Postpartum care services and multi-disciplinary collaboration in Japan

Abstract

The Postpartum Care Services (PCS) programme in Japan is intended to promote physical recovery and psychological rest for mothers and their children after discharge from the delivery facility, as well as nurture the mothers’ own self-care skills and support healthy childrearing for mothers, children and their families. The subsidies for PCS are based on cooperation between psychiatry and obstetrics and between multiple professions, including the local government. The services should also be implemented based on the instruction to medical institutions and the local governments that they should actively screen and approach pregnant women in need of support. This narrative review describes the challenges of expanding the PCS programme nationwide in Japan.

Introduction

Perinatal mental health problems have been recognized as significant complications of pregnancy and the postpartum period in Japan.^1–3 Perinatal mental health problems can functionally impair a woman and are associated with suboptimal development of her children. Active interventions mediated by cooperation among professionals from multiple fields have been observed to decrease the incidence of these serious problems.^1–5

To ensure healthy childrearing and mother–child relationships, it is necessary to build a seamless support system from pregnancy to childrearing,^1–3 with particular emphasis on strengthening support for mothers and children in the early postpartum period. Recently in Japan, the proportion of expectant mothers who need support during pregnancy, including psychological support, has been increasing due to the shift to nuclear families, weakening of local communities and increasing numbers of older pregnancies, poor families and unexpected pregnancies.^3–5 Furthermore, if the mothers who give birth without sufficient support are unable to adapt to the new lifestyle of childrearing, their mental health has been observed to deteriorate, leading to the onset of postpartum depression and other problems.^6–8

The Postpartum Care Services (PCS) programme in Japan is intended to promote physical recovery and psychological rest for mothers and their children after discharge from the delivery facility, mainly by midwives and other nursing staff, as well as to nurture the mothers’ own self-care skills and support healthy childrearing for mothers, children and their families.^9,10 Specifically, the PCS programme provides support for the mother’s physical recovery, breastfeeding guidance and breast care, psychological support such as listening to the mother, specific childcare guidance according to the newborn and infant’s situation, coordination of relationships with close supporters such as family members, and an introduction to social resources necessary for raising children in the community. It is important to note that women at risk of postpartum depression tend not to seek support on their own, so it is necessary for medical or administrative staff to take a proactive approach.^10–12 The Japanese government decided that the municipalities would be obliged to implement PCS starting in 2021, with the goal of a nationwide expansion by 2024. ¹³ This is embodied in PCS and Postpartum Maternity Checkup Programme (PMCP) in municipalities that implement PCS. PMCP is a prerequisite for the subsidy programme, which is to assess the mental health condition of mothers in addition to their physical recovery and breastfeeding status, and report the results to the regional administration, so that PCS can provide what is required.^14,15

This narrative review describes the challenges of expanding PCS with PMPC nationwide in Japan.

Overview of PCS in Japan

Since the ‘Guidelines for Prenatal and Postpartum Support Services/Guidelines for Postpartum Care Services (PCS)’ were published in 2017, they have been used as implementation outlines for postpartum care in each municipality.^9,10 Subsequently, PCS were made a legal requirement in December 2019 and imposed as a duty of effort on all municipalities from April 2021. In May 2020, the Fourth National Outline of Measures for Society with Declining Birthrate stated that the programme should be implemented nationwide in Japan by March 2025, and the guidelines were revised in August 2020.^9,10 The main cost of PCS has been subsidized by the national government (50%) and by local municipalities (50%); and the user’s co-payment has been determined by the local conditions and user’s income. In the guidelines in 2017, there were three types of services in PCS: (i) short-term residential care (overnight stay/short stay); (ii) day care (day service); and (iii) in-home visitation (outreach). The subsidy has been available to mothers and infants within 4 months after delivery who are suffering from postpartum physical or mental health disorders or anxiety about childrearing, or to mothers and children who are deemed to need support. To enable them to live an autonomous parenting life, they have received childcare support through PCS.

