Japan left behind in sexual and reproductive health and rights---medical abortion pills mailed from abroad (Part 2)*
Medical Abortion Pills Across the Sea -Women on Web
By: Yoko Akachi**
What is Women on Web (WoW)?
Women on Web is a Canadian-based non-profit organization that provides telemedicine support services for women around the world seeking abortions.
Women on Web was founded in 2005 by Rebecca Gomperts (Doctor, M.D.), and the team consists of doctors, researchers, activists, and helpdesks. Gomperts is regarded as the first cross-border abortion rights activist in the world. She was also one of the 100 most influential people of 2020 according to the Time magazine.
Those who want to be supported by WoW must first fill out an online consultation on the internet (available in 22 languages, including Japanese). The consultation is reviewed by doctors and if there are no contraindications and other risks, the medicines will be prescribed by a doctor. Supervised by medical doctors, WoW trained local helpdesk is available 7 days a week and will answer any questions people may have before, during, and after the abortion process. The helpdesk provides judgement-free and confidential support and information on how to correctly use the medication, what to expect, and how to recognize if one is having potential complications. E-mail can be communicated in 16 languages.
WHO classifies abortions safe when women obtain "the pills through a telemedicine service such as Women on Web which gives them information and support"[i]. WHO also published its guidelines in 2020 that recommends self-managed abortions as a safe, acceptable, and empowering option up to 12 weeks of pregnancy[ii]
Under Covid-19 lockdowns, telemedicine has become a solution for maintaining and expanding essential and time-sensitive health services. For example, the UK government has temporarily allowed home use of medical abortion for up to the 10th week of pregnancy.
Women on Web's Activities in Japan and The Current State of Data
From 2011 to 2019, the number of women who contacted WoW from Japan and those who received support increased (Graph 1). From 2011 to 2020, a total of 4,175 consultations were made and 2,286 contraceptive and medical abortion pills were shipped.
Google's core update is behind the decline in the number of consultations in 2020. Google updated its algorithm that drastically changed the website’s ranking, and WoW then saw a sharp decline in website visitors.
Data Provided by Women on the Web
More than 4,000 women who consulted Women on the Web
Who consulted WoW about abortion?
The women who had unwanted pregnancies and needed abortions ranged in their age, from their teens to their 40s. The numbers concentrated in the late teens and early 20s, peaking at the age of 20, and decreased towards the 30s and the 40s. Geographically, there were many people from the Tokyo and Osaka metropolis, but consultations were received from all over the country, from Hokkaido to Okinawa. Foreigners living in Japan were also included.
Why did these women have unwanted pregnancies?
Of the 4,159 women consulted from 2013 to 2020, 54 percent said they did not use contraceptives, 39 percent said the contraceptive method was not effective, and 6 percent said they were raped (Chart 2).
Data Provided by Women on Web
Why did they consult WoW on medical abortion?
More than half of the women who consulted between 2018 and 2020 cited "the cost of abortion" as one of the reasons they contacted WoW. Other reasons included difficulty of access to other abortion methods "because of school or work," "because of childcare," "because of prejudice against abortion," and "because they need to hide it from their partners and/or family members." Other reasons also included "because I cannot get medical abortion in Japan”, “because I want privacy”, and “because I want to do the abortion by myself”.
Why did they want to have an abortion?
In 2019, 65% of the women who consulted said that it was financially impossible to raise the child. Other reasons include "I just cannot have children at this point in my life," "My family is complete," "My partner doesn't want children," "I'm too young or too old," and "I want to graduate from school or university."
Using Women on Web services from Japan
Medical abortion is not provided as Mifepristone is not registered in Japan. The Phase III clinical trial of the medical abortion pills in Japan started in 2019. It is unclear whether it will be approved. Moreover, even if it would be approved one day, there is a concern that it will be much more expensive compared to other countries as is the case with morning after pills.
