Giving Birth, Having a Baby in Japan

Intro

We moved to Japan in March, 2002, and confirmed one month later that we were pregnant.  We already had a two year old daughter, so we had some idea what we were doing and what to expect.  But having a baby in a new culture is bound to offer challenges and surprises.  We would like to share our story with others, so you can benefit and learn from our experience.  I want to be clear that our story is just ONE example.  You can have a variety of birth experiences in Japan, and there are different kinds of doctors and hospitals.  However, I will risk making some generalizations starting with this:  If you want a particular type of birth experience in Japan, you may need to work hard to make it happen.

I (Andy) am writing this article because my wife, Hitomi, doesn't have the time.  Neither do I, but that's life now.  I wish you could see all of this through her eyes directly, but I'll do my best to share our joint perspective.

You also should know that I arrived in Japan with zero language ability, but Hitomi is Japanese.  Obviously, her ability to speak Japanese helped a lot.  It helped us to better understand the process we were going through, the cultural stuff and the choices we had to make. 

Finding Out

We actually suspected we were pregnant before arriving in Japan, but there was no time to think about it for the first three weeks.  We found an apartment, a language school, moved in (to the apartment) and handled countless logistics.  Sometime during the whole process Hitomi went to a drugstore and bought a pregnancy test, and it was positive.  She tried to take it easy throughout the whole moving process, but even "taking it easy" was hard work.

A few days after moving in to our apartment, we took a short walk to use a pay phone.  Hitomi suddenly said we needed to go home, because she might be having a miscarriage.  That evening we sat around in shock and regret.  The next morning she went to a nearby women's clinic.  When she came out of her appointment, she had an odd look.  The doctor told her that we had not one, but two healthy babies in there.  That's how we learned we were expecting twins.  

Choosing a Doctor and a Hospital

We live near a train station about 30 minutes outside of Tokyo.  It's a newly developed area, so we have many services nearby.  As we got to know our area, I was surprised that we could easily walk to several clinics and small hospitals.  There was even a "famous" maternity clinic about five minutes walk from our place. 

We learned a lesson when we had our first daughter.  If you have expectations about how childbirth should be handled, then choose your doctor and hospital carefully.  If you want to simply put yourself into the hands of a doctor and do whatever he/she tells you to do, then that's different.  In our case, we wanted a good doctor who would work with us on the birth process.

We didn't have a long list of particulars, and I don't think we are radical by any means.  Here are the things we wanted most, if possible:

• Natural delivery (not a C-Section) unless there was a danger to the child or mother. 

• For us that meant not using painkillers, not inducing labor unless medically necessary and not delivering from the old fashioned "flat on the back, feet in stirrups" position.

• The father in the delivery room.

• Exclusively nursing the baby starting immediately after birth.

• Total rooming in (meaning the baby doesn't sleep in the hospital nursery but in the room with the mother, so the two can bond naturally and the baby can nurse on demand).

• The ability for me to sleep in the hospital room, which is basically necessary in order for total rooming in to work.

In order to make a list like this work, we knew we would need good communication with our doctor and the hospital nursing staff, and the hospital would need matching facilities and policies.

We figured we had a lot going for us.  We lived near several maternity hospitals, and at least one birth clinic.  Plus, we had the impression (from things we had heard in the USA) that the Japanese medical profession is much more natural in their approach to birth than their counterparts in the USA.  On the other hand, having twins complicated our situation.  Doctors and hospitals are more cautious with multiples, and we realized we might have to be flexible, too.

The first thing Hitomi did was to make an appointment at the "famous" maternity clinic near where we live.  The clinic was founded by Catholics many years ago.  The current doctor is the son of a "famous" doctor.  The clinic looks like a large, converted home.  It's a brick building that looks like someone's dream house.  Inside it feels homey, too, except for the reception desk, packed waiting room and the glass window where you can always view a row of newborn babies.

