Abortion in Japan

Memorandums and information about abortion situations and problems in Japan

Partial translation of my book, "Abortion Technology and Reproductive Rights" (2012)

The following is a provisional translation into Japanese of "Section 7: From Rights to Justice" contained in "Chapter 6: Reproductive Health and Rights as Human Rights" of Kumi Tsukahara's 2012 book "Abortion Technology and Reproductive Rights" written in Japanese. Please note that the text translated from the English original into Japanese for my book has been translated into English this time using automatic translation, so the wording is likely to differ from the English original.

Section 7: From Rights to Justice
 The importance of national women's movements in actually promoting reproductive health and rights in diverse national contexts has been demonstrated in studies by Dorothy McBride Stetson and others (Stetson [2001]). Through a survey of policies and movements surrounding abortion in ten Western democracies, they showed that whether international agreements on reproductive rights are translated into national policies and specific health care systems depends largely on the state of domestic movements (Stetson [ 2001: 295]). 2001: 295]). In their comparative study, they found that countries with strong movements were able to achieve results even under conservative regimes with poorly functioning government departments, while countries where the movements were not sovereign tended to have less success (Stetson [2001: 295]). Similarly, the authors of the Center for Reproductive Law and Policy also attribute governments' promotion of reproductive rights (RR) and other women's rights to "the work of women's rights advocates around the world" and argue that "activism for women's rights in all spheres of society" is essential to promoting RR, and that the movement's "work for women's rights in all spheres of society" is essential to promoting RR. The Center for Reproductive Law and Policy [2000→2001: 227-8]).
 As we have seen, the emergence of the concept of reproductive rights was itself a result of the global women's movement, and such a movement was supported by reproductive control technology as a solution to unwanted pregnancy, including safe and reliable contraception and abortion. Only when such solutions existed did women have a concrete sense of entitlement to them. On the other hand, even when safe and reliable methods of reproductive control exist, indirect or direct state prohibition or coercion through patternalistic intervention prevents women from having a sense of entitlement and, consequently, free choice.
 The importance of the women's movement is also evident in cases where women's rights have actually been downplayed in countries that seemingly led the world in aspects of technology adoption. For example, according to political scientist Dag Stenvoll, abortion-on-demand was realized early on in Eastern European countries such as Poland, Romania, and the Soviet Union under communism. In these countries, contraception did not spread as "unnatural, inefficient, and dangerous," while abortion became a commonplace "medical procedure" that was "traditional, safe, accessible, relatively inexpensive," and "as uncomfortable as a tooth extraction" (Stenvoll [2007: 23, 26]). However, according to Stenvoll, the policies in those countries had nothing to do with reproductive choice in modern Western Europe or North America, which involves the knowledge and means of contraception. In Russia, for example, the practice of using abortion as a substitute for contraception persisted, while the abortion care, which was cheap and readily available in public hospitals, was poor. Thus, Russian women "did not have to fight for the freedom of abortion as women in the West did, but they had to fight for more humane abortion care" (Stenvoll [2007: 23, 26]). These facts remind us of the need for the women's movement to demand safe means of birth control and abortion, as well as a more humane and respectful system for women.
 As we have already noted, reproductive health and rights (RHRR) have been declared a universal human right. However, it would be meaningless if the rights that were supposed to have been acquired end up being a "picture-perfect" right. As legal scholar Lynn Freedman warns, reproductive rights are not, and should not be, "free choice in a vacuum of nothingness" (Freedman [1995: 1086]). Even if the "right to choose" were granted to all, the reality of social inequality based on class, age, race, ethnicity, culture, etc., as it is, would make "free choice" unfeasible for the disadvantaged. To address this gap between rights and reality, some non-white women have begun to advocate a new conceptual framework called reproductive justice (RJ). They moved beyond RR, which tends to focus on abortion rights, to recognize the connection between regulating, controlling, and associating women's reproductive capacity and sexuality with sin and the norms of the communities of race, class, gender, sexuality, and nationality on which they themselves are based. and the adoption of this framework (Silliman et al. [2004: 4])38). Let us introduce this new movement.
 According to the ACRJ, reproductive justice is "the full achievement and protection of women's human rights. According to the ACRJ, reproductive justice is a state of justice in which "the full physical, psychological, spiritual, political, social, and economic wellbeing of women and girls is achieved based on the full achievement and protection of their human rights," and they emphasize that those who are not in such a state should work collectively for justice. They emphasize that those who are not in such a state collectively work for justice. ACRJ activists placed particular emphasis on the need to work with various other movements for social justice to advance the reproductive agenda.
 In the RJ movement, a woman's ability to make her own reproductive decisions is analyzed from the perspective that it is directly tied to the conditions of the community in which she lives. RJ focuses on specific issues that arise in the reality of social inequalities, and in particular on the need to ensure that every woman has an equal opportunity to decide for herself the course of her pregnancy. In this framework, the demand for privacy is a key issue. The framework goes beyond the demand for privacy and respect for individual decision-making to the provision of social support that is essential for the optimal realization of individual decision-making, and calls on national governments to fulfill their obligations to protect women's human rights to ensure that such support is provided. We will also take action to demand that their governments fulfill their obligations to protect women's human rights so that such support is provided. We also call on governments to ensure that the choices women make (for example, regarding reproduction) are always safe, affordable, and accessible, regardless of which option they choose, and that these three requirements are guaranteed for every individual's life decisions. We call for government support to ensure that these three requirements are guaranteed for every individual's life decisions.
 Reproductive justice advocates are particularly concerned that the issue of abortion tends to be isolated from other social justice issues, such as issues of economic injustice, the environment, immigrant rights, disability rights, and discrimination based on race or sexual orientation. In reality, however, those social justice issues have a direct impact on the decision-making process of an individual woman40).
 Therefore, ADRJ began working on RJ's movement to eliminate injustice by presenting the following three elementary frameworks to combat reproductive oppression.

