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MIDWIFERYIN
JAPAN
Japanese Nursing Association
Midwifery in Japan 01
Ⅰ. Maternal and Child Health1. Statistics 2
1) Trends in Indicators Concerning Maternal and Child Health 2
2. Policies 3
1) Main Policies 3
2) Main Measures 4
Ⅱ. Midwives in Japan1. Midwifery Regulation 7
1) Definition of the Midwifery Home (Medical Law, Article 2) 8
2) Registration of the Midwifery Home (Medical Law, Article 8) 8
3) Birth Control Instructor 8
4) Obligation to Confidentiality 8
2. Midwifery Education 8
1) Basic Midwifery Education 8
2) Education for Novice Midwives 10
3) Continuing Education 12
4) Certification of “Level III Midwife” 12
3. Number of Midwives 13
4. Evaluation of the Quality of Midwifery Care 14
5. Midwifery Practice 14
1) Importance of Care by Midwives 14
2) Roles of Midwives in Re-modeling of Perinatal Medical Service System 15
3) “Handbook for Introducing Unit Management of a Mixed-Divisions
Ward for Maternity and Other Patients” 16
4) The System Implementation at Facilities 16
Ⅲ. Recent Topics Requiring Special Attention1. “Guide for Protocol Development for Delivery Facilities During Disasters” 18
2. Temporary Transfer System of Midwives 18
3. Pregnancy and Diseases 19
1) Gestational Diabetes Mellitus 19
2) HTLV-1(Human T-cell Leukemia Virus Type 1) 19
References 20
Contents
Midwifery in Japan02
Ⅰ. Maternal and Child Health
1. Statistics1) Trends in Indicators Concerning Maternal and Child Health1)2)
Perinatal and infant mortality rates in Japan, commonly regarded as maternal and child health indicators, rank among the lowest in the world. Special attention, however, should be directed in the future to measures for maternal and child health promotion and to improvement of perinatal medical service system.
(1) Births3)
In Japan, both the number of births and the total fertility rate tend to decrease. Although the birth rate shows a slight increase in the recent years, the increase is not large enough to overturn the ongoing issue of low birth rate in Japan. The total fertility rate in 2012 was 1.41, lower than 2.08 required for population stability. The total number of births in 2012 was 1.05 million, and if the current trend of decreasing birth rate continues, the projected number of births for 2025 is expected to be 0.78 million.
(2) Maternal MortalityThe maternal mortality rate in 2008 was 3.6, showing that Japan has one of the lowest maternal mortality rates
in the world. However, the major causes of maternal mortality are preventable diseases, such as hypertension, and intrapartum hemorrhage.
(3) Perinatal Mortality4)
Japanese perinatal mortality refers to stillbirths after the 22nd week of pregnancy and early neonatal deaths within 1 week after birth. WHO states in its International Statistical Classification of Diseases and Related Health Problems-10 that the “perinatal period commences at 22 completed weeks (154 days) of gestation and ends seven completed days after birth.” Based on this definition, the method of calculating perinatal deaths was revised in 1995 in Japan.
The perinatal mortality rate, which is the combined number of stillbirths after the 28th week of pregnancy and of early neonatal deaths per 1,000 live births is also calculated to compare Japanese data with international data. Japan’s perinatal mortality rate in 2010 was 2.0, which is among the lowest in the world.
There are two main causes of perinatal deaths concerning the fetus, which include “diseases generated during the perinatal period” (85.3%), and “congenital malformations and chromosomal abnormalities” (13.7%). The non-fetal factors include “non-maternal based causes” (36.1%), “complications occurring in the placenta, umbilical cord and fetal membrane” (27.5%), and “maternal diseases that may be unrelated to the current pregnancy” (26.2%).
Table 1: Change in Maternal and Child Health Indicators5)6)7)
Year Population Live Births Birth Rate(per 1,000)
Total Fertility Rate
Maternal Mortality Rate(per 100,000 live births)
Perinatal Mortality Rate(International standard**)
Infant Mortality Rate
(per 1,000 live births)
Stillbirth Rate(per 1,000 births)
1960 93,418,501 1,606,041 17.2 2.00 130.6 41.4 30.7 100.4
1965 98,274,961 1,823,697 18.6 2.14 87.6 30.1 18.5 81.4
1970 103,119,447 1,934,239 18.8 2.13 52.1 21.7 13.1 65.3
1975 111,251,507 1,901,440 17.1 1.91 28.7 16.0 10.0 50.8
1980 116,320,358 1,576,889 13.6 1.75 20.5 11.7 7.5 46.8
1985 120,265,700 1,431,577 11.9 1.76 15.8 8.0 5.5 46.0
1990 122,721,397 1,221,585 10.0 1.54 8.6 5.7 4.6 42.3
1995 124,298,947 1,187,064 9.6 1.42 7.2 4.7 4.3 32.1
2000 125,612,633 1,190,547 9.5 1.36 6.6 3.8 3.2 31.2
2005 126,204,902 1,062,530 8.4 1.26 5.8 3.3 2.8 29.1
2010 128,057,000 1,071,304 8.5 1.39 4.1 2.0 2.3 24.2
2012 127,515,000 1,037,231 8.2 1.41 ― ― 2.2 23.4
* Indicator for international comparison. Sum of the number of stillbirths after the 28th week of pregnancy and the number of deaths in early infancy divided by the number of live births, per 1,000 live births
Midwifery in Japan 03
(4) Infant Mortality4)
The infant mortality rate per 1,000 live births was 2.3 in 2011, showing that Japan has one of the lowest infant mortality rate in the world. The leading cause of infant death is “congenital malformation and chromosomal abnormality”, followed by “perinatal-specific respiratory disorders and cardiovascular disorders” and “unforeseen accidents”. The first leading cause of neonatal deaths within 1 month after birth is “congenital malformation and chromosomal abnormality”, and the second is “perinatal-specific respiratory disorders and cardiovascular disorders”.
After the Second World War, the major causes of infant deaths continued to be infectious diseases including pneumonia, bronchitis, enteritis, and other diarrheal diseases. Those causes have drastically decreased today. On the other hand, the number of infant deaths caused by congenital malformation and chromosomal abnormality, and diseases generated during the perinatal period have not decreased dramatically. These causes warrant further attention in the future.
2. Policies8)
The aim of the policies in Japan is to implement comprehensive maternal and child health care from adolescence to pregnancy, childbirth, neonatal and infant periods. The measures are differentiated for beneficiaries at different periods so that optimal services can be provided that suit their specific needs.
The Maternal and Child Health Act was established to maintain and promote maternal, newborn, and infant health and to contribute to improve the national health by figuring out principles of maternal and child health. The act also aims to provide mothers, newborns and infants health guidance and examination services and other medical measures. It stipulates that it is the role of the municipalities to provide health guidance to pregnant and postpartum women and health check-ups for newborns and infants.
1) Main Policies
(1) Sukoyaka Oyako 21 (Healthy Parents and Children 21)8)10)
Sukoyaka Oyako 21 (Healthy Parents and Children 21), a national campaign has been promoted since 2000 through the combined efforts of related organizations and groups working toward the common goals of systematizing outstanding and new issues and guiding maternal and child health care on its pathway for the 21st century. This program has four main challenges with 61 indicators as goals for the decade from 2001 to 2010. The four main challenges include: reinforcement health measures during adolescence and promotion of health education; ensuring of a safe and comfortable pregnancy/ childbirth, and assistance for infertility; development of environmental systems to maintain and improve pediatric medical standards; promotion of the sound development of children and reduction of anxiety concerning childrearing. An interim evaluation was conducted in 2005 and 2009 to review the program, and the
1. Purposes
2. Major provisions
The purposes of this act is to maintain and promote maternal, newborn, and infant health and to contribute to improve national health by figuring out principles of maternal and child health as well as providing mothers, newborns and infants with health guidance and examination services to take medical and other measures.
1. Health guidance (Article 10)The Municipality shall provide pregnant/ postpartum women with the necessary health guidance on pregnancy, child delivery, and childrearing or shall recommend them to receive such health guidance.
