This is one of the three articles in our special report, published 18 August 2023: “Japan’s approval in 2023 of abortion pills”
PHOTO SOURCE: International Women’s Day rally, Tokyo, 8 March 2023. PHOTO by Philip Fong / AFP in Le Monde, 30 April 2023
by Masako Furukawa
Japanese journalist Masako Furukawa wrote an extensive investigative report based on interviews with 28 stakeholders, using evidence from official documents and other sources, which was published in three parts in the Japanese Yahoo! News on 28-30 July. Here, she describes the interviews and research she conducted to prepare her report.
My report answers the question: “Why was the introduction of abortion pills in Japan delayed for 35 years?” I discovered many problems, in particular, how the Japanese Association of Obstetricians & Gynecologists (JAOG), was involved in causing this extensive delay.
I initially had no idea where the reason for the 35-year delay lay. Therefore, I conducted interviews with a wide range of people: pharmaceutical companies, obstetricians and gynaecologists in the field, executives of JAOG, politicians, bureaucrats, academics familiar with SRHR policy, and women who had campaigned for approval for the pills.
It took me four months to explore and find evidence to support a clear answer to this apparently simple question. I started the investigation in March of this year, one month before the Japanese Ministry of Health, Labour and Welfare (MHLW) approved the abortion pills, with the brand name Mefeego Pack, containing mifepristone and misoprostol. This event marked a step forward in Japan’s reproductive health policy, at last. However, this combination of pills has been approved in more than 93 countries and territories since its approval in France in 1988. Why such late approval?
What has been reported up to this point was not sufficient to know the answer to this question. Some people mentioned the influence of doctors’ organisations, religious forces and politicians, but when I interviewed them in detail, I realised that there was a lot of gossip and predictions. I therefore concentrated on finding evidence to answer this question. My Yahoo reports revealed circumstances that are unique to Japan, mainly in relation to the following three points:
(1) For many years, dilatation & curettage (D&C) has been widely practised in Japan as the main abortion method, blocking the way to using newer options for safe abortion. This arises from the fact that Japanese society has long been lacking in consideration for women’s health, arising from the structure of male domination of both healthcare and politics.
(2) Those familiar with abortion in Japan believed that the JAOG, which is the organisation responsible for abortion in Japan, was responsible for the delay in introducing abortion pills. JAOG’s executives have long been aware of the existence of abortion pills but have remained reluctant to introduce them. From the documents I found and the testimonies of senior members of this organisation who I talked to, it became clear that they had indeed long supported a policy of restricting access to abortion pills, even after Japan had approved Mefeego Pack.
(3) In 2012, Japan was advised by the World Health Organization (WHO) that they should not continue using the less safe curettage methods but should shift to other, safer methods. This has been previously reported. Newly this time, I reported that a person at the centre of JAOG had admitted that he had a negative view of the human rights issues identified by WHO and was reluctant to accept their recommendations.
I also interviewed a number of pharmaceutical professionals, from whom it became clear that in Japan, there has been little social understanding of medicines for women and that the pharmaceutical companies themselves faced difficulties in setting up clinical trials.
I learned that pharmaceutical companies that considered doing clinical trials had applied for approval at least twice before it was given, and there were companies and individuals who had considered the possibility of bringing the pill to market in Japan.
In 1989, the pharma company Japan Roussel (now Sanofi) considered providing mifepristone in Japan. However, a former employee of this company said that “social factors”, including a campaign against abortion, had put a stop to the plan. Furthermore, around 2010, Dr André Ullmann, one of the developers of mifepristone, had contacted Japanese doctors to explore the possibility of introducing the abortion pill. However, due to a lack of interest from Japanese pharmaceutical companies as well as from obstetricians and gynaecologists, this did not take place at the time.
Eventually, development began in 2014, when Dr Ullmann’s UK-based Linepharma headquarters commissioned two Japanese pharmaceutical companies to develop the pill package. But it was not until 2018 that a group of Japanese obstetricians and gynaecologists assigned a staff of doctors to be in charge of the clinical trial. Isamu Ishiwata, who is now the president of JAOG, admitted that they had not paid attention to introducing abortion pills for a long period of time.
