THE BIRTHING ENVIRONMENT IN NARA, JAPAN

Transcription

1 THE BIRTHING ENVIRONMENT IN NARA, JAPAN AND AN INVESTIGATION OF CURRENT ISSUES ON BIRTHING IN NARA Presented by Emiko Naito and Yasuko Tama at the meeting of The Study Group for Birth and Local Medical Care in Iwate on November 25, 2012 This document was translated into English by Emiko Naito.

2 CONTENTS Ⅰ The Birthing Environment in Nara since October, 2006 (E.Naito) Ⅱ Research Report: An Investigation of Current Issues on Birthing in Nara (E.Naito & Y.Tama, the Research Group for Birthing in Nara ) Ⅲ Our Message (E.Naito & Y.Tama)

3 Ⅰ- 1 Naito started to research on the birthing environment in Nara in October, < The Asahi Shimbun on October 18, 2006> Death Case of a woman in labor in Oyodo-cho, Nara on June 8, 2006 A woman in labor fell into a coma. 19 hospitals refused to accept her. She was carried to a hospital in Osaka(neighboring prefecture) 6 hours later and a baby boy was born. But the mother died due to brain bleeding in a few days. It was hard to receive advanced medical treatment in Nara and 50 to 80 pregnant women in serious condition were transported to hospitals outside Nara per a year. In such a convenient society, why was it impossible for 19 hospitals to accept a woman in labor with a serious condition? Why only the hospital in Osaka? Why had it taken 6 hours?

4 Ⅰ- 2. The Birthing and medical environment in Nara since February 24, 2007: Naito lectured on Present and future of the birthing environment in Nara, from the death case of a woman in labor in Oyodo at the 1 st meeting of Machitsukuri Toronkai of 2007 in Katsuragi City, Nara. March, 2007: a group named Osan to Inochi no Zennkoku network started a 1 million signature-collecting campaign for the environment of giving birth with no anxiety and not far from home. 2 May, March, 2010: The joint council of community medicine of Nara Prefecture and 8 special committees held several conferences. Naito audited to almost all of the meetings. 3 The Restructuring Plan of Community Medicine in Nara ( ) started in March, 2009.

5 Ⅰ- 2-1 Present and future of the birthing environment in Nara, from the death case of a woman in labor in Oyodo published on February 24, 2007 Where is it possible to deliver? 11 Hospitals 19 Clinics 1 Nara Prefectural Nara Hospital Nara City 1 Tomio Ob-Gyn Clinic Nara City 2 Nara City Hospital Nara City 3 Saiseikai-chuwa Hospital Sakurai City 4 Sakurai Hospital Sakurai City 5 Nara-Hospital Kinki Univ. Faculty of Medicine Ikoma City 6 Nara Medical University Hospital Kashihara City 7 Tenri City Hospital Tenri City 8 Tenri Yorozu Hospital Tenri City 9 Nara Prefectural Mimuro Hospital Sango City 10 Nara Shakaihoken Hospital Yamato Koriyama City 11 Yamato Takada Municipal Hospital Yamato Takada City 9 Midwifery clinics 1 Aoyagi Maternity Center Nara City 2 Ishii Maternity Center Nara City 3 Midwifery Clinic Wa Nara City 4 Takahashi Ritrsuko (home birth) Nara City 5 Motoyama Midwifery Clinic (home birth) Nara City 6 Akane Midwifery Clinic Tenri City 7 Ishizuka Midwifery Clinic Kanmaki Town 2 Okamura Ob-Gyn Hospital Nara City 3 Shin-Omiya Clinic of Hayashi Maternity Clinic Nara City 4 Takayama Clinic Nara City 5 Hirano Clinic Nara Chiy 6 Sugie Matanity Clinic Ikoma City 7 Tsuji Ob-Gyn Clinic Ikoma City 8 Nakano Ladies Clinic Ikoma City 9 Nanno Ladies Clinic Ikaruga Town 10 Akasaki Clinic Sakurai City 11 Naito Doctor s Office Sakurai City 12 Sakura Ladies Clinic Kashihara City 13 Sakamoto Ob-Gyn Clinic Kashihara City 14 Gotoh Doctor s Office Gojoh City 15 Fujita Ob-Gyn Clinic Kashiba City 16 Goido Clinic of Hayashi Maternity Clinic Kashiba City 17 Tsuji Clinic Tawaramoto Town 18 Hisa Ob-Gyn Clinic Tawaramoto Town 19 Oji Clinic of Hayashi Maternity Clinic Ohji Town 8 Okahashi Chisato (home birth) Ikoma City 9 Hiraoka Tomiyo (home birth) Ikoma City