3. Report on pregnancy (Article 15)Those diagnosed to be pregnant shall immediately report their pregnancy to the mayor of the municipality.
4. The Maternal and Child Health Handbook (Article 16)The municipality shall issue the Maternal and Child Health Handbook to those who have reported their pregnancy.
5. Report on the birth of a low-birth weight child (Article 18)Upon the birth of a baby weighing under 2,500 g, his/ her guardians shall immediately report to the municipality where the baby is located at the time.
6. Medical aid for premature infants (Article 20)The municipality shall provide premature infants with the medical aids, or shall pay the full medical expenses.
2. Health check-ups (Articles 12 and 13)•The Municipality shall provide health check-ups for 18-month-old infants
and 3-year-old infants.•In addition to the above, the Municipality shall provide health check-ups for
pregnant/ postpartum women and newborns/ infants as needed, or shall encourage them to receive health check-ups.
Fig. 1: Outline of the Maternal and Child Health Act9)
Midwifery in Japan04
final evaluation was conducted in 2013. The results of the final evaluation indicated improvement in approximately 80% of the 69 indicators (74 items). Starting in 2014 a new set of indicators will be developed.
(2) Child and Childrearing Support Plan11)
In 2010, the Cabinet decided to formulate a new outline of measures for a society with a decreasing birthrate, “Children and Childrearing Vision -- for the Society Full of Smiling Children --”. The new outline stipulated the basic idea of “Children First (Children at the center)” with the aim of building a society that values children.
In 2012, the Child and Childrearing Support Law was established to construct a new structure by unifying child and childrearing support systems and their funds. It comprehensively promotes improvement in school education, child care for toddlers, and community child and childrearing support. The law aims to achieve this goal through improvement of the approved child institution system, unified benefit payments to approved child institutions/kindergartens/day-care centers (institution-based benefit payment), along with the establishment of benefit payment to small-sized day-care service providers (community-based benefit payments), and the establishment of child and childrearing support conferences.
(3) Improvement of Child and Childrearing Support through Unified Reform of the Social Security and Taxation System
Childrearing support became one of the central targets of the unified reform of the social security and taxation system. A new system for child and childrearing support was established, permanent financial resources were secured for this system.
2) Main Measures8)
The aim of the policies is to implement comprehensive maternal and child health care under a consistent system covering premarital preparation, pregnancy, childbirth and the neonatal and infant periods.
National Plan of the Early 21st Century for the Healthof Mothers and Children (2001–2014)
Childbearing PeriodChildbearing periodPregnancy/Delivery/ Postpartrum PeriodSupport Period
Residents (Parents and children) SchoolsCompanies
NPOs
Medical Institutions Research Institutions
Local MunicipalitiesHealth Parents and Children 21 Promotional Council (Local Community Organizations / Specialized Organizations / Private Organizations) National Government (Ministry of Health, Labour and
Welfare, Ministry of Education, Culture, Sports, Science and Technology, etc.)
(i) Reinforcement Health Measures during Adolescence and Promotion of Health Education
(ii) Ensuring of a safe and Comfortable Pregnancy / Childbirth, and Assistance for Infertility
(iii) Development of Environmental Systems to Maintain and Improve Pediatric Medical Standards
(iv)Promotion of the Sound Development of Children and Reduction of Anxiety concerning childrearing
Teenage Suicide Rate (Down)Teenage Abortion Rate(Down)Teenage STD (Sexually Transmitted Disease) Rate (Down)
Maternal Mortality Rate (Down by half )Rate of Occurrence of Postpartrum Depression (Down)Ratio of Obstetricians, Gynecologists and Midwives Compared to the Population of Pregnant Women (Work toward an Increase)
Ratio of Low-Weight Newborns at Birth among All Live Births (Down)Mortality Rate by Accidents (Down by half )Percentage of Women who Smoke(Cigarettes) during Pregnancy and Parents who Smoke at Home whileRaising Children (0%)
Number of Fatal Cases of Child Abuse (Down)Ratio of Breastfeeding Mothers 1 month after childbirth (Up)Ratio of Pediatricians with Skills to Handle Emotional Problems of Parents and Children (100%)
Cooperation and Co-Working
Establishing monitoring system
Parents
Neonatal/ Infant toToddler/ Child Period
Neonatal/ Infant toToddler/ Child PeriodFetal to Newborn PeriodAdolescenceChildren
Topics
Main goals (2014)
Fig. 2: Sukoyaka Oyako 21 (Healthy Parents and Children 21)8)
Midwifery in Japan 05
(1) Distribution of the Maternal and Child Health Handbook4)
A pregnant woman has to notify the municipality of her pregnancy (Maternal and Child Health Law, Article 15). Upon registration of pregnancy, the Maternal and Child Health Handbook is issued to her (Article 16).
The Maternal and Child Health Handbook originated from the Maternal Handbook first issued in 1942, which established a system of pregnancy registration and provided pregnant and postpartum women with health care support. The Maternal and Child Health Handbook is issued for pregnant women upon request to their municipality. The handbook functions as a maternal and infant health record that can be used to follow the development process, including pregnancy, birth, and infant growth, as well as an immunization record prior to reaching school age. Pregnant women can use their handbook as a database on the pregnancy process beyond the facility where they receive their health check-ups. Furthermore, the handbook can be used by the entire family for basic information on pregnancy, childbirth and child care. Such information is extremely helpful for coherent maternal and child health care throughout the period of pregnancy, childbirth and childcare. Various uses of the handbook are also effective in boosting awareness of the mother and the father.
As part of the measures to combat declining birth rate, the municipal subsidy for antenatal check-ups has been increased and the Maternal and Child Health Handbook now includes free coupons for 14 antenatal check-ups. The
Note 1) : State-subsidized projects
Hea
lth C
heck
-up,
etc
.Adolescence Marriage Pregnancy Child birth Age 1 Age 2 Age 3
Prenatal/ postnatalhealth check-ups(Ultrasound Scan for mothers over35-year old)
Vertical Hepatitis B transmission prevention project
Health check-up for infants
Hearing test for the newborn
Mass-screening for congenital dysbolism, Cretinism tests
1 yr. 6 mo. childhealth checkups
3 yr. childhealthcheckups
Hea
lth g
uida
nce,
etc
.
Home visit services to supportchild-rearing (*2)
Consultation and guidance services for maternal and child health(premarital classes) (classes for newly weds) (parents’ class) (child care class)
Women’s lifetime health assistance projects (*1)(General health counseling and centers for specialized infertility counseling)
Promotion of adolescents healthcare
Promotion of food education
Report on pregnancy and issuance of MCH handbook from local government
Distribution of the Maternity Logo
Home-visit guidance, etc. by public health nurses, etc.Home visit services for all families with infants before 2 months of age(“Hello Baby Project”) (*2)
Intensified projects of child accident prevention
Med
ical
aid
, etc
.
Medical care for premature infants
Medical aid for toxemia in pregnancy
Healthy pregnancy support projects (*1)
Next generation development basic research project for overcoming children’s diseases, etc.(healthy, labour, welfare and sciencere search fund)
Med
ical
m
easu
res,
etc
.
Child mental care network project (*1)Medical care network project for child abuse prevention (*3)
Classifi-cation
Medical aid for specific chronic pediatric diseasesProvision of daily necessities for children with specific chronic pediatric diseasesMedical treatment and education services for children with tuberculosisTreatment guidance services (*1)Project to provide special formulas for children with dysbolism
Subsidy for specificinfertility treatmentexpenses (*1)
*3: General support projects for child abuse/ DV prevention measures, etc.*2: Projects funded by the Subsidies for Next Generation Supporting Program*1: General support projects for maternal and child health measures
: Projects on general finance
Fig. 3: System of Measures for Maternal and Child Health4)
Midwifery in Japan06
Maternal and Child Health Law also stipulates that the municipality provides health check-ups to infants of 18-months and 3-years of age. Other benefits include free coupons for health check-ups for infants and toddlers, although benefits depend on the municipality.
