保健医療科学

2023

Vol.72 No.1 p.14－21

Topics: Recent topics in public health in Japan 2023

＜ Review ＞
Current public healthcare system for improving mothers andchildrenʼs health and well-being in Japan
KODAMA Tomoko 1), OSAWA Eri 1), FUKUSHIMA Fujiko 2)
1)
2)

Department of International Health and Collaboration, National Institute of Public Health
Department of Family and Reproductive Health Nursing, Toho University

Abstract
In recent years, the various environments of mothers and children have changed significantly because of
the declining birth rate, shift to nuclear families, and increasing employment rate of women. In Japan, subsidies for antenatal checkups and support have been provided so that expectant and nursing mothers canhave and raise children with peace of mind. However, the importance of community care and support measures not only during pregnancy but also after birth has been pointed out. Furthermore, with the revisionof the Child Welfare Act and the establishment of the Agency for Children and Families, it is expected thatthe system will be redeveloped and expanded with a focus on children, as well as improving the health andwelfare of mothers.
keywords: maternal and child health, postnatal care, comprehensive support(accepted for publication, December 21, 2022)

I. Introduction
In recent years, the various environments surrounding
the health of mothers and children have changed significantly because of the declining birth rate, the shift to nuclear families, and the increasing employment rate of women.
In Japan, the subsidies and support for antenatal checkups
and delivery have been provided so that pregnant and nursing mothers can have and raise their children with peaceof mind. However, the importance of community care andsupport measures not only during pregnancy but also after
birth has been pointed out. This paper reports on theserecent developments surrounding pregnant and parturient
women.

II. Maternal and child health in Japan in the
SDG indicators
In the UN Sustainable Development Goals (SDGs), under

Goal 3 “Ensure healthy lives and promote well-being for all
at all ages,” there are four targets related to maternal andchild health, which are monitored through 10 indicators [1].
The state, “3.1. reduce the global maternal mortality ratio
to less than 70 per 100,000 live births; 3.2. end preventable
deaths of newborns and children under 5 years of age, withall countries aiming to reduce neonatal mortality to at least
as low as 12 per 1,000 live births and under-5 mortality toat least as low as 25 per 1,000 live births” by 2030. These
indicators were achieved in Japan in the 1960s (Figure 1).
Maternal mortality is defined as the death of a woman
during pregnancy or less than 42 full days after the termination of pregnancy. This does not relate to the durationand site of pregnancy, but to pregnancy itself or its management. In 2020, there were 23 maternal deaths (8.2
per 100,000 live births) across country. Of these, 15 were“direct obstetric deaths,” which were caused by obstetriccomplications during pregnancy, and 7 were “indirect obstetric deaths”, which were caused by diseases that existed

Corresponding author: KODAMA Tomoko
2-3-6 Minami, Wako, Saitama 351-0197, Japan.
Tel: 048-458-6150
Fax: 048-469-2768
E-mail: kodama.t.aa@niph.go.jp

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J. Natl. Inst. Public Health, 72 (1) : 2023

180

500

160

450
400

140

350

120

300

100

250
80

200

60

150

40

100

20
0

Maternal mortality rate (p23 100 000 live births)

Infant mortality rate (per 1000 live births)

Current public healthcare system for improving mothers and childrenʼs health and well-being in Japan

50

1890

1910

1920

1930

1940

1950

1960

Infant mortality rate (per 1000 live births)

1970

1980

1990

2000

2010

2015

2019

0

Maternal mortality rate (per 100 000 live births)

Figure 1 Maternal and Infant mortality since 1890.

before pregnancy or developed during pregnancy and were
aggravated by the physiological effects of pregnancy. The
maternal mortality rate (births (births plus stillbirths) per
100,000 live births) has declined constantly since the 1890s,
reaching single digits in 1963 (Figure1). It has been on a
gradual downward trend since then, reaching 2.7 in 2020.
This value is similar to that of Italy (2.7) and Germany (2.8)
and is the second highest after that of Australia (1.6) andthe Netherlands (1.8)[2]. Also, the infant mortality rate in
the first year of life was more than 150 until around 1920
but was below 100 in 1940 and has since improved rapidly
to 30.7 and 10.0 in 1960 and 1975, respectively; in 2021, it
was very low at 1.7[3].

