1. Recognition of the problems

In addition to dramatic psychological and physical changes over a short period of time, women in pregnancy, childbirth, and the puerperal period are forced to change their lifestyle as they start to assume long-term responsibility for caring for their child with the support of the father. For this reason, it is desirable that the maternal and child health system, carries out its social responsibility to support and protect the health of mothers, children, and their families during this period: this includes both social and psychological aspects and should take a long-term perspective. We need to recognize that support during this period will help create a strong bond between mother and child and will contribute to the smooth mental development of the child.

As a result of perinatal medical services and activities centered around maternal and child health, Japan's maternal and child health is one of the highest in the world. However, there is still room for improvement in the maternal mortality rate.

An improvement in the QOL during pregnancy and childbirth is important in the modern age, and social support in eliminating or alleviating various problems during pregnancy is desirable.

As for treatment for infertility, it is estimated that approximately 285,000 patients are undergoing such treatment. We need to improve the system so that the appropriate medical technology (including auxiliary reproductive options) becomes widely available to couples who are seeking such treatment, thereby allowing them to enjoy the benefits of medical advancement.

In response to the growing interest in measures for "Reproductive Health Rights" worldwide, the "realization of an environment in which childbirth can be safe and assured" and measures to address the declining birth rate, we need to position these subjects as major agenda items for the 21^st century.

2. Direction of the initiatives

(1) Assurance of safety and comfort in pregnancy and childbirth

A. Medical institutions

Medical and health care professionals play an extremely important role in the pursuit of both safety and comfort during pregnancy and childbirth. In particular, further improvement in the following areas is required: revolutionizing the awareness of professionals specifically concerned with childbirth; cooperation between clinics, midwife-run clinics and hospitals, as well as inter-hospital cooperation in maternity treatment; cooperation between obstetricians and midwives; improvement in delivery and hospital environments; cooperation between obstetricians and pediatricians; changes in the contents of community health care services; and cooperation between maternity health management systems in the workplace, which includes industrial physicians and obstetricians.

One of the reasons given for the relatively high maternal mortality rate among other perinatal period indicators are the emergency system for maternal treatment during night hours and holidays. However, we still need to continue to pursue opinion levels of safety for mothers and fetuses in pregnancy and childbirth, focusing on higher-risk pregnant women. At the same time, the system to improve the maternal mortality rate should be enhanced so that if the condition of a mother should change suddenly and requires emergency treatment, proper treatment can be administered.

Mothers are demanding an improvement in the practice of informed consent concerning related treatment and tests, as well as information on supportive environments for mother and child and other follow-up services that they may receive after they leave hospital. We will need to actively respond to such requests. Establishing a relationship of trust and cooperation between the users of medical/health care and the professionals is essential. Therefore, we will need to promote measures to reflect the opinions of users such as providing the necessary information for users to help them utilize the types of care they desire and improvement of the environment that enables users to select medical/healthcare professionals.

Recently, pregnant women are beginning to favor more natural methods of childbirth rather than opting for the standardized safety-first method of delivery. They sometimes also ask for information to be able to take responsibility for choosing the delivery method. If the advantages and disadvantages are fully explained and consent is obtained, we will need to respond to such requests by assuring the women's safety.

With regard to pregnancy, childbirth, and puerperal periods, we need to take care to promote measures that provide support for mothers with chronic disease or physical/social handicaps, and responding to the mental problems of pregnant women, so as to facilitate the formation of an attachment between mother and child in fact and as a policy.

B. Social environment surrounding pregnant women

Further improvement in the following areas is desirable: realization of a household/working environment that shows an understanding of the needs of pregnant women, measures to prevent passive smoking and the establishment of a system where pregnant women are given preference for seats on transportation facilities. In addition, these initiatives should be promoted among all strata of society. An increasing number of women continue to work after pregnancy and childbirth, so improvements in working environments that help realize safe and comfortable pregnancy and childbirth are also important.

(2) Support for infertility

Improvements in the social environment so that anyone who wishes can receive fertility treatment, is desirable. It is essential to improve both the supply of information on the issue, and infertility consultation services, and to standardize treatment methods including counseling based on users' perspectives.

In Japan, legal and other systems are not necessarily fully developed in this area. Issues, such as ethical ones regarding the rights and wrongs of surgery due to reduce the number of babies in multiple pregnancy induced by infertility treatment, external fertilization using the gamete of a third person and surrogate mothers, and the determination of parent-and-child relationships need to be explored. Improvements in these systems are necessary in the future. Measures will also be required to avoid confusion and worries arising from the availability of such technology.

3. Specific initiatives

(1) Assurance of safety and comfort in pregnancy and childbirth

A. Medical institutions

(a) Assurance of safety in delivery

Assurance of safe delivery at clinics, midwife-run clinics, and hospitals is of paramount importance. To this end, we need to establish stronger ties between obstetric hospitals, improve the holiday and night-hour service systems, and establish a system under which pregnant women can be transported to hospitals capable of providing higher level treatment in the event of a sudden change in delivery condition. We should, therefore, devise a set of basic guidelines for this purpose. We should also work on the adoption of risk-based delivery options, the introduction of team treatment with the assistance of midwives, and easier access to hospitals capable of providing higher-level treatment.

