Abstract
Immigrant women report a high level of stress during pregnancy due to language barriers, cultural differences, and differences in the standard of prenatal care. In this study, we evaluated the level of concern Japanese women in the United States feel during pregnancy and their level of satisfaction with their care. This data can be used to modify prenatal care programs and education to address these concerns. Data collected from 96 women showed there was a high level of prenatal concern regarding their baby's health, pain control, the short length of hospitalization after birth, and the lack of breastfeeding support. Despite these concerns, postpartum women ended up being satisfied with all items except the short duration of their hospital stay.
Keywords: immigrant health, prenatal concerns, pregnancy satisfaction, prenatal education
INTRODUCTION
Prenatal stress is known to have negative effects on the development of the child and increases the risk of postpartum depression (Dole et al., 2003; Paarlberg, Vingerhoets, Passchier, Dekker, & Van Geijn, 1995; Pagel et al., 1990; Sutter-Dallay et al., 2004; Wadhwa, Sandman, Porto, Dunkel-Schetter, & Garite, 1993). Pregnancy and the birth experience can be stressful especially for women living in foreign countries where the language and the approach to health care during pregnancy and after birth are different from their own countries (Dennis et al., 2004; Henderson et al., 2013; Jordan & Davis-Floyd, 1993).
Previously reported sources of stress according to pregnant Japanese women living in Hawaii were: the language barrier, the longer distance from family and friends, cultural differences, and differences in health-care attitudes about childbirth (Taniguchi & Baruffi, 2007). The published stressors of pregnant Japanese women living in the United States are distinctly different from the stressors of pregnant American women, as many stem from the differences in standard obstetrical care between Japan and the United States (Ito & Sharts-Hopko, 2002; Yeo et al., 2000).
The Japanese Family Health Program (JFHP) was established in 1994 at the University of Michigan. The program provides culturally and linguistically competent family health care to the Japanese expatriates and residents in southeastern Michigan (Mitka, 2000; Tobin, 2005). In 2000, Yeo et al. reported data on childbirth experiences gathered from interviews with 11 Japanese couples cared for in this program (Yeo et al., 2000). This study showed that Japanese women were appreciative of the option to have epidural anesthesia and felt that there was a better practitioner–patient relationship in United States compared to Japan. The two major concerns identified were related to language barriers and differences in the standard of care during pregnancy between the United States and Japan. The following are practices that are common in Japan but not in the United States: women typically get an ultrasound at each prenatal visit, episiotomies are more commonly done and thought to be an important part of safe birth, routine use of a maternal child handbook, longer hospital stays (about 1 week), the umbilical cord is kept as a keepsake, there is more hands on breastfeeding support, and more education about newborn baths (Ito & Sharts-Hopko, 2002). Prenatal vitamins are not typically recommended in Japan and immigrants have reported to feel pressured to use them when in the United States (Ito & Sharts-Hopko, 2002).
Since 2000, the JFHP has developed a system of care tailored to address the concerns Japanese women have previously reported. In 2011, we began group prenatal care for Japanese women. There are 6 monthly educational sessions of 90 minutes each with a group of 4–12 Japanese women with estimated delivery date within 3 months (Little & Fetters, 2018; Little et al., 2013), which was modified from the Centering Pregnancy method (Ickovics et al., 2007). This program is offered to all Japanese speaking pregnant women who receive prenatal care at JFHP. Women who decide not to participate in the group visit are then scheduled for traditional individual prenatal care visits.
To evaluate the effectiveness of the program and to improve the prenatal care of Japanese women living in the United States, we conducted this study to provide quantitative data on the level of concern that Japanese women have during the prenatal period and to compare that with postpartum satisfaction with the same variables after birth.
METHODS
All pregnant Japanese women who received prenatal care at the University of Michigan JFHP clinic between December 1, 2011 and December 20, 2013 were asked to participate in the study at their first visit for the pregnancy. If the woman agreed to participate in the study, consent was obtained for prenatal and postpartum study participation. The prenatal questionnaire was collected at a prenatal visit between 15 weeks and 25 weeks of gestation. The postpartum questionnaire was collected at the time of postpartum visit, usually 6–8 weeks after birth. Women who did not get prenatal care through the JFHP early enough in pregnancy to complete the prenatal questionnaire were invited to participate in the postpartum portion of the study only when they came to a prenatal visit between 35 weeks and 37 weeks of gestation.