As you may have noticed, I'm enclosing the word "famous" in quotes. In virtually every category of life here, people will say, "So and so is famous."  There are "famous" stores, resorts, soaps, towels, ramen, cream puffs, loaves of white bread and much more.  I have tasted and experienced a number of famous things, though, and I'm convinced the label is often either randomly assigned or (more likely) the result of clever marketing.  In the case of this birth hospital, it had been featured on a TV show that many people watched.  In particular, the TV show highlighted the building's architecture and history, the elegant furnishings, the doctor's "famous" father and the excellent cuisine served to new mothers.  (Actually, you can hardly watch a TV show on any subject that doesn't highlight food, and I've never seen anyone eat a bite of food on TV that didn't throw him/her into contortions of culinary ecstasy.) 

So on with the story.  Hitomi had an appointment with the doctor.  He was in a hurry (more on that later) and didn't appreciate her questions.  His brief answers communicated that she would give birth according to his routine and schedule.  She would be on her back in the old fashioned position for the delivery.  If the babies weren't coming out naturally by the 36th week, then he would induce delivery.  Twins often come out early, but routinely inducing birth for twins in the 36th week was shocking to us.  She could start nursing the babies right away, but they would be confined to the nursery for most of the first three days.  He was genuinely irritated at her questions, so my wife didn't press much further than that.

That was enough.  We started looking elsewhere, although Hitomi continued to see this doctor for routine checkups.  At this point, we started to learn that we had few options.  Several hospitals declined to handle twins at all, including the one natural birth center in our area.  We have a large hospital at the next station.  When Hitomi called and briefly interviewed the head nurse, the nurse said that she was the first person who had ever asked such questions.  That hospital has a policy to completely separate newborns from their mothers for the first three days, although they might allow short visits for nursing.  The point is for new mothers to rest and recover, leaving the babies in the care of the hospital.

We eventually learned that the hospital in my wife's hometown (two hours away by train) was open to most of our priorities.  Many Japanese women go to their hometowns to give birth.  They leave their husbands for about three months, and then return with the baby.  We never intended to consider this strategy, but we were desperate to find a hospital that would work.  In the end, we all moved to Hitomi's parent's house.  We get along well with her parents, and they have a big house, so that was not a problem.  We moved in early October with the twins due in mid-November.

About Japanese Doctors, Hospitals and Nurses/Mid-Wives

I feel like I have left out so much already.  It would be impossible to condense our insights into a short narrative, so I want to pause here and summarize a few thoughts.  Keep in mind that hospitals and doctors vary.  There are a few large, teaching hospitals in Tokyo and Yokohama where many internationals like to go.  I assume that the experience at those hospitals would be quite different, though not necessarily better.

Doctors - Doctors are addressed as "Sensei" in Japanese.  That's the same term used for teacher, professor and priest.  Traditionally, people with the title of "Sensei" are not questioned.  They are the keepers of knowledge, and their students/followers/patients are passive recipients.  Patients who ask questions may be seen as offensive or irritating.  Non-Japanese patients may think their doctors are secretive or even rude.  For this reason, internationals tend to identify and seek doctors who are culturally sensitive to their needs, and some clinics specialize in treating internationals.  We didn't take that route, primarily because we didn't have a car and don't live near to such a place.

One more thing worth understanding is that the medical profession does not have the social standing in Japan that it enjoys in some other places.  In Japan, social status is determined by the group you belong to.  If you are in a more solitary profession, such as doctors or dentists, you don't have a group to belong in that gives you status.  You may earn lots of money, but you don't have the social rewards that go with it.  In short, doctors may try to preserve their authority and respect in their clinics and hospitals, because they lack status outside their own environments.

Finally, the doctors we saw were incredibly busy.  They were seeing patients and delivering babies all day.  We have never been asked to schedule an appointment to see any doctor in Japan.  Sometimes Hitomi would show up and see the doctor right away.  Other times the waiting room would be packed with thirty or more women.  Once when we were visiting the "famous" maternity clinic, a nurse announced to a packed waiting room that the doctor would not see anyone for the next half hour, because he was delivering a baby. 

When a doctor is seeing over a hundred patients a day, and delivering five or more babies in between consultations, he/she may not have time to answer questions.  Our doctor didn't even dispense basic advice.  He didn't say anything about nutrition.  There was no mention of calcium intake, and he discouraged taking vitamins.  His number one response to inquiries was, "Don't worry about it."  The next doctor, in my wife's hometown, was easier to talk to and more forthcoming.  However, he also gave no substantial suggestions beyond his plans for the actual delivery.  We had one appointment in which we spent about 30 minutes asking him questions.  When we left there was a line of women waiting in the hallway. We felt a bit guilty, but it was a relief to finally talk with him about the process.

