Factors affecting the provision of analgesia during childbirth, Japan

Abstract Japan’s universal health-care system means that it is a very safe country in which to give birth. Perinatal outcomes in Japan are excellent, with low infant mortality and neonatal mortality. However, childbirth remains a challenge for many Japanese women, who are faced with a scarcity of places to give birth, limited availability of analgesia and social norms that favour natural birth. The number of birth facilities in Japan continues to decrease as fewer children are born. The numbers of qualified medical staff remain inadequate, with a continuing lack of female physicians, perpetuated by a pervasive negative gender bias. Recruitment efforts are underway, but few doctors want to specialize in obstetrics or gynaecology. Furthermore, around half of female obstetricians and gynaecologists in Japan’s male-dominated medical system stop practising when they have their own children. The difficulty of obtaining analgesia during labour is another problem. Although low uptake of labour pain relief in Japan is said to be due to cultural influences, the root of the problem is a lack of qualified anaesthesiologists and the inflexibility of a system that will not allow other staff to be trained to administer labour analgesia. Problems with labour anaesthesia have been linked to 14 maternal deaths since 2010. Japanese policy-makers need to act to renovate the nation’s obstetric facilities, reorganize regional perinatal care systems, train more obstetricians and anaesthesiologists, promote task-shifting and better integrate biomedical and traditional, non-medical care for pregnant women.


Introduction
At 1.44 births per woman in 2016, Japan's low birth rate is an issue for policy-makers concerned about the country's steadily declining population. Compared with other highincome countries, giving birth in Japan is costly to women, both directly in monetary terms and indirectly in terms of the risks of lost income, job loss and career setbacks. 1 Childbirth is also challenging for women in Japan because the proportion of deliveries with labour analgesia is low compared with other high-income countries. [2][3][4] Perinatal outcomes in Japan remain world-leading. The nation's 2017 infant mortality rate of 1.9 per 1000 live births and neonatal mortality rate of 0.9 per 1000 live births designates it as one of the safest places in the world to give birth. 5 Unfortunately these figures mask some of the difficulties faced by Japanese women in accessing the obstetric care and labour analgesia they need.

Shortage of obstetricians
Japan is lagging behind other countries in gender equality and the role of women in society, politics, education, business and health matters. According to the Global Gender Gap index, the situation is getting worse, with Japan falling from 80th in the world ranking in 2006 to 110th in 2018. 6 Regarding women's health, discrimination against female applicants in the entrance examinations of at least nine Japanese medical schools has recently attracted international attention. 7 Japanese medical facilities have long been understaffed with respect to female physicians in all specialities. According to data from the Organisation for Economic Co-operation and Development (OECD), Japan traditionally has the lowest proportion of female physicians among the most advanced industrialized nations. 8 According to Japan's Ministry of Health, Labour and Welfare, only 3667 (36.6%) of the country's 11 242 obstetricians and gynaecologists are female. 9 The Japan Society of Obstetrics and Gynecology has boosted recruitment efforts for female obstetricians, and tried to enable existing female obstetricians to keep practising. Nevertheless, half of female obstetricians and gynaecologists currently stop practising to have their own children. 10 Furthermore, there are few incentives in terms of good career prospects, attractive wages or equitable working environments to encourage students to specialize in women's medicine.

