MIDWIVES IN

JAPAN

Names:

Rr Salsabila Hafilah (620018)

BACHELOR OF MIDWIFWERY – SEMESTER IV

STIKES TELOGOREJO SEMARANG

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1.1 Background

The development of national and international midwifery services and education

is happening so fast. This shows that the development of midwifery services and
education is important to be studied and understood by health workers, especially
midwives who serve as midwife educators and midwives in services. One of the
factors that causes the continued development of midwifery services and
education is the high mortality and morbidity in pregnant and giving birth
women, especially in developing countries and in poor countries, which is around
25-50%.

Midwifery services are services provided by midwives in accordance with the

authority given with the intention of improving the welfare of mothers and
children in order to achieve a small, happy and prosperous family. Midwifery
services are also mentioned as the overall task that is the responsibility of
midwife practice in the health service system which aims to improve the health of
mothers and children in order to realize family and community health. Midwifery
services are an integral part of health services, with targets: individuals, families
and communities, which include efforts to improve, prevent, cure and restore.

Given the above, it is important for midwives to know the history of the
development of midwifery services and education because midwives as the
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foremost and main force in maternal and infant health services in various service
records are required to follow the development of science and technology and
increase their knowledge through formal or non-formal education and midwives
are entitled to opportunities to improve themselves both through education and
training and to increase the appropriate career path and position.

2.1 History of midwifery in Japan

Midwives have always been respected in Japan. Initial official training was
conducted under the supervision of obstetricians. Under this new medical system
based on German practice, "medical midwives" were required to be over 40 years
old; familiar with the anatomy, normal physiology and pathology of women and
children; have a certificate signed by an obstetrician who had observed them give
10 successful births called new or modern midwives,

In 1899, Midwives lowered the age of eligibility for women to 20 years. These
modern midwives played a role in public health nursing. Thus began the
professionalization of midwifery and its blending with nursing.

The division between traditional and medical midwives where traditional

midwives were trusted by ordinary people, and the need for more midwives led to
a system of midwives who could apply after receiving a short period of education
and without being required to take the newly established national exam. The
division between the male profession of midwifery with its focus on abnormal
birth and the modern female profession, medical midwifery with its concomitant
degradation of normal birth was completed by 1930 with over 50,000 registered
midwives, 85% of whom had taken the national exam.

The first national midwives' association was established in 1927 and included
both medical and traditional midwives. Midwifery was considered a desirable,
respectable, well-paid female profession, and was very popular among women
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entering the workforce. In 1946, under instructions from the general headquarters
(GHQ) of the American occupation, nursing, public health and midwifery all
came under the auspices of the newly formed Japan Nursing Association.
However, in 1955, all but 100 midwives broke away from this organization to re-
establish the Japan Midwives Association (JMA).

The place of birth had been home until shortly after World War II. In 1950,
childbirths at facilities (hospitals, clinics and midwifery homes) took up only
4.6% of all childbirths. Under the post-war guidance by GHQ, Japanese people
shifted over from delivery at home to delivery at facilities. In 1970, childbirths at
facilities (hospitals, clinics and midwifery homes) increased to 96.1%, reversing
the shares of childbirths at home and at facilities in about 20 years. At present,
most people give births at medical institutions, with hospitals taking up 54.3%,
clinics 45.0%, midwifery homes 0.6%,and home 0.2%.

Although all midwives in Japan are nurse midwives, their scope of practice can be
quite different from some other countries. For example, Japanese nurse midwives
do not have prescribing privileges, cannot order lab work, and are not allowed to
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perform episiotomies except in emergency situations. Some of the imposed

practice restrictions have served to encourage reliance on and exploration of
alternative modalities and techniques for more holistic, woman-centered care.

2.2 Midwifery Education in Japan

Midwifery education in Japan began with the establishment of a midwifery
school in 1912 founded by Obgyn, and was only licensed in 1974. In 1899, a new
license and regulations for selection were established.

In 1987, midwifery education began to develop and was under the supervision of
obstretricians. The curriculum used in midwifery education consists of physical
science, biology, social science, and psychology. It turned out that the expected
results of midwifery education were not as expected. Many of the midwives were
unfriendly and did not help many deliveries and midwifery services.