Hospitals - There are many small hospitals in Japan, including maternity hospitals that specialize in nothing but childbirth.  The hospital that we eventually chose was named "Nagai Maternity Hospital."  Our doctor was Dr. Nagai.  His father had built the hospital, and now the son owns and operates it. This is pretty common.  His hospital is a fairly large facility, so he has another doctor working with him.  That makes two doctors handling the entire hospital, including pre-natal care, birth and post-natal care (the hospital did not have a pediatrician).  About five babies were born every day.  The doctors were assisted by a number of nurses and support staff. Compared to hospitals in the USA, this hospital seemed small.  But it was considered somewhat large and modern by Japanese standards.  The big teaching hospitals in Tokyo and Yokohama probably feel more familiar to Americans, which is why many Americans prefer them.

If you don't have a car, you may have to choose from the hospitals and birth clinics near where you live.  Our city hall gave us a helpful guide for our local clinics and hospitals, containing a survey of mothers describing the maternity hospitals.  This would have been very useful, except the hospitals we liked most (the ones with the most natural approaches to birth) wouldn't accept twins. 

Nurses/Mid-Wives - When we started looking at our options, we noticed that most of the hospitals worked with mid-wives.  In the USA, mid-wives are virtually synonymous with "natural delivery."  But that's not necessarily so in Japan.  In the nearby hospitals, mid-wives worked with mothers prior to the delivery (mainly making them comfortable), but doctors delivered all the babies.  We have spoken with other mid-wives who have confirmed that doctors monopolize control of the birth process in most situations.  The lack of empowerment can really weaken the role (and, in some cases, the abilities) of mid-wives.

In our experience, the nurses also worked under the doctor's firm authority.  Once Hitomi was checked into the hospital, she asked the nurses a lot of questions about the birth process.  Some of the answers were alarming, because they completely contradicted what we had heard from the doctor.  For example, she was told that she wouldn't be able to nurse the babies right away, that the babies would be fed formula, and that they would have to stay in the hospital nursery for three days.  We had been assured quite differently about these things, but the nurse said these were all hospital policies.  Then Hitomi noticed that the nurses contradicted each other on these points.  After we spoke with the doctor, he apparently gathered the nurses all together and informed them of the policies that would apply in our case.  That resolved all the inconsistencies right away.  Despite their confident show of authority, it went to show how little the nurses were actually empowered. 

The Birth Story

Moving ourselves over to Hitomi's parent's house was a major event, although we have gotten pretty good at these things by now.  She scheduled an appointment with Dr. Nagai later that week.  We enjoyed a peaceful week, and then all our plans changed in a day.  When Hitomi saw the doctor, he said that one of the babies was in the breach position.  He recommended that Hitomi go on bed rest in the hospital for the remainder of the pregnancy as a precaution.  At first, we rebelled.  First of all, it seemed overly cautious.  Doctors know that most Japanese mothers work hard in their homes, and the only way to force them to rest is to check them in to the hospital.  At least that's my theory.  I also suspect that Japanese doctors are just very cautions in general.  I couldn't imagine an American doctor giving the same advice.  Or could I?? 

 
Hitomi on bed rest for 4 weeks (Andy goes hiking on nearby mountain...)

The problem when you're living in another culture is that you lose perspective, and then it's hard to think straight. Hitomi's parents clearly wanted us to follow the doctor's advice, and she didn't want to do anything that might endanger the health of the babies.  We made some calls.  My father is a doctor.  He thought the doctor was being extremely cautious, but that bed rest itself was not a bad idea.  To make a long story short, my wife checked into the hospital a couple of days later. 

Initially she was placed in a room with five other beds.  Each of the beds was behind a curtain in a small space, with a television and food tray.  Three of the other beds were occupied, but you could hardly hear a sound from the women.  This culture values personal space so highly, and making noise in public places is considered rude.  So everyone kept their curtains shut, and they didn't talk to each other.  The thought of her being confined there for a month seemed awful, so after a few days we asked for a private room.  We wondered about the economics of this decision, but no one seemed to know the details of what insurance would and wouldn't cover -- I'll say more about that later.  At any rate (pun intended), the private room was a huge relief.  We have a two year old daughter, and we were all able to be a normal family together during visiting hours each day (about 4pm to 8pm). 

