This visit to Japan culminated in the birth of the Japan Birthing Association. The brainchild of Nanako Ooba, a well-known childbirth educator in Japan, the Association will bring together all those who are interested in promoting natural childbirth in Japan. The launch event was an all-day seminar and planning meeting, with speakers in the morning and discussion during the afternoon. Over 130 people came to find out more and get involved, and it is clear that there is wide interest amongst a diverse group - midwives, mothers, fathers and others all came together in a common cause.
The morning session opened with a presentation from me on “World Childbirth and the future of childbirth in Japan”, which was a Powerpoint presentation, ably translated by my two interpreters, Yoko and Tomoko. I gave the current statistics for caesarean section in various countries as a starting point then described how we had to help women overcome their fear of childbirth and the ubiquitous spread of epidurals. I spoke about the ways that midwives were taking the lead in reducing both fear and pharmacological pain relief through better midwifery services and gave them a quick summary of what a natural birth involves.
Then came Dr Tomoko Saotome (see my previous Diary entry) who spoke passionately about women’s sexuality and how this is challenged and disturbed by interventionist birth. In a country where episiotomy is universal, except for a very few women who seek independent midwifery care, this was a wake up call to the midwives in the audience who routinely carry out this procedure without much thought.
Hatsue Miyake then spoke about her practice as a midwife. She works a weekly shift in a Midwife House and also does home births. An active member of the Japan Midwives Association, she finished with the invitation for all midwives to join their professional organisation, to strengthen its membership and help get its voice heard.
The afternoon included small group discussions where the theme was exploring ways of drawing attention to, and stopping, the closure of small maternity units as the centralisation of midwifery services continues in Japan. It seems that obstetricians are aging and leaving the workforce and the Government’s response has been to concentrate services in larger district units, which are quite different to the traditional network of smaller community based birth facilities. It was clear to me that everyone was passionate about birth and wanted something to be done about this situation but had few ideas of how to begin. I gave them a quick list of strategies for political action (mentioning some of the events and ideas that had been used successfully in Australia) and although they were glad to have some direction, I am not sure of they have the drive and persistence to carry out these ideas as yet.
In time I am sure that this will develop - after all, this was the first of what I hope will be many such meetings. It was good to be at the birth of another consumer/midwife alliance and exciting to think that the groundswell of change towards better births for women is starting to get organised in Japan. I am looking forward to learning of some progress when I next visit in 2006.
Japan Birthing Association
Address: 1-0-16-504 Tomigaya, Shibuya-ku,
Tokyo 151-0063
Tel: +81-3-5454-8210
Fax: +81-3-5454-8212
www.tanjo.org
Posted by andrea at 09:14 AM
More on the Fureai Hospital in Yokohama
Following up my Diary entry about the Fureai Hospital in Yokohama, Japan, I have received a lovely email from Dr Tomako Saotome who would like me to mentioned that the Head of this lovely maternity unit is Dr Keiji Satoh. It was his idea to establish the mother and baby friendly maternity unit and he enlisted the help of the midwives in the area and together they collaborated, with Dr Saotome and a few others, to establish this outstanding facility.
All of them deserve praise and recognition for their dedication and vision and it is to be hoped that the owner of the private hospital understands the importance and potential of the unit he has within the hospital.
Here are some images of this unique birth place.
The main birth room, with its traditional tatami matting, bamboo walls and sliding doors is a haven of peace and tranquility. The room is set up with three mats in readiness for the breastfeeding clinic, which was about to begin.
The garden can be glimpsed through the door of this small room, once used for Japanese Tea Ceremonies and now a special cosy birth place for some lucky babies.
The breastfeeding clinic in progress. This mother is nursing one baby while the midwife gently massages her engorged breasts to ease discomfort.
Posted by andrea at 08:46 AM
The newest Midwife House in Tokyo
“Be Born” is the name of the new midwife house that I visited in Tokyo. It is in a suburban area, some distance from the downtown area, and is surrounded by regular houses. The building itself is new, and is still being completed, with tradesmen working to finish the “garden” area and complete the installation of the air conditioning and other fittings inside.
This house is owned by Yuriko Tatsuno, a midwife and acupuncturist who also specialises in Ayuvedic medicine and several other forms of complementary therapies. The building has one birth room, a general treatment room and bathroom area downstairs and a lounge and three bedrooms for postnatal stays upstairs, together with a kitchen.
It was party day when we arrived, celebrating the opening of the new midwife house. The house was crowded with visitors, including midwives, women, fathers and babies, all sharing stories and checking out the facilities. As luck would have it, there was a birth going on in the downstairs birth room, while we partied on upstairs - this was the third baby born in the house.
