|EDITED BY

Summer Martins,
Allina Health, United States
REVIEWED BYCharlotte Hord Smith,
Independent Researcher, Carrboro, NC,
United States
Jaime Cidro,
University of Winnipeg, Canada
Sarah Baum,Ibis Reproductive Health, United States
Zoe Josephine Darwin,
University of Huddersﬁeld, United Kingdom*CORRESPONDENCE
Alyssa Lindsey
alindsey72@gmail.com
SPECIALTY SECTION

This article was submitted to Contraception andFamily Planning, a section of the journal
Frontiers in Global Women’s Health
RECEIVED 10 June 2022
ACCEPTED 02 January 2023
PUBLISHED 01 March 2023
CITATION

Lindsey A, Narasimhan S, Sayyad A, Turner D
and Mosley EA (2023) “I can be pro-abortionand pro-birth”: Opportunities and challenges
for full spectrum care among doulas in Georgia.
Front. Glob. Womens Health 4:966208.
doi: 10.3389/fgwh.2023.966208
COPYRIGHT© 2023 Lindsey, Narasimhan, Sayyad, Turnerand Mosley. This is an open-access article
distributed under the terms of the Creative
Commons Attribution License (CC BY). The use,
distribution or reproduction in other forums ispermitted, provided the original author(s) andthe copyright owner(s) are credited and that theoriginal publication in this journal is cited, in
accordance with accepted academic practice.
No use, distribution or reproduction ispermitted which does not comply with theseterms.

TYPE Original Research
PUBLISHED 01 March 2023
DOI 10.3389/fgwh.2023.966208“I can be pro-abortion andpro-birth”: Opportunities andchallenges for full spectrum careamong doulas in Georgia
Alyssa Lindsey1,2*, Subasri Narasimhan1,2, Ayeesha Sayyad2,3,Daria Turner1 and Elizabeth A. Mosley1,2,3,4
1
Rollins School of Public Health, Emory University, Atlanta, GA, United States, 2The Center for Reproductive
Health Research in the Southeast, Emory University, Atlanta, GA, United States, 3Department of Health Policy
and Behavioral Sciences, Georgia State University, Atlanta, GA, United States, 4Division of General Internal
Medicine, Center for Innovative Research on Gender Health Equity (CONVERGE), University of Pittsburgh
School of Medicine, Pittsburgh, PA, United States

Background: The work of full spectrum doulas (i.e., non-medically trained care
workers offering support before, during, and after pregnancy including abortion)—isincreasingly important as abortion access decreases across the U.S. Few studies
have examined the work of community-based doulas in restrictive abortion settingsor how they might further incorporate full spectrum care. As part of thecommunity-engaged mixed methods Georgia Doula Study, this analysis examines
the scope of work of community-based doulas regarding full spectrum andabortion services, doula opinions on full spectrum and abortion work, and potential
barriers and facilitators for full spectrum doula care in metro-Atlanta, Georgia.
Methods: From October 2020 to February 2022, the team recruited 20 communitybased doulas with 8 who provide full spectrum services including abortion. Surveys
covered demographics, doula scope of work, family planning attitudes, andabortion stigma. Survey data were analyzed using descriptive and bivariate statistics.
In-depth interviews further explored those topics. They were de-identiﬁed andthematically analyzed using a semi-deductive approach.
Results: The ﬁndings are organized around ﬁve themes: (1) doulas of all kinds center
reproductive autonomy; (2) abortion doulas play important roles in reproductive
autonomy; (3) doulas have mixed feelings about contraceptive counseling; (4)abortion doulas provide diverse services carrying numerous beneﬁts in a
stigmatized environment; and (5) abortion doulas experience challenges including
stigma but they offer solutions. All but two doulas in this study were interested inlearning how to incorporate contraception and abortion services in their current
scope of work, and most participants supported the role of full spectrum doulas.
Conclusion: This analysis highlights the experiences of abortion and full spectrum
doulas, reactions of the larger doula community to those services, and facilitatorsand barriers to full spectrum doula care in a restrictive abortion setting. There areurgent needs and opportunities for full spectrum doulas to offer life-protecting
services to pregnant people across the U.S. and globally. Coordination efforts for
U.S. abortion care post-Roe v. Wade must include community-based doulas, who
are largely open to aiding abortion clients through education, connection to care,and emotional support.
KEYWORDS

abortion, contraception, doula, birth worker, stigma, family planning, full spectrum doula,abortion doula

Frontiers in Global Women’s Health01

frontiersin.org

Lindsey et al.

10.3389/fgwh.2023.966208

including their scope of work, the beneﬁts of that work, and any
facilitators or barriers for providing care. Community-based doulas
are those that are not afﬁliated with a hospital or clinic, but rather
focus directly on community members, often their own racial/ethnic group or in a particular geographic area (17). In global
settings where abortion has been historically restricted including
Argentina and Northern Ireland, community-based abortion doulas
have served pivotal roles in accompanying people when seeking
and accessing care (18, 19). Further research is needed tounderstand how community-based doulas can further integrate full
spectrum care (including abortion support) in restrictive abortion
settings—especially for socially marginalized community members.
The Georgia Doula Study (20, 21) is a community-engaged
participatory action research project (22) based at the Center for
Reproductive Health Research in the Southeast in Emory University’s
Rollins School of Public Health. Co-led by a doula-researcher and a
non-proﬁt community-based maternal and child health organization,
the study team conducted in-depth interviews and surveys withdoulas in metro-Atlanta, Georgia to understand: (1) How does thedoula community in metro-Atlanta view doula-supported abortion
services and abortion generally?; (2) How do abortion doulas
describe their services?; and (3) What are the facilitators and barriers
to accessing abortion doula support in metro-Atlanta?.

1. Introduction
Following the Supreme Court of the United States’ decision to
overturn Roe v. Wade and federal protection of abortion rights (1),each U.S. state now has the authority to regulate and even outlaw
abortion. In turn, restrictive and harmful abortion bans wererapidly implemented across Midwestern and Southern states
including Georgia, where House Bill 481 (HB 481) has now
outlawed abortion after embryonic cardiac activity (estimated at
6-weeks since last menstrual period) (1–3). Given this increasingly
restrictive abortion environment, the role of full spectrum doulas
offering abortion support is paramount but poorly understood.
A full spectrum doula, as deﬁned by the Birthing Advocacy Doula
Training (BADT) organization, is “a non-medically trained
community care worker who offers support to people during the full
spectrum of pregnancy—from preconception, to birth, to abortion,
to miscarriage, to adoption, to postpartum” (4). The scope of full
spectrum doula care can include supporting clients through in-home
visits, hospital or clinic accompaniment, emotional support, pain
management, education, and advocacy (4, 5). Birth doula
certiﬁcation is typically a lengthy and expensive process that involves
didactic courses as well as practical experience attending births (6).
Notably, abortion and full spectrum doula training is largely decentralized but is provided by doula training agencies like BADT,Dopo, and the Doula Project in New York City (4, 7, 8). Payment
for doula services also varies from doula to doula (with individual
doulas creating their pricing for each of their services as they seeﬁt), patient to patient, and state to state. In some cases, doulas are
funded by insurance (but never for abortion), paid out-of-pocket by
their client, or offered for free (pro bono) or through volunteer
organizations (4, 9).
The limited existing literature on clinic-based abortion doula careshows there are numerous beneﬁts including improved mental andphysical health, respect for reproductive autonomy, and reduced
demand on clinicians (11–16). Doulas use similar non-medical
services for their abortion clients as they would with other prenatal,birthing or postpartum clients such as “hand-holding, massage,
reassurance, providing guidance with breathing, educating about thenature of the procedure or engaging in conversation” [(12), p. 124].
These techniques lead to beneﬁts for clients as well as for physicians
and staff providing abortion care. Clients’ psychosocial needs are
met with abortion doula care and they are “afﬁrmed as moral
decision-makers” [(10), p. 111, (11, 13)]. Additionally, in studies
looking at doula support during ﬁrst-trimester surgical abortion,clients reported feeling their educational needs were met, and theyexpressed gratitude for their doula educating them on abortion andpost-abortion care (14, 16). For physicians and staff providing
abortion care, the presence of an abortion doula in the clinic allows
them to focus on technical aspects of the abortion procedure, whileknowing that their patient’s emotional needs are being met by theirdoula (15). Providers at high-volume abortion clinics may see many
patients throughout the day, but abortion doulas can focus on theirsingle client’s physical, emotional, and educational needs, offeringcontinuous support and guidance.
Less is known about community-based abortion doulas outsideof clinical settings, particularly in restrictive abortion contexts,

