Initiatives for Promoting Patient Safety in Obstetric Care Starting from Advanced Life Support in Obstetrics (ALSO™) in Japan

Abstract

The simulation course in obstetric emergencies aims not only to improve knowledge and skills but also to enhance team approaches and patient safety. Particularly for enhancing team approaches and patient safety, it is effective for team members, regardless of their professional roles, to come together to share learning opportunities that can be applied to real clinical practice. The concept of “To Err is Human,” acknowledging the inherent limitations of human performance, underscores the importance of patient safety and has driven the adoption of interdisciplinary approaches to mitigate these limitations, establishing patient safety as a critical academic field. Advanced Life Support in Obstetrics (ALSO) has swiftly adopted this concept, providing essential simulation‐based training to strengthen medical teams dedicated to ensuring safe childbirth. The ALSO provider certification signifies that an individual has successfully completed a comprehensive educational program qualifying them not only as “a specialist with the requisite knowledge and skills in obstetric care” but also as “a member of a collective of specialists capable of providing safe maternal and child healthcare.” The dissemination of simulation‐based education, such as ALSO and BLSO, along with the related continuous medical education focused on training obstetricians and midwives as instructors, is an important initiative for “distribution of healthcare” through Japan's education in patient safety.

INTRODUCTION

The simulation course in obstetric emergencies aims not only to improve knowledge and technical skills but also to foster teamwork and enhance patient safety. Bringing together team members from diverse professional roles to share learning opportunities has proven particularly effective in improving team approaches and translating skills into real‐world clinical practice. The concept of “To Err is Human,” which acknowledges the inherent limitations of human performance, has gained widespread recognition as crucial for patient safety. ¹ This recognition has led to an increasing emphasis on the need for interdisciplinary approaches to address these limitations, thereby establishing the academic field of patient safety. ² Advanced Life Support in Obstetrics (ALSO™) has swiftly adopted this concept, offering simulation‐based training designed to strengthen medical teams dedicated to ensuring safe childbirth. ³ The ALSO provider certification serves as proof that an individual has completed a necessary educational course not only as “a specialist with the requisite knowledge and skills in obstetric care” but also as “a member of a collective of specialists capable of providing safe maternal and child healthcare.”

Efforts in human resource development for faculty training to strengthen the obstetric healthcare team

In Japan, both the Advanced Life Support in Obstetrics (ALSO™) provider course and its counterpart, the Basic Life Support in Obstetrics (BLSO™) provider course (hereafter referred to collectively as ALSO courses), have been nationally implemented (Figure 1). Considering recent efforts to enhance patient safety within Japanese obstetric care, the Japan ALSO headquarters, under the Organization for the Advancement of Pregnancy, Perinatal and Infant Care (OPPIC), has set a clear goal: “After completing the provider course, participants should be able to initiate efforts to strengthen team‐based medical care for patient safety.” To sustain these efforts, OPPIC has focused not only on disseminating the ALSO courses but also on developing faculty through instructor training programs.

FIGURE 1.

ALSO course participants: As of September, 30, 2024.

The challenges surrounding faculty training in Japanese obstetric care stem from broader societal concerns about patient safety and longstanding difficulties in nurturing young healthcare professionals. An important event that highlighted these issues was the case of a pregnant woman who died at Oono hospital in Fukushima Prefecture, which was treated as a criminal case until the doctor was found not guilty. In the same year, 2004, a new clinical training system was introduced, and since then the shortage of obstetricians has been strongly recognized as a social problem. Subsequently, a series of significant events were reported as serious social issues in obstetric care. This included the suspension of childbirth services in the Oki Islands (2006), and the refusal of numerous advanced perinatal care facilities to admit emergency transports of pregnant women with strokes: one case in Nara (2006) and two cases in Tokyo (2008). These issues have been widely recognized as problems within the entire obstetric healthcare system in Japan. This period when serious problems in obstetric care occurred was described using the term “obstetric care crisis.”

However, even before these incidents became apparent, underlying issues such as workforce shortages, the weak healthcare distribution system characterized by solitary obstetricians in remote areas, and the lack of team‐based medical care systems and their education in not only hospitals but also throughout the community had been present. Particularly, the problem of obstetrician shortages due to the introduction of the clinical training system posed fundamental challenges regarding “education” to the faculties in this field.

