Abortion in Japan

Memorandums and information about abortion situations and problems in Japan

Abortion pills in Japan

English news articles you can read online

I contributed an article to the newsletter of the International Campaign for Women's Rights to Safe Abortion.

Japan: How Japanese doctors who do abortions see the introduction of medical abortion pills in Japan

How Japanese doctors who do abortions see the introduction of medical abortion pills in Japan

by Kumi Tsukahara, 12-13 January 2022,


The situation of abortion in Japan is really not well known to the rest of the world, hidden as it is behind the wall of language, and conversely, most Japanese doctors don't know about the situation of abortion provision overseas. As was reported in the ICWRSA newsletter on 9 January 2022, Linepharma has applied for approval of combined mife-miso medical abortion pills.


In response to this, the Japan Association of Obstetrics and Gynecology (JAOG) released a comment: "For the time being, prescriptions [of these pills] should be made only by doctors who are qualified to perform abortions at medical institutions where hospitalization is possible.” The president of JAOG said: "Doctors should not only prescribe the medications, but also perform subsequent management such as surgical operations in case of failure to expel the uterine contents, so a reasonable management fee is necessary.” He also said that it would be desirable to set the fee for the prescription of the pills at the same level as that for surgical abortion (D&C in Japan), which costs about 100,000 yen (= ± US$ 876).


On 28 December 2021, I appeared on a popular online Japanese TV debate programme and was confronted with an Ob-Gyn doctor who supported the JAOG's position above. However, this doctor was not even a "designated abortion doctor", as represented by JAOG, and when he made a strong defence of the abortion procedure he had performed 25 years ago (D&C) as a resident – saying that aspiration alone would not clean the uterus so curettage was always necessary – I decided to laugh in response; otherwise, I might have shouted at him.


What this doctor said, however, shows that at least some Japanese obstetricians have learned nothing. Instead of learning how to do aspiration abortions with simple training, which can be done on an outpatient basis and are almost always completed by aspiration alone, some of the "designated doctors" use " aspiration followed by curettage" or "curettage followed by aspiration", describing this as “their preference" or "the way they were taught in residency” without reference to evidence of any kind.


The recommendations of the World Health Organization related to methods of surgical abortion, based on comprehensive evidence, were published in Safe Abortion: Technical and Policy Guidance for Health Systems, 2nd edition, 2012, p.31-32 and expanded on p.40-42, as follows:


Dilatation and curettage (D&C) is an obsolete method of surgical abortion and should be replaced by vacuum aspiration and/or medical methods.


For pregnancies of gestational age more than 12–14 weeks, the following surgical method is recommended: dilatation and evacuation (D&E).


Medical abortion with pills is also a recommended method of abortion in the second trimester, with a different regimen and dosage than in the first trimester, even up to 24 weeks of pregnancy.


I also exposed another important fact in that online debate. At one well-known hospital, they charge 210,000 yen (= US$1,840) for an early abortion of up to 12 weeks’ gestation, but 51,000 yen (= US$447) for a mid-term abortion (12-15 weeks’ gestation). The lower price for the mid-term abortion is because those who have undergone mid-term abortions are entitled to a maternity allowance of about 400,000 yen, the same as for childbirth or stillbirth. On top of that, the particular hospital was charging at least 90,000 yen as a "burial fee" for the fetus. Thus, by inducing an abortion at 12-15 weeks, the hospital makes a very large amount of money.


Last summer, a clinic that had set similar prices actually advertised that it could provide cheap abortions if women waited until the mid-term period for the abortion. That clinic was criticized for running an unscrupulous "abortion business" and made the news. But it seems that the well-known hospital is doing almost the same thing.


Another large clinic that specializes in abortion boldly states on its website: "We perform D&C safely" because "in a clinic like ours that does a large volume of abortions, it is easier and safer to clean the curettage instruments than to clean the aspiration tubes”. No concern is expressed for how women will feel and nothing is said about whether this is ethical. It all focuses on efficiency and money. In these circumstances, women's reproductive health and rights are violated.


The following are statements that were made by another ob-gyn doctor working in a chain of clinics on why he uses D&C (usually called the SOUHA method in Japan, literally meaning curettage):


“I will give my opinion by comparing the SOUHA method with the aspiration method. There is no difference in the degree of risk of the surgical operation between these two methods. However, the aspiration method is more likely to leave some blood and tissue in the aspiration instrument for the suction method, and it is more likely to be unclean and carry infection, so most doctors in Japan tend to use the SOUHA method.”


