Panaceas to improve the perinatal care in Japan
Author: Michiko Sakane
Affiliation: Sakane M Clinic, Tsukuba City, Japan
Editors: Moe Hirohara, Akihiko Ozaki
Throughout 2017, there was prominent media coverage concerning deaths of pregnant women in Japan. I assume this was triggered by the press conference given by Dr. Isamu Ishiwata at the end of 2016, referring to the deaths of two women after deliveries at the same hospital in Ehime prefecture in Western Japan. His talk was covered by Yomiuri Shimbun, one of the biggest newspaper companies in Japan, which eventually led to an excessive focus on the issue among the Japanese media outlets. A lawyer, Mr. Kiyonari Inoue, pointed out, "The Japanese news media repeatedly reported different accidents which occurred during labors using epidural anesthesia every couple of weeks, and the people learned four or five cases only within three to four months. As such, the news media delivered a strong impression as if a large number of accidents and lawsuits had occurred in a short period of time"(Inoue, 2017). In fact, a report by a research group of the Ministry of Health, Labor and Welfare (MHLW), which was published on November 22, noted no significant difference in the mortality rates between normal and epidural births (Sankei Shimbun, 2017).
To ensure safety in health care, it is necessary to undertake an unbiased and comprehensive investigation for each accident and/or incident. Meanwhile, those who disclosed their involvement in specific accidents must be protected from any punishment, and their confidentiality must be ascertained. The opposite approach is to agitate conflicts and pursue liabilities among relevant stakeholders. Naturally, these two approaches do not go together. If the news media continues to attack individual health workers in pursuit of liability, safety can never be ensured in health care.
With respect to the system that ensures health care safety, neither the Japan Obstetric Compensation System, sanka-iryo-hosho-seido(Japan Council for Quality Health Care, 2014) nor the Medical Accident Investigation System iryo-jiko-chosa-seidois able to prevent lawsuits in advance. For instance, in Western countries, babies’ families who apply to no-fault compensation systems are not allowed to sue health workers. However, this is not the case with the Japan Obstetric Compensation System. Nonetheless, it appears that, in Japan, this limitation is not acknowledged or discussed sufficiently among the lawyers who are familiar with this system and health professionals working in the obstetrics field.
The annual number of deliveries in Japan is around 1,000,000, and nearly half of the procedures are performed in clinics. Given that approximately 70% of Japanese clinics have only one full-time obstetrician, it is surprising that Japan maintains the lowest rate of maternal and perinatal mortality in the world, and we can say that Japan's perinatal care has made quite a remarkable achievement. However, epidural anesthesia is used in only 6.1% of the labors, though there is an increasing incorporation of this anesthesia at present. In contrast, it is reported that more than 60% to 80% of labors are performed under epidural anesthesia in the United States and France.
In 2012, a well-known labor accident occurred under epidural anesthesia in a clinic in Kyoto, involving a Russian woman and her baby that became bedridden thereafter. Following this accident, their family sued the clinic, seeking compensation of 940 million JPY (approx. 10.8 million USD). Despite my sincere and deepest sympathy for the patients, I would like to suggest that lawyers on the patients’ side to refrain from claiming an unacceptably large compensation that clinics/hospitals cannot afford. Furthermore, no lawsuit should be made with the purpose of seeking criminal liability among health workers. Japan’s legal community should be aware that their attitudes can endanger the Japanese medical system, possibly causing trouble for all Japanese citizens.
It is natural that the Russian woman’s mother claims that obstetrics care should be performed in facilities where multiple obstetricians are available and that clinics operated by only one obstetrician must not be approved. However, we have to recognize that a delivery in a large hospital is not necessarily safer than a delivery in a small clinic. In the accident that occurred at Juntendo University in February 2015, a uterus ruptured during labor under epidural anesthesia. This accident demonstrates that obstetrics anesthesia is technically difficult and demands a unique skillset. However, most of the deliveries using epidural anesthesia are safely conducted. Indeed, 70–80% of epidural anesthesia to reduce labor pain is performed by obstetricians in Japan instead of by anesthesiologists.
In the above accident at Juntendo University, a famous lawyer, who is specialized in health care lawsuits, insisted that the MHLW should withdraw the certification of advancedtreatment hospitals, tokutei-kinou-byouin, from Juntendo University. However, I would say that such a claim may be an overreaction to the accident. Excessive accusations against health workers and medical institutions would deliver substantial mal-effects to the entire Japanese population. In fact, the number of obstetrics facilities has decreased by 22% during the last decade, namely after the case at Fukushima Prefectural Ono Hospital. If this trend continues, a serious shortage of the facilities would occur in the near future. To respond to this issue, Osaka University Hospital plans to create networks with surrounding health facilities, where pregnant women are able to visit clinics for prenatal checkups and to receive epidural anesthesia during labor at university hospitals. However, I am concerned whether university hospitals have sufficient capacities to manage such networks.
The obstetric environment is generally harsh. In response to an obstetrics resident’s suicide, which occurred under excessive workload in July 2015, the Japan Society of Obstetrics and Gynecology and the Japan Association of Obstetricians and Gynecologists made a joint statement that further burden should not be delivered upon obstetricians, while calling for a centralization of obstetrics facilities. To ensure this there should be enhanced support of small clinics rather than leading them to close.
