Abstract
Objectives: On April 26, 2023, the Japanese Ministry of Health, Labour and Welfare approved the use of the medical abortion pill package (called the MEFEEGO Pack in Japan) on the condition that the patient undergoes either “hospitalization or outpatient observation at a facility with beds.” The purpose of this study is to examine the immediate uptake of medical abortion and the current situation of peri-abortion care in Japan.
Methods: The study design was an institution-level national survey. Questionnaires were sent to 3941 facilities to collect information on abortions and abortion consultations performed between May and October 2023.
Results: Responses were received from 2096 facilities (53.2 % response rate). A total of 28,346 abortions were performed before the ninth week of pregnancy, of which the MEFEEGO Pack was used in 435 cases (1.5 %), with no serious complications. The proportion of facilities providing peri-abortion care services in all abortion cases was 10.9 % for mental health support, 3.3 % for counseling information, 50.6 % for support to prevent repeat abortions, and 73 % for contraceptive information. These services were more commonly provided in hospitals with a higher number of obstetrician-gynecologists and abortions, and where interprofessional collaboration was present. Physicians were the main providers of peri-abortion care, while midwives and nurses provided these services at only about 20 % of facilities.
Conclusion: Greater interprofessional collaboration and increased involvement of midwives and nurses are necessary to prepare for a possible increase in the use of medical abortion in Japan.
Keywords: Medical abortion, Japan, Counseling, Contraception, Interprofessional relations
Highlights
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Medical abortion pills were approved in Japan in 2023.
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Medical abortion was used in 1.5 % of 28,346 cases, with no serious complications.
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Mental health peri-abortion care was offered in all cases by only 10 % of facilities.
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Interprofessional collaboration was associated with peri-abortion care.
1. Introduction
On April 26, 2023, the Japanese Ministry of Health, Labour and Welfare (MHLW) approved the medical abortion pill package, known in Japan as the MEFEEGO Pack. It is a combination of two medications: mifepristone and misoprostol. Mifepristone blocks the pregnancy hormone progesterone, and misoprostol is taken 36–48 h later to induce contraction of the uterus. The new introduction of medical abortion in Japan was preceded by a public consultation, with MHLW delaying its approval decision by a month to complete its analysis of public comments (Goto et al., 2023). The MEFEEGO Pack was finally approved on two conditions: that it is prescribed before the ninth week of pregnancy, and that the patient undergoes “hospitalization or outpatient observation at a facility with beds” until a post-marketing surveillance system is established (Ministry of Health, Labour and Welfare, 2023). A similar cautious step was taken in relation to oral contraceptives in 1999 (Goto et al., 1999), whereby MHLW approved the use of oral contraceptives in Japan on the condition that they are prescribed by a gynecologist and that the patient undergoes a gynecological examination and other tests every three months. An MHLW research team that includes authors of this paper is currently undertaking post-marketing surveillance and holding discussions to determine whether the definition of eligible facilities for medical abortions should be expanded to include those without beds.
The oral contraceptive prescribing guidelines issued by the Japan Society of Obstetrics and Gynecology (2005) recommended the GATHER approach, which is intended to promote women's informed choice and to protect their reproductive health and rights (Rinehart et al., 1998). The GATHER approach, which can be applied to the provision of information on different contraceptive methods, is based on the following six principles: (1) Greet clients to welcome them, (2) Ask clients about their and their partners' basic and reproductive health information, (3) Tell clients about family planning options, (4) Help clients choose a method, (5) Explain how to use the method, and (6) encourage them to Return for follow-up. Although there are no such detailed guidelines for the MEFEEGO Pack, the general abortion guidelines issued by the Japan Association of Obstetricians and Gynecologists recommend careful pre-abortion counseling, postabortion mental health care, and contraceptive counseling (Hirota, 2018). Studies have shown that the willingness of patients to use contraception is high at the time of abortion, with one study reporting that postabortion family planning counseling increased the proportion of women using contraception from about 30 % to 70 % (Huber et al., 2016). Counseling on contraception is therefore critical at the time of abortion. In order to expand access to medical abortions, it is important that women are well informed about the abortion method they choose and that they receive appropriate care afterwards, not only physically but also mentally, with the support they need to prevent further unnecessary abortions.