III. Maternal and child health services in Japan
1. Main history of maternal and child healthWith the enactment of the Public Health Center Act in1937, matters relating to maternal and infant hygiene were
stipulated as the business of public health centers. In 1941,
the Maternal and Child Division was established in the
Population Bureau of the Ministry of Health and Welfare
in order to take charge of these administrations. In 1942,
the regulations for the handbook for expectant and nursing
mothers were enacted. The handbook was intended to prevent miscarriages, premature births, and stillbirths and toprotect the mother. As the world’s first registration systemfor pregnant women, it improved the maternal and infantmortality rate and formed the basis for maternal and childhealth administration to the present day. After the war, theChild Welfare Act was issued in 1947, and the handbook
was renamed to the Maternal and Child Health Handbook

and was further utilized from 1965 [4]. In 1977, healthcheckups for children aged 1 year and 6 months and mass
screening for congenital metabolic disorders were introduced, and from 1997, municipalities began to provide basic
maternal and child health services such as health checkups
for 3-year-old children. These efforts contributed to an improvement in infant mortality (Table 1).
2. Measures under the Maternal and Child Health Act [5]Maternal and child health measures in Japan aim to comprehensively promote maternal and child health throughout
adolescence, pregnancy, childbirth, the neonatal period,and infancy and are systematized to ensure that the mostappropriate services are available at each stage. These arebroadly divided into the areas of “health checkups,” “healthguidance,” “medical care support,” and “medical care planning,” each of which is divided into state-subsidized andgeneral-funded projects.
In recent years, many maternal and child health services
have been transferred to municipalities with the aim ofproviding services closer to the population. Prefectures are
responsible for liaison and coordination between municipalities and technical advice based on the Maternal and Child
Health Act and the Community Health Act (Table 2).
3. Healthy Parents and Children 21
It is a vision that presents the main initiatives for maternal and child health in the 21st century and is part of thenational movement Health Japan 21. The first phase, aninterim evaluation, and a final evaluation were conductedfrom 2001 to 2014, from 2005 to 2010, and in 2013, respectively. The second phase began in 2015 and reported that

J. Natl. Inst. Public Health, 72 (1) : 2023

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KODAMA Tomoko, OSAWA Eri, FUKUSHIMA Fujiko
Table 1 Summary of the Acts and Measures for Maternal and Child Health since 1930s.
Year
1937
1942
1948
1961
1965
1969
1974
1977
1994
1999
2000
2003
2004
2005
2011
2013
2015
2017
2018
2019
2022

Act / Measures and projects
Public Health Center Act*, Maternal and Child Health Act*
Introducing Maternity Handbook system
Child Welfare Act, Maternal Protection Act*
Premature infant medical treatment and health guidance
Establishment of Maternal and Child Health Centers
Newborn baby visit, 3-year health examination
Publicly funded system of health examination for expectant and nursing mothers
Projects for Research and Treatment of Specific Pediatric Chronic Diseases(PRT-SPCD)
Health examination for children aged 1 year and 6 months
Mass screening for congenital metabolic disorders
Community Health Act*
Angel Plan (five-year project for emergency childcare measures, etc.)
New Angel Plan, Development of the perinatal medical network
Formulation of ‘Healthy Parents and Children 21’
Child abuse prevention municipal network projects, Introducing newborn hearing tests
Basic Act on Countermeasures for Society with Declining Birthrate*
Act on Advancement of Measures to Support Raising Next-Generation Children*
Specific fertility treatment subsidy programme
PRT-SPCD placed under Child Welfare Act
Newborn screening tests using the tandem mass techniqueTransfer of authority to municipalities for premature infant care and premature infant visit
ʻHealthy Parents and Children 21 (the 2nd Round)ʼ
Establishment Comprehensive Support Centers under Maternal and Child Health Act
Basic Act on Child Care and Development** (enacted in December 2019)
Maternal and Child Health Act amended (included postnatal care services)
Basic Act for Children* (enacts in April 2023)
Act on Establishment of Children and Families Agency (enacts in May 2023)* translated by authors as the official English names of the Acts have not been defined.
** The official English name has not been defined. Act on Comprehensive Promotion of Measures for Providing
Necessary Child Care and Medical Treatment to Children (so-called Basic Act on Child Care and Development) .