In response to the obstetric healthcare crisis, the Ministry of Education, Culture, Sports, Science, and Technology initiated a nationwide program in 2006 to develop medical talent aimed at nurturing young obstetric healthcare professionals. The program by Kanazawa University (Center for the Advancement of Pregnancy, Perinatal and Infant Care: CAPPIC) was selected along with five other university projects. In 2007, CAPPIC acquired the rights to hold the ALSO provider course in Japan. The first ALSO provider course was successfully held at Kanazawa University School of Medicine in March 2008. The overarching aim of these courses was to enhance the capabilities of obstetric healthcare teams to address the obstetric healthcare crisis. Key policy objectives for the nationwide dissemination of the ALSO courses included:

1. New proposals for enhancing team capabilities: Training that brings together all obstetric healthcare providers.

2. Training of primary care physicians: Preparing them to handle obstetrical care effectively.

3. Enhancing skills education: Shifting from “experience/observation” to “active skill acquisition.”

4. Redefining obstetric emergency care: Transitioning from “specialized” to “general” practice.

5. Standardizing obstetric care: Moving from experience‐based to evidence‐based practice.

To achieve these goals, the cultivation of faculty was identified as the most critical element. However, with the commencement of the clinical training system in 2004, there were limited opportunities for Faculty Development (FD) programs aimed at training faculty, establishing milestones for physician training, and providing guidance on evaluation methods. This lack of preparedness hindered the effective implementation of new physician training programs. Obstetrics and gynecology, in particular, faced significant challenges in establishing a mentoring structure, and the reliance on an outdated training system further contributed to a shortage of young professionals in the field. Conversely, the emergency medicine sector, which has actively promoted human resource development since the inception of the clinical training system, widely adopted simulation‐based education programs such as ACLS and BLS. This approach fostered a shared understanding of enhancing team‐based medical care for patient safety throughout the training process. The introduction of the ALSO course in Japan, where education in the obstetric field was primarily lecture‐based at the time, was modeled after this success in emergency medicine. However, there were very few instructors in Japan's obstetric healthcare sector qualified in simulation‐based education, including ACLS or BLS. Consequently, the dissemination of the ALSO course in Japan needed to begin with the cultivation of simulation education instructors.

The development of faculty for the ALSO course begins with the ALSO Instructor Course. The ALSO provider course also serves as a training platform for instructor candidates aiming to become certified instructors. In this program, certified instructors and instructor candidates collaborate as part of an instructor team to guide small participant teams of four to six members through the provider course. In Japan's faculty training, the training includes content on adult education, feedback, coaching, and facilitation. Each time an instructor candidate participates in an instructor team for the ALSO provider course, they receive evaluations and feedback from certified instructors. This process allows them to reflect on their facilitation skills, identify areas for improvement, and engage in experiential learning that drives behavioral change. This experiential learning process enables the ALSO course to mirror the dynamics of obstetric healthcare teams in real clinical practice. As a result, instructor training in the ALSO course functions as a faculty development initiative that supports team‐building in actual clinical settings, thereby promoting the training of many faculty members needed in obstetric care.

The core members of obstetric healthcare teams in Japan are obstetricians and midwives, and similarly, obstetricians and midwives form the core of the instructor teams for the ALSO provider course. To achieve the aforementioned goal of nationwide dissemination of the ALSO provider course, it was essential to cultivate faculty members who shared a unified understanding of the importance of strengthening team‐based medical care across both groups. However, initially, there was a discrepancy in the motivations for participation between the obstetricians and midwives. Additionally, satisfaction surveys conducted after the completion of the ALSO provider course revealed that participation in the course and its emphasis on team‐based medical care were not strongly correlated. Specifically, while the motivation for participation among midwives was significantly higher regarding the goal of strengthening obstetric healthcare teams compared with other participant groups (Figure 2), obstetricians did not exhibit that trend; instead, their motivation was primarily focused on improving knowledge and skills. Furthermore, in the satisfaction survey conducted after the ALSO provider course related to the item “The ALSO provider course contributes to the standardization and quality improvement of team‐based medical care,” the years of experience of obstetricians showed a negative correlation (Figure 3). These findings suggest that to successfully promote the ALSO provider course and its benefits for strengthening team‐based medical care nationwide, a shift in awareness and perspective among obstetricians who aspire to become instructors is necessary.

