Don’t be afraid to ask questions about giving birth in Japan

In Japan, women over 35 are considered 'old' to become mothers. But does that stigma exaggerate the real risks?

by Tomoko Otake

With women in Japan making inroads into various career fields and having more options to choose from, it’s only natural that more of them are starting families in their late 30s or even in their 40s.

Health ministry statistics back up the trend. In 2009, 22.5 percent of the women who gave birth to Japan’s 1.07 million babies were 35 or over. The figure includes 30,566 women who bore children at aged 40 or older, a group that is also growing — in 2006, only 22,139 women gave birth when in their 40s.

Yet Japan has long differentiated, if not stigmatized, pregnant women aged 35 or older, calling all childbirths by such women korei-shussan, which literally means “childbirths at a high age.”

Nobuko Nomura, a 43-year-old mother of a 1-year-old daughter in Tokyo, says that, in her 30s, she was busy with her career as a TV and radio announcer for a major media company. In her late 30s, her husband was posted to a 3 1/2-year assignment in Australia and she quit her job, but while overseas, the couple found themselves enjoying numerous activities, such as scuba diving and watching tennis tournaments, that would have been difficult to do with kids. It was not until they returned to Japan a few years ago that felt it was the right time for them to start a family — and they were soon blessed with the news of her pregnancy.

Though her pregnancy and delivery went smoothly, Nomura says her mother, who had her first child when she was 24, couldn’t stop worrying about her.

“My mother said ‘You are old, you are old,’ so many times, right up to the moment I started having labor pains,” Nomura said. “She said it so often that I eventually found her annoying.”

That does not mean she took pregnancy risks lightly. Nomura says she did all the research she could to ensure a safe childbirth, collecting tips and information from Internet postings, and contacting numerous hospitals before choosing one in Tokyo that had anesthetists on standby around the clock — a service uncommon among hospitals in Japan.

Most women over 35 do have healthy pregnancies and deliveries, but there are some risks that increase with age. Studies show that, for women in their 20s, 10 percent of conceptions end in miscarriage, but for women aged 35 to 39, it is 15-18 percent. For those aged 40 it’s around 40 percent, writes Yasuyo Kasai, an obstetrician at the Tokyo-based Japan Red Cross Medical Center, in her 2007 book titled “Sanjugo kara no Hajimete no Ninshin-shussan (The First Pregnancy and Childbirth at 35 or Over). There are other higher risks of complications — such as pregnancy-induced high blood pressure and diabetes — though this depends on genetics and lifestyle.

The risk of genetic abnormalities in babies also increases with age, but can be diagnosed early with genetic tests during pregnancy. In Japan, however, many hospitals do not offer such tests unless the women ask about them. Ann Tanaka, a registered nurse from the United States who has lived in Japan for 28 years, works as an aide at the Higashi-Chofu Hospital in western Tokyo and gives birth education at the Tokyo American Club, says this could be due to the hospitals’ somewhat “conservative” attitude toward childbirth.

Expected costs of childbirth in Japan

A 2009 health ministry-funded survey of 2,886 hospitals and clinics showed that the average cost of delivery was ¥423,957 nationally, and ¥459,260 in the Kanto region. The cheapest area in which to give birth was the Kyushu- Okinawa region, where the average cost was ¥393,671.

The average length of stay was 6.28 days nationally. Prices are higher if you choose a single room, give birth at night or on a weekend and ask for an epidural.

Women covered by the public health insurance scheme can get up to ¥420,000 of their costs subsidized by the government.

Costs of prenatal visits to doctors and midwives also vary, but many municipal governments issue vouchers for free prenatal screenings at hospitals, clinics and midwife-led birth centers.(T.O.)

“In the States, they are very, very quick to be encouraging and push, almost, for a lot of testing — amniocentesis (for genetic abnormalities) and what’s called the ‘quatro’ blood testing (for Down syndrome),” she says. “In Japan, the philosophy at most hospitals is that those tests are not to be mentioned unless the mother or the father brings it up — and the mother is 35 or older.”