Frontiers in Global Women’s Health

2. Materials and methods
This mixed methods, community-engaged study is overseen by astatewide doula stakeholder steering committee with representationfrom community-based doulas, hospital administrators, clinicians,
insurance payers, and policymakers. The doula stakeholder steeringcommittee ﬁrst identiﬁed the need for a Georgia Doula Study thatinterviews and surveys doulas across the state to support policy
advocacy for doula access, integration of doula care into hospitalsystems, and increased community awareness of doula care. The
steering committee provided guidance on study design, assisted withrecruitment, helped to interpret results, and aided dissemination tocommunity, clinical, hospital, and policy stakeholders.

2.1. Study design and recruitment
This project uses a cross-sectional, observational design andconcurrent mixed methods (qualitative and quantitative). Participant
recruitment and data collection for the larger study occurred from
October 2020 to November 2021. For this sub study, participant
recruitment occurred speciﬁcally during August to November 2021.
Participants were purposively sampled and recruited through emails
to the doula stakeholder steering committee, abortion clinics, andlocal reproductive health and justice organizations in metro-Atlanta.
The research team originally surveyed and interviewed seventeen
doulas between October 2020 and February 2021. In the fall of2021, additional measures on family planning and abortion wereadded to the interview guides, and previous participants were recontacted. Fourteen previous participants were re-interviewed; andthree additional participants were interviewed and surveyed for a

02

frontiersin.org

Lindsey et al.

10.3389/fgwh.2023.966208

non-clinical professional degree, or other. Current employment wasmeasured as full-time, part-time, not employed, and not looking,and not employed and looking. Sexual orientation was measured as(check all that apply) lesbian, gay, bisexual, queer, straight/
heterosexual, don’t know/questioning, self-describe, or prefer not toanswer. Immigration status was measured as (check all that apply)
my parents and grandparents were born in the U.S.; one or moreof my grandparents were born in the U.S.; one or more of myparents was born in the U.S.; I was born in the U.S.; or prefer not
to answer. This was further categorized into not an immigrant(self, parents, and grandparents born in the U.S.), ﬁrst-generation
immigrant (born in U.S. but not parents or grandparents), or
second-generation immigrant (self and one/more parents born in
the U.S. but not grandparents).
Participants were also asked how long they had been a doula (years
and months), what trainings and/or certiﬁcations they have completed,
and what kind of doula services they provide. Doula services provided(check all that apply) were preconception/fertility, prenatal, birth,
postpartum, abortion, full spectrum, radical/justice, death/grief/loss/
bereavement, prison, or other (specify). Preconception/fertility
services include supporting clients, who are trying to become
pregnant. Prenatal services include supporting clients through theirpregnancy before childbirth. Birth doula services can include theprenatal period but focus on emotionally and physically supportinga client through their childbirth. Postpartum services can be wideranging and include emotional support, cooking, and cleaning for aclient or offering newborn care during the months following a birth.
Abortion doulas support clients through pregnancy termination
experiences (12). Full spectrum doulas typically offer morecomprehensive services, often including prenatal, birth, postpartum,
abortion, and miscarriage support (21, 23). Radical/justice doulas
can provide a variety of doula services, but with a speciﬁc lens ofclient empowerment, advocacy, and Reproductive Justice (21, 24).
Death/grief/loss/bereavement doulas offer emotional services toclients who are either personally dying or are close to a person who
was dying or deceased (25). In some cases, this includes clients who
had a miscarriage, stillbirth, or infant loss. Participants were also
asked what percentage of their client base received which doula
services.
All doulas were asked questions that assessed their abortion stigma(See Supplementary Appendix A for survey items). Abortion stigma
was measured using a revised version of the Stigmatizing Attitudes,
Beliefs, and Actions Scale (SABAS) with 37 items (26). The survey
also measured abortion provider stigma (27, 28) through a revised
Abortion Provider Stigma Scale (APSS) with 13 items whereabortion doulas were asked to “indicate how often you have felt or
experienced the following” and given various prompts(Supplementary Appendix A) (27). Additionally, our revised APSS
measured 3 subscales: “disclosure management” (6 items),“discrimination” (2 items) and “resistance and resilience” (5 items).
“Disclosure management” refers to the process of deciding whether
to share or hide one’s identity as an abortion worker, which canlead to silencing and isolation; “discrimination” refers to judgement,poor treatment, and social exclusion because of one’s work inabortion care; and “resistance and resilience” refers to positive
aspects of abortion work including commitment to a mission toserve those in need (27, 28). Higher scores on the overall APSS andtotal of twenty doulas. Notably, some doulas could not be re-contacted
for interview, and two discontinued participation in the study due tothe nature of questions regarding family planning and racial
discrimination. One participant explained they did not see abortion
as within the scope of doula care and were made uncomfortable by
the survey questions about abortion, while the second participant(white) was uncomfortable with the questions about racism anddoula care. All participants were given an additional $20 forcompleting the additional survey and interview. If a participant
completed the survey, but was not available for an in-depth
interview, they were still compensated for their time with a $20 giftcard. Thematic saturation was reached after 20 participants, when
the academic-community study team collectively agreed that no newdata were being collected after multiple iterative cycles of collection
and analysis.

2.2. Procedures
Potential participants were ﬁrst screened for eligibility, which
included practicing as a doula in Georgia for at least six months
and being over the age of 18. While not an original criterion of thestudy, all participants were community-based doulas. Eligible
participants were then consented for participation, given a survey
link, and scheduled for an in-depth interview lasting on-average
60 min. If participants did not respond after two follow-up
outreach emails from a member of the study team, they weredeemed unreachable. Survey data was collected using Qualtrics andno identifying information was collected: all names were replacedwith anonymous participant ID numbers. Interviews wereconnected on Zoom, audio recorded, transcribed verbatim, and deidentiﬁed. All study participants interacted with one of two
graduate research assistants (AL and AS), who were responsible forparticipant recruitment, screening, and interviewing.

2.3. Instruments
2.3.1. Survey measures
The survey (see Supplementary Appendix A) measured
demographic information including gender, race/ethnicity, age,economic status, highest level of education, current employment,
sexual orientation, and immigration status. Gender was measured
as (check all that apply) female/woman, male/man, transgender,
genderqueer, nonbinary, or self-identify. Race/ethnicity wasmeasured as (check all that apply) Black/African American,
Hispanic/Latinx, Asian/Paciﬁc Islander, American Indian/Alaskan
Native/Native Hawaiian, Biracial/multiracial, White, Other(specify), or prefer not to answer. Age was measured as under 25,
25–25, 36–45, 46–55, Over 55. Economic status was measured as“difﬁculty affording necessities such as education costs, food,clothing, transportation, housing, and medical care” with response
categories: yes, currently; yes, in the recent past (within 3 years);
yes, in the past for a limited period of time; yes, historicallythroughout my life; no; or prefer not to answer. Highest level of
education was measured as high school or less, some college,
graduated college, graduate degree, clinical professional degree,

Frontiers in Global Women’s Health03

frontiersin.org

Lindsey et al.

10.3389/fgwh.2023.966208

the “disclosure management” and “discrimination” subscales indicatedhigher levels of stigma while a high “resistance and resilience” subscalescore indicated higher resilience (27).