1. reproductive health--working to provide services
2. reproductive rights--raising legal issues
3. reproductive justice--focus on building the movement itself

 In describing this framework, which is focused on implementing a specific movement, Loretta Ross of the Sistersong Non-White Women of Color Reproductive Health Collective states, "Ultimately, any movement is about service. supports this by stating that ultimately "service," "advocacy," and "organizing" are essential to any movement (Sistersong Women of Color Reproductive Health Collective et al. [2007: 4]).
 Women and girls who are able to see things within a reproductive justice framework will ultimately be empowered within their own families, and RJ's analysis always aims to discuss abortion and contraception in the context of facing the realities of women and girls' situations. RJ focuses on challenging structural "power imbalances" through processes of organizing and empowering women, girls, and communities in a holistic and transformative way. RJ emphasizes challenging structural power imbalances through a process of organizing and empowering women, girls, and communities in a comprehensive and transformative way. There, "the personal will become political.
In RJ's discussion, one is reminded of the emphasis on the interrelationship of various rights, especially on whether women's rights are substantially protected or not. What is important, however, is not only whether a certain right is guaranteed to a certain individual, but also to pay attention to whether there is any abuse rooted in a system that is structurally unjust. Specifically, if a woman who finds herself pregnant decides that she is in a social situation where she has no choice but to consider it practically impossible to "give birth" and "raise a child adequately (in the way she wants)," and therefore chooses not to "give birth," that is not for her an "exercise of her rights," but rather an abrogation of her choice. It would not be an "exercise of her rights," but rather a forced choice. This viewpoint would require a change in the social system to enable her to fully exercise her "right to choose" in practice.
Furthermore, from RJ's point of view, if her psychological and mental health is hindered by the "forced choice not to give birth," as described above, because such a choice conflicts with the "ideal image of motherhood" that is considered "common sense" in her society, then it is necessary to change such "common sense," as well. From RJ's perspective, what is needed is support to give her "truly free choice. Furthermore, if measures to prevent the dilemma of whether or not to give birth (e.g., sex education and contraceptive guidance) are insufficient, then these must be changed as well. In other words, what is required here is a very comprehensive understanding of the current social problems that women and girls face, and a persistent effort to work for change one by one in a concrete manner. Since this is beyond the limits of individual abilities, a sustained "movement" that mobilizes a large number of people will be indispensable to realize this change.
 The need for a grassroots, yet grand women's movement like RJ's is a corollary of the fact that until very recently in history, women have been very rarely represented at key moments of political decision-making on the rights of human beings. Even within approaches to human rights guarantees that prioritize the protection of people from direct state violations of their human rights, it has often occurred that women's human rights are sacrificed in order to protect male-defined cultural, familial, and religious rights41) (Bunch and Reilly [1994: v, 3]). However, because of their own experiences of oppression, women activists, especially feminist women, demand that gender-based oppression and discrimination be eliminated, but do not allow anyone else's human rights to be sacrificed in order to do so. This point also results in difficulties peculiar to the feminist movement, but it also brings the possibility of shifting the view of the "individual" and "human rights" itself and presenting a new view of human beings. For example, in the recent feminist human rights and health movements, the "self" is being constructed and understood as a "connected self.
According to Freedman, the reproductive rights movement was originally a confluence of the women's human rights movement and the women's health movement, but as these two movements proceeded in parallel, sometimes overlapping, they arrived at a new image of "self" (Freedman [1995: 1086 Freedman [1995: 1086]). For example, the mission statement of Development Alternatives with Women for a New Era (DAWN), an organization of researchers and activists who question development from the perspective of Third World women, includes the following statement: "Women's reproductive health should be within the framework of comprehensive human development, where the wellbeing of all people and the full citizenship of women must be promoted," suggesting the need to view people and individuals through a "double lens" (Petchesky and Judd [1998: 4]). Thus, the feminist movement is often characterized by a view of the individual as an entity living in relation to concrete others, a view that runs through both the RHRR movement and RJ.
Whether in RHRR or RJ, feminists have embarked on a process of constructing and understanding each person as a socially and physically "united self," overcoming a worldview that sees each person as a separate and isolated self, protected by rights, having a body of its own, and cut off from the world. This is precisely the process of constructing and understanding the feminine self, which will be discussed in the next chapter. This is precisely the view of the human person that is characteristic of feminist ethics, which will be discussed in the next chapter. Perhaps the "bound self" is rooted in the very specific "self/other" experience of "pregnancy" or is gendered as a person who can have such an experience. --Perhaps this is the view of human beings that we inevitably arrive at as gendered beings capable of such experiences. This new insight still needs to be examined, but we will consider this new "self" again in relation to abortion at the end of the next chapter.


Notes:
(38) The authors introduce RJ as a new kinetic form of women of color, using it as an interchangeable concept with RR.
(39) The following description of RJ is based on Sistersong Women of Color Reproductive Health Collective et al.
(40) In Japan, the problems of single parenthood and discrimination against illegitimate children, as well as the fact that the average income of women is much lower than that of men, may have a significant impact.
(41) See Bunch and Reilly [1994: 17-92] for a record of testimony on "gender-based human rights violations" conducted by the Global Campaign for Women's Rights during the Vienna Conference on Human Rights in 1993.
(42) According to Freedman, this view is called the "integration principle" by Pechesky and others (cf. Freedman [1995: 1086]).

Japan has the lowest ratio of people who are "well informed and aware" about human rights!

Japanese people ignorant of human rights

Human Rights in 2018: A Global Advisor Survey© 2018 Ipsos

A survey on human rights awareness conducted by Ipsos in 2018 for 28 countries. We were surprised to find that Japanese people's "human rights awareness" was very low. However, looking back, I myself do not remember learning education in school about not only "human rights" but also the raison d'etre of the "Constitution", the "United Nations Declaration of Human Rights" and "Human Rights Covenants". Later, I noticed that "human rights" were explained by the Japanese Ministry of Justice as if they were "compassion" and that there was no indication that the obligation to protect people's human rights lies with the "state". It also became clear to me that all international treaties are considered to be under the jurisdiction of the Ministry of Foreign Affairs, and that the Ministry of Justice does not take any action when asked about treaty violations.

©2018 Ipsos

Press Release, Human Rights in 2018

In response to an inquiry from a foreign journalist: sharing information provided

This "training note" and "Safe Abortion Procedures, "a material for press roundatable, are treasure trove of information on abortion methods in Japan

For those who don't read Japanese, please use these translations for "Training Note" and a powerpoint material "press roundtable" you can download from Japan Association of Obstetricians and Gynecologists webcite.


Japanese mid-term abortions (after 12 weeks and under 22 weeks) are artificial abortions using gemeprost. The "Training Note" on the website of the Japanese Society of Obstetricians and Gynecologists, in discussing "late-term abortion treatment," explains that mid-term abortions are to be handled in the same way, and no other methods are indicated.


