A doctor’s impassioned defense of later abortions

Dr. Shelley Sella kept a journal from the very first day she got on a plane to go work for George Tiller, the third-trimester abortion provider who was assassinated in 2009. As the first woman to openly provide third-trimester abortions in the US, she spent nearly 20 years commuting from her home in California to Tiller’s clinic in Kansas, and then, after his murder, to the storied Southwest Women’s Options abortion clinic in Albuquerque, New Mexico.

Sometimes Sella’s journal entries focused on medical protocols, she tells me: “How much misoprostol did I give her? How much Pitocin?” But mostly, she recorded the stories of her patients and the circumstances that led them to her clinic. “I would think, ‘If people could hear these stories, they would have such a different attitude about third-trimester abortion.” 

Going public with those stories felt like an imperative after Sella’s retirement in 2021, a few months before Roe v. Wade was overturned. Her new book, Beyond Limits: Stories of Third-Trimester Abortion Care, is part memoir, part education tool, part defense of a deeply stigmatized form of medical care—one that is likely becoming more common as post-Roe abortion bans lead to delays for patients. Sella focuses on six lightly fictionalized patients and their families, including a couple who learned their baby would likely die shortly after birth, a cancer patient needing an abortion so she could start chemotherapy, a scared teenager who hid her pregnancy from her parents for months, and a victim of domestic abuse. Interwoven is Sella’s own story—her path out of a violent childhood, her coming-of-age during the 1970s feminist movement, and her years as an unfulfilled OB-GYN.

One of Sella’s main goals is to demystify what third-trimester abortion involves: typically, an injection to stop the fetus’ heart, then induction of labor, then a few days later, a stillbirth. Patients receive emotional support—a chaplain at Tiller’s clinic; midwives, doulas and group counseling sessions in Albuquerque—and decide whether they want to see and hold their baby (the word most patients use, Sella says). The process is intense, expensive, and heart-wrenching. 

Sella’s other goal is to challenge mainstream reproductive rights advocates who avoid talking about later-term procedures out of fear that voters will be unnerved, rather than see them as a necessary part of maternal health care and the fight for reproductive autonomy. “I believe now is the time to reevaluate what it means to be pro-choice,” she writes. 

I met up with Sella at a rock-climbing gym in Berkeley, California, where she spent years taking her son for lessons before discovering how much she loved the sport, too. She arrived for our conversation on her bike, sporting purple overalls, a canvas tote bag, and socks printed with pink flamingos—colorful footwear became a wardrobe staple years ago, to cheer up patients who would often stare at the floor when they talked. “Third-trimester abortion is like first- and second-trimester abortion, except that people are more desperate,” she tells me. “And I think we should care for those who are the most desperate, the most vulnerable, the most marginalized.” Our conversation has been edited for length and clarity.

You retired in 2021, after almost 20 years of providing later abortion care. What made you decide you needed to write this book?

There are so many books about abortion, but no one has written anything about third-trimester abortion. So we just hear anti-abortion rhetoric about it, which is scary and wrong. Or if we do hear the very human stories in the third trimester, they’re invariably about fetal indications where the fetus, the baby, has a serious medical condition.

We don’t hear all the other stories. It was very intentional to have three patients in the book with fetal indications and three patients with maternal indications—patients who have medical conditions that make it dangerous for them to continue the pregnancy or who have really difficult life situations. They want their child, if it were born, to have a good life. They don’t think that they can provide that under the circumstances that they’re living under. The fetal-indication patients have the same thought. They want their child to have a good life, but they think that because of the baby’s medical conditions, their child will suffer for as long as it lives.

There’s so much stigma and uneasiness surrounding later abortion. What were the most important messages for you to get across to your readers?

I want people to have an understanding of this care that goes beyond the politics of it, or the legal ramifications. These are real people who are facing difficult situations. I want readers to understand that gestational limits don’t reflect the reality of people’s lives—that these circumstances are not tied to a clock or to a calendar.

Who do you most want to read it?

Everyone.

Of course.

But the main audience are the pro-choice people who are having a hard time with third-trimester abortion. There are a lot of them. They want to be supportive, but they feel uncomfortable, they feel conflicted.

It’s okay to have those feelings. It’s okay to say, “Hey, I don’t know about this, I’m not sure.” That’s fine. You can still support patients who need that care and advocate for laws that don’t place gestational limits. I don’t think people need to support third-trimester abortion care wholeheartedly. But it would be very helpful if there was a movement that recognized the importance of this care.

Did you ever have doubts, in a particular case, about whether you were doing the right thing?  

No, I felt very clear. It was unusual to feel conflicted. And if I did have doubts, I would go back to the patient and look at their situation, and that was the end of the conversation in my head. Let me give you an example: “She’s already got five kids. She’s working two jobs. The guy’s in jail. Her housing situation is terrible, and she’s in the third trimester.”