Across all pregnancies, though, Japan remains one of the safest places to give birth. According to the 2005 statistics compiled by the World Health Organization, the United Nations Children’s Fund, the United Nations Population Fund and the World Bank, Japan’s maternal mortality rate stands at 6 per 100,000 childbirths. This is one of the lowest in the world — lower than some other industrialized nations such as Canada, Finland, the U.S. and Britain.

That doesn’t, however, make the birth choices for women, of any age, any easier, since policies regarding various interventions — ranging from Caesarean section to episiotomy (a surgical enlargement of the vaginal opening) vary depending on institutions and doctors.

The use of epidurals for pain relief is also less common in Japan, and in most cases is only available in “controlled deliveries.” According to Takahiko Kubo, chief of the obstetrics division at the National Center for Child Health and Development in Setagaya Ward, Tokyo, the shortage of anesthetists who specialize in obstetrics has meant less availability of epidurals. Most hospitals offering the procedure have to set the date and time of delivery in advance, which is usually during daytime because there are not enough anesthetists available at night, Kubo says. Women have to visit hospitals at a predesignated time, have their labor induced by drugs, before they can receive epidurals, he says. Hospitals that can offer an epidural during a woman’s natural labor period are still hard to find.

While most women in Japan give birth in hospitals or maternity clinics, about 1 percent of women do so at josan-in — birth centers that specialize in natural births and are run by certified midwives.

At the Matsugaoka Birth Center in Nakano Ward, Tokyo, three out of 10 women it serves are aged 35 or older. Birth centers can handle normal pregnancies only, and with backup support from maternity clinics and obstetricians at major hospitals, they can help women have natural births, says Shoko So, the head midwife of the center.

As with many other josan-in, the Matsugaoka center operates in a traditional Japanese-style house that could be mistaken for a regular home. It offers aromatherapy, maternity yoga and cooking classes (to help women manage their weight and ensure the right diet for breastfeeding). It is even equipped with a special pool for women opting for a water birth.

Researching a birth center, however, is extremely important, as Kubo of the National Center for Child Health and Development warns mothers that some centers fail to meet the operational guidelines set up by the nationwide midwives’ group. Birth centers that do not reach the proper standards, he says, could lead to deaths of babies or babies born with severe disabilities that could have been prevented had the pregnancy been handled at a hospital.

At the Matsugaoka center, So says she makes it her policy to tell expectant women in their 40s at the outset that half of the women their age receiving prenatal care end up being taken to hospitals — either during the pregnancy or when in labor. And all of the women who seek So’s help with delivery must get an obstetrician’s approval when they reach the 36th week of their pregnancy.

“Birth centers offer women a safe birthing option, as they are in very close contact with hospitals and clinics,” So says, noting that, in many of the cases where women are taken to hospitals, the center’s midwives accompany them and offer on-site support.

While all women need to make informed decisions regarding pregnancy and childbirth, those expecting a baby after the age of 35 need to be even more proactive and ask a lot of questions, says Hideki Sakamoto, an obstetrician /gynecologist at the Tokyo Medical and Surgical Clinic in Tokyo’s Minato Ward. According to Sakamoto, who has treated many women in the foreign community and says 70 percent of his clients are 35 or older, a mother’s queries could affect the birthing experience greatly.

“The worst thing you can do is to leave the decisions up to the doctor,” he says. “You have to have a basic stance that you are taking control (of your pregnancy). In testing for genetic abnormalities, for example, you need to go visit the doctor with a clear idea of what you want to know — what kind of tests are available, and what their benefits and downsides are. If you fail to do that, and then 16 weeks into your pregnancy you find out that it’s too late to have a test, it would be very sad. Yet this kind of thing could be happening at hospitals across the country.”

Ann Tanaka is a registered nurse and gives prenatal and postnatal classes at the Tokyo American Club, which are not restricted to TAC members: Tel/Fax: (03) 3482-0728; e-mail: anntanaka@festa.ocn.ne.jp

The Tokyo Pregnancy Group is a group of expectant women in the English-speaking community who share tips and experiences. The blog is full of contact details and tips on giving birth in Japan: tokyopregnancy group.blogspot.com

The March of Dimes Foundation is a U.S. nonprofit organization that offers information on pregnancy and baby health, including fact sheets for expectant mothers aged 35 and over: www.marchofdimes.com