3. Results
Five key themes were identiﬁed: doulas of all kinds center
reproductive autonomy, abortion doulas play important roles in
reproductive autonomy, doulas have mixed feelings about
contraceptive counseling services, abortion doulas provide diverse
services and carry numerous beneﬁts, and abortion doula
experience challenges including stigma but offer solutions.

2.3.2. In-depth interview domains
In-depth interviews covering the topics of abortion andcontraception were conducted with 20 participants. The domains
included abortion doula training, clientele and payment, abortion andcontraceptive counseling services, abortion and contraceptive stigma,
and experiences of racism or other discrimination (seeSupplementary Appendix B). Doulas that reported offering abortion
services were asked to go into detail on their abortion andcontraception services, while other doulas were asked to describe theirthoughts on abortion doula care, abortion, and contraception broadly.

3.1. Demographic information
The doulas sampled for this research project were diverse in termsof race/ethnicity, gender identity, age, and other key demographic
information. As shown on Table 1, about half of the doulas wereBlack/African American (9, 45%) and white (8, 40%) with somedoulas reporting their race as Hispanic/Latinx (1, 5%) or Other (1,10%). While nearly all doulas reported their gender identity as cisgender female, two doulas reported identifying as nonbinary or
genderqueer. Additionally, around half of these sampled doulas
reported being between 25 and 35 years of age (8, 40%), neverexperienced economic difﬁculty (10, 50%), and had attained acollege degree (9, 45%). Nearly all doulas reported being employedfull-time (12, 60%), being straight/heterosexual (16, 80%), spoke
English as their primary language (18, 90%), and did not identify as
an immigrant (17, 85%).
The participants of this study varied in their doula service
characteristics from their time to serving as a doula, the type ofservices they offer, and whether they were certiﬁed (Table 2).
About half of the participants (9, 45%) had been serving as adoula for 1–3 years and a quarter (5, 25%) for more than 3 and up
to 9 years. A third of the doulas reported offering services for lessthan 1 year (2, 10%) or more than 9 years (4, 20%). A majority(14, 70%) of doulas reported being certiﬁed. When asked about
their available doula services, participants ranged widely in thetypes of services they offered. In fact, doulas often reported that
their scope of work included more than one type of care. These
services included preconception/fertility (7, 35%), prenatal(9, 45%), birth (17, 85%), postpartum (12, 60%), abortion (7, 35%),
full spectrum (8, 40%), radical/justice (4, 20%), and death/grief/
loss/bereavement (4, 20%).

2.4. Data analysis
Data analyses on the 20 interviews and survey covering abortionand family planning were conducted from November 2021 to
February 2022. Descriptive and bivariate analyses of quantitative
data employed Stata v.14 (29). Frequencies and proportions were
calculated for categorical variables (ex: type of care provided),
while means with standard deviations were calculated forcontinuous measures (ex: abortion provider stigma). Independentt-tests were conducted to analyze group differences (e.g., abortion
attitudes by type of doula).
In-depth interview transcripts were cleaned of errors and deidentiﬁed before coding was conducted via online, qualitative
software Dedoose v.7.0.23 (30). Team members used memo-ing
techniques to summarize the main content of each interview andidentify the top ten emerging topics of interest from all interviews.
The comprehensive list of emerging topics augmented an existingcodebook from the previous round of data collection. The team useda semi-deductive coding structure that resulted in both deductive
and inductive codes about abortion, contraception, training, doula
scope of work, building doula businesses, underserved populations,payment, challenges, client stories, beneﬁts of doula care, medical
outcomes, ways to improve doula care, COVID-19, anddiscrimination. Two members of the study team coded 1/3 of thequalitative transcripts together, met to reach consensus and clarify
the codebook and its application, then individually coded theremaining transcripts separately. The coding group then developed
analytic memos for each code in order to develop themes within
and across codes. This process was supported by additional analyses
within Dedoose including code co-occurrence and matrices.

3.2. Doulas of all kinds center reproductive
autonomy

2.5. Ethical considerations

All participating doulas were asked questions about abortion andcontraceptive counseling services in the communities that they
served, which revealed a theme that the doula community supports
reproductive autonomy for their clients including (largely)abortion. While most participants were outwardly supportive of therole of abortion doulas, this support did not always translate to aninterest in incorporating abortion or contraceptive counseling aspart of their regular doula offerings.

The study protocol and materials were reviewed by the Emory
Institutional Review Board (IRB) for human subjects’ ethicalclearance, and the study was deemed exempt because the humansubjects’ identities are not easily identiﬁed, and any disclosureswould not place the subjects at risk of damages [see rule 45 CFR
46.104(d)(2i((2ii)].

Frontiers in Global Women’s Health04

frontiersin.org

Lindsey et al.

10.3389/fgwh.2023.966208

TABLE 1 Baseline Characteristics of Community-based Doulas Surveyed andInterviewed in metro-Atlanta Georgia from October 2020 to February 2022
(N=20)TABLE 2 Summary of doula service characteristics of community-based
doulas surveyed and interviewed in metro-Atlanta Georgia from October
2020 to February 2022 (N = 20).

Variable

Variable

Frequency Percent

Race/Ethnicity

Frequency

Percent

Time as Doula

Black or African American

945%

Less than 1 year

2

10%

White

8

40%

1–3 years

945%

Hispanic or Latinx

15%More than 3 and up to 9 years

525%

Multiracial

2

10%More than 9 years

420%

Cis-gender Female

18

90%

Preconception/Fertility

735%

Nonbinary or Genderqueer

2

10%Prenatal

9

45%

Birth

17

85%

Under 25

1

5%

Postpartum

12

60%

25-35

8

40%

Abortion

7

35%

36-45

7

35%

Full Spectrum

840%

46 or Older

4

20%

Radical/Justice

4

20%

Death

4

20%

Prefer not to say

1

5%

Certiﬁed

1470%

Currently experiencing economic difﬁculty

15%

Experienced economic difﬁculty in the past/historically3

15%

Experienced economic difﬁculty temporarily

525%

Never experienced economic difﬁculty

10

50%

Some college/technical degree

420%Non-clinical professional degree210%Graduated college

945%

Clinical professional degree210%Graduate degree

3

15%

Yes, full-time or part-time

15

75%

No, not looking for employment

315%No, looking for employment

210%Straight/heterosexual

16

80%

Bisexual

1

5%

Queer

2

10%

Lesbian1

5%English

18

90%

Other

2

10%

Not an immigrant

17

85%

First generation immigrant

3

15%

Gender Identity

Type of Doula

Age

Economic Status

3.2.1. The role of an abortion doula in reproductive
autonomy
As demonstrated in Table 2, participants varied widely in thecharacteristics of their doula services, with only 7 self-identifying
as abortion doulas and 8 as full spectrum. None of the abortion
doulas were based in clinics, but rather worked as private,community-based doulas that found their clients through social
media, word-of-mouth, or knowing them personally. Regardless of
their scope of work, all participants were asked to describe the roleof an abortion doula, including how the larger doula community
perceived those who provided abortion services. Most surprising
was the overall support of abortion services from non-abortion
doulas. One such doula who offered exclusively birth andpostpartum services, Brenda, stated

Education

Employment

Sexuality“I think there should be a doula for everything… I just feel like[for] everything, especially important things around family,
doulas are amazing. I’m in awe of abortion doulas. I’m happy
to hear that there is such a thing.”

Primary Language

Despite Brenda’s role as primarily a birth/postpartum doula, shevoiced support for doulas that provided abortion services. Other nonabortion doulas also seemed supportive of abortion doula care andthe potential beneﬁts for clients. One such non-abortion doula,
Taylor, commented on the opportunity abortion doulas had toprovide all-options counseling to clients for them to make anempowered decision,

Immigration Status

Frontiers in Global Women’s Health05

frontiersin.org

Lindsey et al.