I didn't mention this before, but Japanese doctors tend to discourage mothers from gaining much weight during pregnancy.  American doctors, especially the ones who seem to speak with the most knowledge, recommend at least a minimum amount of weight gain.  We had learned basic principles from our previous pregnancy, like eating well, getting lots of calcium, and drinking LOTS of water.  We also learned that with twins, you should concentrate on eating and drinking even more.

But in the hospital Hitomi was on a low calorie diet, and her meals each came with a small cup of tea.  We started bringing two liter bottles of water, and she was drinking about one per day.  That's the recommended amount for mothers expecting twins (from the best books we could find) .  But the growing pile of empty two liter bottles really worried the nurses.  They told Hitomi that if she drank too much water, she could retain water and develop Edema.  But that's just wrong.  Edema isn't caused by drinking too much water, but by other dietary and physical factors (the very things that no one talked about with us).  In the end, we carted off the empty bottles every night.

Although one baby remained in the breach position, Hitomi and the babies remained in great health. When we finally had our long (30 minute) consultation with the doctor, he told us we would have to have a C-Section due to the position the babies were in.  We accepted this advice.  It was probably a conservative opinion, but we weren't going to argue with our doctor over something he thought was medically appropriate.  Anyway, we really didn't have a choice at that point.

We did have a choice about when to schedule the operation. The doctor suggested two dates: the beginning of the 36th week and the beginning of the 37th week.  The doctor said that waiting would increase the risk of an emergency C-Section (and the risk that he would have to interrupt his busy schedule at an inconvenient time).  We chose the latter date, in order to give the babies as much time as possible to develop in the womb.  Considering the good health of Hitomi and the babies, I think even the 37th week was a bit early.

The date arrived.  Sometime before the operation Hitomi was given her first round of drugs, and then they dressed her in tight leggings to prevent blood from clotting in her legs.  This was all outside of visiting hours.  I arrived about an hour before the scheduled time.  She had been wheeled into another room, and she was feeling really good because the drugs were working.  When the time came, the nurses came and wheeled her across the hall and through some double doors.  I wasn't allowed inside that room.  I caught a look through the door and I could see why.  It was a strictly utilitarian operating room, with a cleaning bucket (for who knows what) sitting unceremoniously in the middle of the floor. Later, Hitomi confirmed that the atmosphere inside was all business. 

I waited outside, pacing and feeling like I was living out a scene from a movie.  I prayed a lot and kept trying to hear something through the doors.  After about a half hour, a nurse indicated that a baby was coming.  I grabbed my video camera and zoomed in through the window to catch each baby getting bathed in a side room.  Then they were carried out and placed in incubators next to the nursery window.  I alternated shooting video and pictures until Hitomi came out, and then I followed her up to the room.    

We had two healthy twin girls.  The first, Mari, weighed 2644 grams; the second, Maika, weighed 2712 grams -- good sized babies considering they were born three weeks early.

 
Mari and Maika in incubators immediately after birth

If they had been born naturally, they could have gone straight to our room.  As it was, the hospital requires 24 hours in the incubator after a C-Section.  The doctor had agreed to our request not to feed them sugar water or other supplements, so that we would have the best chance of getting them started with nursing when the time came.  By the way, in most cases, it's no problem for a baby to wait 24 hours for the first feeding in a case like this. Most babies can go for up to three days with little or no actual intake (that's about the amount of time it takes for most mothers to start producing a strong flow of milk).  The exception is if the baby's blood glucose level is low (usually measured using a heel stick soon after birth).  In that case, there is a danger of  hypoglycemia, and feeding the baby a supplement can help prevent serious, long term complications.  Again, you need to be in the care of a doctor you can communicate with and trust, so that you'll be ready to follow his/her advice in situations like this.

Following the Birth

Hitomi continued to feel quite good for the rest of the afternoon.  Having the babies in the nursery was not ideal, but we took advantage and rested.  Sometime during the night, the pain began to hit her.  A nurse came and gave her some pills, which helped a little.

