The Current State of Professional Midwives in Japan and their Traditional Virtues

Masafumi Koshiyama, MD, PhD

Professor Department of Women’s Health Graduate School of Human Nursing The University of Shiga Prefecture 2500 Hassakacho, Hikone Shiga 522-8533, Japan; Tel. +81-749-28-8664; Fax: +81-749-28-9532; E-mail: koshiyamam@nifty.com

In Sugitatsu’s paper on the history of Japanese obstetricians and midwives, the Taihouritsuryou, an old Japanese code of laws, reported the appearance of young female doctors (probably, midwives) as low-class government officials in 701.¹ They feed pregnant women, assisted in difficult childbirth, and sometimes used acupuncture needles for treatment. In 712, the Kojiki, Japan’s oldest history book, stated that a pregnant woman had bound a band around her belly to protect her fetus when she was in her fifth month in pregnancy. This signified that she was pregnant and included a prayer for a safe childbirth. In 1178, the Heike monogatari, a collection of poems composed by the members of the old aristocratic society, described five to six women surrounding a pregnant woman who leaned on and clung to the mass they assisted in the childbirth. This poem’s figures show a sitting birth. From 1330, several medical schools were established, and Japanese obstetricians used herbal medicines during childbirth. In the early 17th century, midwives came into being. They emphasized that pregnant women had to bear the pain of labor earnestly, for if they managed to do so, the delivery would be easy. Women delivered in a seated posture, as described above, while pulling a rope hung from a ceiling.

Childbirths in the US were also performed in the seated position around this time and they were also aided by midwives.^2,3 However, between the late 18th and 19th centuries, the handling of childbirth was switched from the midwife to the physician in the US ahead of Japan.

The Parisian François Mauriceau, who was a leading obstetrician in the late 17th century, advocated a reclining position in bed rather than sitting on a birthing stool or chair for childbirth.⁴ This “French Position” or “Lithotomy Position” allowed the obstetrician to more easily examine the patient and fetus during childbirth and perform any necessary procedures. Its use quickly spread in Europe and North America thereafter.

In the early 19th century, the sitting birth was still the most common childbirth position in Japan, but the merits of the dorsal position had been introduced in a book available at the time. Midwives would visit the ubu-ya, the birth house in a town or village, and assist childbirths and bathing of newborns. However, they sometimes called in obstetricians for help with difficult childbirths. The midwives in those times were largely older widows. Because there was a lack of obstetrical textbooks during this time period, most midwives’ knowledge was based on experience, not by studying textbook content. In short, they generally worked on past experience and perception.

In 1871, with the modernization of Japan, a medical system was established and adopted by Western European countries. A license system for midwives was also started. The common style of childbirth changed from the sitting position to a lithotomy one. Many Western doctors came to Japan to teach obstetrics and midwifery in 1910, the midwife certification examination was started. Between the late 19th and early 20th centuries, the place for giving birth shifted from one’s private home to the hospitals in the US, ahead of Japan. After World War II, the baby boom in Japan swelled the population, and most deliveries were performed at home with the assistance of a midwife. However, from 1950, the numbers of childbirths performed instead at a hospital or clinic began to increase with a rate of 50% in 1960 and 99% in 1976. In 1950, 90% of childbirths were assisted by a midwife, but by 1975, a paradigm shift had occurred, and 91% of childbirths were assisted by a physician. As a result, the number of midwives who worked at midwifery homes decreased, and they instead moved to work at hospitals or clinics. In those days, they worked under physicians. Together, these changes resulted in a reduction in perinatal mortality.⁵

Before World War II, childbirth was understood to be a waiting game, in the style of the Germans which almost all Japanese obstetricians and midwives studied, in Japan. After World War II, however, efforts were made to shorten the delivery time by intervention as in the US. Women’s empowerment movements in recent years have increased the average age of marriage, which has subsequently increased the rate of high-risk pregnancies as well as reduced the birth rate in Japan. Before World War II, ensuring the mother’s survival was the main priority. However, after World War II, the newborn’s survival also became a priority. This has subsequently increased the rate of cesarean section births, a procedure that is accompanied by a number of risks, such as pleural effusion, thrombus, hemorrhage and sepsis.

JAPANESE TRADITIONAL VIRTUES

Historically, almost all Japanese have been are Buddhists and the teaching of “Zen”, a tenet of Buddhism, is ingrained in Japanese hearts, as follows: “The virtue of perseverance is needed in humans.”⁶ Since perseverance means accelerating in a positive direction that leads to benefits and joy, its outcome should also be filled with goodness and joy. Buddhists with perseverance have all of the virtues. In other words, the successes experienced in the process of self-practicing and performing good deeds are dependent on an individual’s perseverance. Japanese culture has long focused on praising individuals for making their best effort, not on the outcome of those efforts; as virtue is included in the process, rather than the result. Western societies, by contrast, tend to respect the ends over the means of achieving them and think rationally and systematically by applying scientific laws^.7,8

RECENT CHILDBIRTH STYLES IN JAPAN

Western physicians and midwives lead modern obstetrics and midwifery and develop relevant guidelines, as mentioned above. They often use epidural anesthesia to reduce the pain of labor, and Western midwives and pregnant women regard childbirth control for the process of giving birth involving anesthesia as important. However, Japanese physicians do not use anesthesia very often during childbirth, and Japanese midwives tend to almost never use it. Traditionally, Japanese women endure labor pain, and their deliveries are silent.⁹ They are then pleased by the sense of accomplishment after a successful vaginal delivery, a concept based on the Japanese “Zen” heart. Japanese women respect the process and understand that its outcome will consequently be filled with goodness and joy. Therefore, Japanese midwives place importance on the process and devote extra care for pregnant women throughout the experience. They share in the women’s pain and relieve the pain with their continuous presence, a spirit which has continued in much the same form since the early 17th century. For this reason, Japanese midwives have a negative opinion of painless labor, in contrast to Western societies. Since the early 20th century, Japanese midwives have worked to protect the perineum from injury during delivery, using a hands-on method of assistance, as they are not allow to suture perineal wounds. The suture of the perineum is the work of the doctors. The Japanese midwives take pride in a spontaneous childbirth with no lacerations. In contrast, Western midwives perform episiotomies and suture the wounds themselves with much less of a hands-on approach.¹⁰

As mentioned above, the rates of high-risk childbirth and cesarean sections are increasing in Japan. As such, professional midwives in Japan now receive the best education possible in their field and are equipped with traditional Japanese spirits for treating patients, caring for pregnant women’s minds and bodies with devotion. Such professional midwives are trained to manage patients using various birth position for carrying out a normal childbirth (except for the lithotomy position), and they are trained to immediately change the position as soon as any abnormality occur. They take great effort to monitor the childbirth with devotion and identify any abnormality with modern scientific knowledge in the small midwifery rooms of hospitals and clinics, in cooperation with obstetricians. The title of “advanced midwife” was established in 2015¹¹ and these women do not work under physicians, but rather independently and in harmony with the doctors.

CONFLICTS OF INTEREST

The authors declare that they have no conflicts of interest associated with this study.

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11. The Japan Times News Midwife certificates honor 5,500 professionals who can oversee births solo. 2016. Website. http://www.japantimes.co.jp/news/2016/01/19/national/ science-health/midwife-certificates-honor-5500-professionals-can-oversee-births-solo/#.V1j2kpVJnIV. Accesssed June 1, 2016