Reproductive Health| Volume 29, ISSUE 4, P349-355, July 2019

Download started.


Demographic, Clinical, and Counseling Factors Associated with the Selection of Pregnancy Termination Method in the Second Trimester for Fetal and Pregnancy Anomalies



      Despite women's preference for induction of labor (IOL) or dilation and evacuation (D&E) for pregnancy termination in the setting of second trimester fetal or pregnancy abnormality, many women are not given a choice between delivery methods. We investigated patient and clinical related factors associated with selecting IOL or D&E.


      This retrospective cohort experienced pregnancy termination at 17–24 weeks of gestation for fetal anomaly, intrauterine fetal demise, or premature previable rupture. We compared the demographic, reproductive, social, and clinical experience variables between women who select IOL and D&E, adjusting for confounders through logistic regression.


      One hundred eleven women (21.6%) selected IOL and 403 (78.4%) selected D&E. Greater proportions of women of color (p < .01), lower education (p < .01), lower employment (p < .01), and lower status jobs (p < .01) selected IOL. Women selected D&E more often for chromosomal anomaly (p < .01). In adjusted analyses, women with intrauterine fetal demise (odds ratio [OR], 9.8; 95% confidence interval [CI], 2.8–34.7), premature previable rupture (OR, 110; 95% CI, 23.0–526.8), prior substance use disorder (OR, 35.5; 95% CI–2.7, 473.7), or counseling from obstetrics (OR, 3.3; 95% CI–1.3, 8.4), pediatrics (OR, 3.3; 95% CI–1.3, 8.6), or social services (OR, 12.6; 95% CI, 4.2–37.3) had higher odds of selecting IOL.