The next afternoon they finally brought the twins to our room.  Hitomi was able to nurse them right away, and they latched on even better than our first daughter did.  We were so grateful!  I'm sure my wife's experience helped a lot.  After that, the babies only left our room for a morning bath and a daily weight check.  We were a bit nervous about having them weighed.  Newborns who are being nursed always lose a little weight in the first few days, and then they gain it back.  We were afraid that the hospital staff would make an issue of this.  Just before the babies were born, we heard that another mom wasn't allowed to take her baby home right away because it's weight was too low.  Anyway, they did lose some weight, but it was ok.  The hospital staff were quite impressed at their birth weight and how quickly they started gaining weight again.

 
Hitomi in her room after the delivery; Mari and Maika in our room on day three

We had supporters and detractors from the start.  The mid-wives at the hospital also doubled as lactation consultants.  They were very neutral at first, and didn't provide the kind of push Hitomi really would have appreciated.  But when they saw we were determined to nurse the babies, they were more encouraging.  A couple of nurses had good intentions, but they weren't that helpful.  One told Hitomi that nursing would be too painful and difficult.  Another said or hinted similar things, as if to let Hitomi off the hook.  In both our minds, nursing the babies was one of the best gifts we could give them.  Ultimately, it was Hitomi who endured the pain and sleeplessness to make this possible.

The C-Section itself was easy compared to delivering our first daughter naturally with no pain killers.  But a great thing about natural childbirth is how quickly the body recovers.  The contractions during birth start the process of returning the uterus to its former size.  Nursing provokes further contractions, which continue the process.  The pain may be intense during labor, but it's quite bearable because your baby is being born.

In the case of a C-Section, you usually have the operation before your body goes into labor.  So you skip the contractions, especially the really strong ones that push the baby out.  But the real pain comes in days two through four.  That's because the uterus still needs to contract to it's original size.  Hitomi was given a Pitosin IV to stimulate contractions.  In addition, she was nursing, which naturally stimulates contractions.  Finally, she had twins, so her uterus was the size of a basketball (or so).  The point is that it was very painful. The worst pain was when she was nursing AND on Pitosin, which provoked the strongest contractions.  That's the pain the nurses were warning her about, and it's the reason why many new mothers give up and send their babies to the nursery.  Hitomi thought this pain was worse than when she delivered our first child naturally.

We had a HUGE advantage over the other mothers -- me.  I stayed in the hospital the entire time and helped Hitomi nurse the babies day and night.  It was a lot of work, and I can't imagine how she could have done it otherwise.  Maybe she could have handled one, with the help of the nurses, but not two.  Another advantage is that Hitomi knew what she was doing, because we had great support with nursing when our first daughter was born.  The hospital had some posters in various places that advocated nursing, but the staff didn't provide much help. 

On the other hand, all the new mothers were required to attend a seminar taught by marketing reps from a formula company.  These reps briefly extolled the values of nursing, and then they talked about formula for the rest of the time.  Each mom got a bag of goodies, including baby clothes, bottles and formula, of course.

I don't want to wrap this up without mentioning the morning routine.  Every morning at 8am sharp, the elevator doors opened and both doctors came out.  They were each carrying clipboards and followed by two nurses pushing carts of supplies.  Each doctor went to a door, burst in, and then burst out two or three minutes later.  They quickly checked the moms and babies.  The hospital did not have a pediatrician on staff, just these two doctors who provided 100 percent of any doctoring that was done before, during and after delivery. 

I never got to see what went on during the morning checkups, because I was exiled to the snack room where I sat and watched them move through the hallways. During one of those mornings, it occurred to me that 90 percent of the time these two doctors were the only males in the entire building, always surrounded by female nurses and patients who completely accepted their authority.  They were immersed in this reality for most of their waking lives and couldn't have had much time or energy for anything else. 

 
Andy and Reia hold a baby (on Andy's couch/bed); and friends visiting

By the time we checked out, I think we had attained legendary status.  We stuck out and gave the staff many reasons to remember us.  First, there was my wife's big, blue inflatable nursing pillow (special ordered from www.twinstuff.com for nursing twins).  Then there was her incredible perseverance to keep nursing, after a C-Section, through the pain and lack of sleep.  I think most of the staff expected her to give up, but she kept going.  Then there was the babies' healthy birth weight and weight gain, not too mention their cuteness.  Finally, if all that wasn't enough, there was this blond, blue eyed 6 foot 3 inch American man living in the hospital, roaming the halls late at night and riding off to Starbucks every day on a giant mountain bike.    

