Introduction and Overview
While abortion is legally permitted in many countries, women continue to face profound barriers that restrict their access to safe abortion services and endanger their health. A lack of trained abortion providers, restrictions in service availability, and high costs may all present obstacles too great for women to overcome in a timely manner. When women must travel long distances, wait weeks for abortion services, or allocate scarce funds for the procedure abortion may remain unattainable. Manual vacuum aspiration (MVA) can offer a safe, accessible, and affordable way to provide abortion and overcome barriers that inhibit women’s ability to access services. Similar to electric vacuum aspiration (EVA), MVA has several benefits that make it a worthwhile component of abortion services. Compared to dilation and curettage (D&C), MVA offers a safer, more readily accessible, and potentially less expensive way to offer high-quality services to women throughout the world. This monograph outlines both clinical and practical reasons supporting the use of MVA for induced abortion. Data on the safety, effectiveness, and acceptability of MVA are presented, as well as considerations for providers interested in delivering MVA services. This document is not intended to be a clinical training manual.
Abortion: Too Often Inaccessible
For women all over the world, abortion is a common procedure, essential to women’s health, and integral to the provision of comprehensive health care. Each year, more than 210 million pregnancies occur throughout the world, 40 percent of which are unplanned. More than one-fifth of these pregnancies, including half of the unplanned pregnancies, will end in induced abortion (Dailard, 1999). When trained providers perform abortions using medically accepted methods in hygienic settings, mortality and morbidity rates are extremely low. Under these conditions, the mortality rate is 0.2-1.2 deaths per 100,000 abortions; in comparison, the risk of death during childbirth is six to 25 times higher (Alan Guttmacher Institute, 1999). Yet, the World Health Organization (WHO) estimates that nearly half of all abortions are unsafe because they are performed either by untrained individuals or in unsafe environments (WHO, 1994). More than 60 percent of women live in countries where abortion is permitted on broad grounds—55 percent of women in the developing world and 86 percent of women in the developed world (Dailard, 1999). Nevertheless, women’s access to abortion services is often hampered by other factors, even when it is legally permitted. These factors include the procedure’s cost, lack of trained abortion providers, lack of supplies and equipment, long distances to service-delivery sites, delays in operating room availability, lack of social acceptance of abortion, and failures in infrastructure. These barriers prevent women from obtaining safe and legally permitted services early in pregnancy. By incorporating MVA into service delivery, health systems can meet their obligation to help women access all permissible services and safeguard women’s health and future at the same time. MVA: A Way to Expand Access MVA offers a safe, effective, accessible, and low-cost way to overcome barriers that hamper women’s access to abortion services. MVA can be performed in typical clinical settings and as an outpatient procedure without the need for operating room facilities. MVA does not require electricity and may be performed by midlevel providers, such as midwives, nurse practitioners, and physician assistants. Though D&C was once the standard of care and is still used in many settings, MVA is a highly effective and safer method of uterine evacuation. These qualities can help shift abortion services to community-based health care settings, which not only decreases costs but also expands access to services. A World Health Organization Technical Working Group has listed vacuum aspiration as an essential element of care at the first referral level (WHO, 1991). Trained health care personnel around the world have used MVA technology to improve the quality of abortion care in diverse settings. MVA can also be used to perform menstrual regulation, treat incomplete abortions, perform endometrial biopsies, and back-up failed abortions that were performed by either surgical or medical (pharmacological) methods. The method has the capacity to dramatically expand women’s access to abortion services. In remote areas, MVA may be the difference between safe and effective abortion services and no services at all. MVA can be “extremely effective in improving the accessibility of high-quality abortion services at all levels of the health system…MVA can play a very important role in helping providers offer safe, effective abortion care that is acceptable to women and responds to their needs—that is, care that can truly make a difference in improving women’s health” (Greenslade et al., 1993a).
Manual Vacuum Aspiration: Clinical Overview First-trimester surgical abortion is performed using one of two methods: A vacuum aspiration (also known as “suction curettage”) or sharp curettage (also known as D&C). Vacuum aspiration uses an electric pump or manual aspirator to create a vacuum, and the uterine contents and lining are removed through a cannula (PATH, 1994). Because vacuum aspiration is the safest method for performing a first-trimester abortion, it is the most common method used in industrialized countries. Vacuum aspiration is used for about 97 percent of first-trimester abortions in the United States; Canada, China, New Zealand, Singapore, and other countries use vacuum aspiration for almost all first-trimester surgical abortions (Greenslade et al., 1993b). “Health service managers should make every effort to replace sharp curettage with vacuum aspiration.” (IPPF, 2001)
Where vacuum aspiration is unavailable, sharp curettage is used. In this method, the uterine lining is scraped with a metal curette, often while the patient is under general anesthesia or heavy sedation. Medical experts do not recommend using D&C unless vacuum aspiration and medical methods are unavailable because sharp curettage carries higher risks (IPPF, 2001; WHO, 2000).