The handbook is available in a number of foreign languages (English, Chinese, Korean, Spanish, Indonesian, Portuguese, Thai, and Tagalog) for foreigners residing in Japan and for Japanese residing overseas.
(2) Health/Home Guidance for Pregnant Women and InfantsHealth guidance and home guidance concerning pregnancy, childbirth, and
child care are mainly provided by the municipality (Maternal and Child Health Law, Article 10). As needed, physicians, midwives, or public health nurses visit the homes of and provide health guidance for pregnant and postpartum women, newborns, and premature babies. (Articles 11, 17, and 19)
※ Home-visit Guidance Project for All Infants13)
Home visits are made for all households with infants aged up to 4 months so that their caregivers can discuss various problems or anxieties they have, and information on childrearing support can be provided. At the same time, mental and physical conditions of parents and children, as well as the childcare environment can be grasped, so that households that require support can be detected and appropriate services can be provided. In this way, a home-visit, which is the first opportunity for the household rearing infants to have contact with the local community, will help households keep away from being isolated and secure a sound childrearing environment.
(3) Other Measures① Distribution of the Maternity Logo4)
As part of the Sukoyaka Oyako 21 (Healthy Parents and Children 21) campaign efforts, Maternity Logo was introduced in March 2006. The Logo promotes an environment of safety and comfort for women during pregnancy and child delivery period by promoting public recognition of pregnant women. By displaying the logo while pregnant women use public transportation, it is easier for them to show that they are pregnant, and thus the logo promotes the development of a friendly environment for pregnant/postpartum women. Public administrations and private businesses are actively engaged in increasing the distribution of Maternity Logos by distributing Maternity Logos with Maternal and Child Health Handbooks, and by displaying posters about Maternity Logos.
Maternal and Child Health Handbook12)
”I’m Expecting A Baby.” The Maternity Logo14)
Midwifery in Japan 07
1. Midwifery RegulationThe midwife and her activities are defined under the Act on Public Health Nurse, Midwife and Nurse (No. 203)
established in 1948. The purpose of this law is to improve the quality of public health nurses, midwives, and nurses, and promote medical care and public health. In December 2001, the law was partially revised, and the title of the law in Japanese was changed slightly.
Although the law had traditionally defined only professional roles, the revised law in 2006 added provisions concerning the titles of midwives, nurses and assistant nurses (See Article 42 (3) of the Act on Public Health Nurse, Midwife and Nurse).
In addition, the Japanese Nursing Association (JNA) is a member of the International Confederation of Midwives (ICM) and has adopted the following ICM definition of the midwife, which was revised at the ICM International Council Meeting in Kobe in 1990 and ratified by the International Federation of Gynecology and Obstetrics (FIGO) in 1991, and then by the World Health Organization (WHO) in 1992. The recent revision was made in 2011 as following.
A midwife is a person who has successfully completed a midwifery education programme that is duly recognized in the country where it is located and that is based on the ICM Essential Competencies for Basic Midwifery Practice and the framework of the ICM Global Standards for Midwifery Education; who has acquired the requisite qualifications to be registered and/or legally licensed to practice midwifery and use the title ‘midwife’; and who demonstrates competency in the practice of midwifery.
Scope of PracticeThe midwife is recognised as a responsible and accountable professional who works in partnership with women
to give the necessary support, care and advice during pregnancy, labour and the postpartum period, to conduct births on the midwife’s own responsibility and to provide care for the newborn and the infant. This care includes preventative measures, the promotion of normal birth, the detection of complications in the mother and child, the accessing of medical care or other appropriate assistance and the carrying out of emergency measures.
The midwife has an important task in health counseling and education, not only for the woman, but also within the family and the community. This work should involve antenatal education and preparation for parenthood and may extend to women’s health, sexual or reproductive health and child care.
A midwife may practice in any setting including the home, community, hospitals, clinics or health units. Revised and adopted by ICM Council June 15, 2011
Due for review 201715)
Midwives and their activities are regulated as follows by the Act on Public Health Nurse, Midwife and Nurse, as well
Act on Public Health Nurse, Midwife, Nurse (Acted in 1948, Revised in 2006)[Definition of midwife] Article 3 Under this law, “Midwife” refers to a woman licensed by the Minister of Health, Labour and Welfare,
who practices midwifery or provides health care to pregnant women, women in the postpartum period, and newborn infants.
[Restrictions on midwifery activities] Article 30 Only a midwife licensed under Article 3 shall engage in these activities, except in situations where
those activities are performed in accordance with the provisions of the Medical Practitioner Law (Law No. 201, 1998).
[Restrictions on the use of titles] Article 42 (3) 2. One who is not a midwife shall not refer to oneself as a midwife nor use other misleading titles.
Ⅱ. Midwives in Japan
Midwifery in Japan08
as other related laws, including the Medical Care Law and the Maternal Protection Law.
1) Definition of the Midwifery Home (Medical Law, Article 2)16)
A “Midwifery Home” is a place where a midwife provides midwifery services (excluding those given in a hospital or clinic) to the general public and selective group of people.
The Midwifery Home may not consist of facilities that can accommodate 10 or more pregnant, parturient, or puerperal women.
2) Registration of the Midwifery Home (Medical Law, Article 8)16)
When a midwife has established a midwifery home, she is required to notify the governor of the prefecture where it is located, within ten days of beginning operations.
3) Birth Control Instructor
Maternal Protection Law, Article 15 states as follows: “the practice of instructing women about birth control utilizing the contraceptive devices specified by the Minister of Health, Labour and Welfare is only permitted by physicians and those who are designated by the governor of the prefecture”. Those who may be designated by the governor of the prefecture are midwives, public health nurses or nurses who have finished the courses which the governor of the prefecture certifies according to the standard set by the Minister of Health, Labour and Welfare. (Article 15, Paragraph 2)
Nowadays, it is required to make efforts in a variety of places women and their families become aware of birth control at each life stage in addition to consultation as family planning experts. Persons who play such a role were nicknamed as “Reproductive Health Supporter” by JNA as of 2009.
4) Obligation to Confidentiality
Article 134 of the Penal Code states that physicians, vendors of pharmaceutical products, midwives, lawyers, defendants and notaries, as well as those who previously engaged in these occupations, can be punished by imprisonment for six months or less, or fined a maximum of 100,000yen, if they breached confidentiality without legitimate grounds and disclosed others the clients’ information obtained through their practice.
2. Midwifery Education1) Basic Midwifery Education
(1) Midwifery Education SystemAn applicant for the midwife license is required to have acquired certification as a nurse either prior to or
simultaneously as acquiring the midwifery license. In addition, the person has to have studied midwifery for longer than one year at college or training school to obtain a midwifery license.
As shown in the figure on the next page, there are various midwifery education pathways in Japan.JNA is making an effort to create a system that provides a 4-year basic nursing education in college/universities
unified midwifery education at the graduate level.Midwifery students learn about pregnancy/child delivery/postpartum care in various educational courses. They are
also required to assist with child delivery approximately 10 times during the course of “Practical Training for Midwifery.” The practical midwifery training is provided in a hospital, clinic, or midwifery home. According to the regulations of The Educational Institutions of Public Health Nurses, Midwives and Nurses, the child delivery for midwifery students’ practical training should satisfy the following three conditions,:
1: Delivery of a child during the period from the first day of the 37th week to the seventh day of the 41st week of pregnancy.
2: Vaginal delivery3: Head-first delivery (the fetus is in a head-down position) and single birth (there is only one fetus).
(2) Number of Midwifery Schools/ProgramsOver the past few years, there has been a slight increase in the number of midwifery schools. However, the number
of students accepted for midwifery programs at four-year colleges/universities is small due to the difficulty securing facilities for clinical training. Consequently, the number of those who pass the national examination remains at about the
Midwifery in Japan 09
same level.
(3) Midwifery CurriculumIn l ine with the 1997
r e v i s i o n o f r e g u l a t i o n s c o n t r o l l i n g m i d w i f e r y e d u c a t i o n , t h e c u r r e n t curriculum consists of the Table 2 (See page10).
