Attitudes toward Prenatal Testing and Abortion in
East, Southeast, and South Asia : Based on a
Survey of Women in Nine Countries
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言語: en
出版者: Shizuoka University. Center for Research on
Asia Faculty of Humanities & Social Sciences
公開日: 2024-04-08
キーワード (Ja):
キーワード (En):作成者: Shirai, Chiaki
メールアドレス:所属:

URL

https://doi.org/10.14945/0002000568

Attitudes toward Prenatal Testing and Abortion in East, Southeast, andSouth Asia: Based on a Survey of Women in Nine Countries
Shirai Chiaki

Abstract
Noninvasive prenatal genetic testing (NIPT) is becoming more widespread around the world, but notmuch is known about its current use in Asian countries. Globalization may lead to similar use as in the West,but differences in legal systems, cultures, health and welfare systems, family systems, and values and norms
such as religion and views of life, body, science, and ethics may lead to different attitudes toward and useof prenatal testing. Previously, a survey on reproduction, including questions on third party reproduction,
prenatal testing, abortion, was conducted in 14 countries by Shirai et al. After that, Shirai et al. are currently conducting a research project on prenatal testing and views of disability in nine countries in East Asia,
Southeast Asia, and South Asia- Japan, South Korea, Taiwan, Vietnam, Myanmar, Thailand, Singapore,
Philippines, India. In this paper, I discuss the overall state of the relationship between prenatal testing andabortion. Although it is a simple tabulation of the questionnaire, the suggestion obtained is that the positionof induced abortion in society, including whether it is legal or not and attitudes towards it is one of the
major factors that determines the use of prenatal testing technology.
In Myanmar and the Philippines, abortion is banned. More specifically, in Myanmar, abortion is prohibited except in cases where the motherʼs life is in danger. In the Philippines, it is outlawed without exception, and the Constitution stipulates that the fetus has the same protections as the mother. In bothcountries, a strong stigma against abortion is prevalent throughout the population.
In Taiwan, as in Japan, there is a double standard: there is an abortion offense in the penal code, but
it is conditionally permitted under the Eugenic Health Act. In Taiwan, the law stipulates that abortions canbe performed in cases in which pregnancy or childbirth will cause damage to physical and mental healthand affect family life. These exceptional cases include forced sexual intercourse, pregnancies by close relatives, and cases of fetal disorders.
Abortion is legal in Vietnam, and there are no limitations on the length of the pregnancy or required
health conditions. The Law on the Protection of Public Health states that women have the right to have an
abortion on request and that the Ministry of Health is obliged to ensure medical care.
Based on a simple tabulation of an Internet survey conducted by the authors in nine Asian countries,
this paper suggests that the picture of Japan extracted from the simple tabulation of this survey is different
from that of Taiwan, Vietnam, and the Philippines. In Taiwan and Vietnam, the sense of burden associatedwith raising a child with a disability tends to coincide with the acceptance of fetal disability as a reason forabortion. On the other hand, in the Philippines, disability is also seen as a gift, with large families raisingchildren and a value system present in which abortion is not tolerated by society as a whole. Japan is likeneither of these countries, and although the burden of raising a child with a disability is considered high,the acceptance of abortion is a matter of differing attitudes, and it is likely that different from the patternsof Vietnam and Taiwan, and also from the Philippines.
Key Word: Prenatal Testing, Noninvasive prenatal genetic testing (NIPT), disability, Abortion, Asia