In response, we examined the post-approval frequency of medical abortions and the current status of peri-abortion care as part of MHLW's national survey to monitor abortion complications following the approval of the MEFEEGO Pack. We assumed that introducing medical abortion in a country where surgical abortion was the only option demands a major change in service provision, involving coordination among health professionals, including midwives, nurses, and pharmacists. Therefore, we examined the immediate uptake of the new method and the provision of peri-abortion care by various health professionals. The results are expected to support the development of recommendations on how to improve access to medical abortion and peri-abortion care in Japan. The World Health Organization (WHO;, 2022) includes medical abortion in its Model List of Essential Medicines and recommends avoiding curettage, which is still used in Japan (Nakamura et al., 2021). The introduction of medical abortion is providing an opportunity to draw more professional and societal attention to improving women's access to safe abortion in the country.
2. Methods
This cross-sectional survey targeted 3941 medical facilities throughout Japan that are staffed by at least one physician designated under the Maternal Protection Law. We applied this criterion to reflect that only designated physicians are allowed to provide abortion services in Japan. Survey forms were sent by mail and collected by fax from October 30 to November 30, 2023. We sent one reminder to each target facility during this period. The survey was reviewed and approved by the Ethics Committee of the Japan Association of Obstetricians and Gynecologists (approval number 202210).
We asked for information about abortions performed between May and October 2023. The survey items asked for information on facilities and abortions performed. The former included the number of full-time obstetrician-gynecologists, and the latter included the number of abortions by week of pregnancy, complications, and cases requiring referral or out-of-hours visits. It also included items on the types of pre-abortion clinical tests conducted, provision of four key peri-abortion care services ((1) provision of mental health care, (2) information on counseling services, (3) support to prevent repeat abortions, and (4) information on contraception), and the main service providers of each type of support. The listed peri-abortion care services are in line with the above-mentioned GATHER approach and general abortion guidelines. Response options for these items comprised providing the service in all abortion cases, only providing the service when deemed necessary, and not providing the service at all. The service provider item was a multiple-choice list of six professions (physicians, midwives, nurses, social workers, pharmacists, and administrators). The facility was categorized as having interprofessional collaboration if multiple professions were involved.
This was an exploratory study to monitor the post-approval use of the new medical abortion pill package in Japan. We calculated the frequency of medical abortion and focused on analyzing the provision of the above four peri-abortion care service items. For the tabulation of peri-abortion care providers, we calculated the proportions on the basis of the total number of facilities. We additionally assessed the proportion of peri-abortion care providers when restricting the sample to hospitals and clinics with three or more doctors, which are legally required to employ pharmacists. We deemed that all facilities with designated obstetrician-gynecologists also had midwives, nurses, and administrators. However, social workers are not regulated and thus may not be employed/available at all facilities. We conducted a multivariable analysis to assess factors associated with the provision of these services. The dependent variable was care provided in all cases or when needed, and the independent variables were facility type, number of obstetrician-gynecologists, number of deliveries per year, number of abortions during the study period, use of the MEFEEGO Pack, occurrence of complications, and interprofessional collaboration. We used Stata version 18.0 (Stata Corp, College Station, TX, USA) for the analyses.
3. Results
Responses were received from 2096 facilities, representing 53.2 % of the total number of facilities invited to participate. These facilities included 660 hospitals (55.1 %), 873 clinics with beds (59.6 %), 562 clinics without beds (44 %), and one unknown facility type.
A total of 36,007 abortions were performed, of which 28,346 were performed before the ninth week of pregnancy, when the MEFEEGO Pack can be prescribed. Of these, curettage was used in 3450 cases (12.2 %), aspiration in 18,286 cases (64.5 %), a combination of the two methods in 6175 cases (21.8 %), and the MEFEEGO Pack in 435 cases (1.5 %). Severe complications were recorded in 71 cases (uterine perforation or rupture, 7 cases; bleeding requiring blood transfusion, 2 cases; reoperation for residuals, 48 cases; and complications related to anesthesia, 4 cases), but no complications occurred in the MEFEEGO Pack cases.
The proportion of facilities providing peri-abortion care services in all cases was 10.9 % for mental health support, 3.3 % for counseling information, 50.6 % for support to present repeat abortions, and 72.8 % for contraceptive information (Table 1). Physicians were the main providers for these services, while midwives and nurses were providers at about 20 % of facilities (Table 2). The overall trends were the same whether the tabulation included all facilities or was restricted to hospitals and clinics with three or more doctors, although the latter showed a higher proportion by midwives (Supplementary Table 1). Among facilities categorized as having interprofessional collaboration, the proportion of midwife and nurse involvement in the collaboration was 80 % and 69 %, respectively, for mental health support and/or counseling information (total n = 579), and 78 % and 63 %, respectively, for support to prevent repeat abortions and/or contraceptive information (total n = 530).
