What Would It Mean to Defend All Abortions?
Democrats love to avoid it, and Republicans love to lie about it. But later-abortion care has never been more important.


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On this episode of The Nation Podcast, abortion access correspondent Amy Littlefield joins D.D. Guttenplan to discuss the reality of later-term abortions—and how, even though Roe v. Wade may have been overturned, the conservative crusade to eliminate abortion access rages on.
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Ayana, 28 years old and 28 weeks pregnant, eases herself onto the procedure table at Partners in Abortion Care in College Park, Maryland. She is a Black woman with the tiny bearing and erect posture of a bird. Above her head, a flock of pink and blue butterflies decorates the ceiling. In a few minutes, a doctor will perform an injection to the fetal heart to end her pregnancy.
Ayana had spent months in turmoil over this abortion. As she chased after her two older kids while lugging her 1-year-old on family outings to the arcade and the movies, she tried to imagine hauling two car seats instead of one. While she changed her baby’s diapers, she thought about what a newborn would subtract from him. The family was already stretched thin. Her boyfriend worked for a moving company. Ayana cared for her baby in the mornings, then handed him off to her sister to go to work. She juggled two jobs, teaching kids with autism during the week and answering the phones at a pizza place on weekends. Her oldest son was oblivious to her pregnancy as he raced around playing basketball and video games. But her daughter seemed to sense that her mother was struggling. At 5, she was already trying to cook and change her baby brother’s diapers. When she noticed her mother’s belly growing, she chided her, “We don’t need any more babies.”
Ayana, who had grown up as the oldest of three, knew the pressure another baby would put on her kids. She waited months for a sign; in the end, the sign was her three kids. And now that she’s made her choice, she radiates a sense of unflappable calm. “I just had to realize that I wasn’t ready,” she told me.
The care she is about to receive has been maligned and lied about from the national political stage. Later abortion is banned in all but nine states and Washington, DC, and performed in only a handful of clinics nationwide. It has divided the pro-choice movement, leading to bitter struggles and the resignations of high-profile leaders. Most of the widely celebrated abortion-rights ballot initiatives floated in a record number of states since 2022, when the Supreme Court overturned the national right to abortion in Dobbs v. Jackson Women’s Health Organization, have allowed states to ban it.
Democrats love to avoid it, and Republicans love to lie about it. Even among pro-choice voters, abortions that take place when the fetus looks less like a blob of tissue and more like a baby stir the kind of complex feelings that our political discourse seldom accommodates. As a result, later abortion has never had the widespread support that earlier abortion receives. And under the Trump administration, this care could get harder to provide and receive. Health and Human Services Secretary Robert F. Kennedy Jr. noted during his confirmation hearing in January that the administration wanted to end later abortions, signaling the possibility that Trump might pressure Congress to pass a ban on them or even attempt to do so himself through an executive order. More likely, the administration could restrict medication abortion, disrupting access to earlier abortions and driving up the need for later procedures.
Since Dobbs, abortion bans have already pushed some patients further into pregnancy. And even as clinics in many states have closed, there has been a rise in the number of places advertising later care. After third-trimester-abortion provider George Tiller’s assassination in a Kansas church in 2009, just four providers continued the work he once did, according to the 2013 documentary After Tiller. Today, a new generation of abortion providers has stepped into the breach. In the fall of 2022, the doctor-midwife duo Diane Horvath and Morgan Nuzzo opened Partners in Abortion Care. It’s one of the few clinics in the country that offers abortions to anyone up to 34 weeks; other clinics offer care that late at the discretion of the physician. Horvath estimates there are now at least 15 doctors at a handful of clinics in the United States offering third-trimester abortions, and more who are doing so in hospitals.
For Horvath and like-minded advocates, defending this procedure is a bright line for a movement that has lost Roe and must now build a new, more ambitious framework. Their clarity in fighting for the procedure stems from research showing that later-abortion patients are among the most vulnerable people in the country—disproportionately young, low-income, and people of color.
“These are often children; these are people in poverty; these are people with very few resources; these are people who use drugs,” Horvath told me. “If we’re willing to throw the most vulnerable people under the bus as a movement, then what the hell is our movement doing?”