Here is the translation of concerned parts:

5. late-term miscarriage procedures
(1) Procedures
〇In the case of a late miscarriage (stillbirth) after 12 weeks' gestation, a stillbirth certificate is prepared in accordance with Article 12 of the Ministerial Ordinance on Stillbirth Notification, Stillbirth Certificate, and Stillbirth Examination (Fig. 12). (A stillbirth cremation permit is issued when the patient submits an application for a stillbirth (burial) cremation permit to the municipal office together with the stillbirth notification and stillbirth certificate.)
〇If the uterine contents are not in the shape of a fetus or cannot be recognized as a fetus, or if the pregnant woman is dead and the fetus is certain to die, a stillbirth certificate is not required, even if the stillbirth occurred after 12 weeks of pregnancy.
〇If this is performed as an abortion procedure, a written consent of the couple is required under Article 14 of the Maternal Protection Law (Fig. 13). In addition, notification to the prefectural governor is required under Article 25 of the Maternal Protection Law. This notification is made using the separate report form No. 13 (Fig. 14), which is based on Article 27 of the Enforcement Regulations of the Maternal Protection Law.
〇When a person insured by the health insurance system gives birth, a lump-sum maternity and childbirth allowance is paid. In this case, the term "childbirth" refers to a birth after 85 days (4 months) of pregnancy, stillbirth (miscarriage), and artificial abortion.


(2) Miscarriage treatment
 The procedure consists of three steps: cervical dilation, administration of uterine contractions, and confirmation of uterine contents. The procedure is explained to the woman and her partner, and written consent is obtained.

1 ) Cervical dilation
〇The most important procedure for the safe treatment of miscarriage after the 12th week of pregnancy is cervical dilation.
〇The most important procedure for safe miscarriage treatment after the 12th week of pregnancy is cervical dilatation.
〇The available cervical dilatation materials and their details are described in the next section "III-6. Figure 15 shows an example of a specific schedule for cervical dilation.


2 ) Uterine contractions
① Gemeprost (Gemeprost, Preglandin®)
〇Insert 1 mg of gemeprost (1 piece) into the posterior vaginal canal every 3 hours.
〇The maximum daily dose is 5 mg(5 pieces). If the drug is ineffective, it should be discontinued and resumed the next day or later, or switched to another method.
〇The dosage should be administered by a physician designated under the Maternal Protection Law (for details, see the October 1, 2009 issue of Nissan Women's Medical Association Bulletin, p. 16).
〇The package insert states that administration is contraindicated in the presence of placenta previa or pelvic infection.
〇In the second trimester, it is not uncommon to find a placental limbus near the endocervical opening on transvaginal ultrasonography. In such a situation, the patient should be carefully treated with caution in case of abortion or intrauterine fetal death, paying attention to massive hemorrhage.
〇If there is a history of previous cesarean section, especially if the abortion is performed after 12 weeks of gestation in a pregnant woman who has had two or more previous cesarean sections, special precautions should be taken to prevent uterine rupture, including adequate cervical dilatation. Although gemeprost is not contraindicated in pregnant women with a history of cesarean section, other prostaglandins with a similar structure, such as dinoprost (Dinoprost, Prostalmon F®) and dinoprostone (Dinoprostone, Prostaglandin E2® Tablets 0.5 mg), are contraindicated in patients with a history of cesarean section or hysterectomy.
〇Gemeprost is contraindicated in pregnancies complicated by bronchial asthma because of its potential to induce asthma attacks. Gemeprost is not contraindicated, but theoretically can induce attacks and should be administered with caution.


②Oxytocin (Oxytocin, Atonin®-O Note)
〇After delivery of the fetus and fetal appendages following administration of gemeprost, 5 to 10 units should be injected slowly intramuscularly.
〇It is sometimes used instead of gemeprost in miscarriage and abortion.
〇For intravenous infusion, 5 to 10 units of oxytocin are usually mixed with 5% glucose injection solution (500㎖), etc., and the dosage is adjusted accordingly while observing uterine contractions and other conditions.
〇Because oxytocin is administered without fetal heart rate monitoring and because it is difficult to monitor uterine contractions during miscarriage due to the small uterus, careful attention should be paid to the presence of excessive labor pains.

=====================================
In Japan, mechanical cervical dilation (laminaria is the most common) is performed in principle for all cases of induced abortion with curettage or aspiration in early pregnancy and gemeprost in mid-pregnancy.

See the April 13, 2022(Reiwa 4) document from the 162nd JAOG's regularly scheduled press roundtable. It is titled "Safe Abortion Procedures". There are two slides pasted on each page.


At the bottom of the second page (fourth slide) is titled "Abortion Methods Differences by Time of Pregnancy," and on the left side below it says:

Up to 12 weeks gestation:

Cervical dilation 
  ↓
Removal of uterine contents under general anesthesia

On the right side below, it says:

After 12 weeks of pregnancy (mid-term abortion)
(stillbirth notification required)
  ↓
Form of delivery with uterine contractions (labor contractions)


The first slide (No.5) next page (p.3) is titled "dilatation of cervix (pretreatment)" with the following explanations:

On the left side, "the cervix is closed tightly to prevent delivery of the baby even if the pregnancy progresses.

On the right side:
・How to open the cervix slowly and safely
・Necessary for both early and mid-term procedures

At the bottom, Dylapan is cited as an example.


The following slide (No.6 ) on the same page is titled: Mid-term abortion method (same method as for induction of live birth)

Translation of the numbered words on the far left:

(2) Uterine contractions (vaginal suppositories)

i) Cervical dilator (pretreatment)

Translation of the procedure on in the middle of the left side:

Uterine contractions
 ↓
descent of the head of the baby
 ↓
cervical canal extension
 ↓
cervical ripening
 ↓
cervical canal ripeness
 ↓
onset of labor


Translation of the right side:

Because the cervix is open
・Greater effect of uterine contractions
・Smaller risk of uterine rupture due to contractions

Explanation of the side of the picture of Preglandin:
For a mid-term abortion, a designated doctor of the Maternal-body Protection Act inserts a vaginal suppository every 3 hours.