Those who take part in midwife education are nurses who enter education at the
age of 20. Education lasts for 3 years. The university degree consists of 8-16
credits, which includes 15 hours of theory, 30 hours of laboratory, and 45 hours
of practice. The midwifery education aims to improve obstetric and neonatal
care, as well as improve the needs of the community due to the high abortion rate
in Japan.

Problems that still exist in Japan include the lack of midwives and the
unsatisfactory quality of midwives. Currently, midwifery education in Japan can
be done after graduating from a 2-year nursing school or college or through
midwifery programs offered by universities for 4 years.
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As indicated above, diverse kinds of midwife education are available in Japan.

There are eight types of midwife education courses: schools that teach practical
skills, vocational schools, junior college advanced courses, colleges, college
advanced courses, college short-term courses, graduate schools, and professional
graduate schools. Midwife education courses are incorporated into the two years
of schooling for graduate schools and professional graduate schools, and the four
years of schooling for four-year colleges. The period of schooling is one year or
longer for other kinds of schools.

Schools and training schools with midwife education courses have been
increasing recently, and an increasing number of applicants are passing the
National Midwifery Examination. Professional graduate schools were opened in
2004, and graduate schools and college advanced courses were opened in 2005,
and the courses are gradually increasing. As of 2016, there are 35 graduate
schools and professional graduate schools (18%), 34 college advanced courses
and short-term courses (17%), 81 colleges (41%), four junior college advanced
courses (2%), and 43 schools that teach practical skills and vocational schools
(22%).
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2.3 Obstetric care in Japan

Japan is a country with advanced science and technology and high public health.
Midwifery services after World War II were more contaminated by
medicalization. Services to the community were still hospitalized. Midwives
came from midwifery and public health nurses and midwives only acted as
assistants to doctors.

Japan improved midwifery services and education and began to organize and
change the situation. In 1987, the role of midwives was restored and in 1989,
they were oriented to the life cycle of women from puberty to climax and
returned to normal childbirth.

For the Japanese, childbirth was a dirty and undesirable thing, so many women
who were about to give birth were isolated and labor took place in dark dirty
places such as buildings and warehouses.

2.3.1 Roles and responsibilities of midwives

1. Roles and Responsibilities of Midwives during Pregnancy
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a. Diagnosis of pregnancy.
Auscultation, basal body temperature method, immunologic pregnancy
reaction using reagents, bioexamination, ultrasonic tomography.
b. Diagnosis of pregnancy timing and course of pregnancy.
Maternal health which includes interview, external diagnosis,
examination measurement, internal examination. Fetal health which
includes auscultation, palpation, ultrasound tomography. Laboratory tests
consisting of blood tests, urine tests, blood pressure measurements,
testing for sexually transmitted diseases.
c. Diagnosing the psychological and social aspects of women.
Midwives diagnose the psychological and social aspects of women which
include maternal behavior, changes in sexual behavior, pregnancy support
from family and community, health habits, work, domestic violence.
d. Midwives provide support to pregnant women and partner with families
in preparation for childbirth.
In this case the midwife provides birth preparation education which
includes planning, implementation.
e. Caring for women and their families who suffer from psychological crises
due to premature birth, fetal abnormalities, intrauterine fetal death, etc.

2. Roles and Responsibilities of Midwives during Childbirth

a. Initiation of labor and diagnosis of labor progress.
Physical examination (fetal heart rate, site, uterine contraction
measurement), whole body changes (sweating, facial expression,
behavior, attitude), pelvic examination, lowering of the lowest part of the
fetus, fetal movement, labor reading of monitoring device data.
b. Make a diagnosis of maternal and child health conditions.
In making a diagnosis of maternal and child health, midwives assess the
physical and mental condition of the mother (emotional changes),
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ultrasound, fetal heart rate, fetal movement, amniotic fluid volume,

placenta.
c. Care related to the development of birth mothers and their families.
Basic needs (nutrition, excretion, rest, hygiene), support from the family
is related to the satisfaction and comfort of the client and is believed to
reduce pain.
d. Assist in natural vaginal delivery.
Respect the client's intention, independence and build systems with their
family and cooperate in emergency situations or circumstances.
e. Consider abnormal events and emergency care while being provided.
Also, when explaining to women and their families, based on the
"midwifery practice guidelines" (Japan Midwives Association), assess the
need for transportation to a medical institution and act appropriately to
cope with emergencies.
f. Conduct prevention and early detection of abnormalities in the progress
of accompanying mothers and children of the workforce.
g. Support early contact of mother and child.
h. Supporting the birth experience of the mother woman more positively.

