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Abortion laws in Asia reflect demographic trends, the sway of religion and social traditions. In South Korea (pictured), abortion was illegal until 2019, when it was decriminalized despite opposition from the Christian community.   © AFP/Jiji
The Big Story

Abortion in Asia: The limits of choice

The overturning of Roe v. Wade could be a watershed for U.S. women's rights. Is the same true in Asia?

ISMI DAMAYANTI, KIRAN SHARMA and ARISA KAMEI, Nikkei staff writers | East Asia

"Keeping it was never an option," says Rara, a woman in her 20s from Jakarta, Indonesia.

It was 2017 and Rara (not her real name) was studying communication at a private university in the capital. After falling pregnant by her unmarried partner, who had another girlfriend at the time, she felt she could not disappoint her devout Muslim parents.

Rara's circumstances led her to a small and unassuming clinic in Raden Saleh, a district in Jakarta well-known for providing illegal abortions. Outside the clinic, peddlers were scouting for customers, asking female passersby, "Are you late?" -- a coded offer of pregnancy termination services.

Speaking to Nikkei Asia over the phone, Rara's voice shook as she recounted her experience. She recalled feeling nervous, and the lack of any apparent compassion in the doctor and nurse who tended to her. She was conscious throughout the procedure. "It was traumatic," she said, in tears.

Following her abortion, Rara suffered throbbing pain every month when she had her period -- pain she put up with for a year before plucking up the courage to visit a doctor. Abortion is illegal in Indonesia except in cases of rape or when the mother's life is in danger. Women found guilty of undergoing illegal abortions can be subject to up to 10 years in prison.

Rara confessed that her view on abortion remains complicated, despite having experienced one herself. Before the procedure, she said, "I could never imagine killing a living being, including a fetus. But when I remember that it happened to me, regardless of whether my fetus was alive or not, I think that women in situations like mine must be well accommodated" with safe and legal abortions.

Abortion is legal in Indonesia only in cases of rape or when the mother's life is at risk. The country is majority Muslim, and Islamic law forbids the abortion of a fetus older than 40 days except in emergencies. (File photo by Reuters) 

Rara is one of around 36 million women who have abortions in Asia each year, according to data released in 2017 by the Guttmacher Institute, a U.S.-based sexual and reproductive health and rights research organization. The same data shows that 6% of maternal deaths in the region in 2014 were caused by unsafe abortions.

Across the continent, the right to an abortion remains a contentious issue, located at a complicated intersection of religion, culture, law and politics.

A barometer for women's rights?

An impending decision by the U.S. Supreme Court to overturn the landmark Roe v. Wade case of 1973, which would likely end the right to safe and legal abortions in many states, marks a potential turning point for women's reproductive rights in the West.

In Asia, however, abortion is seldom as black and white as the "pro-life" versus "pro-choice" arguments that dominate Western discourse. Many countries have recently liberalized abortion laws -- from Thailand to South Korea -- while some formerly "liberal" countries, such as China, have begun to examine restricting abortions in response to demographic pressure.

Abortion in Asia presents a contradiction: Thousands of women die every year due to illegal and unsafe abortions, a compelling case for more liberal abortion laws. However, every year in countries where abortion is legalized, such as India and Vietnam, thousands of female fetuses are aborted in the pursuit of a male child.

To grapple with the many gray areas presented by abortion rights, 11 Nikkei Asia journalists in the region interviewed dozens of women, activists, health professionals, politicians and religious leaders. 

Anti-abortion activists rally in front of the U.S. Supreme Court on June 6. A leaked Supreme Court draft opinion revealed in May that Roe v. Wade may soon be overturned, restricting abortion access in many states.   © Getty Images

Their findings reveal that, even in countries where abortion is broadly legal, such as Japan, the issue is too far entrenched in demographics and social norms to be considered a measure of female autonomy.

"[Abortion policies] are not about the advancement of women's rights here," Masako Tanaka, a professor of gender studies at Sophia University in Tokyo, told Nikkei in a recent interview.

Will the Roe v. Wade decision have any impact on abortion rights in Japan, the U.S.'s closest Asian ally? "Probably not," Tanaka said. "Abortion rights are seen as an issue for international politics, far removed from Japan. Here, [abortion] is more about population control."

The same rings true for countries across Asia. From China to Bangladesh, abortion plays a role in limiting, expanding and altering populations.