10.3389/fgwh.2023.966208“I think that mothers need to be given all of their options before
they make a decision to have an abortion. So, I feel like doulas doneed to be there to support if they choose to have an abortion,but on the other hand … let’s ﬁnd resources of people who can
support you if you’re low income. Let’s ﬁnd an adoption
agency if you want to go that route. I don’t think thatabortion is the only answer or the only option for a lot of people.”

TABLE 3 Summary of contraceptive counseling services by communitybased doulas surveyed and interviewed in metro-Atlanta Georgia from
October 2020 to February 2022 (N = 20).

VariableThis call for all-options counseling continued with nonabortion doulas describing what they thought abortion services
looked like and how they personally viewed abortion doulas.
Annie, a doula serving primarily birth and postpartum clients,
expressed her thoughts on the abortion process and the role of
the abortion doula,

Percent

Offers Contraceptive Counseling945%

Trained in Contraceptive Counseling

630%

Does not currently offer contraceptive counseling,but is interested

2

10%

Prenatal

525%

Anytime8

40%

Client’s Request

4

20%

Postpartum

2

10%

Outside Scope

1

5%

Contraceptive Counseling Timing“I think it’s a difﬁcult decision to make [having an abortion],and that they [abortion clients] need support in a lot of ways
during that process … holding their hand while they’re making
that decision, helping them get the resources and then also
being there for them during and then those weeks to months
afterwards.”

as the postpartum piece of their birth preferences like, ‘Okay…
these are some things for you to think about postpartum andafter you have the baby. One of these is birth control, if they
haven’t already asked you, they will. And you need to be awarethat they will ask about it and you need to start thinking about
what you want.’”

3.2.2. Mixed feelings on contraceptive services
While a majority of participants asserted that a doula’s role is tosupport reproductive autonomy, some did not see the doula scope ofwork as including contraceptive counseling. About half (9, 45%) of
the participants reported offering family planning counseling, athird (6, 30%) were trained in contraceptive counseling and some(2, 10%) were not currently offering contraceptive counselingservices but were interested in the future (Table 3). Doulas weremixed on when to begin providing family planning services withjust under half (8, 40%) simply stating that anytime was the righttime to provide family planning support.
Brenda explained why she doesn’t offer contraceptive counselingand hasn’t pursued training in contraceptive counseling,

Overall, participants agreed that the role of a doula is primarily tosupport clients in making informed, empowered decisions throughmajor life changes including births, the postpartum period, orabortions. While this theme of support for reproductive autonomy
was evident, contraceptive counseling continued to be a point ofdisagreement among participating doulas, with some who wereinterested in offering or were already offering this support andothers who had no interest in providing that support in the future.
Doulas that provided abortion or contraceptive counselingservices were asked to describe their interactions with clients. Mostof these doulas also provided abortion services. Mira described herthoughts on how these services intersect,“It doesn’t feel like it falls under the umbrella of the scope of adoula. Unless it happens to come up, you know, and then, ofcourse, talking to supporting families than that would apply but
I’m not sure that speciﬁcally contraception feels like it would beunder the doula umbrella.”“It’s not an easy decision to have an abortion by any means andmost people are not just casually throwing that out there like, ‘Oh
it’s going to be my form of birth control’. That’s not a thing … It is
important to talk about sexual health after those things[abortions]. If you’ve had a miscarriage or a loss, what was thatjourney of getting pregnant? Was that a conscious decision? Was
it an accident? How do we prevent future accidents if that’s notwhat you’re looking for?”Some doulas discussed personal experiences of Black and Brown
clients being targeted for family planning and referenced thehistorical mistrust of the medical system in general due to thehistory of reproductive coercion for Black/brown communities. As
a result, many doulas of color were hesitant to bring these topics
up with their clients or receive further training on contraceptive
counseling.
At the same time, Bailey (a Black full spectrum doula) explainedthat she provides contraceptive counseling precisely because of thecontraceptive coercion Black clients face,

Other abortion doulas reported not offering contraceptive
counseling services but were interested in beginning thatconversation with their clients. Alex, a postpartum, birth, andabortion doula, talked about opportunities to engage postpartum
clients in family planning counseling,“I know that that’s something postpartum folks have a hard timeﬁguring out, how to prevent pregnancies after just having apregnancy … some people believe, ‘If I breastfeed, I won’t get
pregnant’. And it’s like, well, you might!”“Research shows that Black birthing folks are asked about longacting reversible contraceptives earlier and more often thanwhite folks. So, I make sure to bring it up with my clients as far

Frontiers in Global Women’s HealthFrequency

06

frontiersin.org

Lindsey et al.

10.3389/fgwh.2023.966208

abortion doula, talked about the experience of a doula-supported
abortion being necessary because

3.3. Abortion doula services and beneﬁts:“Holding space” and much more“… for a lot of people abortion can be really isolating … they’re theonly one whose body is going through the experience of pregnancy
and so, even if there is a partner or a friend or a community
member who can hold their hand or be there with them, I thinkit can still feel really isolating. And I think the average person
doesn’t always know how to hold space for that or how to say
the right thing … I think the holding space can be important.”

All abortion doula participants were asked to describe theirservices and experiences with clients. While none of these doulas
reported supporting client in an abortion clinic, they described arange of services they provide as well as how their services
beneﬁted clients overall.

The idea of “holding space” for clients continued in otherabortion doula’s descriptions of their services. Doulas who reported
offering both birth and abortion services noted how the range ofemotions experienced by clients was not always so cut and dry.
This made it even more important to hold space for clients to fully
process their emotions, physical pain, and/or other reactions totheir major reproductive experience. Alex described this as,

3.3.1. The scope of abortion doula services
Abortion doulas described their services as mainly walking
clients through the process of abortion by providing physical
comfort, emotional support, educational resources, and “holding
space” for clients to process their abortion experience—that is, anemotional presence that communicates a felt message of trust,empowerment, witnessing, and understanding (16). Nicole
described her usual abortion services as ﬁrst working with the client“Yes, it’s about holding space for what folks are experiencing
physically because it hurts … but also the range of emotion thatcan exist. And that’s not just sadness. Folks assume typicallythat when folks come home with a baby, they’re either throughthe sky, elated and happy and then if someone just comes homefrom having a miscarriage or an abortion that they are
distraught … there are these assumptions around what emotions
look like and that’s not it. So, I really try to make sense of what
the emotional status of my client is and help them cultivate acare plan.”“… to formulate a plan. So that way they experience a reﬂecti[on]of whatever they want. Like I said, everybody’s abortion is not thesame … some of them are at home. Some of them are at thehospital, it just really depends on how it’s done and what theyneed. What level of comfort they need. Sometimes they need thephysical comfort and support of being there.”
Several abortion doula participants afﬁrmed the need for clientsto be given space and resources to make the decision that is best forthem. Bailey stated,

Abortion doulas all described their services as tailored to theclient’s abortion experience and personal needs which could
include emotional, physical, or educational support. “Holding
space” was an important aspect of their offered services, allowing
for clients to process their abortion experience without judgement
or stigma.

“… in a person’s life being pregnant or choosing to have an
abortion or even going through the fertility process, that’s just
one small part of their life. They have 20,000 other things goingon and the doula is the person that’s like, ‘Hey, I have this twohour block set for us to only focus on your pregnancy’ … I thinkthat’s a big piece, holding space to acknowledge the thing that’s
happening, whatever the thing is.”3.3.2. Abortion doula beneﬁts and client stories
Abortion doula participants recognized that the goals of theirservices were similar to the goals of birth, postpartum, or death
doulas. These goals were described as “holding space,” providing
support, and encouraging education. Nicole, an abortion doula,described this as,

While abortion doulas described their care as being personalized
to their client’s needs, several key beneﬁts emerged throughout thediscussion of their work. Reagan, an abortion and full-spectrum
doula, discussed these beneﬁts as,“I believe that it’s having that outside person that’s not going tohave a judgment. That you can share your real, raw emotions
with and know that no matter what decision you choose to
make, they’re still going to be there… to be able to help you ﬁnd
the right clinic… helping ﬁnd funding because there’s a lot of
people who don’t have the funding to get an abortion…
explaining to somebody what’s going to happen and the things
after.”“… the same thing as a birth doula … they [the client] alreadyhave whatever process they’re going to have lined up, whether it
be a D&C [Dilation and Curettage], whether it be taking thepills … they already have it lined up. I just help them formulatea plan. So that way their experience is honored in the way theysee ﬁt … my goal is to provide them with an emotional andphysical presence and then just being there, allowing them toprocess their feelings and making sure they have other resources.”

