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“You might feel some discomfort”, said the male doctor conducting my surgical abortion. ‘How fitting’, I thought, because everything before and after the procedure — including the 10 minutes spent staring at the ceiling while my pregnancy was being terminated — was uncomfortable. There was nothing peaceful about it, yet I was relieved. It was terribly burdensome, yet I felt liberated. However, the loneliness of the experience had no counterbalance.

A study published this year by Altshuler, et al., observed how societally there is a “preferential focus” on motherhood and as a result, there is a marginalisation of abortion. They noted how terminating a pregnancy is perceived as inferior to giving birth, subsequently people who have abortions, and those that surround them such as their family, friends and abortion providers and supporters, are stigmatised.

Furthermore, every year half of all pregnancies — 121 million — are unintended. This means the strengthening of contraceptive services and access to abortion care is needed at a much higher volume. Clinics that specialise in abortions don’t always offer the option of having a companion in-clinic, due to concerns over safety, privacy, restricted space, and limited staff resources.The study also noted that people cope better with an abortion if they feel supported by loved ones. However, there are not many studies focused on the emotional needs during abortion services.

Abortion Law

I live in South Africa, one of the 72 countries in the world that permit abortion on request, with an average legal gestational limit of 12 weeks. Here, the legal gestational limit for an abortion is 20 weeks. Globally, these are the statistics on abortion:

1) 24 countries prohibit abortion altogether.

2) 42 countries only permit abortion if the pregnant person’s life is at risk.

3) 56 countries only permit abortion on the basis of health and therapeutic grounds.

4) On the basis of liberally interpreted laws, 14 countries permit abortion under social and economic actual or foreseeable circumstances that may potentially impact a person’s life because of pregnancy or childbearing.

Abortion laws around the world differentiate dramatically and studies have found that people seeking abortions have low expectations for actual emotional and psychological care due to the stigma and controversy surrounding abortion.

International Safe Abortion Day

The 28th of September is International Safe Abortion Day. This day was initially celebrated in Latin America and the Caribbean in1990 as a day of action for the decriminalisation of abortion. In 2011, the Women’s Global Network for Reproductive Rights declared this day an international day. Due to legislature and politics, seeking a safe abortion has proven challenging for millions of people worldwide. Between 2010 and 2014, it was estimated that 45% of all abortions were unsafe. This means that the procedure for terminating the pregnancy was performed by people lacking the necessary skills, or in an environment lacking the minimal medical standards, or both. Consequently, up to 13% of yearly maternal deaths can be attributed to unsafe abortions.

There is no denying that correct medical attention is a vital part of a successful abortion. However, the reason why a grave portion of abortions are unsafe is based on legislature. Globally, conversations around abortion are still stuck in the legality of the procedure, and ethical and moral viewpoints, which has hindered any progressive steps towards how actual emotional care can improve.

Similar to other medical experiences, people generally appreciate companionship. Although emotional support is multidimensional, the study observed that often abortion stigma manifests itself as shame and embarrassment, which influences the pregnant person’s decisions about accompaniment. However, that should not be interpreted as a desire to be alone.

I was alone during my abortion. I had already made the decision before seeing the two pinkish lines on my pregnancy test. I had to scramble to raise funds for the procedure. Due to the high volumes of patients at the clinics, I had to wait two weeks before I could receive any medical attention. I woke up early that morning and drove myself to the clinic; everyone was professional but friendly. As we waited, the other pregnant people and I shared information about our pregnancies and what led us to our decisions. By asking me frivolous questions, the female nurse assisting the male doctor prevented me from shedding unexpected tears. After the procedure, I had some water and drove off to carry on with the business of the day.

The importance of abortion doulas

A couple of months later, I encountered the work of Zachi Brewster. She is an abortion doula, amongst other exciting things. I was captivated by the work she has dedicated herself to because it is the complementary component that was lacking from my experience.

The Doulas: Radical Care for Pregnant People study noted how, like birth doulas, abortion doulas provide dedicated support and fulfil some of the psychosocial needs for pregnant people. However, few abortion patients, like myself, have access to abortion doulas. Put simply by the study, it is institutional policies and practices that separate abortion patients from getting the support they need. This isolation contributes to structural stigmatisation “by establishing the norm that people having abortions should experience clinical care on their own, which in turn may send a message that they should take full responsibility for the pregnancy and the decision to end it and are undeserving of the benefits associated with [personal support].” So, perhaps a formal and progressive step towards destigmatising abortion both personally and socially would be to incorporate doulas into abortion care.

“There is not enough care in healthcare. You’ll receive the medical attention that you need, hopefully. But it is not necessarily caring,” said Brewster during our conversation. She spent five years of practice in isolation. Even though she found ways to connect with people experiencing an abortion, she, like a majority of abortion doulas, are not incorporated into medical healthcare institutions.

Brewster, therefore, decided to create a supportive online community platform that aims to redefine what a successful abortion looks like, by focusing on the emotional and physical care before, during, and after an abortion. Her online platform is called Dopo, meaning ‘after’ in Italian, which is often the forgotten part when it comes to abortion. The post-abortion experience is sometimes filled with stigma, silence, and a lack of support. Tools are available on the site to practice self-compassion, self-care, and to ask any questions to abortion seekers. Guided and self-guided support is also available to people at any point who are navigating an abortion. A sentimental touch to the online platform involves an inbox where people can leave anonymous love notes for abortion patients. Furthermore, Dopo provides honest and inclusive abortion education and training for everyone, and resources are made accessible for abortion providers.

During my conversation with Brewster, she magnified how abortion care is contextual. Due to abortion laws, the majority of abortion care is “underground” in order to avoid legal and social prosecution. So, how one fulfills the role is broad hence why finding data and information on abortion doula work is challenging.

The use of telemedicine that assisted in self-managed abortions during the global Covid-19 pandemic also shone a light on the various forms of abortion doula. Multiple people such as pharmacists, community health intermediaries, activists, non-profit organisations, hotline operators, friends, family members, and partners came together to ensure safe abortions for people during lockdowns, either legally or illegally. The work of an abortion doula is to support a pregnant person and this is exactly what this constellation of people have done, and keep doing. Furthermore, self-managed abortions have conjured discussions that emphasise the importance of a collective approach to abortion care. Essentially, Pizzarossa and Nandagirithe’s study, observes a much needed shift from a “medicalised and paternalistic model of abortion care” to one that focuses on the agency of pregnant people and their reproductive freedoms.

“In an ideal world, we would not necessarily need doulas,” said Brewster. But in the meantime, it is people like her that are expanding the idea of what a safe abortion looks like, holistically. So experiences like mine, and millions of others, can be more comfortable and safe.