As a result of the April 2008 revision of regulations c o n t r o l l i n g e d u c a t i o n a l institutions of public health nurses, midwives and nurses, the number of credits for clinical midwifery training will increase to nine in 2010. In addition, the 2009 revision concerning extension of the total years of training in the Act on Public Health Nurse, Midwife and Nurse resulted in the increase in total number of credits for completing course from 22 to 28 for students starting the course in 2012 or later. Moreover, births that can be assisted by students will be limited, in principle, to full-term and vaginal births, and cephalic and single births, within a period of from the first stage of labour to two hours later than
Professional Graduate School
No. of passing the national exam
Total no. of educational institution
Midwifery School
Junior CollegeUniversityGraduate
course
200
180
160
140
120
100
80
60
40
20
0
2,200
2,000
1,600
1,800
1,400
1,200
1,000
800
600
400
200
0
1,579
2,072
1,6191,697
1,6231,505
1,4441,388
2010 2013200520001995199019851981
180
197
146
124
98
797870
Fig. 5: The number of midwifery educational institutions and those passing the national midwifery examination18)
* The National Midwifery Examination has been given once a year since 1990, although it was given twice a year until then.
*2*1
Specialty courseat junior colleges
(1 year)
(1) below
ProfessionalGraduate school
(2 year)
1 year within the 4 years course
(1) below
Specialty schoolat colleges/ universities
(1 year)
1 individual yearafter obtaining
the nurse license
(1) below
Specialty courseat colleges/universities
(1 year)
(1) and (2) below
Midwifery school(1 year)
(1) below
Those who (1) hold or (2) are to receive a license as a nurse
High SchoolNursing Program
(2 years)
Five-YearEducation
High School(3 years)
Graduate school(2 year)
(1) below
High School
NursingSchool
(3 years)
JuniorCollege(3 years)
College/University(4 years)
National Midwifery Examination
Fig. 4: Outline of the Midwifery Education Curriculum17)
*1 Offered to those who have completed the classes of 4-year education at college/university required for taking the National Midwifery Examination.*2 There are colleges/universities, junior colleges and graduate schools that even graduates from nursing schools can enter if they meet the institution’s requirements.
Midwifery in Japan10
completing the third stages.Exact curriculum details for the educational programs may be
set at the discretion of each school, depending upon the school’s educational aims.
Table 2: Midwifery Course Content19)
Subject Credit Content
Fundamental of Midwifery
6 ○ �To learn about basics of midwifery as an activity supporting women throughout their lifetime with a focus on reproductive health
○ �To understand the midwife’s role to be responsible for respecting the life of mother and child at the same time and to learn bioethics in depth○ �To nurture the ability to support motherhood and fatherhood development placing particular importance on psychological
and sociological perspectives of the family○ To learn about team approach and coordination/ liaison with the related institutions○ To learn about expertise of midwives, attitudes and stance required for midwifes
Midwifery Diagnostics and Skills
8 ○ �To nurture the ability to diagnose normal/abnormal pregnancy progression and acquire the latest skills that fit the diagnosis○ �To ensure to acquire the essential midwifery skills required for implementing midwifery process, through improved and
strengthened practical training designed for thorough acquisition of essential basic midwifery skills○ �To strengthen the ability responding to emergencies that can occur in childbirth (repair of perineorrhaphy and laceration,
neonatal resuscitation, hemostatic treatment and assistance to parturient women and the family of abnormal newborns, etc.)○ �To strengthen assessment techniques of health conditions of pregnant/puerperant women and newborns and assistance
techniques based on the assessment result○ To nurture the ability to assist childbirth respecting the pregnant and parturient women’s initiative
Maternal and Child Health in Community
1 ○ �To nurture the ability to provide maternal and child health services meeting the various needs of citizens as well as the ability to promote regional maternal and child health in cooperation and collaboration with the related persons in public health, medical care, and welfare
Midwifery Management
2 ○ �To learn about management of midwifery services, operation of maternity clinics, and the perinatal medical care system
Clinical Midwifery Training
11 ○ �To integrate clinical training in midwifery diagnostics and skills, maternal and child health care in the community, and midwifery management. Births assisted by students will be limited, in principle, to full-term, vaginal, cephalic and single births, during a period of from the first stage of labour up to two hours after the completion of the third stage
○ �To provide continuous care at least one case of woman from her mid-pregnancy to one month after delivery during the training period
○ �To include clinical training to strengthen the ability to assess pregnancy progression through antenatal health check-ups support breastfeeding of puerperant women, and conduct newborn babies’ assessment
TOTAL 28 ○ To provide at least 930 hours of lecture, practical training, etc.
( ) The number of credits applied to students starting the course in 2012※ 1 credit corresponds to 45 hours(Note) When the applicant passes the national examination after completing 28 credits, the midwifery license is given by the Minister of Health, Labour and Welfare. Since it is
not necessary to renew the license once it is obtained, the holder can continue midwifery practice indefinitely.
Student Midwives Practice for Neonatal Cardiopulmonary Resuscitation
2) Education for Novice Midwives20)
The Ministry of Health, Labour and Welfare (MHLW) put forth the “Guidelines for Training Novice Nursing Staff” in December 2009 with concrete measures to secure the quality of nursing. This was with the understanding that “training of novice nursing staff is one of the primary ways to uplift the overall quality of the nursing staff, and warrants that as many institutions provide a standardized level of novice training”. In February 2011, ”the Final Report of the Commission that Investigated the Training of Novice Nursing Staff” presented the guidelines for training of novice public health nurses and midwives. According to the report, since trainings of novice public health nurses and novice midwives are often provided at institutions, it is important that the philosophy/basic policy/ structure of the training of novice midwives and trainer development should be aligned with those for novice nursing staff training. As a result, the goals of midwifery techniques that midwives should obtain during the first year after they have started midwifery practice, the elements supporting their midwifery techniques, and examples of technical guidance have been added to the “Guidelines for Training Novice Nursing Staff.”
The major efforts by the MHLW concerning novice nursing staff training are presented in their website. It is pointed out in the “conclusion of the investigative commission on the ideal state of the Act on Public Health Nurse, Midwife
Midwifery in Japan 11
and Nurse (November 2005)” that institutionalization of novice nursing staff training is highly necessary. In the “interim conclusion on improvement and securing of nursing quality (March 2009),” it was also pointed out that it was necessary to urgently examine the contents, methods, and diffusion methods of novice nursing staff training, with an aim to institutionalize and make compulsory the training, and putting them into practice while making efforts to improve the basic nursing education. The Act on Public Health Nurse, Midwife and Nurse and the Act on Assurance of Work Forces of Nurses and Other Medical Experts were amended on July 15, 2009. According to the amendment, clinical training of nursing staff newly engaging in the practice became a nonbinding target, effective on April 1, 2010. According to the amendment, each nursing staff is responsible for improving her/his nursing capacity by undergoing clinical training and other training even after acquiring the license, while the director of the hospital, etc. should also make efforts to provide training and to secure opportunities for nursing staff to receive such training. It is of hope that utilization of the “Guidelines for Training Novice Nursing Staff” in many medical institutions contributes to improving the training of novice nursing staff and their nursing quality, to ensuring medical safety, and to preventing novice nursing staff from giving up their nursing career.
JNA formulated the “Training Guidelines for Newly Graduated Midwives” in 2012.
Table 3: Clinical Ladder for Education for Novice Midwives20)
Novice level Level I Level II Level III Level IV
Goals 1. Able to provide midwifery care safely and surely in accordance with instructions, the procedure, and the guidebook.
1. Able to provide midwifery care safely and surely, having acquired knowledge, skills, and a proper attitude to assist healthy living.
2. Know the contents of midwifery led care for in-patients and outpatients.
*Able to understand the pathological conditions of high risk patients and proper way to cope with them.
