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.8 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). (See Table 5.) 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 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 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. Training Needs: Options & Contraceptive Counseling 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 helping 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 abortioncare. 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 discus 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 reg- ulations 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.