3. Roles and Responsibilities of Midwives during the Postpartum Period

a. Diagnosis of postpartum course.
The activities carried out by midwives in postpartum diagnosis are
physiological changes due to (changes in uterine involution, the nature
and amount of lochia, vulva, breast condition to the nipple, lactation
process, diagnosis of psychological conditions.
b. Encouraging degenerative changes in the postpartum period (such as
uterine recovery), progressive changes (such as changes in the breast),
increasing the self-care skills of postpartum mothers, the basics of child
care to help learn.
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c. Anticipate any deviations from the normal postpartum recovery process

and take appropriate care.
d. With respect to breastfeeding, the midwife will respect the woman's
wishes and care about "10 cases for successful breastfeeding" and
"international standards on the sale and distribution of breast milk
substitutes".
e. Support to cope with changes in family functions and roles.
Assessment and support on assessment of family living environment and
living background, adaptation to changes in family functions and roles,
prevention and early detection of child abuse (Notification under the law
at the time of discovery).

4. Roles and Responsibilities of Midwives in the Neonatal Period

a. Support of mothers and their children and their families for one month
after birth.
b. Assessment of the infant's growth and development, if there are any
deviations, care is provided in collaboration with doctors and other
professionals.
c. Understand the considerations on child care according to the infant's
developmental process, to help promote growth and development.
Nutrition, accident prevention, acquisition of basic lifestyle and assistance
methods, play, disease prevention, etc.

5. Roles and Responsibilities of Midwives in prenatal diagnosis and genetic

counseling
a. Provide information based on the latest research results.
The purpose of prenatal diagnosis is to early detect the risk of fetal
abnormalities and provide appropriate treatment methods.
b. Provide consultation and mental support for decisions and decisions
made during prenatal diagnosis.
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c. Respond to consultations about the mental burden that occurs during

prenatal diagnosis, continuation on childcare after birth.
The midwife will provide some kind of support to clients with
psychological burdens (issues regarding privacy, feelings of guilt,
psychological trauma, views of loss, conflicts) etc.

6. Roles and responsibilities of midwives in women's health

Midwives support the maintenance and promotion of women's health and
support them through daily life care so that women can manage their health.
More specifically, from the point of view of reproductive health / rights, in
issues corresponding to the life stage of women, health education,
dissemination and enlightenment of knowledge, health consultation, health
coaching is carried out.
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7. Roles and Responsibilities of Midwives in Pubertal Care

a. Assessment of mental and physical development and developmental
status by age
b. Assess lifestyle and provide necessary support.
c. To support decisions about sex at their own risk, by supporting them
while cooperating with family, school, local community, peers in terms
of gaining knowledge about life skills, to deepen ideas and values about
life, to provide information by utilizing appropriate scenes, materials,
human resources.
d. In adolescent men and women, do men and women mutual
physiological and psychological, respect for human rights, partnership,
family planning, home and lifestyle management, ready to become
parents, support learning about such as prevention of sexually
transmitted diseases.

8. Roles and Responsibilities of Midwives in elderly care

a. Assessment of physical function and psycho-psychological aspects of
middle-aged and elderly women with aging.
Assessment of physical and psychological functions carried out namely
the circulatory system, respiratory system, digestive system, metabolic
system, gonads, endocrine system, skin, bone muscle system support on
prevention and life
b. Changes in mind and body that accompany aging, being able to manage
our own health, and support to improve future quality of life (quality of
life).
c. Provide support to middle-aged and elderly female partners who have
problems.
d. Assessment of abnormalities that may occur in middle-aged and older
women, and symptomatic care.
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9. Roles and Responsibilities of Midwives in Reproductive Health/Rights

a. Roles and Responsibilities of Midwives in family planning
1) Assessing the physical, psychological, social and economic aspects
of women and their partners, cultural and religious aspects and
providing information so that appropriate family planning can be
established and then providing support.
2) Counseling and health counseling for women and their partners for
conception.
3) Provide and support information so that women and their partners
can choose appropriate methods of fertility regulation.

b. Treatment for sexually transmitted diseases

1) Assess for possible Sexually Transmitted Infections (STIs).
2) Continue to provide counseling and mental support for women and
their partners' decisions regarding response options according to the
examination results.
3) To prevent mother-to-baby infections/sexually transmitted diseases,
participate in educational activities to the community and also take
individual measures according to actual circumstances.

c. Treatment of menstrual disorders

1) Assessment of treatment needs related to menstrual disorders.
2) Support daily life for improvement of menstrual disorder
symptoms.