1. Able to provide individualized care based on the midwifery process.
2. Able to provide care in the in-hospital midwifery clinic with support.
3. Able to provide midwifery care together with the senior midwives in the in-hospital midwifery care unit.
*Able to judge whether the symptom is high or low risk and provide the initial intervention
1. Able to responsibly provide midwifery care of the pregnant/puerperant woman and the newborn throughout the hospitalization period.
2. Able to autonomously provide individualized care in the in-hospital midwifery clinic.
3. Able to play an instructive role in the in-hospital midwifery clinic.
4. Able to autonomously provide care in the in-hospital midwifery care unit.
*Able to detect transition from low risk to high risk symptoms in the early stage and to intervene when necessary.
1. Able to provide creative midwifery care.
2. Able to play an instructive role in the in-hospital midwifery care unit.
3. Able to play an instructive role in the in-hospital midwifery clinic.
*Able to provide instruction to staff in both low and high risk cases.
Table 4: Clinical Ladder for Continuing Education21)
Novice level Level I Level II Level III Level IV
Mat
erni
ty c
are
abili
ty
Dia
gnos
is a
nd c
are
durin
g pr
egna
ncy,
chi
ld d
eliv
ery,
puer
periu
m, a
nd n
ewbo
rn p
erio
d/ P
oint
s to
be
cons
ider
ed d
urin
g th
e ch
ild d
eliv
ery
perio
d
Info
rmat
ion
gath
erin
g
i) Able to understand information required for healthy living behavior diagnosis and pregnancy progress diagnosis in pregnancy/child delivery/puerperium/newborn period with support.
ii) Able to gather information using the fixed form.
iii) Know the lacking information and able to gather the additional necessary information with guidance.
iv) Able to record using correct terms and appropriate expressions based on criteria and procedures of midwifery care.
i) Able to autonomously gather information required for healthy living behavior diagnosis and pregnancy progress diagnosis in pregnancy/child delivery/ puerperium/newborn period
ii) Know the lacking information and be able to gather the additional information.
iii) Able to sort out information required for assessment with guidance.
iv) Able to make records using the correct terms and appropriate expressions.
i) Able to gather all information required for implementing individualized midwifery care among the information required for healthy living behavior diagnosis and pregnancy progress diagnosis in pregnancy/child delivery/puerperium/newborn period
ii) Able to sort out information required for assessment.
i) Able to gather information required for healthy living behavior diagnosis and pregnancy progress diagnosis in pregnancy/child delivery/puerperium/newborn period based on theoretical reasons.
ii) Able to gather information in order to conduct assessment taking mental/social aspects and family backgrounds into consideration.
iii) Able to sort out the information described in ii) considering needs and priority.
iv) Able to gather information intentionally from the relevant persons from different job types.
i) Able to get the picture of overall situation concerning the target including individuality, mental/social aspects, family background, and selectively gather information focused on the required area.
Ass
essm
ent/C
larifi
catio
n of
pro
blem
s (n
eeds
)
Low riski) Know the normal values of vital
signs, various examinations and various physical measurements of pregnant/puerperant women and newborns.
ii) Able to understand anatomy and physiology concerning obstetrics.
iii) Able to understand the meanings of measured values with support.
iv) Able to analyze gathered information of healthy living behavior and the pregnancy progress diagnosis with support.
v) Able to understand the pathological conditions of major perinatal disorders.
Low riski) Know pregnant/puerperant
women’s normal chronological course, and able to understand newborns’ physiology.
ii) Able to analyze gathered information of healthy living behavior and pregnancy progress diagnosis with support.
High riski) Able to understand
pathophysiology and examinations of major perinatal disorders (threatened miscarriage/premature labor, hyperemesis, pregnancy hypertension syndromes, gestational diabetes mellitus, and placenta previa) and the risks of multiple pregnancies.
ii) Able to understand the proper response to abnormality of pregnant/puerperant women and newborns, and how to assist them.
Low riski) Able to analyze the gathered
information of healthy living behavior and the pregnancy progress diagnosis.
ii) Able to clarify the needs of pregnant/puerperant women and newborns.
iii) Able to decide the priority order of the needs.
High riski) Able to clarify problems
occurring to the pregnant/puerperant woman and the newborn.
ii) Able to determine the priorities of the problems.
Low riski) Able to clarify the potential
needs.High riski) Able to clarify potential
midwifery problems.ii) Able to clearly distinguish the
midwifery problems from the general problems*.
Low /high riski) Able to give a correct diagnosis
considering the risks of the target following the diagnosing process (Able to sort women eligible for in-hospital midwifery care)
ii) Able to explain the reasons for the given diagnosis to other midwives and the medical care team members.
iii) Able to instruct junior midwives so that they can make a diagnosis following the diagnostic process.
Midwifery in Japan12
3) Continuing Education
The JNA offers 2-3 day off-the-job training programs for midwives, such as human resource development training concerning establishment and conduct of an in-hospital midwifery clinic and in-hospital midwifery care etc. Similarly, educational programs are also offered by prefecture nursing associations and other organizations.
Since FY2011, JNA has put a priority on enhancing practical competency of midwives amongst midwifery related agendas. In 2012, JNA formulated a continuing education tool that can be applied nationwide, “Guidelines for Applying Practical Midwifery Competency Ladder (Clinical Ladder)” that links the training for novice midwives to in-service professional development provided afterwards.
4) Certification of “Level III Midwife”
Due to the decrease of child birth, obstetric facilities and maternity wards in both hospitals and clinics are decreasing. This leads to the problem of midwives with less opportunities to attend childbirth and improve their midwifery skills. Midwives became less confident of their abilities and are confused when they are to tell others of how competent they are.
Novice level Level I Level II Level III Level IV
Dia
gnos
is
i) Able to make an appropriate diagnosis by analyzing information on healthy living behavior and pregnancy progress with support.
i) Able to make an appropriate diagnosis by analyzing information on healthy living behavior and pregnancy progress with support as needed.
i) Able to make an appropriate diagnosis by analyzing information on healthy living behavior and pregnancy progress.
ii) Able to consider the priority of problems based on the details of the diagnosis.
i) Able to make an appropriate diagnosis by analyzing information on healthy living behavior and pregnancy progress.
ii) Able to set the priorities while considering whether providing midwifery care only is enough, or medical intervention by the physician is required based on the details of the diagnosis.
i) Able to share the given details of the diagnosis with other members of the medical care team including the pregnant/puerperant woman.
ii) Able to give guidance on the details of the diagnosis given and the priorities of the problems.
iii) Able to gather required information, do an assessment, make a diagnosis, and set the priorities in a short time during an emergency.
Pla
nnin
g
i) Able to understand the current conditions and needs of the pregnant/puerperant woman and the newborn.
ii) Able to set goals according to the needs of the pregnant/puerperant women and the newborns with support.
iii) Able to make a consistent plan in terms of the conditions of the pregnant/puerperant women and the newborns, the list of their problems, and the goals with support.
iv) Able to make a specific plan using the 5W1H framework.
v) Able to utilize the midwifery care criteria/standard midwifery plan.
i) Able to set goals according to the needs of the pregnant/puerperant women and the newborns.
ii) Able to make a consistent plan in terms of the conditions of the pregnant/puerperant women and the newborns, the list of their problems, and the goals.
iii) Able to make a specific plan using the 5W1H framework.
iv) Able to make a midwifery plan with the participation of the pregnant/puerperant women and their family members with support.
i) Able to make a midwifery plan considering the individuality of the pregnant/puerperant women and the newborns.
ii) Able to assess and revise the midwifery plan.
iii) Able to make a midwifery plan with the participation of the pregnant/puerperant women and their family members.
i) Able to make a midwifery plan considering mental, social, and family conditions of the pregnant/puerperant women and the newborns.
ii) Able to make a plan and revise it depending on the conditions.
iii) Able to make a midwifery plan with the participation of the pregnant/puerperant women and their family members, and revise it.
iv) Able to make a plan including the collaboration with other related health/medical care staff and revise it.
i) Able to make a plan using an appropriate method considering the priorities of the pregnant/puerperant women and the newborns and their midwifery problems.
ii) Able to set appropriate goals (which can be reached/measured/ assessed) in order to solve the target’s problems.
iii) Able to play an educational/instructive role in the process of making a midwifery plan.