6 Naito drew a map of Childbearing facilities in Nara on February 24, 2007 How surprising it was!! Only the northwestern area in Nara prefecture had childbearing facilities. At first, the map was made as a supplemental material for the lecture on Feb. 24, But, it was placed at the first page of a 7 page resume for the lecture Hospitals 1-19 Clinics 1-9 Midwifery clinics

7 Ⅰ- 2-2 : The joint council of community medicine of Nara prefecture in May, March, 2010 (5 times) 8 special committees Health & Long life Reinvention of public hospitals Rural medical care Emergency medical care Pediatric care Securement of nurses, et al Securement of Doctors Ob-gyn & Perinatal care 4 times Experts from Medical and Nursing schools, Hospital runners, Hospital doctors, Clinic doctors, Nurses, Firefighters, Public health nurses, Staff of the prefecture and municipalities, Midwives et al discussed of Nara medical services from now on and until now (allowed public observation)

8 Ⅰ- 2 3 The RESTRUCTURING Plan of Community Medicine in Nara ( )-(1) THE FOLLOWING PLAN WAS GOING ON IN 2012, TOTAL 73.2 BILLION YEN Childbearing Facilities on November18,2012 Childbearing facilities Hospital Clinic Midwifery clinic Impossible of delivery PlanⅠ Rebuilding of Nara Prefectural Nara Hospital 41.4 billion yen PlanⅡ Upgrading of Nara Medical University Hospital 15.1 billion yen New Plan: Reconstruction of the Medical Care of Nanwa (southland of Nara Prefecture) - Rebuilding and renovation of 3 hospitals No Childbearing facilities 15.8 billion yen The special subsidy for the regeneration of Nara Prefecture local medical care is only 5 billion yen in 2009 (The original plan was 12.5 billion yen).

9 Ⅰ- 2-3 The RESTRUCTURING Plan of Community Medicine in Nara ( )-(2) New Plan is the reconstruction of medical care of Nanwa (southland of Nara) - Rebuilding and renovation of 3 hospitals: Present 3 public emergency hospitals Rebuilding as New Oyodo Hospital (Secondary emergency hospital) No Childbearing facilities!! Renovation as 2 local medical care centers (sanitariums)

10 Ⅱ An Investigation of Current Issues on Birthing in Nara 1 Purpose and Outline of the Research (Tama) <Purpose> Our purpose is to improve birthing environment in Nara through collecting women s opinions and conveying them to the local government. < Outline > Research method: Questionnaire survey (delivery by hand, and collection by anonymous posting) Research period: July - October 2009 Distributed number: 5450 Recipients for distributions: 1 Through public healthcare centers (To participants at maternal classes and infant health check) 2 Through public nursery schools (To mothers) 3 Through The Nara branch of The Japanese Midwives Association (to mothers) 4 Through the acquaintance Collected number: 1307 (collection rate 24.0%, 1 is invalid)