Table 1.
Frequency of provision of peri-abortion care services in facilities with designated physicians in Japan in 2023.
| Services | n (%) |
|||
|---|---|---|---|---|
| Total no. of responses | All cases | When needed | Not at all | |
| Mental health support | 1936 (100) | 210 (10.9) | 361 (18.7) | 1365 (70.5) |
| Counseling information | 1885 (100) | 62 (3.3) | 331 (17.6) | 1492 (79.2) |
| Support to prevent repeat abortions | 1998 (100) | 1010 (50.6) | 580 (29.0) | 408 (20.4) |
| Contraceptive information | 2054 (100) | 1496 (72.8) | 432 (21.0) | 126 (6.1) |
The total number of responses for each service does not sum to the total number of facilities (N = 2096) owing to missing data.
Table 2.
Distribution of health care providers for peri-abortion care in facilities with designated physicians in Japan in 2023.
|
Services |
All hospitals and clinics, n (%)a |
|||||
|---|---|---|---|---|---|---|
| Physicians | Midwives | Nurses | Admin | Pharmb | SWb | |
| Mental health support and/or counseling information | 1094 (52.2) |
619 (29.5) |
465 (22.2) |
12 (0.6) |
3 (0.1) |
73 (3.5) |
| Support to prevent repeat abortions and/or contraceptive information | 1810 (86.4) |
473 (22.6) |
372 (17.8) |
7 (0.3) |
2 (0.1) |
8 (0.4) |
Admin: administrators; Pharm: pharmacists; SW: social workers.
a. Multiple answers were possible. The denominator for each proportion is the total number of facilities (N = 2096).
b. Social workers and pharmacists may not be available at all facilities.
Multivariable analyses showed that the use of the MEFEEGO Pack was not associated with any of the four types of peri-abortion care. The factors associated significantly with the provision of mental health support were the facility type being a clinic without beds (adjusted odds ratio [aOR] 0.60, 95 % confidence interval [95 % CI] 0.41-0.86), the number of obstetrician-gynecologists (aOR 1.08, 95 % CI 1.05–1.12), and interprofessional collaboration (aOR 3.69, 95 % CI 2.94–4.62) (Table 3). Similarly, factors associated with the provision of counseling information were the facility type being a clinic with beds (aOR 0.66, 95 % CI 0.49–0.90) and without beds (aOR 0.57, 95 % CI 0.38–0.85), the number of obstetrician-gynecologists (aOR 1.04, 95 % CI 1.01–1.07), and interprofessional collaboration (aOR 2.86, 95 % CI 2.24–3.66) (Table 4). For provision of support to prevent repeat abortions, the number of abortions (aOR 1.01, 95 % CI 1.00–1.02) and interprofessional collaboration (aOR 2.38, 95 % CI 1.75–3.23) were associated factors (Table 5). Regarding provision of contraceptive information, the number of abortions (aOR 1.04, 95 % CI 1.02–1.06) and interprofessional collaboration (aOR 6.03, 95 % CI 2.77–13.14) showed an association (Table 6).
Table 3.
Factors associated with the provision of mental health support in facilities with designated physicians in Japan in 2023.
|
Total no. of responses |
Mental health support n (%) or median (min, max) |
Multivariable analysisb |
|||||
|---|---|---|---|---|---|---|---|
| All cases | When needed | Not at all | p valuea | aOR | 95 %CI | ||
| Facility type Hospital Clinic with beds Clinic without beds |
631 (100) 789 (100) 515 (100) |
113 (17.9) 59 (7.5) 38 (7.4) |
164 (26.0) 145 (18.4) 52 (10.1) |
354 (56.1) 585 (74.1) 425 (82.5) |
<0.001 |
1.00 0.75 0.60 |
0.56–1.00 0.41–0.86 |
| No. of obstetrician-gynecologists | 1932 | 3 (1, 44) | 2 (1, 56) | 1 (0, 34) | <0.001 | 1.08 | 1.05–1.12 |
| No. of deliveries per year | 1833 | 286 (0, 2892) | 297 (0, 3641) | 111 (0, 2358) | <0.001 | 1.00 | 0.99–1.00 |
| No. of abortions during the study period | 1936 | 2 (0,1300) | 7 (0, 906) | 7 (0, 1481) | <0.001 | 1.00 | 0.99–1.00 |
| MEFEEGO Pack use Yes No |
41 (100) 1895 (100) |
4 (9.8) 206 (10.9) |
10 (24.4) 351 (18.5) |
27 (65.9) 1338 (70.6) |
0.63 |
1.09 1.00 |
0.53–2.23 |
| Abortion complications Reported Not reported |
81 (100) 1855 (100) |
4 (4.9) 206 (11.1) |
20 (24.7) 341 (18.4) |
57 (70.4) 1308 (70.5) |
0.11 |
1.10 1.00 |
0.64–1.87 |
| Interprofessional collaboration Yes No |
557 (100) 1379 (100) |
94 (16.9) 116 (8.4) |
194 (34.8) 167 (12.1) |
269 (48.3) 1096 (79.5) |
<0.001 |
3.69 1.00 |
2.94–4.62 |
aOR: adjusted odds ratio; 95 %CI: 95 % confidence interval; MEFEEGO: an abortion pill package consisting of mifepristone and misoprostol.
