose that you work in abortion.

In Durian’s hands-on hours, she followed various clinic team members and learned how to counsel patients, ask the right questions for a pregnancy-specific medical history, and provide moderate sedation—a specialized skill—for the procedure. She found that she loved the work, especially the opportunity to deeply connect with patients: The complexities of how people came to need an abortion often required individualized problem-solving.

“We’ve had situations where they’re in an abusive situation and they couldn’t come home without a pregnant belly,” Durian said. “So they might come for a fetal demise injection and then go home and say, ‘The baby’s not moving, let’s go to the hospital.’ And that’s her way of getting out of the relationship.”

Since completing her residency, Durian now works as needed at Partners. Without the training and support it provided, she isn’t sure how she could have become an abortion nurse.

“A lot of places require labor and delivery or midwifery experience,” Durian said. “I didn’t have any of that.”

Partners clinic co-founder Morgan Nuzzo, a certified nurse-midwife, said she is very aware of the value of abortion nurses and the barriers that make them scarce.

“We need more nurses in leadership, and we need really talented nurses in abortion care because our patients deserve to have that level of care,” Nuzzo said.

She said one of the reasons she and her co-founder, a physician, are so happy to participate in the residency is because NSRH handles all the logistics: The organization ensures licensing and background checks and provides wraparound support and education.

“They give us a stipend to train these folks,” Nuzzo said. “We’re not required to do it for free. And that’s unique. In this work, there’s a lot of, ‘Do it for the mission.’ And it’s like, well, don’t set yourself on fire to keep everybody else warm, either. And we’ve been doing that for generations, and a lot of us are at the end of our ability to keep doing that without more funding.

“When we’re under siege all the time, we just try and piece together what we can,” Nuzzo added. “This program was created with intention and purpose, and it is innovative in a way that makes it exciting to participate in.”

Though this problem is somewhat opaque to the public, most people who work in abortion are painfully aware of it. Latona Giwa is a doula, a registered nurse, and the executive director of Midwest Access Project, an organization that trains providers in full-spectrum reproductive care. Giwa said most of the people they train are physicians and other advanced practice providers, but increasing the organization’s outreach to registered nurses is a major goal.

“I’ve seen so many nurses hold a patient’s hand through a procedure, physically touch a patient and comfort them,” they said. “A nurse can say, ‘I will be right here with you.’ And I think that means the world to folks who are going through something they’ve never gone through before and don’t know what to expect or are afraid.”

And Giwa pointed out, in the worst-case scenario—and as Cobb’s experience shows—no nurse can mean no abortions that day.

“We are hearing from clinicians that a lack of registered nurses in their clinics is a huge barrier to providing care,” Giwa said.

There is also the fact that people show up needing information about pregnancy options everywhere in the health-care system.

“If we train RNs, we then can have nurses in primary care settings, in care navigation, in telemedicine, in hospitals—everywhere in peripartum care who are helping patients navigate when they need access to abortion care,” Giwa said. “If we get nurses to be abortion advocates, navigators, and care providers, we are really reaching entire communities.”

Training for the future of abortion care

Another facet of this problem is the fact that there were expert abortion nurses working in states where abortion is now essentially banned, like Texas, who are now out of a job—or at least out of a job in their chosen specialty. In response, NSRH has organized an eight-week travel program that matches seasoned abortion nurses with clinics that need them, often in other states.

“Obviously, it’s devastating for patients, but it’s also devastating for nurses who have chosen this career,” Brown said. “That’s an immense amount of knowledge that’s potentially going to be lost. And we know that clinics are seeing increased volume, are seeing patients at later gestation, because of abortion bans, which means you might need more staff. So we came up with this idea of a travel nurse program.”

To make travel feasible, NSRH gives nurses a travel and living stipend for the eight weeks they will be working away from home; they also ensure the nurses are licensed in the state they are traveling to and help with additional insurance and support.

When Cobb was the nursing director at the Kansas branch of their clinic, they worked with NSRH to have a travel nurse placed there.

“The program allowed us to bring somebody in who was vetted,” Cobb said. “That’s a big thing in abortion staffing—you have to really vet folks. Sometimes it’s hard because even if folks are not anti, I really need somebody who is pro-abortion, not just pro-choice, and I think there’s a big distinction.”

Cobb emphasized there are nursing skills particular to abortion and to outpatient care—for instance, if it is difficult to get an IV inserted in an ER, a nurse can call another nurse, or a paramedic, or an anesthesiologist. In the clinic, that’s not an option. But not only that, there is specific emotional work around abortion care.

“This is an emotionally draining job,” Cobb said. “You’re taking on additional risk that you’re not taking on in other areas of nursing. And that can feel really rewarding because you’re providing a service that people need—and it can also take a toll on you.”

Brown agrees.

“Dealing with protesters is draining,” Brown said. “Having safety concerns for your family is draining. And clinics that are able to stay open are typically seeing an increase in volume of patients. So the staff are feeling that strain as well; we’re meeting a higher need.”

Despite all this, nurses interviewed for this story pointed out that there is a stark contrast between the larger political and workforce problems (brutal) and the actual patient care (deeply rewarding). In fact, for many nurses, working in outpatient abortion care is a dream job, one in which teamwork is emphasized over the strict hierarchy of the hospital, where connection with and care for patients is paramount. Cobb said that the work itself is a joy: “When you’re actually sitting with a patient, it’s the best space in health care, truly.”

In that sense, these programs are a radical reimagining. Imagine if abortion care were not always on a shoestring. Imagine if holistic, supportive, safe nursing care was available to every abortion patient. Imagine nurses who actually love their work environment because it centers patient care.

“It is not a drag to work in reproductive health,” McLemore said. “That’s a lie. It’s some of the most fulfilling, the most deeply complicated and complex work, rooted in the messiness of human experience. It is a place where we need our strongest nurses.”