In early March, I spent three days with Horvath and her team at Partners, setting out to demystify this much-maligned procedure. I emerged with a greater sympathy for the argument Horvath and activists like her have been shouting for years: that we are destined to repeat the mistakes that led to Roe’s fall if we cannot find a way to defend these most demonized of abortions.

After Trump’s Supreme Court appointments allowed the high court to overturn Roe in June 2022, Republicans facing an outraged public were left with just one viable talking point: attacking later abortion. By claiming that Democrats supported “abortion in the ninth month” and wanted to “execute” babies after birth, as Trump did on the debate stage in September 2024, Republicans sought to distract from the fact they had just overturned 50 years of precedent. Their goal was to make Democrats look like the extreme ones.
No state allows doctors to “execute” a baby after birth. But a small number of people do seek abortions in the seventh or eighth month of pregnancy. While abortions at or after 21 weeks represent less than 1 percent of all abortions, Democrats responding to the GOP talking point seemed more comfortable denying that they happened at all.
“Nowhere in America is a woman carrying a pregnancy to term and asking for an abortion,” Kamala Harris shot back at Trump during the debate.
The Democratic-allied strategists who shaped the slew of abortion ballot initiatives after Dobbs followed a similar playbook, guided by polling that has long shown that support for abortion declines as pregnancy advances. From Ohio to Arizona to Florida, advocates and consultants crafted language that reinstituted Roe—which allowed states to ban abortion after viability, the point in pregnancy when a fetus can theoretically survive outside the womb, around 24 weeks.
The stakes were high in Missouri in June 2022, when it became the first state in the country to ban abortion after Dobbs. The greatest hope of restoring access was a ballot initiative to enshrine abortion in the state Constitution. Internal polling obtained by The Nation showed that strategists considered a version allowing the state to ban abortion after viability and a version that allowed no gestational limit. The more restrictive version did “marginally” better, by two to four percentage points, thanks to “older and GOP voters,” the pollsters noted, while those most likely to need an abortion—younger people and people of color—were more likely to support the measure with no gestational limit. In the end, as had happened elsewhere in the country, the strategists proceeded with the version that allowed a ban after viability, with an exception to save the patient’s life or to protect their physical or mental health. The policy “met Missourians where they are” and had the “legal teeth” to be effective in the state’s hostile judicial environment, said Mallory Schwarz, the executive director of Abortion Action Missouri, which supported the measure. She told me that some of her base voters had expressed concern about “abortion up until the moment of birth,” showing that even pro-choice voters had internalized this anti-abortion myth.
But Colleen McNicholas, the chief medical officer at Planned Parenthood’s St. Louis affiliate, disagreed with this approach. She thought public outrage over Dobbs presented a golden opportunity to reach beyond Roe and protect access for all Missourians. “It just felt like a really unique opportunity to live our values and the things we put on T-shirts and billboards,” she told me.
When McNicholas refused to sign on to her affiliate’s endorsement of the ballot initiative, her critics sent reporters lengthy anonymous e-mails accusing McNicholas of undermining the campaign. This backlash contributed to her decision to leave Planned Parenthood in January.
“It told me that having courageous conversations about the impact of policies…was dangerous,” McNicholas said. “I have risked far too much, and care way too deeply about the work, to have to worry if those that I should be working with and protected by [are] wishing me harm.”
On Election Day in November 2024, the initiative passed by three percentage points. After months of legal fighting, a few clinics resumed limited services, but many Missourians are still traveling out of state because of various issues, including a lack of providers.

A 29-year-old with light skin and dark hair walks down the hall at Partners, sobbing. She flew here from California, one of the 22 states in the country that ban abortion at or around “viability.” In 2022, 67 percent of California voters backed a referendum that blocks the state from interfering in a patient’s pregnancy decisions, but a state law banning most abortions after viability still stands.