FIGURE 2.

The influence of participant occupations on the motivation to participate, November 2008–April 2012. The motivation for midwives to participate in the ALSO Provider Course is significantly higher regarding the awareness of strengthening obstetric healthcare teams compared with other professional groups.

FIGURE 3.

Analysis of Satisfaction Survey Results After Attending the ALSO Provider Course, November 2008–April 2012. In the satisfaction survey conducted after the ALSO provider course related to the item “The ALSO provider course contributes to the standardization and quality improvement of team‐based medical care,” the years of experience of obstetricians showed a negative correlation. In the analysis of all participants, there was no effect of years of experience.

The catalyst for the shift in awareness among obstetricians was the integration of the “TeamSTEPPS®” ⁴ (Team Strategies and Tools to Enhance Performance and Patient Safety; hereinafter referred to as TS) into the ALSO syllabus. This addition introduced a dedicated chapter on patient safety including TS content, which is now delivered at the start of the provider course globally. These changes marked a significant step toward prioritizing “safety” in obstetric emergency medical care through simulation‐based education. In Japan, preparations were made, including certified instructors completing the TS training course, and from May 2012, the introduction of TS began for all domestic courses.

The incorporation of this enhanced focus on patient safety within the ALSO provider course led to notable improvements in the satisfaction levels among participating obstetricians. In satisfaction surveys conducted after the introduction of TS, the negative impact on satisfaction regarding team‐based medical care in the careers of obstetricians was alleviated (Figure 4). This change highlighted the importance of “patient safety” as a key factor in nurturing core faculty within obstetric healthcare teams. Since then, TS has become widely recognized not only as a central component of the course content but also as an essential knowledge base and skill set required for faculty. It has remained a cornerstone of the ALSO curriculum and a critical component for faculty development. Since this change, the training and certification of instructors among obstetricians and midwives has expanded nationwide.

FIGURE 4.

The relationship between the introduction of TS into ALSO provider courses and analysis of satisfaction survey results. In satisfaction surveys conducted after the introduction of TS, the negative impact on satisfaction regarding team‐based medical care in the careers of obstetricians was alleviated.

Collaborating to develop ob‐gyn provider faculty from coaching to facilitation

The concept of coaching is integral to TS for team building and as a result, Japan's ALSO Instructor Course allocates time to learning coaching methodologies. Anchored in the idea that “the answers needed by others lie within themselves,” participants learn skills and attitudes such as active listening, recognition, and elicit the thoughts and ideas of others. They also undergo practical training in delivering instruction for the ALSO Provider Course. Additionally, to further enhance feedback and facilitation skills, new opportunities have been introduced whereby experts are invited to teach about experiential learning theories and their models during renewal courses for instructors and training courses for instructor candidates. These efforts emphasize “experience” as central to learning, drawing from the experiential learning theory proposed by Dewey, who stated that “learning is built upon the reflection (introspection) of experiences,” ⁵ and Kolb's experiential learning cycle, which emphasizes “reflecting on experience, extracting lessons, and applying them to new situations.” ⁵ This aligns with the PDCA (Plan‐Do‐Check‐Act) cycle used in medical simulation education (Figure 5). By incorporating facilitation methods rooted in the experiential learning model the instructor teams improve the effectiveness of extracting lessons from group work in simulation education. The goal of these initiatives is to ensure that the trained obstetricians and midwives utilize these methodologies in real clinical settings, thereby achieving the strengthening of team‐based medical care (Figure 6).

FIGURE 5.

The process of experiential learning begins with debriefing in the clinical setting of obstetric care.

FIGURE 6.

ALSO Active Faculty Training Pyramid for instructors in Japan. This pyramid has yielded many qualified faculty members who contribute to promoting team‐based healthcare in the field of obstetrics in Japan.

Recently, some ALSO Provider Courses have been conducted where most of the core members of certified instructors are midwife instructors. The presence of midwife instructors and their candidates, who facilitate these provider courses composed of small groups of four to six members, including obstetricians, emergency physicians, non‐obstetrician physicians, obstetrics and gynecology residents, and midwives, has become essential for the development of human resources in obstetric healthcare teams.