The main revisions to the guidelines in 2020 were: (i) the inclusion of mothers with their infants who had given birth less than 1 year after delivery in PCS instead of 4 months after delivery; (ii) the addition of information on the need to support foster parents, fathers, and families with multiple births and infants because either the support for them had been postponed or they needed special support; and (iii) inclusion of the requirement that postpartum care centres be built in conjunction with clinics, midwifery centres and other obstetric facilities. ⁹ Paternal depression has become a focus of interest in recent years in Japan, and it has been a growing belief that the whole family, not just the mother, should be supported. ² In addition, in Japan there are others experiencing problems in their lives, such as multiple infants, low birth weight infants, children with congenital abnormalities and foreign families who cannot speak Japanese. ¹⁶ Japanese administrative agencies have encouraged consultations with some support centres, such as childrearing generation comprehensive support centres and PCS. ¹⁶ The revisions have also included the addition of the need for support for home births, families with multiple births, adoptive and foster fathers, and the requirement that postnatal care centres be established in conjunction with clinics, midwifery centres and other such obstetric facilities. The revisions were made in consideration of the fact that the target period of suicide due to postpartum depression initially peaks around 4 months after delivery, but that problems with mental health are likely to occur due to childcare until about 1 year after delivery;^17,18 and the fact that infants born at 7 months of gestation will be discharged from the hospital around 3–4 months after birth. ⁹ In addition, according to a survey by the Ministry of Health, Labour and Welfare, approximately 60% of Japanese have experienced a home birth, there is a high risk of mental health problems in the presence of multiple births, adoptive parents, and foster parents, and there have been scattered reports of perinatal depression in fathers.^9,12 In addition, to make it easier for medical (obstetric) institutions to engage in PCS, conditions such as dual duties by medical institutions were added. ⁹

Issues for the nationwide expansion of PCS

With the nationwide development of PCS as a mandatory obligation and revision of the guidelines, various issues for the nationwide development of PCS have emerged. The subsidy target of mothers and infants has been changed from ‘4 months after delivery’ to ‘1 year after delivery’. ⁹ However, compared with infants within the first 4 months postpartum, infants around 10 months postpartum are larger and more mobile, and therefore require a large room in which hazards to the infant must be eliminated for mother–child care. In addition, the care of infants varies greatly from person to person, and there are facilities and municipalities that have been forced to renovate or reconstruct because they could not accommodate conventional rooms in their facilities. ¹⁹ Otherwise, some facilities and municipalities have not been able to complete their obligations to develop PCS.

In general, PCS have been subsidized for mothers and infants who have a certificate of residence (i.e. those who pay resident tax, which is a tax that people are obliged to pay to the municipality in which they reside in Japan) in their municipality, since the main body of maternal and child healthcare services is the municipality.^9,20 In addition, since the scale of the programme, including the budget, differences among municipalities, there are potential problems as outsourcing fees to medical facilities and co-payments made by users vary widely. An additional issue has been whether the same support and subsidies can be provided in the municipality in cases where mothers return to their hometown for delivery (many of them do not have a certificate of residence, i.e. they pay resident tax in other municipalities).^15,21 Some of the municipalities have provided subsidies because the user’s parents had a certificate of residence or provided subsidies with different support from those of the residents. It will be necessary to build a common system and procedures, such as having the municipality in which the resident has a certificate of residence compensate for the cost of the subsidy.

Although it would be ideal for the content of PCS to be set up flexibly from the user’s point of view in each area, at present, prospective users themselves should check the status of postpartum care facilities in the municipality in which they plan to deliver or stay from the early stages of pregnancy, and if the scale of facilities is not considered to be sufficient, they should consult with the municipalities in which they live to determine how to obtain support other than postpartum care.^9,21 If the size of the facility is considered to be insufficient, they are required to consult with the municipality where they have their certificate of residence about support methods other than postpartum care.

In the future, it is expected that all mothers who need support will be picked up, and PCS of assured quality will be provided in the same manner anywhere in Japan. However, there is currently no forecast for the realization of such a system in Japan.

Multidisciplinary collaboration in the community related to PCS

For pregnant and postpartum women who are eligible for mental health care or childcare support, obstetric institutions have provided support in collaboration with clinical psychologists, medical social workers, medical staff, and others, depending on the size of the institution.^4,5

Although mental health problems can occur in 10–15% of all expectant mothers, early detection is possible through proactive approaches from medical personnel or local administrations, and social and economic problems are often strongly related.^4,5,12,22 By collaborating with multiple professions to solve problems and provide support, pregnant and postpartum women can expect to reduce their mental health burden and actively face their pregnancy and childrearing. It is impossible to solve social and economic problems and provide support through intervention by medical staff alone. It is also impossible to fully evaluate the necessary intervention by supporters, its content, and effectiveness without an approach from the medical personnel side. What is important is to understand the severity of the mental health condition and dysfunction based on an assessment of the mental health of pregnant and postpartum women, and to clarify the division of roles and methods of cooperation among the various professions according to the nature and severity of the problem, which requires a community-wide approach for looking after pregnant and postpartum mothers who have problems.