11 Ⅱ- 2 Overall Conditions of Nara Pref. at the time of Research (Naito) Table A: Overall birth conditions of each secondary health-care regions of Nara Pref. at the time of research Fig. B: Birth facilities (on ) Healthcare region *1 Area (km 2 ) *2 Population *1 Pop. Density (per km 2 ) *3 Fac. no. *2 *1 Delivery no. (2008) 1 *1 Birth no. (2008) Nara , ,950 2, Towa , ,250 1, Seiwa , ,581 2, Chuwa , ,426 3, Nanwa , Total ,421, ,224 10, Seiwa Chuwa Nara Towa *1 From The plan of Nara Prefecture health-care (since ) *2 Population by national census on *3 Number of facility for deliveries (incl. midwifery clinics) in 2008 Gojoh City Table A: More than 400 Pregnant women of Nanwa deliver at northlands or neighboring prefectures (mainly Wakayama, Mie, and Osaka). Fig. B: Shading shows population density. The vast Nanwa area has only one (1) clinic in Gojoh City. Nanwa Hospitals (9) Clinics (18) Midwifery clinics (9)

12 Ⅱ- 3 Statistical results (Tama) (1) Demographic features (N=1300) 83.1% : years old 94.4% : having experiences of pregnancy & delivery 35 of 39 municipalities were covered. Nara: 125 people, Seiwa: 360 people, Towa: 270 people, Chuwa: 459 people, Nanwa: 73 people. Bearing year of youngest child: 57% was % (409 people) % (250 people) % (350 people) Fig. 図 Age 質問 (N=1283) Ⅰ 生まれた年 (N=1283) 94.5%: Bearing at hospital/clinic 3.0% 2.0% 3.9% 90.3%: Answered satisfied or fairly 8.1% satisfied 88.2%: Recognized lack of facility and/or y/o 46.5% doctors 17.7%: Prenatal checkup outside Nara 46.5% 24.9%: Delivered outside Nara 36.6% 90% : Reached the facility for prenatal checkup/delivery within 1 hr There are no facility near home : 90 people y/o 36.6% Experienced refusal by hospital/clinic:44 people

13 (2) Pregnancy/Delivery and Network Adviser well conferred with Partner: 57.0%, Parent: 45.3% Attendant at delivery (multiple ans. ) by Partner: 571, Parent: 134 Ref.: Reputation of medical organization from Friends: 377 (Top) 80 Differences by age % Adviser : Partner Adviser : One s Own Parents Attendant : Partner Attendant : Parents age Fig. 23 Ques. 10: Attendant at delivery (MA) (people) 図 23 質問 10 分娩時の立会い者 ( 複数回答 ) ( 人)

14 (3) Experiences of practices at delivery According to WHO Guide 図 20 質問 9 出産のケアの経験 Fig. 20 Ques. 9: Experiences of cares/treatments at delivery 十分説明を受けて経験した十分説明を受けずに経験した経験しなかった経験したかどうかわからない Experienced with adequate explanation Experienced with inadequate explanation Not experienced Unclear if experienced Ultrasound 超音波診断 (N=1144) Screening test before delivery 出産前スクリーニング テスト (N=1148) Amniotic diagnosis 羊水検査 (N=1167) Making birth plan バースプランを立てること (N=1165) Vaginal exam in prenatal checkup 妊婦健診のときの内診 (N=933) Pubic shaving 外性器周辺の剃毛 (N=1133) Enema 浣腸 (N=1134) Ecbolic (Oxytocin) 陣痛促進剤 (N=1121) Painless labor 無痛分娩 (N=1104) Installation of fetal heart monitor 分娩の監視装置の設置 (N=1118) Acupuncture, massage, Kampo, herb, 鍼灸 マッサージ 漢方 ハーブ (N=1101) Infusion at delivery room 分娩室での点滴 (N=1125) Freedom position throughout labor 分娩時に姿勢を自由に選ぶこと (N=1114) Amniotomy( 人工的な破水 (N=1116) Vacuum extraction Forceps delivery Episiotomy 吸引分娩 鉗子分娩 (N=1109) Caesarean section 会陰切開 (N=1124) 帝王切開 (N=1120) Ambulance transportation 救急搬送 (N=1106) (%)

