Hold my Hand: How Abortion Doulas Improve Abortion Care

Patients seeking abortion services in the United States face several problems, including factual inaccuracies about the procedure, the stigma surrounding the procedure, and barriers to quality care across the country. The problems surrounding abortion pose a threat to patient autonomy and beneficence—ethical principles that are usually upheld in medicine. Abortion doulas can enhance patient autonomy, improve the quality of medical care, help women talk through their emotions or the associated stigma, and provide other benefits that can address the problems surrounding abortion. Their role ranges from discussing emotional decisions and answering patient questions before the procedure, to simply holding their hand in the recovery room. In this paper, I propose that the use of abortion doulas may help address some of the problems surrounding abortion by mitigating factual inaccuracies, stigma, and barriers to quality care.


INTRODUCTION
Patients seeking abortion services in the United States face several problems, including factual inaccuracies about the procedure, the stigma surrounding the procedure, and barriers to quality care across the country. The problems surrounding abortion pose a threat to patient autonomy and beneficence-ethical principles that are usually upheld in medicine. Abortion doulas can enhance patient autonomy, improve the quality of medical care, help women talk through their emotions or the associated stigma, and provide other benefits that can address the problems surrounding abortion. Their role ranges from discussing emotional decisions and answering patient questions before the procedure, to simply holding their hand in the recovery room. In this paper, I propose that the use of abortion doulas may help address some of the problems surrounding abortion by mitigating factual inaccuracies, stigma, and barriers to quality care.

I. Background
Abortion doulas were started by The Doula Project in New York City. 1 They initially worked with New York City public hospitals and eventually expanded to working with Planned Parenthood clinics, as well as other care providers. 2 Over recent years, abortion doulas have been offered in more states such as California, Arizona, and New Hampshire. Abortion doulas can work independently, in a collective, or in an abortion clinic. 3 More often, they work in a collective where they are trained and employed in clinics that are partnered with the organization. Many abortion doulas started working on a volunteer basis. Now, many are funded by donations, which allow their services to be free for patients. 4 When abortion doulas work independently, their rates are based on the specific services that they provide. 5 Patients can seek out abortion doulas through multiple avenues. They can seek out doulas that work independently, work in an abortion clinic, or through doula organizations, such as the Doula Project or The San Francisco Doula Group.

II. Doulas
The role of a doula has existed since ancient times. The word "doula" comes from the Greek language and translates to "a woman who serves". 6 In 1969, Dr. Dana Raphael originated the use of the word "doula" in the US to describe a person who guides mothers through childbirth and assists them postpartum, specifically helping them breastfeed. 7 Dr. Raphael encouraged emotionally supporting new mothers through creating the new professional role of a doula. 8 Currently, doulas are trained in helping women emotionally and physically during pregnancy, childbirth, and postpartum. Doulas do not provide medical care, but they provide services such as birthing education, massage, assistance with breastfeeding, and educating mothers about the delivery process, such as knowing what to expect and what can go wrong. Research has demonstrated the effectiveness and benefits of doulas. For example, one meta-analysis compared women who received doula support during childbirth to women who did not. The study showed that doula-supported women had shorter labors, decreased complications with delivery, and rated childbirth as less painful than women without doula support. 9 Psychosocial benefits such as reduced anxiety, decreased symptoms of depression, and positive feelings associated with childbirth were significant for the doulasupported group. 10 In the last couple of decades, doulas have become increasingly popular. More recently, doulas have started a movement labeled "full spectrum doula," in which the role of a doula in supporting women has expanded beyond birth to include abortion and adoption. 11

