Made in Japan 2

Doctors, Midwives and Hospitals
The first thing that Matt and I had to tackle was actually confirming 100% that I was pregnant. I was going to have to see a doctor, and not just any doctor. I needed to see one of those wink-wink-nudge-nudge doctors. I was referred to a great OBGYN by an American friend in town, whom had recently given birth herself. Her Japanese husband accompanied Matt and I on our first visit to help out with the translating. She told me her main reason for choosing this doctor over the 3 others in town was that he gave women the option of using an epidural. In Japan, the majority of women have natural births. Actually, this doctor is apparently 1 of 2 in our whole prefecture that offers it up front. This, coupled with the fact that he had experience dealing with foreigners made him an appealing choice.

There was no appointment needed. In fact, I never had to schedule any of my appointments, which was very convenient. After checking in and waiting, we were admitted to see the doc, who was soft-spoken and kind and made us feel at ease right away. There were two main differences that I noticed from that meeting. First, the examination was not done lying down, but sitting up in a birthing chair that I liken to be similar to Darth Vadar’s throne with a gynecological twist. It lifts off the ground and spreads your legs so that the doctor can sit under you, almost like a mechanic working on a car. The first time I sat down and it lifted off, I had to keep myself from laughing out loud. Additionally, doctors usually draw a curtain over your hips so that you can’t see who or what is happening on the other side. I take it that this is has something to do with making the patient feel more comfortable and less embarrassed. He actually asked me if I wanted it opened or closed, and I opted for an open curtain exam. I then discovered that he wasn’t the only one back there, but that there were at least 2 or 3 nurses milling around the office, but they were all respectful and there was no gawking or wide-eyed glares throughout the procedure, so it didn’t bother me too much.

The doc confirmed my pregnancy by pointing to a dark circle on the screen and saying “There is the egg sac.” I asked him “It’s a baby?!”, and he said, “No, it’s an egg sac” which culturally translated really means, “Congratulations, you’re pregnant.” Japanese doctors apparently don’t like to say that you are indeed pregnant until you hit the 10 to 12 week mark. As I was only about 7 or 8 weeks in, he told me to come back in a few weeks so he could double-check and in true Japanese fashion, give me a certificate, which would officially declare my pregnant state. The certificate is actually pretty important, and I’ll cover it in more detail a little later.

Other than what we learned at the examination there are a few more interesting points to note about the maternity system in Japan. Where we live, women usually have their babies at birthing hospitals, opposed to a big general hospital with a maternity floor or wing. I assume that it is the same all over Japan, but I’m not certain. Our hospital has two or three floors. The first floor resembles a walk in clinic with a reception desk, waiting area and doctors’ office. The other floors are where the babies are born and where the mother’s stay after the birth. Women are required to stay in the hospital for at least 5 or 6 days, sometimes longer depending on if you have twins or a c-section or any other complications. A Japanese colleague of mine said his wife was in the hospital for 10 days, but there wasn’t anything wrong with the baby or mother, so he wasn’t sure what the reason was. Perhaps it was just that specific hospital’s policy.

Our hospital also has two resident midwives. Apparently it is the norm for midwives to be an active part of the preparation and birthing experience. According to my local American friend, compared to the doctor, the midwives play a much more active role on the birth day. We didn’t meet our midwife until I was in my third trimester, when she began to give us short classes on breastfeeding preparation, breathing and an assortment of other good stuff.

Because our doctor didn’t speak a lot of English, it was usually helpful to have a Japanese speaking friend tag along with us for each of our appointments. There were times where I felt like it wasn’t necessary, as I was able to get the gist of what he was saying. Still, he seemed nervous whenever I came alone, so 99% of the time I brought a friend with me. The other 1% of the time were the few instances that I suddenly felt sick as a dog and needed him to prescribe me baby-safe cold or headache medicine. So as not to exhaust any one person with the duties of being my sole translator, I rotated three Japanese speaking friends. This has worked fine for us so far.

Frequency of doctors visits seem to match up with the North American standard of visiting once a month for the first two trimesters, and then increasing in the last term. What also matched up were the standard blood, urine and glucose tests, and monitoring of weight gain and blood pressure. What was different (and also great) was that unlike North America, they did an ultrasound for each visit I made, and gave me a picture as well. It’s amazing to watch the baby grow this way and reassuring to see it develop. 

