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 orallocate 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: 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 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 replacesharp 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 car- ries higher risks (IPPF, 2001; WHO, 2000).