a. Chi-square test or Kruskal Wallis test was used.
b. Logistic regression with forced entry was used.
Table 4.
Factors associated with the provision of counseling information in facilities with designated physicians in Japan in 2023.
|
Total no. of responses |
Provision of counseling information n (%) or median (min, max) |
Multivariable analysisb |
|||||
|---|---|---|---|---|---|---|---|
| All cases | When needed | Not at all | p valuea | aOR | 95 %CI | ||
| Facility type Hospital Clinic with beds Clinic without beds |
617 (100) 765 (100) 502 (100) |
40 (6.5) 15 (2.0) 7 (1.4) |
154 (25.0) 120 (15.7) 57 (11.4) |
423 (68.6) 630 (82.4) 438 (87.3) |
<0.001 |
1.00 0.66 0.57 |
0.49–0.90 0.38–0.85 |
| No. of obstetrician-gynecologists | 1881 | 3.5 (1, 34) | 2 (0, 37) | 1 (0, 56) | <0.001 | 1.04 | 1.01–1.07 |
| No. of deliveries per year | 1783 | 285.5 (0, 2892) | 285 (0, 3641) | 141 (0, 2358) | <0.001 | 1.00 | 0.99–1.00 |
| No. of abortions during the study period | 1885 | 2 (0, 57) | 5 (0, 1300) | 7 (0, 1481) | <0.001 | 1.00 | 0.99–1.00 |
| MEFEEGO Pack use Yes No |
41 (100) 1844 (100) |
0 (0.0) 62 (3.4) |
6 (14.6) 325 (17.6) |
35 (85.4) 1457 (79.0) |
0.41 |
0.49 1.00 |
0.19–1.29 |
| Abortion complications Reported Not reported |
79 (100) 1806 (100) |
0 (3.4) 62 (0.0) |
10 (12.7) 321 (17.8) |
69 (87.3) 1423 (78.8) |
0.10 |
0.54 1.00 |
0.27–1.10 |
| Interprofessional collaboration Yes No |
554 (100) 1331 (100) |
27 (4.9) 35 (2.6) |
173 (31.2) 158 (11.9) |
354 (63.9) 1138 (85.5) |
<0.001 |
2.86 1.00 |
2.24–3.66 |
aOR: adjusted odds ratio; 95 %CI: 95 % confidence interval; MEFEEGO: an abortion pill package consisting of mifepristone and misoprostol.
a. Chi-square test or Kruskal Wallis test was used.
b. Logistic regression with forced entry was used.
Table 5.
Factors associated with the provision of support to prevent repeat abortions in facilities with designated physicians in Japan in 2023.
