Japanese women

• Women should avoid getting cold (eg wearing socks to keep warm even in summer).
• Pregnant women are advised to abstain from any activities which require concentration. They may believe that epinephrine released at the time of maternal mental stress may harm the fetus.
• Women may not restrict the types of foods they eat. They may not avoid raw fish or stop drinking green tea (despite the risks of bacteria and caffeine), and may not take prenatal vitamins. The importance of following the dietary recommendations for pregnant women should be highlighted.
• According to Japanese tradition, women in their eighth month of pregnancy should reduce their level of physical activity. Many women move to their maternal home for birth. This is called 'Satogaeri'.
• The more “relaxed” maternity care in New Zealand compared with the “strict” care in Japan (eg less weight management; fewer ultrasounds and blood tests than in Japan) leads to increased anxiety for Japanese women in New Zealand (Doering et al., 2014).
• LMCS may find that Japanese women, although able to speak in English, have communication and language difficulties during pregnancy due to terminological and cultural differences.
• Going back to Japan to give birth, 'Satogaeri' is common among Japanese pregnant women in NZ.

In Japan, very few women have any pharmacological pain relief during birth, compared to women in other developed nations (Doering et al., 2014). The epidural rate for childbirth is 2.6% in Japan compared to 28% in New Zealand. While Entonox and Pethidine are widely utilised by women giving birth in New Zealand, their administration is rare in Japan. The majority of women giving birth in Japan know about breathing methods and water births. The rate of caesarean section in Japan is 18.4% compared to New Zealand’s rate of 23.7% (Japan Ministry of Health Law, 2010; New Zealand Health Information Service, 2007). A New Zealand study of Japanese women’s birth experiences of pain management showed that Japanese women experience conflict over using pharmacological pain relief (Doering et al., 2014). Overcoming labour pain is viewed as an honour in Japan. The linguistic constructions of birth significantly differ in Japanese and in English languages. Contractions and labour pain are separate words in English, but in Japanese are represented as a single word and concept, jintsu. Conceived of in this way, contraction and labour pain accompany each other and cannot be separated (Doering et al., 2014). For these reasons Japanese women may have undue social pressure to accept and overcome labour pains (Yoshida, 2008). Women can be left feeling vulnerable when they are unable to go through labour pain which means that they are not accorded the honour it provides (Doering et al., 2014). When Japanese women have an epidural, they may experience feelings of disappointment, guilt, shame and defeat. It is important to discuss the possible use of an epidural and its meanings prior to birth.

• Childbirth is considered a natural event and is usually drug-free.
• Women in labour are encouraged to eat (depending on the length of the labour), as it is believed that food will provide the strength and energy needed for effective pushing.
• In Japanese culture, having a caesarean section is not viewed positively, but it is considered very important to do what the doctor says.
• Fathers are commonly present during labour.

• In Japan, women stay at their maternal home for up to eight weeks after the baby is born. This is termed 'Satogaeri bunben', the traditional ritual support system for perinatal women. 'Satogaeri' means returning to the original family town or house and 'bunben' means giving birth (Yoshida et al., 2001). During this time, a postpartum woman can rest, recuperate, and learn how to take care of the baby (Yoshida et al., 2001).
• Women’s mothers often come from Japan to care of the woman and her baby.
• A postpartum woman often receives significant support from her mother in taking care of the newborn baby. This should be kept in mind as Japanese women in New Zealand may not have access to this support system.
• In Japan, showering or washing hair is prohibited until three days after birth (including in hospitals). Postpartum women should be informed that in New Zealand showering after birth is recommended, but it is the woman’s choice and she may prefer a sponge bath.
• An extended rest period (traditionally about a month) is encouraged and it is believed that postpartum women should not use their eyes or heads (eg thinking) too much.

• Bathing the infant is acceptable.
• Nappies are changed whenever they are wet or soiled.

• Breastfeeding is strongly encouraged.
• In New Zealand, the majority of Japanese-born women breastfeed their infants.
• Breast massage is practiced by some women to increase lactation.
• Breastfeeding in public is considered embarrassing and shameful. However, women make good use of mothers’ care rooms.

