When caring for people undergoing abortions, Pittsburgh-based doula Alicia Vervain often reassures them their experience is normal.
How she provides this support depends on the client. In addition to answering questions, she sometimes prepares herbal teas or chats about recipes. Once, someone asked Vervain to sing “Helpless,” a swoony, upbeat song from the musical Hamilton.
Doulas provide reproductive health support during life’s most critical moments, which can range from when someone is trying to conceive, to giving birth, to deciding to end a pregnancy.
The latter isn’t a duty often associated with doulas, but these non-medical caregivers can help abortion patients navigate the possible pain, discomfort, and emotions that arise when ending a pregnancy, along with the logistical hurdles in seeking care. This can involve helping patients find funding, connecting them to other services, or, as in Vervain’s case, singing show tunes to put someone at ease.
Prior to the COVID-19 pandemic, Vervain mostly supported patients during in-office procedures. But in 2020, in order to minimize the spread of the virus, some clinics stopped permitting doulas to accompany patients.
This coincided with the Biden administration loosening rules for medication abortion in 2021. Instead of being required to go to a clinic for an in-person screening, a patient now can be remotely assessed using telehealth, and prescribed medication to terminate their pregnancy.
Sources tell Spotlight PA that the change in telehealth care contributed to a nearly 25-year trend in which medication abortion has become increasingly common. Medication abortions accounted for just 6% of terminations in 2001, according to the Guttmacher Institute, a think tank that advocates for expanding access to abortion. In 2023, it was 63%.
That means instead of undergoing an in-office procedure to remove the pregnancy, it’s now more likely that patients take a two-pill regimen that essentially induces miscarriage. As a result, for a growing number of people, the abortion process happens at home.
These shifts have changed the nature of Vervain's abortion doula work, which now primarily takes place outside of clinics. Instead of chatting through a 20- to-40-minute procedure, she’s more likely to text with patients throughout the day or two it takes for them to pass a pregnancy.
Sometimes, Vervain even sleeps on clients’ sofas to ensure they have enough pain medication and hot water bottles to soothe their cramping, which can be severe. On occasion, she provides child care, as more than half of Americans who get abortions in the U.S. are parents.
"I can keep the kids out of the room so that [the patient can] just get as much rest as she wants. And, you know, binge a favorite TV show all night like moms rarely get to do," Vervain said.
In addition to COVID-related changes, the increasing number of medication abortions is also driven by the U.S. Supreme Court's 2022 ruling that overturned the constitutional right to the procedure. Currently, it's illegal in 13 states, while another 5 ban it at or before 12 weeks of pregnancy.
These laws are changing the landscape of abortion access. Compared with before the ruling, more patients are crossing state lines for care, and some clinics only provide medication abortions as a way to meet this increased demand.
Patients who travel for an abortion sometimes go alone, said Julie Chor, an OB-GYN at the University of Chicago. That means some are passing their pregnancy in a hotel room by themselves in a city where they don’t know anyone, and have no friends or family they can call on.
“Those are the patients that, I think in particular … would benefit tremendously from having doula support,” Chor said, adding that people who travel for in-office procedures that involve pre-operative care and recovery can also use extra support.
Having a doula can make a significant difference, agreed Kathryn J. LaRoche, a public health anthropologist at Purdue University.
LaRoche researches abortion pain management, and said that sometimes patients are alarmed by the amount of blood or the severity of cramping during a medication abortion. That’s because they’re often told by clinicians that passing a pregnancy feels like a heavy period.
"What I have learned in talking with hundreds of women about their periods and their medication abortions is … what everyone thinks is a heavy period is different," LaRoche said.
Because people aren’t sure what’s normal, they’ll sometimes go to an emergency room, where clinicians might not be trained in abortion care. So instead of information and reassurance, LaRoche said, the only thing patients get from such visits is a bill.
To prepare people for the physical discomfort, Vervain explains that intense contractions and heavy bleeding that lasts a couple of days are normal. However, she cautioned that patients have a range of experiences, and noted that for some the pain is minor. Also, people can find the process surprisingly emotional.
"The flood of hormones alone that hit as the medication is working in your system, and as you're beginning to release the pregnancy, can have really unexpected effects," said Vervain. "Having someone there who's not going to be surprised by that is helpful."
Because doulas are aware of how cost-prohibitive abortions are for some patients, many do this work for free. That includes Vervain, as well as Philadelphia-based Kai Kornegay, who has been supporting abortion patients for about four years.
In their day job, Kornegay works for an abortion fund, which gives them practical knowledge of the at-times chaotic reproductive health system. For example, Kornegay will explain to people seeking procedural abortions — which occur in-person at a medical facility — that they need someone to accompany them if they want sedation during their appointment. Or they'll remind people to turn off phone location sharing in order to keep their health care private.
Because Kornegay is not a social worker or licensed medical professional, they’re not required to report suspected child abuse or neglect. They said this allows clients to be more open with them; this can be particularly important for Black and brown patients who might be hesitant to become involved with social services or the justice system due to systemic racism.
For instance, if someone is seeking an abortion because they're dealing with domestic violence, Kornegay will offer to connect that person to related resources, such as free therapy or emergency housing. But they make it clear that whatever the patient decides, it's their choice.
"I always like to start off by telling people, 'I'm not the feds, I'm not the cops. Like, that's not my energy,’” said Kornegay. “I really am coming to you like, you know, neighbor to neighbor, friend to friend.”