“Whether the SOUHA method or the aspiration method is better for abortion surgery makes no difference in terms of the occurrence of surgical sequelae if the doctor is experienced. The reason one of the two surgical methods is being used and not the other is customarily determined by the university you graduated from.


“The main surgical method used in most university hospitals is the SOUHA method. The abortion procedure itself is not so difficult that it makes a difference, so it is difficult to make a difference based on the surgical method. Since both procedures are simple, it is impossible for the differences in the procedures to cause problems such as post-abortion sequelae or difficulty in conceiving in the future. If there is a problem, it is usually caused by incomplete disinfection of the instruments.


“In principle, we use the SOUHA method. This is because many doctors are accustomed to this method, and because the number of surgeries is so large. If you use the aspiration method with limited disinfection and sterilization of instruments, it is not suitable in a clinic with a large number of surgeries.


“There is no difference in after-effects or side effects between the different surgical methods, but rather it depends on cleanliness. All the instruments used in the SOUHA method are cleaned and sterilized after each surgery, but with the aspiration method, the instruments are collected in a bottle through a long tube. Since there is a high rate of blood and tissue remaining in the connection between the bottle and the tube, as well as the instruments (since the aspirator is not cleaned or sterilized every time), it is impossible to deny the unclean condition.”


In sum, the designated doctors for abortion in Japan always say that the method they are used to is the safest, or that experienced doctors can safely use curettage. But WHO evidence says D&C should be obsolete because it requires general anaesthesia and hospitalisation and carries greater risks.


Clearly, much more related to abortion care in Japan must be changed alongside the introduction of medical abortion pills.

Currently we're also currently running a signature campaign on Change.org!

Reduce burdens imposed on women to get abortion!!


One out of every four women in the world has experienced an unwanted pregnancy. In other countries, abortion is considered a natural medical treatment that protects women's mind and bodies.


In Japan, the application for the approval of abortion pills is currently underway. In order to respect the health and rights of all women living in Japan, we demand the following 5 points.


1. Promptly approve the abortion pills as an option for women who have an unwanted pregnancy.

2. Provide abortion pills at a reasonable price and make them available to all who need them regardless of their financial situation.

3. Descriminalize abortion under the Penal Code and abolish the spousal consent requirement under the Maternal Body Protection Law as both misogynistic and patriarchal laws unfairly hurt women and prevent them from accessing abortions.

4. Lift the ban on online medical treatment and home administration of the abortion pills in order to secure the access to abortion for everyone regardless of where she lives and in order to protect her privacy.

5. Increase the number of occupations that can handle the abortion pills in order to improve access and lower the price of abortion.


The UN Human Rights Covenant clearly stipulates access to information and means of safe abortion for all who need one as the social right and the ability to choose abortion for themselves as the liberty right.


In approximately 30 countries including the UK, France, and New Zealand the abortion pills are all covered by public insurance or other kinds of subsidies. Online prescribing has been implemented in Australia, the UK, France, and other countries as well. The International Federation of Obstetrics and Gynecology has decided to encourage online prescription and home use of abortion pills during the pandemic in March 2020. In March 2021, they added, "After 1 year of the operation, the safety and effectiveness of the system has been confirmed. This method should be permanent so that all women can have a safe abortion in privacy.''


As you can see, abortion in Japan imposes heavy physical burdens on women compared to other countries. In addition, Japan has stigmatized abortion by suppressing women from speaking out for abortion. Are you aware that abortion is still criminalized in Japan? Although abortion seems to be freely available in Japan, The Penal Code (Article 212) criminalizes a woman ending her own pregnancy by taking drugs.


However, many countries around the world are now trying to decriminalize abortion. Even countries like Ireland, a predominantly Catholic country has eliminated the criminalization of abortion in a referendum in 2018.


In addition, the Maternal Body Protection Law which allows women to seek legal abortion under exceptional circumstances gives husbands the right to make decisions regarding their wives' bodies. Even if the wife does not want to continue her pregnancy, her husband can force her to do so.


Currently, in other countries, forcing a woman to continue an unwanted pregnancy is considered torture and a violation of human rights. Only 11 countries require spousal consent for abortion while the other 192 countries don't.


The Eugenic Protection Law enacted in 1948 stipulated that only "designated physicians" that had been trained in obstetrics and gynecology should be allowed to perform Dilatation and Curettage procedure, a surgical procedure in which the cervix is dilated so that the uterine lining can be scraped with a spoon-shaped instrument called curette to remove abnormal tissues as the medical field was not as advanced and developed as it is now.


As a result, suction abortion which is actually considered safe enough to be performed by midwives has not been widely performed in Japan.