So the patient in the hallway faced a grueling journey from one of the nation’s bluest states. First she had to raise close to $20,000 to pay for the abortion itself. At least 90 percent of Partners’ uninsured patients cobble this funding together from abortion funds and clinic discounts. Yet by the time she made her decision, raised the money, and flew to Maryland, an ultrasound had put her well past Partners’ limit. (Another clinic in Maryland, CARE in Bethesda, will see some patients up to 35 weeks and six days, but it seemed highly unlikely that this patient, at 35 weeks and five days, could be seen there in time.)
It was too late. She was going to have a baby.
Though this happens about once a week, it hits the staff like a brick every time. A hush sets over the nurses’ station.
“It definitely is challenging to have to tell someone no, especially when you know you’re the end of the line,” said Jenni Villavicencio, the doctor on duty that week. Clinic co-owner Diane Horvath stands nearby, recalling how terrified she felt when her daughter was born. Sara Fatell, a nurse with short curly hair and a knack for lightening the mood, chimes in with a memory from the trenches of newbornhood: One day, her sleep-deprived wife noticed that their baby had a rash and wailed, “We have to be in charge of its skin, too?”
No one here takes forced pregnancy lightly. The Turnaway Study, a major analysis of women who were denied abortions for being too far along, found that such patients were more likely to wind up trapped in poverty and abusive relationships. The staff will give the women references for sympathetic adoption agencies. But just 9 percent of the study’s subjects who had been turned away wound up placing their babies for adoption. Those who surrendered infants for adoption faced higher levels of regret and negative feelings about their pregnancy than those who parented or had abortions. “In fact, of the three groups, the relinquishing mothers…were far more likely than those who parented to wish that they still could have had their abortion,” adoption researcher Gretchen Sisson wrote in her book Relinquished.

Ayana, the 28-weeks-pregnant patient, enrolled in a military academy when she was 15, eager to take the fastest route out of high school in Washington, DC. She trained for the Air Force and learned to fly. The first time she steered a plane into the air, it was terrifying to watch the water stretch out below her. But once she got the hang of it, it was fun. During her training, she met a man she thought of as her best friend—until he confessed his feelings for her, and they began dating. When he told her he didn’t want her to leave for the Air Force, she stopped flying. Now the couple have three children and work three jobs combined to support them.
Research from the University of California, San Francisco, shows that people seek abortions after 24 weeks for one of two reasons: They receive new information—such as finding out late that they’re pregnant or learning that their health is at risk or the fetus has a serious anomaly—or they face barriers, like the out-of-pocket costs of abortion. One person in the study didn’t know she was pregnant until 26 weeks because a chronic medical condition masked her pregnancy symptoms. Another found out at 29 weeks that her fetus’s brain was not developing—a diagnosis that was not possible earlier.
In Ayana’s case, the barrier she faced was her own ambivalence, as she agonized over what a fourth child would mean for her future and family. Her case is not especially common; while 37 percent of women in the Turnaway Study reported that taking the time to decide whether to have an abortion slowed them down, the time needed was often days, not months. The study found no significant difference in the amount of time that patients in early or later pregnancy took to make up their minds.
If she had lived almost anywhere else in the country, it might have been too late. But Ayana lives in an area that’s home to three third-trimester clinics, in a state where Medicaid covers abortion. Partners accepts Medicaid because it wants to serve low-income patients, but it has chalked up a huge loss and struggled to keep its doors open as a result. The state reimbursement rate for an abortion like Ayana’s is $1,600; the cost to the clinic for her care exceeds $10,000.
In the procedure room, Dr. Villavicencio sits at Ayana’s feet and looks her in the eye. Almost six feet tall with tattoos on both arms, a brown ponytail, and a gold ring in her nose, Villavicencio tries not to loom over her patients. She arrived here after her own unexpected journey: A first-generation Latina who was raised Catholic, she was a staunch anti-abortion activist until her early 20s, when the complex life experiences of her patients made her realize that abortion was necessary.
“We’re going to clean your belly off, and then I’m going to do the procedure,” Villavicencio says. “Do you want to know details about it?”
“Yes,” Ayana replies. She’s been channeling her anxiety into research, watching videos about later abortion on YouTube. She declines the sheet they usually suspend from the ceiling to prevent patients from seeing the injection.