Access to birth facilities
Several years ago, Japan's decreasing number of childbirth facilities became a national talking point, as expectant mothers found it increasingly difficult to find somewhere suitable to deliver their baby safely. 11 Obstetric services in Japan are provided by hospitals or clinics staffed by obstetric doctors and midwives. Medical facilities with 20 or more inpatient beds are defined as hospitals, and those with fewer than 20 inpatient beds as clinics. Among obstetric hospitals, core facilities are selected and designated as perinatal medical centres by the central government. Most pregnant women give birth at hospitals or clinics and approximately 50 percent of women give birth at private clinics. 12 The private clinics are usually managed by only a few obstetricians, commonly fifty to sixty years of age. 13 Due to burdensome working conditions and an ageing workforce, clinics have steadily been closing and most pregnant women now have to go to a hospital for their delivery. Thus, the burden on small-or middle-size birth hospitals has increased, sometimes leading to their closure. In 1996, there were 1818 clinics and 1003 non-perinatal medi-Abstract Japan's universal health-care system means that it is a very safe country in which to give birth. Perinatal outcomes in Japan are excellent, with low infant mortality and neonatal mortality. However, childbirth remains a challenge for many Japanese women, who are faced with a scarcity of places to give birth, limited availability of analgesia and social norms that favour natural birth. The number of birth facilities in Japan continues to decrease as fewer children are born. The numbers of qualified medical staff remain inadequate, with a continuing lack of female physicians, perpetuated by a pervasive negative gender bias. Recruitment efforts are underway, but few doctors want to specialize in obstetrics or gynaecology. Furthermore, around half of female obstetricians and gynaecologists in Japan's male-dominated medical system stop practising when they have their own children. The difficulty of obtaining analgesia during labour is another problem. Although low uptake of labour pain relief in Japan is said to be due to cultural influences, the root of the problem is a lack of qualified anaesthesiologists and the inflexibility of a system that will not allow other staff to be trained to administer labour analgesia. Problems with labour anaesthesia have been linked to 14 maternal deaths since 2010. Japanese policy-makers need to act to renovate the nation's obstetric facilities, reorganize regional perinatal care systems, train more obstetricians and anaesthesiologists, promote task-shifting and better integrate biomedical and traditional, non-medical care for pregnant women.
cal centre hospitals, but by 2017 these numbers had fallen to 1350 clinics and 649 non-perinatal medical centre hospitals. 11 Increasingly, pregnant women in Japan have to travel to large hospitals and in some instances, they may have to travel over 100 km to receive antenatal care and appropriate medical care for delivery.
To prevent the decrease in birth facilities, one possible solution would be to encourage shifting of obstetric tasks to other health workers. However, the work of midwives has historically been severely restricted in Japan; they are not allowed to perform even an episiotomy or a perinatal suture or to prescribe any type of medication. Under these constraints, midwives alone can manage only uncomplicated, low-risk pregnant women. Deliveries at home or at a midwifery centre have become extremely rare; 99.3% (939 518 out of 946 065) of babies are now born in hospitals or clinics. 14 Some hospitals have tried to maintain a midwifery department where midwives can comprehensively manage deliveries. However, the births that midwives can manage are increasingly limited as maternal age is rising. The mean age of mothers having their first child has increased from 27.6 years of age in 1996 (among 574 043 women) to 30.1 years of age in 2016 (among 459 751 women). 14,15 The number of pregnant women with complications, such as preeclampsia and gestational diabetes mellitus, has also been steadily increasing. 16 Japan urgently needs to train more obstetricians and to ensure they are proficient in providing comprehensive, optimal care for both mother and baby.

