Sexual & Reproductive Healthcare 6 (2015) 255–256
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Sexual & Reproductive Healthcare
journal homepage: www.srhcjournal.org
Short communication Clinical experience and perception of abortion: A cross-sectional survey of gynecologists in Japan Maki Mizuno *
Division of Health Science, Kanazawa University, 5-11-80 Kodatuno, Kanazawa 920-0942, Japan
ARTICLE INFO ABSTRACT
Article history: This study describes aspects of early induced abortion from the experience and perspectives of a sample Received 17 December 2014 of gynecologists in Japan. The survey questionnaire data were collected from 343 gynecologists from Sep- Revised 8 April 2015 tember to October 2010. Approximately 83% of participants preferred using only dilation and curettage Accepted 23 April 2015 (D&C), and 10.4% used electric vacuum aspiration (EVA). The cost of surgical abortion was not covered by insurance. Most gynecologists used intravenous pain management during abortion. Approximately Keywords: 50% of the gynecologists were opposed to introducing medical abortion in Japan. Abortion © 2015 Elsevier B.V. All rights reserved. Mifepristone Gynecologist Dilation and evacuation Dilation and curettage Pain management
Introduction The aims of this survey were to describe Japanese gynecologists’ clinical experience and perceptions of medical abortion in order to The number of abortions performed in Japan has decreased over provide safe and high quality early abortion services for women and each of the past 10 years. However, the number of abortions re- couples seeking abortions. ported by gynecologists only among women aged less than 20 years increased from 20,357 (6.9 per 1000 women) in 2010 to 20,659 (7.1 Methods per 1000 women) in 2012 [1]. In addition, cases of repeat abortion (at least 1 abortion per- This study was a cross-sectional survey of certified physicians formed previously) increased among all abortion cases from 25.4% designated by the local medical association. Eligible participants were in 2008 to 36.3% in 2011 [2]. Unless the procedure is being carried identified from August 2010 to September 2010 using informa- out specifically for health reasons, national insurance does not cover tion obtained from professional associations. The questionnaires were the cost of abortion. then distributed by 932 hospital managers to gynecologists at that In Japan, the Maternal Protection Law allows women to request hospital. The completed questionnaires were returned by the re- termination of pregnancy or abortion until up to 21 weeks of ges- sponding gynecologists to the researchers by mail. tation for reasons that are considered justifiable, such as rape, The questionnaire asked participants about their demographic physical health, or socioeconomic hardship [3]; 98% of women who data and details regarding their practice in the hospital. Partici- undergo abortions do so for physical health or economic reasons pants were also asked about medical abortion, pain management [4], and more than 97% of abortions are performed before 12 weeks and whether they used ultrasonography during abortion procedures. of gestation [5]. Under the law, an abortion may be performed only Descriptive statistical analyses using statistical software SPSS in a medical facility and by a physician designated by the local version 20 were performed based on providers’ responses to spe- medical association [3]. The World Health Organization (WHO) rec- cific questions. Chi-square tests and t-tests were conducted to ommends using drugs, such as mifepristone, for abortion, and examine differences in duration of abortion experience and pre- medical abortion is a popular method worldwide [6]. However, the ferred early abortion method. P values ≤ 0.05 were considered Japanese government bans the use of mifepristone; thus, surgical statistically significant. methods are commonly used for first trimester abortions in Japan. Result
The response rate for the questionnaire survey was 36.8% * Division of Health Science, Kanazawa University, 5-11-80 Kodatuno, Kanazawa, = 920-0942, Japan. Tel: +81 76 265 2556. (n 343), and 86.9% of participants were male gynecologists. Ap- E-mail address: [email protected]. proximately 50% of participants had over 30 years of work experience http://dx.doi.org/10.1016/j.srhc.2015.04.005 1877-5756/© 2015 Elsevier B.V. All rights reserved. 256 M. Mizuno/Sexual & Reproductive Healthcare 6 (2015) 255–256
Table 1 Gynecologists’ duration of experience with abortion.
Topics Work experience in abortion care
Total 10–19 years (%) 20–29 years (%) >30 years (%) n = 307 n = 30 n = 115 n = 162
Type of first trimester abortion services D&C 256 (83.4) 26 (86.7) 98 (85.2) 132 (81.5) EVA 32 (10.4) 3 (10.0) 11 (9.6) 18 (11.1) No answer 19 (6.2) 1 (3.3) 6 (5.2) 12 (7.4) US during abortion procedure Intraoperative US routinely during first trimester abortion 38 (12.4) 5 (16.7) 20 (17.4) 13 (8.0) US for difficult cases 117 (38.0) 17 (56.6) 49 (42.6) 51 (31.5) Occasional US due to being understaffed or an environmental problem 80 (26.1) 5 (16.7) 30 (26.1) 45 (27.8) No US 72 (23.5) 3 (10.0) 16 (13.9) 53 (32.7) Pain management IV pain management 277 (90.3) – – – Local anesthesia 10 (3.2) – – – Other 20 (6.5) – – –
D&C, dilation and curettage; D&E, dilation and evacuation; US, ultrasonography. in early abortion services. A total of 85% of participants worked in that D&C is less safe than vacuum aspiration and considerably more a private clinic, and 5.2% worked in a general hospital maternity unit. painful for women. The rates of major complications of D&C are 2–3 Regarding the number of early abortions performed over 1 month, times higher than those of vacuum aspiration [6]. Therefore, vacuum 43.1% (n = 148) of respondents performed ≤5, 32.9% (n = 113) per- aspiration and medical abortion should replace D&C. Few gyne- formed 6–10, and 15.2% (n = 52) performed 11–20. cologists routinely used intraoperative during first trimester The cost of a termination was dependent on the stage of preg- abortions. Regardless of the surgeon’s skills and experience, however, nancy. The costs of first trimester abortions (gestational age < 12 ultrasonography can help to assess complete evacuation. The cost weeks) ranged from USD 600 to 1700 (mean, USD 1012). Pregnan- of surgical abortion is not covered by insurance, and hospitals make cy terminations were not covered by insurance, and the cost of individual determinations of the fees for services, resulting in a wide services varied among hospitals. Eighty-three point four percent price range. (n = 256) of participants preferred using only the D&C method, 10.4% In most European countries, abortion is covered by social secu- (n = 32) preferred using only the Electronic vacuum aspiration (EVA) rity either for all women or at least for women with low salary [7]. method; these differences were not statistically significant between The most common reason that Japanese women seek abortion is those with >30 years and those with <30 years of abortion expe- financial hardship, yet the lack of insurance coverage and high hos- rience. A total of 38.0% of respondents (n = 117) used ultrasonography pital costs place abortion services out of their reach. Recently, there during the procedure for only high-risk cases, and 26.1% (n = 80) used have been issues of illegal personal import of mifepristone in Japan. ultrasonography because of being understaffed or because of an en- There are certain health and financial problems related to illegal per- vironmental problem. A total of 12.4% (n = 38) respondents used sonal import of mifepristone [8]. ultrasonography during all abortions, and 23.5% (n = 72) never used Thus, providing medical abortion and care guidelines is an im- ultrasonography during the procedure. The majority of gynecolo- portant first step toward the development of more comprehensive gists (n = 277; 90.3%) administered intravenous pain management abortion services. To improve the accessibility and availability of safe during abortions, and there was no statistically significant differ- and high quality abortion services, D&C and EVA should be re- ence in use of pain management between those with >30 years and placed by medical abortion, and this should be covered by medical those with <30 years of abortion experience (Table 1). About half insurance. Abortion is considered to be a sensitive topic among the of respondents (n = 166; 48.4%) knew about medical abortion, but Japanese; therefore, the low participation rate may have led to over- half of gynecologists (n = 163; 47.5%) disagreed that medical abor- estimation of respondents’ experiences and perceptions among the tion should be introduced in Japan. A total of 36.5% of respondents gynecologists surveyed. (n = 125) thought medical abortion entailed more risks than sur- gical abortion, and nearly half (n = 163; 47.5%) thought there was References a higher possibility of incomplete termination with medical abor- tion compared with surgical abortion. [1] Ministry of Health, Labour and Welfare. Reports for public health administration 2012: maternal protection. Official Statistics Japan. p. 9–10. 2012. Discussion [2] National Institution of Population and Social Security Research. The Fourteenth Japanese National Fertility Survey in 2010; attitudes toward marriage and family among Japanese singles. Annual Population and Social Security Surveys. Medical abortion is the preferred method for abortion in most 2011. developed countries, while in Japan, surgical abortion is the primary [3] Ministry of Internal Affairs and Communications. Maternal protection law. Act method. In 2012, the WHO released guidelines for “safe abor- no 156, Japan. 1948. < tions” that recommended either medical abortion or vacuum [4] Official Statistics Japan. Reports for maternal protection law. http://www.e -stat.go.jp/SG1/estat/List.do?lid=000001047118#TOP>; 2000. aspiration abortion [6]. However, medical abortion is rare in Japan; [5] Sato R, Iwasawa M. Contraceptive use and induced abortion in Japan: how is it in this study, half of the gynecologists were not aware of drug- so unique among the developed countries? Jpn J Popul 2006;4:33–54. used early abortion. Because there are no widely accepted guidelines [6] World Health Organization. Safe abortion: technical and policy guidance for health systems. 2nd ed. Geneva: World Health Organization; 2012. p. 2–4. for medical abortion in Japan, it is difficult to obtain accurate in- [7] Abortion Legislation in Europe. International Planned Parenthood Federation, formation about its use. Japanese medical care is highly advanced updated January 2012.