The population bomb

The first country in Asia to legalize abortion, Japan introduced the procedure as part of the Eugenic Protection Act (now revised as the Maternal Health Act) in 1948. The country's population was booming following soldiers' return from World War II, but a postwar economic downturn threatened food security.

To curb population growth, the Act was updated in 1949 to permit abortion for economic as well as medical reasons, and in cases of rape. It also allowed the voluntary and involuntary sterilization of women with hereditary diseases, mental illnesses and intellectual disabilities. The law required married women seeking an abortion to get written consent from their spouse.

By the early 1960s, annual births in Japan had fallen from an all-time high of 2.7 million in 1949 to around 1.6 million. "It's impossible to say whether the legalization of abortion directly brought about a decline in the birthrate, but state intervention in family planning after the war can certainly be seen as a success," Isabel Fassbender, assistant professor and researcher of gender studies at Doshisha Women's College in Kyoto, told Nikkei.

Japan's births in 2021 plumbed a record low for the sixth year in a row. Abortion rights activists think the shrinking population is fueling the stigmatization of abortion. (Photo by Wataru Ito)

As long as Japan's population was growing, attitudes toward abortion remained relatively lax. In an interview with Nikkei, Yukako Ohashi of the reproductive rights group Soshiren recalled how, in the 1960s, doctors would often knowingly accept fake spouse's signatures from women wanting an abortion. "It's only in the last couple of decades that doctors have got strict about the spousal consent law," Ohashi said.

Activists in Japan maintain that government concerns about an aging population have been fueling the stigmatization of abortion in recent years. Japan's birthrate began declining in the late 1970s, and in 1982, there was an attempt by the government to erase the "economic reasons" condition from the Maternal Health Act to make abortion harder to access. The proposal prompted the founding of Soshiren, which organized mass protests and prevented changes to the law.

While abortion remains legal, high prices -- the procedure can cost as much as $1,500 -- and increasingly strict implementation of dataizai, punishment for illegal abortions, make accessing abortion difficult for many women. Doctors found guilty of aborting a child without written consent from the mother and, if she is married, her husband, can be subject to up to five years in jail -- up to seven years if the woman dies as a result.

The Maternal Health Act states the father's consent is only necessary if the parents are married, and even then it says that the mother's consent alone is sufficient if the father's cannot be obtained. But lack of knowledge of the law leads many doctors to ask for male consent, just in case.

It is not unusual for unmarried women to be turned away by doctors for failing to present the signature of a male partner -- there are even cases of rape victims being asked to provide the signature of their abuser.

Senior citizens chat in Lin Dai Lu Park, Fuyang, China. Falling birthrates and concerns about an aging population are driving more restrictive attitudes toward abortion in China and Japan.    © AP

Campaigners have been calling for the requirement of spousal consent to be erased. But policymakers are making no moves toward reform. When asked about the necessity of the spousal consent rule, Taizan Kamide, deputy director of the Maternal and Child Health Division in Japan's Ministry of Health, Labor and Welfare, told Nikkei that "all we can do is ensure that the Maternal Health Act is correctly applied and followed by everyone."

Fassbender from Doshisha Women's College doubts Japan's abortion laws will be updated so long as the population is declining. Data released by the government on June 3 reveals there were 811,604 births in Japan last year, a drop of 3.5% from the previous year and a record low for the sixth consecutive year.

"On the surface, politicians won't say that policies on abortion and contraception come from a population control perspective," Fassbender told Nikkei. "But in reality, of course, they do."

In China, too, access to abortion is shaped by demographics. The procedure was a legal and widely available measure to curb population growth under the one-child policy, which was introduced in 1980. Parents with unauthorized pregnancies could face serious fines, compulsory sterilization and forced abortion.

The Chinese government estimated that, by 2016, some 400 million births had been prevented by the policy, although some analysts dispute this finding.

But as China's population growth slows, restrictions on abortion could be on the horizon. Abortion remains legal, but the State Council in 2021 laid out guidelines calling for a reduction in "non-medically necessary abortions."

Despite China's population growth reaching its slowest pace since 1960 last year, dropping to 0.034%, abortions have been increasing every year since 2017, according to China's National Health Commission. A report published in the Chinese Journal of Practical Gynecology and Obstetrics in 2021 showed the total number of abortions in China averaged roughly 9.5 million per year for the past five years.