Summary of MVA Performance
Mechanism of Action. A cannula is attached to the vacuum aspirator and inserted through the cervix. The contents of the uterus are aspirated using a vacuum equivalent to that produced by an electric vacuum aspiration pump.
MVA is an appropriate technique for induced abortion, spontaneous abortion, menstrual regulation, treatment of incomplete abortion, and endometrial biopsy. Effectiveness. For uterine evacuation: Studies show that vacuum aspiration (including MVA) typically has more than a 98 percent rate of effectiveness. Complication rates for the four major complications most commonly associated with uterine evacuation (excessive blood loss, pelvic infection, cervical injury, and uterine perforation) are lower for vacuum aspiration than for Ipas flexible cannulae used with MVA. MVA uses a handheld vacuum source with a plastic cannula to perform uterine evacuation. A vacuum equivalent to that produced by the electric pump used in electric vacuum aspiration (EVA) is transferred into the uterine cavity. MVA is as safe and effective as EVA and has been used for decades (Greenslade et al., 1993b). MVA is very effective for Abortion Research over the past 30 years there has been studies on vacuum aspiration in more than 400,000 cases, in more than two-dozen countries, and over 50 studies. The findings are clear, vacuum aspiration is safe and effective for first-trimester abortion. The body of literature reveals that vacuum aspiration’s effectiveness ranges from 87 to 100 percent. In most of these studies, the method’s effectiveness rates exceeded 98 percent. (Greenslade et al., 1993b; Hemlin and Möller, 2001; Freedman et al., 1986; Westfall et al., 1998; Creinin, 2000; Edwards and Creinin, 1997). More studies have examined the effectiveness of electric vacuum aspiration than manual aspiration. Because the mechanisms of action, and level of vacuum, for the two methods are the same (Balogh, 1983; Freedman et al., 1986; Roy, 1974), however, effectiveness data for EVA is applicable to MVA. In several studies where both MVA and EVA were used, the two methods had equivalent rates of effectiveness (Hemlin and Möller,2001; Balogh, 1983; Freedman et al., 1986). Twelve research reports over 25 years have specifically examined the effectiveness of MVA for induced abortion, gathering data on almost 20,000 women. In these studies, MVA’s effectiveness ranged from 95 to 100 percent. In the largest study, Laufe analyzed complication rates associated with 12,888 MVA procedures in 21 countries. The procedure’s effectiveness was greater than 98 percent (Laufe, 1977). (See Table 1 for research reports examining MVA’s effectiveness.)
MVA for Early Abortion
In countries such as Bangladesh and Vietnam, MVA has been used for several decades to provide early abortion and menstrual regulation before confirmation of pregnancy. Prior to the mid- 1990s, however, there were few documented studies on the use of MVA before the seventh week of pregnancy, due in part to the difficulties in confirming pregnancy at this early stage. The advent of new, highly sensitive pregnancy-detection techniques has encouraged many providers to adopt MVA for early abortion. The procedure is being used in countries such as the United Kingdom, the United States, and South Africa to offer women the option of having an abortion early in pregnancy. In the United States, MVA before the seventh week of pregnancy was first described in 1995 by Dr. Jerry Edwards, Medical Director of Planned Parenthood of Houston and Southeast Texas. Dr. Edwards’ method combines MVA with sensitive pregnancy tests, a transvaginal ultrasound, and on-site tissue inspection to provide abortion as soon as the pregnancy is confirmed. Edwards’ research indicates that MVA for early abortion is 99.2 percent effective.—Benson et al., 2001; Edwards Ipas’ MVA instruments have been shown to be particularly effective in providing first-trimester abortions. A study compared the Ipas double-valve aspirator with other vacuum sources used at centers in Bangladesh, Southeast Asia, and Yugoslavia. The Ipas aspirator proved as safe and effective as the other methods (Balogh, 1983). Where medical abortion is available, it is appropriate to offer women a choice between MVA and medical abortion. MVA is also very effective in serving as a backup when medical abortion fails. Between two and 10 percent of medical abortion patients require a surgical procedure either because of patient request or incomplete abortion (MacIsaac and Darney, 2000). In most instances, MVA offers a simple and inexpensive way to provide backup on an outpatient basis, and in the same clinical setting as medical abortion. Medical abortion providers who are able to perform backup surgical abortion services can offer patients another choice among first-trimester procedures. Studies in countries as diverse as India, the United States, Vietnam, and the United Kingdom have all shown that vacuum aspiration is extremely effective in providing first-trimester induced abortion. Further, effectiveness rates remain high, regardless of the country’s medical system or level of development. Vacuum Aspiration is very safe for Induced Abortion, vacuum aspiration is one of the safest surgical procedures available, and the safest way to perform a first-trimester abortion. Vacuum aspiration can be used for almost all patients.
