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

2025/03/17

"Sexual and Reproductive Health and Rights (SRHR)" is a vital concept that guarantees individuals the right 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 for women to decide for themselves whether or not to have children, and if so, when and how many. Thirty years after the discussions at the 1994 International Conference on Population and Development (Cairo), it has now deepened into a broad concept for addressing a diverse range of issues.

For example, it is based on the premise that women have the right to make decisions regarding their own bodies without discrimination or coercion—including infertility 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, it is essential to have appropriate support to obtain unbiased and correct information, understand one's own values, and make a decision with conviction. This is an important role for professionals involved in women's health.

It is said that recognizing that one can make their own choices, even in small matters, brings power to a person. This is even more true if the decision relates to one's own body, health, and future way of life. Shared Decision Making (SDM) is a process in which the individual facing a difficult choice and the medical professional share information about the benefits and risks of options, as well as values and ideas, influence each other, and decide through dialogue. SDM is known 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 these tests is now provided to pregnant women when they receive their Maternal and Child Health Handbook, but 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 were those who had been alerted to fetal abnormalities during ultrasound examinations at prenatal checkups. Even when told that the fetus is in a lethal condition, there are certainly people who say, "I don't want to give up on continuing the pregnancy," and those who choose not to have 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 SDM, and sometimes "advocating" for them, leads to the ethical provision of medical care and support.

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

While the safety of painless delivery is said to be established based on the track records of other countries, this is based on the premise that an anesthesiologist in a centralized maternity facility handles the anesthesia. In Japan, there are many painless deliveries in small-scale facilities where an anesthesiologist is absent, 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 at the site of midwife education that the number of obstetric facilities handling deliveries is gradually decreasing even in neighboring areas. I also hear voices from people who want a second child saying, "The place where I felt 'I want to give birth here again' is gone." I strongly hope that local obstetric care will be protected.

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

The important thing is that a system expands 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 regarding women's health and sexual and reproductive health, can continue to contribute to women and their families in places where they can demonstrate their inherent strengths.