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Where Should Women Deliver Babies in Japan?

Where Should Women Deliver Babies in Japan? Maternal mortality is rare in Japan, with only 7.1 maternal deaths per 100,000 live births in 1998.1 However, this rate is relatively high when compared with the infant mortality rate (3.6 per 1000), which is the lowest in the world.1 In their article in this issue of THE JOURNAL, Nagaya et al2 exhaustively examine the causes of these maternal deaths and conclude that more than a third could have been prevented if the women had been treated in a hospital with better staffing of obstetric and anesthesia services and better laboratory facilities. Based on their findings, they recommend that all deliveries should occur at designated regional medical facilities and be attended by more than 1 physician. Many maternal deaths result from emergency conditions that are difficult to predict. Consequently, to decrease maternal deaths, it may be necessary to do what the authors have advocated. The Japanese government took tentative steps in this direction in 1995 by establishing grants to regional medical centers for expanding their maternal and child care units.3 However, following the recommendation of Nagaya et al would require a major restructuring of the present Japanese health care system because currently only about a third of deliveries take place in such large facilities. Thus, before attempting to institute changes, it is important to examine the evidence put forth by the authors. Their conclusion is based on the fact that the preventable maternal death rate was 14 times lower in transferring facilities compared with receiving facilities. However, while a greater share of receiving facilities are large, and more transferring facilities are small, both encompass facilities of different sizes. A better indicator of the relationship between facility characteristics and preventable maternal death rate would be the number of obstetricians in each facility. The data of Nagaya et al show that although the rate of preventable maternal deaths is somewhat higher for facilities with 1 obstetrician (4.09 per 100,000 live births), the rate for facilities with 4 or more obstetricians is only slightly lower (3.41) and the lowest rate is for facilities with 2 or 3 obstetricians (1.60). Thus, restricting all deliveries to designated regional facilities may not have the intended impact on lowering the maternal death rate. The multidisciplinary committee that determined preventability of maternal deaths in the study by Nagaya et al also appears to have had conditions under ideal circumstances as their criteria. However, the death might not have been preventable under the circumstances in which it actually occurred, given the absence of anesthesiologists, other obstetricians, and laboratory facilities in the smaller facilities. The authors recommend that high-risk patients should receive their ambulatory care also at a designated regional medical facility. Although this approach may improve prenatal care, it would affect only those maternal deaths that were predictable based on risk factors identified at the time of the ambulatory visits. Nagaya et al attribute the decrease in maternal mortality rates from 1990 and 1995 to a decrease in ectopic pregnancy. Although the number of deaths due to ectopic pregnancy did decrease from 10 (0.82 per 100,000 live births) in 1990 to 2 (0.16) in 1992, it increased again to 5 (0.42) in 1993, and most recently, was 3 (0.25) in 1998. More consistent decreases occurred earlier between 1980 and 1985 when the number of deaths from ectopic pregnancy declined from 22 (1.40) to 12 (0.84),4 which coincided with the time the use of ultrasound examinations became routine. Limiting deliveries to designated regional medical facilities will encounter resistance from patients and obstetricians. The reason two thirds of Japanese women currently choose to have their deliveries in clinics and small hospitals is not necessarily because they are less expensive, but probably because these smaller facilities provide more personalized service and have better amenities. In addition, clinics and small hospitals often are located relatively close to women's homes, which is an important consideration because many women choose to return to their hometown for their delivery so that their mothers can provide assistance following the birth of the child. Whether women are prepared to forgo these advantages for a very small decrease in risk needs to be evaluated. The highest rate of unpreventable and preventable maternal deaths occurred when no physicians were present, ie, during deliveries at home or by independent nurse midwives. Thus, the readily accessible and convenient small facilities have made it possible for virtually all deliveries to be performed by obstetricians in facility settings with a decrease in maternal mortality. At the macro policy level, the marginal costs of developing and maintaining regional medical centers to which deliveries are limited must be weighed against the marginal benefits of decreasing preventable maternal deaths—a decrease of 1 maternal death per 100,000 live births. Obstetricians also are likely to resist limiting all deliveries to designated regional facilities. Uncomplicated vaginal delivery can be a lucrative business in Japan. Unlike other medical services, the fee for this service is not regulated by the national fee schedule because childbirth is neither a disease nor an injury and thus not part of the standard coverage. Instead, the patient is given a fixed amount from insurance plans that more or less pays for the cost of hospitalization and delivery and the patient has the freedom to go to any facility. Consequently, physicians and hospitals compete on the basis of perceived quality and amenities, as well as price, although price may be a secondary consideration for the prospective parents who usually are willing to spend money for the festive and infrequent event of giving birth. Moreover, charges to patients tend to be about the same because the lower costs for providing professional services in the smaller facilities are usually offset by the higher costs for providing better amenities. Entrepreneurial obstetricians, practicing in clinics and small hospitals that they own and manage, have been successful