The National Population and Family Planning Commission in February said it plans to reduce teenage and premarital pregnancies to decrease the number of abortions, over concerns of an aging population.

A couple takes pictures with their baby at the Tiananmen Gate in Beijing on Nov. 2, 2015. China's government replaced its one-child policy with a two-child one in 2016, after the population began to age. (File photo by Reuters) 

Although these statements are seen as signals of more restrictions on abortions, activists think legal abortions are here to stay.

"The policy has not changed and will not likely change ... because China believes in eugenics," Lu Pin, a journalist and leading Chinese feminist, told Nikkei. "The Chinese government and individuals both worry about the births of unhealthy infants. Even though the government needs more births, they will not prioritize that over eugenics."

Sex selection

In India, home to more than 17% of the world's population, abortion has also historically played a role in shaping the population. As a perverse result of the legalization of the procedure in 1971, many fetuses identified as female get aborted as couples try for male children. According to India's latest National Family Health Survey (2019-2021), an average of 929 girls were born for every 1,000 boys over the last five years.

Especially in rural areas, traditional gender roles and the belief that a male heir is required for family businesses lead many couples to seek abortions of female fetuses. A girl is often seen as a financial burden who will be married off and sent to another house with a dowry.

For this reason, women's rights campaigners are reluctant to press too hard for more liberal abortion rights. "As social activists, we cannot raise much hue and cry [about abortion rights, because] these rights can be [easily] misused," said Manasi Mishra, head of research and knowledge management at the New Delhi-based Center for Social Research, a nongovernmental organization that works to empower Indian women.

India legalized abortion in 1971 in cases of medical emergencies and sexual assault. The country updated its Medical Termination of Pregnancy Act last year to allow abortions up to the 24th week of pregnancy -- the limit was previously 20 weeks -- in cases of rape, incest and for minors and differently abled mothers. But abortions for the purpose of sex selection are strictly illegal.

India even forbids doctors from telling patients the sex of an unborn child, but many go abroad to find out the sex and then visit illegal clinics for an abortion, if they can afford it. Around eight women a day die in India due to unsafe abortions, according to the Guttmacher Insitute.

"No doctor indulging in the illegal practice of sex determination will give you in writing the gender of the unborn baby, but may tell you verbally," says Shashi, a teacher in New Delhi who works with NGOs to educate girls in the capital's slums.

Newborns at Wadia Hospital in Mumbai on July 11, World Population Day, 2017. India liberalized its abortion laws in 2021 but aborting female fetuses for sex selection purposes remains illegal.   © Getty Images

"Then there are several grounds -- fetal abnormality, failed contraception, etc. -- which can be given as reasons to abort an unwanted baby," leaving little scope for the authorities to find out, adds Shashi, who only shared her first name.

Another country where sex selection is rife is Vietnam, which has the world's third-highest abortion rate. The country averaged 64 abortions per 1,000 women annually from 2015-19, lower only than Georgia and Azerbaijan, according to the Guttmacher Institute.

At a sleek clinic in central Ho Chi Minh City, for example, the walls are bare but for a small sign made by the office printer and directed at the ultrasound technicians: "Do not reveal the gender of the baby."

Similarly to India, in old Viet customs, men inherited land and brought wives home to take care of their parents. Hence male children were traditionally favored in order to continue the line of succession, whereas girls would leave the family to move in with in-laws after marriage.

But male preference is not the only reason for the high abortion rate. The U.S. military's use of the dioxin-laced defoliant Agent Orange during the Vietnam War, and the deformities it continues to cause, also play a role, as do the relatively large population of 99 million and the fact that women's rights are core to the communist ideal of equality.

Among women who terminate pregnancies, some are wary of birth defects if they have been exposed to dioxin, while others fear passing on HIV and other diseases, according to research by anthropologist Tine Gammeltoft.

Abortion has been legal since the 1960s, and was key to the government's two-child policy, which was introduced in 1988 and halved the birth rate from 4.2 to 2.1 children per woman within two decades of being implemented.

The two-child policy was reversed five years ago. Son preference is also waning, and Vietnam now treats reproductive rights as human rights, said Nguyen Thi Thuy Hanh, vice head of the population department at Hanoi Medical University.

"The health and the life of women improve because they can decide for themselves what they want to do in terms of number of children," she told Nikkei.

