This analysis aimed to estimate the costs and cost- effectiveness of providing first-trimester medication abortion and manual vacuum aspiration (MVA) services to inform planning for first-trimester service provision in South Africa and similar settings.  It found that the cost per complete medication abortion was lower than the cost per complete MVA. This analysis supports the scale-up of medication abortion alongside existing MVA services in South Africa. Women can be offered a choice of methods, including medication abortion with MVA as a back-up, without increasing costs.