On the next page (p.4) , you can find the explanation of D&C and EVA as "Methods of Early Abortion."
>>
During the Japanese D&C, the contents are generally pinched out using forceps before curettage. For this reason, physicians sometimes confuse D&C with D&E. In the upper left corner of both slides, it says: "general anesthesia (intravenous anesthesia)". Also, the third line of the upper slide says: (cervical dilation, removal of uterine contents and curettage) and the third line of the lower slide says: (cervical dilation, aspiration of uterine contents and curettage).

Thus, in Japan, general anesthesia and cervical dilatation are also used even the suction method is used.


Furthermore, the description of MVA on the next page (p. 5) similarly states "anesthesia (anesthesia methods vary)" in the upper left corner, suggesting that it may not necessarily be general anesthesia. The third line of the description is: (cervical dilation, aspiration and curettage of uterine contents), which again indicates that cervical dilation is performed even for MVA.


You can see how many D&C were used in 2012. At the bottom of this page, under the title "Abortion Methods in Our Country," the results of a nationwide abortion survey conducted during the year 2012 are presented. The response rate was 58.6%, with 108,148 abortions counted.


The results are tabulated for pregnancies less than 12 weeks (93.3%) and more than 12 weeks (6.7%), with the left-hand headings in order:

Percentage of clinics 84.2%, 53.5%

Abortion Method
 Combined curettage and aspiration 46.8%, -
 Curettage method         32.7%, 8.1%
 Aspiration method         20.3% -
 Drug method           -, 78.5%
 Combination of drug and curettage -, 12.2%


This means that at least as of 2012, curettage alone was used in 32.7% of cases and the combination of curettage and aspiration in 46.8%, for a total of 79.5% of cases. This is a slight improvement over the previously reported figures.


Furthermore, you can see that the overwhelming majority of mid-term abortions at 12 weeks gestation or more were performed with "drugs".

Current abortion situation in Japan

In response to an inquiry from an foreign researcher

I'll publish my email response here as well.

In Japan, abortion is in principle a crime under the Penal Code, but abortion under 22 weeks of pregnancy is permitted under certain conditions.


Those conditions are:

  • The abortion must be performed by a doctor designated under the Maternal Protection Law ("a designated doctor").
  • Consent must be obtained from the woman and her spouse.
  • It is available when the health of the woman is seriously compromised for economic or physical reasons, or if the pregnancy is the result of sexual violence.
  • Economic reasons (strictly limited to cases where the woman's health is severely compromised for economic reasons, i.e., extreme poverty level) are interpreted expansively and used for 99.9% of abortions.


The penal code stipulates:
Chapter XXIX Crimes of Abortion
(Abortion)
Article 212 When a pregnant woman causes her own abortion by drugs or any other means, imprisonment with work for not more than 1 year shall be imposed.
(Abortion with Consent; Causing Death or Injury)
Article 213 A person who, at the request of a woman or with her consent, causes her abortion, shall be punished by imprisonment with work for not more than 2 years. If the person thereby causes the death or injury of the woman, the person shall be punished by imprisonment with work for not less than 3 months but not more than 5 years.
(Abortion through Professional Conduct; Causing Death or Injury)
Article 214 When a physician, midwife, pharmacist or pharmaceuticals distributor, at the request of a woman or with her consent, causes her abortion, imprisonment with work for not less than 3 months but not more than 5 years shall be imposed. If such person thereby causes the death or injury of the woman, imprisonment with work for not less than 6 months but not more than 7 years shall be imposed.
(Abortion without Consent)
Article 215 (1) A person who, without the request of the woman or her consent, causes her abortion shall be punished by imprisonment with work for not less than 6 months but not more than 7 years.
(2) An attempt of the crime prescribed under the preceding paragraph shall be punished.
(Abortion without Consent Causing Death or Injury)
Article 216 A person who commits the crime prescribed under the preceding Article and thereby causes the death or injury of the woman shall be dealt with by the punishment prescribed for either the crimes of injury or the preceding Article, whichever is greater.


As for spousal consent for abortion required by "Maternal-body Protection Act":

  • The intent is not to seek the consent of the perpetrator of forced sexual intercourse.
  • The spousal consent for abortion is not legally required in cases such as broken marriages(including domestic violence), where consent was difficult to obtain.
  • For unmarried women, consent is not required since the partner is not the spouse.


However, in order to avoid being sued later by their male partners, many doctors ask women to give "spousal consent," which is not legally required.


Emergency contraceptive pill is basically only available at certain pharmacies with a prescription from an obstetrician/gynecologist, but starting next week, November 28 (not in this summer), 150 pharmacies nationwide will begin "trial sales" without a prescription; those under 16 cannot use them and will be referred to an obstetrician/gynecologist if requested; minors between the ages of 16 and 18 must be accompanied by a parent. The fee is expected to be around 6,000-8,000 yen (€37-49). Other details have not yet been announced.


Mefeego Pack (a combi-pack product of one mifepristone and four misoprostol tablets) is available up till 9 week 0 day, on condition of hospitalization at a clinic or hospital with beds, or on condition of waiting in the hospital until the expulsion of the gestational sac.
Misoprostol, an ulcer treatment, is also available in Japan, but it is considered "contraindicated in pregnant women" and therefore cannot be given additionally for abortion.


In 1984 vaginal suppositories Preglandin (gemeprost) by Ono Pharmaceutical got available and still is only for termination of pregnancy after 12 week. Japanese "designated doctors" won't perform D&E. The Preglandin was tried for early abortion (less than 12 weeks) and succeeded, but Japanese designated doctors at the time, who considered early-term abortions to be sufficient for lucrative surgical procedures (D&C), convinced Ono to file an application for a drug only for the second trimester, concealing the clinical trial data for the first trimester.


Price for abortion: €600-1300 (up to 12 w); €3100*(from 12w up to 22w)
*After 12 weeks of pregnancy, a lump-sum maternity allowance is granted for "delivery" regardless of whether the fetus is alive or dead. Some facilities charge an additional fee.


Designated doctors are obstetricians and gynecologists who have been designated by prefectural medical boards as physicians who can legally perform abortions after completing a certain amount of surgical abortion training and undergoing an examination of the medical facilities where they work and their personal qualifications.