By the way, we stayed in the hospital for ten days.  That's a pretty standard amount of time following a C-Section.  It could be more or less depending on the hospital.  I don't remember the expected length of stay for natural deliveries, but it was several days.

The Bill and Insurance

I'm not going into great detail here.  I just think it's worth saying a little about the finances.  We have Japanese health insurance.  If you are covered by Japanese health insurance, your policy and payment amounts may vary depending on where you live.  We live in Yokohama.  Even though we gave birth in Odawara, the  amount we received was affected by the system in our city.

In our case, we received a lump sum of for several thousand dollars.  It came in two parts, with the first payment coming a couple of months after the babies were born.  That means we needed to pay the hospital up front, and the payment was a reimbursement.  We paid the hospital a large deposit in advance, and then we were expected to pay the rest when we checked out.

In addition to this lump sum, our insurance eventually sent another payment for some specific expenses covered separately.

Since we had twins, we received a larger amount than you would receive for a single baby, and it seemed like a lot of money.   In fact, some people told us we would make money off the whole thing.  However, Hitomi spent an entire month in a private room.  The difference in cost between the private and group rooms was not covered, so we had to pay that ourselves.  In the end, we ended up paying a significant amount.  But the charges for the private room were absolutely NOTHING compared to the what a similar room would have cost in the USA.  When you consider what we pay for insurance here, our medical care has been quite inexpensive.

On top of that, we learned that the city of Yokohama pays a monthly subsidy to families with young children in order to help with the extra expenses.  They pay 5000 yen per month for the first and second children, and then 10,000 yen per month for each child after that.  You have to apply at your local city hall to receive these payments, and they continue until a child is five years old.  We're very grateful -- every bit helps. 

Questions, Feedback, Comments

Question:   My wife is also Japanese.  After your twins were born, were they registered in your wife's family registry? I would like are children to have my Family Name. Were you able to register your twins in your name or did they have to be registered with a Japanese family name?  We would really appreciate your insight in this. It is a little difficult to get straight answers.

(Response:  When we got married, my wife changed her name in her Japanese family registry to my last name spelled in Katakana.  All of our kids are likewise in the family registry under the same name.  If you want to register their names in Romanji (English letters), that may be a problem.  On their passports, they have a choice of either Katakana or Romanji.  Keep in mind that you can register them differently in the two home countries.  For example, in the USA our daughters each have middle names, but in Japan they are officially registered with just first and last names.  They don't use middle names in Japan, so we chose not to register them with one here.)

Comment:  (from Cornelia Kurz of TokyoWithKids.com)  Your readers might find the following link useful: Japan With Kids - Forums: Immigration/visas/re-entry permits: Baby born in Japan -- now what?  http://www.tokyowithkids.com/discussions/messages/178/557.html

Comment: Great job on your webpage. I agree with about 90% of your opinions and recommendations. There is only one I take issue with and would suggest you add a caveat.  Regarding intake by the newborn in the first days after birth. It's true the baby won't starve or be harmed by minimal intake. However blood glucose must be monitored, this is done with a heel stick. It is particularly important in cases where the mother either had gestational diabetes or a family history of diabetes. Babies who are either small for gestational age or large for gestational age (over about 3,500 grams) are also more likely to see a drop in blood glucose levels. The research on this is very clear, there are serious long term implications from hypoglycemia in newborns (learning disabilities, lower IQ, etc). I agree it's best to only offer the breast, with the only exception being evidence of lowered blood sugar in a baby who cannot (or will not) latch on. In US nurseries the standard of care is to do a heel stick on all newborns approximately 4 hours after birth, and if they show clinical signs of hypoglycemia (most commonly jitteriness).  I reply to this both as a mother (son born in Sicily 1993, daughter born in England 1997) and a nurse/family nurse practitioner. 
Congratulations on your lovely twins and older daughter. Started the college and wedding fund yet? :)

(Response:  Thanks for the correction.  I used this information to edit the part of the article that you were referring to.  Thanks to anyone who takes the time to point out errors or parts of this story that need clarification.)