Japan: 'Abortion in Japan before COVID-19 and the way ahead' with Dr. Kumi Tsukahara
Updated: May 21, 2020
As the cherry trees blossomed in splendour across Japan in early March, many people were enjoying hanami ( cherry blossom viewing ) with families and friends. The government had not declared a state of emergency and hence many were seen taking selfies and ignoring COVID-19 warning signs put up in public places. Barely a month later the number of confirmed cases in Japan has exceeded 10,000 , and now the health system is reeling under the impact. One ambulance carrying a patient with coronavirus symptoms was turned away by 80 hospitals before he could be seen. More than 200 people have now died of COVID-19 and the capital Tokyo remains the worst-affected area. There is such a shortage of PPE that the Mayor of Osaka asked citizens to donate raincoats which could be used rather than the protective gear fabricated from garbage bags. There is a shortage of tests, testing facilities and hospital beds. In the midst of this crisis, we spoke to our ASAP member in Japan to find out the situation of women seeking safe abortion access.
Dr. Kumi Tsukahara, a part-time lecturer of Kanazawa University, told us:
“As of now MVA or Manual Vacuum Aspiration is the only safe abortion method approved in Japan. The MVA kit has been approved since 2017 and exclusively sold by a company which appears to be monopolizing the market, and the cost is 20,000 Japanese yen per set, about 185 US dollars. No wonder this high-priced MVA system has not been spread widely, except for the after-treatment for miscarriages, the cost of which is covered by medical insurance. It is deplorable but Dilatation & Curettage (D&C) is still the first and only prerequisite method taught in their trainings, and remains the most prevalent procedure for abortion. Electric vacuum methods are also available, but Japanese doctors usually (almost always) use metal cannulae instead of safer plastic ones. ” Q. So, what is the cost of abortion services to women in Japan?
“As of now the prices of EVA and D&C are about the same, usually more than 100,000 JY, or 928 US$ for the termination of pregnancy less than 12 weeks LMP. Mifepristone has not been registered for use in Japan. It is finally under evaluation in clinical trials but the approval will take two or three more years, they say. In any case, feminist activists, including me, are worried that the price of abortion pill could be set very high by OB-GYN doctors who effectively monopolize abortion market due to the Maternal Protection Law originally enacted as the Eugenic Protection Law in 1948.”
Q. Can you tell us more about this law?
“This law authorizes the Japan Medical Association (the group of all the licensed medical doctors in Japan) to designate abortion providers who can perform abortion legally. It is a kind of business monopolization, which is usually prohibited, but this is the exception in Japanese legal system to give such a power to a private sector. Thus, each of the 47 Medical Associations (branch organizations of JMA) provides training and gives license to the trained OB-GYN doctors. Mid-term abortion is almost always done by administering a prostaglandin vaginally. It is a pity that the pregnant women are experiencing labour for abortion. And, usually there is no post-abortion psychological care for them either.”
Q. Is there a high rate of unwanted pregnancies in Japan?
“In terms of contraception, low-dosed contraceptive pills were finally approved in 1999, but have not been widely used until now due to poor accessibility and high price. Condom is still the number one contraceptive method in Japan, and of course, causing lots of unwanted pregnancies. The emergency contraceptive pill was approved in 2011, but only available after seeing a doctor and getting a prescription. Women in Japan are also demanding that emergency pills be made available on an over-the-counter basis, but creating an environment with easier access to birth control remains an issue. Last year the Ministry of Health, Labor and Welfare considered making the emergency contraceptives an OTC drug, but they adhered to face-to-face medical treatment. In the end, on July 2019, they partly allowed online prescription under two strict conditions:
1) the OB-GYN doctor has to receive a special training for prescribing the pill; and
2) the woman seeking the pill is either living in a place where there is no medical institution nearby, or she is in a critical mental condition to see a doctor(probably assuming the case of rape).
Online prescription was allowed only if these two conditions were met. From April 2020, the ministry temporarily lifted these strict conditions because of COVID- 19, so every OB-GYN doctor is now allowed to prescribe both contraceptive pills and emergency contraceptive pills to any woman who seeks them by telephone or internet. However, the ministry is not actively proclaiming this decision, so most women do not know about this temporary measure. In addition, lots of the OB-GYN doctors shrink from prescribing emergency pills because they fear that they will be blamed if something goes wrong due to their lack of information and inexperience with the pills.” Moreover, the Ministry of Health, Labor and Welfare keeps posting a notice on the internet which practically bans the import of “unapproved” abortion pills on the ground that such pills might cause “massive bleeding” and other dangerous side-effects. I have tried to persuade them to withdraw such a notice because it is biased and irrelevant, but only to be ignored. Unfortunately, their notice has been repeatedly used as a proof of the danger of the abortion pill. Q. Currently how has abortion access been affected under the state of emergency and is there any support being offered by the government to facilitate?
“There is no government support with regard to abortion services at all. And unfortunately, the impact of COVID-19 on women's reproductive healthcare is hardly argued in Japan. Before the pandemic, a case of domestic violence and child abuse had attracted the media's attention for months, so TV and newspapers occasionally report concerns about increasing domestic violence and child abuse under the state of emergency, by citing alerts from the United Nations. But there is no public attention toward women's reproductive healthcare including abortion. It is an epoch-making affair that the government lifted a ban on internet prescription of emergency contraception pills. Although it is only temporarily, Japanese women now have access to online prescription of ECP. This is a big gain for us. After this, some Japanese feminists began tweeting about this measure. As it has not had a big impact on the whole society yet, there are a lot of things we should do for Japanese women’s reproductive health and rights.”
Q. Moving forward how do you see things changing? Immediately after the declaration of a national state of emergency or in the long term, for instance what can we do to advocate for improved access in the future and system strengthening?
“I have been trying to get Japanese feminists to recognize the problems surrounding reproductive healthcare in Japan and pay more attention to safe abortion for years. Now that several influential feminists have realized the seriousness of our problem, and as a result of the severity of the situation due to the pandemic, some of them began trying to do something to make a change. In my opinion, now is the time to tell Japanese women that their reproductive rights are being violated. We need to mobilize them. For that, we want information from other countries, especially on Asian women's situation. Japanese women have been deprived of their rights in the patriarchal society, and disempowered by the pro-natal government for generations, especially in the area of reproductive health and rights. Sexuality and abortion have been so stigmatized that even feminists have not touched the issues for a long time in Japan. But there is a sign of change now. Victims of sexual violence have come forward to tell their sufferings since last year. It is called 'flower demo (demonstration)' where such victims and their supporters get together and share their feelings and experiences. This is a kind of #metoo movement in Japan, and some of the women (and men) who are empowered by it are eager to know more about the injustice towards women in our society. Another good news is that several women members of the Diet (Japan's bicameral legislature) have finally shown some concern about the problem of Japanese people's ignorance on and indifference to women's reproductive health. We are planning to have an online public debate on this issue in May with a Diet member.” Q. What is your hope for the future and how can we support your cause?
“I hope that we can advocate better access to safe abortion and contraception together for people in Japan and Asia. I will do my best to let you know our situation and I would like you to help us by giving your information to stimulate the Japanese society and the government.”