Japanese society and the entanglement of government, doctors and women

ARJC Asia & Pacific Regional Webinar: Challenges in Reproductive Justice around Asia and the Pacific held on November 17, 2023

Presentation manuscript by Kumi Tsukahara PhD


Thank you very much for inviting me today. I am Kumi Tsukahara. I’m researching on the issues of abortion in Japan. Today, I would like to give a brief overview of the situation of reproductive health and rights in Japan, focusing on abortion. [1]


In the late 19th century, Japanese imperial government created its first criminal code which banned abortion in 1880, and soon it re-issued a new criminal code in 1907 that regulated abortion more strictly, and it’s still in effect today. In 1948, faced with poverty and a rapidly increasing population after the defeat of the war, Japan established the Eugenic Protection Law (EPL), which provided forced sterilization to the disabled and legalized abortions for several reasons. [2]

In 1952, they added an economic clause, and a single designated doctor gained the authority to decide whether or not to perform legal abortions. By loosely interpreting this clause, the doctors performed a large number of abortions. Abortion became a lucrative business for them. This is the base of our problem. [2]


This graph shows the dramatic change in the number of abortions in Japan. The official numbers of abortions were over 1 million per year for nine straight years. Other nations banning abortions at that time criticized Japan as an “abortion paradise.” [3]

In addition, the forced sterilization articles of the EPL came under attack as discriminatory toward disabled people. So, Japan revised the law in 1996 as the Maternal-body Protection Law (MPL), having only abortion articles remain. [2]


This graph shows the evolution of contraceptive use in Japan and how the approval of the birth-control pill in 1999 did not contribute to an increase in use of contraceptive pill among Japanese. Birth control pills are rarely used even now. I am so concerned that the abortion pills approved this year may follow the same path. [4]


Here is a summary of the legal status quo. The penal code criminalizes and stigmatizes abortion. The MPL allows designated doctors to perform abortion only after obtaining consent from the pregnant woman and her spouse. In reality, 99.9% of abortions performed because of threatened maternal health for economic reasons. [5]


This chart shows the difference in abortion methods between Japan and WHO. Japanese doctors have been using D&C for early abortions since abortion was legalized in 1948. Although the use of aspiration methods has increased just recently, even the latest data show that D&C is used alone or in combination with aspiration in 60% of the early-term surgical abortion procedures. [6]


In April this year, the abortion pill, mifepristone and misoprostol, was finally approved in Japan for termination only up to 9 weeks. All the abortions are exclusively performed legally only by designated doctors, with no health insurance coverage. [6]


Here is a compilation of pictures of abortion methods used in Japan. Abortion by surgeries usually costs 700 – 1500 US dollars. Please refer to the brief explanation about “designated doctors” in the box. [7]


Here is a list of issues regarding the handling of oral abortion pills approved this year in Japan. Abortion pills are so safe and effective that the WHO has included them in their essential drug list as you know. However, in Japan, only designated doctors could prescribe them, hospitalization is required, and the price is very high, equivalent to a surgical procedure. [8]


This year, the UPR of the UN Human Rights Council took place for Japan, the Japanese government received many recommendations regarding SRHR. Several countries called on Japan to abolish the criminal offense of abortion and to implement comprehensive sexual education to guarantee human rights. However, Japan rejected most of the requests. They answered that Japan would respect "the unborn" as a human life and dismissed the guarantee of human rights for women, citing the ethics and morality of the people. This attitude of the government has been the same for almost half a century. [9]


This diagram illustrates the relationship between three interest groups in conventional Japanese society regarding abortion: medical doctors, the government and lawmakers, and women. The medical associations have provided organizational votes and donations to support ruling party legislators, and the government has adopted policies that favor the doctors, as the EPL and the MPL protect their interests. On the other hand, the government has bound women by criminalizing abortion and stigmatizing it. Meanwhile, doctors have monopolized and stigmatized abortion by maintaining outdated and ethically problematic abortion methods. Women have been forced to internalize shame and guilt and remain silent because of stigmatized abortion. [10]

To break this vicious cycle, we need to proclaim reproductive rights as a universal human right. Promoting this concept enable women to confront their shame and guilt and raise their voices. Empowered, self-respecting, and united at home and abroad, women can advocate that it is essential for the government and doctors to guarantee women's reproductive health and rights. We demand that doctors respect WHO guidelines and scientific evidence; similar pressure can be applied to them by WHO and FIGO. Meanwhile, empowered women could ask the government to abolish discriminatory abortion-related laws and introduce comprehensive sexual education. The UN and other countries can also put pressure on the Japanese government. [10]


Our basic principle is "justice" based on human rights. Even though the current situation differs from country to country, it is imperative to spread this transnational principle to all people and realize reproductive justice. [10]

Thank you for your attention.


Refer to the PPT for this presentation: here

[number] refers to the page of the PPT.

Consent issue casts shadow on safe abortion in Japan

Japan Times, by Kathleen Benoza, 2003, Septmber 28

www.japantimes.co.jp

Main Texts:

As the world observes International Safe Abortion Day on Thursday, there is growing focus on the movement in Japan for safe and accessible abortion practices. The recent approval of the first abortion pill in the nation offers a glimmer of hope, but archaic rules governing consent — rooted in Japan's eugenics history — persist, casting a shadow on safe access.


The 1996 Maternal Health Act, which includes the spousal consent law, evolved from the 1948 Eugenic Protection Act, which opened the path for legal abortion. The former abolished eugenic provisions to create the law Japan follows today.


The current law stipulates that abortion must be carried out in the early stages of pregnancy with the consent of one's spouse.


The health ministry approved the country’s first abortion pill, the Mefeego pill pack produced by British drug manufacturer Linepharma, in late April, providing women in early pregnancy with an alternative to a surgical procedure. The ministry says the spousal consent law is also applicable to abortion pills.


Among the countries with legal abortion, 15 require spousal consent for induced abortions, according to a World Health Organization database. Many of those nations have strong religious influences.


In Japan, exceptions to the consent rule are granted in situations where a spouse's identity is unknown or they are unable to convey their intentions.


There is no provision in the law for unmarried women. The health ministry has clarified that a partner's consent is not required for unmarried women, women who can prove their marriage ended because of domestic violence or those impregnated through rape.


Despite this, because of misconceptions and concerns regarding legal consequences, many doctors continue to insist on obtaining a man's consent.


In some cases, the policy has led to tragedy.


In 2021, a 21-year-old former nursing school student received a suspended prison sentence for leaving her newborn in a restroom at a park. During her trial, the woman said that a hospital demanded male consent for an abortion, which she couldn't obtain.