As far as we know, Matt and I are the first full foreign couple to have a baby at this hospital, and possibly even in our town. I’ve been told that, unlike physician’s back home, Japanese doctor’s are not used to fielding too many questions or requests from their patients. I think this has something to do with trusting in their authority, as they are the ones with the training and experience and the rest of us are merely first time pregnant ladies who have yet to learn what a Kegel is. However, our doctor was very patient and always happily answered all our questions. We were never made to feel like our questions were inappropriate. If anything, the doctors and nurses went out of their way to make us feel comfortable. One day in my second trimester, in the middle of an ultrasound, the doctor pointed out to me all the parts of the baby…his head, stomach and even his bladder. I joked with him that he had all his fingers and toes too, right? He immediately zoomed the camera into the feet and carefully counted all the delicate tiny toes on the baby’s feet. Yes, there were definitely 10 toes.  

Maternity Leave
I am definitely not an expert on official Japanese maternity leave laws. What I do know is that most Japanese women take about 2-3 years off to stay home with their kids. According to friends, there’s a small percentage of women that return to work quickly, probably due to circumstances out of their control. In this case, their baby’s are placed in the care of a family member or day care, known as hoikuen.

This is the leave terms that I was offered by Miyazki Prefecture, which is technically my employer as I work as an Assistant Language Teacher at a prefectural high school. Maternity leave policies might vary depending on whom you work for. Officially, I’m allowed 6 weeks of mat-leave before my scheduled due date. My school office said this is the maximum I can take off, but if I wanted to shorten it a bit, that would be fine. If my energy doesn’t fail me, I may opt to do so, simply because I want to make one last full paycheck. The prefecture/school will stop paying my paychecks from the point in time that I enter into maternity leave up to the point in time that I return back to work. In the meantime, I will be paid what I think is an unemployment benefit, by the government. I won’t receive full compensation, only 2/3rds of my normal pay. The money will be deposited directly into my bank account, and my school office is helping with all the paperwork involved with that transaction.

No matter when the baby is born, early or late, I will only have a total of 8 weeks off before I have to return to work. I asked my school if I could use some paid vacation days to supplement this time, because it’s obviously very, very short. They said that I couldn’t, as I needed to prove that I was returning back to work to qualify for the unemployment pay and health insurance benefits. However, I could return to work after 8 weeks for a day or two to show that I am officially back on the job, and then I can use my paid vacation days as I see fit. I also asked them if I shortened my pre-birth maternity leave by a couple weeks, if those weeks could be added to my post-birth leave. Again, the prefecture wouldn’t allow it.

Paperwork and Documents
Nothing in Japan is official unless there is a document with a little red seal on it that says so. When I returned to the hospital at the 10-week mark, I was issued a certificate that stated that I was indeed with child. It also had the scheduled due date printed on it. Once you have been issued this document, you will need to take it to your city office and register your pregnancy. When you register, they will give you an assortment of information pamphlets (all in Japanese), the Mother and Child Health Handbook, and discount coupons for your future doctor’s appointment. I also got a free sample of Soy Joy, a fruity soy-based energy bar. Hmmmm.

The Mother and Child Health Handbook, also known as the Boshi Techo, is really important. It’s used to record all the test results of mom and baby before the birth, as well as all doctor’s visits and immunizations of your child up until the age of six. Apparently, it is also a necessary document for some passport applications, so don’t lose it or throw it away too hastily. There are versions of the book in many languages including English. Here are a few links that review the handbook in greater detail:

http://www.tokyowithkids.com/fyi/boshi_techo.html
http://www.tokyo-icc.jp/guide_eng/child/01.html
http://www.city.kawagoe.saitama.jp/koryucenter/e/guide/40.htm

The coupons are equally important, because they are going to save you a heap of cash. I’ll cover them in a little more detail in a moment.

One other document that is worth mentioning is the one your job will require to process your maternity leave. My school asked for this piece of paper sometime in my second trimester. I can’t for the life of me remember the name, but when I explained what my school needed to the doctor in my broken Japanese, he knew exactly what I meant. He wrote it up in a couple of minutes and put it in a sealed envelope. I believe it contains the name of the hospital and your official due date and cost me 1000 yen.