|
Total no. of responses |
Provision of support to prevent repeat abortions n (%) or median (min, max) |
Multivariable analysisb |
|||||
|---|---|---|---|---|---|---|---|
| All cases | When needed | Not at all | p valuea | aOR | 95 %CI | ||
| Facility type Hospital Clinic with beds Clinic without beds |
630 (100) 822 (100) 545 (100) |
239 (37.9) 444 (54.0) 326 (59.8) |
235 (37.3) 225 (27.4) 120 (22.0) |
156 (24.8) 153 (18.6) 99 (18.2) |
<0.001 |
1.00 1.17 1.22 |
0.86–1.60 0.84–1.76 |
| No. of obstetrician-gynecologists | 1994 | 1 (0, 34) | 2 (0, 37) | 2 (0, 56) | <0.001 | 0.99 | 0.96–1.01 |
| No. of deliveries per year | 1888 | 88 (0, 1749) | 239 (0, 3641) | 194 (0, 2892) | <0.001 | 1.00 | 0.99–1.00 |
| No. of abortions during the study period | 1998 | 7 (0, 1481) | 8 (0, 295) | 3 (0, 183) | <0.001 | 1.01 | 1.00–1.02 |
| MEFEEGO Pack use Yes No |
41 (100) 1957 (100) |
26 (63.4) 984 (50.3) |
8 (19.5) 572 (29.2) |
7 (17.1) 401 (20.5) |
0.23 |
0.91 1.00 |
0.39–2.14 |
| Abortion complications Reported Not reported |
81 (100) 1917 (100) |
40 (49.4) 970 (50.6) |
28 (34.6) 552 (28.8) |
13 (16.1) 395 (20.6) |
0.43 |
1.18 1.00 |
0.63–2.20 |
| Interprofessional collaboration Yes No |
513 (100) 1485 (100) |
292 (56.9) 718 (48.4) |
160 (31.2) 420 (28.3) |
61 (11.9) 347 (23.4) |
0.001 |
2.38 1.00 |
1.75–3.23 |
aOR: adjusted odds ratio; 95 %CI: 95 % confidence interval; MEFEEGO: an abortion pill package consisting of mifepristone and misoprostol.
a. Chi-square test or Kruskal Wallis test was used.
b. Logistic regression with forced entry was used.
Table 6.
Factors associated with the provision of contraceptive information in facilities with designated physicians in Japan in 2023.
|
Total no. of responses |
Provision of contraceptive information n (%) or median (min, max) |
Multivariable analysisb |
|||||
|---|---|---|---|---|---|---|---|
| All cases | When needed | Not at all | p valuea | aOR | 95 %CI | ||
| Facility type Hospital Clinic with beds Clinic without beds |
643 (100) 855 (100) 555 (100) |
419 (65.2) 633 (74.0) 443 (79.8) |
174 (27.1) 180 (21.1) 78 (14.1) |
50 (7.8) 42 (4.9) 34 (6.1) |
<0.001 |
1.00 0.87 0.83 |
0.51–1.49 0.45–1.53 |
| No. of obstetrician-gynecologists | 2050 | 1 (0, 37) | 2 (0,30) | 2 (1, 56) | <0.001 | 0.97 | 0.93–1.00 |
| No. of deliveries per year | 1939 | 135 (0, 1767) | 269 (0, 3641) | 167 (0, 2358) | <0.001 | 1.00 | 0.99–1.00 |
| No. of abortions during the study period | 2054 | 6 (0, 1481) | 8 (0, 295) | 1 (0, 80) | <0.001 | 1.04 | 1.02–1.06 |
| MEFEEGO Pack use Yes No |
43 (100) 2011 (100) |
37 (86.1) 1459 (72.6) |
5 (11.6) 427 (21.2) |
1 (2.3) 125 (6.2) |
0.14 |
1.65 1.00 |
0.21–12.77 |
| Abortion complications Reported Not reported |
83 (100) 1971 (100) |
61 (73.5) 1435 (72.8) |
21 (25.3) 411 (20.9) |
1 (1.2) 125 (6.3) |
0.12 |
4.25 1.00 |
0.58–31.24 |
| Interprofessional collaboration Yes No |
528 (100) 1526 (100) |
406 (76.9) 1090 (71.4) |
115 (21.8) 317 (20.8) |
7 (1.3) 119 (7.8) |
0.003 |
6.03 1.00 |
2.77–13.14 |
aOR: adjusted odds ratio; 95 %CI: 95 % confidence interval; MEFEEGO: an abortion pill package consisting of mifepristone and misoprostol.
a. Chi-square test or Kruskal Wallis test was used.
b. Logistic regression with forced entry was used.
4. Discussion
The findings of this study fill an important gap in our understanding of access to medical abortion and peri-abortion care since the introduction of medical abortion in Japan in April 2023.
We found that the MEFEEGO Pack was used in less than 2 % of early abortion cases, which is expected to increase with improved access. Japan first approved oral contraceptives in 1994, the year of the International Conference on Population and Development in Cairo, but medical abortion was not approved until 29 years later. Japan lags behind in securing women's access to modern reproductive health products, and it is not surprising that according to the State of World Population report 2024 (United Nations Population Fund (UNFPA) Division for Communications and Strategic Partnerships, 2024), the proportions of contraceptive use and demand for family planning satisfied with modern methods among women aged 15–49 years in Japan are as low as 41 % and 69 %, respectively, compared with 69 % and 86 % in the United Kingdom, and 67 % and 81 % in the United States.
