Japanese laws make abortion an economic issue
In light of yesterday’s U.S. Supreme Court decision to allow individual states to outlaw abortion, we are here posting an article we wrote about Japanese abortion practices in 2012 in our money blog for The Japan Times. Though the article is still on the newspaper’s website, it seems to be behind the paywall and not necessarily in its original complete form. Of course, some of the information contained herein have changed in the past decade, especially with regard to contraception and non-surgical forms of pregnancy termination. We plan to write a new article about abortion in Japan in the coming weeks, but, essentially, the legal and financial matters mentioned below are still in place.
Contrary to what most people believe, abortion in Japan is not legal. The reason abortions are performed freely in Japan–officially about 210,000 in 2010, though there certainly were more–is due to amendments to the daitaizai (illegal abortion) law. These amendments, implemented shortly after World War II, allow for a pregnant woman to abort her child if the pregnancy threatens her life or health, or if the woman is financially unable to raise the child. It is assumed, for legal purposes, that the vast majority of women who undergo abortions do so for economic reasons. However, since there is no real provision for having women state her reasons when seeking an abortion, and no woman in Japan has been prosecuted for aborting a fetus since World War II, the procedure is considered effectively legal. It is also quite expensive. Unless the abortion is being carried out for health reasons, national insurance will not cover it. This situation has lead to a paradox: Most women in Japan who seek abortions ostensibly do so because of financial hardship, but are nevertheless forced to pay a great deal of money to have those abortions performed.
According to our own Internet survey of gynecology services and comments on various blogs and websites, the cost of an abortion up to the twelfth week of pregnancy ranges from ¥80,000 to ¥150,000, which is only the cost of the procedure and does not include consultation fees and medication. However, after the twelfth week of pregnancy, the cost increases considerably. Abortions performed between the twelfth and 22nd week of pregnancy cost between ¥300,000 and ¥500,000. Also, if the patient suffers from a chronic condition that could complicate the procedure, such as asthma, she is required to undergo the procedure at a general clinic, which tends to be more expensive than a women’s clinic or a gynecology office. Of course, if a physician concludes that the pregnancy threatens the woman’s life or health, insurance can be used for the abortion, and if the cost of the operation goes above a certain level, she can even receive a refund for any money she pays out of pocket. Even if the cost does not rise above that designated level, if she files an income tax return she can deduct the cost of her abortion on her return, including money she paid for sanitary napkins and even the taxi fare to the clinic. But this is only if the procedure was done for health reasons. Other costs that apply but usually aren’t mentioned have to do with the aborted fetus. If an abortion (or miscarriage) takes place after the eleventh week of pregnance, the attending physician has to fill out a death report that the mother files at the local city office. She then has to pay for cremation. There are also optional costs for mizuko kuyo, or memorial services for aborted babies, which start at about ¥40,000.
The high cost of pregnancy termination figured into a recent survey carried out by the Asahi Shimbun, which sent questionnaires to 932 medical institutions that offer abortions, of which 343 responded. The two most common methods for surgical abortions are suction and D&C (dilation and curettage). The former method literally vacuums the fetus out of the uterus. With the latter method (soha-ho), the doctor cuts the fetus into pieces and scrapes the pieces out through the cervix. According to the Asahi article, suction is the preferred method in most developed countries, while in Japan most gynecologists use the D&C method. Of the survey respondents, 11 percent said they offer only suction, 35 percent D&C, and 48 percent both. In 2003 the World Health Organization released guidelines for “safe abortions” that recommended either suction or the so-called abortion pill (RU-486 or mifepristone). D&C was recommended during the early stages of pregnancy only when the other two methods were not available. The article also said that the American Centers for Disease Control has stated that D&C results in 2 to 3 times more serious side effects than the suction method and that used properly the abortion pill is perhaps the safest method.
The abortion pill is available in most developed countries but not Japan, and the Asahi article implies that there is little chance of it being approved in the near future. Though the pill is expensive–in the U.S., it’s about $500–it is still cheaper than a surgical abortion. There is no indication in the article as to the relative costs of the two surgical methods, but the writer says the reason for the preference for D&C in Japan is that “most abortions are performed by older doctors who prefer to use the method they’re accustomed to.” One gynecologist quoted in the article says that “Japanese doctors” prefer D&C because “they are more skillfull with their hands.” The Japan Gynecological Academy reported only 21 “accidents” related to abortion procedures in 2010, but this figure is not reliable since most abortions are not covered by insurance and so reporting is not thorough.
We contacted the director of a women’s clinic in Tokyo to ask about the Asahi article. The director answered on the condition that we not use her name or the name of the clinic, and she took issue with almost everything the article stated. The WHO recommendations were misrepresented, she said, since they were mainly targeted at developing countries, many of which do not permit abortion. In these countries the suction method is preferable because it is easier. Doctors in those countries may not possess the skills necessary for a D&C, which the director says is a more efficient method of abortion when carried out properly. She also believes D&C is safer. As to whether one method is less expensive than another, she says they’re about the same in Japan, but in any case since they aren’t covered by insurance each institution sets its own price for abortion procedures. She offered no opinion on the abortion pill and whether the government would ever approve it, but she did imply that the risks were underappreciated. If the government ever did approve its use she believed it would be very expensive since pharmaceutical companies would be free to set a high price, citing the cost of so-called emergency contraception pills in Japan as evidence. The cheaper pills cost ¥5,000 for two, while the more expensive ones (less side effects) are ¥15,000 for two. She said gynecologists remain “astonished” at these prices. In the U.S., they cost between $10 and $70.
It should be noted that the number of abortions continues to drop every year (during the 1950s the number averaged a million a year) thanks to the introduction of the low dose birth control pill more than a decade ago, even though the health ministry reports that in 2009 only 3 percent of women used it as a contraception method. The cost of using the pill in Japan runs about ¥3,000 a month and also is not covered by insurance if used to prevent pregnancy.