The WHO points out that D&C cause more pain than aspiration and made it clear that the old-fashioned perforation is not a safe way to end a pregnancy and should be switched to safer methods in their 2012 guidelines, "Safe Abortion, Second Edition."


9 years later, in July 2021, the Ministry of Health, Labor, and Welfare (MHLW) finally asked the Association of Obstetricians and Gynecologists to inform its members about the aspiration. However, whether the method had been properly switched or not is still unclear.


Thanks to women's movements since 1960s, abortion has been legalized and the suction method was introduced around 1970.

In the 1980s, the abortion pills were developed and by the beginning of the 21st century, they had been legalized and available in most of the developed countries.


However, for a long time, Japan did not opt for these safer methods and continued to use the old-fashioned method of curettage, which has caused heavy physical and emotional burdens on women.

The punishingly high cost of abortion in Japan is also a hardship for women. In a survey conducted in 2010, some medical institutions said that the price of a mid-term abortion at their clinic was up to 600,000 JPY (about 5,250 USD). The number of women cannot have abortion due to the lack of money and are accused of having isolated births in the restroom, which deeply connects to the social structure of Japan that disregards women.


According to some survey, 80 countries around the world provide free abortion, the three quarters of those have full or partial insurance coverage for abortion costs.


The abortion pills are chosen as essential medications by WHO and proven as only because safe and effective. The pills are also quite inexpensive, whose average price is 730 JPY (about 6.5 USD) worldwide.


However, some doctors in Japan have suggested that prescribing the abortion pills should be as expensive as the conventional abortion procedure (around 100,000 yen).


The women with financial difficulties would continue to have the same difficulties affording abortion if the price was set like that.


We need your support in order to make our country a place where all women can live safely and peacefully with fundamental human rights to control their lives, bodies and destinies without physical and mental burdens.


Worked with Kumi Tsukahara, Megumi Hayashi, and Manami Fushimi from the RHR Literacy Laboratory.

News Navigator: How do abortion pills work, and will Japan approve them?
January 21, 2022 (Mainichi Japan)

Mifepristone pills, marked "MF," and misoprostol pills, marked "ML," which have been used widely outside Japan as induced abortion medication, are seen in this photo provided by Tokyo University professor Yutaka Osuga.


The Mainichi Shimbun answers some common questions readers may have about abortion pills used in medical abortions to terminate unwanted pregnancy via oral medication.

Question: First of all, what is an induced abortion?

Answer: It's the artificial stopping of a pregnancy and the removal of a fetus and placenta, administered when a pregnant person cannot give birth for various reasons. About 145,000 were done in Japan in 2020.

Q: What procedures are available in Japan?

A: Currently, only surgical abortion is allowed. One is curettage, in which a metal instrument is used to scoop out the contents inside the uterus. The other is suction abortion, in which a tube providing a gentle vacuum is used to empty the uterus. The former has a high risk of complications -- including uterine injury in rare cases -- and many women experience mental shock. Surgery isn't cheap either, and costs around 200,000 yen (roughly $1,750).

Q: Does the abortion pill cause a burden on the maternal body?

A: The impact on body and mind cannot be underestimated. By taking the medication, the fetus and placenta that have not yet grown will naturally exit the uterus, but it takes more days than surgery would. Painkillers are also needed for the bleeding and pain.

Q: Is abortion by medication allowed overseas?

A: Over 80 countries permit it. In many countries, abortion pills are free or cost just hundreds of yen. Some allow online consultations to take the medication at home. The idea is that abortion is an important medical service for women's health and lives. However, some countries and regions entirely prohibit abortion.

Q: Will it be available in Japan?

A: In December 2021, a U.K. pharmaceutical company applied for approval to the Ministry of Health, Labor and Welfare. The examination procedure takes about a year. If approved, it will be Japan's first abortion pill.

(Japanese original by Satoko Nakagawa, Lifestyle and Medical News Department)

Approval sought for first abortion pill in Japan, report says
Pharmaceutical company Linepharma International plans to seek approval for Japan’s first abortion pill next month. | GETTY IMAGES (Japan Times)
Nov 21, 2021


Pharmaceutical company Linepharma International plans to seek approval for Japan’s first abortion pill next month following successful trials in the country, the Yomiuri newspaper reported.


Linepharma, which received its pharmaceutical license in Japan in July, will seek approval for a combination of two drugs called mifepristone and misoprostol to terminate pregnancy, the paper said. Approval for the drug combination could be forthcoming within a year, Yomiuri said, citing sources familiar with the matter.


