Keiko Tsuji: Sexual and Reproductive Health and Rights—Supporting "Choices True to Oneself"

"Sexual and Reproductive Health and Rights (SRHR)" is a critically important concept that guarantees individuals the ability to make choices about their own bodies that are true to themselves. This encompasses not only being healthy in relation to sexuality, pregnancy, and childbirth, but also the right of women to decide for themselves whether or not to have children, and when and how many children to have. Thirty years after the discussions at the 1994 International Conference on Population and Development (Cairo), the concept has deepened into a broad framework for addressing a diverse range of issues today.

For example, it is based on the premise that women have the right to make decisions about their own bodies without discrimination or coercion—including matters such as fertility treatment, induced abortion, prenatal testing of the fetus, and pain relief during labor—and that they can receive the necessary medical services and support.

Decisions regarding sexual and reproductive health often involve difficult challenges fraught with time constraints and ethical issues. To make a choice that is true to oneself, appropriate support is essential for obtaining unbiased and correct information, understanding one's own values, and reaching a decision with conviction. This is a vital role for professionals involved in women's health.

It is said that recognizing the ability to make one's own choices, even in small matters, empowers people. This is especially true if the decision relates to one's own body, health, and future way of life. Shared Decision Making (Graduate School of System Design and Management) is a process in which the individual facing a difficult choice and the healthcare provider share information about the benefits and risks of options, as well as values and ideas, influencing each other and deciding through dialogue. Graduate School of System Design and Management has been shown to improve people's health, increase satisfaction, and encourage internal change and growth.

In recent years, prenatal testing for fetuses in early pregnancy (hereinafter, prenatal testing) has been positioned within comprehensive care for pregnant women in Japan, based on the principles of SRHR. After much discussion, information regarding such tests is now provided to pregnant women when they receive their Maternal and Child Health Handbook; however, it remains a difficult issue involving ethical challenges. Many of the women the author encountered in the genetic counseling department were considering prenatal testing due to their age, but not a few had abnormalities suggested by ultrasound during routine prenatal checkups. Even when told that the fetus is in a lethal condition, there are certainly those who say, "I don't want to give up on continuing the pregnancy," and those who choose not to undergo prenatal testing even if a previous child had a congenital disorder.

While it is predicted that the scope of testing will expand in the future, I believe that picking up and "listening" to a person's "true voice" in Graduate School of System Design and Management—and sometimes "advocating" for them—will lead to the ethical provision of medicine and care.

As part of measures against the declining birthrate, the government is considering the introduction of insurance coverage for childbirth costs, which would make fees uniform nationwide. Additionally, earlier this year, the Tokyo Metropolitan Government announced a policy to subsidize the cost of epidural analgesia (hereinafter, painless delivery) by up to 100,000 yen. Japan has one of the lowest rates of painless delivery among developed nations, but the proportion of total births rose from 5.2% in 2018 to nearly 12% in 2023, and is expected to continue increasing.

While the safety of painless delivery is said to be established based on the track records of other countries, this is predicated on anesthesiologists in the department of anesthesiology being in charge of anesthesia at centralized maternity facilities. In Japan, many painless deliveries occur in small-scale facilities where no anesthesiologist is present, and it is difficult to say that safety in such cases has been sufficiently examined. While the number of medical institutions offering painless delivery is increasing, I strongly feel in the field of midwife education that the number of obstetric facilities handling births is gradually decreasing even in neighboring areas. I also hear voices from people wishing for a second child saying, "The place where I felt 'I want to give birth here again' is gone." I strongly hope that regional obstetric care will be protected.

Students in the elective midwifery course at this faculty have previously learned methods of environmental adjustment and midwifery care related to the action of oxytocin—which relaxes the mother and progresses labor—at hospitals and birth centers that value naturalness and empathy and aim for physiological childbirth. However, the decrease in the number of births has brought significant changes to this learning environment, causing difficulties. The declining birthrate is considered a complex issue including socio-economic challenges. In some countries, reforms to insurance coverage for childbirth costs and perinatal medical systems have led to the cessation of midwife education and a rapid centralization of birth facilities. In others, however, the voices of those involved have reportedly led to the establishment of systems for realizing woman-centered childbirth.

The important thing is to expand a system where high-quality information is provided, safety is ensured, and everyone can choose a "childbirth true to themselves." I hope for a world where midwives, who possess a wide range of knowledge and skills in women's health and sexual and reproductive health, can continue to contribute to women and their families in settings where they can demonstrate their inherent strengths.