When Rayna Tsuchiya was going through her first pregnancy in Japan 13 years ago, she was fearful of going to prenatal checkups.
Originally from Thailand, she’d heard horror stories about foreign women’s maternity experiences, like being scolded for not knowing Japanese, being rejected by hospitals due to the language barrier or having to decipher complex paperwork.
“I felt uneasy every time, just thinking about how I’d be treated,” she said.
Despite her fears, her doctors and nurses worked hard to make everything comfortable, and did what they could to explain or translate until she understood, Tsuchiya said.
Tsuchiya lives in Karuizawa, Nagano Prefecture, where she gave birth to her three boys. Today she speaks near-flawless Japanese and volunteers for Mother’s Tree Japan — which offers pre- and postnatal support to foreign mothers across the country — holding online advice sessions for fellow Thai moms.
Compared with some countries, Japan can be a comfortable place to give birth, with government subsidies covering a majority of the cost. Stipends are available for pre- and post-childbirth costs, dayslong post-birth hospital care and required post-birth visits from municipal workers to check in on both mothers and newborns.
Plus, the maternal mortality rate — the rate of women who die during and following pregnancy — is among the lowest worldwide, with four deaths per every 100,000 live births in 2020, compared with a global average of 223, according to the World Bank.
Still, giving birth to a child in a foreign country where you're unaccustomed to its language and maternity practices can also add new levels of anxiety to expecting mothers.
Japan’s norm of natural birth
Foreign mothers often face differences between what is considered the norm in their home countries and what has traditionally worked for Japanese bodies.
Maternity care providers often go about their work without considering how things are done elsewhere, said Tomomi Tsubonoya, founder and director of Mother’s Tree Japan, which assists foreign women via interpretation, appointment accompaniment and community building, as well as group and one-on-one guidance.
Tsubonoya started the organization in Tokyo’s Toshima Ward — home to one of the capital’s largest foreign populations — with support from the ward and a local university. The organization has since expanded to serve mothers across Japan.
“Mothers often cry when I ask, ‘How is it done in your country?’ because no one had ever asked them in Japan,” Tsubonoya said. “They’re always told, this is how you raise a child in Japan, this is how you bathe a child here, etc.
“That was really shocking to me and I realized how much we impose our culture onto others in Japan without value or respect for others, which can be harmful.”
That’s why, Tsubonoya says, a key to making the childbirth experience more positive for foreign women is listening, being open to their heritage and traditions, and providing options.
In Japan, a majority of mothers give birth naturally unless there are complications. In a 2018 report by the health ministry, about 75% of women had a natural childbirth, followed by 19% who had a C-section and only 5% used an epidural.
This is in stark contrast to 65% of births using an epidural and 14% natural births in France, and 41% and 26%, respectively, in the United States.
According to the same report, only about a third of Japan's hospitals and clinics offered the epidural option.
So when Tsuchiya gave birth to her three children, she just went with the flow and did so naturally, as her hospital recommended. She doesn’t remember being offered other options.
Back in Thailand, however, many mothers opt for epidurals.
“I should’ve asked,” she said. “If I had the choice I would’ve chosen a pain-free birth, because I think birth should be as comfortable as possible.”
Because natural childbirth is often considered the norm, mothers are also often told to limit their weight gain in order to lessen the risk of complications.
But that might not necessarily make sense for foreign women.
“What makes sense for a Japanese body is not necessarily how it works for foreign bodies,” said Janique, a 35-year-old mother of two born in Jamaica and raised in Canada.
“Many Japanese women have a much smaller frame and are generally smaller. ... So for them, you can understand why, because they might be at a higher risk of getting hypertension and serious health problems if they gain too much weight.”
Janique, who asked to only use her first name due to privacy concerns, gave birth to her first daughter in Canada, and then to her second in Japan just over a year ago.
For both pregnancies, she gained around 18 kilograms. In Japan, she was encouraged to keep her weight gain to around 1 kg a month.
When her blood samples came back normal, her longtime gynecologist cocked her head to the side and questioned whether the weight gain was healthy. Still, she said, the doctor listened intently about her past pregnancy and what proved to be successful for her in Canada.
Birth plan options
Yuki Ashimura, who hails from Indonesia, is expecting her second child this year.
Ashimura speaks fluent Japanese and has lived in Japan for over 20 years. She also became a Mother’s Tree Japan volunteer, specifically serving Indonesian mothers.
During her pregnancies, comments from people in her home country were tough to deal with. Family and friends back in Indonesia were shocked when she told them she wouldn’t be prescribed supplements in Japan.
“The biggest problem was talking to my mom and family, and the difference in culture,” she said.
And after going through a grueling pregnancy the first time round — including five months of bed rest and around 30 hours of labor — Ashimura has opted for a home birth for her next child. It’s something she believes will be most comfortable and personalized for her. But it's a rarity in Japan.
According to another health ministry report in 2022, home births accounted for 0.2% of births in Japan.