Moral minority

Restrictions on abortion are especially strong in countries with entrenched religious beliefs, such as in Muslim Bangladesh, the Catholic Philippines, and Buddhist Thailand.

In Bangladesh, abortion remains strictly illegal. But back street abortions are common -- the Association for Prevention of Septic Abortion, Bangladesh (BAPSA) provides post-abortion care to around 90,000 women suffering from complications caused by unsafe abortions every year, according to its director, Dr. Altaf Hossain.

Religion also underpins attitudes toward abortion in the Philippines, which forbids the procedure with some of the strictest laws in the world. The country's penal code punishes a woman who undergoes and anyone who assists an abortion with up to six years of imprisonment.

But anecdotal evidence shows more Filipinos have started to adopt an open mind on decriminalizing abortion, said lawyer Clara Rita Padilla, speaking for Pinsan, the Philippine Safe Abortion Advocacy Network. Around 30,000 people have signed a Change.org petition launched by Pinsan calling for the decriminalization of abortion.

President-elect Ferdinand Marcos Jr. appeared to echo these changing attitudes during his recent election campaign, claiming he supports abortion in limited cases.

Philippine President-elect Ferdinand "Bongbong" Marcos, Jr. has pledged to consider supporting abortion in cases of rape, incest or disability. (Photo by Ken Kobayashi)

"Maybe [there are] cases where we can see that abortion is justified," Marcos said in January when asked about the issue, citing circumstances of rape, incest, and underage mothers.

His stance risks a clash with the Philippines' influential Catholic Church, to which more than 80% of the population belongs.

Father Jerome Secillano, executive secretary of the committee on public affairs of the Catholic Bishops' Conference of the Philippines, told Nikkei that while some people's approach toward abortion may be evolving, the church remains steadfast.

"The church's teaching on abortion does not change and isn't changing," he said. "The church considers [abortion] plain murder no matter the circumstances."

Marcos, who is set to take office on June 30, has admitted that "I cannot argue with theology, all I argue is the statistics," referring to the thousands of women who have been hospitalized or who have died due to botched illegal abortions.

Those who seek to terminate pregnancies in the Philippines often resort to underground clinics where dangerous methods are performed, including heavy abdominal "massage" to expel a fetus, according to the Guttmacher Institute and other reports. Eleven women are hospitalized every hour and three die every day in the Philippines due to unsafe abortions, according to 2012 data cited by Pinsan.

For advocates like lawyer Padilla, these grim statistics are a reason to keep pushing for the decriminalization of abortion. She is also counting on the incoming president. "[H]e made a pronouncement," she said, "and it's up to him to make his pronouncement a reality."

In Thailand, abortion was narrowly legalized in 2021 in a last-minute effort by lawmakers to maintain some penalties on women and abortion providers. Before the amendment, the country’s penal code had subjected women found guilty of abortion with up to three years in prison and abortion providers with up to five years.

Abortions are now legal under any circumstances if performed no more than 12 weeks into a pregnancy. Passing this law was a stopgap measure that came after Thailand’s constitutional court ruled the previous penalties unconstitutional. The amendment was passed by a landslide in the Senate. A proposal by the opposition Move Forward Party to allow abortion up to 24 weeks was rejected by the lower house.

Politicians fear the subject remains taboo for conservative voters in the predominantly Buddhist country. According to religious beliefs, a person would be unable to atone for the bad karma that abortion generates. 

In South Korea, conservative Christians, who make up 30% of the population, and demographic pressures kept abortion illegal until last year. Dubbed "a win for women's rights" by the International Planned Parenthood Federation, South Korea decriminalized abortion in 2019, ruling punishment for women and doctors who have or perform abortions was unconstitutional.

South Korea's Constitutional Court chief justice, Yoo Nam-seok, and other justices sit for the ruling on the decriminalization of abortion in Seoul, South Korea, on April 11, 2019.   © Reuters

The ruling took effect in January 2021, but the National Assembly has yet to decide on regulations, such as up to how many weeks into pregnancy abortion will be allowed.

The decriminalization of abortion underscores shifting social sentiment in South Korea, where the procedure had been illegal since 1953. Abortion was forbidden in the government's attempt to maintain a large population after the Korean War. 

