For Aoyama, abortion was the only choice she felt she had, after her fiance raped and impregnanted her.
As a victim of domestic violence, Aoyama knew she wasn’t in the right mental state to raise a child. She loved the baby, of course. But who was to know whether she might scapegoat the child, directing pent-up anger at her kid? She was scared of herself. And though guilt engulfed her, she terminated her pregnancy. “I felt I had killed my baby,” she told VICE World News.
“I couldn’t protect myself and in the end, I had to kill my kid in this way,” she said, requesting the use of a pseudonym to discuss intimate matters.
She recalled how the abortion left her bleeding for days. “After the surgery, I couldn’t walk or even stand—I had to lie down on the taxi ride home,” she said. Remembering the pain from over 12 years ago, she said she wished the abortion pill—what she called a less invasive termination method—was an option.
“We need to have this in Japan.”
“It felt like torture. Not only was it a difficult time, but the surgery itself was so painful. If there’s an option to opt out of the surgery, then it should be available—we need to have this in Japan,” she said.
In December, British pharmaceutical company Linepharma applied to the Japanese government for approval of their abortion pill. If endorsed, the pill would be the first medical abortion drug in the country, which abortion rights activists have said would make reproductive healthcare a lot more accessible and affordable.
But even before the pill has been formally approved, a process that’s expected to take up to a year, leading health experts worry that greater access could lead to abuse.
Katsuyuki Kinoshita, the head of the Japan Association of Obstetricians and Gynecologists, a powerful industry group that represents a majority of doctors, said if the pill was deemed safe after clinical trials, then Japan has no choice but to approve it. “However, I am concerned that people will think this medicine can make abortions easier,” he said in an interview with Japanese broadcaster NHK.
He added that only qualified doctors should be allowed to prescribe the pill, as heavy bleeding, a rare side effect of taking the medicine, could occur. “It’d be best to set the price of the abortion pill to how much the surgery costs—about 100,000 yen ($861),” he said. In some nations, the abortion pill is provided free of charge by the government.
But Kumi Tsukahara, a reproductive health and rights researcher and activist, called the push to make abortion pills as expensive as surgeries “unbelievable,” accusing Kinoshita and other doctors of trying to hold on to their effective monopoly on carrying out abortions. “These doctors are only thinking about their business,” she told VICE World News.
“In Japan, surgical abortions are already so expensive and unaffordable for some women,” she said. Abortions and contraceptives are not covered by national health insurance.
To price the abortion pill so high defeats the purpose of medical abortions, which help widen access to lower income women, Tsukahara added.
As a medication, the abortion pill is used to end early pregnancies, or within 70 days of the first day of a person’s last menstrual period. It requires taking a combination of two pills: mifepristone, a hormone blocker, and misoprostol, which causes miscarriage-like contractions that help push out the embryo. After taking both medications, it takes about two to 24 hours for the pregnancy to be removed and is usually accompanied by cramping and vaginal bleeding.
Since China became the first country to approve the two abortion-inducing drugs in 1988, this nonsurgical method is now available in over 80 countries. It’s been listed as a safe and essential medicine by the World Health Organization from 2005. In the United States, where the hormone blocker mifepristone was approved in 2000, about 42 percent of all abortions were medically induced in 2019.
But in Japan, where abortions have been legalized since 1948, dilation and curettage remains one of the most popular abortion methods. This procedure, also known as uterine scraping, accounts for over 50 percent of all abortions nationally, though it’s been deemed “obsolete” by the WHO since 2012. (The rest were carried out by manual vacuum aspiration, which uses suction to remove the pregnancy tissue, or dilation and evacuation, which is a combination of both methods.) The procedure requires dilating the cervix and using sharp metal curettes to scrape the walls of the uterus, posing significant pain and risk of blood loss for the patient.
In Linepharma’s most recent clinical trials, the drugs ended 93 percent of its recipients’ pregnancies within 24 hours, with most reporting mild side effects.
But for reproductive rights activist Tsukahara, who has had an abortion herself, what was of greater concern was how doctors encouraged people to wait to terminate their pregnancies after 85 days—when they’d be eligible for a lump-sum payment for childbirth—to afford high abortion costs.
In Japan, pregnant people covered by public health insurance receive 420,000 yen ($3,691) to cover the medical costs of childbirth. People who experience premature births, stillbirths, miscarriages, and abortions—including terminations for financial reasons—are still qualified for payment, so long as they reach 85 days.
Tsukahara said she knew she wanted to abort after confirming her pregnancy at five weeks, but was encouraged to wait an additional three weeks by her doctor. “I cried every day for those last few weeks,” she said.
“I thought of that fetus as a baby, and I knew that the baby was getting bigger and bigger. I kept thinking, ‘I’m going to have to kill that baby,’” Tsukahara said.
Activists note that in addition to introducing a cheaper abortion method, Japan also needed to offer greater access to contraceptives and sex education to prevent unwanted pregnancies.
“The reality is that there are women who want to use birth control pills but are unable to, due to high costs,” Kazuko Fukuda, a sexual and reproductive health rights activist, told VICE World News.
Currently, condoms are the most widely available form of birth control in Japan, which are on average 82 percent successful in preventing pregnancy.
Birth control pills, which are 91 percent effective and a common method in Europe and parts of Southeast Asia, are only used by 2.9 percent of Japanese people of reproductive age. Low use is often attributed to high costs—one month’s worth of pills costs about 2,500 yen ($21.82)—and concerns about side effects. The pill was only approved in 1999 in Japan, nearly four decades after it was authorized for use in the United States.
In addition, Japan is one of at least 12 countries that still require people to get spousal consent for abortions. Though the law changed last year to exclude domestic violence victims, activists say requiring third-party permission treats women’s bodies as public property.
Aoyama recalled being rejected by multiple hospitals for an abortion because she was unable to get spousal consent from her abusive partner. “Even after explaining I was being abused by my fiance and was unable to get the consent form signed, doctors would ask me, ‘But you’re living together right? You’re engaged, aren’t you?’” she said.
Had it not been for her family and boss, who allowed her to work shorter hours as she recovered from her abortion surgery, Aoyama said she might have ended her life.
“That’s how depressed I was. But because I had their support and they told me not to blame myself, I was able to overcome this difficult point in my life,” she said.
Though she described her abortion as a pain she’d have to carry with her to her grave, Aoyama said she was glad she made the choice to terminate her pregnancy. She wished all women had the freedom to choose.
Correction: A previous version of this story misstated how long after Tsukahara became pregnant did she want an abortion, the name of the industry body of Japanese obstetricians and gynecologists, and the amount of insurance payout for pregnant people. We apologize for the errors.