10. Roles and Responsibilities of Midwives in midwifery management

As a professional, midwives perform administrative work in practical areas
responsible for their own facilities and management, or to participate in the
management of management, committed to appropriate support and
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prevention of emergency medical accidents, to provide quality midwifery ca

re, to contribute to health, medical care and well-being.

The activities carried out are:

a. Set out the philosophy and purpose of the facility to provide safe and
comfortable care.
b. Maintain human resources and material resources necessary for
operational management, and develop business or maintenance standards
and operational procedures. Adjust human relations in work and improve
work as necessary.
c. Understand the legal provisions necessary for midwifery practice and
handle documents and records appropriately.
d. Develop business management according to the characteristics of the
midwifery facility or organization and evaluate the quality of care.
e. Develop a medical safety system based on the characteristics of risk
management in the perinatal period.

11. Roles and Responsibilities of Midwives to maintain autonomy as

professionals
In order to maintain professional activities, midwives are responsible for
self-study and improving their quality as midwives. To do this, midwives
participate in studies in the field of midwifery, outside the area of activity,
goals and between midwives, care lessons, doctors, through interaction with
other professionals, to improve the reform and quality of midwifery services.

Activities carried out to maintain autonomy as a professional, namely:

a. Through the activities of professional organizations, increase the role and
function of midwives in special fields.
b. To fully fulfill their professional responsibilities midwives must evaluate
their work and improve their level of midwifery care.
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c. As professionals, conduct research to collect practical data and provide

midwifery practice based on the basis of improving midwifery care and
quality assurance.
d. Critically evaluate and interpret the results obtained by research, and use
them for practical use.
e. Utilize the results obtained from research for basic education and
continuing education programs.
f. Midwives create an organization of midwives, respect each other, and
make contributions to improve the quality of midwifery care.
g. Midwives sensitively consider social needs that change over time,
learning and collaborating in networks with care partners and other
professionals.
h. Midwives participate with care recipients in policy decisions affecting
midwifery work and midwifery education.
i. The midwife makes necessary recommendations to administration to
improve maternal and child health service outcomes.

2.4 Health System in Japan

Josan-shi (助産師) - Midwife
A midwife is a woman who provides midwifery services or health education to
pregnant and postpartum women or newborns with a license from the Minister of
Health, Labor, and Welfare (Article 3 of the Law on Nurses, Midwives, and
Public Health Nurses).

This license can only be obtained by women. Midwives are granted the right to
establish a midwife house, but must notify the governor of the prefecture that has
jurisdiction over the location of the house within ten days of its establishment
(Article 8 of the Medical Services Act).
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The location of births in Japan has shifted from home births to facility (hospital or
clinic) births over the past 50 years. As such, midwives working in hospitals or
clinics account for about 87%, forming the majority, while those working in
midwives' homes accounted for about 5% in 2007.

The health service delivery system has recently been intended to be more
intensive due to a decline in birthing facilities, as well as obstetricians and
gynecologists. The Ministry of Health, Labor and Welfare provides subsidies to
encourage coordination and role-sharing between doctors and midwives. Facilities
providing "obstetric clinics in hospitals" or "obstetric care in hospitals" where
midwives offer self-care in hospitals or clinics have also increased.

Japan is a country with an area of about 377,864km2 with a population of 126.9

million people. The per capita income of the population is U$ 37,870, the
majority of which comes from the technology-laden industrial
sector. Geographically, Japan is an island country consisting of hilly land and
volcanoes.

Like developed countries, Japan also has a high expectation of life. Unfortunately,
this is not offset by an increase in birth rate. This has resulted in a decrease in the
number of productive age population. This will be a challenge, because it can
increase the budget of the pension system and health insurance.

Starting from the voluntary collection of food by each resident, in order to meet
the basic needs of the entire community, the health insurance system in Japan is
growing rapidly today.