It is a modern building, not at all like the other midwife house in the downtown area, but as it settles down, I am sure that a cosiness of a modern variety will develop. The bathroom area was very large by Japanese standards, with the usual small, very deep sunken bath and a large flat area with two hand-held showers. Apparently, after the birth, the woman is laid on a special bed brought into the bathroom, and given a shower. Her hair is washed and she is given a massage treatment as well. Sounds very pleasant!
It was busy the day we were there and it would be good to visit again when things had settled down and it wasn’t so crowded. I am sure I could have learned a lot from Yuriko who has a wealth of experience to share. Perhaps next time.
Posted by andrea at 01:10 PM
A glimpse into old Japan.....
The photos I took in Japan have finally come back from the lab, so now I can share some glimpses into the birth scene in Tokyo.
The Oldest Midwife House in Tokyo
This birth house was established in 1906 and have been in continuous service ever since. The sign at the front door proudly proclaims its presence in this little shopping area of downtown Tokyo.
The Midwife House is staffed by a team of midwives, some of whom (such as Hatsue Miyake on the left) have home birth practises as well. Teruko Fukuoka (centre) is the owner of this Midwife House and showed me (right) proudly through her domain.
This is the birth room in the annexe, that is available for those who want a more traditional Japanese setting for the birth of their baby.
Nanako Ooba (who sponsored my visit), Hatuse and Teruko showed me how they utilise the bath during the many water births that happen in this house.
Teruko gave me this photo of a new mother and baby in the tub.
Next time, I’ll tell you about the newest Midwife House in Tokyo!
Posted by andrea at 02:07 PM
The best maternity hospital in the world?
The highlight of my visits to Japanese birth facilities was the Fureai Hospital in Yokohama, a city of 4 million people adjacent to Tokyo. The early immigrants to Japan settled in Yokohama because it was the entrance port to Japan and it has a reputation for a more cosmopolitan atmosphere (not all that readily apparent to the untrained eye!). However, it is seen locally as more progressive in many ways and this hospital is a good example.
The hospital is a converted modern hotel and offers a range of medical services along with a small birth unit which is located on the 8th floor. There was no hint of “hospital” in the lobby area downstairs and as I stepped out of the lift to visit the maternity unit, I could have still been in a hotel. Pastel shades of wallpaper, pretty dados, not a single poster or sign on the wall (“wash your hands!” etc) - just an airy light atmosphere and a pervading sense of peace.
The unit is the brainchild of Dr Tomoko Saotome, an obstetrician who specialises in women’s health and sexuality. She is a wonderful woman, with a sensitivity and insight that has no doubt been influenced by spending time in the West and the birth of her own two children. She has created the best maternity unit I have ever seen.
There are the usual birth rooms, which are large and sun-filled and women stay in the same room for labour and birth (unusual for Japan). The postnatal rooms on the same floor are also very low key and homelike, with warm colours and comfortable furniture. A small nursery (now used as a storage area!) and bathrooms complete the picture.
The most striking feature of this unit is the area to one side, where they have set up a birth room in what was thought to be the traditional Japanese restaurant area of the former hotel. A series of interconnecting small rooms, complete with tatami matting, sliding paper screens and bamboo walls and ceilings have been left untouched, and in place of the tables and seating, futons and cushions offer a comfortable space for labour and birth. A small room once used for Tea Ceremonies is also sometimes used for birth and this room has a wonderful view through sliding screens onto a well established Japanese roof garden, complete with trees, a stream and numerous plants and shrubs. Access to this garden is also possible through a small passageway with stepping stones set in gravel in the traditional manner.
On the morning of our visit there were three futons set out in the birth room and a breastfeeding clinic was about to get underway. Women with breastfeeding babies could visit and seek advice from a midwife or just meet and socialise with other breastfeeding mothers. One new mum was having her breasts massaged as she fed her baby, and other babies happily crawled around. The midwife who was in attendance is in independent practice nearby, and offers home births, her midwife house for births and postnatal clinics in this hospital.
The maternity unit caters for a limited number of clients to ensure that each woman receives the best of care and is able to achieve a peaceful birth. Around 30 women each month give birth there, under the supervision of the midwives and Dr Saotome. This small number has become a problem because the hospital’s owners want to make more money by making the facilities available to more women. Dr Tomako is insistent that if this happens the special nature of this unit will change and she is fighting to save it as it is.
Most hospitals that I visit have a sameness about them and a predictable arrangement of medical equipment and clutter that all scream “hospital”. This maternity unit was completely different and an outstanding example of what can be achieved when a person of vision has the chance to follow through in all aspects. It should be used as a showcase for others in Japan to follow and Dr Saotome deserves wide recognition for her achievements. The managers of this Hospital perhaps don’t yet realise what a public relations bonanza they have on their doorstep!