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Overview of prenatal testing and induced abortion in Asia
Prenatal examinations in Japan are characterized by multiple ultrasound examinations performed during
antenatal checkups and a smaller number of screening examinations using maternal blood. Ultrasonography
is performed as a medical checkup with the purpose of managing the mother and monitoring the growth of
the fetus. Obstetricians and gynecologists familiar with prenatal examinations consider ultrasound examinations distinct from the more precise tests, such as the nuchal translucency test. However, fetal “abnormalities” may be detected during a prenatal checkup, with amniocentesis and other diagnostic procedures
implemented in such cases.
Japan has traditionally been cautious about maternal blood screening tests out of concern that prenatal
testing discriminates against people with disabilities. However, with the introduction of NIPT in 2013, tests
began to be performed by non-obstetricians and spread rapidly.
In recent years, some clinics have begun to specialize in fetal diagnosis. Prenatal testing will undoubtedly become increasingly liberalized; however, this trend also poses a significant problem such as ethicalconflicts and lack of counseling support.
In Myanmar and the Philippines, abortion is banned. More specifically, in Myanmar, abortion is prohibited except in cases where the motherʼs life is in danger. In the Philippines, it is outlawed without exception, and Article 12 of the Constitution stipulates that the fetus has the same protections as the mother.
The crime of abortion is defined in the Criminal Code of 1870 and in Articles 256–259 of the Amended
Criminal Code of 1930. However, it is permissible to save a womanʼs life, according to Article 11-4 of thePenal Code. In both countries, however, black-market abortion is a fact of life, despite the strong stigma
against abortion among the population.
In Taiwan, as in Japan, there is a double standard: there is an abortion offense in the penal code, but
it is conditionally permitted under the Eugenic Health Act. In Taiwan, the law stipulates that abortions canbe performed in cases in which pregnancy and childbirth will cause damage to physical and mental healthand affect family life. These exceptional cases include forced sexual intercourse, pregnancies by close relatives, and cases of fetal disorders.
However, a pregnant woman needs the consent of her spouse to have an abortion, and in the case ofa minor, the consent of a parent or guardian is required. In late 2000, the oral abortion drug RU486 wasapproved for use within seven weeks of conception. Surgical abortion is permissible within 24 weeks ofgestation.
Abortion is legal in Vietnam, and there are no limitations on the length of the pregnancy or required
health conditions. In Article 44, the Law on the Protection of Public Health states that women have theright to have an abortion on request and that the Ministry of Health is obliged to ensure medical care. However, it must not be performed in a medical institution that is not licensed by the Ministry of Health. Article
243 of the Penal Code defines an illegal abortion as a case in which a person performs an illegal abortion
on another person.
In Japan, there is a double standard. The Penal Code stipulates that abortion is a crime, but the Maternal Protection Law of 1948 allows abortions in cases of forced sexual intercourse or if the mother is indanger. It also stipulates that spousal consent is required for abortion. The following year, economic reasons
were added to the law, and abortions became permissible as an alternative to contraception. Abortions havealso been performed for economic reasons when fetal disabilities have been identified.
In a recent research project, the authors conducted interviews in 14 Asian countries with obstetricians,― 16 ―

gynecologists, and other health professionals as well as women who had given birth, finding that the accessibility of abortion and attitudes toward it may influence the type of prenatal testing undertaken.
In the research project just before that, in Myanmar and the Philippines, prenatal genetic testing, such
as NIPT, was not widespread, but non-genetic prenatal testing is common. Although advanced medical careis provided in Manila, the metropolitan area of the Philippines, the women surveyed identified precisionultrasound and fetal function evaluation as tests they themselves had undergone. The obstetrician/gynecologist replied that their hospitalʼs board of directors does not approve of in vitro fertilization (IVF), but fetal
surgery is allowed and will be performed unhesitatingly and professionally in the future. Another public
hospital obstetrician/gynecologist responded that even in cases in which a black-market abortion failed andbleeding would not stop, he/she would perform a cesarean section, even in the second trimester of pregnancy, thus using medical techniques to save the fetus.
In Myanmar, the women themselves said that abortion was totally unacceptable. However, they had
access to woman-centered contraception, such as the oral contraceptives, injections, and implants at public
expense or at low cost. Access to contraception is similar in the Philippines.
In the urban areas of Taiwan and Vietnam, NIPT was used particularly often as a screening test.
In Vietnam, accessing emergency contraception and early abortion is relatively low barriers to access.
Abortion costs are covered by health insurance if the abortion is motivated by medical issues in the fetus
or the pregnant woman. Our respondents stated that maternal serum markers and combined marker andNT testing were widely used, and that abortions were sometimes performed without a definitive test.