Japan is well resourced to create a quality health insurance system for its
people. Health insurance is provided to all people, in accordance with the
program followed, ranging from general diseases to diseases that require special
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treatment using the latest technology such as Tuberculosis (TB). In Japan there
are currently more than 1000 mental hospitals, 8700 general hospitals and 1000
comprehensive hospitals with a total of 1.5 million beds. Plus 48 dental
clinics. 000 and a total of 79,000 health service units with outpatient and inpatient
facilities.

Data on Health Facilities and Infrastructure in Japan

1990 1995 1998 1999 2000 2001

Hospital beds per 1000 persons 13,6 13,3 13,1 13 13 12,9

Personnel per bed 0,79 0,91 0,97 0,98 1 1,01

Average length of stay (in days) 50,5 44,2 40,8 39,8 39,1 38,7

Occupancy rate 83,6 83,6 84 84,6 85,2 85,361

Admission rate per 100 persons 8,2 9,2 9,8 10,1 10,3 n.a.

Source : Klaus-Dirk Henke, Jonas Schreyögg, Towards sustainable health care

systems, 2004

At the beginning of 1990, there were nearly 191,400 doctors, 66,800 dentists,
333,000 nurses and more than 200,000 certified alternative medical personnel. In
Japan, doctors can freely make claims for the various health services they wish to
provide. And there are also no restrictions for patients in determining whether
they want to use the services of a general practitioner or by a specialist. Indicators
of health workers in Japan can be seen in the following table:
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Number of Medical Personnel

1990 1995 1998 1999 2000 2001
Physicians per 1000 inhabitants 1,7 1,9* 2 n.a. 2 2,1**
General practitioners per 1000
n.a. n.a. n.a. n.a. n.a. n.a.
inhabitants
Specialists per 100 persons n.a. n.a. n.a. n.a. n.a. n.a.
Dentists per 100 persons 0,6 0,7* 0,7 n.a. 0,7 0,7**
Source : Klaus-Dirk Henke, Jonas Schreyögg, Towards sustainable health care
systems, 2004

From year to year there was an increase in Total Health Expenditure to GDP in
Japan, in 1995 total health expenditure in Japan amounted to 6.9% of total GDP,
which then continued to increase quite high in 2005 to 8.2% and then fell again to
8.1% in 2008. Health expenditure is still dominated by health expenditure by the
government, where the composition of government expenditure is at >80% of
total health expenditure. In 1995 the share of government expenditure reached
83% of THE and private sector spending was only 17%, and this dominance
continued until 2008 with a ratio of 80:20, the government still plays an important
role in the process of implementing the health insurance system in Japan. The
government since 1995 has budgeted 15.9% of total government expenditure in
the health insurance sector and this has continued to increase until 2008 to 17.9%.

Private insurance in the period 1995 to 2002 contributed little to the formation of
private sector health spending, amounting to 2.5% in 1995 and decreased to 1.8%
in 1996 and fell again in 1997 to 1.5%. Interestingly, in 2003 there was an
increase in the percentage of private insurance contributions in private sector
health spending, from 1.7% in 2002 to 13.1% in 2003. This is a result of the
revision of the health insurance system in Japan in 2003 to impose costs on the
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elderly population in providing health insurance benefits and the shift in the
management of health insurance for the self-employed and elderly to be managed
by local governments. So the community along with the increasing level of the
country's economy, many people are shifting their participation from programs
guaranteed by the government to private insurance programs. This means that the
accumulated funds collected by the public have effectively contributed to the
implementation of health insurance in Japan.

Japan Health Expenditure Indicator

Source : http://stats.oecd.org

Benefits in health insurance in Japan apply to all hospitals both government and
private, but do not apply to the "family doctor" system. The hospital is only a
service provider, for the costs incurred by the hospital submit a claim to the
patient's Insurance Institute. For annual medical check-up (kenshin) is provided
free of charge for the entire population. Insurance covers costs ranging from
hospitals, doctors, to medicines according to the type of participant insurance,
and of course there are differences in benefits received. Because of the difference
in contribution to each type of insurance , there are differences in benefits
obtained by participants of each type of insurance.
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HEALTH INSURANCE PLANS IN JAPAN