• The use of the Edinburgh Postnatal Depression Scale (EPDS) during the early postnatal period can be a simple and useful screening instrument for the onset of early postnatal depression in Japanese women (Klainin & Arthur, 2009). In the EPDS Japanese version, the recommended cut-off point is 8/9. However this should be used with caution. A score of 9 or higher indicates that depressive symptoms have been reported and that a reliable clinical assessment interview is required (Yamashita, 2000). The Western standard cut-off score is 12/13.
• The EPDS has a validated translated Japanese version for use in screening for postnatal depression (refer to the section under Edinburgh Postnatal Depression Scale (EPDS) – Translated versions).
• In a study on postnatal depression in Japanese women living in England and in Japan, regardless of the traditional support system of Satogaeri bunben, the incidence of postnatal depression among Japanese mothers is exactly the same as reported for Western mothers (Yoshida, 2001).
  • There was no difference in terms of the incidence of depression between two groups of Japanese mothers, one group living in England and the other living in Japan, although their living circumstances and socioeconomic background, including education level, were different.
  • In Japan, the traditional support system for perinatal women termed 'Satogaeri bunben' did not lower the incidence of postnatal depression.
  • Japanese mothers in both groups did not express their depressed mood when they answered the self-report questionnaire for detecting postnatal depression.
• Japanese women express their feelings through physical conditions such as stomach aches, diarrhoea, constipation and fatigue.
• Postnatal depression may also be expressed as worrying about their babies (Yoshida et al., 1997).
• It is important to screen Japanese women for postnatal depression, particularly as women may not ordinarily express their emotions (Yamashita et al., 2000; Yoshida et al., 2001).

Screening for postnatal depression

• Listen VERY carefully if Japanese women share any negative experiences or feelings.
• Ask specific questions eg “Are you able to sleep when your baby is sleeping?” How long does it take you to fall asleep?” instead of “How’s your sleeping?”
• Pay attention to physical symptoms in mothers.Observe Mother-Baby interaction (eg using NCAST - the Nursing Child Assessment Satellite Training tool (Sumner & Spietz, 1994).
• Use screening tools such as the validated EPDS Japanese version.
• Ask follow up questions regarding any positive answers on the screening tools.

Screening tools validated for Japanese populations (Yumoto, 2016)

• Handout the EPDS in English and Japanese. The Japanese version is available through: http://www.perinatalservicesbc.ca/health-professionals/professional-resources/health-promo/edinburgh-postnatal-depression-scale-(epds)
  • The cut-off score for Japanese women ≥ 9.
  • Ask follow-up questions if the answer to Q10 is 1 or above.
    • “When was the last time you felt that way?”
    • “What was the situation?”
    • “What kind of thoughts did you have?”
    • “Did you tell your partner or family about feeling this way?”
    • “How often does it happen?”
    • The Postpartum Depression Predictors Inventory-revised (PDPI-R) (Beck, Records & Rice, 2006) identifies 13 risk factors, often contributing to postnatal depression: First 10 risk factors: Prenatal Version of PDPI-R (range = 0 - 32).
    • All 13 risk factors: Postnatal Version of PDPI-R (range = 0 - 39).
  • Self-report, followed by a brief interview (in English).
  • Japanese version (PDPI-R-J) developed and validated by Ikeda and Kamibeppu (2013).
  • Cut-off score for Japanese women = 5.5 for Prenatal and = 7.5 for Postpartum.
• Mother-to-Infant Bonding Scale Japanese version (MIBS-J) (Yoshida et al., 2012)
  • Handout in Japanese and English.
  • A higher score indicates worse mother to infant bonding.
  • No cut-off scores (range = 0 - 30).
  • Ask follow up questions if answers to Q3 (Resentful) or Q5 (Angry) are positive:
    • “When was the last time you felt this way?”
    • “What was the situation?”
    • “How did you handle it?”
    • Listen to the woman’s struggles and difficult feelings in a non-judgemental way.
• Be sure to use culturally appropriate cut-off scores with screening tools.

What to do if screening is positive (Yumoto, 2016).

• Encourage the woman to talk to her GP or mental health professional.
• Write a letter to the GP with the screening results.
• Refer to maternal mental health if moderate to severe.
• Talk to family members about postnatal depression.
• Provide psycho-education about postnatal depression.
• Help the woman to identify and access extra support.
• Develop plans together with her for self-care.

Note: Information on postnatal depression for Japanese families:www.pref.nagano.lg.jp/seishin/heisetsu/jisatsuyobo/documents/sango_utsu_02_naka.pdf

Information in Japanese for partners to support mothers with postnatal depression http://www.fathering.jp/sangoutu/.

• When arranging for a home visit, make it clear to the woman, that you don’t expect her to put any effort into preparing the house, herself, or her baby for the visit.
• It is important to arrive on time; if you are running late let the woman know.
• It is necessary to remove your shoes when you enter the house.