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

International Campaign for Women’s Rights to Safe AbortionのNEWSLETTERに掲載された記事

Japan, Madagascar, Kenya, FIGO Videos, Sedation, SAAF - Newsletter - 21 January 2022

By Kumi Tsukahara

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.






 包括的な証拠に基づく、中絶手術の方法に関連する世界保健機関の勧告内容は、『安全な中絶 第2版』(”Safe Abortion: Technical and Policy Guidance for Health Systems, 2nd edition, 2012, p.31-32, and expanded on p.40-42)に以下の通り示されている: