TOKYO -- Hiroshi Hihara is a harried gynecologist with a small clinic wedged between the bars and neon signs of Shinjuku, the neighborhood that four generations of doctors in his family saw transformed from rice paddies to skyscrapers. Hihara's great-grandfather practiced Chinese herbal medicine in Shinjuku at the end of the 19th century, and his grandfather and father were both obstetricians who delivered babies in the family clinic before and after the Second World War.
Today, Tokyo women are too affluent and sophisticated to have their babies in such small clinics, much preferring the big city hospitals. Hihara, in a sign of the times, does not even deliver babies. Instead, he makes his living on his infertility work and abortions, many of them for married women whose method of contraception, typically condoms and rhythm, has failed.
Although Hihara, 42, is a member of a Buddhist temple, he considers himself, like most Japanese, not at all religious. But he says he is not comfortable with abortion. "Abortion is legal and approved by the government, and if a patient wants it, I can't turn her down," he says. "She's entitled to it. But I am not happy to do it." And yet, he performs some 200 abortions a year, and quietly admits, when asked, that his fees from abortion represent "a large portion of my income."
Caught in this moral and economic trap, he resolves his feelings in a uniquely Japanese way. First, he tells each abortion patient to make an offering after the operation at any of the Buddhist temples selling miniature stone statues, or mizuko-jizo, which women can buy in memory of an aborted fetus.
Thousands of such statues stand on display at temples these days, and although some are for miscarriages and stillborn children, the vast majority are for abortions. Many of the statues are decorated with crocheted hats, plastic bibs and little pinwheels, all put there by women to keep the soul of the aborted fetus warm and amused. At Hase Temple in the seaside town of Kamakura, 3,000 mizuko-jizo are nestled in the hillside. At Zojo-ji Temple in Tokyo, women sometimes bring the mizuko-jizo little stuffed animals, baby bottles of apple juice or pacifiers.
Once a month, Hihara says, he himself also visits a temple, although not the one where he is a member, and makes an offering for the mizuko-jizo. He gives about $100 to the Buddhist priest to chant a prayer over one of the statues. "Perhaps you will think I am a hypocrite," he says. "But I think it's a good thing for me to go. I am the person who performed the abortions."
Japan may be the richest, most technologically advanced nation in the world, but it depends on an antiquated system of birth control that forces women to rely heavily on abortion in a society that at the same time disapproves of it. At its core, the story of abortion and birth control in Japan is also about the low status and passivity of Japanese women, and about a male medical establishment marked by caution, tradition and -- critics claim -- greed.
Japan's abortion rate, though declining, is still believed by many health officials to be one of the highest among industrialized non-communist nations. One reason is the lack of alternatives. The government bans the use of the birth control pill as a contraceptive, and doctors do not encourage sterilization, IUDs or diaphragms. Nearly 75 percent of Japanese continue to use condoms and rhythm despite their high failure rate. The Japanese, in fact, use condoms more than any other people in the world. They are widely available in drugstores, supermarkets and vending machines; embarrassed housewives can buy them from door-to-door saleswomen. Abortion is the widely used backup for failed contraception. And yet, while abortions have been legal and easily accessible in Japan for more than 40 years, women who have them feel stigmatized because abortion is regarded by many Japanese, even those who accept it, as "killing a baby."
These contradictions have become more apparent in recent months. In July, the Ministry of Health and Welfare began a review process that will most likely lead, in one or two years, to approval of the newer and safer "low-dose" estrogen pill that has been on the market in the United States since the mid-1970s and is taken by 60 million women worldwide. (A higher-dose pill is available in Japan for regulating menstrual cycles and treating other disorders.) But supporters of the pill are nervous about a recent government report showing that Japan's birthrate is at an all-time low. The report prompted some male ruling party politicians, fearful that there will not be enough young Japanese taxpayers to support social services in the future, to call upon women to bear more children.
"Japan is the only country that legalized abortion and approved family planning, but does not use the pill," says Takashi Wagatsuma, a leading obstetrician, who for two decades has lobbied for approval of the pill. "Japan is a unique country. It is almost a crazy country."
The government justifies its ban by citing the danger of side effects, but some Japanese doctors charge that the government is actually trying to protect politically influential private practitioners who depend on abortion fees. Others say the Health Ministry fears that the pill will encourage promiscuity, importing to a chaste island nation the degradation of the American sexual revolution. (In fact, surveys show that premarital sex is the norm in Japan.) Ministry bureaucrats are also known to be concerned about lawsuits, which have proliferated in recent years over the side effects of government-approved drugs.
Japanese feminists, who might have been expected to support the pill as another contraceptive choice for women, are also worried about the health hazards of what one called "an invasion of artificial hormones." They have instead focused their energies on lobbying the government for more abortion rights.
Japan's actual abortion statistics are debatable. The government reports that 498,000 abortions were performed in 1987, or 18.6 for every 1,000 women of childbearing age -- similar to the rate of most Western European nations and well below the rate of 27 per 1,000 in the United States. But the widespread belief in the Japanese medical community is that the government figure is too low because many doctors underreport abortions to avoid paying taxes on the fees. A first-trimester abortion in Tokyo costs about $800.
Ten years ago, Minoru Muramatsu, a public health specialist, calculated that Japan's abortion rate was three times the government figure, comparable to rates in Eastern Europe. Other doctors question these calculations, and Muramatsu himself, now retired, admits his numbers may be high. But even more conservative experts calculate the abortion rate at 1 1/2 to two times the government figure.
Takayo's Story Takayo has had three abortions. "I am not ashamed of them," she says. "But they are something to keep private, in my heart." At her request, only her first name has been used for this article.
Her story, like so many others in Japan, is that of a woman who left the birth control decisions to her husband, and who knew only the condom as a form of contraception. For Takayo, abortion was legal and common, the reason she says she does not feel ashamed. But society also told her it was killing a baby. She says she is not a religious person, but today she is filled with guilt and regrets. "I should have had those children," she says. "Now I want to bring them back. When I was young, I thought only of myself."
Married women like Takayo account for the great majority of abortions in Japan. Teenage abortions are increasing, but their number remains small.
Takayo is 42, the mother of a 17-year-old daughter and the wife of a businessman who owns a company that makes women's clothes. He has been successful, so the family lives in a house, not the usual apartment, in Akabane, a suburb of Tokyo. Takayo has a high school education and is a patient of Kiyoshi Omura, a well-known obstetrician and gynecologist in Akabane, who called her and asked if she would talk about her abortions. She reluctantly agreed, but said she preferred to tell her story over the phone.
Takayo first met her husband in the late 1960s when she was a clerk at a cosmetics firm and he was a leader of the company's labor union. Soon they were living together. He quit his job, determined to become a songwriter; they decided to delay marriage until they were more secure financially. But within a year she was pregnant. "Except for the very safe days, he always used a condom," she says.
The pregnancy was a dilemma for her. Although she wanted to have the baby, she and her husband had no money and decided they couldn't possibly afford to raise a child. "I really suffered, worrying about whether to have the abortion," she says. By the time she made her decision, she was at the end of her first trimester. Or as she puts it: "The baby was three months old."
Takayo, like most Japanese, draws little distinction between a fetus and an infant. According to Samuel Coleman, the author of "Family Planning in Japanese Society," a 1968 survey of 1,500 Japanese women found that two-thirds believed the fetus is a human life at conception. Even Japanese feminists who have lobbied for more abortion rights sometimes refer to "killing the baby."
Coleman finds that the reasons lie at least partially in Shinto and Buddhism, Japan's two major religions. Although neither religion promotes active opposition to abortion, Buddhism is based on the ideal of overcoming one's sense of ego. In this context, a woman who aborts wrongly puts her own ego before her fetus. Shinto, an ancient religion based on ancestor and nature worship, holds that an aborted fetus can place a curse on the woman who aborts. One marginal religious sect in Japan, the Seicho no Ie, which draws on Christian, Buddhist and Shinto beliefs, does actively oppose abortion, but it does not have as much influence as American antiabortion groups.
Abortion was legalized after World War II, when the devastated country could barely support the people who survived. The prospect of more Japanese children to feed -- as well as mixed children fathered by the American occupation troops -- inspired the 1948 Eugenic Protection Law.
Takayo was pregnant again almost immediately after her first abortion. "I was very upset," she says, beginning to cry into the phone. "Even more upset than the first time. When my husband started the songwriting business, we only had money for food. We had no extra money. My husband's parents used to send us rice. We didn't know what to do. But my husband didn't feel that he could raise children because of our finances."
She had a second abortion, then became pregnant again. This time she miscarried. In 1971, she and her husband married, and two years later she was pregnant for the fourth time. By then, her husband had quit the music business and took a job in the company he now owns, and they decided they could finally afford a family. "I was very tired of abortions," she says. The baby, now her 17-year-old daughter, was born in 1973; two years later, she was pregnant for the fifth time. But after a bout with German measles during her pregnancy, her doctor warned of severe damage to the fetus and recommended abortion.
"Now I regret all the abortions," she says. "To look at my own daughter -- now I really feel sad to lose those children. If I had known a better way of birth control, maybe I could have avoided that kind of tragedy. I regret I didn't have that kind of information when I was young." She never questioned her husband's use of the condom. "I never saw it as either a good or a bad thing," she says. "I didn't know about anything else."
Although the condom is popular again because of the "safe sex" era in the United States, it has a contraceptive failure rate, in actual use, of 15 percent. Doctors in Japan tell their women patients that the condom is effective only if it is used at all times of the month, and from the beginning to the end of intercourse. But doctors say that Japanese couples do not often use condoms during a woman's so-called "safe" period. This combination condom-rhythm method of birth control is said to have a failure rate of 30 percent. Both feminists and doctors say that the condom would be used more effectively if Japanese women were not afraid to speak up and take the initiative on birth control during sex.
"In actual intercourse, women feel they can't tell their partners to use condoms," says Megumi Tanaka, the editor of More, a popular women's magazine and the publisher of the More Report, a respected survey of Japanese sexual attitudes. "Men do whatever they want to do. And also, men say, 'It's okay, I can put it on in the middle.' "
Kiyoshi Omura, Takayo's doctor, feels equally exasperated. "I don't know about America, but in Japan I think that women rely on men too much," he says. "In my experience, 99 out of 100 women will say that they have to ask their husband's permission before using the pill or an IUD. But I tell them, 'It's the woman's responsibility to think about it. This isn't determined by your husband.' "
Takayo has only recently heard of oral contraceptives, through an article in a women's magazine. "I understand that the pill is the easiest way," she says. And yet, if the pill were made available in Japan, Takayo says she most likely would not take it. "I've never heard anything about the pill from my friends in the neighborhood, and besides" -- she begins to laugh a little -- "my husband and I don't make love as often as we used to. He is very busy with his own work, and I don't have the energy anymore. So the pill isn't really necessary."
At the end of the conversation, she agrees to meet in person. A week later, she is serving tea at her dining room table, in front of large glass doors that open onto a small garden of vegetables and chrysanthemums. Dressed casually in a cotton sweater and a long print skirt with her hair pulled back neatly in a navy blue ribbon, Takayo has the look of a well-to-do and organized Japanese housewife. Her daughter, who knows nothing of her mother's abortions, is at home, so for an hour there is awkward chitchat about cooking, gardening and children.
But afterward, in the car on the way to the train station, Takayo immediately speaks up. "I thought abortion was easy," she says. "That's why I did it. My husband and I thought because we were poor we had no choice. Why was I so stupid?"
She relieves her guilt in the Japanese way. "Very recently, I felt very sad for what I had done," she says. "So I went to a temple and made an offering to the mizuko-jizo." 'Abortion First, Contraception Second'
Yumiko Jansson is a rare breed of Japanese woman: a feminist. There is only a minor women's movement here, mostly comprising small groups that organize around specific issues, such as sexual harassment.
"I give lectures to both Swedish women and Japanese women," says Jansson, who is married to a Swedish businessman. "Both groups are educated, both are well informed. The only difference I can see is that Swedish women can fight because they are not afraid. But we cannot fight, because we are still afraid. Japanese women are still totally dependent on men. We are raised not to confront. We are raised to be harmonious."
Jansson is 46, the author of several books, the mother of two and the translator into Japanese of Alice Walker. She is also part of a group that promotes reproductive freedom and lobbies the government on health issues.
"The basic attitude of the government is abortion first, contraception second," she says. But she thinks the government's ban of oral contraceptives "has been a wise decision" because of the potential side effects of the pill's synthetic hormones. Like other feminists, she takes a laissez-faire position on the pill: She and her group will not oppose the pill if it is permitted in Japan, but neither will she push for its approval.
Other women take the same attitude, although the scientific basis for their fears is questionable. Tazuko Makitsubo is the director of an unusually frank sex education film for high school students. Yet it features a teacher who tells his classroom that birth control pills "are not designed for youth, because of your hormone imbalances." Asked about the teacher's statement, Amy Pollack, a physician and the associate medical director for the Planned Parenthood Federation of America, says she is "unaware of a scientific basis" for his comment. "I would say just the opposite," she adds. "The pill is an excellent form of contraceptive, particularly for teenagers, because it creates a regular hormonal state which leads to regular menstrual cycles."
Makitsubo's sex education film has been approved by the Ministry of Health and Welfare, but she asserts that she did not feel any government pressure to include the teacher's warning about the pill. "The government says the pill has side effects," she adds. "I say, and other doctors say, that introducing the pill for young girls is not good."
Those Japanese doctors in favor of the pill frequently complain that the Japanese press sensationalizes news of studies about the pill's side effects.
"Whenever I ask a woman why she would not want to use the pill, she will say, 'The pill has bad side effects,' " says Kiyoshi Omura, Takayo's doctor. "And then I will ask her, 'What kind of side effects?' But she won't know. She just has the idea that the pill is a bad thing."
Doctors say the pill's minor side effects include possible headaches, weight gain or loss, spotting and amenorrhea, the failure to menstruate. Major studies do not show any definite cause and effect between the pill and breast cancer, but more research is underway. The pill is currently used by 32 percent of American women in their childbearing years, and is the second most popular form of birth control in the United States. Sterilization of men and women, used by 38 percent of couples, is the most popular method. Condoms are used by 16 percent of U.S. couples. About 4 percent of American women use diaphragms and 3 percent use IUDs.
'It Depends on the Ladies' If the pill is approved in Japan, and the consensus among doctors is that it most likely will be, will Japanese women use it? In June, a survey released by one of Japan's largest newspapers showed that fewer than 10 percent of Japanese women said they would use the pill if it were made available. Doctors say that at the least, oral contraceptives will take a long time to catch on.
"It's the $64,000 question," admits Douglas Ross, the president of Nippon Syntex KK, the Japanese subsidiary of a major American oral contraceptive maker that has applied with its Japanese distributor for permission to market the pill in Japan. "We've obviously got lots of estimates, but it depends on the ladies here. We don't know if the women are going to take this on and say, 'I want to control this.' I guess we're back where we were in other countries 15 years ago."