15 Experiences of practices delivery (Fig. 20)& Informed Consent -The consideration referring to the division of WHO s guide - The following figures are percentages of experiences of practices, including adequate and inadequate explanation. The underlined portions are responses from women who delivered only one child in 2008 and Practices which are Demonstrably Useful and Should be Encouraged - Birth plan:39.6% (41.2%) - Freedom in position and movement throughout labor: 23.5% (24.3%) 2. Practices which are Clearly Harmful or Ineffective and Should be Eliminated - Enema: 35.3% (25.1% ) - Pubic shaving: 44.4% (46.5%) - Oxytocin (at any time before delivery in such a way that their effect cannot be controlled ( ): 33% (30.9%) - Routine intravenous infusion in labor ( ), Routine prophylactic insertion of intravenous cannula ( ): 60.9% (67.8%) 3. Practices which are Frequently Used Inappropriately - Fetal heart monitor: 45.5% (45.8%) - Episiotomy: 56.8% (55.8%) 4. Contentious items at home and abroad - Freq. ultrasound: 90.8% (Every time 72.6%), Inadequate explanation 39.2% - Freq. vaginal exam.: 96.4% (every time 69.4%), Inadequate explanation 40.7% Our research proves these practices neither cannot be controlled nor Routine.

16 (4) What is Necessary for a Secure Birthing Environment 1 Medical system 2 Life in general: working, consulting organizations, sexuality education, health condition, etc. Fig. 25 Que. 13: Necessary things for secure birth Very necessary Fairly necessary Not very necessary Not necessary Cooperative system of medical 医療機関の協力体制 institutes Increase 産科医が多くなること of obstetricians Increase 助産師が多くなること of midwives Nearby hospital/clinics 近い病院診療所 Nearby midwifery 近い助産所 clinics Prenatal checkup at 妊娠検診全額公費負担 public expenses Delivery at 出産費用全額公費負担 public expenses New approaches 助産師の新しい取り組み of midwives Getting the knowledge 性と出産の知識を得ること for sex and delivery Nearby consulting institutes 相談機関が身近にあること Women themselves to care for 女性が健康な体をつくること being healthy and fit Improvement of women s 女性の働き方の改善 way of working Improvement of men s 男性の働き方の改善 way of working Others (N=1272) (N=1275) (N=1275) (N=1272) (N=1251) (N=1271) (N=1263) (N=1258) (N=1271) (N=1270) (N=1269) (N=1277) (N=1277) その他 (N=87) (%)

17 Ⅱ- 4 From Free Descriptive Answers (by Naito) Responses given as free descriptions on questions 12, 15 and 16 were summarized into the categories of A, B or C. Multiple appeals may be included in one person s response. Data shown as : Response number Response rate (coverage: 1300) A:Appeals or requests number (rate) B (C) No. Questionnaires and Categorized responses 12 Any anxieties or problems during pregnancy, in after delvery? 786/ % A: Appeals of anxieties & problems 941/984 (95.6%) B 15 Requests(Opinions) to administrations or medical fronts? 610/ % A: Requests to administrations 710/805(88.2%) B 16 Requests to midwives? 501/ % A: Desires to midwives 352/619 (56.9%) B: Thanks 169/619 (27.3%) C A B C Thanks MD, Hospital Complaint

18 Ques A Breakdown of the 941 appeals of anxieties or problems during pregnancy, in and after delivery Order Appeals % Summaries 1 Complaints to doctors or hospitals/clinics: Inadequate explanation, Hard to inquire of doctors because they are busy, Consulting service, Dubious C-section/episiotomy/ecbolic 2 Would I be able to deliver safely? Is the baby healthy? 72 respondents actually reported having trouble before or during pregnancy (About 10% of the respondents of Q.12) 3 Postpartum life (mainly after discharge from hospital): Physical trouble, mental trouble or together Nurturing after leaving hospital Nurturing alone 4 Breastfeeding: does not flow well, don t know how to give the breast. Is there enough breast milk? Mastitis No guidance No consulting service 5 Taking care of the siblings (during pregnancy, during hospitalization, after leaving hospital) No one to seek support Sense of isolation Desire for a place to easily seek consultation Far delivery facilities (9 per 30 women in Nanwa) Postpartum life, mainly after leaving hospital Housework and childcare bef./after birth, Taking care of siblings, Lack of supporting relationships, Lack of supporting facilities/organizations Others Anxiety about emergency medical service Because women s worker (going to work place, weekday s medical checkup, difficult to balance and child care, reinstatement, unemployment) 21.0 There were many requests upon the care given during pregnancy and childbirth, but because there is no system established for the care after childbirth, thus there were few requests upon care after childbirth

