Who Gets a Third-Trimester Abortion and Why? Doctor’s New Book Unpacks Politicized Procedure

Third-trimester abortions are a frequent target of anti-abortion activists. Yet abortions that occur at 28 weeks and beyond are rare: They make up fewer than 1 percent of all abortions in the United States. They’re also difficult to obtain: Though legal in 11 states and Washington, D.C., only 19 clinics in the country provide abortion care for pregnancies as advanced as 24 weeks—late in the second trimester—and beyond.

Now, one of the relatively few U.S. doctors who’s performed these abortions has released a new book shedding light on the highly-politicized procedure. In Beyond Limits, long-time OB-GYN Dr. Shelley Sella documents the experiences of six former patients, all of whom received abortion care during their third trimester at her New Mexico clinic.

Sella’s mentor was Dr. George Tiller, the OB-GYN murdered in 2009 by an anti-abortion fundamentalist at church. Her book, which draws from journals she kept from 2002 to 2021 while caring for patients, also shows what it’s like to provide abortions while enduring harassment, threats, and violence from protesters.

Virtually anyone—married or single, teenaged or middle-aged—can find themselves needing an abortion later in pregnancy can find themselves needing an abortion later in pregnancy, Sella found in her nearly two decades of practice. Some of her patients wanted their pregnancies but learned their fetuses had developed a fatal anomaly—or “fetal indication,” in medical terminology.

Other patients, trapped in abusive relationships, feared that bringing another baby into the world could risk both their lives and the lives of their existing children. Sella calls this circumstance a “maternal indication” for a later abortion.

Sella, who trained with home-birth midwives—an approach to birth that she incorporated into her abortion practice–retired in 2021. In an interview with Rewire News Group, she discussed the core findings of her book, and explained why their lessons matter now more than ever.

The following conversation has been edited for length and clarity.

In your book, you group people seeking third-trimester abortions into two categories: those seeking abortions for maternal indications and those seeking abortions for fetal indications. Can you talk a little more about that?

That’s something that Dr. Tiller started. In a way, it makes sense, because with fetal indications, there’s a condition where either the baby won’t survive or, if it will, will survive with major disabilities. Maternal indications are for [when the pregnancy is untenable due to] difficult social situations.

But I wonder if I started practicing now with what I know, if I would make that kind of distinction. Both groups come to the conclusion that they can’t handle the pregnancy for whatever reason. Because even if it’s a highly desired pregnancy, you get information about your baby’s condition that maybe is worsening over time, and you realize, “Well, maybe I could have handled it when it was just one condition, but then I learned that there’s another, and another. And I don’t feel that I can handle this with my family.” Or, “I don’t want this for the child.”

That’s thinking that a maternal indication patient would have too: “Maybe if my rent hadn’t just gone up, and maybe if food stamps hadn’t just been cut off, and maybe if my partner wasn’t now in prison, I would have been able to handle it.”

What was your goal for the book?

We think so rigidly about gestational limits [on abortion care], that we need to have them. Even politically, the line is, “Because otherwise these ballot measures won’t pass.” That’s the standard way of thinking, even if we’re pro-choice. “Can we all agree—15 weeks? Six weeks? Conception?”

I really reject that.

The situations that people are in don’t follow a clock. The reality is, things come up. Things change. Things get worse. So why do we think, “This is the dividing line, and before that, maybe it’s okay, and after that, absolutely not?”

Because you set up this limit, that means anyone who’s passed it is a criminal if they seek an abortion, or if something untoward happens in the pregnancy. We see that all the time with the criminalization of pregnant women [for using] drugs and alcohol.

It all ties up with notions of fetal “personhood.” Now it’s a person, now it has rights, and now it has more rights than you.

When people hear more and are educated, they look at [gestational limits] in different ways. The book, and the conversations I’m having are opening people up to, “Wait—we don’t need to have these rigid lines.”

(Read more: Missouri’s Abortion Rights Amendment Fell Into the Fetal Viability Trap)

That’s one thing that you do in this book that’s so powerful—you break down the narrative of who deserves not only our empathy, but who deserves good care.

If we are to hear about a third trimester patient, invariably, we hear about the fetal indication. If we see pictures, she’s often blonde—the straight, white woman with the desperately-wanted pregnancy, and then there was this diagnosis. Absolutely, she deserves care.

But then there are other patients who are equally deserving … I was also very deliberate about including a teenager. Teenagers are the most stigmatized, I think, of all. I really wanted people to understand why a teenager would have a third-trimester abortion, what their situation was. I hope that people come away with the book realizing, “Wait, these situations are also important, and they’re also deserving of an abortion.”

The goal really is to help shift the narrative.

(Read more: How to Talk to Young People About Abortion)

Please explain the differences between a first, second, and third-trimester abortion?

A first-trimester abortion could be medication abortion. So, taking a pill to induce a miscarriage or, in a clinic, a vacuum aspiration.

In the second trimester, the pregnancy is bigger. The cervix needs to be prepared so that it can open. You’re using instruments to take the pregnancy out, and it’s usually not intact.

But third-trimester-abortion is an induction of labor, and delivery of a stillborn. So that’s really more midwifery, obstetrics.

(Editor’s note: In a typical third-trimester abortion, Sella writes in her book, the fetus’ heart is stopped with digoxin, a medication delivered by injection that slows the heartbeat until it stops. After, the patient’s cervix is dilated—a process that can take days, particularly for patients who’ve never before given birth. Then, they are given misoprostol, which further softens and contracts the cervix to induce labor of a stillborn. Afterward, Sella does a dilation and curettage. Patients can elect to see their baby, hold it, and take photos.

The length and cost of a third-trimester abortion, along with the fact that pregnant people often have to travel for care, means that patients face several obstacles: They must take time off work; pay for transportation, hotels, and food; and arrange for child care at home.)

What should we be thinking about, going forward, regarding abortion laws and restrictions?

It’s almost like, what should we be dreaming about?

When it comes to abortion: safe, legal and accessible for all. Period.

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