About 140,000 abortions were carried out in Japan in 2020, according to the newspaper, all via surgical procedures. By contrast, medication-induced abortion was introduced in France in 1988 and is available in more than 70 countries, the report said.

Expanding access to safe abortions in Japan
In Japan, a surgical procedure is currently the only option for women choosing to end a pregnancy. The introduction of a medication-led solution would offer a cheaper, safer alternative. | GETTY IMAGES (Japan Times)

BY MAGDALENA OSUMI
STAFF WRITER


May 2, 2021
Choosing to get an abortion is not an easy decision to make. But women in Japan who do so, due to a variety of reasons, may soon have a safer alternative to surgical procedures — currently the only option they have.


LinePharma, a British pharmaceutical maker, is planning to seek the Japanese government’s approval for the use of its first oral “abortion pills” in Japan as a safe and affordable method of inducing abortion in early stages of pregnancy.

The move comes amid an ongoing debate in Japan to offer safer, affordable abortion options for women who want to end their pregnancy.


It was reported that the drugmaker is expected to apply for regulatory approval of the medication by year-end. The regimen, which is used worldwide and is available in most developed countries, is considered highly effective and is recommended by the World Health Organization (WHO) as a “safe abortion” method.


How does the abortion pill work?

The abortion pill is the common name for a combination of two medicines ー mifepristone and misoprostol, which have been considered an affordable and a safe method for terminating a pregnancy even in the second trimester.


The patient first takes mifepristone, a drug to block the hormone progesterone that is released by the ovaries and is responsible for preparing the uterus for pregnancy, which stops the embryo from growing.


Then, 36 to 48 hours later, the patient takes the second pill containing misoprostol, a synthetic medication that is also used to prevent stomach ulcers. This induces contractions in the uterus and relaxes the cervix so the embryo and placenta can be expelled. While mifepristone in most cases may only be dispensed in clinics under medical supervision, misoprostol can be used either under clinical supervision or taken at home.


Side effects for abortion pills can include bleeding, vomiting, diarrhea, fever, pain or infection.


Globally, mifepristone was first approved in 1988 in China and France as an abortion pill. It was eventually replaced with a regimen of mifepristone and misoprostol, which together offered lower risk of an incomplete procedure.


Various surveys have shown that the medication works in more than 90% of cases in the first nine weeks of pregnancy, and its effectiveness was confirmed through clinical trials in Japan on 120 women in the first nine weeks of pregnancy. The results, which were disclosed at a meeting of the Japan Society of Obstetrics and Gynecology in April, showed that the drugs induced abortion for 112 women, or 93% of those surveyed, within 24 hours.


If the abortion is incomplete, which is more likely as pregnancy grows, the patient can take an extra dose of misoprostol.


However, the medication cannot be used in cases of ectopic pregnancy, adrenal failure, hemorrhagic disorders or other conditions including steroid-dependent asthma.


Why is medical abortion being considered in Japan now?

Women’s rights advocates and medical experts have long been calling for the government to grant better access for women to safe abortions. But amid the pandemic, more women are opting to terminate their pregnancies for financial reasons, with some trying out medication yet to be approved in Japan.


According to a recent study by the health ministry, some 8% of women who were pregnant between October and November last year decided to end their pregnancy for reasons linked to the COVID-19 pandemic.


Surgical abortion, which is usually conducted in the first eight weeks of pregnancy, costs around ¥100,000 while surgeries performed beyond the 12th week could cost double that. After 22 weeks, abortions cannot be conducted in Japan unless it is medically necessary.


The high cost of surgical abortion has also been prompting women to turn to medication from foreign websites, not only raising legal concerns but also increasing the risk of health issues if the procedure is performed incorrectly.


Safety concerns in particular have prompted women’s rights groups and medical experts to renew calls for the authorization of medical abortion in Japan.


The WHO has stressed that medical abortion places less physical and mental burden on women than surgical methods. Mifepristone and misoprostol have been used in more than 70 countries, but have remained unavailable in Japan.


What abortion methods are currently available in Japan?

As condoms remain the main birth control method in Japan and their use is often dependent on cooperation from their male partner, many women turn to emergency contraceptive medication to prevent unwanted pregnancies.


Birth control pills are used by a very small percentage of Japanese women mainly because of their high cost and difficulty in obtaining a prescription.


Medication known as the “morning-after pill” is aimed at suppressing ovulation to prevent pregnancy. However, it needs to be taken within 72 hours of unprotected sex to be effective. This method is often used by people who have had problems with their regular contraception methods, for example a broken condom or a missed birth control pill, as well as women trying to avoid pregnancy after being raped. Emergency contraception is not covered by national health insurance.


