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Djerassi on birth control in Japan - abortion 'yes,' pill 'no'
STANFORD -- The number of abortions performed each year in Japan is grossly under-reported, a factor that contributes to continued resistance to the legalization of oral contraception, a team of Stanford researchers report in the Feb. 15 issue of the journal Nature.
In the article, "Why Japan Must Legalize the Pill," chemistry Professor Carl Djerassi and James Raphael and Hiromi Maruyama of the Asia/Pacific Research Center estimate the actual number of abortions in Japan at two to three times the "official" number of about 410,000 a year.
Djerassi, inventor of the modern oral contraceptive, and his colleagues said legalization of the "normal," or low-dose, oral contraceptives in Japan would modernize birth control there "by 50 years," and significantly lower the number of abortions.
The authors said their estimates on actual numbers of abortions in Japan are the most reliable ever assembled. They were made under several different assumptions of contraceptive use and coital frequency, and included all available data on women in the 15-44 age group. (The most common forms of birth control in Japan are condoms and the "rhythm" method, Djerassi said.)
"It is clear that even widely varying parameters do not change the overall conclusion that official figures understate the abortion rate" by as much as 300 percent, the researchers wrote.
Japan is the only industrialized country except for Ireland where oral contraceptives are illegal, the authors noted.
"Yet, Japan was the first industrialized nation after the Second World War where abortion (through the private sector) became the principal method of officially sanctioned birth control," they wrote.
The Japanese Ministry of Health and Welfare, or Koseisho, is currently considering legalizing oral contraceptives, although previous attempts have failed and there is continued resistance to such a move in Japan for a number of reasons.
Contrary to media and industry expectations that the government would legalize the pill by early 1992, "approval was withheld on the grounds that it might lead to reduced condom use at a time when AIDS prevention was considered the highest priority."
But, the Stanford authors said, this resistance to legalize oral contraceptives could be attributed to other "more complicated reasons that had existed long before Koseisho became belatedly concerned with AIDS in 1991."
These include lingering government concern about the potential loosening of sexual mores; concern over Japan's low birth rate; opposition to the pill by condom manufacturers and by private physician abortion-providers who fear a large loss of income; and the lack of pressure from Japanese women for legalization of oral contraceptives.
On the lack of pressure from Japanese women for a legal pill, the authors attribute it "in part because of their ignorance of the greatly reduced risks and non-contraceptive benefits of low-dose oral contraceptives."
On the birth rate, the authors say using this argument "as a basis for continuing a ban of one of the most widely used methods of contraception is both illogical and unacceptable," since "economic and socio-cultural factors control the birth rate of a modern population; the quality or use of contraceptive methods is a secondary effect."
"If we accept that legalization of the pill . . . would have no effect on the low birth rate in Japan and that sexual mores among the younger Japanese population have been changing without the pill . . . two of the three cited objections to approval of the pill have little merit," the authors wrote. "The third - loss of income to abortion providers - clearly should not drive Koseisho policy."
Abortion and contraception are "about the only things not covered" by Japan's national health care system, Djerassi said, and the private abortion industry is currently worth at least $400 million (U.S.) annually.
"The cost per abortion is about three times what it is in the United States," Djerassi said. "It's an enormous source of income for Japanese physicians, and they have a major incentive not to report abortions" for tax reasons, he said. In addition, some women may be hesitant to report they had abortions, adding to the low numbers.
Raphael, who is director of research at the Asia/Pacific Research Center, said the team found that many women, in an attempt to keep the abortions private, pay in cash, which makes it even more tempting for the physician to not report the procedure.
"The time has arrived for the Japanese government and media to acknowledge the persistent high rate of abortion in Japan, and to consider its reduction a high priority on medical and social grounds," the researchers wrote. Legalizing the pill, they estimated, could reduce the number of abortions performed each year by at least 300,000, that figure reached using "conservative" sets of data.
Legalization should be augmented by an extensive public education campaign, the authors wrote, given the low level of sex education in Japanese schools and the "very long history of unfavorable publicity in Japan about the pill's negative side-effects," which is due in part to the fact that most Japanese women's knowledge of the pill is based on problems associated with a high-dose version that is legally prescribed to treat menstrual difficulties.
"When the pill is eventually legalized, it should be packaged with a detailed insert (listing risks and benefits as well as instructions on use) of the type required by the U.S. Food and Drug Administration," the researchers concluded. "A sensitively written insert accommodating Japanese cultural practices and up-to-date medical facts would offer an educational bonus far beyond that of ensuring proper contraceptive use. If the leitmotif of government policy became 'The Pill Yes! Abortion No!,' birth control in Japan would be modernized by 50 years."
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