With respect to peri-abortion care, all women received support to prevent repeat abortions in only half of facilities, mental health support was offered in only one in ten facilities, and counseling information was offered in only one in thirty facilities. Notably, the type of abortion method had no association with the provision of any of the four services. These services should be provided in all cases regardless of the abortion method, but the use of a newly introduced method warrants careful monitoring. The provision of care is particularly important given the social barriers to access to abortion in Japan. There is a double-standard legal framework, in which abortion is included in the Criminal Code but permitted under the Maternal Health Protection Law, requiring spousal consent (Shimoyama, 2023). Accordingly, the analysis of public opinion on medical abortion collected by the MHLW just before its approval showed that 16 % were opposed on the basis of arguments about the life of the fetus and the risk of complications (Goto et al., 2023).
The involvement of midwives and nurses in peri-abortion care in only one in five facilities is concerning, particularly given that our results indicate that interprofessional collaboration facilitates care. Moreover, the proportion of facilities where pharmacists were involved in providing peri-abortion care was very small, even when restricting the analysis to hospitals and clinics with three or more doctors that are mandated to employ a pharmacist. Recent reviews of studies from mostly Western countries have reported that effective collaboration can improve the quality of care, leading to better patient satisfaction, quality of life, treatment adherence, and self-management of disease (Wei et al., 2022). Despite the positive effects, interprofessional collaboration has yet to be implemented effectively in Japan, and the competency framework was proposed only recently (Haruta et al., 2018). Although peri-abortion care services were more likely to be provided at hospitals with a higher number of obstetrician-gynecologists, we believe that given the shortage of these specialists in remote regions of Japan, midwives and nurses could take on the role of providing high-quality peri-abortion care (Ishikawa, 2021). Further studies about care provision in remote regions are necessary. More than two decades have passed since it became clear that mid-level practitioners, including midwives and nurses, can provide early abortion services and that it is cost-effective in high-resource settings (Berer, 2009; Sjöström et al., 2016). However, the authors' communication with practicing midwives and midwifery educators in Japan revealed that they were unaware of the approval of medical abortion and the importance of the role they were expected to play in providing care, not to mention the lack of teaching about medical abortion in nursing and midwifery schools. The Japan Academy of Midwifery (2023) recently translated and posted a Japanese executive summary of the WHO's guidelines on abortion care. There is an urgent need to promote such information provision, as well as to offer appropriate clinical training to midwives and nurses. Given the social stigma attached to abortion in Japan, emotional distress among abortion providers should also be addressed in such training (Shimoyama, 2023).
To assist healthcare providers in shared decision-making with their clients, our group developed a leaflet using illustrations and infographics (Japan Association of Obstetricians and Gynecologists, 2025). This written information can also be used to train healthcare providers. Following the approval of medical abortion in Canada in 2015, a similar leaflet was used to train pharmacists (Bancsi and Grindrod, 2019). In our analysis, only a few facilities reported pharmacist involvement in peri-abortion care. Given the potential for over-the-counter marketing of medical abortion (Kapp et al., 2017), pharmacists should also be included in interprofessional collaboration to improve access to and the quality of medical abortion care in Japan.
The present study has three limitations. First, the response rate was lower than 60 %. The survey was distributed as a post-approval survey, and thus facilities without experience of providing medical abortions may not have responded, resulting in an artificial increase in the proportion of medical abortions presented in our data. Second, the four listed peri-abortion services were not explicitly defined in the survey, and thus the differences between them may have been unclear. Future studies should add the respective definitions. Third, the direction of association for the number of obstetrician-gynecologists with the provision of contraceptive information was negative, contrary to other peri-abortion care services. Although the association was marginal, this might have resulted from the unclear framing of the question.
This is one of the first studies reporting on the immediate uptake of medical abortion and peri-abortion care in Japan since the introduction of medical abortion in 2023. The low number of medical abortions as a proportion of the total number of abortions in the country deserves attention, especially in light of the risks associated with other more frequently used surgical procedures. More interprofessional collaboration, including the involvement of midwives and nurses in the provision of peri-abortion services is desirable to prepare for a possible increase in the use of medication abortion. At the time of the approval of the MEFEEGO Pack, we recommended that “the Japanese government should collect women's opinions early in the decision-making process regarding reproductive health products in order to incorporate women's opinions into health policy-making” (Goto et al., 2023). In addition to some of the medical issues discussed here, complex legal, cultural, and economic issues may also contribute to the low uptake. Examples include stigma and double-standard legal frameworks, as mentioned above. Furthermore, in the case of the Netherlands (Rademakers et al., 2001), women's views on different abortion methods were surveyed shortly after approval, and in the case of Korea (Nguyen et al., 2010), even before approval. Further research on the views of women, midwives, and nurses about the new medical abortion method is warranted to find ways to improve access to safe abortion in the country.