Amid calls for the emergency contraceptives to be made available over the counter, the government is looking to approve nonprescription sales of the morning-after pill this year.

Meanwhile, the only procedure to terminate a more advanced pregnancy in Japan is surgical abortion, which is performed in accordance with the Maternal Health Act at obstetrics and gynecology clinics.


Given the limited access to emergency contraception, surgical abortion is still the most common method of terminating a pregnancy.


According to the health ministry, in fiscal 2019 there were 156,430 abortions in Japan, or 6.2 per 1,000 women of child-bearing age. Since 1949, when surgical abortion was legalized, Japan has seen a decrease in the number of such procedures.


Why is Japan relatively late in introducing medical abortion?

Japan is not affected by pro-life movements based on religious grounds — unlike countries such as the United States, which have been entangled in a debate surrounding the moral, legal and religious status of induced abortion.


But the health ministry has warned against the drug’s easy use due to the risk of mass bleeding, which is listed as a possible side effect by the pharmaceutical company.


In fact, Japan’s health ministry banned imports of mifepristone by individuals without a doctor’s prescription back in 2004 out of concern the drug could be misused.


Japan’s stance, however, has been decried by activists and medical experts. In 2012, WHO pointed out that the surgical abortion common in Japan carries the risk of damaging the uterus, urging the nation to introduce medical abortion.

U.K. company will seek to offer Japan’s first abortion pill
By MIREI JINGUJI/ Staff Writer(Asahi Shinbun)

April 30, 2021 at 15:45 JST

Photo/Illutration
Mifepristone and Misoprostol, abortion pills widely used overseas (provided by Yutaka Osuga, professor at the University of Tokyo)


British pharmaceutical company LinePharma is expected to soon apply to the health ministry to have its abortion pill approved for use in Japan.


The drug company has concluded the final phase of clinical trials in Japan and confirmed that the pill aborts the pregnancy more than 90 percent of the time.


As soon as the company completes an additional clinical trial, it will file the application.


If approved, it will be the first abortion pill in Japan.


Some experts, though, have expressed concerns over the use of such emergency contraception.


According to the company, 120 women between the ages of 18 and 45, who were in the ninth week of their pregnancy or earlier and wished to terminate the pregnancy, participated in the clinical trial.


They took one tablet of Mifepristone, which suppresses the progestational hormone needed to sustain pregnancy. Two days later, they took four tablets of Misoprostol, which constricts the uterus.


Yutaka Osuga, a professor of obstetrics and gynecology at the University of Tokyo, oversaw the clinical trial and presented the results at an April conference of the Japan Society of Obstetrics and Gynecology.


Osuga said the data was “either equating to or surpassing the data from overseas.”


It came amid a growing need for access to sexual and reproductive health care around the world.


“There has been growing demand in Japan for abortion pills that are widely used and considered safe and effective around the world,” he said.


If the drug is approved, Osuga said women will have more options for abortion according to their own needs.


LinePharma said the company is currently conducting an additional clinical trial for a comparative analysis between Japanese and international patients that examines how the drug differs in participants’ blood concentration.


Abortion pills were first approved in France in 1988. Currently, more than 70 countries and regions have approved the use of this kind of drug with a doctor’s prescription.


The World Health Organization in 2012 issued a guideline that recommended the abortion pill as one of the safest and most effective ways to end a pregnancy.


In Japan, however, abortions can only be performed through operations.


Drug-induced abortions are still illegal in Japan, partly due to the lack of discussion on the subject matter.


According to the health ministry, 156,430 abortion operations were conducted in fiscal 2019.


But amid reports of illegally imported abortion pills causing harmful health effects, such as heavy bleeding, the health ministry responded in 2004 by introducing new import restrictions.


But people continued to purchase the drugs over the internet. In 2018, a woman in her 20s in Miyagi Prefecture took an abortion pill made in India that she bought online and then suffered from heavy bleeding and spasms.


Health care workers and women have urged the ministry to approve abortion pills under the control of doctors based on guidelines by expert bodies such as the WHO.


Kunio Kitamura, an obstetrician-gynecologist who chairs the Japan Family Planning Association, said the public should be educated about bleeding and stomachaches caused by the drug and ways to protect the patient’s health.


To put the drug into practical use, Kitamura said, those who consider taking it should see a doctor to confirm the pregnancy and ensure the completion of abortion, as well as to ensure they are choosing the right option for them and to learn how to take the pill.


The ministry needs to establish detailed rules for the procedure and measures to respond to emergency cases, such as a patient feeling ill while taking the pill, Kitamura said.