Table 2 Transfer of authority to municipalities under
Maternal and Child Health Act
Year
1992
1992
1997
1997
1997
1997
1997
2013
2013
2013

Items
Dissemination of knowledge
Maternal and Child Healthcare Handbook
Health guidanceHome visits for newborns
Health checkups
Pregnancy Notification
Visit guidance for Mothers, etc.
Notification of low birthweight infants
Visit guidance for premature infants
Medical and infant care services

Article No.
9
16
10
11
12,13
15
17
18
19
20

(i) the health disparities between regions should be eliminated so that a certain quality of maternal and child healthservices are available and lives are protected wherever achild is born in Japan; (ii) maternal and child health services
should be developed in recognition of the differences anddiversity of individuals and family environments due toillness, disability, and economic status; and (iii) a society inwhich all children grow up healthy should be the goal. The
Ministry of Health, Labour and Welfare (MHLW) conducted
a midterm evaluation and found improvements in U34 outof 62 indicators. However, major challenges remain, such as

16

maternal mental health, teenage suicide, and the number ofdeaths due to child abuse [6].
4. Basic Act on Child Care and Development
In 2019, the Act on Comprehensive Promotion of Measures for Providing Necessary Child Care and Medical
Treatment to Children (so-called Basic Act on Child Careand Development) came into force [7]. This Act aims tocomprehensively promote relevant legacies with the basic principles of seamless support throughout the growth
process, provision of appropriate medical care for child development, etc. based on scientific findings, and the development of an environment where children can be born andraised with peace of mind, in order to ensure the healthy
development of children. Under this Act, prefectures needappropriate consideration in the preparation of healthcare
plans in child-rearing support project.
5. Postnatal care projects
In Japan, the age of childbirth has increased in recent
years because of factors such as women marrying later inlife, and at the same time, the aging of parents caring forchildbearing mothers and increase in the percentage of

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Current public healthcare system for improving mothers and childrenʼs health and well-being in Japan
women in paid employment have led to calls for the improvement of public postnatal care. For women and babies
who need postnatal care less than a year after childbirth,the Postnatal Care Service, which provides physical andmental care and childcare support with a budgetary measure. The Maternal and Child Health Act was amended in
2019, making it a statutory obligation for municipalities
to make efforts, and it came into force in April 2021[5].
MHLW has established implementation standards for postnatal care services by ministerial ordinance with revision of
the guidelines and promote efforts to develop the services
nationwide, including subsidizing the services and building
facilities through the Projects.
6. Comprehensive support centers for child care
Since 2015, the establishment of centers (Comprehensive
Support Centers for Child-Rearing Generation) that provide
comprehensive consultation and support for various needsfrom pregnancy to child-rearing. It has been promoted nation-wide and 1,603 municipalities (out of 2451 locations)established as of April 1, 2021 [4]. The centers has publichealth nurses and other professionals to provide “maternaland child health services” such as health checkups, and“child-rearing support services” in an integrated manner.
Also, they formulate support plans by coordinating relevantorganizations with offering necessary information. These
centers operates under the amendment of the Maternal andChild Health Act in April 2017.

IV. Maternal and child health from the perspective of Universal Health Coverage
1. Family planning
In the midst of postwar impoverishment, an increase in
abortions occurred and the Government budgeted for familyplanning projects to promote the spread of conception control from 1952 to protect maternal health. Since then, thespread of conception control has been promoted through theactive cooperation of private family-planning promotion organizations. Conversely, Japan’s coverage index in the UHC
Reproductive Health Family Planning in the UN Sustainable
Development Goals does not show sufficient achievement,
and challenges are still being observed [1].
The number of abortions peaked at 1,170,000 in 1955
(number of notifications) and has been decreasing year by
year, but in 2020, there were still 141,000 abortions. The
abortion rate for women under 20 years of age (per 1,000
female population aged 15–19 years) peaked at 13.0 in 2001
and has decreased to 3.8 in 2020. Abortion is regulated by
the Maternal Protection Act, which aims to protect the lifeand health of the mother. Additionally, the Act stipulates