CRediT authorship contribution statement
Aya Goto: Writing – original draft, Methodology, Investigation, Formal analysis, Conceptualization. Veronika J. Wirtz: Writing – review & editing, Methodology, Investigation. Masako Hayashi: Writing – review & editing, Methodology, Investigation, Data curation, Conceptualization. Junichi Hasegawa: Writing – review & editing, Methodology, Investigation, Conceptualization. Kotaro Fukushima: Writing – review & editing, Methodology, Investigation, Conceptualization. Hideo Matsuda: Writing – review & editing, Methodology, Investigation, Conceptualization. Akihito Nakai: Writing – review & editing, Supervision, Methodology, Investigation, Funding acquisition, Conceptualization.
Authorship
AG planned analyses, analyzed data, and drafted the manuscript; VJW interpreted results and contributed to manuscript revision; MH planned the survey and analyzed data; JH, KF, and HM planned the survey and contributed to revision; and AN planned the survey, interpreted results, and supervised the overall project. AG, MH, JH, KF, HM, and AN contributed to an early report. All authors reviewed and approved the final manuscript.
Funding
This research was supported by Health and Labour Sciences Research Grants from the Ministry of Health, Labour and Welfare, Japan (Grant Numbers: 23DB0201 and 24KC2010).
Declaration of competing interest
The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: Akihito Nakai reports financial support was provided by Government of Japan Ministry of Health Labour and Welfare. If there are other authors, they declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.
Acknowledgment
We thank Oliver Stanyon for editing this manuscript.
Footnotes
Supplementary data to this article can be found online at https://doi.org/10.1016/j.pmedr.2025.103041.
Contributor Information
Aya Goto, Email: agoto@hsph.harvard.edu.
Veronika J. Wirtz, Email: vwirtz@bu.edu.
Masako Hayashi, Email: hayashi@nms.ac.jp.
Junichi Hasegawa, Email: dr.hasejun@outlook.com.
Kotaro Fukushima, Email: k-fukushima@fukushima-clinic.jp.
Hideo Matsuda, Email: hideomatsuda@matsuda-pc.jp.
Akihito Nakai, Email: nakai-3@nms.ac.jp.
Appendix A. Supplementary data
Supplementary material: Supplementary Table 1. Peri-abortion care providers in facilities with designated physicians required to employ pharmacists in Japan in 2023
Data availability
The authors do not have permission to share data.
References
- Bancsi A., Grindrod K. Medical abortion: a practice tool for pharmacists. Can. Pharm. J. 2019;152:160–163. doi: 10.1177/1715163519840270. [DOI] [PMC free article] [PubMed] [Google Scholar]
- Berer M. Provision of abortion by mid-level providers: international policy, practice and perspectives. Bull. World Health Organ. 2009;87:58–63. doi: 10.2471/BLT.07.050138. [DOI] [PMC free article] [PubMed] [Google Scholar]
- Goto A., Reich M.R., Aitken I. Oral contraceptives and women’s health in Japan. Jama. 1999;282:2173–2177. doi: 10.1001/jama.282.22.2173. [DOI] [PubMed] [Google Scholar]
- Goto A., Satoh K., Reich M.R. Two pills and women’s health in Japan. Lancet Reg Health West Pac. 2023;40 doi: 10.1016/j.lanwpc.2023.100946. [DOI] [PMC free article] [PubMed] [Google Scholar]
- Haruta J., Yoshida K., Goto M., Yoshimoto H., Ichikawa S., Mori Y., Yoshimi K., Otsuka M. Development of an interprofessional competency framework for collaborative practice in Japan. J. Interprof. Care. 2018;32(4):436–443. doi: 10.1080/13561820.2018.1426559. [DOI] [PubMed] [Google Scholar]
- Hirota Y. Training note no. 99: All About Abortion. Japan Association of Obstetricians and Gynecologists. 2018. https://www.jaog.or.jp/notes/note8514/
- Huber D., Curtis C., Irani L., Pappa S., Arrington L. Postabortion care: 20 years of strong evidence on emergency treatment, family planning, and other programming components. Glob Health Sci Pract. 2016;4:481–494. doi: 10.9745/GHSP-D-16-00052. [DOI] [PMC free article] [PubMed] [Google Scholar]