The safety of abortion drugs has been validated in several reliable studies; the probability of serious complications requiring hospitalization, blood transfusion, surgery, etc. was less than 0.4%[iii],[iv]. The US FDA updated the label of Mifeplex in 2016, confirming that medical abortion is very safe and very effective[v],[vi] One of the changes to the mifepristone label was an increase in eligibility from 49 days’ to 70 days’ gestation.
On the website of the Ministry of Health, Labor and Welfare (MoHLW) of Japan, however, there are still pages with warnings about drug safety and warnings about personal import restrictions ("Warning on Mifeplex (MIFEPREX) (an unapproved oral abortion pill in Japan)"), but they are all based on outdated information.
It also contains information that may be misleading. For example, the MoHLW and the Japanese media sensationally emphasize "heavy vaginal bleeding" as a side effect, but bleeding is part of the process because medical abortion is similar to spontaneous abortion. It is supposed to bleed. Like spontaneous abortion and childbirth, there is a risk of heavy bleeding, but this risk is the same as when a woman has a miscarriage and can be easily treated by a doctor or trained healthcare provider. It is estimated that out of every 100 women that do medical abortions, 2 or 3 women need to go to a doctor, first aid center, or hospital to receive further medical care.
According to the Ministry of Health, Labor and Welfare, receiving the prescription through WoW is classified as "individual import" in their system. This means that when importing Mifepristone, the necessary procedure is required as stipulated by the Act on Securing Quality, Efficacy and Safety of Products Including Pharmaceuticals and Medical Devices. The procedure requires a doctor's medical certificate or instructions, and the prescriptions made by international medical doctors are recognized as medical instructions. In other words, it is acceptable for people in Japan who need Mifepristone to order medicine from WoW if they follow the procedure. (Based on an interview with the Ministry of Health, Labor and Welfare by the editorial department of HuffPost Japan)
Conversely, if a person other than the doctor designated by the Maternal Health Act has a medical abortion, there is a possibility that the individual will be judged to have committed a crime. This includes the pregnant woman herself. An abortion remains to be a penal offence in Japan.
Gomperts gave the following comment to the Japanese government which has not yet approved medical abortion. “The Japanese government, which has ratified the International Covenant on Economic, Social and Cultural Rights (ICESCR), is obliged to secure WHO essential medicines, including contraceptives, other contraceptive methods, emergency contraceptives, and abortion drugs. Japanese women have the right to have access to abortion pills, and it is a shame that the Japanese government has not yet registered them for use in Japan. Abortion pills are extremely safe, they have been used for more than 30 years by millions of women all over the world. It is an essential medicine according to the WHO. This situation of medical abortion in Japan is similar to the path followed by contraceptive pills. Although widely used in other countries since the 1960s, the Japanese government had refused to register contraceptive pills for decades. Women protested when Viagra was approved promptly and successfully in 1999, and the contraceptive pill was then finally approved in Japan.”
To value a woman's body is to value the future of Japan
Unsettled by Covid-19, and with unclear prospects, the poverty and isolation are driving the socially vulnerable to the margins. This includes young women. Unless sexual violence is eliminated, unless there is a 100% effective, safe, and accessible contraceptive method, unless poverty is eradicated, unwanted pregnancies can occur.
The Penal Code of Japan makes abortion de jure illegal in the country. The exceptions to the law are broad enough that it is widely practiced. The presence of the penal offense, however, affects the access and care the women receives and how the women perceive their choice. The countries that impose legal restrictions on abortion have the highest rates of unintended pregnancies while they have the lowest rates in countries where abortion is widely legal[vii].
It is not only the women´s well-being that is affected by unwanted pregnancies and births. Children born by unintended pregnancies are more likely to be abused. Having not yet wanted to become a parent through unintended pregnancy, both the mother and the child are likely to suffer from childcare, which of course directly affects the child and creates a sad chain of events. And it bounces back as a cost to the society in the form of social assistance, medical expenses, crime, etc.
In the future, SRHR in Japan will become further complicated by the issue of low fertility rate.
