Invited review article
Abortion as a Sexual and Reproductive Health/Rights Issue and the Possibility of Expanding Abortion Care Specialties in Japan
2023 Volume 23 Issue 1 Pages 2-7
Details
2023 Volume 23 Issue 1 Pages 2-7
Sexual and reproductive health/rights are intrinsic human rights encompassing privacy, sexual diversity, choice of sexual behavior, and the decision to have children. Achieving sexual and reproductive health necessitates respecting individual rights and emphasizing the importance of reproductive rights. This review aims to discuss the current state of the abortion services in Japan, highlight challenges in providing abortion care, and explore the potential for the nursing profession to expand its expertise in this area. In 2022, the World Health Organization (WHO) updated its recommendations for safe abortion, marking the first revision in a decade, and revised its abortion care guidelines. Additionally, in 2023, Japan approved oral medication for abortion, thus providing an increased number of options for abortion. However, this development also poses challenges for nursing professionals who may encounter unfamiliar care situations. Establishing specialized abortion care can considerably benefit women undergoing abortion, thereby ensuring they receive high quality care tailored to their needs.
The Cairo Plan of Action, a significant outcome of the 1994 International Conference on Population and Development, marked a crucial milestone by introducing the concept of reproductive health/rights within the framework of human rights. Subsequently, the 1995, World Conference on Women in Beijing further emphasized on the importance of sexual reproductive health/rights (SRHR) as a fundamental human right for women. Over the years, the international community has undertaken numerous efforts to realize and promote the SRHR, leading to its firm establishment as a crucial global principle. However, despite these advancements, many countries still struggle to ensure universal access to SRHR for their populations. Japan lags in the progress of SRHR initiative. This review focuses on abortions, recognizing the importance of women having the right to access safe abortion services. The aim of this review is to discuss the current state of the abortion services in Japan, highlight challenges in providing abortion care, and explore the potential for the nursing profession to expand its expertise in this area. By comparing the prevailing trends and practices in other countries, this review will provide valuable insights into how Japan can improve its approach to abortion care and bolster its commitment to women’s reproductive health and rights.
Abortion in Japan is governed by the Maternal Health Act, where “Induced Abortion” refers to the artificial termination of a pregnancy when the unborn child cannot survive outside the mother’s body. The legal treatment of abortion varies across countries because of conflicts between fetal life, a woman’s right to self-determination, and religious considerations. In Japan, abortion is permissible up to a pregnancy period of less than 22 weeks, but historical laws from the Meiji period still consider abortion illegal. Despite this, the Maternal Health Act allows for abortion under certain conditions, maintaining its practice. Notably, requirement for spousal consent poses a barrier to abortion based solely on a woman’s choice. Owing to the effectiveness of outdated laws and systems, the SRHR of women in Japan are not adequately safeguarded.
There are two abortion methods: surgical and medical. In Japan, for pregnancies at less than 12 weeks, Dilation and Curettage (D&C) and Vacuum Aspiration (VA) are commonly employed. However, the World Health Organization (WHO) called for safe abortion methods for all women in 2003 and recommended transitioning away from D&C [1]. Despite these recommendations, Japan continues to use, D&C (35.3%), D&C followed by VA (27.1%), VA only (10.6%), and VA followed by curettage (21.2%) for early pregnancy abortions [2]. Curettage is still used in > 60% of abortion procedures. The latest abortion care guidelines suggest the use of safe alternatives, such as VA and medical abortions [1]. These alternatives result in reduced harm to the mother and uterus during surgery and anesthesia, lower the risk of infections, and ensure pregnancy termination without undue pain. In Japan, the use of medical abortion (MEFEEGO®Pack comprising Mifepristone and Misoprostol) for abortions up to 9 weeks gestation was recently approved in April 2023. The Ministry of Health, Labour and Welfare issued guidelines for its proper use, requiring administration under the supervision of a designated physician under the Maternal Health Act. However, it is currently indicated that medical abortion should be performed in hospitals where patients can be hospitalized until an appropriate system for its use is established [3] [4].
Medical abortion has gained widespread popularity globally as an accessible and effective method, particularly in approximately 30 countries, including the United Kingdom and France, where it is covered by public medical insurance or subsidized. This remotely accessible abortion method allows safe and effective administration of abortion medicines at a healthcare facility or enables individuals to self-administer them outside of a facility, such as in the comfort of their homes, provided they have access to accurate information and quality-assured medicines. Even those managing their abortions at home during the first 12 weeks of gestation may still seek or require support from a trained health worker at some stage of the process [1]. During the COVID-19 pandemic, the United States implemented telemedicine abortion programs, demonstrating the safety and efficacy of fully remote, asynchronous medication abortion care using a published protocol [5] [6]. These services proved to be effective, safe, efficient, and acceptable, without the need for an ultrasound scan. In the United Kingdom, the National Institute for Health and Care Excellence recommends abortion before definitive ultrasound evidence of intrauterine pregnancy [7]. Additionally, the International Federation of Gynecology and Obstetrics endorses the permanent adoption of telemedicine abortion services [8]. Thus, medical abortion’s popularity stems not only from its effectiveness but also from its positive impact on various aspects of the abortion process. By being a non-invasive method, medical abortion does not affect fertility and ensures privacy, convenience, and acceptability for individuals seeking abortion services. Notably, these improvements in accessibility and acceptability do not compromise the safety or efficacy of the procedure.
