Erin Steuter, head of the sociology department at Mount Allison University in New Brunswick, had a doula with her first birth at 27, a doula for her second birth at 30 and she wishes she had had a doula for the abortion she had when she was 18. The role of the doula in childbirth in the United States has become that of a hand holder, back massager, quiet supporter and advocate in a wide variety of birth settings. The doula, a person with non-medical training in labor support, focuses on the emotional and psychological elements of the birth. The doula's role is unique in that she or he is the only person involved in the birth process solely focused on the emotional and psychological status of the mother. Doula care is expanding across the United States as more people become familiar with the concept and more women seek out their services for labor and delivery. As this expansion continues as a part of the wider movement to change the standards of maternity care in the United States (by lowering intervention rates, increasing midwifery care and educating women about birthing options), there are doulas trying to apply their skills to another arena of women's reproductive lifecycle: abortion care.

For some women, the need for emotional support during pregnancy termination is high. Erin explained, "Even though I was very clear in my heart and mind that the abortion was exactly the right thing to do for me at that point in my life, it was nonetheless a very frightening experience. The medical staff at the hospital were not kind to me and there was no discussion about what was happening to my body, it was just a procedure that they were doing to me as coldly and clinically as possible." As the number of providers decreases (it has dropped 37% since 1982) and the number of women having abortions continues to go up, clinics and abortion providers are overextended and under-resourced. Not only are many providers not well equipped to provide adequate support, but the procedure itself can also be a painful one, during which many women are fully or at least partially conscious. Raquel Valentin, Practice Manager for the Family Planning Division at Beth Israel Hospital explained, "Many first trimester abortions are being done with local and moderate sedation. This means that the women are still awake and emotional." The decision to use moderate sedation is based on both the women's choices and the higher risks associated with full anesthesia but can result in an experience that can be both frightening and, at times, painful.

In at least one abortion provider setting, a group of women is looking to provide additional support to women during pregnancy termination. The Birth Sisters, an existing doula program at Boston Medical Center (BMC), is in the process of adding abortion to their already comprehensive list of support services offered. The program, fully funded by the hospital, provides women with support from the early stages of their pregnancy through the postpartum period, often from doulas who can provide culturally competent services to the burgeoning Latino immigrant population served by the Medical Center.

Within the Birth Sisters program, the doulas have developed specialties, which are accompanied by further training in a particular area. Some of the Birth Sisters have specialties in domestic violence, others in breastfeeding. In an effort to meet the needs of women having abortions, the program is looking to expand the program to include compañeras, doulas who would provide this abortion support. The idea is currently in the research stages, and the members of the program have developed a needs assessment that will provide data on what kind of support women who are terminating their pregnancies at BMC need. They plan on having the compañeras meet with the women before the abortion, accompany them during the procedure and then meet with them at periodic increments afterwards as well (two weeks, two months, four months, etc). This mimics the role of a birth doula, who frequently meets with women before and after the birth, and goes beyond the support that most abortion providers currently offer. Dr. Nilda Moreno, an OB/GYN and member of the Birth Sisters program, explained, "We don't only want to provide emotional support but also contraceptive support. We want them to have all the information to prevent unintended pregnancies." Dr. Moreno also explained that the training will be similar to what counselors at Planned Parenthood receive, but with a special focus on emotional support. In addition, they also plan on providing support to women having medication abortions, who usually go home and pass the pregnancy on their own.

The idea of providing a support person to women during pregnancy termination is not a new one. Planned Parenthoods, other abortion clinics and feminist health centers have a history of trying to provide support to women having abortions, in the form of options counseling and also with accompaniment during the procedure. Other abortion settings provide similar support in the form of specially trained counselors, or patient advocates. When these programs are already providing models for supporting women during abortion procedures, why doulas?

Erin explained why she would have wanted a doula at her abortion: "I feel that a doula would have helped me understand what was happening to my newly pregnant body, the process of the abortion, and the after care for my body." Doulas employ a variety of techniques with women in labor, some that help prepare her mentally for the labor, others that mediate pain, and others that focus on relaxation. Many of these techniques could have useful applications in the support of women during pregnancy terminations, as Erin describes. Explaining how the abortion procedure works is similar to visualization used by doulas during labor, when the doula helps the woman to visualize the baby moving down into the birth canal with the strength of each contraction. These visualizations can help the woman better cope with the pain of labor by enhancing her understanding of the purpose and cause of the pain she is feeling. In addition, pain mediation techniques, like massage, acupressure and breathing could all be helpful for some women during these abortion procedures.