19 Ques. 15: Requests to governments or medical fronts Requests to governments are ca. 90% (710 appeals) - Followings are the breakdown: Order Requests % 1 -Wish to prepare medical (birth) system, - Increase of medical staff, - Increase of nearby birthing facilities, - Better treatment of medical staff, - Better emergency care system 2 Finance: - Reduce of the financial burden for pregnancy (maternity check up, infertility treatment), birthing and nurturing, - The current system to receive medical care by public expenses is difficult to use. (can not be used out of prefecture.etc) Most common answers to Q.12: Complaints on doctors or hospitals/clinics, Meanwhile, answers to Q.15 top with : Requests of system formation of medical care (birth) System formation for birthing and nurturing at ease Environment for working women to give birth and to work with nurturing at ease: Increase of childcare personnel & childcare center, Administrative support(infant health check etc.) to be available on the weekend,reinstatement support after childbirth 5 Enhancement of public local healthcare centers: More consulting, Interacting with other members of the community, Improvement of the support system after childbirth(mainly after leaving hospital) Others - Wish to prepare support system after child birth -Meeting place support where mothers - Improving(raising)the quality of medical staff - Freedom of information - Wish to natural birth

20 Ques. 16: Requests to midwives Top 7 of A: Requests to midwives (352) as follows: Order Requests % 1 Talking and counseling ~, Teaching in and advice(67) To increase midwives (Easy to talk to, experienced, not requiring episiotomy etc.) (62) 3 On attending (How to attend )pregnant women (Talking to,encouragement, To snuggle up women`s mind, Watching tenderly, Secure, Affectionate, Polite) (57) 4 Delivery by midwives for normal birth (Partnership and cooperation with doctors) (32) 5 Teaching how to : take care of the breasts, breast feed, wean the baby (31) What do midwives do? Make it easy to identify a midwife. (30) To unify instruction contents, The gaps of indivdual skills should be improved (19) Top of B (Appreciations) : got good advices, Assisted, Emotional support) Top of C (Complaints) : forcing their opinion~, Bleak, Harsh) Common points among A (Requests), B (Appreciations) and C (Complaints) Desires and appreciations for kind support, but complains to unkindness

21 Ⅲ Our Message Ⅲ-1 Findings from Our Research 1. Crisis awareness are held by women across medical districts. 2. Requests regarding medical systems are to increase medial staff/facilities and to improve their work environment, considering regional differences. Many women experienced no facilities for delivery, no option, refusal, etc. 3. Other specific needs: a) A high rate of needs for care after discharge b) A high rate of needs for support in addition to medical care consultation services, childcare supports, etcetera c) Reducing economic burden of pregnancy, birth and childcare d) Addressing the high rate of C-section experiences e) Addressing issues of receiving care outside of Nara Prefecture 4. Capacitation of midwives There are needs for seeking the professional for care after delivery, consulting, sexual education and normal delivery, although women apt to rely on doctors, hospitals and clinics. 5. Women want to undergo prenatal checkup and care during delivery after they are explained in full and with consent. 6. Agenda: a) Establishment of postpartum care system (mainly after discharge) b) Solution of difficulties with regard to hospital visit c) Assurance of informed consent d) Appreciation of differences in age (especially younger mothers) e) Further research for women whom we couldn t reach