Reagan’s overview of abortion doula care beneﬁts is important as
it shows that while abortion doulas may seem to only be serving
clients in a short, time-sensitive window, the beneﬁts of their care
expand to before and after a client’s abortion experience. Bailey

Abortion doulas also described varying their services based on
the speciﬁc needs of the client and the context of the abortion
experience. While these services varied widely, Bailey, an

Frontiers in Global Women’s Health07

frontiersin.org

Lindsey et al.

10.3389/fgwh.2023.966208

shared a speciﬁc abortion client’s story, highlighting the beneﬁts of
doula support before, during, and after a procedural abortion,

provided their services pro bono. Imani, a long-time abortion
doula, discussed this in more detail,“My client was 24 or 25 weeks along and we had to travel toMaryland because I think the cut off in Georgia is 20 weeks or
22 weeks [at the time] … we raised the money to pay for the
Airbnb and all the things. I helped them fundraise to be able tocover the abortion and lodging and travel and all that, and thenI also served as their abortion doula. It was a two-day
procedure, so I traveled with them and then we were in the
Airbnb together. I went to the clinic with them - I couldn’t go
in because COVID, but I was basically in the waiting room forthe entire two days. They [the abortion providers] let me comein during the actual procedure … and hold my client’s hand.
And then the aftercare as far as making sure that the anesthesia
wears off okay and that they have enough food and water andthings like that. I made a belly oil … to rub on their belly andcabbage leaves on their breasts where it felt uncomfortable orfelt painful and then I followed up a couple of weeks later.”“The major challenge, I would say, is just them [the client] being
able to pay for it … the client’s ability to afford it, to pay for it, andto count it as a necessity … it’s tough … like I said, every abortion
doula client that I’ve had was pro bono … and of course I did thatso that I can get the experience, but also because the need wasthere and I don’t like to turn people away just because they
can’t pay.”
This challenge to afford abortion doula services was even more
difﬁcult when considering the cost of an abortion procedure andparticular client circumstances. Reagan highlighted the factors
contributing to the issue of funding by stating that“… a lot of young people don’t have, like, an extra $250 to $500 orwhatever laying around, especially if they’ve already had to accesscare related to the thing. Like if they’ve needed to go and get an
abortion … I think it’s deﬁnitely ﬁnancial because I know rightnow, if I got pregnant, I wouldn’t be able to afford a doula.
And I am one.”

Bailey’s client’s story highlighted the wide range of beneﬁts thatabortion doula care offers clients during their abortion experience,
especially when facing restrictions that force inter-state travel.
From navigating those restrictions, raising funds, and evenphysically supporting where possible, the beneﬁts are impactful andcrucial to ensuring a client has access to a safe and timely
abortion. Alex also shared an experience supporting an abortion
client and what the beneﬁts of doula care looked like,

Reagan points out that most people, even doulas, would not beable to afford an abortion procedure and doula support. This is amajor challenge to accessing abortion doula support, especially for
low-income, young, or otherwise impacted clients.

“I think being able to process is really important, like being able tojust take time and space to process. And sometimes that looks likesaying nothing and literally saying nothing. I don’t think that myclient and I spoke much at all that night, like with everything that
we were doing in the space and we sat together. She got a backmassage from me … We did yoga, we painted, we created a fortin the living room and engulfed ourselves in things that were
stress-relieving and comforting. I think it’s having a container toprocess and hold emotion.”

3.4.2. Lack of awareness
Another main challenge was lack of awareness of abortion doula
services. Abortion and full-spectrum doula, Mira, described thischallenge in the context of the client accessing care,“… most people who are getting abortions aren’t looking forabortion doulas. That’s the big thing … it’s not a common
practice, it’s not something that’s easily advertised or sold as aservice.”

These stories highlight the ways in which abortion doulas are able
to effectively meet the needs of their clients and improve their overall
abortion experiences.

Abortion doulas then speculated that providers were also
unaware of abortion doulas and their potential beneﬁts. Lisa
discussed abortion provider lack of awareness as,

3.4. Abortion doula challenges and solutions“I’ve never spoken with providers who provide abortion services.
I’m not sure that it’s in their lexicon of what an abortion doulais … when you even say the word ‘abortion doulas’ they
[abortion providers] would probably say, ‘It’s not anything I’ve
ever heard’.”

Accessing and providing abortion doula services do not comewithout challenges. When asked to describe the challenges clients
may face in accessing their services, abortion doulas
overwhelmingly agreed on three major challenges: affordability ofservices, lack of awareness, and abortion stigma.

Abortion provider lack of awareness can impact the abortion
experience of clients, especially when looking for ways to besupported during their abortion experience. Even more challenging
is the lack of awareness that doulas and birth workers haveregarding the ability to support clients during abortion experiences.
Alicia, a doula interested in providing abortion services, described
her ﬁrst time meeting an abortion doula as,

3.4.1. Financial challenges
Doulas explained that one of the main challenges, especially forclients who need to pay out-of-pocket for their abortion, wasﬁnances. Due to the inability of clients to afford both an abortion
and a doula for that abortion, many abortion doulas in this study

Frontiers in Global Women’s Health08

frontiersin.org

Lindsey et al.

10.3389/fgwh.2023.966208“I had already been a doula and training and stuff, and I had
never met … someone who was an abortion doula and [theytalked] to me about that [abortion doula support] and I wasjust like, ‘Oh my gosh’ … So yeah. I deﬁnitely think not a lot of
doulas are offering this type of service.”

Survey results indicated that stigmatizing attitudes, beliefs, andactions about abortion (SABAS) were low with a mean of 22.29
out of an 18 to 40 scale (Table 4), where higher scores indicate
more stigmatizing attitudes, beliefs, and actions about abortion.
Abortion doulas reported slightly lower mean SABAS than otherkinds of doulas (20.8 vs. 23.1), but these differences were notstatistically signiﬁcant (t = .65, P = .53)
At the same time, survey results revealed a relatively high overall
abortion provider stigma scale (APSS) score with a mean of 24.00 out
of a 17 to 27 scale (Table 4). Abortion doulas reported moderate
disclosure management (mean score of 10.86 out of a 7 to 15
scale), low to moderate discrimination (5.86 out of a 5 to 7 scale),and moderate resistance and resilience (mean of 7.00 out of a 4 to
11 scale) (Table 4).
When doulas reﬂected on the possible stigma perpetrated by thelarger doula community, most believed that their doula community
was accepting of abortion doulas. However, some like Annie felt
there were negative perceptions of abortion doulas:

Lack of awareness also led to misconceptions of abortion doula
support by non-abortion doulas. Annie, a birth and postpartum
doula who expressed interest in learning more about abortion
doula support, talked about the volunteering she does related toabortion,“I do volunteer at a place… it’s technically an anti … I teachclasses, I don’t do the counseling side of it because they’re a prolife clinic. But they gave me little tidbits and things like that,
I’m not trying to convince them [clients] not to have an
abortion, so we don’t necessarily align there.”
Faith-based doulas, like Taylor, also expressed an interest inabortion doula work but only after the abortion experience under
the assumption that abortion patients will struggle with theirdecision:“Probably not well … because a lot of doulas are, although somedoulas are very open, I think a lot of doulas come from like
upper middle-class families that are … you know. They justwouldn’t do that in our area.”“It [abortion doula work] is something that I’m interested in. I,
obviously as a Christian, I don’t agree with abortion. But I
would like to be in a professional place and be able to assist if
somebody is struggling after what happened … after they madethat decision, something like that.”

