Clinical Updates in Reproductive Health

Safety and effectiveness

Last reviewed: January 28, 2021

Key Information:

  • Vacuum aspiration is effective and safe, with success rates over 98% and major complication rates under 1%.

Quality of evidence: High

Effectiveness

A successful vacuum aspiration requires no further intervention to evacuate the uterus. In a large United States-based observational study of 11,487 first-trimester aspiration abortions done by physicians, nurse practitioners, certified nurse midwives and physicians assistants, the need for repeat aspiration due to incomplete abortion was 0.28% and ongoing pregnancy was 0.16% (Weitz et al., 2013).

Safety

A 2015 systematic review analyzed 57 studies reporting data for 337,460 aspiration abortions performed before 14 weeks gestation in North America, Western Europe, Scandinavia and Australia/New Zealand (White, Carroll, & Grossman, 2015). Major complications requiring intervention (such as hemorrhage requiring transfusion or perforation necessitating repair) occurred in ≤ 0.1% of procedures; hospitalization was necessary in ≤ 0.5% of cases. Studies looking at different cadres of providers (physician assistants, nurses, nurse midwives, etc.) in other settings have had similar results (Hakim-Elahi, Tovell, & Burnhill, 1990; Jejeebhoy et al., 2011; Warriner et al., 2006; Weitz et al., 2013). In two studies that compared newly trained midlevel providers to experienced physician providers (Jejeebhoy et al., 2011; Weitz et al., 2013), there were no observed differences in abortion success or complication rates.

A retrospective cohort study conducted in the United States compared rates of procedural complications during outpatient aspiration abortion through 13 weeks and six days gestation in women with at least one medical comorbidity (diabetes, hypertension, obesity, HIV, epilepsy, asthma, thyroid disease and bleeding/clotting disorders) to women without comorbidities. The overall rate of complications—which included uterine perforation, blood loss greater than 100mL, cervical laceration and retained products of conception that required reaspiration—was 2.9%; there was no difference between the two groups (Guiahi, Schiller, Sheeder, & Teal, 2015). Two retrospective cohort studies, that together included 5,288 aspiration abortion procedures performed before 13 weeks gestation, found no differences in complication rates between obese, overweight, and normal weight women (Benson, Micks, Ingalls, & Prager, 2016; Mark et al., 2017).

Mortality

In the United States, the mortality rate from legal induced abortion between 2008-2013 was 0.62 deaths per 100,000 reported abortions; mortality rates disaggregated by abortion type or length of pregnancy are not available (Jatlaoui et al., 2017). In comparison, during the period from 2011-2013 the mortality rate from live birth in the United States was 17 deaths per 100,000 live births (Creanga, Syverson, Seed & Callaghan, 2017). A secondary data analysis that compared mortality rates associated with live birth to those from legal induced abortion in the United States found that the risk of death from childbirth was 14-fold higher than the risk of death from abortion (Raymond & Grimes, 2012). In the 2015 systematic review about the safety of vacuum aspiration in multiple countries referenced above, no deaths were reported (White et al., 2015).

Complication rates by study

  Upadhyay, 2015 Weitz, 2013 Jejeebhoy, 2011 Warriner, 2006 Hakim-Elahi, 1990
Number of women included 34,744 11,487 897 2,789 170,000
Location USA USA India South Africa and Vietnam USA
Provider type Not specified Experienced physicians and newly trained nurse practitioners, certified nurse midwives and physician assistants Newly trained physicians and nurses Experienced physicians, midwives and doctor-assistants Experienced physicians
Time period 2009-2010 2007- 2011 2009-2010 2003-2004 1971-1987
Total minor complication rate 1.1% 1.3% 1% (all reported as incomplete abortion) 1% 0.85%
Incomplete abortion 0.33% 0.3% 1% 0.9% Not reported (0.35% re-aspiration rate)
Ongoing pregnancy 0.04% 0.16% Not reported Not reported 0%
Minor infection 0.27% 0.12% Not reported 0.1% 0.5%
Total major complication rate 0.16% 0.05% (6 complications: 2 perforations, 3 infections and 1 hemorrhage) 0.12% (1 complication: 1 high fever) 0% 0.07% (hospitalizations for perforation, ectopic pregnancy, hemorrhage, sepsis or incomplete abortion)
Death 0% 0% 0% 0% 0%

 

References

Benson, L. S., Micks, E. A., Ingalls, C., & Prager, S. W. (2016). Safety of outpatient surgical abortion for obese patients in the first and second trimesters. Obstetrics & Gynecology, 128(5), 1065-1070.

Cates Jr, W., Schulz, K. F., & Grimes, D. A. (1983). The risks associated with teenage abortion. New England Journal of Medicine309(11), 621-624.

Creanga, A., Syverson, C., Seed, K., & Callaghan, W. (2017). Pregnancy-related mortality in the United States, 2011-2013. Obstetrics & Gynecology, 130, 366-373.

Guiahi, M., Schiller, G., Sheeder, J., & Teal, S. (2015). Safety of first-trimester uterine evacuation in the outpatient setting for women with common chronic conditions. Contraception92(5), 453-457.

Hakim-Elahi, E., Tovell, H., & Burnhill, M. (1990). Complications of first-trimester abortion: A report of 170,000 cases. Obstetrics & Gynecology76(1), 129-135.

Jejeebhoy, S. J., Kalyanwala, S., Zavier, A., Kumar, R., Mundle, S., Tank, J., & Jha, N. (2011). Can nurses perform manual vacuum aspiration (MVA) as safely and effectively as physicians? Evidence from India. Contraception84(6), 615-621.

Mark, K. S., Bragg, B., Talaie, T., Chawla, K., Murphy, L., & Terplan, M. (2017). Risk of complication during surgical abortion in obese women. American Journal of Obstetrics & Gynecology, DOI: 10.1016/j.ajog.2017.10.018. Epub ahead of print.

Raymond, E. G & Grimes, D. A. (2012). The comparative safety of legal induced abortion and childbirth in the United States. Obstetrics & Gynecology, 119, 215-219.

Upadhyay, U. D., Desai, S., Zlidar, V., Weitz, T. A., Grossman, D., Anderson, P., & Taylor, D. (2015). Incidence of emergency department visits and complications after abortion. Obstetrics & Gynecology, 125(1), 175-83.

Warriner, I. K., Meirik, O., Hoffman, M., Morroni, C., Harries, J., My Huong, N., & Seuc, A. H. (2006). Rates of complication in first-trimester manual vacuum aspiration abortion done by doctors and midlevel providers in South Africa and Vietnam: A randomised controlled equivalence trial. The Lancet368(9551), 1965-1972.

Weitz, T. A., Taylor, D., Desai, S., Upadhyay, U. D., Waldman, J., Battistelli, M. F., & Drey, E. A. (2013). Safety of aspiration abortion performed by nurse practitioners, certified nurse midwives, and physician assistants under a California legal waiver. American Journal of Public Health103(3), 454-461.

White, K., Carroll, E., & Grossman, D. (2015). Complications from first-trimester aspiration abortion: A systematic review of the literature. Contraception92, 422-438.