22 Ⅲ- 2 Proposals for Secure Birthing From The Research Group For Birthing In Nara on January 22, Enhancement of medical systems in the whole Nara Prefecture and special attention to areas with poor medical resource such as the medical area of Nanwa and so forth. Women request the improvement of the hard conditions of medical staff as well as the enhancement of medical systems in Nara. For the enhancement, we request not to standardize the treatment of all regions, but to make consideration upon the differences in regional conditions and implement flexible and effective measures. The specific requests are as follows: (1) Increase of doctors, midwives, nurses, et al and their better treatment on their salary and working conditions (2) Increase of delivery facilities which enable delivery near home and efficient systems for emergencies (3) Undertake on keeping the residents of the prefecture up-to-date on information (4) As for Nanwa, providing public delivery facilities or making plans of support systems by midwives as soon as possible

23 2. Supporting women s daily lives, especially by establishing support systems for the postpartum phase. The current medical care system and government services for women are mainly performed as the health examination in prenatal term and the care at delivery. But women need not only the services in medical institutes and the support by medical staff but also the support of daily life, especially the support after leaving hospital. We request affirmative approaches to support; childcare after leaving hospital including midwife visits, problems with lactation, housekeeping, women s body and mind after delivery, taking care of the siblings, starting to work again, and getting into childcare without a long waiting list. 3. Support based on the actual conditions of pregnancy, birth and childcare Several points on the actual conditions concerning women s pregnancy and birthing were made. For example, 1 of 5 women perform the health examination in prenatal term and 1 of 4 women perform the delivery outside the prefecture, respectively. And the rate of C- section is showing tendency towards increase. Based on those facts, we would like to address the need for the followings: (1) Establishment of public expense system which is easy to utilize beyond each local government (2) To provide care and support on the acknowledgement of the fact that rate of C- section is 1 per 4, 5 cases. (The current system is often under the assumption of vaginal birth.)

24 4. For both men and women to learn and know about birthing, to connect mutually, and for women themselves to raise their voices Our aim is not making unilateral demands to administrations and medical resources. We think it s important that; we connect with women who cannot receive government services of health examination in prenatal term or research, men and women together learn about birth, and women connect mutually and raise their voices. We hope that the government supports will become the forth for it, and women to promote their ability to deliver normally in order to make Nara prefecture a community where it is possible to give birth at ease.

25 Ⅲ- 3 Proposals from present Nara 1. To establish an obstetrical department in the planned new secondary emergency hospital of Nanwa! 2. There are 500 birth refugees per year in Nanwa. If the planned new hospital will not have an obstetrical department, we request a system making midwives always available at site! 3. To enhance care in postpartum phase! 4. Therefore, to establish a continual care system from the time in pregnancy to child-rearing!

26 Ⅲ- 4 Let s Make a Society where we can give birth at ease together! A society where it is possible to give birth at ease is not only necessary for women and children, but also for every member of the society. The society of secure birth can be realized only by everyone s cooperation. The support for pregnant women is only made possible by the activities during peacetime. Thank you for your kind attention!

27 Related information Ethical Review Approval of the Committee of Research Ethics of the Graduate School of Humanities and Social Sciences of Osaka Prefecture University in 2009 External fund of this report The Subsidy Study promoted by Special Research Fund of Graduate School of Osaka Prefecture University in 2009 The Study of the Supportive Measures for safe and Secure Birth From the research on actual conditions/needs (Investigation representative: Yasuko Tama) The Grant-in-Aid Basic Research (c) of Scientific Research Fund of MEXT in 2009 The Ethnological and Anthropological Study concerning the Transfiguration of childbirth and nursing concentrating on recent Yamato (Investigation representative: Manami Yasui) The Grant-in-Aid Basic Research (c) of Scientific Research Fund of MEXT in The Delivery, Birth and Normalization as the Care (Investigation representative: Yasuko Tama) Reference WHO 59 Articles of WHO Care in Normal Birth: a practical guide translated by Ritsuko Toda, Rural Culture Association, 1997 Reference blog, HP 内藤恵美子の blog (Naito Emiko s blog): 安心してお産ができる奈良県にしたい (Wish to make Nara Prefecture where women can give birth at ease): 田間研究室 (Tama Laboratory):