- Ishikawa M. Distribution and retention trends of obstetricians and gynecologists in Japan: a longitudinal study. JMA J. 2021;4:262–269. doi: 10.31662/jmaj.2020-0125. [DOI] [PMC free article] [PubMed] [Google Scholar]
- Japan Academy of Midwifery The translation of WHO's abortion care guidelines executive summary. 2023. https://www.jyosan.jp/modules/topics/index.php?content_id=95
- Japan Association of Obstetricians and Gynecologists, no date. If you are thinking of having an abortion. 2025. https://www.jaog.or.jp/wp/wp-content/uploads/2024/04/a4ff861e99c793f4029032dc2111587e.pdf (accessed 24 August 2024). [In Japanese]
- Japan Society of Obstetrics and Gynecology Guidelines for the use of low-dose oral contraceptives (Revised edition) 2005. http://www.jsognh.jp/common/files/society/guide_line.pdf (accessed 23 September 2024). [In Japanese]
- Kapp N., Grossman D., Jackson E., Castleman L., Brahmi D. A research agenda for moving early medical pregnancy termination over the counter. BJOG. 2017;124:1646–1652. doi: 10.1111/1471-0528.14646. [DOI] [PMC free article] [PubMed] [Google Scholar]
- Ministry of Health, Labour and Welfare Minutes of the Pharmaceutical Affairs Subcommittee of the Pharmaceutical Affairs and Food Sanitation Council, April 21, 2023. 2023. https://www.mhlw.go.jp/stf/newpage_34977.html (accessed 23 September 2024). [In Japanese]
- Nakamura E., Kobayashi K., Sekizawa A., Kobayashi H., Takai Y., Medical Safety and Education Committee of the Japan Association of Obstetricians and Gynecologists Survey on spontaneous miscarriage and induced abortion surgery safety at less than 12 weeks of gestation in Japan. J. Obstet. Gynaecol. Res. 2021;47:4158–4163. doi: 10.1111/jog.15014. [DOI] [PubMed] [Google Scholar]
- Nguyen T.T., Jang M.C., Choe Y.S., Ko W.S., Pyo H.S., Kim O.S. Feasibility, efficacy, safety, and acceptability of mifepristone-misoprostol for medical abortion in the Democratic People’s Republic of Korea. Int. J. Gynaecol. Obstet. 2010;109(3):209–212. doi: 10.1016/j.ijgo.2010.01.012. [DOI] [PubMed] [Google Scholar]
- Rademakers J., Koster E., Jansen-van Hees A.C., Willems F. Medical abortion as an alternative to vacuum aspiration: first experiences with the “abortion pill” in the Netherlands. Eur. J. Contracept. Reprod. Health Care. 2001;6:185–191. [PubMed] [Google Scholar]
- Rinehart W., Rudy S., Drennan M. GATHER guide to counseling. Popul. Rep. J. 1998;48:1–31. [PubMed] [Google Scholar]
- Shimoyama H. Abortion as a sexual and reproductive health/rights issue and the possibility of expanding abortion care specialties in Japan. Niigata Journal of Health and Welfare. 2023;2023-2024(23):2–7. [Google Scholar]
- Sjöström S., Kopp Kallner H., Simeonova E., Madestam A., Gemzell-Danielsson K. Medical abortion provided by nurse-midwives or physicians in a high resource setting: a cost-effectiveness analysis. PloS One. 2016;11(6) doi: 10.1371/journal.pone.0158645. [DOI] [PMC free article] [PubMed] [Google Scholar]
- United Nations Population Fund (UNFPA) Division for Communications and Strategic Partnerships . UNFPA; New York: 2024. State of World Population Report 2024. [Google Scholar]
- Wei H., Horns P., Sears S.F., Huang K., Smith C.M., Wei T.L. A systematic meta-review of systematic reviews about interprofessional collaboration: facilitators, barriers, and outcomes. J. Interprof. Care. 2022;36(5):735–749. doi: 10.1080/13561820.2021.1973975. [DOI] [PubMed] [Google Scholar]
- World Health Organization (WHO) Abortion Care Guideline. 2022. https://www.who.int/publications/i/item/9789240039483 accessed 23 August 2024. [PubMed]
Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
Supplementary material: Supplementary Table 1. Peri-abortion care providers in facilities with designated physicians required to employ pharmacists in Japan in 2023
Data Availability Statement
The authors do not have permission to share data.