in gaining a large share of the local market. Direct evidence that more deliveries are being done by successful obstetricians is not available. However, the number of deliveries per month in clinics with beds has increased from 2.7 in 1993 to 3.0 in 1996,5 despite the decrease in the total number of deliveries. The distribution of deliveries by size of facility reflects the general pattern of medical services in Japan. About half of all inpatient beds (excluding those for psychiatric care and other specialized inpatient care) are in facilities with less than 200 beds.6 While the occupancy rate of these small facilities is somewhat lower than that of the larger facilities, they continue to play an important role in providing health care. These smaller facilities tend to be in the private sector and, in almost all cases, are owned and managed by physicians. In contrast, the larger facilities tend to be in the public sector. For instance, hospitals run by voluntary agents play a relatively minor role in Japan and the well-established ones, such as the Red Cross hospitals, are grouped together with public-sector hospitals. This division arose from historical circumstances and has been reinforced by the way hospitals and physicians are reimbursed. Although both are paid on a fee-for-service basis, fees are tightly controlled by the government fee schedule that must be adhered to by all payers and providers (the exception is normal deliveries as noted earlier). These fees are negotiated between the Ministry of Health and Welfare and the Japan Medical Association and are revised about every 2 years. Because of the strict cost-containment policy and the political power balance among the providers, the fees for high-technology care tend to be particularly low and are below the costs to providers. In public-sector hospitals, this deficit is covered by subsidies from the local and national governments. As a consequence, the better staffed and equipped larger hospitals tend to be in the public sector, whereas the less well equipped and staffed hospitals are in the private sector. Thus, there is a de facto division in the services provided by the public and private sectors: the public sector provides high-technology care, and the private sector provides routine services and long-term care. Unlike in the United States, office-based physicians in Japan rarely have hospital privileges; as a result, their practice is limited to ambulatory care or to the inpatient facilities of their clinics. On the other hand, in all hospitals, physicians, except for owners of private-sector hospitals, are employed by the hospital and receive a fixed salary. Inpatients are admitted from the large ambulatory care departments that are maintained by virtually all hospitals. Thus, it would be difficult for office-based obstetricians to perform or assist in deliveries in hospital settings. Quality is a problem for both small and large facilities in Japan and clearly needs to be improved. Very few hospitals have a quality assurance and improvement department. A hospital accreditation organization was created in 1997 and has only just started operations.7 Medical education is also less developed in Japan than in the United States, and recertification is not required by any of the specialty boards. Part of the reason lies in the lack of competition. Public-sector hospitals, subsidized by the government, have no problem attracting patients, and their primary concern is, on the contrary, to stem the overflow. On the other hand, private-sector hospitals usually lack the resources to invest in improving professional quality. As a consequence, their efforts tend to be focused on making services more convenient to the patient, such as providing evening and weekend consulting hours and better amenities.8,9 The article by Nagaya et al draws attention to the relationship between medical errors and hospital size and staffing. An Institute of Medicine report focused on the need to report and investigate medical errors10 but did not comment on this relationship. The marginal costs involved in decreasing errors must be weighed against the marginal benefits. Effects on patients' social well-being, as well as physician and hospital reimbursement, must also be assessed. Changing the present system in Japan as the authors recommend, so that small medical facilities provide local ambulatory care and only designated regional facilities perform deliveries, would be an even more difficult task than it may first appear. References 1. National Institute of Population and Social Security Research. 1999 Jinkou no Doukou—Nippon to Sekai [1999 Population Trends—Japan and the World]. Tokyo, Japan: Kousei Toukei Kyokai; 1999. 2. Nagaya K, Fetters MD, Ishikawa M. et al. Causes of maternal mortality in Japan. JAMA.2000;283:2661-2667.Google Scholar 3. Ministry of Health and Welfare (Japan). Directive of the Director General of the Child and Family Bureau to Prefectural Governors: On Implementing the Development of Maternal and Child Medical Facilities [in Japanese]. Tokyo, Japan: Ministry of Health and Welfare; 1995. 4. Ministry of Health and Welfare (Japan). Vital Statistics of Japan (1980-1998) [in Japanese and English]. Tokyo, Japan: Kousei Toukei Kyoukai; 1982-2000. 5. Ministry of Health and Welfare (Japan). Heisei 8 Nen Iryou Shisetsu Chousa Byouin Houkoku [1996 Survey of Medical Institutions and Hospital Report]. Tokyo, Japan: Kousei Toukei Kyokai; 1998. 6. Ministry of Health and Welfare (Japan). Heisei 9 Nen Iryou Shisetsu Chousa Byouin Houkoku [1997 Survey of Medical Institutions and Hospital Report]. Tokyo, Japan: Kousei Toukei Kyokai; 1999. 7. Japan Council for Quality of Health Care. Rijichou yori Hyokasha e no Tegami [Letter to Surveyors From the Chair]. Tokyo, Japan: Japan Council for Quality of Health Care; 1999. 8. Campbell JC, Ikegami N. The Art of Balance in Health Policy—Maintaining Japan's Low-Cost Egalitarian System. Cambridge, England: Cambridge University Press; 1998. 9. Ikegami N, Campbell JC. Health care reform in Japan: the virtue of muddling through. Health Aff (Millwood).1999;18(3):56-75.Google Scholar 10. Institute of Medicine. To Err Is Human: Building a Safer Health System. Washington, DC: Institute of Medicine; 1999. http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png JAMA American Medical Association

Where Should Women Deliver Babies in Japan?

JAMA , Volume 283 (20) – May 24, 2000

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References (10)

Publisher
American Medical Association
Copyright
Copyright © 2000 American Medical Association. All Rights Reserved.
ISSN
0098-7484
eISSN
1538-3598
DOI
10.1001/jama.283.20.2712
Publisher site
See Article on Publisher Site

Abstract

Maternal mortality is rare in Japan, with only 7.1 maternal deaths per 100,000 live births in 1998.1 However, this rate is relatively high when compared with the infant mortality rate (3.6 per 1000), which is the lowest in the world.1 In their article in this issue of THE JOURNAL, Nagaya et al2 exhaustively examine the causes of these maternal deaths and conclude that more than a third could have been prevented if the women had been treated in a hospital with better staffing of obstetric and anesthesia services and better laboratory facilities. Based on their findings, they recommend that all deliveries should occur at designated regional medical facilities and be attended by more than 1 physician. Many maternal deaths result from emergency conditions that are difficult to predict. Consequently, to decrease maternal deaths, it may be necessary to do what the authors have advocated. The Japanese government took tentative steps in this direction in 1995 by establishing grants to regional medical centers for expanding their maternal and child care units.3 However, following the recommendation of Nagaya et al would require a major restructuring of the present Japanese health care system because currently only about a third of deliveries take place in such large facilities. Thus, before attempting to institute changes, it is important to examine the evidence put forth by the authors. Their conclusion is based on the fact that the preventable maternal death rate was 14 times lower in transferring facilities compared with receiving facilities. However, while a greater share of receiving facilities are large, and more transferring facilities are small, both encompass facilities of different sizes. A better indicator of the relationship between facility characteristics and preventable maternal death rate would be the number of obstetricians in each facility. The data of Nagaya et al show that although the rate of preventable maternal deaths is somewhat higher for facilities with 1 obstetrician (4.09 per 100,000 live births), the rate for facilities with 4 or more obstetricians is only slightly lower (3.41) and the lowest rate is for facilities with 2 or 3 obstetricians (1.60). Thus, restricting all deliveries to designated regional facilities may not have the intended impact on lowering the maternal death rate. The multidisciplinary committee that determined preventability of maternal deaths in the study by Nagaya et al also appears to have had conditions under ideal circumstances as their criteria. However, the death might not have been preventable under the circumstances in which it actually occurred, given the absence of anesthesiologists, other obstetricians, and laboratory facilities in the smaller facilities. The authors recommend that high-risk patients should receive their ambulatory care also at a designated regional medical facility. Although this approach may improve prenatal care, it would affect only those maternal deaths that were predictable based on risk factors identified at the time of the ambulatory visits. Nagaya et al attribute the decrease in maternal mortality rates from 1990 and 1995 to a decrease in ectopic pregnancy. Although the number of deaths due to ectopic pregnancy did decrease from 10 (0.82 per 100,000 live births) in 1990 to 2 (0.16) in 1992, it increased again to 5 (0.42) in 1993, and most recently, was 3 (0.25) in 1998. More consistent decreases occurred earlier between 1980 and 1985 when the number of deaths from ectopic pregnancy declined from 22 (1.40) to 12 (0.84),4 which coincided with the time the use of ultrasound examinations became routine. Limiting deliveries to designated regional medical facilities will encounter resistance from patients and obstetricians. The reason two thirds of Japanese women currently choose to have their deliveries in clinics and small hospitals is not necessarily because they are less expensive, but probably because these smaller