As the health ministry's assurances are not legally binding, clinics are allowed to have their own practices, especially because only designated doctors appointed by the medical associations in each prefecture can perform abortion procedures at specified medical facilities, said Kumi Tsukahara, director of the Reproductive Health Rights & Literacy Institute.


She argues that this system allows doctors to act in their own interests and engage in practices that should not be permitted under a legitimate framework.


“As long as doctors prioritize avoiding potential issues, the requirement for spousal consent will remain,” Tsukahara said.


Some concepts from the old law, including the requirement for spousal consent, remain unchanged to this day, said Yoko Matsubara, a professor at Ritsumeikan University who specializes in the history of science and bioethics, with a focus on eugenics.


"Doctors have had spousal consent ingrained in their practices,” Matsubara said. “Factors like women's rights or respecting human rights, those elements are not included in the law.”


Matsubara said she believes doctors want to support women with such a life-changing decision, but bypassing the conditions specified in the Maternal Health Act could potentially lead to imprisonment.


Medical practitioners can be imprisoned for up to seven years under the law if they don’t obtain spousal consent. Under the penal code, women who have an abortion without spousal consent or take medication to induce their own abortion can face up to a year in prison.


Due to these provisions, abortion is fundamentally considered a crime, Matsubara said. But with the consent of one's spouse, abortion in the early stages of pregnancy is possible with no questions asked, she said.


When it comes to laws concerning women, lawmaker-initiated legislation is common, said Misako Iwamoto, political scientist and expert on legislative processes in Japan, adding that amending the Maternal Protection Act would require approval by a majority in parliament.


The most recent government report shows that about 16% of lawmakers are women.


Iwamoto said that politicians in Japan tend to place the responsibility for abortion primarily on women, viewing matters such as spousal consent and birth control pills as connected to women's sexual agency.


In July, Japan reviewed recommendations received during the Universal Periodic Review by the United Nations Human Rights Council, which assesses human rights in all U.N. member states every 4½ years.


During the assessment, Japan rejected recommendations both involving the Maternal Health Act and the abortion crime law. Japan's representatives cited the need for thorough parliamentary discussions to amend the Maternal Health Act and emphasized the importance of protecting the fetus as a biological entity before making a decision to abolish the abortion crime law.


"I believe there is a need to change the law to eliminate the abortion crime and establish a law that clearly outlines the regulations doctors must adhere to in abortion procedures,” Matsubara said.

women march for the right to access abortion in Japan Open Access NewsWomen's Health News Japan’s health ministry approves first abortion pill in its history April 24, 2023

Open access 2023/4/24

www.openaccessgovernment.org

I didn't know this article uses my comments without my knowledge.

Kumi Tsukahara, director of the Reproductive Health Rights Literacy Institute, said: “Being able to control one’s own pregnancy is already the minimum requirement for gender equality. Although this discussion is on medicine, we must not lose sight of how this is a human rights issue.”

International Campaign for Women's Right to Safe Abortion, August 18, 2003

Special Report on Japan’s approval in 2023 of abortion pills : three reports

ICWRSA Japan Special Report

1. Japan’s crawl towards medical abortion: Why was Japan the last of the G8 countries to approve mifepristone?
by Marion Ulmann


2. What my Yahoo Japan! articles revealed about the long-delayed approval of abortion pills in Japan
by Masako Furukawa


3. Are medical abortion pills deleterious drugs containing a poisonous ingredient? No!
by Kumi Tsukahara

UN experts say Japan has made strides on business and human rights, but must tackle systemic challenges

TOKYO/GENEVA (4 August 2023) – UN experts today commended Japan’s commitment to implement the UN Guiding Principles on Business and Human Rights (UNGPs), and urged the government to address deeply embedded unfair gender and social norms to ensure full protection for human rights in the country.
UN experts say Japan has made strides on business and human rights, but must tackle systemic challenges | OHCHR

The Approval of the Oral Abortion Pill Mefeego Pack and Remaining Issues

Japan's abortion situations-- Past, Present, and Future

Linepharma's Mefeego Pack, containing one Mifepristone and four Misoprostol tablets, has been called "Japan's first oral abortion pill. "Japan's first abortion pill" was Preglandin (ingredient name: gemeprostol), a transvaginal mid-term abortion pill approved in 1984. Since then, for a long time in Japan, early-term abortions were mainly performed by curettage, while this archaic vaginal suppository was for later abortions.


Until recently, Japanese people were not much interested in oral abortion pills: in a 2014 survey of Japanese women in general, a majority said they had never heard of abortion pills, and more than one-third said that they could not distinguish them from emergency contraceptives, whereas less than 10% of respondents correctly recognized that abortion pills were not on sale in Japan and put on sale in foreign websites. The U.S. medical consulting firm that conducted the survey was also involved in the 2017 approval of the manual aspirator Women's MVA System. Japan's Galapagosized abortion care was slowly beginning to change due to these external pressures.


Japan is one of the few countries where abortion came before contraception. Although abortion was legalized soon after the Second World War and later was simplified so that it could be performed virtually at the discretion of a single doctor. In contrast, oral contraceptives did not come until 1999 and are not still very popular.


The conventional lack of interest in oral abortion pills in Japan is due in part to a lack of education, which has led to a lack of awareness on the part of women to control their pregnancies, as well as a social problem in which the barriers to accessing contraceptive information and methods are too high. For example, both contraceptives and emergency contraceptives require a "doctor's prescription" in Japan and are extremely expensive. For young women who have never been pregnant, going to an obstetrician/gynecologist can be very uncomfortable, and even the cheapest monthly birth control pills cost 2,000 to 3,000 yen, while an emergency contraceptive pill costs 10,000 to 20,000 yen.


Nevertheless, abortion pills gathered attention in April 2021 when news broke that Linepharma would apply for approval of "Japan's first oral abortion pill. Female journalists indeed showed a high level of interest personally, and I believe women's movements like ASAJ wielded influence by providing information and lobbying lawmakers on abortion pills around 2020.


In December 2021, Linepharma K.K. applied for approval of a combination pack for oral abortion consisting of two drugs, Mifepristone and Misoprostol. The following year, the Pharmaceuticals and Medical Devices Agency (PMDA) conducted a review and issued a report in November stating that the approval was appropriate.