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“swipe left below to view more authors”Swipe →Despite Republicans’ claims that later abortion involves ripping live babies apart, an injection is the standard first step at this stage to end the pregnancy. After the shot, the fetus no longer has a heartbeat. Opening the cervix to prepare for removal of the pregnancy takes another day or two.
“We place the needle where we need to go in the pregnancy, and we inject a medication that will stop the heartbeat of the fetus,” Villavicencio explains. They’ll numb her skin first, which might burn a little.
“I’m ready,” Ayana says.
At Ayana’s request, Partners co-owner Morgan Nuzzo puts on music. Mellow R&B plays through a speaker on the wall, and Ayana pulls her leggings down to expose her round belly. She closes her eyes and squeezes a purple ball that Nuzzo hands her, as Villavicencio sticks a long needle into her abdomen.
“You’re doing fantastic,” Villavicencio says. “Everything’s going exactly as we expected it to.”
A single tear wells in Ayana’s eye. Even as she guides the needle, Villavicencio notices; she tries not to leave her patients alone in these moments.
“Is that just like a random tear, or are you having some emotions?” she asks.
“A little emotion,” Ayana says quietly.
“Whatever you need to feel, you feel.”
The music is soothing. The room is quiet.
“It is relaxing, though,” Ayana says as they finish pushing lidocaine through the syringe. Moments later, Villavicencio confirms on the ultrasound that the heart has stopped.
“Do you want to talk about any of the emotions that you were having?” she asks, when they’re sitting at eye level again.
“I just got a little emotional once it started moving,” Ayana says softly.
“Understandable,” Villavicencio replies, reassuring her that the procedure doesn’t cause the fetus any pain or discomfort.
That is an abortion at 28 weeks.
For Republicans, it’s a coveted talking point. For Democrats, it’s a liability. For Ayana, it’s a chance to be the mom she wants to be.

If hearing the details of a later abortion makes you uncomfortable, you’re not alone. But a new crop of polling shows that while support for abortion has historically dropped when the procedure is done later in pregnancy, that may be changing in the wake of Dobbs, as people become more hostile to government intrusion at any stage of pregnancy. In a recent poll, 66 percent of respondents said the decision to have an abortion in the last three months should be between a person and their doctor.
Later-abortion advocate Erika Christensen had an abortion at 32 weeks, when she learned that her fetus would not be able to breathe outside the womb; she traveled from New York to Colorado for care. Since then, she’s had innumerable conversations with people who feel uncomfortable about abortions like hers—but who still don’t think they should be banned. For her, that level of acceptance is enough.
“I had an abortion in the third trimester; I don’t expect every American to have the same understanding that I do,” Christensen, a cofounder of Patient Forward, said. “However, I do believe that I am in line with most Americans when we agree that we do not want the state to punish people for having them.”
People are routinely punished for pregnancy outcomes in this country already. In the year after Dobbs, Pregnancy Justice reported a record 210 prosecutions for conduct associated with pregnancy, loss, or birth. Most of these cases happened in Alabama, Oklahoma, or South Carolina, where courts “have expansively interpreted the personhood of viable fetuses,” according to a new report from Pregnancy Justice on how viability leads to criminalization. In Ohio, a Black woman named Brittany Watts was arrested for miscarrying in her bathroom. While she had been told her fetus was not viable, Ohio law defines viability based on gestational age.
“It didn’t matter if she was having a miscarriage; it only mattered that this fetus was a size and age where it could, in some universe, survive,” said Karen Thompson, the legal director of Pregnancy Justice.
The month after Watts’s arrest, Ohioans passed a ballot initiative that enshrines the legal right to abortion in the state Constitution but allows the state to continue banning it after viability except to save the patient’s life or health.
“Viability,” though, is a slippery target, one that changes depending on each pregnancy. As Shelley Sella, a retired third-trimester-abortion doctor, writes in her new book Beyond Limits, a pregnancy can become nonviable because a patient doesn’t have the resources to support it. Sella trained under Dr. George Tiller and was the first woman doctor in the country to openly provide third-trimester abortions.