Providers should always follow any prescribed precautions for medications and procedures. The conditions requiring precautions for MVA procedures are similar to those of other surgical first-trimester abortions and potential complications are the same. About 98 percent of vacuum aspiration procedures occur without complications (Cates and Grimes, 1981; Laufe, 1977; Freedman et al., 1986). Vacuum aspiration results in 4 significantly fewer complications than D&C, including incidences of excessive blood loss, pelvic infection, cervical injury, and uterine perforation (Cates and Grimes, 1981; Laufe, 1977; Freedman et al., 1986). A major study of 50,000 vacuum aspirations performed in the U.S. found that “incidence of excessive blood loss was 50 [percent] lower with vacuum aspiration than with sharp curettage (0.5 compared to 1.0 complications per 100 procedures)” (Tietze and Lewit, 1972). WHO now recommends MVA as the preferred method of uterine evacuation, suggesting that sharp curettage be used only if MVA is not available (WHO, 2000). (See Table 2 for data on the safety of MVA compared with sharp curettage.) Studies on the safety of vacuum aspirations have found extremely low complication rates. For example, safety data from 170,000 first-trimester EVA procedures performed at three U.S. outpatient clinics over a 16-year period found a rate of nine complications per 1,000 procedures, with only 0.7 complications per 1,000 procedures requiring hospitalization and no deaths (Hakim-Elahi et al, 1990). Similarly, a report on 12,888 MVA procedures occurring in 21 countries found an immediate complication rate of 0.8 per 100 procedures, and no deaths (Laufe, 1977). Specific data on the safety of MVA find few complications associated with the method. In general, MVA demonstrates the same level of safety as EVA, and greater safety than sharp curettage (Laufe, 1977; Freedman et al., 1986). (See Table 3.) A recent Vietnamese study examined 210 first-trimester MVA abortions and included extensive follow-up. Patients completed a daily symptom diary for seven days after the MVA and data for Vacuum Aspiration (VA) was viewed by a health care provider weekly for five weeks. No serious complications such as infection or heavy bleeding occurred among the study group (Do et al., 1998). MVA remains a safe procedure when practiced in the primary care setting. One doctor in independent family practice examined the complication rates of 1,677 MVA abortions performed in this setting. MVA was 99.5 percent effective, with a minor complication rate of 1.25 per 100 procedures; minor complications included infection (12 cases), retained products of conception (8 cases), and other complications not requiring hospitalization (1 case). These minor complications were easily treated, and there were no major complications or deaths among the procedures reviewed. The author’s Safety of Manual Vacuum aspiration (per 100 procedure includes that MVA may be safely and effectively provided in the primary office setting (Westfall et al., 1998).