As for mothers and fetuses who require emergency treatment, each prefecture should be provided with a general perinatal maternal and child medical center in charge of tertiary medical care, which is capable of accepting and transporting such mothers and fetuses. This center should be positioned at the core of the perinatal network system, comprising a community perinatal maternal and child center responsible for secondary medical care area, general obstetric hospitals, clinics, and midwife-run clinics responsible for primary medical treatment, so as to secure transportation systems for mothers and newborns, provide information concerning perinatal medical treatment and hold seminars for medical professionals.

(b) Information supply

We should promote the supply of information to users on the medical services options for pregnancy and childbirth. In particular, medical institutions should take initiatives in order to offer the wide range of services that are desired by users.

(c) Assurance of QOL in delivery

It is desirable to provide natural delivery options in hospitals, clinics and midwife-run clinics to pregnant women who desire this style of delivery. The introduction of an in-hospital/in-clinic birth center in which midwives play the leading role in providing support and care for natural deliveries with doctors being consulted where necessary, is considered to be a system which is able to incorporate both safety and comfort. In cases where such services are offered at midwife-run clinics, in order to ensure safety, it is necessary to distinguish normal from abnormal deliveries at an early stage and transport mothers to obstetric hospitals, as required, and establish a system under which any abnormal conditions in newborns can be detected at early stage and proper treatment given. To this end, it is necessary to improve the detection of abnormal deliveries and establish a cooperative system between midwife-run clinics and medical institutions including the obstetric department and newborn department.

From the viewpoint of pursuing QOL and effective medical care, we should study risk-based applications and conduct the EBM review concerning the application of treatment and other obstetric technology in normal deliveries.

Participatory childbirth preparation classes in and out of medical institutions and continued care and counseling responding to the needs of the individual, are also important. For instance, we should offer prenatal classes that cover breast-feeding coupled with other types of support, and should prepare a system that can support the formation of an attachment between mother and child. However, we should remember not to pressure mothers into thinking that breast-feeding is the only way if they are unable to depend solely on it. We should also respond to families' requests concerning attendance at delivery, rooming-in, sharing of the room by mother and newborn and the use of residential style delivery facilities.

(d) Response to psychological problems

We should adopt medical check ups and delivery styles that respond to the psychological problems of pregnant women and strengthen counseling by specialists. As an approach to alleviating child-rearing anxieties, we should promote mental care services including "Prenatal Visits" (prenatal child health care guidance) in cooperation with obstetric and pediatric departments. With regard to delivery by mothers suffering from chronic diseases, handicap or reactive disorders due to abnormal perinatal conditions (e.g. miscarriage, stillbirth, etc.), we should strengthen ties between the obstetric, pediatric and internal medicine departments and psychiatrists, and establish a consultation system that utilizes psychologists. Social support for the socially handicapped pregnant and puerperal woman is also desirable.

(e) Preparation of the foundation

In order to secure safety and respond to the needs of the individual, we will need to improve both the medical facilities and staffing level of doctors and midwives. We should also try to create an environment in which female doctors find it easier to work [See p29.3. (2). A].

B. Community health care and industrial health care

(a) Community health care

At the prefectural level, we should establish a cooperative system among the obstetric units responsible for medical care from the primary stage to the tertiary stage, in order to decrease the maternal mortality rate.

In the secondary medical care area, we should strengthen ties between medical institutions, midwife-run clinics, public health centers and municipal health centers. At the same time, we will need to provide information on maternal and child health care under the leadership of public health centers and municipal health centers, etc., offer learning opportunities, hold educational classes for parents and actively support the development of child rearing circles. Considering the increasing number of parents who are seeing and holding babies for the first time, we should shift from a guidance oriented "parent education" to an opportunity for sharing experiences through peer support.

At the municipal level, the importance of health check-ups during pregnancy and the risk of deliveries at home or elsewhere without the assistance of a doctor or a midwife will be communicated clearly through the "Maternal and Child Health Handbook" or by providing guidance during visits, in order to secure safety in pregnancy and delivery. We also should provide care for the high-risk parturient mothers by issuing Maternal and Child Health Handbooks to reduce anxiety about childbirth and child rearing, and offer home help services during the puerperal period to assist new mother.

As a measure to raise social awareness of the needs of pregnant women in the early stages of pregnancy, the distribution of pregnancy badges should also be considered.

(b) Industrial health care

We should attempt to create a working environment in which pregnancy and childbirth for working women is a safe and comfortable experience. We should aim to create working environments that are pregnant women-friendly, in which appropriate care will be provided to female workers in their pregnant or post-childbirth period depending on their situations. This will be done by the use of a maternity health care guidance contact card in the workplace, cooperation between industrial doctors and obstetricians and liaison between the health care management department and human resources department of the company. In the future, leave for infertility treatment should be discussed openly in order to make such treatment more accessible to working men and women.

(2) Support for infertile couples

We should improve consultation systems and medical treatment service systems for the treatment of infertility.

Regarding the counseling system, we should set up a prefectural counseling center specializing in infertility.

As for the medical treatment service system, we should devise a set of guidelines concerning the standardization of treatment and counseling systems to assure safety. In addition, we should provide sufficient support for people who are worried about treatment or who are suffering from psychological pressure from their families and society regarding their inability to have children. Furthermore, we should set up a counseling system which enables people to choose and decide on a method of treatment after having obtained appropriate information concerning the different treatments, tests and prognosis associated with infertility, and which can fully cope with the anxieties that arise during the course of the treatment [See p38.4.c. (a)].