On Jan. 27, the health ministry approved public sale of the so-called abortion pill in Japan. As pointed out by Asashi Shimbun in its coverage of the news, Japan is one of the last developed countries to approve what is usually referred to as “medication abortion.” The U.S., for example, approved the pills in 2000. In France and China, they’ve been available since 1988. Nevertheless, there will still be many obstacles for people who wish to use the abortion pill in Japan.

Asahi reports that 126,000 abortion procedures were carried out in Japan in 2021. Of these, between 80,000 and 90,000 cases could have been treated with abortion pills, since the procedures were performed up to the ninth week of pregnancy, which is the deadline for prescribing the drugs. In actuality the abortion pill is two pills. One is mifepristone, which halts the pregnancy. The second pill, taken up to 48 hours after the first one, is misoprostal, which initiates bleeding to empty the womb within 8 hours after ingestion. In 90 percent of cases, the proper use of the two pills will lead to the end of the pregnancy. The amount of bleeding that results is said to be greater than the amount of bleeding that accompanies a surgical abortion, but the other possible side effects that attend a procedure, such as those related to anesthesia, are greatly mitigated with the abortion pills. Individuals who do not completely abort the pregnancy will have to undergo the procedure. 

In this regard, one of the possible obstacles for obtaining abortion pills will be the places where it is distributed. Most early term abotions take place at clinics that do not have hospitalization facilities in case of emergency medical situations. According to the health ministry, the second pill should be taken in the morning of a weekday so that the bleeding occurs in the afternoon, when clinics are still open, so if a procedure is needed the patient can have it done right away. However, if the reaction to the pills is more serious, the clinic must have a system in place to respond to such reactions, such as an affiliation with a hospital, so the Japan Society of Obstetrics and Gynecology is recommending that at least for the first six months after the abortion pills become availalbe, their use should be limited to hospitals or clinics that have access to hospital services.

The biggest obstacle, however, is financial. Though the cost hasn’t been finalized yet, the government is saying it may set the price at about ¥100,000, which is the same as the cost of an early term abortion procedure. The main reason for the high price of the pills, which only costs the equivalent of ¥1,088 in the World Health Organization’s (JSOG) guidelines, is to guarantee staff in the case of a medical emergency brought on by the use of the pills. It’s assumed that over time the price will come down as its use spreads—in the U.S., for example, 64 percent of abortions that take place up to the ninth week of pregnancy are carried out medicinally. One gynecologist—a male, to be precise—told Asahi that use of the pill “won’t spread” if complications ensue, so he and his colleagues will only prescribe it “with caution.”

A subsequent Asahi article mentioned how a women’s expert group of female physicians and midwives has made an appeal to the government to set the price of the abortion pills lower than the price for an abortion procedure. Since the health ministry is presently drawing up guidelines there is still time before the pills go on sale, but in principle, doctors can charge anything they want for the pills since, like surgical abortions, they aren’t covered by national insurance. The women’s expert group has also asked the government to allow both surgical and medication abortions to be covered by insurance—or, even better, be free of charge—since they consider pregnancy termination to be a fundamental reproductive health issue. Of course, childbirth is also not covered by national insurance, but both central and local governments subsidize childbirth costs up to a point, often in the name of boosting Japan’s low birthrate.  

As implied by the previous Asahi article, the JSOG may be the most significant obstacle, since it is the expert group that wants the health ministry to set the price of the abortion pills at ¥100,000. Though they say this is to guarantee emergency facilities, many interested parties think that gynecologists will lose a lot of business once the pills are available and the price inevitably comes down. These doctors not only make money on the procedure, but also on ancillary in-patient care, which is not necessary with medication abortions. Women’s groups are insisting that the health ministry follow “international guidelines,” which suggest a very low price for the pills and do not say anything about hospitalization. 

And one more obstacle: The Japanese law that governs abortions mandates that a “spouse” (or, presumably, the equivalent) must approve the procedure, and women’s groups are insisting that such approval not be mandated for abortion pills, though, of course, these groups also insist that spousal approval not be required for surgical abortions. It’s assumed that many if not most abortions are carried out now without such approval because doctors don’t necessarily have strict criteria for confirming it, but the legal condition by itself can be seen as an obstacle.