Patients are Highly Satisfied with MVA
The majority of women who have had an MVA procedure are very satisfied with the experience. Patient acceptability is a very important consideration when making decisions about what kind of abortion services to offer. Ensuring that patients have a positive experience is an integral part of offering high-quality services. Between 88 and 95 percent of women say they would recommend MVA to a friend. One study examining the satisfaction of patients who were randomly assigned to have either EVA or MVA found that the majority of both groups were very satisfied with their procedure. No major differences in acceptability were found between the two groups (Thornburn Bird et al., 2001). In another study where women opted for a first-trimester procedure using either medical abortion or vacuum aspiration, 82 percent of those who chose vacuum aspiration reported that they were “very” or “somewhat” satisfied. Seventy-eight percent said they would recommend vacuum aspiration to a friend, and 93 percent said they would choose vacuum aspiration if they needed another abortion (Harvey et al., 2001). A U.S. study randomly assigned women with no treatment preference to receive either MVA or medical abortion, and then examined the patients’ satisfaction. Ninety-two percent of women who received MVA said they would choose the same method again, compared to 63 percent of medical abortion patients. Such response indicates high patient satisfaction with the MVA method (Creinin, 2000). Where MVA is provided in an office setting or lower-level health facility, women may also appreciate the greater personal attention and less institutional environment (Westfall et al., 1998). Because MVA uses a handheld, non-electric aspirator, the procedure does not generate any noise. This leads to a gentle and silent procedure and one which is often more comfortable for the woman. Doctors in Vietnam have noted that MVA’s lack of noise helps reduce patient’s anxiety during the abortion procedure (unpublished focus group discussions, 1998). Some MVA providers have commented that patients ask for the “quiet abortion,” indicating the patient’s preference for this aspect of the MVA procedure. One study of 108 women found that EVA patients felt the noise associated with the procedure increased their pain although, in general, the patients’ pain perception was not significantly different between the two techniques (Edelman et al., 2001).
Abortion is a highly personal experience, and what is best for one woman may not be for another. Women place a high value on being able to choose between abortion methods. Moreover, the ability to choose yields high satisfaction regardless of which procedure women select. The option to choose between abortion methods helps to increase patient satisfaction and has emotional benefits for the woman, regardless of the method selected (Jensen et al., 2000; Creinin, 2000).
Pain management with MVA is simple and affordable:
MVA allows a lower level of pain control medication than sharp curettage. Local anesthesia which has been proven to be very safe for use in abortion procedures—can be effectively used in conjunction with analgesics for pain control during MVA. Local anesthesia reduces recovery time and requires fewer expenses for personnel, infrastructure, and equipment. In contrast, the D&C procedure is typically performed with a general anesthetic or heavy sedation. This level of pain management is expensive, and general anesthesia is associated with an increased risk of complications from blood loss, cervical injury, uterine perforation, and subsequent abdominal hemorrhage (Grimes et al., 1979; Greenslade et al, 1993b). Heavy anesthesia also places a strain on the health care system, as it requires more complicated facilities and equipment. In many countries, reliance upon general anesthesia limits the settings in which surgical abortions can be performed. The patient’s reduced perception of pain with MVA is particularly notable in comparison with the D&C procedure. In focus groups with Vietnamese physicians, participants consistently described a reduction of patients’ pain as a major benefit of MVA. Reducing pain also lessens the patient’s anxiety and fear, thereby improving her overall satisfaction with the procedure. As an added benefit, enhancing the woman’s experience and lowering her pain makes the procedure more comfortable for providers as well (Focus Group, 1998). By allowing pain to be effectively managed with a local anesthetic, analgesics, and verbal support, MVA lowers costs, improves safety, enhances patient satisfaction, and expands service availability. Manual Vacuum Aspiration: Service Delivery Providers appreciate the simplicity, portability, and cost-effectiveness of MVA. Any provider who engages in gynecological services is probably well equipped to provide MVA. The method can be offered with little in the way of specialized instruments and by allowing pain to be effectively managed with local anesthetic, analgesics, and verbal support, MVA lowers costs, improves safety, enhances patient satisfaction, and expands service availability. The instruments do not require electricity, and providers at various levels of the health care system can safely perform MVA. Further, there are few additional expenses once the MVA instruments are purchased, the staff trained and the facility arranged. MVA is easy to use in a variety of settings, including first-referral level sites, primary care facilities, medical offices, and clinics. Its simplicity helps move abortion services out of the hospital and operating room settings where D&C is typically performed (Magotti et al., 1995). (See Table 4.) MVA also allows providers to offer women safe and effective abortions in a private office or when the operating theater is booked, reducing delays and decreasing the number of staff required for the procedure. The burden on health care systems is reduced when a provider is able to perform an abortion at the time the woman presents at the facility, rather than waiting for physicians and operating rooms to