III. Ethical Considerations Factual Inaccuracies
Complete and accurate medical information is fundamental to informed consent and autonomous decision making. Inaccurate medical information about abortion is very common and can come from multiple sources. Currently, there are 29 states that have policies restricting abortion that are not based on scientific evidence. 12 While both state policies and national media may convey false information to the public about abortion, perhaps what is most surprising is when these inaccuracies are presented to patients by physicians or medical facilities. In most states, policies mandate that any medical facility providing abortions develop and present written material to patients that is intended to educate the patient about the abortion procedure. 13 However, in some states, laws have been passed that mandate the inclusion of misinformation in these materials. 14 Healthcare providers try to mitigate the harm of this inaccurate information by prefacing it with qualifiers, disclaimers, and apologies. 15 However, they are still not able to completely avoid harm from the outdated and misleading information, which also often intends to dissuade patients from receiving an abortion. 16 The most common factual inaccuracies include stating that an abortion leads to an increased risk of breast cancer, that the fetus can feel pain as early as 12 weeks old, and that psychological effects of the procedure can lead to suicide and "post abortion traumatic stress syndrome." 17 All these statements are false and not supported by scientific evidence; in fact, psychologists and the Diagnostic and Statistical Manual of Mental Disorders (DSM-V) do not recognize a post-traumatic stress syndrome associated with abortion. 18 Furthermore, another common inaccuracy in almost 20 states includes materials with contact information to "Crisis Pregnancy Centers" that provide false information with the intent to deter women from having an abortion. 19 Even once piece of inaccurate information can impede a patient's ability to make an informed, autonomous decision. When these false facts are given to patients from the hands of trusted medical professionals, it has a more influential impact than when portrayed in media and advertisements. Trust is a core value in the medical profession that determines the patient-physician relationship, and a part of this trust is communicating accurate and up-to-date information; if this trust did not exist in medicine, how would any patient make an informed decision? Where would they turn to for guidance and advice? 20 Challenges to informed consent and autonomy exist throughout medicine, as consent forms are complicated and filled with medical vocabulary that is often hard to understand. Signatures are sometimes scribbled onto forms before a procedure with minimal discussions to assess the patient's understanding of the many risks and benefits. However, abortions have an additional layer of complexity regarding informed consent due to the religious and moral implications of choosing an abortion, while other common medical procedures, such as an appendectomy, do not carry the same implications. For example, a patient consenting to general surgery would probably not wonder if their physician's advice against the surgery is due to his or her own moral values, or what the moral weight of the surgery will have on their conscious afterwards. Informed consent, regardless of procedure, should prioritize informed decision-making with evidencebased medicine without moral overtones. When inaccurate, biased, and false information is given to patients from medical institutions, it not only threatens the trust between patients and medical staff, but also prevents women from making an informed decision about their reproductive health.
If abortion doulas can be a source of correct, up-to-date medical information, then women can make informed decisions based on thorough and accurate facts that allow them to exercise autonomy. Abortion doulas are well situated to correct the factual inaccuracies patients face for several reasons. First, abortion doulas are trained through a curated program with partnered medical facilities. 21 In other words, abortion doulas are thoroughly trained in patient-centered care that facilitates continuous patient support, which ranges from emotional support to providing accurate medical information when addressing patient concerns. Second, they have the time before the procedure to meet with the patient and discuss pre-abortion care topics such as providing information, addressing concerns, and preparing the patient for potential stigmatization. 22 Simultaneously, the doula can evaluate for any risk factors that may indicate negative emotions after the abortion, such as lack of social support, self-esteem, psychological stability, or multiple abortions. 23 Third, abortion doulas can provide post-abortion care counseling. While the doulas also have limited time with patients after the procedure, they would have more time than other healthcare professionals, such as nurses, to make sure the patient understands the medication regime while also offering psychological counseling for the patient on grief, guilt, and forgiveness. 24 With doulas providing technical post-procedure information, this allows them to answer any more questions that the patient may have about misleading, biased, out-of-date, or false information. Therefore, doulas can enhance patient autonomy by giving more accurate information.

IV. Stigma
Another critical problem facing patients who seek abortions is the stigma surrounding the procedure itself. An abortion requires many decisions to be made: do you want to be sedated or awake for the procedure? If you are awake, do you want someone to hold your hand or someone to talk to? Do you want to have privacy after the procedure? In fact, the first decision to be made is whether to have the abortion at all. For some women, that decision is immediate, quick, and assured. For others, the decision can be morally conflicting, such as due to religious reasons, society's stigma, or other reasons. The moral conflict a woman faces when deciding on an abortion is determined by how much moral weight they apply to a fetus or embryo. 25 An abortion can make a woman feel as though they are a bad person or doing something morally wrong, especially if they place more weight on the moral status, or viability, of the fetus or embryo. 26 Regardless of why a woman feels conflicted, the bottom line is that these feelings exist, which can affect their decision-making abilities during the actual process.
Our society stigmatizes women for having an abortion, it is our "modern-day Scarlet Letter." 27 This stigma is under-researched but often theorized to be based on gender-biased roles of women in society. 28 Women who receive an abortion are labeled as "irresponsible" for having an unwanted pregnancy, or "selfish" and "unmotherly" for not wanting children. Therefore, women avoid judgement and prefer privacy during their abortion-but are these choices made because that is truly what a woman desires, or are they making these choices to avoid stigma? And, if they are making these choices to avoid stigma, how does it affect their autonomy as a decision-maker for their own healthcare choices? There is a difference between secrecy and privacy: women may want to keep their abortion decision private, like any other medical decision or health information. 29 However, some women make the decision in secret to avoid judgment and stigmatization.
There is evidence that stigma plays a role in every decision of the abortion process. For example, one study explores the reasons why some women prefer to be awake versus asleep during the procedure. Women who choose to be asleep want to be less emotionally present for the fear of "seeing something" during the procedure. On the other hand, women who choose to be awake want to feel present, safe, and receive support during the process. 30 The study also found that most women rated an abortion procedure a "good experience" if care was provided in a discreet and private manner. 31 By preferring anesthesia and privacy, many women try to avoid dealing with the stigma and judgement from others. The stigma also prevents women from seeking or receiving social support. 32 While some women may make these choices because it is what they truly want, others might choose these options to avoid others witnessing their decision and from being stigmatized as a woman who "got an abortion." 4 Although abortion doulas cannot completely abolish the overarching societal stigma, they can help in several different ways on an individualistic level. Abortion doulas may fit the role of personalizing each experience to fit patients' specific preferences. Doulas have the time and appropriate training to understand and discuss the emotional burdens that come along with the social stigma that surrounds abortions. 33 They have the training to explore the patient's reasons for their decisions and can make sure they are comfortable with them. They do so in a non-judgmental way and strive to act as an advocate for the patient. 34 By listening to women and validating their decisions, women may not feel as many negative emotions surrounding the stigma or feel empowered that they made the right decision for themselves, regardless of social labels. This validation and empowerment gives women more agency in their own healthcare decisions while also providing emotional support in a situation that requires many difficult choices. Abortion doulas would become a support system for women, thereby promoting feminist ethics by normalizing emotions in a morally charged decision. They also promote the principal of beneficence by helping patients address any conflict between societal stigma and the woman's own beliefs and morals.