How Are We Going to Pay For This?
Having lived in both Canada and the United States, I feel like I have experienced both ends of the Health care system rainbow. On one end of the spectrum Canadians pay for their health care through their taxes and government subsidies. Everyone gets the same level of care, and I would say that level is pretty good. In all my 28 years of living there my family never once received a bill for any of our numerous hospital visits and yearly check-ups, which included at least 3 childhood broken arms, my dad’s quad-bypass and the births of both my lovely nieces.

On the other side is the United States. We left the US for Japan in the summer of 2009, so I’m not entirely clear what changes to the system have been made since the Obama administration came into power. However, before we left I was able to gather that most citizens purchased private insurance or received coverage through their employer. As far as I know the government didn’t subsidize health care, except when it came to programs geared towards senior citizens and low-income families. A few of Matt’s family members are either doctors or nurses, and through talking with them, I found that the level of health care was very good. I never needed to be treated for anything complicated, so my first hand experience there was limited. However, in the year that we lived in Minneapolis, I visited the doctor once, and I was most definitely billed for it, even though I was covered under Matt’s work insurance. That was the year that I learned what the word ‘co-pay’ meant.

The Japanese health care system is happily somewhere in the middle of this medical rainbow, and overall I’m satisfied with it. In the year before I was pregnant, Matt and I both visited the doctor a few times, and found the level of care to be good, although in our small town I get a sense that it is a little more basic than in larger city-centers. That said, everything we’ve ever needed treatment for, from strange skin infections to nagging coughs, have been successfully addressed. Patients pay 30% of their health care costs and the government fits the bill for the remaining 70%. The fees for all our visits have thus far been very reasonable, but again, our medical issues were small affairs up until now.

Being pregnant is no small affair. There are multiple doctor’s visits to be made, tests to be done and one big medical showdown at the end of it all. Top that off with the Japanese policy of keeping moms a week in the hospital after the birth, and you can imagine that even just 30% of the cost would feel pretty hefty. Rumor has it that childbirth isn’t actually covered by national health care, because technically there is nothing wrong with you and you aren’t actually sick, so it somehow falls outside the national system. From what I can gather it is either the prefecture or the municipality that helps to compensate parents for the cost of having a having a baby.

This is how it has worked for us so far. When we handed in our proof of pregnancy to the city office, along with the Mother’s Handbook we received about 14 discount coupons, just enough for every one of my prenatal doctor’s appointments. On average, a normal visit costs me 2000-3000 yen with a coupon. A normal visit includes a urine test, recording of weight and blood pressure, an ultrasound and a small chat with the doctor. There are a few free coupons that are meant for special visits, so you don’t have to pay anything at all. I just had one of these special visits, which included a glucose/blood test, urine test, ultrasound, chat with the doctor and a short lesson on breastfeeding with the midwife. Also, I believe there were coupons included for the baby’s first two checkups. The amount of coupons you receive may vary depending on your prefecture.

In regards to the cost of delivery and hospital stay, I have been told that we will receive a lump sum payment from the government that should cover the cost of both. You can opt to receive the payment personally sometime after the baby is born, or have it paid directly to the hospital. We opted to have it paid directly to the hospital so we don’t have to dig into our savings and then sit around waiting for the government to pay us back. The amount is in the ballpark of about 300,000 to 350,000 yen. If you need a cesarean or opt for an epidural or private hospital room, you will probably have to pay out of pocket, as the lump sum just covers a basic birth. In addition, the hospital offered us a cheap insurance package (maybe 3000 yen?) that pretty much everyone gets, which covers the cost of medical care for the baby in the event that there are any serious medical complications after the birth.

Before the tsunami hit, parents received a child allowance every month from the national government to help assist them with cost of raising their child. It seems like this program might be on the chopping block. The amount is somewhere in the vicinity of about 13,000 yen a month, and there was even a proposal to raise it to 26,000 yen, but after reading the following article, I realize now that we can’t count on this money being there in the future:

http://www.japantoday.com/category/politics/view/govt-to-give-up-on-increasing-child-allowances-in-fy-2011