become available. According to a 1997 study by de Pinho and McIntyre, the cost is also reduced; in South Africa, first-trimester procedures performed in health centers cost 26 percent less than those performed in community-based clinics and 133 percent less than hospital-based abortions (as cited in Althaus, 2000). A shift to performing MVA outside the hospital and/or operating room setting helps conserve resources that can then be directed to family planning and other essential health care services for women and their families. Other locales face more challenging difficulties in providing medical care, such as a lack of trained health care professionals or inadequate equipment. MVA makes safe abortions possible in low-resource or remote areas, particularly where other methods are not feasible. MVA presents a means of offering surgical services by trained midlevel providers, which is especially important in regions with low doctor-patient ratios or few available physicians. When health professionals must travel to rural areas to offer health care, MVA offers a convenient, portable, and cost-efficient way to ensure that abortion services reach remote areas of the country. MVA allows safe abortion without electricity and provides an excellent backup method for EVA where electricity is unreliable. Equipment and Facility Requirements Adopting MVA services requires few, if any, changes to either facilities or infrastructure. Because of its simplicity, MVA can be offered in lower-level health facilities and as an outpatient procedure. It is suitable for integration into hospital OB/GYN wards, private practices, community clinics, emergency rooms, and other settings. Optimally, providers will have a private space for counseling and discussing the procedure with the patient, as well as a comfortable and appropriate place for the patient to recover after the procedure. If private space is not available, providers should find a way to counsel women that respects privacy and confidentiality. The abortion itself can be performed in a small examination or procedure room, which should be well-lit, well-ventilated, and large enough to accommodate a gynecological examination table. The instruments necessary for MVA are significantly less expensive than those required for EVA. Supplies needed for sterilizing or high-level disinfecting instruments and for examining the products of conception are generally simple.
Midlevel providers can safely perform MVA at the primary health level without an increase in complication rates. In Bangladesh, female paramedics (called Family Welfare Visitors) use MVA instruments to perform menstrual regulation under medical supervision. The complication rates for abortions conducted by paramedics appear to be lower than those reported in studies in which physicians performed the abortion (Greenslade et al., 1993b; Freedman et al., 1986; Cates and Grimes, 1981). To assess non-physicians’ ability to provide safe abortion, a U.S. study examined rates of complications for vacuum aspiration abortions provided by physicians versus physician assistants.Over a two-year period, data were collected on 2,458 first-trimester abortions. There were no significant differences in complication rates between physicians and physician assistants for overall, immediate, or delayed complications (Freedman et al., 1998). In Vietnam, where only physicians offer D&C services, using MVA for first-trimester abortion has expanded the range of providers. Midwives and other medical staff are now trained to perform MVA, making services more widely available—and lessening the burden on physicians and hospitals (Focus Group, 1998). Where abortion facilities are scarce, the widespread adoption of MVA and the training of providers can help provide quality services on the local level (Greenslade et al., 1993b).
Equipment and Personnel Costs
MVA is a relatively inexpensive service to provide and is much less expensive than EVA in terms of initial costs. Reusing the MVA aspirator after disinfection or sterilization helps reduce costs. In some settings outside the U.S., the cannulae are also sterilized or high-level disinfected. Even when limited to single-use, MVA instruments are considered inexpensive in many facilities; costs of replacing instruments are offset by the higher costs associated with staff time, sterilization, and disinfection. Additional savings are realized when abortion services are moved out of the operating theater or emergency room, reducing expenditures for anesthesia, hospital infrastructure, sterile supplies, and patient recovery care. A study in Sweden estimated that performing MVA in the clinic (rather than providing EVA in an operating room) would result in cost savings of 24 percent from the operating theater and surveillance time alone. The authors estimate that, if one-tenth of Sweden’s abortions were conducted with MVA, the national savings would be about the U.S. $1,140,000 annually (Hemlin and Möller, 2001). Shifting to MVA reduces medical expenses related to the treatment of complications such as uterine perforation, excess blood loss, pelvic infection, and cervical injury. The Joint Program for the Study of Abortion (JPSA) review of 250,000 cases indicates that the complication rate for MVA is approximately half of that for D&C. A 50 percent decrease in complications will create a corresponding reduction in the expenses of treating complications (Grimes et al., 1977). Using midlevel providers rather than physicians to perform abortion services also lowers staffing costs. Staffing costs will vary depending on the type of facility where abortion is being performed, and the level of providers staffing that facility. Costs in staff time are also associated with follow-up visits. Because of MVA’s effectiveness, many providers do not require a follow-up visit and many women, particularly those in rural areas, do not find it feasible to return for a second visit. Some clinics, however, require or encourage patients to return for a follow-up exam to confirm that there are no complications and that the procedure was successful.
