their pregnancy, a heavy use of technology considered necessary to assure a healthy baby and safe birth. pregnant women in japan have a strong belief related to ultrasonography. as a result, most pregnant women in japan often receive fetal sonogram in every prenatal visit. they believe that monitoring normal development of the fetus will facilitate safe delivery. additionally, because japanese women prioritize safe delivery, episiotomy is often performed in all birth cases. screenings for domestic violence and maternal depression are not often conducted during prenatal visits in japan, while in the us 35% of women are screened for domestic violence and 47% for maternal depression. genetic screening tests, such as amniocentesis, are available in japan but rarely used. contrary to us culture, the idea of having a "normal" or "abnormal" fetus is not as much a part of the traditional japanese conception of pregnancy. rather, the japanese paradigm sees a fetus as inherently a work in progress, or "perfectible." ob-gyns rarely initiate open discussion of the possibility of undergoing amniocentesis or triple marker tests with pregnant patients. in fact, the health ministry issued guidelines in 1999 according to which ob-gyns have no obligation to inform patients of these tests. having an abortion due to fetal abnormalities is very rare. some theorize that the reason for this is because the role of mother is so highly valued, while others suggest that women, freed from the pressure of holding down a job during motherhood, are less daunted by the time required to care for a child with additional needs. local conceptualization of pregnancy pregnancy is considered a period of mental and physical discipline for women, a process during which women literally make their babies. the outcome of a pregnancy is deeply tied to a woman's conduct; women are considered responsible for minimizing miscarriage and premature birth. there are many theories as to why this may be. primary to understanding this idea is the japanese principle of ganbaru, a fundamental notion that can be traced to many aspects of japanese lifestyle. it means a general ability to "try as hard as possible at whatever one does." for example, women are often reprimanded by their doctors to try harder if they are gaining what is considered too much weight (e.g. no more than 22 pounds is recommended, while some doctors advise less). if a pregnant japanese woman is gaining too much weight, she may be instructed to weigh herself daily until she meets the goals set by her ob-gyn. men are considered to be far removed from pregnancy because it isn't occurring in their bodies; they are therefore often exempt from maternity courses, medical visits, as well as sometimes the birth event itself. preparation for birth during the fifth month of pregnancy (which is the american fourth month because, in japan, months are counted as having four weeks while in the usa some months are 4 and some 5) women often go with a mother or grandmother to a shrine that is dedicated to safe childbirth. here the women pray for a safe childbirth and purchase a special pregnancy sash, or obi to wrap around the abdomen of the pregnant woman. this sash is meant to protect the uterus from the cold, keep the fetus stable and prevent it from growing too large. the ritual also aids in creating maternal identity. food environment, or kankyo, is also a key concept in the japanese theory of gestation. this idea surpasses the western concept of what you feed yourself you feed your baby by encompassing ideas about certain foods being related to coldness or heat. sweets, for example, are considered a cold food that should be avoided in pregnancy as the womb is meant to be warm. also promoted is the idea that a pregnant woman should eat foods native to japan. the concept moto ni modoru in this context suggests that in regard to food, one should go back to the origin when pregnant. in other words, japanese babies are made of japanese food which comes from japanese soil. traditional thoughts about proper food to eat in pregnancy relate to the idea that women are not just vessels, but active vehicles working toward creation. emotional behavior emphasis is also made in prenatal care on keeping a tranquil heart, limiting stress, and trying to elevate your spirits, becoming spiritual (even if you're usually not), and stroking the baby from time to time. this concept of mental wellbeing is called shinkyo and many doctors will be more lax on nutrition if they feel the food pressure is stressing out a woman and putting her spirit in danger. sexual activity topics not typically covered with the physician during prenatal visits for which japanese women may turn to popular magazines include: sex during pregnancy, information regarding the birth experiences other women, unusual methods for delivery, as well as explanations of many medical terms. rest, activity, and movement or personal behavior stress and physical difficulty are considered harmful to the healthy development of pregnancy. work is considered one of the many environmental factors women are supposed to control. the maternal and child health handbook details for women acceptable "postures for physical activity in daily life." they are also instructed in this book to keep their bodies warm at all times, stabilize their bellies, and protect themselves against bumps. labor location satogaeri shussan, or going back home, is a traditional custom in japan according to which pregnant women return to their natal homes for labor and childbirth. this tradition, though waning in contemporary japan, reinforces family ties and also reflects the practical needs of the mother to be. often a woman will switch doctors at this time. it is more common today for a mother to stay at home and have her mothers, sister, or mother-in-law come to look after her, especially in the case of a second pregnancy, than to go to her parents' house. additionally, the most recent change introduced new medical procedures, change in birth attendants, and change in birthplace. food and drink eating and drinking during labor are usually encouraged by medical providers in japan. japanese women tend to eat voraciously in labor, which counters common practice in american hospitals. eating is encouraged, especially by midwives, so that the laboring woman will have energy to