But the country's Christian community remains largely opposed to abortion and is lobbying legislators to reflect their beliefs in the pending revisions of the criminal law. Choi Jung-yoon, secretary-general at the Korea Pro-Life Association, told Nikkei that the new bills are too lenient.

"We cannot accept [the ruling] because we believe there's life from the moment of fertilization," Choi said. "We are offering prevention education services as well as consulting services for pregnant women in emergencies and those who suffer from side effects after abortion."

Choice comes at a price

Access to abortion is considered essential by feminist campaigners in the U.S., with the tightening of abortion laws considered a step backward for women's rights. In response to the looming Roe v. Wade decision, renowned American feminist Gloria Steinem told media in May that "the very definition of patriarchy is trying to control women and birth-giving."

But in several Asian countries, access to abortion can in fact threaten women's bodily autonomy.

In Indonesia, a case of forced abortion went viral in late 2021, graphically demonstrating how access to abortion can be misused. A woman named Novia Widyasari from Central Java was forced to take an illegally obtained abortion pill by her policeman boyfriend, Randy Bagus, after twice falling pregnant by him.

Social pressure not to have children out of wedlock, largely fueled by Islamic beliefs, led Bagus to fear he would lose his job if Widyasari went through with the pregnancy. Already depressed after being forced to abort her first child, Widyasari committed suicide four months after Bagus coerced her to abort her second, by poisoning herself with potassium in December 2021.

Bagus was fired from the police force and sentenced to two years in prison for his involvement in an illegal abortion. The prosecutor had demanded three and a half years. There was an attempt to include forced abortion as a criminal act in Indonesia's new Bill on Eradication of Sexual Violence, passed in April, but to no avail. Coercing a woman into an abortion is still not a criminal offense.

Pressure on unmarried mothers to have abortions is also rife in China, feminist Lu told Nikkei. She explained that the right to an abortion in China should not be mistaken as a sign of women's empowerment -- premarital pregnancies still carry a social stigma, and unmarried mothers are not guaranteed social benefits.

"People think premarital abortions are normal and it is something you should do if [you fall pregnant and are] not married," Lu said.

Women's rights activists in India fear legal access to abortion can be misused for sex selection purposes. Here, a woman in Hazipur, India, awaits her abortion operation in 2010.   © Getty Images

In India, forced sex-selective abortions are a problem. Mishra, the research head from New Delhi, estimates that only around 10% of India's 15 million abortions every year are performed out of the mother's choice. In most cases, family pressure plays the ultimate role, largely due to preference for a male child, especially in northern India.

Even in countries where forced abortions are rare, legal access to abortion does not necessarily equate to more female autonomy. In Singapore, for example, although women can terminate pregnancies up to the second trimester, they are legally required to undergo counseling and must wait 48 hours before consenting to the procedure.

Women's rights activists argue that the counseling rule prevents women from freely making decisions on abortion. "Counseling and waiting periods may give the impression that seeking an abortion is reprobate or morally unsound -- something to feel guilty or regretful over," Shailey Hingorani, head of research and advocacy at the Association of Women for Action and Research in Singapore, told Nikkei. 

In Japan, similar concerns about the government's proposed conditions for legalizing the abortion pill, which is set to happen within the year, have divided reproductive rights activists. Currently, only surgical abortions are legal in Japan, with the most popular method being dilation and curettage, which rakes out the fetus with a metal tool and was declared unsafe by the World Health Organization earlier this year.

Recent government discussions suggest that, if the abortion pill is legalized, spousal consent and costly hospitalizations -- not covered by national health insurance -- will be necessary for a prescription. "Maintaining the need for male consent for the abortion pill demonstrates an underlying notion that women are weak beings who cannot decide on their own," Soshiren's Ohashi told Nikkei.

Michiyo Ono, a member of JOICFP, a Japan-based nongovernmental organization advocating for women's reproductive rights, is more optimistic. The proposed conditions of legalization "have many downsides," she told Nikkei. "But legalizing the abortion pill would be a step in the right direction."

Ono's message rings loud and clear among women's rights activists throughout Asia: Having some access to safe abortion, however complicated, is better than having no access at all.

Additional reporting by Lien Hoang in Ho Chi Minh City, Cliff Venzon in Manila, Marrian Zhou in New York, Francesca Regalado in Bangkok, Dylan Loh in Singapore, Jaewon Kim in Seoul, Faisal Mahmud in Dhaka and Alice French in Tokyo.

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