Training Needs: Medical Procedures
The services currently provided at a given facility will determine staff needs for training and oversight for introducing MVA. For those already performing EVA, the addition of MVA requires only minimal additional training in the differences between the two methods of suction. D&C providers, on the other hand, need training not only in the MVA procedure but also in performing abortions for patients under local rather than general anesthesia and/or heavy sedation. For providers who do not currently offer abortion services, but who are interested in expanding the services they offer, training and staffing needs may be more substantial. Staffing requirements vary depending on the location of services and the way that health care is managed in that environment. The range of the medical and logistical duties includes answering patients’ questions about abortion; greeting and providing intake services; helping with financial screening and aid; conducting physical examinations; performing MVA; assisting with follow-up appointments and questions, and handling complications. Abortion complications are extremely rare; nevertheless, all providers must be able to handle these situations if they arise. Staff will also need to be trained in CPR and in managing other emergencies as well as emergency transport. Ideally, providers who are offering abortion services (including MVA) incorporate counseling so that the woman is fully informed of her choices and the course of treatment. For many women, effective counseling is key to the patient’s successful abortion experience, and integral not only to providing information and support but also to help the patient make her decision. One U.S. study found that the greatest factor influencing the woman’s satisfaction with her abortion care was the information and counseling she received (NAF, 2001). A woman experiencing an unintended pregnancy and seeking an abortion is likely to be under a certain amount of psychological, physical, or logistical stress and coping with multiple issues (Mogul Garrity and Castle, 1996). Service providers should aid and support each woman in making the best decision for her unique situation. Staff must be able to respond with information and assistance in a caring and patient-centered manner to make the experience as positive as possible for the woman. Providing counseling and information to women seeking an abortion is a special and important skill that requires training for new abortion providers and staff. Contraceptive counseling is another essential component of patient-centered abortion care. A woman seeking an abortion does so because she does not want to be pregnant at that time; she may want to avoid childbearing for the immediate future, if not longer. Pregnancy can occur almost immediately after abortion. The abortion procedure, therefore, offers a convenient opportunity for women to receive contraceptive information and services. The brief recovery period after MVA is an opportune time to discuss contraception with patients. In Turkey, the Ministry of Health has concentrated on linking menstrual regulation and contraceptive counseling and services with great success; the prevalence of effective contraceptive method use immediately following menstrual regulation is between 86 and 92 percent (Greenslade et al., 1993b). Contraceptive counseling and care can be integrated into abortion services regardless of whether the procedure is performed in a doctor’s office, hospital setting, clinic, or community health center. What matters most is that the patient leaves with information and methods she can use to prevent further unwanted pregnancies.
Providers should investigate regulations, practice guidelines, or legal requirements that may apply to the provision of MVA. For example, some communities have specific regulations that apply to the facilities in which abortions occur. There may also be laws that direct the manner in which staff is to be protected from exposure to blood, amniotic fluid, and fetal tissue. In some locales, providers are required to send all tissue samples to a laboratory for analysis and incineration. Local governments or regulatory bodies typically determine these requirements, so managers and providers should seek advice about the laws in their specific area. Additional equipment or supplies may be necessary to comply with these regulations. Some countries and communities have laws that mandate the type of provider who can perform abortions. In some places, the original intent of these laws was to protect women from unsafe procedures performed by untrained individuals. However, such laws may act as a barrier to abortion services. For example, some local laws require midlevel abortion providers to be supervised by a physician; lack of a supervisory physician can result in delay or non-delivery of abortion services.
In countries as diverse as the United States, Vietnam, South Africa, Bangladesh, and the United Kingdom, manual vacuum aspiration has helped expand women’s access to safe and effective abortions. By bringing abortion into a wider variety of facilities, MVA can help overcome barriers that have traditionally hampered access to services. The introduction of MVA to health care professionals’ range of services helps both providers and patients. MVA is extremely safe, affordable, and has very few complications. The simplicity and versatility of the technique along with the low cost of instruments, allow providers to offer MVA in settings where EVA is not available. MVA can help to increase the number of providers and facilities offering safe abortions, provide services in areas with unreliable or nonexistent electrical supply and minimize the need for general anesthesia and operating room settings. This technology, tested and used for almost 30 years, is an important tool for addressing reproductive health needs into the 21st century. MVA can assist nations in implementing the international agreement made at the five-year review of the International Conference on Population and Development (ICPD+5) to ensure safe and accessible abortion services to the full extent of the law. MVA can expand women’s access to safe abortion services, ultimately reducing maternal mortality and morbidity throughout the world.