Results of Internet women survey in nine Asian countries
What follows are the results of a 2021 Internet survey of 100 women each who had given birth andwhose youngest child was under five years old in each of nine Asian countries, Japan, South Korea, Taiwan,
Vietnam, Myanmar, Thailand, Singapore, Philippines, India. This survey is part of study project JSPS KAKENHI Grant Number JP 20H01564, Prenatal Testing and Disability in Modern Asia: International Comparison. This survey was approved by Shizuoka Universityʼs Institutional Review Board (20-32).
The questionnaire was translated into each countryʼs official language, and it was noted that participants
could fill it out in their native language.
While Japan has relatively standardized health and welfare systems for both urban and non-urban
areas, in some Asian countries, urban and non-urban areas have completely different systems. For this reason, the population was allocated by region in the survey.
From here, a summary of the survey results is presented. A high percentage of women in all countries
received ultrasound examinations as prenatal testing. This may be related to measures implemented toreduce perinatal and neonatal mortality rates, such as confirmation of placental position. In countries otherthan Japan, the percentage of respondents who underwent combined fetal examinations, fetal function
evaluations, or similar tests was high, while the percentage of respondents who underwent NIPT was highin Singapore, Thailand, Vietnam, Taiwan, South Korea.
The respondents were asked about the testing they had undergone during their pregnancy with their
youngest child and their current awareness of the test as reported below. The Figure 1 show those who
underwent prenatal genetic testing and those who recommended that they do so. The red, right bars indicate
the percentage of “yes” responses. The percentage of respondents who answered “recommended by a doctor” was low in Japan.
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Figure 1
Prenatal genetic testing recipient was recommended by a physician to undergo prenatal
genetic testing (red, right is yes)

Figure 2 Prenatal genetic testing recipient was recommended by a husband/partner to undergo
prenatal genetic testing (red, right is yes)
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Figure 3 Prenatal genetic testing recipient was recommended by no one to undergo prenatal genetic
testing (red, right is yes)

Figure 2 indicates whether husbands/partners recommended testing. As in the case of doctors, thepercentage of respondents who answered that their husbands/partners recommended the testing was also
very small in Japan. In other countries, the percentage of respondents who said that doctors recommended
it tended to be larger.
Figure 3 is the percentage of respondents who answered that no one recommended that they take thetest. This answer was most common in Japan. In other words, many Japanese respondents took the test on
their own without being advised to do so by their doctors, husbands, or partners, revealing a completely
different pattern from that of other Asian countries. In other countries, physicians were frequently reported
to make this recommendation.
Although this question was assumed NIPT, this finding is probably related to the fact that in the past,
the committee of Japanʼs Ministry of Health, Labor, and Welfare that evaluated maternal serum markers
expressed the view that physicians do not need to actively inform pregnant women about testing. It may
also reflect the taboo against taking genetic tests in the society as a whole.

A person to consult when test results indicate a possible genetic abnormality.
In Japan and South Korea, husbands/partners were very often the consulting parties when a fetus wasfound to have a disability, while doctors and other specialists were consulted less often. On the other hand,
doctors and other specialists were the most common parties consulted in other countries. In Japan, a higher percentage of respondents indicated that they would consult their husbands or partners, rather than
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Figure 4 Allow prenatal testing for fetal abnormalities to save the life of the unborn child (left sideof each country is strong affirmation, right side is strong denial, and rightmost is “donʼt know”)

Figure 5 Allows prenatal testing for fetal abnormalities to determine whether to have the baby or not(left side of each country is strong affirmative, right side is strong negative, and the rightmost is “I
donʼt know”)― 20 ―

doctors or specialists, if they learned that their fetus had a disability.
The survey also asked how contraceptive decisions were made. In countries other than Japan, thetendency was for respondents to make decisions on their own without consulting with their husbands/
partners, but in Japan, a high percentage of respondents consulted with their husbands before making decisions. In general, women in Japan tend to consult with their husbands/partners rather than with specialists, but if these consultations with their husbands are not adequate, they often find themselves in a difficult
situation.
The survey also revealed differences in national trends regarding attitudes toward abortion, healthconditions, parenting goals, and feelings about the birth of a child with a disability.
Prenatal testing for the purpose of saving the life of the child was strongly favored in the Philippines,
Thailand, Vietnam, and India (Figure 4). Prenatal testing to determine whether to terminate a pregnancy
was strongly favored in Taiwan and Thailand (Figure 5). These differences are statistically significant.
In Taiwan, the percentage of respondents who would allow a fetus to be examined for abnormalities
to inform the motherʼs decision about whether to give birth was higher than the percentage of respondents
who would allow an abnormality to be examined to save the life of the unborn child.