Pra
ctic
e
i) Able to explain the midwifery practice without fail before starting it.
ii) Able to carry out the items to be acquired during the novice midwife training.
iii) Able to provide the pregnant/puerperant woman and the newborn with care services according to the midwifery care plan with support.
iv) Able to conduct the observations required for treatment and diagnosis and to appropriately report it.
v) Able to conduct the indicated tasks correctly and safely following the midwifery care standards and procedures.
vi) Able to correctly record the practice carried out following the midwifery recording procedures.
vii) Understand how to cope with in an emergency.
viii) Call others for help in an emergency.
ix) Know what items are required in an emergency and prepare them according to the procedures.
x) Able to understand the clinical pathway when using it.
i) Able to explain the midwifery practice without fail before starting it.
ii) Able to use the basic midwifery skills with support.
iii) Able to provide the targets with midwifery care safely and surely following the standards and procedures according to the midwifery care plan.
iv) Able to make records using correct terms and appropriate expressions following midwifery care standards and procedures.
v) Able to provide Basic Life Support and Advanced Life Support in an emergency (including neonatal resuscitation).
vi) Able to conduct practice following the clinical pathway when using it.
i) Able to carry out midwifery practice according to the midwifery care plan.
ii) Able to provide the necessary care considering conditions and responses of the pregnant/puerperant women and the newborns.
iii) Able to record new information other than the needs and problems on the list in a timely manner and make an addition or revision to the plan.
iv) Able to act properly as a member of the team in an emergency.
i) Able to conduct practices according to the plan while checking the responses of the pregnant/puerperant woman and her family members.
ii) Able to play a central role in providing care to the pregnant/puerperant women and newborns in the facility/department overall.
iii) Able to play a central role in an emergency.
iv) Able to play an educational/instructive role in the in-hospital midwifery clinic.
v) Able to conduct activities properly in collaboration with other related health/medical care professionals.
i) Able to exercise creativity and innovativeness in providing midwifery practice.
ii) Able to provide nursing/midwifery care with various approaches.
iii) Able to cope with an emergency, and take the leadership.
iv) Able to play an educational/instructive role at all times.
v) Able to support the staff playing an educational/instructive role.
Eva
luat
ion
i) Able to accurately report the result of the midwifery care provided by the midwife herself.
ii) Able to tell what she did not know during her midwifery practice.
i) Able to ask questions regarding her midwifery practice and solve them.
ii) Able to assess the midwife’s own midwifery practice on an basis with support.
iii) Able to revise the plan for a continuing problem.
iv) Able to record the summary of the performed midwifery practice.
i) Able to assess the result of the midwifery care provided by herself on reasonable grounds.
ii) Able to assess the extent to which the goal was achieved, and to revise the plan.
iii) Able to explain and record the summary of the care provided by herself.
iv) Able to assess the variances when using clinical pathways.
i) Able to assess if the midwifery care provided by herself met the needs of the pregnant/puerperant woman and the newborn.
ii) Able to make self-evaluation concerning whether she is a good role model for the junior midwives and students.
i) Able to make qualitative/quantitative evaluation of the midwifery care provided by herself.
ii) Able to evaluate the midwifery care provided by other staff and give guidance.
Midwifery in Japan 13
Therefore, Japanese Nursing Association created a “Clinical Ladder of Competencies for Midwifery Practice” and published a guidebook introducing methods of how to apply this clinical ladder to practicing midwives in August 2013. In this clinical ladder, midwifery abilities are based on 3 framework, “ethical understanding”, “maternity care ability” and “professional autonomy”. The ladder starts from “level novice” up to “level IV”. (See figure for detail)
Now, the Japanese Nursing Association along with four other midwife organizations (Japan Midwives Association, Japan Academy of Midwifery, Japan Society of Midwifery Education, and Japan Institute of Midwifery Evaluation) has established a certification system of midwives at “level III” of the clinical ladder. The certification is scheduled to start in August 2015.
The aim of certifying “level III” midwives is to acknowledge them as a “midwife with ability to perform midwifery with autonomy and independence”, and by creating a distinct expected levels for their abilities, midwives will know how they may improve their profession. It is expected that the standards of midwifery to raise, securing the quality of care for mothers and their newborns. Additionally, it may lead to the confidence of midwives, enabling other professions to recognize the competencies of a midwife, and may promote the unique role of a midwife.
3. Number of MidwivesThe number of midwives employed in 2012 was 35,185, or 0.28 per population of 1,000. About 62% of midwives
work at hospitals and 25% at clinics. Additionally there are midwives who are currently unemployed, or working as public health nurses or nurses.
Fig. 6: The required status to achieve each level of Clinical Ladder of Competencies for Midwifery Practice
Prepared by Japan Nursing Association, Working group regarding strengthening practical midwifery competency
II
IV
III
I
Novice
1. Able to provide creative midwifery practice.2. Able to play an instructive role in the in-hospital midwifery clinic.3. Able to play an instructive role in the in-hospital midwifery care unit.4. Able to provide instruction to sta� in both low and high risk cases.
1. Able to provide individualized care based on the midwifery process.2. Able to provide care in the in-hospital midwifery clinic with support.3. Able to provide midwifery care together with the senior midwives in the in-hospital midwifery care unit.4. Able to judge whether the symptom is high or low risk and provide the initial intervention.
1. Able to provide midwifery care safely and securely, having acquired knowledge, skills, and a proper attitude to assist healthy living.2. Know the contents of midwifery led care for inpatients and outpatients.3. Able to understand the pathological conditions of high risk patients and proper way to cope with them.
Able to provide midwifery care safely and securely in accordance with instructions, the procedure, and guidelines.
1. Able to responsibly provide midwifery care of the pregnant/puerperant woman and the newborn throughout the hospitalization period.2. Able to autonomously provide individualized care in the in-hospital midwifery clinic.3. Able to play an instructive role in the in-hospital midwifery clinic.4. Able to autonomously provide care in the in-hospital midwifery care unit.5. Able to detect transition from low risk to high risk symptoms in the early stage and to intervene when necessary.
0
4,000
8,000
12,000
16,000
20,000
24,000
28,000
32,000
36,000
OthersNursing educational /research institutesMaternity homeClinicHospitalHealth centers /
Municipalities
2012201020052000199519901985198019751971
Fig. 7: Number of Midwives by Place of Employment (by year)22)
Midwifery in Japan14
4. Evaluation of the Quality of Midwifery CareSince 2000, the Professional Committee on Midwifery of JNA has considered
indicators and measurements for evaluating the quality of midwifery, taking into account “Essential Competencies for Basic Midwifery Care (ICM. 1999)”. To grasp the current situation in Japan and compare it with other countries, the committee conducted a survey of 2,000 midwives in terms of core competencies listed by the ICM. In line with its findings, evaluation criteria of midwifery in the phases of pregnancy, delivery and puerperium were set in 2003 from the standpoint of the level of midwifery care how midwives should be able to practice23). The second version of evaluation criteria was drawn up in 2007 in line with the survey results in 200524). For the new criteria, competency levels were integrated and the description of each level was simplified. If these criteria are used in maternity facilities nationwide, they are expected to become more standardized and to contribute to assuring the quality of midwifery care.
5. Midwifery Practice1) Importance of Care by Midwives
Midwives must respect the wishes of the pregnant women and their families, and support them so that they can enjoy good health, safe delivery, and successfully transition to parenthood. Therefore, midwives must be able to make accurate diagnosis and offer appropriate care, and empathetically share both joy and sorrow together with their patients. In addition, besides supporting women during delivery, with respect for women’s reproductive health rights, it is vital that midwives continue to provide comprehensive measures to support women’s health throughout their lifetime.
JNA is developing a project with an aim to “providing midwifery care to all pregnant women, those in the puerperium, and newborns.” As part of this project, the “Guidelines for Applying a Practical Midwifery Competency Ladder (Clinical Ladder)” was developed as a tool for midwives to evaluate their own midwifery capacity. Using the tool, midwives can objectively evaluate their own midwifery experience, and understand their own level on the Clinical Ladder.
