Retired Arizona nurse Mary Cross volunteers as an abortion doula for Planned Parenthood Arizona. (Jerod MacDonald-Evoy/Arizona Mirror)

A 39-year-old single mother of two got up extra early on a recent Wednesday morning, hoping to be one of the first outside the Planned Parenthood clinic near Phoenix, Arizona.

The upside of not telling anyone about her abortion was that she wasn’t going to have to explain herself. The downside was that she couldn’t receive any pain medication, since she’d have to drive herself home. After scraping together $770 to pay for the procedure — $250 of which she said came from an abortion fund — she couldn’t afford an Uber for the 80-minute round trip. So she was overcome with relief when not only did the busy clinic not turn her away, but a retired nurse named Mary Cross offered to be her abortion doula, free of charge.

“I was very, very happy that she was in the room,” said the patient, who asked not to be named, given the stigma and legal uncertainty around abortion in the U.S. (Abortion is currently mostly legal in Arizona through 15 weeks’ gestation, amid ongoing litigation over an 1864 law banning abortion.) “I wanted to keep [the abortion] as private as possible, but it still isn’t something that you want to go through alone without sedation.”

The overturning of Roe v. Wade in June 2022 was a turning point for the reproductive health community, and the public at large. A longtime operating room nurse, Cross now had free time and an urge to get involved.

“I’ve always had a choice of what I wanted to do with myself, with my career, with my body,” said the 70-year-old from Tempe. “And now here I was a retired nurse, and the law changed. That really was the trigger that sent me to be more involved in a hands-on kind of way.”

Cross started attending regular conference calls hosted by Planned Parenthood to learn about ways to get involved. At one of those meetings, Planned Parenthood Arizona nurse Kischea Talbert talked about a program she was developing to offer free doula services to patients at their clinics.

“My ears perked up immediately,” Cross said. “I started thinking, ‘That’s something I could do. That’s something I have a skill set for.’ So I texted her right away.”

Doulas are trained, non-medical patient advocates, typically associated with pregnancy and childbirth and end-of-life care. But there’s a growing movement in the U.S. to have advocates provide physical and emotional support to other potentially high-anxiety reproductive health services, such as abortion and miscarriage management, as well as for Pap smears and birth control insertion, which Talbert said can be challenging for patients with past sexual trauma.

In addition to her nursing duties, Talbert became a patient navigator in April 2022, when it was anticipated the U.S. Supreme Court was going to overturn Roe v. Wade. In this role, she helps connect patients with financial and transportation services to access legal abortions. In the early days before the high court’s ruling, Talbert said she attended a presentation by Planned Parenthood Global, in case she might have to start navigating patients to Mexico if abortion became illegal or inaccessible in Arizona, which still has the Civil War-era abortion ban on the books.

Mexico decriminalized abortion in 2023, but even before, abortion drugs had been widely available. Talbert said Planned Parenthood Global has a relationship with several clinics in Mexico that were using doulas to help patients manage the symptoms of medication abortion, which is essentially an induced miscarriage. She said the presenters reported better patient outcomes and less need for medical intervention, which they attributed to the doula program. As a former labor and delivery nurse who worked with postpartum patients and in the neonatal intensive care unit, Talbert was very familiar with doulas.

“I immediately said to myself, ‘Oh, that would be great if we had that program here at Planned Parenthood Arizona,’” Talbert told States Newsroom. “Because in my mind, I’m thinking from a nurse’s perspective how beneficial this would be to have our patients have something like this, and especially at the time, because we didn’t know what the future of abortion care was going to be. So I wouldn’t really let it go.”

With the help of Ohio’s Southwest affiliate, which was the first national Planned Parenthood affiliate to start a doula program, Talbert said Planned Parenthood Arizona launched theirs in October 2022.

The Arizona affiliate currently has approximately 20 active doulas, a mix of nursing and pre-med students, retired nurses, and other working professionals, Talbert said. They are asked to volunteer at least two three-hour shifts a month and are trained annually in trauma-informed care, health-privacy laws, breathing techniques, and abortion procedures and laws. She said Arizona held its third doula training last month.

An optional free doula is offered to patients coming in for procedural abortions, wellness exams, birth control insertions, or gender-affirming care at the affiliate. The goal is to soon have doulas available for medication abortion services. Talbert said they’re applying for a grant through Planned Parenthood Federation of America to potentially be able to pay doulas a stipend.

