Midwives have always been revered in Japan. In ancient times, they were simply known as “the grannies who delivered life.” From the middle of the Edo period, about 250 years ago, they were known as granny midwives and were exempt from the edict prohibiting anyone from crossing the procession of a feudal lord and his vassals, a crime punishable by death. If a granny midwife spoke up to say she was on her way to a birth, she was allowed to continue on her way while the rest of the village prostrated themselves until the procession passed. This privilege was granted to physicians, as well.
The end of isolationism and the beginning of the Westernization of Japan began in the Meiji Period (1868–1912) with the overthrow of the feudal government. New systems of education, medicine, urban planning, etc., began to be imported from various Western countries, and granny midwives’ practices came under governmental regulation within the newly formed Bureau of Hygiene. Official training was implemented, initially under the auspices of obstetricians. Under this new medical system based on German practices, “medical midwives” were required to be more than 40 years old; familiar with the anatomy, normal physiology and pathology of women and children; have a certificate signed by an obstetrician who had observed them delivering 10 successful births; and banned from using obstetrical devices. The so-called new or modern midwives, or Western midwives, were to attend “normal” labors only, calling on a physician if the labor turned “abnormal.” The first restrictions implemented also outlawed midwives from continuing to perform abortions or to sell medications.
The Midwives’ Ordinance of 1899 lowered the age of eligibility to women 20 years of age. These modern midwives were considered vital messengers of public hygiene such that, to a certain extent, their role also included the new job of public health nurse. Thus began the professionalization of midwifery and its intermingling with nursing.
Divisions among traditional and medical midwives, the incomplete pervasion of modern medicine into the rural areas where granny midwives were trusted by commoners, and the need for more midwives led to a three-tiered system with some midwives being able to register after receiving a shorter term of education and without being required to take the newly established national exam. Battles of who were the “true” midwives began to emerge. However, the professionalization of midwifery was well under way, and medical midwives eventually won out. The division between the male profession of obstetrics with its focus on “abnormal” birth and the female profession of modern, medical midwifery with its concomitant relegation to “normal” birth was complete by 1930 with over 50,000 registered midwives, 85% of whom had taken the national exam.
The first national association of midwives was established in 1927 and included both medical and granny midwives. Midwifery was considered a desirable, respectable, well-paid, female profession and was very popular among women entering the work force. In 1946, under instructions from the general headquarters (GHQ) of the American occupation, nursing, public health and midwifery all came under the auspices of the newly formed Japanese Nursing Association; however, in 1955, all but 100 midwives broke away from this organization to reestablish the Japanese Midwives’ Association (JMA). (In 2002 it was decided to change one of the characters in the Japanese name of the JMA to a gender-neutral character, rather than specifying that a midwife must be female. Despite heated discussion, the decision was made in order to bring the name in line with the new, gender-neutral word for nurse. However, as of this writing, there are no male midwives in Japan.)
Prior to WWII, midwifery education was a two-year, direct entry path. Under GHQ leadership, all midwives in Japan were required to be licensed as nurses first, followed by a period of six months of midwifery education. Add-on midwifery education is now a minimum of one year but can be up to three years, including the more recent option of graduate level midwifery studies. A variety of paths to licensure still exists, from vocational schools to university education; however, a direct entry certification bypassing nursing education or based on apprenticeship no longer exists in Japan. Licensing is received after passing a national exam. Aspiring midwives are required to have attended only 10 supervised births, certainly not enough to set up shop as an independent practitioner. Even those who aspire to owning their own practice one day generally tend to spend at least a few years honing their skills in a hospital setting before garnering experience in a midwife-run birth house or striking out on their own.
Although all midwives in Japan are nurse-midwives, the scope of practice can be quite different from some other countries. For example, Japanese nurse-midwives do not have prescription privileges, cannot order lab work, and are not allowed to perform an episiotomy except in emergency situations. Some of the imposed practice limitations have served to foster reliance on and exploration of alternative modalities and techniques for more holistic, woman-centered care.
Midwives are required to have a practice agreement with an obstetrician if they want to open their own independent clinic. Recent changes in the guidelines reduce midwives’ autonomy even further by requiring all decisions regarding women’s eligibility for midwifery care to be made in collaboration with (or in actuality, with the de facto permission of) an obstetrician.
Midwifery guidelines, set up by the Japanese Midwives’ Association but heavily influenced by obstetrical societies, have also become stricter and more limiting of practice in recent years. For example, independent midwives are no longer allowed to attend breeches, twins, VBACs or
Rh- mothers. As older obstetricians retire, the art of vaginal breech birth even in a hospital setting is also disappearing. Induction and cesarean rates are, unsurprisingly, on the rise. According to the obstetrical guidelines in Japan, GBS-positive women, as well as those of unknown status, are theoretically allowed to give birth outside of a hospital setting as long as midwife-obstetrician collaborative care is in place. Antibiotic treatment is usually required. I am unaware of any midwife willing to attend a woman who chooses not to receive antibiotics, as this would place not only her own ability to practice in jeopardy, but the ability of all midwives, as the political atmosphere is rigid and punitive. In fact, it is equally unlikely to find an OB who would flout the antibiotic guideline. All of these changes have taken place on a large scale only in the past decade or so.