“The fact that we did not encourage the pharmaceutical companies to introduce the method may also have had an impact.”
What became increasingly clear to me through historical review and interviews with senior executives of JAOG, was that they firmly believed that surgical abortion procedures, including curettage, are safe. Dr Ishiwata repeatedly emphasised how safe their methods of curettage and aspiration, with aspiration also sometimes including some curettage.
“From the very beginning, Japanese doctors have performed surgical abortion methods so safely that they are world-class,” he said. “As recognised in Japan’s Maternal Protection Law, abortion is performed to protect motherhood and health. In Japan, our surgical methods are the safest in the world without the use of pills.”
On the other hand, Dr Ishiwata did not mention any psychological aspects of how women undergoing curettage or aspiration perceived the procedures, compared to abortion pills. I learned, however, that in the UK there have been surveys of how women themselves feel about the abortion methods available. I also learned that in Sweden, women who have chosen medical abortion have been surveyed about how they felt after using it. In both countries, the mostly very positive results have been published.
Dr Ishiwata’s answers made me wonder why JAOG did not appear to be interested in the wishes of women. So, I decided to ask not only the chairperson but also the vice-chairperson, Dr Tsugio Maeda, who told me about the circumstances that make it difficult for women’s views to be reflected in the abortion pill policy. He said:
“When we discussed our views on early abortion pills inside our organisation in 2013, there was only one woman in the group who we discussed it with.”
I feel that this lack of consideration for women’s wishes and views in an ob/gyn association is closely linked to other gender gap issues existing in Japan. Despite the approval, the environment for abortion in Japan has not improved. Even after the introduction of the abortion pills, various developments have emerged that have hindered access to their use.
In practice, Mefeego Pack began to be used in May 2023, but even at the end of July, there were only 30 or so medical facilities in the country that were providing them. When a very small number of doctors took the initiative and started offering the pills, their colleagues called the health authorities and requested that detailed checks be put in place. It seems that their peers would monitor doctors who provided abortion pills. If such obstructive behaviour, which makes it difficult to provide medical care, continues, doctors in the field may become reluctant to introduce or continue offering the pills.
As my interviews continued, it became clear that JAOG’s intentions continued to reflect efforts to restrict the use of the Mefeego Pack even after approval.
A statement by a JAOG executive suggested that he had heard that the strict conditions of use of the abortion pills were “heavily influenced by conservative politicians”.
This suggested the involvement of politicians in making the restrictive policy but also suggested that JAOG was aware of the political developments, i.e. that they were “close to the politics”. I therefore began to focus my research on the relationship between JAOG and politicians.
While looking through JAOG’s documents, I found a “business report”, which records the activities of the association’s officers. I examined those from 2012, before the Phase 1 trials of the pills were launched, up to the present time. I found there were some close links with certain politicians. I drew attention to the behaviour of JAOG’s senior management in 2021, at the time when Linepharma completed Phase III trials. At the same time as abortion pills were being discussed in the Parliament, a Parliamentary group on obstetric care had been established among parliamentarians. Executives of JAOG were at the same time also negotiating with the department in charge of abortion pills at the Ministry of Health, Labour and Welfare, and were also actively interacting with politicians. The politicians who had been appointed to the parliamentary group were those belonging to a conservative faction. I therefore also looked at the political funding bodies of the MPs who had joined the parliamentary group. I extended my research to their income and expenditure reports, and discovered that large donations had been paid by JAOG to those MPs. In the same year, the total amount paid to several Conservative MPs was more than three million yen (± US$ 27,272).
Did the politicians return the favour to JAOG?
These questions led me to interview a Conservative politician who had received donations, a member of the House of Representatives, who denied any connection, saying that the donations had nothing to do with the abortion pill policy, as the parliamentary group was established for a different purpose. He also said that he had not interfered in the approval of the pills.
Meanwhile, the post-approval management system for abortion pills was discussed in the Liberal Democratic Party’s Health and Labour Sub-Committee. I was told:
“It was pointed out within the Liberal Democratic Party that the operation of post-approval abortion pills should be tightened.”