“Whether a pregnancy is viable—as defined by the mother—is the issue for every abortion,” Sella writes. In a sense, this definition harks back to the 1800s, when abortion was legal until “quickening,” the point when a pregnant person could feel the fetus move—a doctrine that relied on the judgment of women, not doctors. Male doctors who were seeking to assert their professional superiority over lay midwives succeeded in advancing laws that banned abortion in every state by 1910. Those laws were all nullified in 1973 by Roe, which protected abortion until “viability,” a threshold determined by doctors.
Sella’s definition would put the ability to determine viability back in the patient’s hands, demanding a level of trust in pregnant people that has never been part of our modern healthcare system—much less our abortion politics.
For Sella, defending later abortions requires a new paradigm of trust that—if the movement and the public can embrace it—will make us better able to defend all abortion. “If we can open our hearts to the most desperate among us, we can understand all who seek to have an abortion,” she writes.
This radical trust in pregnant people may not exist yet in our politics—but it does exist in clinics like Partners. Sella’s framework helped me navigate a personal tension I felt as I walked the hallways there. I happened to be nine weeks pregnant at the time. My embryo, the size of a grape, already had a nickname; my husband and I called it “the little cocoa bean.” While I dutifully took my vitamins and surreptitiously rubbed a belly bump that only I could see, I watched women end pregnancies much farther along than mine.
Thanks to Sella’s framework, I felt better equipped to embrace this contrast. I had become pregnant on purpose at the right time for my family; my pregnancy was viable.
Scarlet’s pregnancy, while far more advanced, was not.
Scarlet (a pseudonym) is a young black mother in a gray sweatsuit, with straight hair that frames her face. “I don’t want to see,” she tells Dr. Villavicencio, opting for the sheet between her face and belly that shields her from watching the injection.
Scarlet traveled from a state that does not have any clinics that offer care as late as she needed it.
She found out she was pregnant at 16 weeks. It took her time to get out of denial, reach a decision, and raise the $12,000 she needed for this abortion.
Learning that the fetus was a girl terrified her because of her own history of abuse. Already she was hypervigilant about leaving her baby alone with relatives.
Her baby was the reason she decided her pregnancy wasn’t viable.
In the exam room at Partners, Scarlet is talking about her baby and how they like to do puzzles together when Villavicencio performs the injection to end her pregnancy. Scarlet is not as far along as Ayana, so her procedure takes just two days. After the injection, Villavicencio inserts dilators that will expand in her cervix overnight. As Villavicencio prepares for the procedure, Scarlet talks about her guilt over the fact that this is her second abortion. She’s been reading her Bible, she adds.
“Is it OK if I tell you what I think?” Villavicencio asks. When Scarlet says yes, Villavicencio channels the language of her Catholic upbringing. “Any God I believe in knows your heart and knows you’re a good mom,” she says. A right decision can be a hard decision, she adds.
Lee McKeever, a nurse practitioner, helps Scarlet take deep breaths as Villavicencio inserts rods that look like dark matchsticks into her cervix.
“We can all tell,” Villavicencio says soothingly, “what a good mom you are.”
It was Villavicencio’s patients who changed her anti-abortion views. Watching people navigate the medical and emotional complexities of pregnancy, she realized that their choices did not fit into the black-and-white logic she’d been raised with. She came to see her patients as the experts in their own lives.
Over time, her relationship to her Catholic faith evolved; on her shoulder she has a tattoo of her interpretation of the Garden of Eden, with the forbidden fruit depicted as a papaya—the fruit used to train people in abortion techniques.
“Eve had all the knowledge,” she tells me.
In 2020, Villavicencio became a leading spokesperson for the American College of Obstetricians and Gynecologists (ACOG), the main professional organization for ob-gyns. She was charged with representing in the press the policies that set the gold standard for the profession. These included a 2022 policy she helped craft that omitted ACOG’s previous opposition to most post-viability abortions and that strongly opposed “any effort that impedes access to abortion care and interferes in the relationship between a person and their healthcare professional.”