Japan's population is declining, the population is aging, and there is less babies being born. According to 2019 demographic statistics released by the MoHLW, the total fertility rate, which is the number of children a woman will have in her lifetime, was 1.36, declining for the fourth consecutive year. The number of children born fell to the lowest number on record.
The Technical Intern Training Program for foreigners by the Japanese government is supposed to be a technology transfer to developing countries. Undeniably, its other objective is to address Japan's labor shortage. In November 2020, two Vietnamese technical interns in Kumamoto and Hiroshima prefectures respectively gave birth and were arrested on suspicion of corpse abandonment and infanticide. Foreign technical trainees are supposed to be subject to the Japanese labor standards laws, but in many cases, they come to Japan with a heavy debt in their home country, live in unfamiliar environments, work for low wages, are young, and are in vulnerable positions. They fear dismissal from their employers or forced return home. The young women came to Japan with dreams and worked hard. It ended in a way that they themselves least desired. The current state of SRHR in Japan, declining fertility rate, and a system to supplement the labor force from overseas---it is clear who suffers most from the distortions of the society.
When the issue of declining fertility rate is discussed in Japanese policies, the focus often zooms into marriage, women's career, work-life balance, etc. Everything starts, however, with women making their independent decisions about her body and her life. She decides whether or not to give birth, how many and when if giving birth. This is deeply influenced by how much the society values the female body and her overall health. Only in a society where women can independently and freely choose safe contraceptives, abortion, and mental and physical well-being, we will see safe pregnancy, childbirth, and healthy individuals being realized.
SRHR topics such as sexual violence, contraceptives, and abortion have long been a taboo in in Japan. In this case, "something that is not supposed to exist but do exist" is in fact so important that it determines the life of the individuals, the happiness of each child and the family, and the future of the society.
Now is the time to break the silence on SRHR.
[i] The Guardian. 27/9/2017. Boseley S. Almost half of all abortions performed worldwide are unsafe, reveals WHO. https://www.theguardian.com/world/2017/sep/27/almost-half-of-all-abortions-performed-worldwide-are-unsafe-reveals-who
[ii] WHO 2020. WHO recommendations on self-care interventions Self-management of medical abortion https://apps.who.int/iris/bitstream/handle/10665/332334/WHO-SRH-20.11-eng.pdf?sequence=1&isAllowed=y
[iii] Raymond EG, Shannon C, Weaver MA, Winikoff B. First-trimester medical abortion with mifepristone 200 mg and misoprostol: a systematic review. Contraception. 2013 Jan;87(1):26-37. doi: 10.1016/j.contraception.2012.06.011. Epub 2012 Aug 13. PMID: 22898359.
[iv] Upadhyay UD, Desai S, Zlidar V, Weitz TA, Grossman D, Anderson P, Taylor D. Incidence of emergency department visits and complications after abortion. Obstet Gynecol. 2015 Jan;125(1):175-183. doi: 10.1097/AOG.0000000000000603. PMID: 25560122.
[v] Jones R and Boonstra H, The public health implications of the FDA’s update to the medication abortion label, Health Affairs Blog, 2016, http://healthaffairs.org/blog/2016/06/30/the-public-health-implications-of-the-fdas-update-to-the-medication-abortion-label/
[vi] FDA, Questions and answers on Mifeprex, 2019, https://www.fda.gov/drugs/postmarket-drug-safety-information-patients-and-providers/questions-and-answers-mifeprex
[vii] Guttmacher Institute, 2020. Unintended Pregnancy and Abortion Worldwide Fact Sheet. https://www.guttmacher.org/fact-sheet/induced-abortion-worldwide
* Original article in HuffPost Japan:
** Yoko is an independent consultant who works in the areas of global health, development, and gender. She has previously worked for international organizations such as WHO and the Global Fund to Fight AIDS, Malaria, and Tuberculosis. She has a doctoral degree from Harvard T.H. Chan School of Public Health and a bachelor´s degree from the University of Tokyo.