Linepharma's oral abortion drug, named "Mefeego Pack," was finally approved on April 28, 2023, after deliberations by the First Division of the Pharmaceutical Affairs and Food Sanitation Council of the MHLW at the end of January 2023, a month of public comment, and deliberations by a higher-level Pharmaceutical Affairs Subcommittee. In addition to being strictly controlled as a "deleterious" drug, the conditions of approval stated that the drug "must be administered under the confirmation of a designated doctor under the Maternal Body Protection Law" and "must be used for the time being in a hospitalized facility (hospital or clinic) where hospitalization is possible, and after Misoprostol administration, the patient must remain in a hospital or on standby until the patient expels the pregnancy.


Only the designated doctors under the Maternal Body Protection Law can perform abortions in Japan. There is no coverage by health insurance, and individual medical institutions can determine the method and fee of abortion. In addition, women have to get spousal consent before taking abortion pills. Furthermore, even if they ease regulations in the future, there is still a risk of violating the crime of self-abortion under criminal law if the person performing the abortion takes the abortion pill by themselves.


Mefeego Pack became available on May 16, 2023, and medical institutions wishing to handle it can take Linepharma's e-learning course to register. However, it is not yet ready for accessible use. I pointed out six problems below:


First, there is a lack of providers: as of June 15, 2023, only 14 medical institutions appear on Linepharma's website, "Find Hospitals and Clinics Where You Can Ask About Abortion Pills." Since this is a free medical service, they may be waiting to see how other hospitals will operate, but some parts of Japan have no medical institutions offering the service. It seems unlikely that the system will spread rapidly.


Second, the fees are likely to be high. Only two of the 14 locations listed above clearly indicate their prices on the websites. One sets the flat fee of 128,000 yen for surgical or medical abortions, while the other charges 89,000 yen, including the cost of a preliminary medical examination. Although Linepharma has not disclosed the wholesale price of the abortion pill, the Japanese Association of Obstetricians and Gynecologists assumes the cost of the medicine is about 50,000 yen to justify the price at medical institutions as about 100,000 yen, including the pill, consultation, examination, and treatment in case of failure. It is said to be slightly cheaper than surgery, but the price is left to the judgment of individual medical institutions and cannot be predictable.


Third, hospitalization or waiting in the hospital "until the pregnancy expels" is mandatory, although only for a while. Since the conventional abortion procedure for early pregnancy in Japan has been a one-day operation, if "hospitalization" is required for those who wish to take the medicine, there will be people who give up. It is also unclear whether they can stay in a private room or whether the patient can be with a chaperone. If it takes longer to complete the abortion, the cost of hospitalization may increase.
There are also concerns about whether the patient will experience emotional distress from encountering other expectant mothers and newborns because of the long time spent in the medical facility. Another problem is that, unlike surgery, you are awake, but they don't offer mental health care.

Furthermore, in the case of in-hospital waiting, there is no indication of rules for what to do "if the pregnancy has not been expelled" by the end of clinic hours. The advantage of the abortion pill is that it "de-medicalizes" abortion. There should be an option to take the Misoprostol alone, which expels the pregnancy product, at home.


Fourth, there is no option to complete the abortion with the medication alone as much as possible by giving additional doses of Misoprostol; the WHO's 2022 "Guidelines for Abortion Care" states that you can consider "repeated doses of Misoprostol application if necessary to complete the abortion..." However, giving additional Misoprostol is not an option for Japanese doctors who only perform the surgery if it fails. Giving additional Misoprostol should be an option, as this would increase the number of people who could complete the abortion with the drug alone.


Fifth, ultrasound (echocardiography) is a requirement for taking the medication in Japan. After the Corona disaster, "self-administered abortion," where the patients have the medicine at home very early in the pregnancy without requiring an echo, has become widespread in other countries. The International Federation of Gynecology and Obstetrics (FIGO) encouraged "online prescription of abortion pills and self-administered abortion in early pregnancy" as a temporary measure in March 2020, when WHO declared the COVID-19 pandemic, and after confirming that this method was used safely and effectively, in March 2021 it "made this method permanent The statement "this method should be made permanent" was issued in March 2021.

Although ultrasound can confirm pregnancy around the 6th week, the latest pregnancy test reacts at 4 to 5 weeks. Recently, medical abortion (VEMA), performed at a very early stage when ultrasound cannot confirm the pregnancy, has shown promise as a beneficial method that hastens the completion reduces risks, and serves as a screening test for ectopic pregnancies.


Sixth, abortion pills are also effective in treating patients with comorbid abortions, but this is not an option in Japan. Only to offer the highly invasive "surgery" is nonsense when you can use the pill for comorbid miscarriages.


Since there are no uniform guidelines for the handling of abortion pills in Japan, there should be a wide range of discretion for individual doctors. They should put the patient first, demonstrate "professional autonomy," and improve access to abortion pills.

Evidence that Mifepristone is a "deleterious drug"?

I received a response from the MHLW, but......

The abortion drug Mefeego Pack, approved in Japan, has been designated a "deleterious drug" by the Japanese Ministry of Health, Labor, and Welfare. According to them, Mifepristone and Misoprostol are both "deleterious" drugs. When I asked for scientific evidence to support this, I received a response.

However, there is a part of their response that I did not understand, so I will translate it into English below.

A part of their answer I couldn't comprehend:

(i) Mifepristone

(1) The results of embryo-fetal development studies indicate that the non-toxic dose of mifepristone is 0.5 mg/kg/day for mice, 0.5 mg/kg/day for rats, and 0.25 mg/kg/day for rabbits, and that these human equivalent doses are lower than the clinical dose (4 mg/kg/day when the human body weight is 50 kg) These human equivalent doses are lower than the clinical dose (4 mg/kg/day for a 50 kg human body weight).

(See the Mefeego Pack Drug Interview Form "IX. Toxicity Studies (5) Reproductive and Developmental Toxicity Studies," p. 85)

On the interview form referred, I bolded the numbers where they matched.