I’ll include some pictures in the Photo Gallery at the end of these articles on Japan.
Posted by andrea at 09:32 AM
Japanese Midwife Houses
I am back in Sydney after my whirlwind trip to Japan. It was very busy and although I had a little time to write up my experiences, it was difficult to upload them. Therefore, I will give you my impressions and notes over the coming days, along with some photos.
Here is the first instalment:
The oldest Midwife House in Tokyo was established in 1906 and is still going strong. It is a traditional Japanese house, tucked away in a small street, next to the other shops in this corner of the downtown area (Higashi-Mukoujima, Sumida-ku). Visiting it was a great privilege, and I shown around by Teruko Fukuoka, whose mother was the first midwife. She herself is 84 years old, although you would never know this as she nimbly moved about, proudly showing off her facilities and caring for the three new mothers in residence.
On the ground floor level is a lounge area for waiting and a consultation room. There is an ultrasound machine and other mod cons, tucked in and around the old style furnishings. Upstairs is the meeting and class room with a bathroom to the side. The small, deep bath is very popular, with around 50% of women giving birth in this tiny tub. There are 3 post-natal rooms, with traditional tatami matting, mattresses on the floor and all the other furniture one would expect in a home. Another room is equipped with a normal hospital bed and this is used for those rare cases when there is a problem and assistance might be required. There is even a small nursery with a humidicrib, although any really sick baby is transferred to the nearby hospital.
The meals are prepared by a cook and women generally stay 2 or 3 days after the birth.
This birth house has an annexe, where women who would have liked a home birth if they had the opportunity, can give birth in a traditional Japanese setting. The birth room (bedroom) has tatami matting, a futon on the floor, wood and paper screens that slide back to reveal a Japanese garden, and the rooms are decorated with Japanese woodcuts, soft lighting and appropriate colours and furnishings. The clothes for the new baby are set out on a cushion beside the duvet covered futon and the whole room exudes a peacefulness and serenity that is very welcoming and conducive to a spiritual experience. This was modern Japanese living with the old fashioned touch that seemed very much in keeping with the midwifery philosophy of care that underpins this service. It was wonderful.
While I was there, I learned two useful and interesting techniques: how the bind the woman’s belly after birth to help support her pelvic floor muscles as they return to normal (so that’s how they regain their sylph like figures!) and another use for Moxa. More about these ideas later.
When the Midwife House opened, there were 50 to 60 births each month, keeping the midwife and her team of five assistants very busy. These days the number of births each year is around 180, and when I visited there were three mothers who had given birth in the previous 24 hours. The women were up and active and proudly swapping stories and babies - I was handed two babies to cuddle which was delightful.
Even though there are around 350 midwife houses in Japan, this number is dwindling. Midwives today are less interested in the business side of running this kind of service and I was told that many of the younger generation of midwives didn’t have the same “passion” as their older sisters. These community birth centres are vital for preserving the essence of midwifery and for offering educational opportunities for trainee midwives. These are the only places where student midwives are likely to see a normal, natural birth with no drugs and women being actively involved in the process.
I will be visiting the newest Midwife House in the next couple of days and I am looking forward to learning more about this unique approach to midwifery care.
Posted by andrea at 12:43 PM
Giving birth in Japan
I have arrived in Japan, to present three separate programs over the coming days. Today I have been re-orientating myself to the Japanese birth scene and coming to grips with Tokyo - an amazing place!
My hosts, the Birth-Sense Institute an the Japan Birthing Association (more of these later) have given me some useful background, ahead of the weekend events, which will be for two different groups of health professionals. Today I will be working with childbirth educators on teaching strategies and activities, so this will be different, but it is always helpful to have an idea of how maternity services are managed when working in any new country.
What I have discovered so far is that Japanese women on the whole chose private obstetric care and give birth in one of the 2,500 maternity hospitals around the country. However, there is a strong tradition of local community based midwifery, with independent midwives offering services at their own “birth houses” and at present there are 350 of these in Japan. These are quite separate from the hospitals and are supported by the community - home birth is rare here (perhaps because of the style of houses and general living conditions?). There is a hospital in Yokohama that has a birth centre with tatami mats and a Japanese tea room and I will be visiting this unique service in a few days, so more on this later.
Midwives and obstetricians are aging here, as everywhere else and 52% of obstetricians are over 52 years old, which is of concern. Finding replacements for both midwives and doctors as they retire is an issue that will need to be addressed, just as it is everywhere, it seems.
