A Study on Maternal and Child Health Policies in Japan from the Perspectives of Reproductive Health/Rights

本文具体描述了导致“政府资助”或公立妇幼保健中心（以下简称“妇幼保健中心”）发展和最终衰落的因素，并考察了“政府资助”设施的特点和问题，以及它们的延续能力和局限性。通过这一分析，目的是根据我向现有妇幼保健中心分发的问卷，确定在制定和促进日本妇幼保健政策的过程中需要解决的问题。在1957年至1974年的初期阶段，母婴健康中心由两个科组成，即接生科和健康指导科，主要由本地助产士负责。目前，在全国范围内正式注册为妇幼保健中心的设施共有126个（妇幼保健中心协会，2001年，《日本城市、乡镇和村庄保健中心手册》，2001年财政年度，《保健中心协会》）。<问卷调查>根据负责妇幼保健的地方政府官员的答复，截至2004年，在126个送回调查表的55个设施中，有两个地方政府保留了妇幼保健中心的初始形式，即维持和运营接生科，而其中34个地方政府已经取消了接生科，其余19个地方政府的设施从一开始就没有接生科。这种消除的主要原因是负责的助产士年龄老化，新来的助产士无法获得，以及地方政府设施的用户数量减少。<访谈b>我对两个地方政府现有母婴健康中心的助产士，以及八个地方政府在母婴健康中心创办阶段曾在母婴健康中心工作的助产士、公共卫生护士和地方政府雇员的一系列访谈进行了回顾，结果表明，最初的两个母婴健康中心有以下特点：1)市长或村长认识到母婴健康中心的必要性和重要性；2)全面建立地方政府（包括助产士）与母婴健康中心兼职医生的合作制度；3)高级助产士正在培训年轻助产士；4)母婴健康院的助产士会互相分享有关妇女使用者的资料，并在有需要时互相支援；5)助产士与公共卫生护士的联动咨询体系保持良好。另一方面，受访的8家母婴健康院在90年代陆续关闭了接生科，一方面是由于地方政府对分娩的不同看法和（或）工作类别的竞争，与兼职医生产生了分歧，另一方面是由于助产士的雇用方式不利，助产士的职业地位不稳定，导致助产士的老龄化加速。换句话说，这两个废除的原因和上面提到的第2点和第3点作为增长的因素是同一枚硬币的两面。我的采访进一步表明，使用母婴中心的人数下降的原因是，不仅妇女用户自己选择医院，认为它们比母婴中心更安全，而且在产前体检中医生的各种检查和建议现在是强制性的，使她们对在母婴中心分娩犹豫不决。<结论>总之，我在全国范围内对母婴健康中心的研究表明，在母婴健康中心项目方面，孕产妇健康政策的启动和取消主要由政府管理人员控制，而不考虑助产士和妇女使用者作为设施的主要行动者的意见，医生在决定是否继续母婴健康中心的分娩科方面发挥主要作用。少

<Introduction>This paper concretely describes factors which led to the development and eventually the decline of "government-funded", or public maternal child health care centers (henceforth, MCHCCs) and examines the characteristics and problems of "government-funded" facilities along with their capacity to perpetuate themselves and limitations. Through this analysis, it aims to identify the issues to be addressed in the process of formulating and promoting maternal and child health policies in Japan, drawing on my questionnaires distributed to existing MCHCCs. At their initial phase from 1957 to 1974, MCHCCs consisted of two sections, Delivery Section, where locally-based midwives took major responsibilities, and Health Guidance Section. At present, those facilities officially registered as MCHCCs total 126 nationwide (Association of Maternal and Child Health Care Centers, 2001, Zenkoku Shichoson Hoken Senta Yoran (A Handbook on Health Care Centers in Cities, Towns, and Villages in Ja … More pan), fiscal 2001, Association of Health Care Centers).<Questionnaire survey>Among 55 out of 126 facilities, which returned the sheets, as of 2004, two local governments retained the initial form of MCHCCs, that is, maintained and operating Delivery Sections, whereas 34 of them had already abolished those Sections and the rest of 19 local governments had facilities lacking Delivery Sections from the very beginning, according to the responses given by local government officials responsible for maternal and child health. The main reasons for this elimination lie in the aging of midwives in charge, the unavailability of incoming midwives, and a decrease in the number of users of local government facilities.<Interviews >The review of a series of my interviews with midwives working at existing MCHCCs intwo local governments as well as midwives, public health nurses, and local government employees who used to work at MCHCCs during their pioneering stage in eight local governments demonstrates that the first two MCHCCs shared the following characteristics : 1)The mayors or village/town heads recognize the necessity and importance of MCHCCs ; 2)A system of cooperation between local governments (including midwives) and part-time medical doctors stationed at MCHCCs is fully established ; 3)Senior midwives are training younger midwives ; 4)The midwives working at MCHCCs share the information concerning women users among themselves, ready to support each other if need be ; and 5)The linkage and counseling system between midwives and public health nurses is smoothly maintained.On the other hand, the eight MCHCCs interviewed closed their Delivery Sections one after another in the 1990s, partly because local governments were in disagreement with part-time medical doctors due to the difference of views toward child delivery and/or the rivalry in their job categories, and partly because the aging of midwives was accelerating resulting from the unfavorable method of employing midwives and the instable status of midwives as occupation. In other words, these two causes for abolition and the points 2) and 3) raised above as the factors for growth are the two sides of the same coin. My interviews further suggest that the decline in the number of MCHCC users is explained by the fact that not only women users themselves came to choose hospitals, judging that they are safer than MCHCCs, but also various testing by and advices from medical doctors during antenatal medical checkups now rendered compulsory make them hesitate to give birth at MCHCCs.<Conclusion>In sum, my nationwide research on MCHCCs has revealed that the launch on and elimination of maternal health policies in terms of MCHCC programs is predominantly controlled by government administrators, regardless of the opinions of midwives and women users as main actors utilizing facilities and that medical doctors play a chief role in deciding whether or not to continue MCHCC's Delivery Section. Less