Objective We conducted a systematic review to examine the prevalence of minor and major complications following first-trimester aspiration abortion requiring medical or surgical intervention. Study Design We searched PubMed, Cumulative Index to Nursing and Allied Health Literature, Scopus and the Cochrane Library for articles published between 1980 and April 2015 that reported on repeat aspiration, hemorrhage, infection, cervical/vaginal trauma, uterine perforation, abdominal surgery, hospitalization, anesthesia-related complications and death. We limited our review to studies that included ≥ 100 abortions performed by physicians in North America, Western Europe, Scandinavia and Australia/New Zealand. We compared the prevalence of complications that required additional interventions for abortions performed in office-based clinics and surgical center or hospital clinic settings. Results From 11,369 articles retrieved, 57 studies met our inclusion criteria. Evidence from 36 studies suggests that ≤ 3.0% of procedures performed in any setting necessitates repeat aspiration. Hemorrhage not requiring transfusion occurred in 0-4.7% of office-based procedures and 0-4.1% of hospital-based procedures but was ≤ 1.0% in 23 studies. Major complications requiring intervention, including hemorrhage requiring transfusion and uterine perforation needing repair, occurred in ≤ 0.1% of procedures, and hospitalization was necessary in ≤ 0.5% of cases in most studies. Anesthesia-related complications occurred in ≤ 0.2% of procedures in six office-based studies and ≤ 0.5% of procedures performed in surgical centers or hospital-based clinics. No abortion-related deaths were reported. Conclusions The percentage of first-trimester aspiration abortions that required interventions for minor and major complications was very low. Overall, the prevalence of major complications was similar across clinic contexts, indicating that this procedure can be safely performed in an office setting. Implications Laws requiring abortion providers to have hospital admitting privileges or facilities to meet ambulatory surgical center standards would be unlikely to improve the safety of first-trimester aspiration abortion in office settings.