Access to labour analgesia
The prospect of giving birth is an anxious time for most first-time mothers, yet in Japan women know that painkillers are rarely given, if at all. Physicians and other health workers report that more and more women are requesting epidural anaesthesia, but few obstetric centres, hospitals included, are willing or able to provide this care. Furthermore, the cost of 420 000 Japanese yen (3803 United States dollars at the average exchange rate in 2018) that the national health insurance scheme contributes towards having a baby will not cover such an expense.
Up until the mid-18th century, labour pain was considered to be a natural part of the birth process. 17 The introduction of ether and later chloroform in the 19th century led to labour analgesia becoming increasingly popular among those who could afford it, driven by economic progress in industrializing countries. However, inhalation of systemic analgesic agents during labour was linked to deaths of mothers and neonates, 18 and the prevalence of labour analgesia therefore remained low until the beginning of the 20th century. After the introduction of epidural analgesia, first used in labour in the 1940s, this safe and effective technique soon became widely adopted where it was available and affordable and infrequently used in developing and resource-poor countries with inadequate health systems. 18 Labour analgesia can be categorized as either non-pharmacological or pharmacological. Modern, safe and effective techniques, such as epidural infusion of narcotics, local anaesthesia mixtures and patient-controlled analgesia, during and after childbirth are now available. Neuraxial analgesia is now one of the most commonly used analgesic techniques during labour in high-income countries. In 2018 the World Health Organization (WHO) confirmed that "epidural analgesia is recommended for healthy pregnant women requesting pain relief during labour, depending on the woman's preferences." 19 However, only 6.1% of Japanese women (36 849 out of 608 450) are given access to pain relief during delivery, according to a representative study by the health ministry. 20 This compares with figures of 73.1% (1 920 368 of 2 625 950) in the United States of America 21,22 and 83.8% (10 475 of 12 500) in France's national perinatal survey. 23 In France, unlike Japan, government incentives to promote childbirth have drastically reversed declines in fertility. In Japan, the annual number of births is continuing to decrease, down to 921 000 in 2018 from 946 065 in 2017. 24 Although labour analgesia is less common in Asia than in Europe or the United States, the proportion of deliveries with labour analgesia in Japan is low even compared with other countries in Asia: 10% in China, 40% in the Republic of Korea and 60% in Singapore. [2][3][4] For a variety of reasons, some pregnant women in Japan prefer not to use pharmacological interventions for managing labour pain. Instead, they use a wide variety of techniques that attempt to enhance the psycho-emotional and spiritual components of care, such as breathing exercises, massage, acupressure, yoga and hydrotherapy. Using these non-pharmacological approaches, women cope with their labour pain and maintain a sense of personal control over the birth process. 25 Although in other countries pregnant women can seek physical, emotional and information support before, during and after labour from non-medical supporters known as doula, 26 in Japan pregnant women receive such support from midwives. In this respect, it can be said that labour support in Japan has evolved towards delivery with nonpharmacological care. However, Japan's unique health-care system, whereby traditional medicine is fully integrated with modern medicine in daily practice and covered by health insurance, may also have an impact. Japanese physicians, all trained in conventional scientific-based medicine, employ both biomedicine and traditional Japanese kampo medicine in clinics and university hospitals. 27,28 Kampo medicine using various herbs is used for a wide variety of conditions, with the prescription rate being highest for disorders associated with pregnancy, childbirth and the puerperium. Kampo extracts are known to have fewer and relatively milder effects than biomedical drugs in pregnant and postpartum women. Unfortunately, as a result, pregnant women in Japan who wish to use labour analgesia often cannot get access to it. According to the Japanese Association of Obstetricians and Gynaecologists, only an approximate of 720 out of 2391 hospitals and clinics in Japan offer epidural anaesthesia or combined spinal epidural anaesthesia, 20 while the health ministry lists only 360 facilities providing labour analgesia in 2019. 29

Shortage of anaesthesiologists
The reason why Japanese pregnant women have not used labour analgesia is often explained as being due to cultural beliefs, including the perceived social norm favouring a natural birth. In general, there has been a reluctance to use any medical intervention during normal childbirth because, in the past, both women and obstetricians considered birth as being simply physiological rather than potentially patho-Childbirth in Japan Yuto Maeda et al.
logical. 30 This view meant avoidance of any form of anaesthesia or analgesia. Furthermore, many Japanese women, especially the older generations, believe that the mother-child bond is forged and evolves through labour and the pain suffered. Women also fear that pain medication will cause the newborn to be weak and unhealthy, even though women who do not use analgesia for the first child, frequently decide to use it for subsequent births. 31 More women in Japan are opting to receive neuraxial analgesia during labour, even though the proportion remains low, increasing from 2.6% in 2009 to 6.1% in 2017 according to Japan's health ministry. 12,20 A possible factor in the low uptake of labour analgesia is not so much cultural beliefs as a shortage of anaesthesiologists. According to the World Federation of Societies of Anaesthesiologists, the number of physician anaesthesiologists per 100 000 population in Japan (9.6) is half to onethird the figure for most other OECD countries, such as the United States (20.8), United Kingdom of Great Britain and Northern Ireland (17.9) and France (15.1). 32 Reflecting Japan's patriarchal society, only 2260 (31.8%) of the 7107 qualified anaesthesiologists are female. 9 This situation has been worsened by the lack of task-shifting by existing anaesthesiologists, resulting in a scarcity of health workers who can perform and manage labour analgesia safely. 29 A temporary solution to Japan's shortage of anaesthesiologists would therefore be to accelerate plans to delegate anaesthesiologists' tasks to other trained health workers. 33 However, this approach is rarely implemented under the current rigid Japanese medical system. For example, Japan has no nurses qualified or authorized to administer anaesthesia. Nurses are not allowed to administer labour analgesia, even after an anaesthesiologist has inserted an epidural catheter. In addition, task-shifting from anaesthesiologists to obstetricians is difficult. As discussed above, midwives or nurses cannot take over obstetricians' jobs, such as an episiotomy or a perineal suture, and are not allowed to manage delivery comprehensively, even when a pregnant woman is perceived to be at low risk of complications. Consequently, although there seems not to be a shortage of obstetricians and gynaecologists in Japan, 34 physicians frequently cannot offer to perform labour analgesia. To help ensure a full and comprehensive service is provided to women giving birth in Japan, strict policies are needed to ensure that sufficient numbers of doctors specialize in obstetrics and gynaecology, as well as anaesthesiology. Coupled with a mechanism to ensure a balanced geographical spread of qualified staff, these policies would offer some hope to pregnant women. Unfortunately, this will take time, with 11 years of training needed for qualified obstetricians in Japan.