Up until now, only a few hospitals have created their own clinical ladders. However, developing a standardized version of the Clinical Ladder to help evaluate the midwifery competency level of Japanese midwives anywhere in Japan,
Level 1 Able to perform with advice / under instruction
Level 2 Able to provide care independently / Able to do independently according to the manual
Level 3 Able to provide individual care by using various methods to achieve the goal / Able to give guidance to students and junior fellows / Able to lead and coordinate a team
Level 4 Able to objectively grasp the situation with a few clues and identify the core of problems / Able to coordinate care, including by other than a nursing team, to set ambitious target
Table 5: Evaluation of the Quality of Midwifery Care at Medical Facilities (Partly excerpted)24)
113 To understand and respond to the course of delivery for a parturient woman and her family
Answer at the item level
4 3 2 1 Not applicable
Answer at the sub-item level
113.1. Able to understand the course of delivery for parturient women and their families in the facility
4 3 2 1 Not applicable
113.2. Able to explain the course of delivery to a parturient woman and her family 4 3 2 1 Not applicable
113.3. Able to respond to a parturient women and their family according to the course of delivery
4 3 2 1 Not applicable
Diagnostics and care in the intrapartum period Aim: To provide appropriate midwifery care in respond to the progress of delivery for a mother to have a baby safely and for her and her
family to be satisfied with their experiences
Evaluation of the Quality of Midwifery Care at Medical Facilities: Evaluation Criteria for Self-Check, 2nd version24)
Midwifery in Japan 15
has been a revolutionary movement. It is of hope that the use of Clinical Ladder will spread ubiquitously to improve midwives’ skills in the future.
2) Roles of Midwives in Re-modeling of Perinatal Medical Service System
Following the recent decrease in the number of facilities dealing with childbirths and obstetricians/gynecologists, ensuring safe and secure childbirth places is an urgent issue. Under such circumstances, midwives are expected to play more important roles than ever.
The MHLW formulated the “Vision for Securing Safe and Desired Medical Care” in June 200825), stipulating that physicians and nursing staff should more closely cooperate, and that under such cooperation midwives can exercise their expertise for safe and secure childbirth. S i n c e 2 0 0 8 , t h e M i n i s t r y h a s b e e n operating the grant project for trainings for midwives etc., and facility improvement for the purpose of establishing the “in-hospital midwifer y care” and the “in-hospital midwifery clinic” as a system in which midwives provide midwifery care on their own initiative.
In the past, the outpatient system in which midwives take the initiative in providing health check-ups and health guidance for pregnant women and the system in which midwives provide birth assistance services in hospitals and medical clinics as they have usually been doing in maternity homes were operated depending on pregnant and parturient women’s risks. JNA has placed these two systems as “in-hospital midwifery clinic” and “in-hospital midwifery care” respectively under the “In-hospital midwife-led care system”. In this system, midwives provide the necessary care to pregnant and parturient women depending on their risks in cooperation with physicians at medical institutions.
In-Hospital Midwife-Led Care System26)
The in-hospital midwife-led care system is a system to effectively utilize midwives. The “In-hospital midwifery clinic” and the “In-hospital midwifery care” make up the nursing/midwifery system in which midwives take the initiative in providing antenatal health check-ups, childbirth support, and health guidance at hospitals and clinics.
◆ In-hospital Midwifery Clinic An outpatient service where midwives provide health check-ups
and health guidance to pregnant and postpartum women.
◆ In-hospital Midwifery Care The method and the system allow midwives to provide
independent midwifery care to pregnant women admitted for delivery, and to mothers and children after delivery, especially for low-risk deliveries which can be assisted by midwives.
Japanese Nursing Association, February 2009
In-Hospital Midwife-Led Care System(IHMLCS)
Obstetrics/andGynecology ward
Obstetrics unit
In-hospitalMidwifery Care
Unit
ObstetricOutpatient
Service
In-hospitalMidwifery
Clinic Collaboration Collaboration
Fig. 8: In-Hospital Midwife- Led Care System26)
Midwifery in Japan16
3) “Handbook for Introducing Unit Management of a Mixed-Divisions Ward for Maternity and Other Patients”27)
The number of child delivery facilities is decreasing, partly due to the decrease in the number of children born and the lack of obstetricians. Medical institutions handling fewer cases of child delivery are forced to hospitalize maternity patients with patients from diferent divisions in the same ward (Mixed-divisions ward) Accordingly, newborns are facing a higher risk of infection. JNA formulated a “Handbook for Introducing Unit Management of a Mixed-Divisions Ward for Maternity and Other Patients” in September 2013, and it suggests that the staff should form isolated clusters to take care of maternity patients in the mixed-divisions ward. The handbook was distributed nationwide to approximately 2,700 institutions handling child delivery. Through exchange meetings between obstetrics managers and seminars on the basics of obstetrics management, the idea of forming isolated clusters for maternity patients has spread. The association will make further efforts to familiarize a wider range of people with the idea, so that it can contribute to improve the current system to provide a better child delivery environment.
4) The System Implementation at Facilities
The number of facilities implementing the in-hospital midwifery clinic and the in-hospital midwifery care tends to increase following the trends toward re-modeling of perinatal medical care system. The increase of these facilities is also led by the national government’s financial support concerning improvement of facilities/ equipment for implementation of the in-hospital midwifery clinic or in-hospital midwifery care and conduct on training.
In each facility, midwives, physicians, and the relevant staff are preparing for the in-hospital midwifery clinic and the in-hospital midwifery care in cooperation so that they can be operated depending on the community needs and the roles of the facility. Midwives are providing proactive care mainly to low risk pregnant/ parturient women. Regarding
Obstetrics Outpatient ServiceHealth check-up by a physicianHealth guidance by a midwife
• Risk assessment• Needs identification of the pregnant woman and the family
In-hospital Midwifery Clinic
Health check-up and healthguidance by a midwife
Obstetrics Outpatient Service
Health check-up by a physicianHealth guidance by a midwife
Risksincrease/decrease
check-ups atvarious stages
Childrearing Assistance• Telephone counseling• Home-visits, “Konnichiwa Akachan (Hello baby)” project
Diagnosis/Treatment by a
physician
Report to thephysician Assistance
for Physician
Midwifery outpatient serviceHealth check-ups and health
guidance of mothers and children by a midwife
Breastfeeding consultation service
Obstetrics Outpatient Service Postnatalhealth
check-up Pediatrics Outpatient Service
Midwife-led Birth AssistanceIn-hospital midwifery care
Physician-led Birth AssistanceCare provided by a midwife
Risks increase
Pregnancy
Labor
Postpartum
Childrearing
Pregnant women
Postpartum Midwifery CareHealth check-ups and health
guidance of mothers and children by a midwife
Fig. 9: Provision of Care by Obstetric Medical Care Team depending on the risk26)
C O N T E N T S1 産科混合病棟の現況 5
2 ユニットマネジメントの提案 10
4 産科病棟に必要な助産師の人数 15
3 事例から学ぶ、ユニットマネジメントへの道 12
より充実した母子のケアのために産科混合病棟ユニットマネジメント導入の手引き
“Handbook for Introducing Unit Management of a Mixed-Divisions Ward for Maternity and other Patients”27)
Midwifery in Japan 17
high risk pregnant/ parturient women, they are providing midwifery care in cooperation with physicians depending on their conditions. The criteria of reporting to the physician for changes in pregnant/ parturient women’s risk level is set through discussion by midwives and physicians in the facility based on the guidelines indicated by Health and Labour Sciences Research Grant.