Cross was part of the first training cohort and began her official volunteer duties in early 2023. When she can, she likes to volunteer at least once a week. She said she thinks of her job as comforting patients and distracting them from pain and anxiety. Even patients who do receive sedation might be nervous about the IV, and might feel nauseated afterward. She’s there to remind them to breathe, and to offer them a cold compress or some 7UP.

“I may tap you on the shoulder, if that’s okay, or I may squeeze your hand, if I’m holding your hand,” Cross said. “And I’ll remind you to take a big deep breath through your nose. We’ll practice it before sedation starts in: ‘I’m going to ask you to blow it all the way out, and then blow it out, blow it out, blow it out till you can’t blow anymore. Take another big deep breath.’ And that kind of calms people, or at least focuses their attention on something else.”

The 39-year-old patient told States Newsroom she used a doula for her oldest child’s birth more than 20 years ago and her youngest’s six years ago, both without any pain medication. She had never related doulas with abortion. But alone in the clinic that day — already stressed from waiting in a growing line of pregnant walk-ins, as abortion protesters shouted with megaphones — it made sense.

“She held my hand the entire time and made sure that I was okay, to help keep me calm and breathing through the pain of the procedure,” the patient said of Cross.

But most crucially, she said, Cross distracted her when the 5-to-10-minute procedure became suddenly overwhelmingly painful. She described the pain as similar to labor pains — without pain medication — going from zero to 10 centimeters in less than two minutes.

“I got really dizzy,” she said. “When I started to focus too much on the pain or the discomfort of what was going on, [Cross] would tap my shoulder or remind me to breathe. At one point, she even pointed out a really pretty necklace that one of the nurses was wearing and just kept talking me through … I’m not going to say that having the doula there made all the pain go away and it was like rainbows and sunshine, but it did help a lot. It helped make it manageable.”

Though the doulas focus on the patients, Talbert said they also provide many services to the staff, such as making copies, folding towels, and cleaning. She said one doula created a coloring book for patients that also includes their discharge instructions. They make care bags for patients with special candy for nausea and fidget toys.

A year later, Planned Parenthood Arizona’s chief medical director, Dr. Jill Gibson, said their doula program has been indispensable for both patients and staff. She said several affiliates across the country are currently developing similar programs.

Gibson said abortion access has been more scarce in Arizona since Roe v. Wade was overturned, especially in the northern and eastern parts of the state. Planned Parenthood has several clinics in Arizona but only the clinics in Glendale, Tempe and Tucson provide abortions. Gibson said the clinics are typically booked out and regularly turn away walk-ins. There are also several independent clinics in Arizona. Gibson said most of their patients are Arizonans, some of whom are terrified undocumented immigrants and many of whom have to drive long distances, and have to plan for two appointments 24 hours apart, one of the state’s many abortion regulations. She said absorbing patients’ hardships is a draining practice and something the doulas assist with.

“A lot of the stories that we hear are devastating, and so to have another layer who can help absorb some of that trauma has been actually extraordinarily helpful for our staff,” Gibson said. “I feel like before I worked as an obstetrician-gynecologist, I didn’t know anything about the world.”

For the patient who talked to States Newsroom, the unplanned pregnancy upended her already challenging life. She said she arrived at the clinic by 7 a.m. and barely made the cutoff for walk-ins. It was nerve wracking, she said, because she knew she was running out of time. It had taken nearly three months for her to realize she could be pregnant. Already a grandmother at almost 40, she said she mistook her pregnancy symptoms for early menopause. And by the time she obtained the abortion, she was already about 12 weeks along. If she’d waited any longer, she was told the price would climb to $1,000, and her insurance doesn’t cover abortion. And if she waited three more weeks, she would have to leave the state to get a legal abortion.

“If I’m having trouble getting the money together for this procedure, there’s no way I can raise another child, not even close,” she said. “So I went in knowing that it was probably going to be pretty rough for me. But having [the doula] there I honestly think that it made a world of difference.”

Cross said she typically does feel drained after a long doula shift spent absorbing patient and staff anxiety. But she said it’s rewarding work.

“I would recommend to anybody to be a doula with abortion care, reproductive care, [anybody] that really believes that we should have the ability to choose if and when to have children and to bring those children up in an environment that we feel is safe,” Cross said. “And this is that opportunity to help those people that are making that choice.”