This stigma was not just felt from the doula community, but also
from the participant’s larger community of friends, family, andspiritual leaders. Regan described,“I got a phone call from my spiritual teacher, “Oh my gosh, you
cannot say that! You cannot say that you’re promoting
abortions!”. And I said, I’m not promoting anything! I am
saying, if you are in that situation, I am here to help.”

3.4.3. Abortion stigma
Misconceptions around what abortion doulas do like thosehighlighted in the previous section, stem from larger abortion
stigma. Abortion ban policies, such Texas’s SB 4 and SB 8 bills andGeorgia’s embryonic cardiac activity (estimated 6 weeks) abortionban following the Supreme Court decision to overturn Roe
v. Wade, perpetuate abortion stigma. Several doulas reﬂected on
the impact of restrictive bans on their doula services. Imani stated,

Despite stigma felt by abortion doulas, participants described
their desire to continue working in the abortion space as both adoula and advocate. Alex described this desire in the context of
their work as both an abortion and birth/postpartum doula,“… there are just too many reasons that abortion care should beaccessible. You’re not going to change my mind about that. And
I think what really confuses people with me in particular is“… with all the legislation that’s being passed … maybe trying toﬁgure out the workarounds and making sure that we don’t getin trouble or sued. How we will be able to help people and notendanger our own selves … I’m really concerned about that. I
don’t want to – if we [Georgia] turn into Texas, I don’t want tobe sued by some random John walking down the street for$10,000 because of my job.”

TABLE 4 Abortion attitudes, beliefs, and actions Among community-based
doulas surveyed and interviewed in metro-Atlanta Georgia from October
2020 to February 2022 and their experiences of abortion provider stigma.

Georgia also has a history of restrictive abortion bans (e.g.,
mandatory counseling, mandatory waiting period, and at ﬁrst a
22-week limit now brought down to the estimated 6 weeks) that
impact the way that abortion doulas interact with clients andabortion providers. Lisa explained,“… there are very few providers that could give any information oreven would give any information for fear of retribution or
backlash on abortion services, especially here in Georgia.”

Frontiers in Global Women’s Health09

Variable

Obs

Mean

Std.
Dev.

Min

Max

Stigmatizing Attitudes,
Beliefs, and Actions Scale(SABAS) Total

14

22.29

6.27

18

40

Abortion Providers Stigma
Scale (APSS) Total

7

24

3.32

17

27

APSS DisclosureManagement

7

10.86

3.34

7

15

APSS Resilience

8

7

2.67

4

11

APSS Discrimination

8

5.86

.83

5

7

frontiersin.org

Lindsey et al.

10.3389/fgwh.2023.966208

augment recently published media articles and commentaries
discussing the impact of abortion doula services, typically inresponse to issues such as COVID-19 and the proliferation ofabortion restrictions in the U.S (31–33). Some argue that
community-based abortion doula services can overcome stigma andrestrictions by providing factually correct educational materials totheir clients and supporting them in ﬁnding accessible and safe
abortion. Internationally, lay community health workers havealready been shown to provide informational support andprocurement of pills for self-managed abortion (34). COVID-19 has
made it even more necessary for community care workers likedoulas to provide support during a potentially isolating andstigmatizing abortion experience, especially in areas where restrictive
abortion laws are being implemented (33). Moreover, studies about
abortion restriction impacts on marginalized communities—like thereproductive justice community-led Georgia Medication Abortion
study with Black and Latinx women—emphasize the importance ofabortion doulas in educating and supporting disadvantaged pregnant
people to access safe abortion care (35).
Most of the participating doulas endorsed abortion care as one
way to support pregnant people’s reproductive autonomy throughan often-stigmatized reproductive health decision. Non-abortion
doulas expressed interest in supporting abortion clients, but were
not currently doing so. However, it was unclear if this was due tolack of awareness (about opportunities to get trained and providecare) or stigma surrounding abortion work. In the future, doula
training and certifying organizations must include abortion and full
spectrum support in the scope of work. Similarly, efforts tocoordinate abortion care nationally must include community-based
abortion and full spectrum doulas, who are connecting patients to
information and care. Given the changing post-Roe landscape,abortion and full spectrum doulas are increasingly vital resources forpeople accessing abortion, especially in restricted and criminalized
settings like Georgia.
In the U.S. and globally, restrictive abortion policies embody,
exacerbate, and enact abortion stigma, which is felt not just by
abortion patients but also providers and—the current ﬁndings
would suggest—doulas (28, 36, 37). This study is the ﬁrst tomeasure stigmatizing abortion attitudes of doulas using the
SABAS (26) as well as the abortion provider stigma felt by
abortion doulas using the APSS (27). Our results show that,
overall, doulas do not have stigmatizing attitudes, beliefs, or
actions about abortion which suggests they are supportive of theirclients, regardless of pregnancy outcome. On the other hand, themoderate to high abortion provider stigma scores suggest thatabortion doulas are experiencing stigma, particularly in the formof disclosure management more so than overt discrimination. Thissuggests that abortion doulas are having to carefully decide whenand how to disclosure or hide their abortion work, despite theirresistance and resilience against stigma.
In discussing how to improve full spectrum doula care inGeorgia and beyond, many abortion and full spectrum doulas
spoke about doula work in general needing to evolve to maximize
client autonomy in making reproductive health decisions.
Speciﬁcally, this could include teaching clients how to “doula
themselves” or empowering abortion clients, especially, with theinformation and skills to be their own advocates. This

when I go from saying that abortion care should 10,000% beaccessible, and I’m like, oh, yes, but natural birth should also be
10,000% accessible … I can be pro-abortion and also be pro-birth.”
In stating that doulas can work both in abortion and birthservices, Alex and other abortion doulas once again expressed thatthe doula’s role is to support a person’s reproductive healthexperience even in the face of considerable stigma. When asked
about how about how doula work can improve in Georgia, many
acknowledged the stigma and obstacles to healthcare that many
pregnant people face in the United States. Alex states,“There’s an active attempt to rid our country of the ability to end a
pregnancy or to have an abortion. And that is very scary. I thinkthat abortion care is going to be looking different soon and again,
like I started off saying, I think that abortion care and sexual
reproductive health care is honestly something that should becommunity based. It’s not something that has to happen in a
hospital or medical setting … you don’t have to go through all
the obstacles of getting health care … for something that could
be very vulnerable … they [clients] deserve to be respected
through that and held with integrity.”This need for change is echoed in other doula’s responses. While
this question is asked with the intention of seeing how doulas canbest support their clients, some doulas envisioned doula work to
fully empower clients to make the decisions necessary for theirsexual and reproductive health. Bailey describes this vision of how
doula work can change as,“… people want to take control of their own health. I think people
know that doulas are important, and doulas are great, and people
also want to take back their own health and we need to think
about what are the ways we can equip people to do that.”

4. Discussion
The Georgia Doula Study is a unique community-engaged
participatory action research project that explores abortion doulacare from the perspectives of all types of doulas in a restrictive
abortion context. This mixed methods study identiﬁed important
themes and recommendations for improving practice and policy inthe increasingly restrictive U.S. abortion landscape. Lessons learned
from this study can be widely applied to restrictive abortion
settings globally.
To date, the majority of abortion doula literature discusses clinicbased abortion doulas and their in-clinic services; the current study
ﬁlls an important gap by focusing on community-based abortion
doulas. Previous studies primarily focused on how in-clinic abortion
doula support can mitigate pain and emotional discomfort duringﬁrst trimester procedural abortions (14, 16). Participants in thiscurrent study described the abortion doula support they provide
primarily outside of clinic settings. This included supporting clients
before, during, and after abortion with securing funds, providing
information, talking through all of the options, physical support,
and post-abortion care at home. Our ﬁndings align with andFrontiers in Global Women’s Health10

frontiersin.org

Lindsey et al.