Having had her first birth at the beginning of the COVID-19 pandemic, she and her husband see the option as a more personalized, relaxed and familial.
“I can have my daughter, my brother-in-law, my parents-in-law present, so I thought, ‘Oh, that’s a beautiful thing,’” Ashimura said. “Someone told me, birth isn’t about where you do it, but who you do it with. So that really made me think.”
The key for most of these mothers is to ask questions and to seek the options that are best for them amid these different rules, regulations and traditions, such as those on natural birth and limited weight gain.
“Do your research and maybe interview gynecologists,” Janique said. “Before you go too deep with a doctor, find out the hospital’s rules ... because everyone’s health is different.”
When Janique first learned she was pregnant with her second child and would need to give birth in Japan, she called Tokyo’s Himawari hotline, a medical information service for foreign nationals.
Janique told the operator where she lives and that she was looking for a female doctor as well as a hospital that had English-speaking staff and would let her family be with her during labor despite COVID-19.
It wasn't long before someone got back to her with a list of options.
While she eventually found a hospital she liked, one hospital denied her service, citing the fact that they couldn't serve someone who didn’t speak fluent Japanese.
She understood the risk factors they were considering though, as in an emergency situation decisions might need to be made quickly, and “didn’t take it too much to heart,” she said.
Under the law, doctors are not allowed to reject a patient unless there is “justifiable reason.”
Not being able to communicate adequately in Japanese is unlikely to be considered a “justifiable reason,” but there hasn’t been enough discussion of its legality, Dr. Minako Shimazaki, who is well versed in medical treatment for foreign nationals, wrote in a Japan Medical Association journal in 2018.
But Tsubonoya of Mother’s Tree Japan has seen many cases in which foreign nationals were rejected from hospitals or were required to obtain and be accompanied by an interpreter for all prenatal checkups and childbirth.
Meals for vegetarians and Muslims
For Prachi Gupta, a Temple University Japan assistant professor in economics hailing from India, the biggest source of support when she gave birth to her second child just two months ago came from a WhatsApp group of over 200 Indian women living around her Tokyo neighborhood.
A simple message in the chat group would garner words of advice from dozens of mothers. And following recommendations from friends, she chose St. Luke’s International Hospital in Tokyo’s Chuo Ward, an institution well known for serving foreign nationals.
But diet was a challenge for Gupta.
“The meals in the hospital can be tricky. (Here) they don't understand the concept of vegetarian very easily,” she said. “Many times, there were errors and then when you tell them, then they understand. But there's a lack of variety in vegetarian meals in hospitals, so I missed that and there is scope for improvement there.”
The diets prescribed or encouraged during the nine months of pregnancy are meals and staples that have historically met Japanese women’s meal preferences, like a combination of miso soup, white rice, fish or another source of protein, and pickled vegetables.
But that doesn’t work for everyone.
Tsubonoya says this is something she hears often, especially from vegetarian and Muslim mothers, particularly the latter.
"During COVID-19, there were instances where deliveries weren’t allowed, so some people only ate things like yogurt, white rice and miso soup,” she said. “Fish might be okay, but if there are additives or pork oil in something, (Muslims) cannot eat it, meaning they are given very few options.”
'Supporting the heart'
With all the differences in health and preferences that can exist for each pregnancy, those who care for mothers play a big role in how the experience plays out.
In Japan, midwives are deployed at hospitals during check-ups and labor to guide mothers and families throughout the process. Midwife Miyuki Brown says it’s important for those looking after foreign women to first remember that they must "support the heart."
Brown recently started a Facebook community made up of 100 Japanese midwives hoping to better serve foreign mothers during pregnancy.
As an adviser assigned to Asao Ward in Kawasaki, she visits mostly new Japanese mothers at home to check on them and their babies. But some of the mothers she serves are from Bangladesh and India.
Being the Japanese wife of a British man, her passion for better serving foreign nationals in her field began when she started to notice how her husband was treated in everyday life in Japan.
“I started to notice that if my husband was shopping and I accompanied him, workers would almost always speak to me first even though he was the person clearly shopping,” Brown said.
“Or if he was at the grocery store and asked someone for help, workers would say, ‘I don’t understand English’ and run away from him,” she said. “If that happens daily, you’d be frustrated, right?”
Brown recalled working as a hospital midwife without knowing much English. She sometimes found herself wishing she wouldn’t get assigned a foreign patient.
She also saw the reluctance fellow midwives displayed around foreign patients, as they worried that because they didn’t speak perfect English or know the patient’s native language, they wouldn’t be able to provide the best support.
But this is a mindset that needs to change, Brown said.
“As a midwife, while a lot of the medical and technical terms need to be exactly translated, a large part of our work consists of getting to know the mother and the support of the heart,” she said. “So even if it’s in Japanese, we can also communicate support through gestures, like a gentle pat on the back.
“Care isn’t just about the words. You have to have the hope that the person has a great childbirth experience, because childbirth is a memory that will always stay with you.”
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