• contraceptives
• oral
• contraception behavior
• health education
• Health Services Accessibility
• intrauterine devices
• copper

For many Japanese women and girls who are at risk of unintended pregnancies, access to emergency contraceptive pills (ECPs) is limited. Obtaining ECPs is very difficult in Japan because they require a prescription and are expensive as they are not covered by the national health insurance.1 The Ministry of Health, Labour and Welfare (MHLW) recognised this and debated whether or not to approve over-the-counter (OTC) access that does not require a prescription. Although 92% of public comments were supportive of ECPs being made available OTC, the MHLW did not approve the change because of some concerns around the uncertainty of ECP effectiveness, misuse and abuse.2 However, according to the World Health Organization, ECPs are safe and effective medicines that all health systems should provide in view of the right of women and girls of reproductive age to access ECPs and avoid unintended pregnancies.3 4 In Japan, while the number of births in 2016 was 976978, the annual number of unintended pregnancies was estimated to exceed 610 000. Additionally, because cases of unintended pregnancy and sexual violence are increasing, especially in the era of the coronavirus disease pandemic, the issue of ECPs availability needs to be addressed.1 5

In Japan, levonorgestrel-only ECPs (LNG ECPs) and copper-bearing intrauterine devices (IUDs) are the currently available emergency contraception (EC) methods for women and girls. Since May 2011, LNG ECPs have been sold in Japan as ‘NORLEVO TABLETS 1.5 mg’ by ASKA Pharmaceutical Co., Ltd. (Tokyo, Japan) alone, until the generic label was sold in March 2019. We investigated trends in the use of LNG ECPs in Japan to identify the relationship between the accessibility and use of ECPs (our methods are outlined in the online supplemental methods). After the MHLW approved LNG ECP use in 2011, ECP use increased among women aged 18–39 years, comprising 0.08% of all women and girls of reproductive age in Japan (figure 1).

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Figure 1

Japan: proportion of cumulative use of emergency contraceptive pills (ECPs) among women aged 18–39 years who have ever had sexual intercourse (online supplement methods). United States (US): proportion of women who have ever used ECPs among women aged 15–44 years who have ever had sexual intercourse (online supplement methods).

Conversely, in the United States (US), LNG ECPs have been available via prescription since 1999, while OTC access without age restriction was permitted in 2013. With the increased accessibility of OTC ECPs, the percentage of women in the US who use these medications increased from 0.8% in 1995 to 20% in 2015 (figure 1). In Japan, 160 000–180 000 abortions are performed annually;5 therefore, it is necessary to provide EC options, disseminate accurate information regarding EC using mass media, and provide sex education for teenagers.6 To our knowledge, there are no data concerning the amount of knowledge Japanese teenagers have about EC, and obtaining this information seems important for further research on this subject. Similar to the increasing use of LNG ECPs in the US, the approval of OTC sale of ECPs could increase the accessibility and use of ECPs in Japan.

Other EC options, including copper-bearing IUDs and the generic LNG ECP, are not discussed here. Since 2004, copper-bearing IUDs (‘NOVA-T380’) have been exclusively sold by Bayer Yakuhin, Ltd. (Osaka, Japan) in Japan, but the number of shipments is only a few thousand annually. Therefore, we excluded copper-bearing IUDs from our study because of their less common use compared with ECPs.

To date, 19 countries allow direct OTC access to EC and 76 countries allow individuals to obtain ECPs from a pharmacist without a prescription.1 Therefore, among developed countries, Japan may appear backward concerning its sexual and reproductive health policies and rights. We hope that the MHLW will approve ECPs as OTC medications, and continue its efforts to improve access to ECPs and thus preserve the rights of women and girls in Japan.