Obstetric simulation education aimed at patient safety as the foundation for strengthening obstetric healthcare teams

In response to the obstetric healthcare crisis, relevant academic societies have resolutely advanced the initiatives of Team Japan. Key pillars of this movement include investigations into the causes of maternal mortality in Japan, proposals for maternal safety based on those findings, the establishment of obstetric clinical guidelines, the development of the obstetric medical compensation system, and investigations into the root causes of cases of neonatal cerebral palsy. As mentioned earlier, the driving force behind these initiatives is the critical issue of patient safety. Furthermore, a national initiative toward patient safety, which began in the United States around the year 2000, has gradually permeated Japan as part of hospital functional assessments, fostering a shared mental model of patient safety not only among physicians but also among all healthcare providers. Within this framework of medical reform, the number of participants in the ALSO Provider Course has steadily increased across the nation, with 12 621 participants completing the course as of September 30, 2024.

The ALSO Provider Course begins with a chapter on Safety in Pregnancy Care. Initially, participants learn about the fundamental causes of medical errors, the importance of effective communication skills and tools within healthcare teams, and the critical role of team‐based medical care in protecting patient safety as a concept of TS. Drawing on reports that discuss the inherent limitations of humans, which state that “To Err is Human”, ¹ participant learns strategies to compensate for these limitations and prevent errors through effective teamwork. Over the subsequent 2 days, participants engage in comprehensive training that equips them with the knowledge and skills to build a shared mental model within their teams, applied through simulations addressing various aspects of obstetric emergency medical care.

Particularly emphasized in the course are the “hands‐on” and “debriefing” training sessions (Figure 5) which serve as the starting point for strengthening team‐based medical care in real clinical practice. The lessons gained through these experiential learning processes must be applied to the diverse and dynamic situations encountered in obstetric emergency medical care. Additionally, to prevent errors in labor management, it is crucial to have a process for situational monitoring that can respond to the rapidly changing conditions in obstetric medical settings. TS introduces situational monitoring through the acronym “STEP,” which stands for the Status of the patient, Team members, Environment, and Progress toward the goal. ⁶ In the ALSO Provider Course, this shared language is reinforced through practical training, case discussions, and team approach simulations so that it can be applied to any obstetric emergency. In the context of team situational monitoring, participants are trained in methodologies to strengthen weak links in the care process by employing the four key skills of TS: Leadership, Communication, Mutual Support, and Situation Monitoring. ⁶ Through this learning process, the significance of awareness and psychological changes, as well as the importance of huddles aimed at problem‐solving, emerge as vital elements. In essence, a huddle is understood as an important communication opportunity that reflects personal awareness (individual recognition) across the team, gathers team members in the same room, and converts individual concerns into shared issues for the team to progress in the same direction for patient safety.

Simulations that align with these principles are integrated into group exercises focused on fetal heart rate monitoring and case discussions about medical complications within the ALSO Provider Course. These activities train participants to bridge differences in perception and foster team awareness and collaborative decision‐making. In Japan's ALSO Provider Course, particular emphasis is placed on the communication tool CUS (Concern, Uncomfortable, Safety Issue), which encourages individuals to express their concerns and utilizes huddles to incorporate them into the team's collective understanding. This, in turn, serves as a crucial switch that integrates all elements of the four key skills, acting as a driving force aimed at preventing errors proactively in a team setting, thereby establishing the foundation for strengthening team‐based obstetric care.

From TeamSTEPPS to the patient safety bundle

The American Academy of Family Physicians released the 9th edition of the ALSO provider manual at the end of 2020, which expanded on the AIM Patient Safety Bundle (AIM PSB). This bundle was developed through interdisciplinary collaboration by the Council on Patient Safety in Women's Health Care as part of the Alliance for Innovation on Maternity Health (AIM). ⁷

The patient safety bundle described in the ALSO provider manual consists of four R's: readiness, recognition and prevention, response, and reporting/system learning. It addresses not only emergency conditions such as obstetric hemorrhage and hypertensive disorders in pregnancy but also encompasses a wide range of topics including maternal mental health and obstetric care for women with substance use disorders. ⁷ Launched as a new initiative in the United States, where maternal mortality rates are higher than in other developed countries, the AIM PSB was funded and announced by the American College of Obstetricians and Gynecologists, based on improved outcomes and initiatives in California.

In Japan, where the AIM PSB is relatively new, OPPIC established a working group to analyze its content and provide clear explanations, resulting in the following supplementary descriptions:

• A series of care provided to patients with the same conditions or within the same healthcare environment.

