IJGO（国際産婦人科連合FIGOの国際ジャーナル）CORRESPONDENCE
日本人の若い医師（空野ら）の短報に対して、日本産科婦人科学会会長らが不誠実な回答をし、空野らが反論したのについて、往年の中絶アクティビストがイギリスから提言。末尾に仮訳を載せました。
Letter to the editor: The introduction of 21st century abortion methods in Japan—Policy based on all WHO recommendations is needed https://obgyn.onlinelibrary.wiley.com/doi/10.1002/ijgo.14369
It was very dismaying to read the letter to the editor by Japanese OBGYNs Masakazu Terauchi and Tadashi Kimura1—a member and the President, respectively, of the Japan Society of Obstetrics and Gynecology (JSOG), which is a member of FIGO—written in response to the Brief Communication by Sorano et al.2 The correspondence implies that too little has changed in Japan for the past 40 years as regards who is permitted to provide abortions and which abortion methods are being used. A pharmaceutical company applied last year for approval of medical abortion pills in Japan, and a decision is expected later this year. The introduction of abortion pills in most countries has contributed to major changes in all aspects of abortion care, but Sorano et al. express concern that little may change in
Japan for women needing abortions, even if the pills are approved.
It is important that these concerns are aired, so that they can serve to explore what needs to change in Japan—especially the continuing reliance on D&C and the current relative lack of availability of both vacuum aspiration methods and abortion pills—and to raise questions about what women and girls with unwanted pregnancies in Japan need but are not getting right now from the state and abortion services.
I write as an advocate of more than 40 years for women's right to safe, legal abortion as a public health and human rights necessity, based on the long-standing, international consensus on “the basic right of all couples and individuals to decide freely and responsibly
the number, spacing and timing of their children and to have the information and means to do so”.3Terauchi and Kimura do not discuss these matters from the point of view of those who need to terminate an unwanted pregnancy, however. Perhaps most importantly, they do not acknowledge decades of evidence of the tremendous safety of both medical and aspiration methods of abortion compared to D&C, and the far greater simplicity of providing them, let alone going through them.
They do acknowledge, however, that “the situation [in Japan] might not perfectly satisfy the regulations proposed by the WHO”,1 but this appears to be a serious understatement. Which of the WHO recommendations on best practice for abortion care are they implementing? WHO does not support the use of D&C at all, for example, and has not done so for many years.4
Manual vacuum aspiration was first described by Harvey Karman and Malcolm Potts in the 1970s, initially for the management of incomplete miscarriage. Its use was soon refined and extended to the termination of pregnancy and became the main method of abortion up to 14–16 weeks.5
Misoprostol was first developed in the USA in 1973 to treat gastric ulcers, but the side effect of causing a miscarriage was known from quite early on. In the early 1980s, the fact that misoprostol can be used to terminate a pregnancy was discovered by a woman who
had bought these pills for gastric ulcers. She read the package insert and, thanks to her, the news spread rapidly on the grapevine in Brazil and across Latin America, becoming a safer alternative method in illegal settings and reducing maternal mortality from complications
of unsafe abortion as early as 1989.6 Since then, abortion pills (mife-miso in combination, or miso alone) have been used increasingly around the world, even without clinical oversight.
Mifepristone was developed by the pharmaceutical company Roussel-Uclaf in about 1980 and was first put on the market in France and China in 1988, in combination with a prostaglandin that was later replaced with misoprostol.7,8
Is this not common knowledge among Japanese OBGYNs who are designated abortion providers? I know from attending international conferences and personal contact with the women's movement in Japan that they certainly know all of this and have been calling for
access to both of these methods for some 20 years if not more.
Unfortunately, OBGYNs in Japan appear to have a monopoly on the provision of abortion care and also on which method(s) to use—still mainly D&C. The high fees for abortion also seem to be under the control of OBGYNs, as the letter by Terauchi and Kimura indicates. One can only assume that as it is a private service, the fees can be so high because the Japanese government is not responsible for the services, and does not challenge the control of the designated OBGYNs.
It is difficult not to conclude that this situation would be threatened if all the recommendations of WHO, FIGO, many midwives' associations and the women's health and abortion rights movements (both in Japan and internationally) became national policy.
The message is clear in the new WHO Abortion Care Guideline, published on 8 March 20229: stop doing D&Cs; stop using anesthetics; stop providing services in tertiary hospitals; omit unnecessary inpatient and overnight stays; train midwives, nurses, and GPs to provide abortions using 21st century methods at primary care level; and allow self-managed
abortion with pills in the first trimester. Last, I would add, please stop arguing to keep the charges for abortions both private and exceedingly high, when such high fees are not justifiable if WHO's recommendations are all followed.
As a membership organization that both must and wants to represent all their members, FIGO has been in a very difficult position as regards abortion for a long time. In the past, many of their members were anti-abortion altogether (many still are). It has taken years of
hard work for them to begin to turn this around. However, in Japan, abortions have been provided legally since 1948. The issue in Japan is that time has stood still while methods and providers elsewhere have changed. However, it is not only in Japan that D&C continues
to be favored or insisted upon by OBGYNs, or for which training is still offered as a method of clinician choice. A first step might be to update existing evidence of the extent of continuing D&C use in every country in order to challenge its persistent use.
Moreover, surely all medical associations (national and international) whose members include abortion providers should put pressure on their members to teach and practise only those abortion methods recommended by WHO as the universally recognized, highest standard of evidence-based practice in safe abortion care.
Finally, Terauchi & Kimura claim that because D&C is not covered by public health insurance, it is logical that provision of medical abortion pills (MA) should not be covered either. However, the cost of providing MA and MVA/VA is substantially lower than D&C because MA and MVA/VA can be done on an outpatient basis at primary level, do not require anesthetic but only pain relief, and most importantly, as regards cost, can safely be provided in most cases by a trained nurse, midwife, or community health worker—all of which means that the cost is substantially lower. In addition, medical abortion pills can be arranged by telemedicine for the first trimester as self-managed abortions at home, if the woman wishes. But most importantly, public health insurance should cover all abortions, because all abortions are essential health care.
Marge Berer, International Campaign for Women's Right to Safe Abortion, London, UK.