In Japan, the health insurance system is divided into 3 clusters in general,

namely:
1. Employer-Based Insurance (Shakai Kenkou Hoken)
Employer-Based Insurance is a workplace-based insurance system that
provides financial assistance to workers who are paid by the company and
also to their dependent family members by providing insurance benefits in the
event of illness, childbirth, injury, and death. The family of the insured is a
family up to the 3rd level, which is up to grandparents and grandchildren.
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Family of the Insured in Insurance Employer-B ased Insurance

Source : http://www.sia.go.jp

This insurance system is divided into several forms, including:

a. Union Managed Health Insurance
b. Government Managed Health Insurance
c. Seaman's Insurance
d. National Public Workers Mutual Aid Association Insurance
e. Local Public Workers Mutual Aid Association Insurance
f. Private School Teachers' and Employees' Mutual Aid
Association Insurance
Union Managed Health Insurance also known as Society Managed
Insurance is a type of insurance that provides the most benefits for its
participants. This is because the management of this insurance is managed
professionally by professional associations (society), most of which come
from workers from large companies. This insurance covers as much as 25.4%
of the total population. Those who act as guarantors in this insurance are
private insurers who work with societies to manage their health
funds. Government Managed Health Insurance, is insurance for workers from
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small to medium scale companies, where the government acts as a guarantor

in their health insurance. So this insurance system is a health insurance for
workers managed by the government. This insurance system covers 30.7% of
the total population who are workers from small to medium enterprises. For
the last four types of insurance is a type of insurance for civil servants, at the
central and regional levels and includes teachers, both state and private
employees, as well as members of the navy, this insurance is also known
as Mutual Aid Associations.

The financing system in this type of insurance comes from two parties,
namely workers and employers, which in general contributes to all
types of Employer-Based Insurance insurance is 8.5% of participants' income
which is divided equally between workers and employers. A worker who
works for a company that has ≥5 people must be registered with this
insurance, or if working for a Hojin company regardless of age and
nationality. In particular, the company or factory referred to here must have a
legal determination (formal), both engaged in production and services. This
also applies to part-time workers who have either 3/4 of the working days or
hours of full-time workers.

To obtain coverage from this insurance, employers must take and submit an
"Application to Enroll in Employee Health Insurance or Employee Pension
Insurance" form (Shikaku Shutoku Todoke - Kenko Hoken or Kosei Nenkin)
at the Local Social Insurance office within 5 days of a worker being
recruited. Family members who are dependents of workers can also get
protection from this insurance if they are family members up to the third tier
of participants, most of whose finances are borne by workers. When a
dependent family member of the worker is eligible for protection, the
employer must submit a dependent protection application form (Hifuyosha
Ido Todoke) within 5 days of the change in dependents.
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The benefits obtained from this insurance are quite complete ranging from
outpatient and inpatient health services, additional services in health services,
ambulances, services for diseases that require special treatment, birth to
funeral services, given to participants and insured. Even up to health services
that are not included in the form of services in insurance can be provided to
participants and insured with further arrangements and the imposition of cost
sharing on services received by participants and insured. The benefits received
by participants are 80% of the total cost and for the insured are divided into 2,
namely 80% for inpatient services and 70% for outpatient
services. Exemptions are given to workers for health services who achieve
cost sharing that exceeds 64,000 yen (34,500 yen for those with low incomes)
per month, then the entire cost is covered by insurance.

2. National Health Insurance (Kokumin Kenkou Hoken)

An insurance system tha t covers people who are not covered by
the Employer-Based Insurance insurance system. This includes farmers,
workers in the informal sector and self-employed. This type of insurance is
divided into 2, namely:
• National Health Insurance for each city
• National Health Insurance Union

Each city has the authority to regulate the implementation of this type of
insurance, where the financing scheme and the provision of benefits are
adjusted to the conditions of each region. This insurance also applies to
foreign nationals who live ≥1 year, for foreign
nationals who have a gaijin card can receive National Health Insurance insur
ance serviceby registering themselves at the social security office in the city
they live in.This insurance membership is adjusted to the participant's city of
residence, meaning that participants who move their city of residence must
abolish their membership in the old city and then register a new membership
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in their new city of residence. For foreign nationals every time they move
cities, live, get or change jobs and leave Japan, they must always report to
the Social Security Office.