Central to the concept of doula care for abortions is the follow up component. This is where most clinics and providers are unable to provide the longer-term support that a doula could. "I would also have welcomed their support in confirming that my body would, in the future, be ready and able to make a baby and that I would be a good mother when the time was right," Erin says. An important component of birth doula work, this follow-up allows the doula to check in with the woman throughout the months following her abortion, when additional concerns and issues may arise.

Susan Yanow, supporter of the Birth Sisters project and former director of the Abortion Access Project, explained that she sees abortion care as just another service that doulas can provide, in addition to the other areas where they already provide support. "I don't want to carve out abortion in any way that minimizes or maximizes it," she explained. Instead of implying that women who have abortions need a lot of support, this is simply another opportunity to help women within the broader context of doula care. To her it's important that women do not feel that abortion is being stigmatized and that women are not being sent the message that they need support during their abortion. "For some women," Susan reminded me, "all they feel after their abortion is relief."

"The reasons a woman decides to have an abortion are complicated, and her feelings are really complicated. We need to take care of all of it." Susan explained that what she doesn't want to do is send the message that all women need support; and she worries that it will simply add to the stigma that women already feel around abortion. Some women have social networks, family members and friend who will be there for her; some don't need any special attention at all. But for the women who do need it, Susan agrees that it should be available to them. At the Birth Sisters program, a large majority of the women they serve are immigrants from Latin America, many of who are terminating pregnancies that they acquired while crossing the US-Mexico border. These pregnancies can be a result of rapes that are not an uncommon occurrence for immigrants who come into the United States without documents.

For many in the midwifery and doula community, the idea of a doula offering her services to a woman terminating a pregnancy is controversial. Abortion is a topic that is rarely breached at midwifery and doula meetings and conferences, and in many ways has become the elephant in the room of the birthing rights movement. The reasons for this are varied, from a strong religious contingent within doula and midwifery communities to women who feel strongly that they are working on behalf of mothers and babies. A thread in reaction to an article I wrote for Campus Progress about being a radical doula on the site Alldoulas.com provoked an interesting discussion about this issue. One poster explained, "I am an advocate for moms and babies. Aborting babies is totally opposite from that in my view. As much as I believe in a mothers right to choose how she will give birth, I also strongly believe in the baby's right to live. When I was new in this doula work, I started out assuming that most in the childbirth field would naturally be pro-life. It was very hard for me to comprehend how doulas and midwives could be pro-abortion."

One woman and advocate who is working to force abortion advocates and birth activists to dialogue with one another is Lynn Paltrow. Executive Director of the National Advocates for Pregnant Women (NAPW), Lynn has been advocating on behalf of pregnant women for most of her career. Last Spring, Lynn and NAPW hosted the Summit for Health and Humanity of Pregnant and Birthing Women in Atlanta, Georgia. What transpired was a gathering of abortion advocates, reproductive rights activists, midwives, doulas and birthing rights academics. Not everyone in the room was in support of abortion. Not everyone in the room understood the benefits of natural childbirth. Lynn explained in her article on TomPaine.com, "Participants moved beyond the divisive abortion debate to find common ground in the experiences of pregnancy and the increasing limitations to care and support that all pregnant and birthing women face." The Birth Sister's Compañera project, along with two other similar abortion doula projects (one in New York City and another in Washington State) arose from conversations that began at the summit.

In the last few years, we have seen the abortion climate in the United States become increasingly hostile. The current administration, including its newly appointed Supreme Court, seems adamant about limiting women's access to abortion procedures. Medical students aren't being trained to do the procedure, yet the need for abortion services remains steady. Some women make the decision to have an abortion within a supportive and loving environment, and they are able to cope well with the emotions that can come along with terminating a pregnancy. But other women make the decision alone, or without the support of a partner or families. It's these women who will benefit the most from having a doula at her side-someone who has no investment in her pregnancy, and simply wants to hold her hand, distract her, make her laugh or explain the procedure to her. But it's also about more than just helping a woman survive that one procedure, it's also about trying to mediate the impact it has on the rest of her reproductive life. "I had a hard first labor," Erin recounted. "I wonder if I had trouble connecting to my birthing body as a result of the abortion experience. Once I worked with a doula for the birth of my two very much wanted and planned children, I could imagine what it would have been like to have a doula at the abortion."