Then a ban on abortion after six weeks took effect in Ohio, and doctors in the state rallied behind a ballot initiative to repeal it. Like most initiatives, this one would allow the state to continue banning abortion after fetal viability. The Ohio section of ACOG endorsed the initiative, calling the viability limit “reasonable.” Local sections are supposed to comply with ACOG’s national positions, but officials voted to allow the endorsement in a closed-door meeting. Incensed, Villavicencio denounced the decision, only to be told she was hurting the movement by speaking out.
“Which is really upsetting,” she told me in the break room when she was between patients, “given that I’m one of the few people who actually does this care and takes care of the patients that are left behind.”
The vitriol she faced from her peers was the final straw in her decision to resign from her position as a spokesperson for ACOG and found her own advocacy group, Raven Lab, with Colleen McNicholas.
“What’s become clear to me is that our own movement is very uncomfortable with later abortion, and that we have a lot of work to do before we can claim that we are truly justice-based,” Villavicencio told me.
The next morning, Scarlet arrives for her procedure and confesses that she had carrot cake for breakfast. “At least it has vegetables in it,” jokes Lee McKeever, the nurse practitioner. A diffuser on a desk emits the scent of lavender. McKeever gives Scarlet medication to block pain and put her in a semi-sedated state. Then Villavicencio uses a series of metal dilators to open her cervix. McKeever leans over Scarlet’s shoulder and, with the quiet voice of a yoga instructor, tells her that the procedure is underway and that she’s safe.
“Breathe in slowly with the waves,” Allison, a patient care technician, tells Scarlet, playing the sound of ocean waves over the speaker. “Breathe those waves out.”
Twenty-five minutes later, the procedure is finished, and Villavicencio massages Scarlet’s uterus to stop the bleeding—a common practice in postpartum care. A few hours later, Scarlet looks alert as she listens to her discharge instructions. She tells me she can’t wait to get home to her baby.
“I’m OK now,” she says. “I’m still going to think about it, of course, but I’m OK.”
Ayana arrives for the third and final day of her procedure.
“You can do this, OK? You’re superstrong,” Villavicencio says as she removes the dilators that were inserted the day before. She uses an instrument to break Ayana’s water and then injects pain medicine into her cervix.
“I’m fine,” Ayana tells the staff as she sits up on the procedure table afterward. “This is way better than the hospital.”
She spent the previous afternoon at the mall buying shoes for her kids: sparkly light-up ones for her daughter and Nikes for her son. Now she sips cranberry juice and chews ice in a darkened recovery room, waiting for the contractions to intensify. As her labor progresses, she paces the hallway. Nurse Sara Fatell leads her through a series of hip thrusts and squats, and Villavicencio and the clinic manager, Alliah, join in. The clinic starts to look like an aerobics class, but it does the trick.
They bring Ayana to the exam room and give her sedating medication. All she will remember later is lying down and falling asleep. But the staff talk to her like she is awake, as Villavicencio uses instruments to remove the fetus and placenta. A technician makes footprints of the fetus for Ayana to take home, as she requested.
“I just feel like I took a great nap,” Ayana says when she wakes up. A nurse hands her a pink envelope with the footprints and tells her she can go back to work tomorrow.
Ayana looks and sounds like she has just been relieved of a heavy weight. Sella says in her book that she often saw patients experience this exact transformation after they ended unwanted pregnancies. “There is an openness to their faces I hadn’t seen before,” Sella writes. “Their personalities shine through, and they are glowing. It makes sense. They have been relieved of a huge physical and emotional burden, and it shows.”
“Thank you so much for all your help,” Ayana tells the staff before she leaves. Her boyfriend is on his way to pick her up, with all three kids in the car. With a new lightness, she walks out into the lobby, and back to her life.
Editor’s Note: This piece has been updated to reflect that after publication, The Nation learned of an additional clinic that has begun publicly offering care up to 34 weeks to anyone who is medically suitable for outpatient care. For current information on clinics, see the Later Abortion Initiative at Ibis, AbortionFinder.org, and INeedAnA.com.
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