Birth doulas provide nonmedical support to pregnant women during labor and delivery. And there's growing interest in the services of death doulas, who provide similar assistance at the end of life.

Lesser known is the work of abortion doulas, who provide patients with information, logistical help and emotional support as they undergo surgical or medication abortions. These companions, who are mostly volunteers, work independently or through groups that have emerged in the past two decades, including Twin Cities-based SPIRAL Collective.

L. (who asked that her name not be used) is a Minneapolis abortion doula who received her training through SPIRAL. She explains how caring for a patient might involve offering to hold their hand during the procedure and checking in on their pain and bleeding afterward. In terms of emotional support, her focus is on holding space for difficult feelings.

"There's no right or wrong emotion to feel," she said. "It's safe to feel anything. Most of what I do is affirmation." She sometimes cites a saying in the reproductive justice movement that reminds patients they are not alone: "Everyone loves someone who has had an abortion."

After the fall of Roe vs. Wade in 2022, Minnesota became the state with the fewest abortion restrictions in the Upper Midwest. While the Minnesota Department of Health has not yet released 2022 abortion data, providers say the number of people seeking abortions in Minnesota has risen due to an influx of patients traveling from neighboring states and beyond. That has increased demand for abortion doulas, and made their work more complex.

The SPIRAL Collective (Supporting People in Reproduction, Abortion and Loss) is thought to be the only organization, independent of medical clinics (some of which provide their own doulas) offering free abortion doula services in Minnesota and the surrounding area. What started as an informal grassroots network has now become an established nonprofit serving clients who are increasingly coming from beyond the Midwest, as far away as Texas.

Part of SPIRAL's mission is ensuring that those who terminate a pregnancy — nearly one in four American women — receive the same access to information and support as those anticipating childbirth. The group places extra attention on the needs of pregnant people who face disparities in accessing health care, including people of color, those with disabilities and those who are gender-nonconforming or lower-income.

"Everybody comes to us because we're the only ones doing what we do," said Shayla Walker, a member of SPIRAL's leadership team.

Walker is also executive director of Our Justice, a Minnesota-based abortion assistance fund. She explained how SPIRAL's transportation services and day-of support picks up where Our Justice leaves off.

"It doesn't matter if we pay for their abortions, if they can't get there," she said.

Due to the long distances between some patients in rural Minnesota and abortion providers, Walker noted, hiring a ride can be cost-prohibitive, if it's even available.

"In conversations about abortion access, especially with the fall of Roe, a lot of people are focusing on people traveling from another state," Walker said. "But they're not even realizing what a desert we have here, when so many people in greater Minnesota can't access care because of a lack of transportation."

Providing support

Abortion doulas aren't licensed or registered and their support can take different forms, depending on the client's preference.

The doula might begin by helping to find a provider and preparing for a procedure. On the day of the appointment, doulas sometimes bring the client to and from the hospital or clinic (some require patients to have an adult companion). They can support the patient during the procedure by helping facilitate conversations with medical professionals as well as offering reassurance and listening without judgment.

Since medication abortion has become widespread — it's now used in more than half of all legal abortions in the U.S. — doulas also provide at-home support, either in person or via text, phone or video chat. SPIRAL's doulas offer patients after-care supplies to ease discomfort and follow up with a post-procedure check-in.

SPIRAL hosts two-day abortion doula trainings about twice a year, drawing about 30 to 50 attendees annually. Prospective doulas tend to be women in their 20s and 30s, who own a car and have capacity to volunteer their time. While the trainers focus on surgical and medication abortion processes and suggest comfort measures, there also is an emphasis on the psychological aspect of assisting abortion patients.

Mai'a Williams, who worked as a birth doula and a midwife before joining SPIRAL's leadership team, explains that the doula's role isn't to anticipate what the patient might feel — which could be relief, or guilt, or any number of other emotions.

"Your job is to be there as sort of an empty bowl, to be filled up by what they're actually feeling, without taking it in and making it personal," she said.

Patient care

L. is among the many abortion doulas who keep their work private because of threats of violence from abortion opponents and, in some states, legal risk. (In Texas, Oklahoma and Idaho, for example, people who assist abortion seekers can face civil or criminal lawsuits.)

As the eldest daughter of Hmong immigrants, she views caregiving as a core value, and became an abortion doula as a way to put that value into practice. In the past few years, she has assisted more than a dozen clients, many of whom have been Hmong people who appreciate her understanding of their cultural background.

L. says most of her assistance involves helping clients with planning and connecting them to resources. The common theme for her clients has been the many hurdles they face in securing an abortion, especially before several of Minnesota's abortion restrictions were declared unconstitutional in July 2022.

"The typical thing I hear from people is the frustration in navigating these systems: 'I have a waiting period,' 'I have to get judicial bypass,' 'I have to figure out child care,' 'I have to figure out how I'm getting somewhere,' " she said. "There's some frustration or anxiety or sadness about things that are beyond their control that make it much harder for their experience to be one of peace."

Empowering patients

Just the Pill, a Minnesota-based provider of medication abortion, has staff available to discuss emotional or physical concerns, but some patients prefer to connect with a doula who is outside "the medical industrial complex," explained Emily Clingan, the virtual clinic manager.

"Many people have discomfort or trauma surrounding hospitals and clinics, so some people are more comfortable with care in the context of their home," she said.

Doulas have helped Just the Pill manage an increasing patient volume, Clingan said, by assessing patients' symptoms to determine if they should contact a clinician. The doulas can also help patients feel a greater sense of agency.

"That's what's so empowering about doulas, is that care can look different for the individual and their needs, and it can be guided by the individual and not the other way around," she said.

While the doulas work on an individual level, their collective efforts can have a broader impact on equitable access to abortion. "Logistical navigation, providing knowledge and also providing emotional support and care — all of those are ways in which abortion doulas intervene on the inequitable landscape of abortion access, which perpetuates health inequities," said Hadija Steen Mills, a graduate research assistant at the University of Minnesota's Center for Antiracism Research for Health Equity.

Rowan Emmanuel, a longtime SPIRAL leader, says that as a queer, trans, BIPOC person, they appreciated how SPIRAL included and supported people with marginalized identities. Emmanuel noted that the work of abortion doulas isn't novel — though it might feel as if it is.

"What's new, if you put it in a larger context, is these current oppressive realities that we're living in," Emmanuel said. "In our current climate, this work is special because community is taking back care. This community is redefining the narrative and telling their stories."