The choice of second trimester abortion method: evolution, evidence and ethics.

Decades after its introduction, dilatation and evacuation (D&E) is still not universally offered by gynaecologists who provide second trimester abortion. Three lines of evidence point to D&E as the preferred method for most women. First, the uterus has evolved to expel its contents early and late in pregnancy, not in the middle. Hence, induction of labour with medical abortion forces the uterus to perform a task it is not designed to do. Second, cohort studies and randomised, controlled trials over the past 30 years have consistently shown that D&E is safer and more effective than labour induction abortion, regardless of the abortifacient used. Third, the ethical principles of beneficence, autonomy and justice require that D&E be routinely offered by gynaecologists who perform second trimester abortions. The uneven geographical availability of D&E may stem from lack of information, lack of requisite equipment and training, or lack of motivation. According to the principles of evidence-based medicine and bioethics, these barriers to better care for women can and should be overcome.