Midwife Counseling Mothers Childbirth Support at In- Hospital Midwifery Care
Maternal Check-ups at In- Hospital Midwifery Clinic Midwife Performing Ultrasound
Midwifery in Japan18
1. “Guide for Protocol Development for Delivery Facilities During Disasters”28)
In order to share the lessons learnt from the Great East Japan Earthquake in 2011, JNA visited the affected areas and conducted an investigation to grasp the conditions of the delivery facilities of the affected areas, and held a symposium to present our findings. Survey results of the delivery facilities suggested that only a few facilities had manuals for dealing with child delivery during disasters. Since such manuals were intended for the entire medical facility, they only dealt with general, unspecialized procedures for how a hospital should act during an emergency. JNA created a “Guide for protocol development for delivery facilities during disasters” in 2013, to provide specific ideas and guidance to delivery facilities when they prepare a disaster management manual.
2. Temporary Transfer System of MidwivesJNA proposes a temporary transfer system of midwives as a system that contributes to correcting the uneven
distribution of midwives, and possibly strengthening midwives’ practical skills. In the temporary transfer system of midwives, a midwife is transferred to a remote facility as a midwife for
approximately half a year to one year while being under the employment contract with the original employer. In addition to amending the uneven distribution of midwives, the system can contribute to the local community by providing midwifery care to all pregnant/postpartum women in need. Strengthening midwives’ practical skills through practice in normal child delivery assistance is another one of the system’s objectives.
Ⅲ. Recent Topics Requiring Special Attention
The Executive Director in charge of midwifery (the second from the right) and staff of Midwives Division hold the guide
Leveling the quality ofmidwifery careVisualizes midwives’ ability
Clin
ics
Hos
pita
ls
Stre
ngth
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Utilization of Temporary Transfer System of Midwives
Making the acceptance and dispatch of midwives easier for clinics and hospitals during clinical training and transfers.Knowing what and to what extent of midwifery care an individual self (or others) can perform.
Utilizing temporary transfer system or ordinary transfer aimed for efficient development of abilities.Possible without placing a burden on each other’s facilities.
Acquiring skills through collaboration of facilities with different characteristics.
Fig.10: Utilization of Temporary Transfer System of Midwives
Midwifery in Japan 19
3. Pregnancy and Diseases1) Gestational Diabetes Mellitus
Since the International Association of Diabetes and Pregnancy advocated the global criteria for diagnosing gestational diabetes mellitus in 2009, the definition and diagnostic criteria for gestational diabetes mellitus were also revised in Japan in July 2010.
The introduction of the new diagnostic criteria is said to have increased the incidence of gestational diabetes mellitus 4-fold, from 2.92% to 12.08%. Considering the risks of gestational diabetes mellitus on the fetus, however, the new diagnostic criteria are important for safer perinatal management of the mother and child. Since midwives are professionals who can provide appropriate assistance during each period of pregnancy, they can promote both maternal health as well as the health of the babies to be born, making their contribution to society significant.
2) HTLV-1 (Human T-cell Leukemia Virus Type 1)
“HTLV-1” is considered a virus to cause adult T-cell leukemia, HTLV-1-associated myelopathy, and other diseases. Although the presence of the virus is not necessarily accompanied by visible symptoms, one in every 1,000 persons develops adult T-cell leukemia. In Japan, approximately 1% of the population are said to be carriers of the virus.
It was found that when a mother has HTLV-1, her baby can also be infected with HTLV-1 through breast milk. The possibility of infection in case of long-term breast feeding is 15% - 20%, and even for babies who are not breastfed a possibility of infection is approximately 3%. Although a preventive method of freezing breast milk at -20°C before feeding has been proposed, there are still no absolute preventive measures.
In Japan, the HTLV-1 Antibody Test has been added to the standardized test items of health check-ups for pregnant women since 2012. Accordingly, there are women who find out that they are carriers for the first time when they are pregnant. Midwives are expected to provide HTLV-1 carrier mothers with various assistances, including consultation on feeding methods and supporting their mental health.
Midwifery in Japan20
References1) MHLW, Population Survey (2005・2006・2009)2) Mothers’ and Children’s Health and Welfare Association, Maternal and Child Health (2007・2009)3) MHLW, Annual Health, Labour and Welfare Report (2007)4) Health, Labour and Welfare Statistics Association, Journal of Health and Welfare Statistics, (2013/2014 Vo.60 No.9)5) MHLW, Annual Health, Labour and Welfare Report (2013)6) MHLW, Population Survey (2005, 2006, 2009, 2012)7) Mothers’and Children’s Health and Welfare Association, Maternal and Child Health Statistics of Japan (2007・2009・
2012)8) Health, Labour and Welfare Statistics Association, Journal of Health and Welfare Statistics, (2010/2011 Vol.57 No.9)9) Health, Labour and Welfare Statistics Association, Journal of Health and Welfare Statistics, (2010/2011 Vol.57 No.9,
2013/2014 Vo.60 No.9)10) Study Group for Evaluation, etc. of Sukoyaka Oyako 21 (2010), Report of the 2nd Interim Appraisal of Sukoyaka Oyako
21, Final Report for Evaluation of Sukoyaka Oyako 21 (2013)11) Public Health Nursing in Japan, Misako Miyazaki, et al, Japanese Nursing Association Publishing Company (2012)12) Mother and Child Health Organization Website http://www.mcfh.co.jp/items/detail/7213) MHLW Website, Outline of Home-visit Guidance Project for All Infants, accessed January 2014,
http://www.mhlw.go.jp/bunya/kodomo/kosodate12/01.html 14) MHLW Website, the Maternity Logo,
http://www.mhlw.go.jp/houdou/2006/03/h0301-1.html#betten215) International Confederation of Midwives, The Definition of the Midwife (2011)16) MHLW Website, Definition of the Midwifery Home, accessed January 2014,
http://www.mhlw.go.jp/shingi/2005/06/s0608-11/2a.html17) Japanese Nursing Association Publishing Company, Statistical Data on Nursing Service in Japan (2012) 18) Nursing Issues Study Group (ed.), Statistical Data on Nursing Service in Japan (1981・1986・1991・1997・2000・2003・
2004), Japanese Nursing Association Publishing Company, Statistical Data on Nursing Service in Japan (2010・2011・2012・2013)
19) MHLW, Guidelines on the Management of Nursing Educational Institutions (2009)20) Japanese Nursing Association, Training Guide for New Graduate Midwives (2012) 21) Japanese Nursing Association, Guidelines for Applying a Practical Midwifery Competency Ladder (Clinical Ladder)
(2012) 22) Nursing Issues Study Group (ed.), Statistical Data on Nursing Service in Japan (1983・1989・1998・2006), Japanese
Nursing Association Publishing Company, Statistical Data on Nursing Service in Japan (2007・2009・2011・2012・2013)23) Midwives’ Division of JNA, Evaluation of the Quality of Midwifery Care at Medical Facilities: Evaluation Criteria for Self-
Check, 1st version (2003)24) Midwives’ Division of JNA, Evaluation of the Quality of Midwifery Care at Medical Facilities: Evaluation Criteria for Self-
Check, 2nd version (2007)25) MHLW, Vision for Securing Safe and Desired Medical Care (2008)26) Japanese Nursing Association, Report of FY2008 Project of In-Hospital Midwife-Led Care System Promotion (2009) 27) Japanese Nursing Association, Handbook for Introducing Unit Management of a Mixed-Divisions Ward for Maternity
and Other Patients” (2013)28) Japanese Nursing Association, Guide for Protocol Development for Delivery Facilities During Disasters(2013)
*Resources listed above are available only in Japanese.*Data are accessed in and valid as of March, 2014.
Midwives DivisionDepartment of Health Promotion PolicyJapanese Nursing Association5-8-2 Jingumae, Shibuya, Tokyo, 150-0001 JAPAN
URL: http://www.nurse.or.jp/jna/english/
E-mail: [email protected]
Publication year: 2015
No part of this publication may be reproduced or copied in any form without the advance written permission of the
Japanese Nursing Association. Short excerpts (under 300 words) may be reproduced without authorization, as long as
the source is clearly indicated.
Photos by courtesy of Aiiku Hospital, Kyorin University Hospital and Japanese Red Cross Medical Center
MIDWIFERYIN
JAPAN
Japanese Nursing Association