In obstetric institutions, nurses play the most important role in mental health care and midwives play the role of the closest support professional for expectant mothers and their families.^4,5 Specifically, it is important to begin by listening to the feelings and words of all pregnant and postpartum women and show empathy for their feelings. This is the foundation for building a relationship of trust and working together with the pregnant and postpartum women to find a solution. Even if the case is referred to a psychiatrist or other multidisciplinary department, it is important for nurses to show empathy by accepting the content of the consultation and feelings expressed so that pregnant and postpartum women will not be misunderstood, they will not feel abandoned, and they will continue to receive consultations afterwards. However, in fact we cannot deny the possibility that frequently, due to increased workload, nurses are not able to provide the necessary psychological support for every woman, in addition to their other duties. ²³ Such care services require adequate resources and personnel.

The medical social worker provides information on support and social resources, serves as a liaison to relevant community organizations, and explains financial counselling and procedures to medical staff. It is important to share information about pregnant and nursing mothers and discuss support measures with opinions from each specialty, including psychiatrists, paediatricians and local administrative staff as necessary.

According to interviews with municipalities conducted in recent years in Japan,^24,25 a system of information-sharing and cooperation between obstetric facilities and municipalities has mostly been built, and paediatric care facilities can provide support according to the growth and development of the child; however, unfortunately there are few psychiatric facilities where breastfeeding mothers can be examined, and cooperation with psychiatry is still insufficient in Japan.

Consultation and assistance organizations in local communities in Japan

The 2017 revision of the Japanese Maternal and Child Health Act made the establishment of ‘Comprehensive Support Centres for Child Rearing Generations’ a statutory requirement. ²⁶ It has been expected to serve as a comprehensive window for maternal and child healthcare services in municipalities as a one-stop centre to address the problems of the past, in which it was difficult to share sufficient information with and promote cooperation among related organizations, and support was divided according to systems and organizations. The essential tasks of the centre will be to understand the actual situation of pregnant women and infants, provide consultation services for pregnancy, childbirth, and childcare, offer necessary information, advice, and health guidance, formulate support plans, and liaise and coordinate with healthcare and welfare-related organizations. ²⁶ However, until these arrangements are completed, the maternal and child health departments of municipalities are currently the main contact and consultation points.

Postpartum Maternity Checkup Programme

To date, in Japan, obstetrics and gynaecology departments have conducted a health checkup (i.e. medical checkup) for almost all women to ascertain their physical recovery and breastfeeding status during the first month postpartum. In April 2017, PMCP was launched, ¹⁵ which is a programme to monitor physical recovery and the breastfeeding status as well as mental health status, and to report the results to the municipality so that PCS can be provided to support postpartum women when necessary.

The fact that PMCP requires an understanding of the mental health status of mothers as part of the programme indicates that medical personnel can screen high-risk mothers such as those with postpartum depression, which could not be identified during pregnancy, without hesitation.^27–29 The Edinburgh Postnatal Depression Scale (EPDS) is mainly used to assess their mental health status, in which a score of 9 or higher is considered a category at risk of depression.^9,15,30 In PMCP in Japan, the EPDS is used to screen for depression and also as a tool for supporters to communicate with mothers and provide basic mental health care in the form of listening and empathy. In fact, the more support-requiring mothers tend not to receive antenatal checkups for economic reasons;^4,5 and even if they do, they tend not to express their problems to healthcare providers. Therefore, in order to enable all women in Japan who need support to have their mental health and related living conditions monitored in PMCP, it would be ideal to have a unified subsidy programme in all municipalities, as is the case with PCS.

Conclusion

This narrative review has described the current status of PCS in Japan based on my support experience at one of the major perinatal centres in Tokyo, Japan. It should be noted that subsidies and insurance coverage for maternal mental health are all based on the premise that support for pregnant women with mental health problems is provided through cooperation between psychiatry and obstetrics and between multiple professions, including the local government.^9,15 It should also be remembered that these programmes are based on the instruction to medical institutions and the local government that they should actively screen and approach pregnant women in need of support, whereas until now they have only waited for consultation and requests for support from pregnant and postpartum women.