It covers 34.7% of the total population, and consists of 3,249 National Health
Insurance for each city and 166 National Health Insurance Unions. This type
of insurance gets a subsidy from the government of 50% of total government
expenditure on health spending. Participants and dependents in this type of
insurance get 70% benefit and must pay 30% as cost sharing, and there is an
additional possibility for the cost of medicines, because not all types of drugs
are covered by this insurance. Participants share medical expenses up to a
certain amount, which if exceeds the limit, then all costs will be covered by
insurance. The contribution made by participants depends on the economic
capabilities of each participant. The amount of premium to be paid is
approximately calculated from the participant's salary, property (assets) and
the number of dependent families. The average contribution paid by
participants is 4% of the participant's salary, in 1997 each household
contributed an average of 158.6 thousand yen per year, and there was
assistance of 530 thousand yen per household per year from the
government. Premium payments are made by bank transfer or through health
insurance offices in each city.

This insurance also provides considerable benefits, which is 70% of the total
cost, meaning that participants provide cost sharing of 30%. The services
provided are also quite complete as well as Employer Based Insurance
insurance, ranging from general and special illness, dental care, childbirth to
death and funeral of participants or insured. However, the benefits provided
do not include orthodontics, cosmetic surgery, vaccinations, abortions,
injuries from drunkenness and fighting. Traffic accidents to a certain
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maximum extent are the burden of participants, but if they exceed this limit,
the cost will be fully covered by insurance.

3. National Health Insurance For Elderly

It was first introduced in 1983 to spread the burden of providing health
services to insurance schemes that have been running in Japan, and the
introduction of cost sharing for the elderly. Membership for this insurance is
intended for residents with the age of ≥70 years or for residents from the age
of 65-69 years who have permanent disability (disability). Elderly people in
this category are usually included in the netional health insurance scheme,
specifically the cost sharing of this insurance participant is 500 yen per day,
up to a maximum of 2000 yen per month for the same health facility, for
outpatient services and 1,100 yen per day for inpatient services. This
insurance forms a financing collected from other types of insurance. As in
1997, data shows the contribution of each type of insurance to insurance
financing for the elderly, where the number of Government Managed
Insurance participants who contributed to insurance for the elderly amounted
to 5.4% of all participants, Society Managed Insurance as much as 2.9%,
Mutual Aid Association as much as 4.1% and National Health Insurance as
much as 21.1%. In its development, cost sharing from participants was
eliminated, with a guarantee system of 70% guaranteed by funds collected
from participant contributions and other types of insurance, 20% borne by the
central government and 10% borne by local governments. In an effort to
increase long-term health coverage for the elderly population, the proportion
covered by public funds was increased in 1992 from 30% to 50%. In 2003, as
an anticipatory form of the population ageing phenomenon, the government
shifted the management of health insurance for the elderly population to local
government and imposed additional fees for elderly residents who were
participants in this insurance. This insurance covers as much as 10.1% of the
total population who are elderly and disabled residents aged 65-69 years.
 26

The System Implementation at Facilities

The Guidelines 2018 stipulate that the scopes of practice for in-hospital
midwifery care and in-hospital midwifery clinic should be specified through
consultation between obstetricians and midwives, in accordance with the
functions of the medical institutions and local needs. Midwives who provide
care during pregnancy have the roles to undertake the management of
mothers, provide comprehensive support based on their familial backgrounds
and living environments, and request necessary support from related
professionals and in necessary periods, so that mothers, children, and their
families can live a safe and secure life in their local communities
 27

REFERENCES

1. Demographic Survey 2016, available at

https://www.mhlw.go.jp/toukei/list/81-1a.html (accessed on 6 August 2018)
2. New Edition of Midwife Operational Handbook, Edition 3, I. Basics 2018,
2018
3. Japanese Nursing Association, "Report of FY2008 Project of In-hospital
Midwife-Led Care System Promotion", 2009
4. National Institute of Population and Social Security Research, available at
http://www.ipss.go.jp/pp-
zenkoku/j/zenkoku2017/db_zenkoku2017/s_tables/1-10.htm (accessed on 6
August 2018)
5. Health, Labour and Welfare Statistics Association, “Trends in National Health
Vol.64, No.9, 2017/2018,” p.75, Table 28
6. Japanese Nursing Association Publishing Company, “Latest Public Health
Nursing, Edition 2, Details 1”