I would like to introduce a program that launched two years ago in Japan. The course, which is designed for small clinics operated by minimal staff, provides basic training for possible emergency cases, such as a transfer of pregnant women with life-threating conditions to a tertiary care center. One obstetrician with more than twenty years of experience mentioned that he had been involved in critical care cases only a few times during his career. Given how rare it is to encounter such critical events, many doctors are unprepared for emergency cases without continuous training throughout their careers. In this respect, comprehensive support is required for obstetricians working in small clinics to receive necessary training on a regular basis. Another recommendation from the Japan Society of Obstetrics and Gynecology is an improvement in the quality of operations performed in clinics, including learning cutting-edge skills and/or knowledges of obstetrics anesthesia.
The current argument regarding the use of epidural anesthesia during labor does not consider fact that it is women who experience the pain. Is there any male in the world who can understand labor pain? I have given birth in Japan and the United States. When I was a fourth-year resident in the department of cardiology, I experienced a membrane rupture on the first day of my maternity leave. I took prostaglandin and gave birth, bearing severe pain that began 30 minutes after I took the drug. The pain was extreme and made me hesitate to become pregnant again. In 1996, I bore my third child at the Maggie Wimins Hospital in Pittsburgh. I used epidural anesthesia in my labor, as 80% of the pregnant women used epidural anesthesia during their labors at the hospital. The pain was far milder than that I had experienced before, and I felt sorry that most Japanese women do not have this option. Furthermore, I learned that there had been a risk of a ruptured uterus during my first delivery because of excessive uterine contractions caused by prostaglandins. I finally realized that I previously had the misconception that the labor pain is inevitable.
Although 21 years have passed since then, the use of epidural anesthesia during labor is still not common in Japan. One possible reason for this may be that most high-class members in Japanese medical communities are men, and women’s voices are not sufficiently taken into account in the decision-making process in such organizations. Please note that among 40 directors of the Japan Society of Obstetricians and Gynecologists (11,000 or more members in total), only 6 (15%) are women. Only 4% (1/25) and 7% (29/390) are female directors and female representatives, respectively, in the Japan Society of Obstetricians and Gynecologists (approximately 16,500 members). I believe that this situation needs to be ameliorated by applying a quota system to achieve a certain proportion of female members at management/higher positions in organizations.
In conclusion, panaceas to improve the perinatal care in Japan are as follows.
1. For the public: be aware that no further obstetrics facilities should be forced into closure.
2. For small-scale health providers: keep up with cutting-edge obstetrics knowledge and skills, receive training for emergency cases, and ensure improved transparency in how patients are treated in daily practice.
3. For the Obstetricians and Gynecologists Association: centralize human resources in hospitals and enhance support for small clinics. Promote grief care when accidents occur. Introduce the quotasystem when selecting representatives.
4. For health care safety organizations: establish frameworks to prevent lawsuits.
5. For the MHLW: Provide the necessary budget for safe deliveries. Consider the use of epidural anesthesia during labors to mitigate further decline of the birthrate.
6. For the news media: Stop an excessive pursuit of liability among health workers.
7. For police: Do not intervene in medical errors unless they are intentionally committed by health workers.
8. For lawyers on the patient side: Avoid insisting for an excessive amount of compensation against health workers and facilities when accidents occur. Do not agitate the hostile emotions of bereaved family members.
9. For lawyers on the health care side: Prevent excessive interventions from the news media. Block lawsuits if they are preventable.
Of note, women play a major role in childbirth,and they should have the option of using epidural anesthesia during labor. The relevant stakeholders should make an effort to achieve environments in which all pregnant women have the choice to decrease their labor pain, and health workers in the obstetrics field can work with a lesser workload.
Inoue,Y. (2017).?Vol.259?医療事件報道のあり方—無痛分娩事故報道を契機に手直しをー. Medical Research Information Center. Medical Governance Association. (Online). (Accessed February 14, 2018). Available from:?http://medg.jp/mt/?p=8040
Sankei Shimbun. (2017).?出産時の痛みを麻酔で和らげる「無痛分娩」厚労省の研究班「妊婦死亡率変わらず」と報告. Sankei News. (Online). (Accessed February 14, 2018). Available from: www.sankei.com/life/news/171122/lif1711220035-n1.html
Japan Council for Quality Health Care. (2014). Guide to The Japan Obstetric Compensation System for Cerebral Palsy. (Online). (Accessed February 15, 2018). Available from:?www.sanka-hp.jcqhc.or.jp/documents/english/bira_english_color_201407.pdf[m6]?
 Calculated based on the currency rate 1 USD = 86.6474 JPY as of 31/12/2012
 The case of Fukushima Prefectural Ono Hospital in 17 December 2004 is a medical affair, which drew a substantial public attention at that time. The doctor performed a Caesarian section on a woman with placenta previa, and then she died due to massive bleeding associated with the placenta accreta. Although the doctor was arrested on suspicion of causing a death through professional negligence?on??February 18, 2006,?his innocence was confirmed in the trial on??August 20, 2008.?There was massive criticism among health workers when he was initially arrested. A primary reason for the criticism is that the death of the woman was regarded as a mistake of the doctor, who worked as the only obstetrician working full-time with limited resources and support from the hospital. This case led to the decrease of the obstetricians and clinical facilities engaged in obstetrics care for fear of being involved in lawsuits.
This article is a summary of the presentations by Dr. Sakane at the"Symposium on the Promotion of Health care Reform from Clinical Practice Perspective”held onDecember?3, 2017