• An action plan to bridge the gap between goals/ideals and real clinical practices.

• Improvement of teamwork is necessary to provide high‐quality healthcare.

• Contribution to better patient outcomes.

• Opportunities for reflection on care and consideration of improvements across the organization.

• Individual facilities (organizations) can modify and adjust the bundle to meet their specific needs.

This AIM PSB can be seen as a new framework for “enhancing team‐based medical care for patient safety” within the ALSO Provider Course. This aligns perfectly with the core ideas presented at the beginning regarding the implementation of the ALSO course in Japan. Since 2020, training courses and renewal courses in Japan have progressively incorporated this concept into the ALSO Provider Course curriculum. Additionally, as part of efforts to promote the ALSO course, Japan established an annual academic meeting beginning in 2015. Held in 2023 and 2024, this meeting provides a platform for institutions involved with ALSO across the country to share AIM PSB‐related initiatives through designated presentations. By continuing these opportunities, the aim is to strive nationally for the realization of “enhanced team‐based medical care for patient safety.”

Necessary obstetric simulation education to support the centralization and distribution of healthcare

What does the “Advanced” in ALSO signify? According to the Oxford English Dictionary, it is defined as “far on or ahead in any course of development; hence progressive, ahead of one's time.” ⁸ But in the context of contemporary healthcare, what specific value does this term bring?

Through updates to patient safety in the ALSO syllabus and efforts to promote this education in Japan, faculty development centered on ALSO education has formed an educational paradigm that aligns with Japan's needs. As originally envisioned, obstetric providers have established a robust framework for simulation education focusing on obstetric emergency care. Moreover, in recent years, new simulation courses for obstetric emergencies and neonatal resuscitation led by academic societies in the obstetric field have become widely available in Japan. Furthermore, since 2011, OPPIC has launched the BLSO Provider Course, which addresses pre‐hospital obstetric emergencies through nationwide simulation training. Notably, more than 50% of participants are emergency medical technicians (Figure 1), and this initiative is working to strengthen the transportation system considering the ongoing issues of regional depopulation and declining birthrates, which have led to a decrease in facilities handling deliveries.

Meanwhile, Japan's policies promoting work style reforms have raised concerns about further reductions in local obstetric providers and delivery facilities, potentially exacerbating the ongoing obstetric healthcare crisis. Recently, the eighth Medical Care Plan has been announced by various prefectures in Japan to address these issues. As the distance between the delivery facilities and the living areas of local residents continues to increase, the term “centralization of healthcare” is widely used throughout Japan. However, can simply concentrating obstetric providers, such as physicians and midwives, in urban secondary and tertiary perinatal medical facilities truly be considered “centralization of healthcare” to ensure patient safety? In such situations, the time required to provide obstetric emergency care only becomes longer. Especially in a disaster‐prone country like Japan, can “centralization of healthcare” adequately ensure safety for pregnant women during disasters in regions where access to medical care has worsened? For effective centralization of obstetric healthcare, it is essential to ensure a certain level of “distribution of healthcare” within the regional medical collaboration system. Therefore, in the future, obstetric simulation education will not be sufficient if confined only to hospital‐based training. As disaster response training is conducted throughout regions, simulations that strengthen regional collaboration systems for maintaining patient safety must be repeated, allowing for the construction of a medical system in normal times based on disaster medical collaboration frameworks.

The necessity for this was strongly illustrated by the Noto Peninsula earthquake that occurred on January 1, 2024, in Ishikawa Prefecture, where OPPIC is located. This large‐scale disaster severely affected the region, particularly in “Oku Noto,” the most rural area where new obstetric healthcare crisis cases have emerged in recent years, resulting in a fragile obstetric healthcare provision system becoming a social issue. It is not difficult to imagine the critical risks that large‐scale disasters pose to obstetric healthcare in regions that do not receive adequate “distribution of healthcare.” In fact, during the acute phase of the Noto Peninsula earthquake disaster, pregnant women in the Oku Noto area, who had lost access to obstetric care, found themselves in critical situations. Moreover, three out of the five delivery facilities in the Noto Peninsula became unable to provide obstetric care, jeopardizing the continuity of obstetric healthcare services. To overcome this crisis, OPPIC sought assistance from faculties of the ALSO course across Japan and NPO humanitarian assistance organizations. Approximately 50 obstetric healthcare providers (including obstetricians, midwives, and nurses) from around the country responded to the disaster area within 3 months of the event. They supported the medical team at Keiju Medical Center, a regional obstetric healthcare hub in Noto, Ishikawa Prefecture, contributing significantly to the “distribution of healthcare during disasters.” In Japan, a disaster‐prone nation with many rural living areas like the Noto Peninsula, the experiences of the ALSO faculty in reinforcing obstetric healthcare teams during disasters may serve as a valuable model for future Disaster Business Continuity Plans in obstetric healthcare, aligning with the humanitarian charter outlined by the Sphere Project. ⁹