      Patient characteristics, medical factors, and type of counseling are associated with the selection between D&E and IOL for anomalous pregnancies. Institutional, regional, and state policies should permit women both delivery methods to preserve autonomous decision-making at the time of pregnancy termination.
      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Women's Health Issues
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Ashok P.W.
        • Kidd A.
        • Flett G.M.M.W.
        • Fitzmaurice A.
        • Graham W.
        • Templeton A.
        A randomized comparison of medical abortion and surgical vacuum aspiration at 10-13 weeks gestation.
        Human Reproduction. 2002; 17: 92-98
        • Autry A.M.
        • Hayes E.C.
        • Jacobson G.F.
        • Kirby R.S.
        A comparison of medical induction and dilation and evacuation for second-trimester abortion.
        American Journal of Obstetrics and Gynecology. 2002; 187: 393-397
        • Belanger E.
        • Melzack R.
        • Lauzon P.
        Pain of first-trimester abortion: A study of psychosocial and medical predictors.
        Pain. 1989; 36: 339-350
        • Borgatta L.
        • Kapp N.
        Labor induction abortion in the second trimester.
        Contraception. 2011; 84: 4-18
        • Brown S.D.
        • Ecker J.L.
        • Ward J.R.
        • Halpern E.F.
        • Sayeed S.A.
        • Buchmiller T.L.
        • Donelan K.
        Prenatally diagnosed fetal conditions in the age of fetal care: Does who counsels matter?.
        American Journal of Obstetrics and Gynecology. 2012; 206: 409.e1-409.e11
        • Brown S.D.
        • Donelan K.
        • Martins Y.
        • Sayeed S.A.
        • Mitchell C.
        • Buchmiller T.L.
        • Burmeister K.
        • Ecker J.L.
        Does professional orientation predict ethical sensitivities? Attitudes of pediatric and obstetric specialists toward fetuses, pregnant women and pregnancy termination.
        Journal of Medical Ethics. 2014; 40: 117-122
        • Crandell L.
        Psychological outcomes of medical versus surgical elective first trimester abortion.
        Nursing for Women’s Health. 2012; 16: 296-307
        • Finer L.B.
        • Frohwirth L.F.
        • Dauphinee L.A.
        • Singh S.
        • Moore A.M.
        Reasons U.S. women have abortions: Quantitative and qualitative perspectives.
        Perspectives on Sexual and Reproductive Health. 2005; 37: 110-118
        • Gerdts C.
        • Fuentes L.
        • Grossman D.
        • White K.
        • Keefe-Oates B.
        • Baum S.E.
        • Potter J.E.
        Impact of clinic closures on women obtaining abortion services after implementation of a restrictive law in Texas.
        American Journal of Public Health. 2016; 106: 857-864
        • Grimes D.A.
        • Hulka J.F.
        • McCutchen M.E.
        Midtrimester abortion by dilatation and evacuation versus intra-amniotic instillation of prostaglandin F2 alpha: A randomized clinical trial.
        American Journal of Obstetrics and Gynecology. 1980; 137: 785-790
        • Grimes D.A.
        • Smith M.S.
        • Witham A.D.
        Mifepristone and misoprostol versus dilation and evacuation for midtrimester abortion: A pilot randomized controlled trial.
        British Journal of Obstetrics & Gynaecology. 2004; 111: 148-153
        • Guttmacher Institute
        State laws and policies: Targeted regulations of abortion providers.
        • Hammond C.
        • Chasen S.
        Dilation and evacuation.
        in: Paul M. Lichtenberg E. Borgatta L. Grimes D.A. Stubblefield P.G. Creinin M.D. Management of Unintended and Abnormal Pregnancy. John Wiley & Sons, New York, NY2009
        • Henshaw R.C.
        • Naji S.A.
        • Russell I.T.
        • Templeton A.A.
        Comparison of medical abortion with surgical vacuum aspiration: Women’s preferences and acceptability of treatment.
        British Medical Journal. 1993; 307: 714-717
        • Ho P.C.
        Women’s perceptions on medical abortion.
        Contraception. 2006; 74: 11-15
        • Kelly T.
        • Suddes J.
        • Howel D.
        • Hewison J.
        • Robson S.
        Comparing medical versus surgical termination of pregnancy at 13-20 weeks of gestation: A randomised controlled trial.
        British Journal of Obstetrics and Gynaecology. 2010; 117: 1512-1520
        • Kerns J.L.
        • Swanson M.
        • Pena S.
        • Wu D.
        • Shaffer B.L.
        • Tran S.H.
        • Steinauer J.E.
        Characteristics of women who undergo second trimester abortion in the setting of a fetal anomaly.
        Contraception. 2012; 85: 63-68
        • Kerns J.L.
        • Vanjani R.
        • Freedman L.
        • Meckstroth K.
        • Drey E.A.
        • Steinauer J.
        Women’s decision making regarding choice of second trimester termination method for pregnancy complications.
        International Journal of Gynecology and Obstetrics. 2012; 116: 244-248
        • Jones R.K.
        • Jerman J.
        Abortion incidence and service availability in the United States, 2014.
        Perspectives on Sexual and Reproductive Health. 2017; 49: 17-27
        • Lohr P.A.
        • Hayes J.L.
        • Gemzell-Danielsson K.
        Surgical versus medical methods for second trimester induced abortion.
        Cochrane Database of Systematic Reviews. 2008; : CD006714
        • National Academies of Sciences, Engineering and Medicine
        The Safety and Quality of Abortion Care in the United States.
        The National Academies Press, Washington, DC2018
        • Turok D.K.
        • Gurtcheff S.E.
        • Esplin M.S.
        • Shah M.
        • Simonsen S.E.
        • Trauscht-Van Horn J.
        • Silver R.M.
        Second trimester termination of pregnancy: A review by site and procedure type.
        Contraception. 2008; 77: 155-161
        • U.S. Bureau of Labor Statistics
        2010 SOC User Guide.
        Date: 2010
        Date accessed: December 9, 2016


      Emily Maistrellis, MSc, was a graduate student of the Harvard T.H. Chan School of Public Health in the Department of Society, Human Development and Health at the time of this study. She is now with the Program on Global Health Justice and Governance at Columbia University Mailman School of Public Health, where she conducts research on abortion policy, health systems access, and sexual and reproductive health, rights, and justice.


      Elizabeth Janiak, MA, ScD, is Instructor in Obstetrics, Gynecology, and Reproductive Biology at Harvard Medical School. She conducts interdisciplinary social science investigations of how policy, health systems, and provider-level factors affect the availability and quality of domestic abortion and contraceptive care.


      Raina Hammel, MD, is a resident physician in Obstetrics and Gynecology at Tufts University School of Medicine. Her interests include family planning and patient advocacy.


      Shelley Hurwitz, PhD, is Director of Biostatistics in the Center for Clinical Investigation at Brigham and Women's Hospital, faculty member at Harvard Medical School. Research areas include women's health, behavioral and psychosocial research, patient-oriented physiologic research, and clinical trial design.


      Laurent Delli-Bovi, MD, is Assistant Professor in Obstetrics, Gynecology and Reproductive Biology at Harvard Medical School with a private practice that specializes in abortion and general gynecology.


      Deborah Bartz, MD, MPH, is Assistant Professor, Obstetrics, Gynecology, and Reproductive Biology, Harvard Medical School, with a practice specializing in family planning at Brigham and Women's Hospital. She is the Director of Education for the Connors Center for Women's Health and Gender Biology.