sterilization procedures, practical guidance on fertility control, notification by doctors, and penalties.
2. Antenatal health checkups
For antenatal health checkups, the Maternal and Child
Health Act provides a budget from the national government
for the municipalities to set the necessary fees and examination fees for the checkups. According to the results ofa survey on the state of public expenditure on antenatal
health checkups in 1,741 municipalities nationwide in April
2018, the national average amount of public expenditure
covered was 105,734 yen. The method used to issue examination tickets to pregnant women was the “examination
ticket method” (*1) in 1,476 municipalities (84.8%) and the“supplementary ticket method” (*2) in 265 municipalities(15.2%). Of the 1,476 municipalities using the medical
examination ticket system, 1,476 municipalities (100.0%)
performed all the test items specified in the desirable standards (*3), which are considered at the recommended level
A in the Guidelines for Obstetric and Gynaecological Practice 2017 [8].
In an ecological study conducted by the authors analyzing
the uptake of antenatal health checkups (PNC) by prefecture, inadequate PNC use was positively correlated withpopulation and population density, divorce rates, the proportion of foreign nationals and low high school enrollment
rates, with no association found with the number of obstetricians and gynecologists or other healthcare professionals.
Inadequate PNC use was also found to be more common in
urban areas with higher numbers of foreign nationals andlower levels of education [9].
*1 The “examination ticket system” refers to a system
in which pregnant women bring a ticket to a medical institution indicating the items to be examined each time theyreceive a medical checkup.
2 The “assistance ticket method” refers to a method inwhich pregnant women bring a ticket with a subsidy amountto a medical institution for a medical checkup, with theitems to be examined each time being determined by the
medical institution).
*3 “Desirable standards” refer to the test items specified in the “Desirable Standards for Health Examinations
for Pregnant Women” (MHLW Notification No. 226 of 31
March 2015).
3. M edical insurance and maternity and childbirth
benefits
There is a system of maternity leaves and childbirth benefits (for deliveries after 12 weeks of pregnancy) within thehealth insurance system. The maternity leave allowance isa system whereby when an insured person takes time off

J. Natl. Inst. Public Health, 72 (1) : 2023

17

KODAMA Tomoko, OSAWA Eri, FUKUSHIMA Fujiko
work for delivery and is not paid all or part of her remuneration and is paid to stabilize her life and protect the mother.
It covers 42 days before delivery (98 days for multiple pregnancies) and 56 days after delivery. Conversely, households
on public assistance also have maternity benefits under the
publicly funded healthcare system.
Normal pregnancies and deliveries are not covered bynational (public) medical insurance, however, the economic
burden placed on the child-rearing generation is not negligible, the lump sum maternity and childcare payment in
the medical insurance system (health insurance, national
health insurance, etc.) have been set and it increased to420,000 yen in principle from October 2009. (For the facilities not registered by the “Obstetric Medical Compensation
Scheme,” the amount was 390,000 yen.) In principle, thislump sum is paid directly to hospitals and other institutions
by the respective medical insurers [10].

treatment. As 16% of those who have experienced infertility treatment (from total numbers of men and women (23%for women only)) have left their jobs because they wereunable to balance infertility treatment and work [14], there
is a need to develop a workplace environment where people
can continue working with peace of mind while undergoinginfertility treatment. MHLW has amended the Enforcement
Regulations of the Act on Advancement of Measures to
Support Raising Next-Generation Children and establisheda new system to certify companies that work on “balancing
infertility treatment and work”[14]. Additionally, consultation centers set up in each prefecture to provide medical
and professional advice on infertility, as well as support
such as peer support activities by people with experience inthe field.

V. Infertility treatment (publicly funded andcovered by insurance)

The maternal and child health field has also benefited
from medical advances. Early detection and treatment ofphenylketonuria and other congenital metabolic disorders
and congenital hypothyreosis (cretinism) can prevent
mental retardation and other psychosomatic disorders. For
this reason, newborn mass screening tests using blood
are conducted in all prefectures and designated cities for
all newborns. In 2014, the tandem mass method wereintroduced in all prefectures and designated cities. Furthermore, carnitine palmitoyltransferase 2 deficiency wasadded in 2017[15]. Municipalities were also required tocheck the examination status of all infants, and prefectures
were required to monitor the implementation status anddiscuss necessary measures. The 2020 amendment further
requires municipalities and medical institutions to provide
information on treatment options (sign language, hearing
aids, cochlear implants, etc.) according to the child’s needs
and to ensure that there is no delay in diagnosis.

The declining birth rate has been attributed to women
marrying later in life and the increasing age of the firstchildbirth, therefore, the need for infertility treatment has
increased accordingly. Since 2004, the Specified Infertility
Treatment Expense Assistance Project has been implemented, and “general infertility treatment” such as artificial
insemination and “assisted reproductive medical treatment”
such as in vitro fertilization and intracytoplasmic sperm injection have been covered by insurance from April 2022 [11].
This is based on the guidelines compiled by the Japan Society for Reproductive Medicine after evaluating the level ofevidence for the effectiveness of each of the assisted reproductive medical treatment and general fertility treatment
techniques being used in Japan. In assisted reproductive
medical treatment, a series of basic medical procedures,from egg retrieval to embryo transfer, are all covered byinsurance. Furthermore, additional treatments that are performed in accordance with the patient’s condition and are
positioned as advanced medical treatment can be combinedwith insured treatments. The status of approval review ismade public for medicinal products used as standard for fertility treatment [12].
Furthermore, as psychological support for infertility andinfertility patients, a training project was launched in 2021
to develop peer supporters who have experienced similar
treatment in the past, in addition to support by doctors,
midwives, nurses, psychologists, and other professionals[13]. It has also been pointed out that infertility treatment
involves multiple hospital visits, a heavy psychologicalburden, and difficulties in coordinating work schedules for18