push. movement, activity, and emotional behavior walking is encouraged during labor by most medical providers in japan. but making loud sounds is not considered acceptable during labor. pain in japan, primary and secondary level maternity hospitals and clinics do not use epidurals. most japanese women alleviate pain in others ways such as breathing, movement, and massage/acupressure. many japanese women believe that the mother child bond is strengthened through labor. others fear that pain medication will make the fetus weak and unhealthy. some japanese women who do not use pain medication for the first labor decide to use it in subsequent births. attendants during labor and supportive behavior female relatives traditionally help japanese woman through labor. while men traditionally do not help in labor, one recent 2011 cohort study revealed that about half of japanese women now have their husbands in the laboring room. massage, stroking, and acupressure by female relatives are commonly utilized techniques to help a woman in japan through labor. birth birth attendant and assistants births in japan are attended by either licensed doctors or experienced midwives. childbirth in japan underwent three significant changes. during the edo era, from 17th to 19th centuries, birth attendant had been an officially recognized as a profession in japan. in the beginning of the 19th century however, traditional birth attendants were replaced by modern birth attendants also known as “kindai-sanba”. while statistics suggest that only 2.8% of births in japan are attended by midwives, it is estimated that closer to half of all births in japan are midwife-attended. the discrepancy is likely because of a legal provision that doctors must sign his or her name when both a doctor and midwife are present at birth. in actuality, it is a frequent occurrence in hospitals that a midwife attends an entire labor and birth, and a doctor is only called in at the final pushing stage. professional midwives had a national midwifery association in japan from 1927 until it was dissolved by u.s. occupying forces after wwii. since 1948, the education system for midwives was combined with nursing education, both of which require three years of training. the word for midwife also changed after 1947. the original word sanba (san meaning birth and ba meaning old women) was changed to josan-pu (josan meaning help delivery, and pu meaning woman). and in 2002 it was changed again to josan-shi (josan meaning help and shi meaning teacher) to avoid gender connotations. traditionally, midwives in japan continuously share strong relationships with the families of the baby they delivered. because japanese people believe that babies are transferred to humans by god and that midwives are people who facilitate the process, midwives often stay as godmothers of babies that they help deliver. moreover, midwives often continue to live in the community near their godchild babies for this religious reason. in 2006 there were 25,775 midwives in japan: 88% worked in hospitals and clinics, 6% were independent, and 6% were employed by universities, and government institutions. independent midwives attend birth in one of the 388 practicing maternity homes nationwide. in 2012, the number of midwives in japan were 35,185: 62% worked at hospitals, 25% at clinics, and 13% at health centers, maternity homes, universities and others. medical education in japan lasts six years, and begins directly after high school. the first four years of training are considered preclinical, and the final two years are clinical. in 2006, there were 79 medical schools in japan, and the students were 32.8% female. a recent law now requires training for an additional two years after graduation. the field of obstetrics in japan differs from the us in the high value placed on normal physiologic birth, and in the concept of obstetrics as a field largely distinct from surgery. locus of decision making power doctors are often addressed as sensei in japanese, significant because people with the title of sensei are typically not questioned. other positions that share this title, e.g. teacher, professor, and priest are – as keepers of knowledge – traditionally obeyed. (engel 1989) patients who ask too many questions risk seeming offensive or irritating, and a good patient is a passive one. consequently, mode of delivery is thought to be best decided by obstetricians, not by laboring women (matsuoka & hinokuma 2009) for example, requesting a cesarean without medical reason is perceived as unacceptable. the care provided by independent midwives at maternity homes or in home births is traditionally woman centered, the locus of decision-making power remains with the laboring woman. location of birth in 2005, 51.5% of japanese babies were born in hospitals, 47% in private physician-run clinics with fewer than nineteen beds, 1.0% in maternity homes, and 0.2% at home. birth position japanese women predominantly give birth in a semi-sitting position, though some literature suggest the lying down, lithotomy position, is still used. pain painkillers are thought to complicate deliveries and women are discouraged by ob-gyns from taking them during childbirth. therefore, japanese births tend to be without pain medication. furthermore, there is a more positive image of a woman capable of natural birth. without pain medication, labor displays the woman's strength and responsibility. some believe that not experiencing pain during birth hinders bonding between mother and baby. if a japanese woman would like an epidural during labor, she must give birth at one of the few private and expensive hospitals that provide them. pursuing this option is still relatively rare in japan today. many midwives practice perineal massage to promote stretching, ease birth, and minimize maternal trauma. activity and movement in facing birth without pain medications, many supportive techniques are used such as breathing, position changes, movement, massage, stroking, and acupressure. emotional behavior japanese women are expected to experience labor and birth quietly, with an emphasis on breathing techniques. screaming or shouting by a laboring or birthing women may be met with a request such as, "no voicing" from an attendant, and a refocus on breathing and remaining calm. behavior for complications obstetricians, especially the older generation