facilities provide more personalized service and have better amenities. In addition, clinics and small hospitals often are located relatively close to women's homes, which is an important consideration because many women choose to return to their hometown for their delivery so that their mothers can provide assistance following the birth of the child. Whether women are prepared to forgo these advantages for a very small decrease in risk needs to be evaluated. The highest rate of unpreventable and preventable maternal deaths occurred when no physicians were present, ie, during deliveries at home or by independent nurse midwives. Thus, the readily accessible and convenient small facilities have made it possible for virtually all deliveries to be performed by obstetricians in facility settings with a decrease in maternal mortality. At the macro policy level, the marginal costs of developing and maintaining regional medical centers to which deliveries are limited must be weighed against the marginal benefits of decreasing preventable maternal deaths—a decrease of 1 maternal death per 100,000 live births. Obstetricians also are likely to resist limiting all deliveries to designated regional facilities. Uncomplicated vaginal delivery can be a lucrative business in Japan. Unlike other medical services, the fee for this service is not regulated by the national fee schedule because childbirth is neither a disease nor an injury and thus not part of the standard coverage. Instead, the patient is given a fixed amount from insurance plans that more or less pays for the cost of hospitalization and delivery and the patient has the freedom to go to any facility. Consequently, physicians and hospitals compete on the basis of perceived quality and amenities, as well as price, although price may be a secondary consideration for the prospective parents who usually are willing to spend money for the festive and infrequent event of giving birth. Moreover, charges to patients tend to be about the same because the lower costs for providing professional services in the smaller facilities are usually offset by the higher costs for providing better amenities. Entrepreneurial obstetricians, practicing in clinics and small hospitals that they own and manage, have been successful in gaining a large share of the local market. Direct evidence that more deliveries are being done by successful obstetricians is not available. However, the number of deliveries per month in clinics with beds has increased from 2.7 in 1993 to 3.0 in 1996,5 despite the decrease in the total number of deliveries. The distribution of deliveries by size of facility reflects the general pattern of medical services in Japan. About half of all inpatient beds (excluding those for psychiatric care and other specialized inpatient care) are in facilities with less than 200 beds.6 While the occupancy rate of these small facilities is somewhat lower than that of the larger facilities, they continue to play an important role in providing health care. These smaller facilities tend to be in the private sector and, in almost all cases, are owned and managed by physicians. In contrast, the larger facilities tend to be in the public sector. For instance, hospitals run by voluntary agents play a relatively minor role in Japan and the well-established ones, such as the Red Cross hospitals, are grouped together with public-sector hospitals. This division arose from historical circumstances and has been reinforced by the way hospitals and physicians are reimbursed. Although both are paid on a fee-for-service basis, fees are tightly controlled by the government fee schedule that must be adhered to by all payers and providers (the exception is normal deliveries as noted earlier). These fees are negotiated between the Ministry of Health and Welfare and the Japan Medical Association and are revised about every 2 years. Because of the strict cost-containment policy and the political power balance among the providers, the fees for high-technology care tend to be particularly low and are below the costs to providers. In public-sector hospitals, this deficit is covered by subsidies from the local and national governments. As a consequence, the better staffed and equipped larger hospitals tend to be in the public sector, whereas the less well equipped and staffed