10.3389/fgwh.2023.966208

be in community with other doulas that are interested in ensuring
reproductive autonomy for their clients, regardless of pregnancy
outcome. Doula training and certifying organizations must work to
include abortion and contraceptive counseling in their scope of
education for all doulas. By supporting all clients through theentire spectrum of reproductive health experiences, doulas canensure that clients feel adequately supported in their full
reproductive autonomy. Finally, abortion de-stigmatization efforts
are needed at the community level broadly and within the doula
community, speciﬁcally. Supportive interventions like the Providers
Share Workshop (which has been tested domestically, in Latin
America, and in Africa) could also reduce the stigma load on
abortion doulas in the U.S. and globally (37).
This study also highlights important lessons and potential
opportunities for future research. Primarily, this study
demonstrates the value and importance of community-engaged
participatory action research, especially in the realm of abortionand contraception care. Second, future studies need to further
explore the perspectives of clients who are served by abortion andfull spectrum doulas. Understanding how clients view and value
abortion doula care would inform how abortion doula support canmeet ever-changing needs in the years to come. Third, futurestudies must explore full spectrum doula care in rural areas andwith immigrant communities.
Finally, it is also important to recognize that abortion and full
spectrum doula care in the U.S. will continue to rapidly evolve
given that federal abortion protections were overturned and statelevel abortion bans like Georgia’s can now be enacted. In
particular, studies from the U.S. and globally have shown that selfmanaged abortion using medication can be safe and effective given
the right amount of support including from doulas andcommunity health workers (34, 41, 42). Abortion doulas can offer
pivotal emotional, informational, logistical, and physical support
during abortion, even in restricted settings and in this new era.

overarching need to reevaluate the role of doula work in thehypermedicalization of reproduction is critical and has beenpreviously discussed in both the gray and scientiﬁc literatures (8,38). Notably, volunteer abortion doula collectives have been
instrumental in supporting the abortion experiences of people
throughout the U.S., regardless of age or economic background(39, 40). While study participants did not report being a part ofany such collective, many expressed the desire to connect withother full spectrum/abortion doulas, especially as restrictive
abortion policies are enacted. As the movement towards full
spectrum and abortion doula services continues, it will be
important for doula training and certifying organizations,abortion doula collectives, and doula policy advocates to beintentional about how they serve abortion clients.

4.1. Limitations and delimitations
The current study has a number of limitations, which must be
considered when interpreting the results and implications. First,
this is a qualitative study with 20 doulas and therefore is notintended to be generalized to broader populations or to provecausality. Second, the recruitment strategies—primarily throughthe doula stakeholder steering committee and abortion clinics inmetro-Atlanta—might have introduced sampling bias, but there is
no standard list of all doulas in the metro area and, therefore, amore systematic recruitment process was not feasible. This study’s
approach allowed the team to leverage partnerships with
community-based organizations and abortion providers. Finally,at least one doula did not participate in the in-depth interviews
about abortion and full spectrum doula care—and it is possible
more doulas like them never began the study—because of antiabortion sentiments. It is therefore possible that our results do
not reﬂect the full range of doula perspectives on abortion andfull spectrum care but rather the perspectives of doulas who werecomfortable answering questions about abortion.

Data availability statement
The de-identiﬁed data supporting the conclusions of this article
will be made available by the authors upon request, without undue
reservation.

4.2. Recommendations and conclusions
The practice implications of this study include (1) increased
awareness of and funding for full spectrum doula care, (2)organizational support for existing full spectrum doula collectives
across the U.S., (3) engagement of all doulas in full spectrum carethrough increased opportunities for training in abortion care andcontraceptive counseling, and (4) abortion de-stigmatization efforts
at the community-level. The doula community and general public
need to better understand what full spectrum doula care is andhow to access abortion doula support. Additionally, ﬁnancial
support (e.g., from abortion funds, insurance companies, private
donors) is needed so clients can pay for abortion doula services or
to facilitate abortion doulas offering pro bono services while still
being compensated for their skills and labor. Full spectrum doula
collectives exist across the U.S., but more funding andorganizational support are needed to ensure their sustainability andreach (8, 39). Such collectives could serve as a space to train
doulas in abortion and contraceptive services as well as a space to

Frontiers in Global Women’s Health

Ethics statement
The studies involving human participants were reviewed andapproved by Emory Institutional Review Board (IRB). Written
informed consent for participation was not required for this study
in accordance with the national legislation and the institutional
requirements.

Author contributions
EAM conceptualized the Georgia Doula Study and secured
funding. AL, DT, and AS conducted all surveys, interviews, andqualitative data coding. AL wrote the ﬁrst draft of this manuscript.

11

frontiersin.org

Lindsey et al.

10.3389/fgwh.2023.966208

authors declare that the research was conducted in the absence ofany commercial or ﬁnancial relationships that could be construed
as a potential conﬂict of interest.

EAM and SN provided research mentorship to AL and AS
throughout data collection and analysis including training inqualitative and quantitative methods. EAM and SN provided
comments and edits on the ﬁrst draft of this manuscript andduring manuscript revision. All authors contributed to the article
and approved the submitted version.

Publisher’s noteAll claims expressed in this article are solely those of the authorsand do not necessarily represent those of their afﬁliatedorganizations, or those of the publisher, the editors and thereviewers. Any product that may be evaluated in this article, or
claim that may be made by its manufacturer, is not guaranteed or
endorsed by the publisher.

Funding
Center for Reproductive Health Research in the Southeast
through grants from an Anonymous Foundation and theCollaborative for Gender and Reproductive Equity, a sponsored
project of Rockefeller Philanthropy Advisors.

Supplementary material
Conﬂict of interest
The Supplementary Material for this article can be found online
at: https://www.frontiersin.org/articles/10.3389/fgwh.2023.966208/
full#supplementary-material.

EAM works as a consultant for the community-basedorganization co-leading the Georgia Doula Study. The remaining

References
1. Gerstein J, Ward A. Supreme court has voted to overturn abortion rights, draft
opinion shows. Politico. (2022). Available from: https://www.politico.com/news/2022/
05/02/supreme-court-abortion-draft-opinion-00029473

16. Wilson SF, Gurney EP, Sammel MD, Schreiber CA. Doulas for surgicalmanagement of miscarriage and abortion: a randomized controlled trial. Am J Obstet
Gynecol. (2017) 216(1):44.e41–6. doi: 10.1016/j.ajog.2016.08.039

2. Center for Reproductive Rights. After Roe Fell. After Roe Fell. (2022). Available
from: https://reproductiverights.org/maps/what-if-roe-fell/

17. Rivera M. Transitions in black and latinx community-based doula work in the US
during COVID-19. Front Sociol. (2021) 6:611350. doi: https://doi.org/10.3389/fsoc.2021.
6113503. Clark EA, Cordes S, Lathrop E, Haddad LB. Abortion restrictions in the state ofGeorgia: anticipated impact on people seeking abortion. Contraception. (2021) 103(2):121–6. doi: 10.1016/j.contraception.2020.10.010

18. Campbell E, Connor N, Heaney S, Bloomer F. Training abortion doulas inNorthern Ireland: lessons from a COVID-19 context. BMJ Sex Reprod Health. (2021)
47(4):e17. doi: https://doi.org/10.1136/bmjsrh-2021-201098

4. Birthing Advocacy Doula Training (BADT). Everything You Want to Know about
Full Spectrum Doula Work. (2021). Available from: https://www.badoulatrainings.org/
blog/everything-you-want-to-know-about-full-spectrum-doula-work

19. Ruibal A, Fernandez Anderson C. Legal obstacles and social change: strategies of
the abortion rights movement in Argentina. Polit Groups Identities. (2020) 8(4):698–713. doi: https://doi.org/10.1080/21565503.2018.1541418

5. Hodnett ED, Gates S, Hofmeyr GJ, Sakala C. Continuous support for women duringchildbirth. Cochrane Database Syst Rev. (2013) 7:CD003766. doi: https://doi.org/10.1002/
14651858.CD003766.pub5