(1) Female rat fertility and early embryogenesis to implantation study

Mifepristone was administered to female SD rats at a dose of 0.5 mg/animal/day (approximately 2.5 mg/kg/day) for 24 days starting 8 days before mating, and pregnancy status was evaluated the day after the last dose84) . Compared to the control group, there was no effect on the number of mated animals or pregnancy rate, but the number of implantations per pregnant rat was significantly reduced.
 Tamura et al. conducted a female fertility study in which female SD rats were treated with mifepristone at doses of 0, 0.8, 4, or 20 mg/kg/day from 2 weeks prior to mating until 7 days of gestation85). The 20 mg/kg/day group showed persistent keratinization of the vaginal mucosa and arrested sexual cycle. 20 mg/kg/day for the entire period The 20 mg/kg/day group mated 10/10, all were infertile; the 20 mg/kg/day pre-mating only group mated 10/10, with 6/10 pregnant animals and increased preimplantation embryo loss rate.
 The number of pregnant animals in the 20 mg/kg/day post-mating group was 0/10. 4 mg/kg/day pre-mating group showed no effect on the number of mated animals, pregnant animals, or absorbed embryos, while the post-implantation embryo loss rate increased during the entire period and in the post-mating group. Since the cessation of the sexual cycle, the decrease in the number of pregnant animals and the number of implants, and the increase in the number of absorbed embryos were due to the pharmacological effects of mifepristone, 20 mg/kg/day was considered a non-toxic dose.


(2) Embryo-fetal development studies in mice, rats, and rabbits

A study on embryo-fetal development of pregnant CD1 mice, SD rats, and HY rabbits was conducted using repeated oral administration of mifepristone during organogenesis.86),87),88) In all three species, an increase in the number of absorbed embryos (≥ 0.5 mg/kg/day in mice, ≥ 1 mg/kg/day in rats, ≥ 2 mg/kg/day in rabbits) was observed. 2 mg/kg/day or more in rabbits) were observed in all three animal species. However, no teratogenicity was observed in mice or rats. Some morphological abnormalities were observed in fetal rabbits, but the frequency of occurrence of these fetal abnormalities varied, and they were also seen in the control group, so the relationship to dosing was not clear. The non-toxic dose for the mother was considered to be 0.5 mg/kg/day for mice, 0.5 mg/kg/day for rats, 0.25 mg/kg/day for rabbits, and for embryos and fetuses, 2 mg/kg/day for mice and rats and 1 mg/kg/day for rabbits.

The first thing I couldn't understand was that at the end of (1), it says the non-toxic dose is 20 mg/kg/day, so isn't 4 mg/kg/day (i.e., the value for a 50 kg person given 200 mg of Mifepristone). This is smaller than the non-toxic dose, so Mifepristone should be non-toxic at least for this?

 Also, (2) is a "repeated dose" experiment, but in humans, Mifepristone is only given once. There is no way it can be administered repeatedly. Wouldn't it be better to compare the results with those in which all animals were given only one dose in accordance with the human dosage?

 Furthermore, (2) is an experiment looking at the effects on the embryo/fetus, and suddenly there is talk of a "non-toxic dose to the mother animal".


It is strange. I'll inquire again next week.

A big but awkward step forward

My report

In Japan, the Mefeego Pack, a combi-product of one Mifepristone and four Misoprostol tablets, was launched on May 16, 2023, and the Japan Women's Foundation's Dr. Miho Uchida's clinic began offering "oral abortion pills" for the first time in Japan on Thursday, May 25, 2023.

As far as we could confirm on May 27, 11 hospitals or clinics joined the providers listed on the website of the manufacturer Linepharma K.K. as institutions that can handle this drug, however on Monday morning, all the other clinics that followed the lead of Dr. Uchida's Fides Ladies Clinic disappeared from the list.

As of the time of our review over the weekend, there was no detailed information on the abortion pill offerings on the websites of these ten medical institutions, so we assume that either Linepharma has decided to withhold the listings until they provide more detailed information, or that each of the clinics, aware of their lack of preparation, has voluntarily suspended their listings.

Anyway, because abortion pills are provided outside the insurance system and not covered by any public funds, women must pay the equivalent of the most expensive legal surgical abortion in the world. At Dr. Uchida’s clinic, the total fee for medical abortion is the same for the surgery is set at 99,000 yen.

In Japan, written consent of the spouse is still legally necessary as a pre-condition for any method of abortion. In addition, the patients cannot take abortion pills very early in the pregnancy, as the doctor prescribes the medications only after they could confirm the pregnancy in the uterine by transvaginal ultrasound which means usually after 6th week. However, according to Dr. Christian Fiala of Austria, who spoke at the #Action for Safe Abortion Japan online event on May 28, taking abortion pills very early is effective when an echo test is unavailable. If nothing happens, he says, then one should suspect an ectopic pregnancy and go to a higher-level medical facility. Very early MA also serves as a screening for ectopic pregnancy.

Japanese abortion patients should take both medications in front of a physician, and after taking the misoprostol, they are forced to stay in the medical institution until the pregnancy expels. Many obstetrics and gynecology facilities in Japan are not dedicated to abortion services and often house expectant mothers, new mothers with babies, infertility treatment, and gynecology patients in the same waiting room, which is an uncomfortable place for abortion patients to be. Now, however, abortion patients are required to remain in the hospital for up to eight hours (doctors say 90 % of the cases finish in 8 hours, but what about the remaining 10%!?) after taking the misoprostol. The Ministry of Health, Labor, and Welfare and the Japanese Association of Obstetricians and Gynecologists state that this in-hospital waiting rule is "temporary" and will be lifted once safety is sufficiently confirmed, but the criteria for lifting are unclear.


The JAOG also states that patients who come to the hospital to take Mifepristone on the first day at any time, and Misoprostol two days later at 9:00 a.m. should remain in the hospital until the pregnancy expells and that if the expulsion is not completed by 5:00 p.m., surgery will be performed next day or later. However, whether the patient will be hospitalized for a fee or sent home at their own risk is not explained clearly.


Because the Japanese health insurance system or any public funds do not cover abortion costs, women must pay the equivalent of the most expensive legal surgical abortion in the world. Some people may have to pay for hospitalization, backup surgeries, and multiple hospital visits out of their pocket.


"The approval of the abortion pills in Japan means that women now have more options," says Dr. Uchida. ”From now on, Japanese women no longer have to risk their lives to use foreign abortion pills by self-determination. Now a qualified doctor can fully explain the options and risks of abortion and make the best choice for her is a step forward for Japan from the perspective of 'reproductive rights'."


But it will likely take a little longer for Japan to achieve reproductive rights that guarantee women themselves to make the best choices for themselves.