Pregnancy care follows familiar patterns and in recent times an emphasis on weight gain has returned. Where once weight gain was not considered important, now an arbitrary limit of 8 kgs is often recommended and women are being scared into limiting their weight gain with the threat of problems if the baby is bigger. This is also happening in the West, although given that westerners are often much larger than the Japanese, the suggested limits are probably a little higher than 8 kg. This seems like a ridiculously small amount of extra weight for a pregnancy and must surely be producing unnecessary anxiety in the minds of pregnant women (as well as setting the stage for unnecessary caesareans).
The way births are managed in hospitals is not very different from anywhere in the West where medical care dominates. There are some differences, however. For example, women usually labour, in first stage, in shared rooms with three beds and only curtains for privacy. Fathers are generally allowed in, but in some places with is not possible and women labour alone. Japanese women labour very silently, and the only medication for pain is the epidural.
I asked about pethidine and nitrous oxide use and was pleased at the mystified and puzzled looks I received - these are not drugs used in labour here at all, as far as I can tell.
All labouring women will have a monitor (CTG) attached and labour will be expected to proceed at a dilatation rate of 1 cm per hour with no more than 2 hours in second stage. There are no restrictions on food and drink in labour, unless it is known that the woman is to have a caesarean birth.
Most of this will be familiar, as these are routine procedures in most part of the world.
However, in Japan, shaving and enemas are standard and every woman will be given an episiotomy. It seems the research on these basic interventions has not reached these shores, even though these practises, especially shaving and enemas, were abandoned in the West 25 or more years ago.
Second stage requires a move to another room, and women give birth on their backs on the beds. All breech babies are delivered via caesarean. I asked about oxytocics for third stage and was told that these are routine, and given before the placenta arrives. It is also still routine to give every woman prophylactic antibiotics immediately after birth, even when there are no indications of infection.
Postnatally, most women breastfeed, and there are around 40 BFHI accredited hospitals in Japan.
This is the results of my initial research in birth in Japan. Later in my stay I will be visiting some birth houses and independent midwives and I am sure to get a very different story from them. I know that they aim for completely natural births and I am looking forward to finding out how this is achieved.
Posted by andrea at 10:16 AM
Giving birth in Japan
I have arrived in Japan, to present three separate programs over the coming days. Today I have been re-orientating myself to the Japanese birth scene and coming to grips with Tokyo - an amazing place!
My hosts, the Birth-Sense Institute an the Japan Birthing Association (more of these later) have given me some useful background, ahead of the weekend events, which will be for two different groups of health professionals. Today I will be working with childbirth educators on teaching strategies and activities, so this will be different, but it is always helpful to have an idea of how maternity services are managed when working in any new country.
What I have discovered so far is that Japanese women on the whole chose private obstetric care and give birth in one of the 2,500 maternity hospitals around the country. However, there is a strong tradition of local community based midwifery, with independent midwives offering services at their own “birth houses” and at present there are 350 of these in Japan. These are quite separate from the hospitals and are supported by the community - home birth is rare here (perhaps because of the style of houses and general living conditions?). There is a hospital in Yokohama that has a birth centre with tatami mats and a Japanese tea room and I will be visiting this unique service in a few days, so more on this later.
Midwives and obstetricians are aging here, as everywhere else and 52% of obstetricians are over 52 years old, which is of concern. Finding replacements for both midwives and doctors as they retire is an issue that will need to be addressed, just as it is everywhere, it seems.
Pregnancy care follows familiar patterns and in recent times an emphasis on weight gain has returned. Where once weight gain was not considered important, now an arbitrary limit of 8 kgs is often recommended and women are being scared into limiting their weight gain with the threat of problems if the baby is bigger. This is also happening in the West, although given that westerners are often much larger than the Japanese, the suggested limits are probably a little higher than 8 kg. This seems like a ridiculously small amount of extra weight for a pregnancy and must surely be producing unnecessary anxiety in the minds of pregnant women (as well as setting the stage for unnecessary caesareans).
The way births are managed in hospitals is not very different from anywhere in the West where medical care dominates. There are some differences, however. For example, women usually labour, in first stage, in shared rooms with three beds and only curtains for privacy. Fathers are generally allowed in, but in some places with is not possible and women labour alone. Japanese women labour very silently, and the only medication for pain is the epidural.
I asked about pethidine and nitrous oxide use and was pleased at the mystified and puzzled looks I received - these are not drugs used in labour here at all, as far as I can tell.
All labouring women will have a monitor (CTG) attached and labour will be expected to proceed at a dilatation rate of 1 cm per hour with no more than 2 hours in second stage. There are no restrictions on food and drink in labour, unless it is known that the woman is to have a caesarean birth.