Another member of the House of Representatives was also interviewed. He is the chairman of the House of Representatives Health and Labour Committee. He acknowledged that the post-approval regulation of the pills reflected the wishes of some members of the House:
“The rule that the pills could only be used on an inpatient basis in a facility with inpatient beds was decided in the following way: Initially, many Liberal Democratic MPs were of the strict opinion that the use of the pills should be conditional on everyone using them to be admitted to hospital. The MPs eventually agreed to relax the conditions “a little”. He also said: “I am not particularly knowledgeable about obstetrics policy. It was JAOG who provided this specific advice when considering the use of oral abortion pills.”
When did JAOG seek to tighten the strict provision of the pills? To find out, I re-read the project report and found that a “Request for the oral abortion pill RU 486” had been submitted to the responsible section of the Ministry of Health, Labour and Welfare on 25 September 2013. That is where the strict operational requirements for the abortion pills, as desired by JAOG, were first stated. Also stated were concerns about the impact of the pills on the profitability of departments of obstetrics and gynaecology, all of whom charge women privately for abortions.
I therefore requested an interview with the person who submitted this request, Dr Katsuyuki Kinoshita, who was president of JAOG until last spring. After several rounds of negotiations, the interview took place in mid-June. When I asked about the reason for the 35-year delay, Kinoshita replied:
“We knew about the pills early on, but we didn’t think it was necessary to introduce them to Japan. Some doctors in the field said: ‘We are performing curettage and aspiration safely. We don’t need to introduce the pills.”
I also told Kinoshita that some women do not wish to have surgery such as curettage and that the WHO has recommended medical abortion pills as being much safer. However, he replied:
“The WHO says that the pills are safer. But in Japan, I don’t think we need to follow it; the WHO is doing things mainly to deal with people in developing countries.”
This is of course not true. He also acknowledged that the wishes of JAOG were also reflected in the decision to limit the provision of abortion pills to medical institutions with in-patient beds. Ultimately, Kinoshita’s comments suggested that JAOG was complicit in the long-standing delay in the introduction of the pills.
In Par 3 of my Yahoo article, I raised the issue of legislation. The reason behind the delay in introducing abortion pills was the influence of the old penal code, experts on the abortion issue said, which “criminalises abortion” and makes abortion a “crime carried out by women”. In Japan, whenever there is a report of an unassisted childbirth, the woman is always blamed. One of the women pointed out that this is because, at its roots, Japan is still a country with an “abortion law”.
Based on my findings, I am convinced that reluctance on the part of doctors is what is holding back the wider introduction and use of abortion pills.
Furthermore, I believe the media have been lax in their pursuit of attention to the case so far. While reporters, including those covering political and social sectors, show interest in certain subjects and scoops, no one seems to pay much attention to sins of omission, i.e. failing to do what should have been done to improve the quality of women’s reproductive health care. As a result, the responsibilities of doctors’ organisations and conservative politicians were also rarely pursued by the media in detail.
Male domination of health care, politics and media in Japan has maintained a significant lack of attention to women and women’s health. This is both a structural problem and a problem involving strong prejudice and political power. Women’s reproductive health needs more attention. Recently, when I covered a press conference held at the Ministry of Health, Labour and Welfare, by a women’s organisation that is organising an action to expand the provision of oral contraceptives, there was only one male journalist among the media present.
Through my research, I was reminded of the need for journalists, both men and women, to continue to make visible the root of the problems surrounding women’s reproductive health issues, including the sins of omission on the part of those in power.
About the author:
Masako Furukawa is a journalist who graduated from Sophia University in Japan. She has written non-fiction articles about the lives of celebrities for the weekly magazine AERA’s “Portrait of Today” series. She is also the author of “Cancer Patient Studies of Awareness” (NHK Publishing Shinsho) and other works.
The original text of her three reports in Yahoo Japan (which are in Japanese only):
PART 1: “The long road to abortion pill introduction and barriers after approval” https://news.yahoo.co.jp/articles/e5688b69db3b3837d043b907f75a081d830f668f
PART 2: “Why medical associations have remained reluctant to introduce abortion pills”
PART 3: “Review of ancient Japanese abortion crimes and criminal law”