Attitude towards abortion
We now turn to attitudes toward abortion. We presented a variety of conditions and asked whether
abortion was permissible. The percentage of respondents who said that no conditions are necessary forabortion was small in all countries in Figure 6. This indicates that some conditions were considered neces-

Figure 6

Permissibility of abortion: abortion possible without conditions (red, right bar is yes)― 21 ―

Figure 7

Permissibility of abortion: maternal risk (red, right bar yes)sary. In which cases did people think abortion is acceptable?
Figure 7 shows the percentage of respondents who said that abortion is permissible “if the continuationof the pregnancy would be dangerous to the pregnant person.”
Overall, the percentage of respondents who answered that abortion is permissible was higher than thepercentage who said that it is not. The level of permissibility was particularly high in Japan, with risk to thelife of the pregnant person being the most common justification cited. For the Philippines, abortion in cases where the motherʼs life is in danger tends to be more permissible than in other conditions, but still, unlike
in other countries, more than 70% of respondents said that it is not permissible.
Figure 8 shows the percentage of respondents who answered that abortion is permissible in cases ofpregnancy resulting from violence. In Japan, the percentage of respondents who said that it is permissible
was higher. The same is true for South Korea.
Figure 9 shows the percentage of respondents who said that abortion is permissible when the fetus isfound to be sick or disabled. A different trend can be seen in the case of maternal risk or pregnancy due toviolence. In Taiwan, more than 80% of the respondents answered that it is permissible. Maternal hazards
and fetal illness or disability were almost equally represented, indicating a very high level of permissibility.
In Vietnam, the tolerance for abortion in cases of violence was not very high, but the tolerance when
fetal illness or disability is found to be present was as high as the figure for maternal risk. In Japan, Singapore, and India, attitudes were split 50–50. In the Philippines and Myanmar, the percentage of respondents
who said abortion was unacceptable was around 90%.
Finally, Figure 10 represents the response that abortion is not allowed under any circumstances. In thePhilippines, this response was given by a majority. Myanmar also had an agreement rate of over 20%. All― 22 ―

Figure 8

Figure 9

Permissibility of abortion: sexually violent pregnancies (red, right bar is yes)

Permissibility of abortion: fetal disease or disability (red, right bar is yes)
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Figure 10

Permissibility of abortion: unacceptable in any case (red, right bar is yes)

Figure 11

Views on childrenʼs disabilities: Burden (red, right bar is yes)
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this suggests that attitudes toward abortion vary from country to country, and there seem to be some patterns
in the conditions under which abortion is acceptable.
Especially in relation to prenatal testing, abortion is more acceptable in Taiwan and Vietnam than in
the other countries we surveyed, especially when the fetus has a disability.
In addition to the permissibility of abortion within the legal system, attitudes and ideas about abortion
correlated with attitudes and ideas about prenatal testing. In this survey, prenatal testing for life-saving
purposes at birth, prenatal testing for the purpose of determining whether to continue a pregnancy, and theacceptability of having an abortion due to a fetal disease or disorder were associated at a statistically significant level with whether a woman would be willing to undergo NIPT or non-genetic testing (combined,
fetal full examination, or fetal function assessment) if pregnant (except in countries with a ceiling effect on
responses).

Views on children and Disabilities
The graphs in this section visualize the answers to a question about how the participants feel aboutchildren with disabilities. As shown in Figure 11, a high percentage of respondents in South Korea, Japan,
and Taiwan answered, “Raising a child with a disability is a burden.” These three countries have very low
birthrates.
As shown in Figure 12, the percentage of respondents who answered, “I am worried about the futureof my child with disabilities” was high overall, especially in Vietnam, Taiwan, Thailand, Japan, and South
Korea. Myanmar was unique in having a particularly low percentage of agreement.

Figure 12

Views on childrenʼs disabilities: Anxiety (red, right bar is yes)
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Figure 13

Figure 14

Views on childrenʼs disabilities: Gift (red, right bar is yes)

Views on childrenʼs disabilities: Special talented (red, right bar is yes)
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We next discuss the percentage of respondents who answered that “children with disabilities are a gift,”with the Philippines showing a high percentage of agreement in Figure 13. South Korea, Japan, Vietnam,
Taiwan, and Thailand had low levels of agreement.
Finally, as shown in Figure 14, for the item “Children with disabilities are children with special talents,”
the Philippines again had a high frequency of agreement, as did India and Myanmar. South Korea, Thailand,
Japan, Singapore, Taiwan, and Vietnam had weaker agreement. These views on disability were probably acomposite of individual circumstances, childcare availability, family burdens, public welfare, medical awareness and medical standards, and views of the body, life, and religion.
We now turn to the relationship between differences in attitudes toward prenatal testing based on viewsof disability, For example, in Japan, there was a statistically significant disparity between the beliefs that“raising a child is a burden” and “I feel sorry for my family and surroundings” in cases of child disability, on
one hand, and the acceptance of undergoing testing for the purpose of determining whether to have an
abortion, on the other hand. This is one example of the association between how a childʼs disability is perceived and prenatal test acceptance.