Most of this will be familiar, as these are routine procedures in most part of the world.
However, in Japan, shaving and enemas are standard and every woman will be given an episiotomy. It seems the research on these basic interventions has not reached these shores, even though these practises, especially shaving and enemas, were abandoned in the West 25 or more years ago.
Second stage requires a move to another room, and women give birth on their backs on the beds. All breech babies are delivered via caesarean. I asked about oxytocics for third stage and was told that these are routine, and given before the placenta arrives. It is also still routine to give every woman prophylactic antibiotics immediately after birth, even when there are no indications of infection.
Postnatally, most women breastfeed, and there are around 40 BFHI accredited hospitals in Japan.
This is the results of my initial research in birth in Japan. Later in my stay I will be visiting some birth houses and independent midwives and I am sure to get a very different story from them. I know that they aim for completely natural births and I am looking forward to finding out how this is achieved.
Posted by andrea at 10:13 AM
Chichester Home Birth Conference
Next March, the Chichester Homebirth group is presenting one of their special Conferences, this time in Bristol, UK. These are a very popular event and offer an opportunity for midwives, parents and others interested in home birth to gather and share ideas.
Next year’s event is titled “Home Birth: A new concept?” and all the details are now on a web site, that has information about past events and a down-loadable registration form for this coming Conference.
The main speakers will be Mavis Kirkham, Mary Cronk, Jonathan Montgomery, Lynne Leyshon and myself. We’ll be tackling a variety of topics related to home birth and I have been asked to address: “Have women changed?” An interesting challenge!
Providing home birth options is Government policy in the UK, yet its availability depends on the attitudes and capacity of the various Area Health trusts and PCTs to implement. This has been successful in some areas and a failure in others - the lack of staff to provide the service being the most often quoted problem. I am sure these issues will come up next March and that there will be lively discussion on how to make the home a more often chosen birth place by women.
Will I see you there?
Posted by andrea at 01:56 PM
Camden Birth Centre
Another busy week draws to a close - where does the time go?
The workshop at Campbelltown on Monday and Tuesday gave me the chance to catch up with developments in that area. The Hospital at Campbelltown and the Birth Centre at Camden (about 17 kms away) are part of the same Area Health Service. This AHS has been under a cloud due to many problems, and some deaths, which have been attributed to a number of factors. Some administrators have gone, some staff have left and the situation is improving, however, it has left moral amongst staff at a low point and a degree of suspicion and distrust as well.
Camden has a lovely Birth Centre, which is currently closed. The obstetricians in the area have refused to cover for births at Camden, forcing women to travel and give birth in the larger Hospital at Campbelltown. When the Birth Centre was closed, there were two very noisy protest marches of mothers and babies which received extensive media coverage and as a result, the State Government, under a lot of pressure to provide better services in the area, has promised Camden will re-open as a midwifery only unit. For the women of the area this is good news, but many have heard it all before, and are sceptical that it will ever happen.
Into this scene has come two top midwifery administrators to sort out the mess, clear away the blocks and get the service running. A caseload model is the preferred option, and is close to being implemented, once the annualised salary issues are resolved. The midwives in the area who have been patiently waiting for 5 years, are close to giving up and are beginning to doubt the promises. While their frustrations are understandable, this is the very time that a final concerted effort (push?) is needed to get this baby born.
Until Camden Birth Centre re-opens, the midwives from that Unit will be providing pre and post natal care on that site and bringing the women to Campbelltown for the births. This is far from ideal, but at least does offer the midwives in Campbelltown the chance to witness the working of this model and to learn from some very experienced midwives. Eventually it is to be hoped that the midwifery services across both hospitals will be similar so that women can be assured of having midwifery style (not obstetrically influenced) care wherever they choose to give birth.
Managing major changes of this nature are hard on everyone. Improvements and new developments never happen fast enough and usually take longer to negotiate than planned. An additional pressure comes from the fact that these new midwifery-only hospitals are a new concept that is being gradually introduced, amid a flurry of angst from the doctors and considerable political pressure from various stakeholders. The midwives in these new units must feel they are being watched like fish in a tank, with hungry predators waiting to pounce!
The medical model of obstetric care is a robust and almost unshakable system that is very hard to shift. However, the realities of high costs, over-servicing (30% caesarean rates), unjustifiable restrictions on women and lack of choice are forcing a re-think of the way birth is managed in this State. Camden could be one of the leading lights in this process and given a chance, I feel sure that it will succeed, just as other midwifery unit have done in the recent past.
Posted by andrea at 11:16 AM
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