Manual vacuum aspiration involves use of a hand-held plastic aspirator providing a vacuum source attached to a cannula (thin tube) and manually activated to suction the uterine contents. Plastic cannulae, which vary from rigid to very flexible, are used with MVA aspirators.

Conditions for Use
Manual vacuum aspiration is appropriate for first-trimester abortion, menstrual regulation, treatment of incomplete abortion for uterine sizes up to 12 weeks from the last menstrual period (including miscarriage, spontaneous abortion and removal of retained products from an induced abortion) and endometrial biopsy.

This method can be performed by a physician or by a trained mid-level provider. Because MVA does not require electricity, it can be used in decentralized, rural settings with intermittent electricity supply (Baird and Flinn, 2001). As with vacuum aspiration in general, MVA services can be provided in a clinic setting on an ambulatory, outpatient basis, requiring fewer facility resources and reducing the cost of care, compared with electric vacuum aspiration and sharp curettage (Forna and Gülmezoglu, 2002). These qualities can help shift abortion- and postabortion-care services to community-based health-care settings, which not only decreases costs but also expands access to care. A World Health Organization Technical Working Group listed vacuum aspiration as an essential element of care at the first-referral level (WHO, 1991).

Reduced waiting times and increased local availability of care also make this an acceptable method to many women. In addition, MVA creates little noise during the procedure, which some women prefer (Bird et al., 2001).

The Process
After the woman has made an informed decision and undergone a medical examination confirming that MVA is clinically appropriate, a clinician places a speculum in the vagina. Next, a cannula of the appropriate size (determined on the basis of uterine size), is inserted through the cervix into the uterus. The cannula is attached to a vacuum-charged aspirator. The aspirator serves as the source of vacuum to suction the products of conception through the cannula into the cylinder.

Safety and Effectiveness
Manual vacuum aspiration is extremely effective and very safe (WHO, 2003). Most studies show that vacuum aspiration is successful in approximately 99 percent of cases (Greenslade et al., 1993).

This method results in few complications, especially when performed before or at 12 weeks since the woman’s last menstrual period. Compared with sharp-curettage method, use of MVA requires less cervical dilatation and is associated with less blood loss, shorter hospital stays and a reduced need for anesthetic drugs (Hyman and Castleman, 2005; Forna and Gülmezoglu, 2002).

Results of a randomized trial indicate that mid-level health-care providers can perform MVA procedures as safely as physicians can (Warriner et al., 2006).

Pain Management
Women undergoing uterine evacuation with MVA generally experience three sources of discomfort: anxiety, cervical dilatation and uterine cramping. These sources require different pain-management strategies. The health-care provider should create a pain-management plan, together with the woman, in advance to reduce any physical pain and anxiety and to minimize medication-induced risks and side effects. Pain during a uterine evacuation with MVA can be reduced with a combination of verbal support, oral medications, local anesthetic to the cervix (paracervical block) and a gentle clinical technique.

Other Options
When MVA is unavailable, women may have other options, depending on the availability of a health-care provider trained and equipped with alternative methods, and the woman’s clinical circumstances. These alternatives to MVA include electric vacuum aspiration, medication abortion, sharp curettage and carrying the pregnancy to term with prenatal care.

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