Conclusion and future considerations
Regarding non-invasive prenatal genetic testing (NIPT), Japan tended to have a low take-up rate relative to other Western and Asian countries. In the survey, more than 80% of the respondents in countries/
regions other than Japan were recommended to take this test by their doctors, and between 20% and 50%
were recommended by their partners. In Japan, 30% of the respondents were recommended by their doctors,
and less than 20% by their partners. More than 60% of the respondents answered that they were not recommended by anyone, which shows a completely different trend from other countries. This indicates thatthe respondents usually made the decision alone.
All countries and regions generally reported positive attitudes toward prenatal testing for the purposeof saving the unborn child and for deciding whether or not to have a baby. Japan was more in favor of theformer, and South Korea and Taiwan supported the latter, but both countries reported strong agreement.
Attitudes toward and engagement in examinations were expected to be related to abortion. Taiwan and
Vietnam most commonly supported abortion accessibility for reasons of fetal disease or disability. Vietnam
appeared to have a lower percentage of tolerance for pregnancies due to sexual violence and a higher tolerance for abortions for medical reasons, such as maternal risk or fetal disability. Taiwan also had highacceptance of abortion for pregnancies resulting from sexual violence and a higher percentage for maternal
danger and fetal disability, which were equally acceptable. In Japan, on the other hand, attitudes toward
abortion due to fetal disease or disability were split between positive and negative, with greater acceptanceof abortions due to maternal risk and sexually violent pregnancies. The acceptance for pregnancies resulting
from sexual violence was the highest in Japan among the nine countries. A different trend was observed in
the Philippines. Most Filipino respondents agreed that abortion is not allowable without conditions, withless than 30% approving of abortion when the mother is in danger and less than 10% approving of abortionin the case of a sexually violent pregnancy or a diseased or disabled fetus.
In the case of children with disabilities, less than 10% of respondents in the Philippines reported thatparenting was a burden, and the percentage of respondents who reported that child with disabilities was agift or had a special talent was notably higher than in other countries.
In Japan, Korea, and Taiwan, on the other hand, 40%–50% said that raising a child with a lifelong― 27 ―

disability is a burden, and only 10%–20% said that a child with a disability is a gift or has special talents. In
Vietnam, the percentage of respondents who said that raising a child with a disability is a burden was nothigh (20%), but the percentage who said it is a gift or associated with special talents was also small (10%–20%), as in Korea and Taiwan.
Various factors correlated with the prevalence of prenatal testing and the choice to take such tests. They
included coping with disability, whether society takes public responsibility for the care of children withdisabilities and their families or the families take private responsibility—and, if families take private responsibility, whether the families are large or small groups. Other factors included views on disability, views on
life, cost, and attitudes toward abortion, health, and medical systems.
The picture of Japan extracted from the simple tabulation of this survey is different from that of Taiwan,
Vietnam, and the Philippines. In Taiwan and Vietnam, the sense of burden associated with raising a childwith a disability tends to coincide with the acceptance of fetal disability as a reason for abortion. On theother hand, in the Philippines, disability is also seen as a gift, with large families raising children and avalue system present in which abortion is not tolerated by society as a whole. Japan is like neither of thesecountries, and although the burden of raising a child with a disability is considered high, the acceptance ofabortion is a matter of differing attitudes, and it is likely that different from the patterns of Vietnam andTaiwan, and also from the Philippines.
However, with regard to the Japanese responses, for example, there was not necessarily a relationshipbetween the general attitude toward prenatal testing and the respondentʼs attitude toward taking such a testin their own next pregnancy, and it is possible that independent mechanisms were at work. Such a detailed
analysis is a subject for future work.
Although the survey asked about attitudes toward disability; attitudes toward family, life, and science;experiences of and reasons for prenatal testing; and parties consulted, this report has focused only on attitudes toward abortion and prenatal testing. The other subjects are matters for future research. In addition,in this study, we also conducted an interviews survey after the Internet survey, so we plan to include thatin our analysis in the future.

Acknowledgement
This work was supported by JSPS KAKENHI Grant Number JP 20H01564.
I would like to express my sincere thanks to those who cooperated in the survey and to my co-researcher, Ms. Miyako KIMURA, Ms. Setsuko SUGANO, Ms. Yuko NIKAIDO, Ms. Hyunsoo HONG, Ms. Mizuho
MATSUO.

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