Research Article Clinical Obstetrics, Gynecology and Reproductive Medicine Clin Obstet Gynecol Reprod Med, 2016 doi: 10.15761/COGRM.1000131 Volume 2(1): 120-126 ISSN: 2059-4828 Barriers to dilation and evacuation practice among Maternal-Fetal Medicine subspecialists: quantitative and qualitative results from a national survey Jennifer L Kerns 1 *, Lauren I Lederle 2 , Melissa G Rosenstein 1 , Jema K Turk 1 , Aaron B Caughey 3 and Jody E Steinauer 1 1 University of California, San Francisco, Department of Obstetrics, Gynecology and Reproductive Sciences, San Francisco General Hospital, 1001 Potrero Ave, Ward 6D, San Francisco, CA 94110, USA 2 University of California, San Francisco Department of Medicine, San Francisco, CA 94143, USA 3 Oregon Health and Science University, Department of Obstetrics & Gynecology, 3181 SW Sam Jackson Park Rd, Portland, OR 97239, USA Abstract Objective: To quantitatively and qualitatively describe specifc barriers encountered by Maternal-Fetal Medicine (MFM) subspecialists to providing second-trimester termination by dilation and evacuation (D&E) using a mixed methods approach. Methods: We surveyed all members of the Society for Maternal-Fetal Medicine, and all faculty and fellows associated with MFM fellowships regarding practice characteristics and barriers to second-trimester termination. We categorized barrier responses into fve categories: lack of training, logistical issues, negative culture, personal issues and no barriers. We compared respondent characteristics across barrier categories. We qualitatively analyzed barrier-related themes from respondents’ comments using a grounded theory approach. Results: Of the 689 (32%) physicians who completed the survey, 591 (86%) reported at least one barrier to D&E provision. Main barriers among D&E providers (n=216) and D&E non-providers (N=473) difered, with providers reporting negative culture (37%) and logistical issues (33%) and non-providers reporting personal issues (36%) and lack of training (28%). Qualitative themes related to practice barriers paralleled the above categories. Conclusion: Addressing logistical barriers faced by D&E providers may streamline D&E services. Establishing routine D&E training in MFM fellowships is critical for supporting MFMs who wish to provide D&E. Collaborative partnerships with family planning subspecialists may facilitate this process. Correspondence to: Jennifer Kerns, MD, MPH, University of California, San Francisco/San Francisco General Hospital, 1001 Potrero Avenue, Ward 6D, San Francisco, CA, 94110, USA, Tel: (415) 206-3157, Fax: (415) 206-3112; E-mail: jennifer.kerns@ucsf.edu Key words: abortion, abortion providers, maternal-fetal medicine Received: February 01, 2016; Accepted: February 20, 2016; Published: February22, 2016 Introduction In 2011 there were an estimated 1.06 million induced abortions [1], making abortion one of the most common medical procedures in the US. Dilation and evacuation (D&E) and induction termination are both safe and efective methods of second-trimester abortion [2]. D&E is faster, more predictable, more cost-efective, has a lower complication rate, and is associated with higher patient acceptability as compared to induction termination [3-7]. However, because of the inadequate number of D&E providers in the U.S., many women do not have timely access to D&E [8]. An estimated 87% of counties in the US do not have a trained D&E provider [9]. Only half of obstetrics and gynecology residency training programs routinely teach abortion, and only 18% of residents receive training in D&E [10]. Furthermore, only one in fve abortion providers performs D&E afer 20 weeks [8]. Limited access leads to a delay in presentation for care [11], the downstream efects of which include higher risk of complications [12] and increased cost of providing care [8]. More than 2,000 Maternal-Fetal Medicine (MFM) subspecialists practice in the US, and nearly one-third of them report that they provide D&E [13]. Te decision to include D&E in their scope of practice is likely related to practice setting, desire for continuity of care with patients, institutional culture, and training. Family planning (FP) subspecialists most frequently report unsupportive nursing staf, logistical issues, and unsupportive administration as barriers to D&E provision [14]. Given the training and practice diferences between MFMs and FPs, MFMs may encounter diferent barriers to D&E provision. Te primary aim of this study is to elucidate the specifc barriers MFMs encounter in providing D&E using a mixed methods approach. By identifying barriers for D&E providers and non-providers, we will be able to develop specifc, targeted interventions that support and encourage MFMs who want to ofer D&E services to their patients. Materials and methods We conducted a survey in 2010 of all US members of the Society for Maternal-Fetal Medicine (SMFM), and all faculty and fellows associated with MFM fellowships. We obtained names and postal