There’s the answer. I would do the exercise of, “Wait a minute. It’s not about me, it’s not about the decisions I would make”—which, anyway, you never know what decisions you would make. You don’t know until you’re in that situation.

There was a time in your life when you thought you might be in that situation. You were abused as a child.  

In the past, when I would give a talk, I would say something like, “I had a difficult childhood experience.” That was a step towards saying what it really was. Incest. I want to name it.

It wouldn’t be an honest book if I didn’t. And if it wasn’t going to be honest, then I didn’t want to write it, because my childhood experiences—and this is something I only realized years into doing this work—were the underlying impetus.

Childhood trauma is part of what drove you to do this work.

In my early 20s, working at the Los Angeles Feminist Women’s Health Center and in medical school, I just had this kind of radical passion. It was exhilarating. It was this time of ferment. The women’s health movement was growing. Everyone was a lesbian feminist, everyone—I’m exaggerating [laughs]—was wearing flannel and jeans. I was very strident and dogmatic. I don’t know that I put all the pieces together. 

And then as you get older, you have experience, and you get more reflective. It took a long time to realize I wasn’t just a burgeoning feminist who sees the world, recognizes the patriarchy and the male control of medicine, and has a critique of that. Yes, that’s all true, but that’s intellectual. 

I wonder whether the pace of the clinic helped me slow down. Third-trimester abortion care takes time. It’s not a fast-paced setting. You have time to develop relationships with people, hear their stories, sit with them. 

It’s not like I took care of so many victims of incest, but I did take care of some. I had to be very careful. This is their life. This is not about me, it’s about them. I was always very conscious of that with patients, but more so in those situations. Some, I would see with their parents, who supported them in a very loving way. And I was so appreciative that they had someone who really was there for them.

A lot of abortion-rights activists and Democratic politicians ignore third-trimester abortion. Recently, we’ve seen states pass constitutional amendments to protect abortion access—but only in the first two trimesters or to the point of “viability.” Those amendments still let states ban later abortion, just like Roe v. Wade did.

Yeah. The amendments are not good, actually. They enshrine in state constitutions this notion of “viability.” I wonder about people who have their own conflicted feelings about abortion care later in pregnancy and if they let those feelings determine what they think will succeed politically. A lot of it is how you educate and inform people. I think you can frame the issue in a way that helps voters see the humanity of the person who needs the care.

Now’s the time to push back on viability and gestational limits, because Roe has been overturned. Roe was problematic from day one, and it only got more and more problematic as there were more and more restrictions passed. So to think, “Let’s go backwards and restore Roe,” to me, is wrong thinking. We have an opportunity to think big.

When people talk about “viability” they’re usually talking about the 23- or 24-week point during pregnancy, when a doctor decides that the fetus could survive outside the woman’s body.  You lay out an idea of “viability” in the book that’s much broader. 

The usual notion of viability is entirely about the fetus and its ability to survive outside the womb, with or without artificial support—meaning medical intervention, mechanical technology. By “support,” they don’t mean adequate economic financial support, housing, educational opportunities, family support. They’re only talking about the fetus, and they’re not at all talking about the woman, the patient. So I think that’s problematic. 

It’s not anything I made up. It’s not some radical notion. Well, maybe it is a radical notion, I guess.

“Radical” is a loaded word.

Or maybe “holistic,” to use the 1970s, 1980s term. The pregnant person decides whether the pregnancy is viable to them—not the court, and not the state. It’s that individual person’s definition, because that person knows best, and we should trust them to make the best decision.

The book is a way to introduce this concept to a more mainstream audience and to start questioning this outdated notion of viability, which is so constraining and dangerous because of how it’s used to criminalize patients: “This is a viable fetus, you ingested drugs, so you’re guilty of child abuse.” Or medical people use that viability line to deny emergency care to people who are miscarrying: “Even though your water has broken and you’re bleeding, the fetus is viable because its heart is beating, so we have to wait.”

You were one of very few abortion providers in the country doing third-trimester or post-viability abortions. Now that you’ve retired, how do you think about your legacy?

I’m happy to debunk that myth that there’s a shortage of third-trimester providers. There are more than you realize. They’re young, and they’re energetic, and their model of care is not exactly the same as mine. They’ve got their own thing going. All power to them.

The model of care that we offered at Southwest Women’s Options was such an important part of why I embraced this work so much. When I was in residency, when I was an OB-GYN, I was frustrated. It was so mechanistic. The demands of the institution where I worked determined the kind of care I could provide. In Albuquerque, it was the opposite. We could care for patients how I thought everyone should be cared for in every medical setting. I felt like we were treating patients with such a high level of love.

I didn’t do it on my own. It was a whole group of people working together to create this incredibly beautiful practice. I’ve worked with lots of people, I’ve trained lots of people, and it gives me a tremendous amount of satisfaction for them to see this model of care. They may not be in settings where they can offer it. But at least they saw it and they experienced it. The patients certainly experienced it. They saw that they were important, that it was important for them to be cared for. Maybe they saw what’s possible, what good care means.