hospitals are in the private sector. Thus, there is a de facto division in the services provided by the public and private sectors: the public sector provides high-technology care, and the private sector provides routine services and long-term care. Unlike in the United States, office-based physicians in Japan rarely have hospital privileges; as a result, their practice is limited to ambulatory care or to the inpatient facilities of their clinics. On the other hand, in all hospitals, physicians, except for owners of private-sector hospitals, are employed by the hospital and receive a fixed salary. Inpatients are admitted from the large ambulatory care departments that are maintained by virtually all hospitals. Thus, it would be difficult for office-based obstetricians to perform or assist in deliveries in hospital settings. Quality is a problem for both small and large facilities in Japan and clearly needs to be improved. Very few hospitals have a quality assurance and improvement department. A hospital accreditation organization was created in 1997 and has only just started operations.7 Medical education is also less developed in Japan than in the United States, and recertification is not required by any of the specialty boards. Part of the reason lies in the lack of competition. Public-sector hospitals, subsidized by the government, have no problem attracting patients, and their primary concern is, on the contrary, to stem the overflow. On the other hand, private-sector hospitals usually lack the resources to invest in improving professional quality. As a consequence, their efforts tend to be focused on making services more convenient to the patient, such as providing evening and weekend consulting hours and better amenities.8,9 The article by Nagaya et al draws attention to the relationship between medical errors and hospital size and staffing. An Institute of Medicine report focused on the need to report and investigate medical errors10 but did not comment on this relationship. The marginal costs involved in decreasing errors must be weighed against the marginal benefits. Effects on patients' social well-being, as well as physician and hospital reimbursement, must also be assessed. Changing the present system in Japan as the authors recommend, so that small medical facilities provide local ambulatory care and only designated regional facilities perform deliveries, would be an even more difficult task than it may first appear. References 1. National Institute of Population and Social Security Research. 1999 Jinkou no Doukou—Nippon to Sekai [1999 Population Trends—Japan and the World]. Tokyo, Japan: Kousei Toukei Kyokai; 1999. 2. Nagaya K, Fetters MD, Ishikawa M. et al. Causes of maternal mortality in Japan. JAMA.2000;283:2661-2667.Google Scholar 3. Ministry of Health and Welfare (Japan). Directive of the Director General of the Child and Family Bureau to Prefectural Governors: On Implementing the Development of Maternal and Child Medical Facilities [in Japanese]. Tokyo, Japan: Ministry of Health and Welfare; 1995. 4. Ministry of Health and Welfare (Japan). Vital Statistics of Japan (1980-1998) [in Japanese and English]. Tokyo, Japan: Kousei Toukei Kyoukai; 1982-2000. 5. Ministry of Health and Welfare (Japan). Heisei 8 Nen Iryou Shisetsu Chousa Byouin Houkoku [1996 Survey of Medical Institutions and Hospital Report]. Tokyo, Japan: Kousei Toukei Kyokai; 1998. 6. Ministry of Health and Welfare (Japan). Heisei 9 Nen Iryou Shisetsu Chousa Byouin Houkoku [1997 Survey of Medical Institutions and Hospital Report]. Tokyo, Japan: Kousei Toukei Kyokai; 1999. 7. Japan Council for Quality of Health Care. Rijichou yori Hyokasha e no Tegami [Letter to Surveyors From the Chair]. Tokyo, Japan: Japan Council for Quality of Health Care; 1999. 8. Campbell JC, Ikegami N. The Art of Balance in Health Policy—Maintaining Japan's Low-Cost Egalitarian System. Cambridge, England: Cambridge University Press; 1998. 9. Ikegami N, Campbell JC. Health care reform in Japan: the virtue of muddling through. Health Aff (Millwood).1999;18(3):56-75.Google Scholar 10. Institute of Medicine. To Err Is Human: Building a Safer Health System. Washington, DC: Institute of Medicine; 1999.

Journal

JAMAAmerican Medical Association

Published: May 24, 2000

Keywords: infant

There are no references for this article.