20. Lindsey A, Mosley E, Sayyad A, Turner D, Narasimhan S. “Doulas do need to be
there to support if they choose to have an abortion”: family planning attitudes andstigma among doulas in Georgia. Contraception. (2022) 116:79. doi: https://doi.org/10.
1016/j.contraception.2022.09.049

6. Hardeman RR, Kozhimannil KB. Motivations for entering the doula profession:
perspectives from women of color. J Midwifery Womens Health. (2016) 61(6):773–80.
doi: https://doi.org/10.1111/jmwh.12497

21. Turner D, Lindsey A, Shah P, Sayyad A, Mack A, Rice WS, et al. “Doulas shouldn’t
be considered visitors, we should be considered a part of [the] team”: doula care inGeorgia during the COVID-19 pandemic. Sexual Reprod Health Matters. (2022) 30(1):1–23. doi: 10.1080/26410397.2022.2133351

7. Dopo. We Are Dopo. Dopo Abortion Care and Education for All. (2022). https://www.wearedopo.com/
8. The Doula Project. About Us. (2019). https://www.doulaproject.net/

22. Wallerstein N. Commentary on community-based participatory research andcommunity engaged research in health for journal of participatory research methods.
J Participatory Res Methods. (2020) 1(1):13274. doi: 10.35844/001c.13274

9. Turner D, Lindsey A, Shah P, Sayyad A, Mack A, Rice WS, et al. “Doulas shouldn’t
be considered visitors, we should be considered a part of [the] team”: doula care inGeorgia, USA during the COVID-19 pandemic. Sex Reprod Health Matters. (2022) 30(1):2133351. doi: https://doi.org/10.1080/26410397.2022.2133351

23. Mahoney M, Mitchell L. The doulas: Radical care for pregnant people. The Feminist
Press at the City University of New York (2016).

10. Altshuler AL, Ojanen-Goldsmith A, Blumenthal PD, Freedman LR. A goodabortion experience: a qualitative exploration of women’s needs and preferences inclinical care. Soc Sci Med. (2017) 191:109–16. doi: 10.1016/j.socscimed.2017.09.010

24. Pérez MZ. The radical doula guide. The Radical Doula (2012). https://radicaldoula.
com/the-radical-doula-guide/

11. Altshuler AL, Ojanen-Goldsmith A, Blumenthal PD, Freedman LR. “Going
through it together”: being accompanied by loved ones during birth and abortion. Soc
Sci Med. (2021) 284:114234. doi: 10.1016/j.socscimed.2021.114234

25. Rawlings D, Tieman J, Miller-Lewis L, Swetenham K. What role do death doulas
play in end-of-life care? A systematic review. Health Soc Care Community. (2019) 27(3):e82–e94. doi: https://doi.org/10.1111/hsc.12660

12. Chor J, Goyal V, Roston A, Keith L, Patel A. Doulas as facilitators: the expanded
role of doulas into abortion care. J Fam Plann Reprod Health Care. (2012) 38(2):123–4.
doi: 10.1136/jfprhc-2011-100278

26. Shellenberg KM, Hessini L, Levandowski BA. Developing a scale to measurestigmatizing attitudes and beliefs about women who have abortions: results from
Ghana and Zambia. Women Health. (2014) 54(7):599–616. doi: 10.1080/03630242.
2014.919982

13. Chor J, Hill B, Martins S, Mistretta S, Patel A, Gilliam M. Doula support duringﬁrst-trimester surgical abortion: a randomized controlled trial. Am J Obstet Gynecol.
(2015) 212(1):45.e41–6. doi: 10.1016/j.ajog.2014.06.052

27. Martin LA, Hassinger JA, Seewald M, Harris LH. Evaluation of abortion stigma
in the workforce: development of the revised abortion providers stigma scale.
Women’s Health Issues. (2018) 28(1):59–67. doi: https://doi.org/10.1016/j.whi.2017.
10.004

14. Chor J, Lyman P, Tusken M, Patel A, Gilliam M. Women’s experiences with doula
support during ﬁrst-trimester surgical abortion: a qualitative study. Contraception.
(2016) 93(3):244–8. doi: 10.1016/j.contraception.2015.10.006

28. Harris LH, Debbink M, Martin L, Hassinger J. Dynamics of stigma in abortion
work: ﬁndings from a pilot study of the providers share workshop. Soc Sci Med.
(2011) 73(7):1062–70. doi: https://doi.org/10.1016/j.socscimed.2011.07.004

15. Chor J, Lyman P, Ruth J, Patel A, Gilliam M. Integrating doulas into ﬁrst-trimester
abortion care: physician, clinic staff, and doula experiences. J Midwifery Womens Health.
(2018) 63(1):53–7. doi: 10.1111/jmwh.12676

Frontiers in Global Women’s Health

29. StataCorp. Stata statistical software: release 16. College Station, TX: StataCorp LLC(2019).

12

frontiersin.org

Lindsey et al.

10.3389/fgwh.2023.966208

30. Dedoose version 7.0.23, web application for managing, analyzing, and presenting
qualitative and mixed method research data. Los Angeles, CA: SocioCultural ResearchConsultants, LLC (2016). www.dedoose.com

36. Kumar A, Hessini L, Mitchell EMH. Conceptualising abortion stigma. Cult HealthSex. (2009) 11(6):625–39. doi: https://doi.org/10.1080/13691050902842741
37. Mosley EA, Martin L, Seewald M, Hassinger J, Blanchard K, Baum SE, et al.
Addressing abortion provider stigma: a pilot implementation of the providers shareworkshop in sub-saharan Africa and Latin America. Int Perspect Sex Reprod Health.
(2020) 46:35–50. doi: 10.1363/46e8720

31. Iati M. Abortion doulas brace for increasingly fraught work if Roe falls. Washington
Post (2022). https://www.washingtonpost.com/nation/2022/05/11/abortion-doulas-post-roe/
32. Lee S. Hold my hand: how abortion doulas improve abortion care. Voices Bioethics.
(2022) 8. doi: https://doi.org/10.52214/vib.v8i.9027

38. Rowlands SAM, Wale J. A constructivist vision of the ﬁrst-trimester abortion
experience. Health Hum Rights J. (2020) 22(1):237–49.

33. Onyenacho T. Abortion doulas help people navigate the process. They say their work
was more crucial than ever in the pandemic. The Lily (2021). https://www.thelily.com/
abortion-doulas-help-people-navigate-the-process-they-say-their-work-was-more-crucialthan-ever-in-the-pandemic/

39. Wesleyan Doula Project. Our History. (2022). Available from: http://www.
wesleyandoulaproject.org/history
40. Basmajian A. Abortion doulas. Anthro Now. (2014) 6(2):44–51. doi: 10.1080/
19492901

34. Berro Pizzarossa L, Nandagiri R. Self-managed abortion: a constellation of actors, acacophony of laws? Sex Reprod Health Matters. (2021) 29(1):23–30. doi: https://doi.org/
10.1080/26410397.2021.1899764

41. Moseson H, Herold S, Filippa S, Barr-Walker J, Baum SE, Gerdts C. Self-managed
abortion: a systematic scoping review. Best Pract Res Clin Obstet Gynaecol. (2020)
63:87–110. doi: https://doi.org/10.1016/j.bpobgyn.2019.08.002

35. Mosley EA, Ayala S, Jah Z, Hailstorks T, Hairston I, Rice WS, et al. “I don’t regret it
at all. It’s just I wish the process had a bit more humanity to it … a bit more holistic”: aqualitative, community-led medication abortion study with Black and Latinx Women in
Georgia, USA. Sex Reprod Health Matters. (2022) 30(1):2129686. doi: 10.1080/26410397.
2022.2129686

Frontiers in Global Women’s Health

42. Kavanaugh ML, Carlin EE, Jones RK. Patients’ attitudes and experiences related toreceiving contraception during abortion care. Contraception. (2011) 84(6):585–93.
doi: 10.1016/j.contraception.2011.03.009

13

frontiersin.org