VI. Trends in newborn mass screening

VII. Amended Child Welfare Act and establishment of Children and Families Agency
In Japan, it has been reported that young people
sometimes find it difficult to have hope in childbirth andchild-rearing and feel a sense of entrapment [16]. Many single-parent families are struggling to make ends meet, andone in seven children live in poverty. In 2020, the number ofconsultations and responses to cases of child abuse, truancy,and so-called cyber bullying reached a record high. The environment surrounding children, their guardians, and families remains severe, with no end to the number of serious
deaths due to abuse, and the number of consultations andresponses to child abuse by child guidance centers exceed-

J. Natl. Inst. Public Health, 72 (1) : 2023

Current public healthcare system for improving mothers and childrenʼs health and well-being in Japaned 200,000 cases in FY2020. Against this background, theisolation of mothers raising children (approximately 60% of
mothers say that there is no one in their neighborhood who
can take care of their children) and the inadequate use ofvarious local childcare support services for children in needof support are mentioned.
In light of the situation where such households with difficulties in child-rearing are becoming more apparent thanever, the Act on partial amendment of the Child Welfare
Act, was passed on June 8, 2022. This includes the implementation of comprehensive and systematic support forchildren in need of protection and the duties of municipalities, obligatory establishment of child and family centers.
From this background, the Act on the Establishment of
the Children and Families Agency was passed at the 208th
ordinary session of the Diet [17]. The Preparatory Office for
the Establishment of Children and Families Agency, Cabinet
Secretariat, is preparing for the launch on 1 April 2023.

VIII. Conclusions
In recent years, the various environments of mothers andchildren have changed significantly because of the declining
birth rate, shift to nuclear families, and increasing employment rate of women. In Japan, subsidies and support for antenatal checkups and have been provided so that expectant
and nursing mothers can have and raise children with peaceof mind. In recent years, the importance of community careand support measures not only during pregnancy but also
after birth has been pointed out. Furthermore, with therevision of the Child Welfare Act and the establishment of
the Children and Families Agency, it is expected that thesystem will be redeveloped and expanded with a focus onchildren, as well as improving the health and welfare ofmothers.

Acknowledgment
This study was supported by a Health, Labour and Welfare Sciences Research Grant from the Japanese MHLW
(grant 21BA1002).

Rererence[1] 大澤絵里, 児玉知子．持続可能な開発目標モニタリン
グ指標における日本の母子保健の向上とその指標の限界．保健医療科学．
2021;70(3):242-247.
Osawa E, Kodama T. [Improving maternal and child healthin Japan by monitoring Sustainable Development Goal
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Ministry of Health, Labour and Welfare. [Nimpu kenko
shinsa no kohi futan no jokyo ni kakaru chosa kekka ni
tsuite (Survey on the status of public funding of antenatal
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KODAMA Tomoko, OSAWA Eri, FUKUSHIMA Fujiko
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https://www.mhlw.go.jp/stf/seisakunitsuite/bunya/kodomo/
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hyojunteki ni mochiirareru iyakuhin (Standard medicines
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Current public healthcare system for improving mothers and childrenʼs health and well-being in Japan＜総説＞
日本における母子の健康と well-being のための保健制度の現状
児玉知子 1），大澤絵里 1），福島富士子 2）1）

国立保健医療科学院国際協力研究部
東邦大学看護学部看護学科

2）

抄録
近年，少子化や核家族化，女性の就業率の上昇など，母子を取り巻くさまざまな環境は大きく変化している．日本では，これまで妊産婦が安心して子どもを産み育てることができるよう，妊婦健診の助成や支援が行われてきた．一方で，妊娠中だけでなく，出産後の地域ケア・支援策の重要性も指摘されている．さらに，関連法規の改正や子ども家庭局の創設等により，母子の健康や福祉の向上だけでなく，子どもを中心とした社会制度の再整備・拡充が期待されている．
キーワード：母子保健，産後ケア，包括的支援

J. Natl. Inst. Public Health, 72 (1) : 2023

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