To increase contraceptive methods, Japan is moving ahead with an initiative to approve the abortion pill more than three decades after it first appeared on the market. But does it really benefit reproductive rights? Can abortion in Japan qualify as “safe” under the guidelines set forth by the World Health Organization? We interviewed Dr. Sakiko Enmi, an obstetrician and director of the Safe Abortion Japan Project, to search for answers and learn more about the reality on the ground.
Japan announced in April 2021 to consider introducing the abortion pill 33 years after it was first introduced to the world. Although abortion in Japan is legal, it has various limitations in terms of accessibility. Chapter 29 of the Crime of Abortion in the Penal Code criminalizes “abortion with oneself or by drugs” and can be imprisoned for up to a year, while Chapter 3 of the Maternal Health Protection Law shows that doctors cannot conduct an abortion without obtaining consent from the relevant person (the pregnant individual) and the spouse. On top of these, the price of an abortion varies from 100,000 Yen (931 USD) to 200,000 Yen (1826 USD), which, according to Dr. Sakiko Enmi, can be counted as among the most expensive abortion fees in the world. “If a miscarriage happens because the heartbeat of the fetus stops in the womb, you may have the same surgery as an abortion. In the case of a miscarriage, the insurance is applied and it will cost 20,000 yen. In the case of abortion, there is no insurance coverage and it costs 100,000 to 200,000 yen,” says Dr. Enmi.
The Question of ‘Safe Abortion’ in Japan
The World Health Organization (WHO) recommends medication abortion (the so-called “abortion pill”) or vacuum aspiration as a safe method of abortion. (Suction methods include manual vacuum suction for simple outpatient procedures.) Also, the WHO cites restrictive legislation, high costs, and stigma as factors that prevent access to safe abortion.
The WHO’s guidelines for safe abortion express that the curettage method should now be obsolete and changed to a vacuum aspiration method. However, there are still medical institutions in Japan that practice the curettage method.
“The manual vacuum suction kit that has been in use overseas since the 1970s was first introduced to Japan in 2015. However, vacuum aspiration is still not common, and medical institutions continue to perform the curettage method that puts a metal instrument in the uterus and scrapes it out. There are doctors who still think that the curettage method employed in Japan is safe with few complications, but I think conducting surgery that the WHO does not recommend will not only damage women’s physical health but also their mental health. That is why I think Japan also needs the option of the abortion pill,” says Dr. Enmi.
Abortion Pill To Be Recognized in Japan
The abortion pill is considered by the WHO to play a pivotal role in establishing access to “safe, effective and acceptable” abortion care. The WHO suggests that up to 12 weeks of pregnancy, an abortion pill can be used at home without direct management of a healthcare provider, which can lead to improvement in empowerment and self-management.
“In Japan, it is expected that an application for approval of medical abortion pill will be submitted by the end of the year, so it is possible that the abortion pill will be approved and available in another year or two. Clinical trials are underway in Japan where doctors are in charge from the time an abortion pill is taken until the uterine contents are discharged, so basically, there is a possibility that it will be managed in the hospital setting. In addition, if it is not discharged in time, there is a possibility of surgery. In other countries, if you can not discharge after taking the pill for once, you may have to take it again or wait for 1 to 2 weeks until it becomes effective. I think for those who are wishing for an international standard, we have to make the access safer for people,” explains Dr. Enmi.
Another thing that the WHO suggests is giving full, correct, and easily comprehensible information. “There are doctors who think that if the abortion pill is recognized, there will be more women who rush to the hospital which would increase the burden of the doctor. For those women, the pill can be introduced properly by explaining the side effects, when to visit the doctor and in what circumstances a visitation is not required. These kinds of explanations and the ‘We Trust Women’ perspective is important,” says Dr. Enmi.
According to the WHO, the average price of the abortion pill is around 4 to 12 US dollars. For the WHO, the abortion pill is an essential medicine whose price should be obtainable by anyone. “Unfortunately, there was a report in the newspaper where a professor of obstetrics and gynecology remarked that the abortion pill in Japan could be charged the same as the surgery fee in line with the view of hospital administrators.” Dr. Enmi further states that there is a lack of perspective on sexual reproductive health rights. “I think hiking the prices to align with hospitals’ business considerations is a claim that ignores human rights,” says Dr. Enmi. She added, “There are two drugs used for medical abortion. One of them is approved as a gastric ulcer treatment drug in Japan and the price is 33 yen per pill.”
Laws on Abortion: Asking Rapist’s Consent Is Not Required But…
The Maternal Health Act requires pregnant individuals to ask their spouses’ “consent” for abortion. This year, the Ministry of Health, Labour, and Welfare declared that the consent of the spouse will not be required in cases of domestic violence. If someone gets pregnant as a result of rape, the consent of the rapist is not necessary. However, there are still many cases where doctors ask for the consent of the sexual partner or the rapist.
“Asking for the spouse’s consent is, of course, a problem, but a bigger problem is some doctors’ broad interpretation of the ‘spouse’ that leads to asking the consent of the men regardless of the circumstances. In the cases of unmarried people or de-facto marriages, the boyfriend or sexual partner is not considered as a spouse. Therefore, legally speaking, consent is not required. Of course, a rapist’s consent is not necessary either,” says Dr. Enmi. “Recently, the Ministry of Health, Labour and Welfare announced that, in cases of sexual violence, the spouses’ consent is not necessary. However, I think that, in actual practice, the situation hasn’t changed all that much. Recently, I have been told by a sexual assault victim that a doctor had requested the rapist’s consent and that has put the victim in a troubling situation.”
But why would doctors ask for consent that is not even required by the law? “I think it’s a real problem that doctors are requesting consent when the law does not mandate it. For some doctors, they are worried about being sued. The International Federation of Gynecology and Obstetrics (FIGO) published a declaration stating that ‘As obstetrician-gynecologists, our ethical obligation is to make sure that we provide health care based on science under the framework of reproductive rights.’ That is why obstetrician-gynecologists in Japan should also adopt an understanding of reproductive rights. Women have the right to make decisions over our body by ourselves as well as to decide whether to give birth or not to give birth to a child,” answers Dr. Enmi.
“Japan might have the most expensive abortion in the world”
Why does Japan have one of the most expensive abortion fees in the world? “Since abortion is treated as jiyuu shinryo (treatment not covered by health insurance), that means that each medical institution can decide the fee freely and cannot be regulated. That is why the market price (for abortion) during early pregnancy costs about 100,000 yen to 200,000 yen,” says Dr. Enmi. “When the morning-after pill was introduced to Japan in 2011, the price was set high out of consideration for the development period and the opinions of doctors, even though it’s available overseas at affordable price. The reason for the price hike is said to be to ‘avoid abuse’ of the pill’s usage. Abortion in Japan is so expensive that I think it gives an impression of being a punishment.”
But if the fee is decided freely, what if we demand it be set lower? “Having a safe abortion is a woman’s right and high costs prevent the access of safe abortion. The WHO states that in order to prevent women from discrimination and stigma, abortion should be incorporated into the health care system as a public service or a publicly funded non-profit service. After the introduction of the abortion pill, I hope everyone to pay close attention to how much the overpriced abortion in Japan will change. If there’s a possibility that this abnormal situation in Japan will not change, I think it is necessary to raise our voices,” says Dr. Enmi.
For more information please check the Safe Abortion Japan Project’s website https://safeabortion.jp/