The loss of personnel and obstetric healthcare services in regional areas is not “centralization of healthcare”; rather, it represents a “retreat from healthcare.” This retreat accelerates regional population decline, fails to address falling birth rates, and further reduces medical services, potentially making the underlying obstetric healthcare crisis even more apparent. We must remain mindful that the risk of repeating this history still exists.

The ALSO Manual reminds us that standardized team training, while vital, is sometimes insufficient for ensuring patient safety. Even with the most excellent team training, desirable results cannot be achieved without a supportive organizational structure. This means that effective teamwork contributing to patient safety should be rooted in and functioning throughout the organization. We, as healthcare providers, must recognize this value of being “Advanced” and build opportunities for simulation education accordingly. Moving forward in Japan, it is essential to expand and intensify efforts to reinforce organizational structures that support effective teamwork throughout the regional medical collaboration network.

CLOSING REMARKS

The dissemination of simulation‐based education programs, such as ALSO and BLSO, along with the related continuous medical education focused on training obstetricians and midwives as instructors, is an important initiative for “distribution of healthcare” within Japan's framework for “patient safety.” Through the implementation of ALSO, Japan's educational paradigm has constructed an active training pyramid for instructors, yielding many qualified faculty members who contribute to promoting team‐based medical care in the field of obstetrics (Figure 6).

Japan faces specific challenges in obstetric healthcare, including a high proportion of postpartum hemorrhage among the causes of maternal mortality. To address these issues, OPPIC is committed to cultivating a larger “expert group” capable of delivering team‐based medical care to “better protect mothers and children.” Looking ahead, we will continue to offer ongoing educational opportunities in advanced obstetric simulation as part of Team Japan.

AUTHOR CONTRIBUTIONS

Takanari Arai: Writing – original draft.

CONFLICT OF INTEREST STATEMENT

The author of this article has been actively involved in the promotion of the ALSO course in Japan since its inception, receiving a salary from the research institution mentioned herein as fair compensation for their administrative work related to the course. This article provides an objective summary of the achievements and effects of the nationally disseminated ALSO course activities initiated in 2007, presented in a review format by the representative of these activities. The author believes that his professional roles do not pose any conflict of interest, and he has taken measures to ensure that his positions do not compromise the independence of the content of this article. Specifically, the author has maintained strict separation between their administrative responsibilities and the research activities reported in this publication.

Arai T. Initiatives for Promoting Patient Safety in Obstetric Care Starting from Advanced Life Support in Obstetrics (ALSO™) in Japan. J Obstet Gynaecol Res. 2025;51(3):e16239. 10.1111/jog.16239

DATA AVAILABILITY STATEMENT

For the data in Figure 1, you can always check the latest data from the website of NPO Organization for the Advancement of Pregnancy, Perinatal, and Infant Care (http://www.oppic.net). The data in Figures 2, 3, 4 are the only existing data for the results presented here. The statistical data that formed the basis for these results was lost in the 2024 Noto Peninsula earthquake, when the hard disk that stored them was damaged beyond repair. The results presented in this article are essential data for explaining the main point of this invited paper, and they also represent rare and original results in past survey research reports in the field of obstetric medicine education. The data introduced here have also been presented at several academic conferences in the field of obstetrics, but this article, which was submitted to a medical journal, is the first time that they have been published. I hope that the results of this survey will be utilized and verified again, especially now that patient safety education in obstetrics has become more important, and I have decided to present them in this invited paper on this occasion. I strongly hope that this data will be widely disseminated for the further development of providers and faculties in obstetrics in Japan and for safer and more protected Mothers and Babies throughout Japan.