Integrated definition of sexual and reproductive health and rights is “Sexual and reproductive health is a state of physical, emotional, mental and social well-being in relation to all aspects of sexuality and reproduction, not merely the absence of disease, dysfunction or infirmity. Therefore, a positive approach to sexuality and reproduction should recognize the part played by pleasurable sexual relationships, trust, and communication in promoting self-esteem and overall well-being. All individuals have a right to make decisions governing their bodies and to access services that support that right” [10]. A report including a new definition of SRHR by The Guttmacher Lancet Commission was released in 2018 (Figure 1 ) [9] [10]. The Committee was established in 2016. In 2015, the United Nations adopted the Sustainable Development Goals (SDGs), where the SRHR were specified as targets under Goal 3 (Health) and Goal 5 (Gender Equality). However, it is noted that the SDGs do not fully encompass certain critical SRHR issues, such as safe abortion, the prohibition of discrimination based on sexual orientation and gender identity, and the sexuality of adolescents. Therefore, the report presents an evidence-based vision, aiming to facilitate the realization of comprehensive SRHR services and pave way for transformative change.
The Guttmacher Lancet Commission report advocates for “an essential package of SRHR services and information” that should be universally available, in line with the new definition of SRHR. This updated definition now includes “safe abortion care,” which may not have been part of the essential package previously. The committee strongly recommends that countries expand their access to this package of services. Notably, in 2022, the WHO issued new guidelines on abortion, aiming to support countries in delivering lifesaving care [11]. These abortion care guidelines encompass various recommendations to ensure safe abortion services, such as disseminating accurate information on care to all need, making medical abortion pills more accessible, broadening the range of healthcare professionals who can provide services, and introducing telemedicine where appropriate.
In Japan, abortion services are exclusively provided at medical facilities. Even the recently approved medicines for abortion cannot be prescribed online and necessitate visits to medical facilities [3]. Consequently, obstetricians/gynecologists and nursing staff play a significant role in providing care during abortions. Midwives are highlighted as instrumental in offering information and ongoing support to individuals taking decisions regarding abortion [12] [13].
Nursing professionals involved in abortion care must approach it with respect for women’s SHRH. However, due to the emotional aspect associated with abortion and personal views on abortion, nurses are considered a high-risk group for post-traumatic stress disorder [14]. Early surgical abortion typically does not require hospitalization and is a brief procedure, whereas medical abortion can be time-consuming. Additionally, midwives caring for second-trimester abortions may experience emotional distress, especially while handling the fetus after the abortion [15]. Perceptions and feelings regarding abortion are linked to attitudes toward abortion care and perceptions of its complexity [16]. Those with a positive attitude toward abortion care exhibit high work engagement and job satisfaction, acknowledging their role in providing the quality care [17]. However, the stigma surrounding abortion often denies or hampers women’s access to abortion care. Addressing this, the value clarification and attitude change workshops on abortion conducted in various countries improved participants’ knowledge and attitudes with respect to abortion, particularly among those with the least knowledge and most negative attitudes [18]. Thus, specialized training specific to abortion care is essential for care providers, and the development of educational programs for this purpose is urgently required. According to abortion care guidelines, comprehensive abortion care encompasses information provision, abortion management (including induced abortion), care related to pregnancy loss or spontaneous abortion, and post-abortion care. Medical abortion is recommended by various healthcare professionals, including nurses and midwives, and can be safely and effectively performed by trained nurses [19]. However, education for care providers in Japan is still lacking, highlighting the need to enhance abortion care education in basic nursing training or offer specialized postgraduate programs for abortion care specialists. In the future, it will be crucial to study not only the experiences of women who undergo abortions but also the experiences of nursing professionals providing abortion care, particularly with respect to approved medical abortion in Japan.
As pregnant individuals seek abortion care, it is crucial to integrate health services into the healthcare system to ensure equitable and non-discriminatory service delivery. Efforts are still required to establish strong linkages to quality abortion care within the healthcare system, with a strong focus on upholding human rights and promoting gender equality in all healthcare contexts [1].
With the availability of increased abortion methods, Japan has taken a positive step towards guaranteeing SRHR for its women. However, the stigma surrounding abortion in Japanese culture and society continues to adversely affect the physical and mental health of individuals involved in the abortion experience, including both those seeking abortion and care providers. Successfully transitioning from the notion of abortion to the broader SRHR concept of choice for health will depend on the future efforts of those engaged in sexual and reproductive health services.
Many thanks to Editage (www.editage.jp) for English language editing.
No conflicts of interest in this study.