Although each independent midwife will have her own style and modalities she works with, there are virtually no regional differences in actual midwifery practices except with regard to overall accessibility. Some are willing to push the limits slightly, but it is a national system in which renegades are not looked upon kindly. The few that pop up quickly disappear in accordance with a common Japanese saying, “The nail that sticks up will be hammered down.” Midwives have been losing ground in the past two decades. The fear of political repercussions from an overarching obstetric society, along with a general fear among many midwives of taking on more responsibility due to either insufficient training or back up, have been huge stumbling blocks for developing systems that support more independent midwifery in Japan.
In 1955, 95% of births were attended by midwives at home. The switch from homebirth with midwives to hospital birth with doctors occurred relatively recently and within a matter of only a few years. By the end of 1965, 95% of births occurred in hospitals under the supervision of obstetricians. Despite the historical reverence for midwives and the relatively recent move to obstetric care, midwives have been rapidly losing autonomy in the past decade.
As further backdrop, it is important to note that since 1980, Japan has had one of the lowest infant mortality rates in the world—a statistic worth boasting about. Marsden Wagner attributed this, at least in part, to the involvement of midwives at most births. Currently, approximately half of births take place in the maternity wards of general hospitals, university-affiliated teaching hospitals or dedicated maternity hospitals. The other half takes place in smaller, doctor-run maternity clinics of fewer than 20 beds. In the vast majority of hospitals and clinics, much of the direct care during labor is performed by midwives, albeit under obstetrician orders and supervision. Prenatal education regarding diet, exercise, etc., is provided by midwives at several visits throughout pregnancy.
By law, only obstetricians and midwives are allowed to perform internal exams to check for progress during labor. Blaming a shortage of midwives, some facilities have allowed nurses to perform this duty in recent years, causing an uproar within the medical community. Despite the fact that most women will see a midwife several times during their pregnancy, many women do not understand the distinction between nurses and midwives. This may be partly due to a system in which midwives are required to rotate as nurses in all hospital departments, not only obstetrics, and very few facilities distinguish between nurses and midwives by employing differing name tags or uniforms.
Presently, slightly more than one percent of all births are attended by midwives in independent practice and occur in midwife-run birth houses or in private homes. In the past decade, in a set-up referred to as the “semi-open system,” midwives are sometimes allowed to accompany their client to the hospital as a support person during a transfer rather than be turned away at the door, as has been common practice. It is also unusual for doctors who run their own clinics to have privileges at hospitals, although use of the relatively new “open system” is growing. Approximately 2875 institutions, one-tenth of all hospitals in Japan, provide obstetric services. In-hospital birth centers have cropped up since 2008; there are currently 69 certified Baby Friendly Hospitals throughout the country.
Japan has had universal health care since 1961; however, pregnancy and childbirth are not covered by insurance as they are not considered a disease. To accommodate this philosophy, a governmental cash disbursement is given either directly to the family or to the hospital after the birth and covers most of the costs of birth in a public facility or part of the cost in more expensive private facilities. Ambulance service is free for childbirth emergencies and complications are covered by insurance with a 30% co-pay.
The predecessor to today’s Maternal and Child Health Handbook, which every pregnant woman receives when registering her pregnancy with her local city office, was initiated in 1942 with the express purpose of boosting women’s fertility during WWII and ensuring that “women have strong children.” It is a record of doctor or midwife visits, blood pressure and urinalysis, notes about the birth itself and a record of growth and vaccinations of the child up to six years of age. Originally, the system provided three prenatal visits with a midwife. The current system provides coupons for up to 14 free visits with a doctor or midwife, as well as many infant wellness and vaccination visits at local public health centers to assess growth and determine the need for referral to additional services.
The past decade has seen a push for centralization of services in large perinatal centers, a lack of consistent back-up for smaller facilities, more litigation and an extremely low birth rate. The mean age of primiparous women in 1970 was 25.6 but in 2013, it was 30.4. All of these factors have contributed to multiple hospital closings. The remaining facilities fill up quickly, forcing women to decide by 15 weeks, sometimes even by their first appointment at 6 to 8 weeks, in order to reserve a place eight months down the road. Choices in rural areas are particularly sparse. Several well-publicized cases of osan nanmin or childbirth refugees, women who are unable to access maternity facilities, and tarai mawashi, literally “barrel rolling,” in which women died during transport between a small doctor’s clinic and a larger hospital when one hospital after another would not accept the patient for lack of beds or staff, are now leading to a call for an increase in local prenatal care facilities, along with massive centralization in perinatal care centers for birth itself. The importance and benefits of continuity of care have not been a large part of the discussion so far. There are several midwives who believe the situation has reached an all-time low and the limits of centralized care are being recognized which may be an opportunity for a resurgence of independent midwifery care.