Nationwide debate
The scarcity of anaesthesiologists represents a threat to safe and pain-free childbirth in Japan, especially as about half of all births occur in private clinics. 12 These commercial clinics do offer labour analgesia. However, clinics are often understaffed, with only a few obstetricians, who often resort to performing neuraxial anaesthesia by themselves. Moreover, due to the scarcity of anaesthesiologists, most deliveries with neuraxial anaesthesia are elective procedures, which may require abnormal use of labour induction and instrumentassisted delivery, increasing the risks of abnormal uterine bleeding. 12 The gravity of the current situation is demonstrated by the fact that since 2010, there have been 14 cases in Japan in which the use of anaesthesia and pain relief in labour and delivery resulted in the death or serious complications for the mother and/or infant. 12 These incidences have attracted widespread attention, stimulating intense debate. Among these 14 deaths, only one was directly related to labour analgesia. All other deaths were due to bleeding, embolism and infection. Although eight deaths happened in private clinics, considering that about a half of deliveries with labour analgesia are managed in such clinics, 12 we could not confirm that deliveries with labour analgesia in private clinics were at particularly high risk. However, the Japanese Association of Obstetricians and Gynecologists reported that emergency care or transport of patients to a higher-level facility might have been delayed in several deaths since those private clinics were short-staffed and usually did not store blood for transfusions. 12 The association has since clarified the risks of labour analgesia, stressing that neuraxial anaesthesia during delivery did not increase the maternal mortality rate in Japan. However, evidence from the United States indicates that maternal death and severe morbidity can arise in any setting where physicians and other health workers caring for women in labour and providing analgesia have not received life-support training, planning and experience. 35 A lack of qualified staff and facilities has also been recognized as a factor behind the proportion of caesarean section deliveries in Japan rising to 23.2% (10 761 out of 46 451 deliveries), well above the WHO-recommended rate of no more than 10-15%. 9 To improve the quality of obstetric anaesthesia, the Japan Society for Obstetrics and Perinatology plans to issue qualifications for medical staff providing labour analgesia. However, the society will limit the requisite qualifications to obstetricians and anaesthesiologists and thus the problem of a shortage of human resources will remain. In Japan no suitable and sustainable solution has yet been proposed to improve both the safety and availability of labour analgesia, meaning that women will continue to suffer during childbirth.

Conclusion
Globally, women's health issues are increasingly becoming a higher priority. According to the Japanese government's latest 4th Basic Plan for Gender Equality, 36 the current policy aims to make gender equality the most important issue in Japan by 2020 and to make the country internationally recognized for its gender impartiality and equal opportunity. All current evidence points to these goals being unrealistic. Nevertheless, Japan must accelerate efforts to improve gender equality in all areas and especially in health matters. This includes ensuring full and unrestricted access to prenatal care, resources and expertise, as well as access to safe, pain-free childbirth and comprehensive medical care before, during and after birth.
In 2015, the Japan Society of Obstetrics and Gynecology announced major plans to renovate and modernize obstetrics and gynaecology services nationwide. 37 However, considering that the number of obstetrics facilities, especially small-or middle-size facilities in rural areas, have steadily decreased, simply intensifying work at these facilities will not solve the problem and could impair access to perinatal care. Provision of optimal care for both mothers and babies will necessitate access to Policy & practice Childbirth in Japan Yuto Maeda et al.
appropriate medical institutions and expert care. Consequently, Japan needs to overhaul and remodel its obstetrics facilities, reorganize the regional perinatal care system, 11 promote task-shifting, train more obstetricians and anaesthesiologists and better integrate medical and non-medical care for pregnant women. If this is not done, the nation will be failing in its duties and responsibilities, accelerating Japan's move down the Global Gender Gap index. At the same time Japan risks failing to meet its commitments to the sustainable development goals, to its own policy targets and worse still, increasing the neglect of the rights, health and equality of women in the country. ■