V. Barriers to Quality Care
Access to abortion is limited: only 62 percent of American women live in counties with an abortion provider. 35 Many insurance companies do not cover abortions and clinics are often busy with limited availability, staff, and resources. Additionally, many women would need time off from work, childcare, transportation, and other resources to make it to any medical appointments-abortion care is not an exception. Currently, there are no professional programs for abortion providers to offer post-abortion counseling. 36 Additionally, in busy clinics, hospitals, or non-profit organizations such as Planned Parenthood, physicians attempt to provide as many abortions as possible to as many patients, leaving little time for post-abortion care. Provider burn-out is a major problem throughout healthcare, which has become more pronounced throughout the COVID-19 pandemic. Many providers, nurses, and other hospital staff are overworked and underpaid while hospitals themselves are overcrowded and underfunded. Moreover, abortion providers may be especially vulnerable to burn-out as they tend to both their patient's medical and emotional needs during a procedure that has both physical pain and a plethora of emotion surrounding it. 37 With an increase in patient number due to decreased availability of services and a physician's responsibility to tend to the patient's emotional well-being and physical pain, this increases the risk of provider burn-out, which in turn, can affect the quality of medical care given to women receiving abortions. 38 Abortion doulas can fill the role of providing post-abortion care and help alleviate provider burn-out in many ways. First, as mentioned previously, they have the time before the procedure to meet with the patient and discuss pre-abortion care topics, provide information, and answer questions. 39 Secondly, abortion doulas can provide patients with the post-abortion care counseling that many physicians and nurses are not able to provide. This role has multiple effects. While post-abortion counseling can help address factual inaccuracies through answering questions, it can also allow doulas to make sure the patient understands the medication regime and how to deal with the pain that follows the procedure. 40 With doulas providing technical post-procedure information, this relieves understaffed nurses of some of their many tasks and responsibilities in the postabortion recovery room; this will likely decrease the number of women who come back to the clinic or hospital with complications or additional questions. By discussing various emotions during post-procedure counseling, doulas support women by listening to their feelings. Some women may feel relief and joy after the procedure, while other may feel despair, regret, grief, or shame. When a doula listens to and supports a patient, they validate their emotions and indirectly validate their abortion decision, thereby improving the quality of the experience.
Lastly, the integration of doulas into routine abortion care allows physicians and staff to concentrate on the procedure itself. 41 The doula can offer patient-centered, hands-on care to the patient while the rest of the healthcare team focuses on their own technical tasks. 42 Doula support can also decrease the need for more clinic staff in the procedure room by "decreasing the redirection of clinic staff resources," thus creating a more efficient medical environment. 43 As the historical role of a doctor playing every role is becoming more obsolete, and the idea of a multi-faceted, integrative healthcare team is becoming the norm, it makes sense that an abortion doula can fill a niche on a healthcare team for emotionally laden procedures like abortions. The niche that the doula fills is to support, comfort, and be present with the patient throughout the entirety of the procedure in a nonjudgmental way. While nurses and doctors can be supportive, sympathetic, and caring, their jobs and roles include other responsibilities that do not allow them to be a continuous presence for the patient throughout their visit. 44 By having a person on the healthcare team whose job is to provide patient support, even if it is simply to hold their hand, the patient is more likely to be treated as a whole and provided better quality medical care.

CONCLUSION
Inaccurate information, stigma, and quality of care barriers are only a few of the many problems facing patients who want to receive an abortion. Each problem poses ethical challenges while also impeding quality medical care and adding to patients' emotional burdens. Inaccurate facts and stigma hinder an informed decision, and thereby, threaten patient autonomy. The stigma of abortion can also lead to patients experiencing more negative emotions. Furthermore, healthcare barriers include a wide range of problems, from understaffed clinics to provider burn-out, all of which affect the quality and access to care for patients seeking an abortion. Abortion doulas are part of the solution to these problems. They are an extra resource, a set of hands for the patients to hold in the procedure room, and an expert in providing emotional and social support for the patient. They can enhance a patient's decision-making skills, support the patient's emotional well-being, answer factual questions, counter stigma, and help provide quality medical care. Therefore, abortion doulas enhance patient autonomy, promote beneficence, improve access to quality abortion care, and fill a necessary role during the abortion process.