Survey Instruments
Prenatal questionnaires collected demographic data, a pregnancy knowledge test, readiness score for giving birth and infant care, and the Japanese prenatal concern questionnaire (JPCQ). Postpartum questionnaires included the same information with the exception of the Japanese pregnancy satisfaction questionnaire (JPSQ) instead of JPCQ.
The pregnancy readiness scores assessment questions and knowledge test and were provided by Dr. Ickovicks (Ickovics et al., 2007). Readiness for both giving birth and infant care were assessed by asking the patient to rate how prepared they felt for giving birth and infant care on a scale of 0–100. The postpartum readiness questionnaire assessed how ready women were when they went into the hospital in labor using the same 0–100 scale. The knowledge test is a 19 item scale which was meant to assess prenatal care knowledge on topics of nutrition, substance use, labor, baby care, and breastfeeding. The same knowledge test was administered at the prenatal visit and postpartum visit.
The Patient Participation and Satisfaction Questionnaires (PPSQ) (Littlefield & Adams, 1987) was modified based on previous research and clinical experience with this population to create a Japanese specific pregnancy satisfaction questionnaire (Ito & Sharts-Hopko, 2002; Taniguchi & Baruffi, 2007; Yeo et al., 2000). Eighteen of the original 25 questions were retained from the PPSQ and then thirteen additional questions were added to create the JPSQ. Items from the JPSQ were converted to concern questions during pregnancy to create the Japanese Pregnancy Concern Questionnaire (JPCQ).
A Likert scale was used to assess concerns on the JPCQ with following assigned numerical values: (a) not at all concerned, (b) slightly concerned, (c) somewhat concerned, (d) moderately concerned, (e) extremely concerned. We considered any item with a score of three or higher to signify a high level of concern. A score of two or less was considered to be of low concern. A Likert scale was used to assess satisfaction on the JPSQ with the following assigned numerical values: (a) not at all satisfied, (b) slightly satisfied, (c) moderately satisfied, (d) very satisfied, (e) extremely satisfied, or not applicable. We considered a score of four or more to reflect a high level of satisfaction. A score of three or less reflected a low level of satisfaction.
All survey instruments were translated into Japanese by three independent bilingual individuals with back translation, then pretested for reliability.
Statistical Analysis
Linear mixed models were used to assess the difference between prenatal and postpartum readiness and knowledge scores. Independent sample t-tests were used to compare scores between multiparous and nulliparous women. Pearson correlations were used to assess for associations between concern and satisfaction between the JPCQ and JPSQ.
The study protocol was approved by the Institutional Review Board of University of Michigan (HUM00052627).
RESULTS
Data was collected from 96 women. Twenty-one responded to the prenatal questionnaire only, 23 responded to the postpartum questionnaire only, and 52 responded to both questionnaires (Figure 1). All first time mothers (primiparous women) chose to participate in group prenatal care visits and the majority of experienced mothers (multiparous women) chose to participate in group prenatal care visits. Table 1 shows demographic data of the enrolled women. The average length of time the women had been in United States when they gave birth was 27.1 months. The majority of the women reported a limited ability to speak English. Thirty-one of 38 multiparous women (81.6%) previously gave birth in Japan. Forty-eight of 66 women who gave birth vaginally received epidural anesthesia (72.7%).
Figure 1.
Flow diagram illustrating Japanese women's level of participation in the in the study.
TABLE 1. Demographics.
| Demographics, N = 96 | Mean (SD), Range |
|---|---|
| Age | 33.5 (3.6), 25.6–42.4 |
| Months in United Statesa | 27.1 (29.4), 1–152 |
| Weeks of gestation, N = 75 | 39.3 (1.4), 35.1–42 |
| Birth weight (gram) N = 75 | 3053.5 (408.9), 1980–3825 |
| Number of family members including newborn, N = 95 | 3.5 (0.68) 2–6 |
| Number (%) | |
| Parity | |
| First birth | 58 (60.4) |
| Second or multiple births | 38 (39.6) |
| Location of previous birth | |
| Japan only | 31 (81.6) |
| Experience in birthing outside Japan | 7 (18.4) |
| Marital status | |
| Married | 96 (100.0) |
| Husband's nationality | |
| Japanese | 90 (93.8) |
| American | 4 (4.2) |
| Other nationality | 2 (2.1) |
| Occupation | |
| Homemaker | 91 (94.8) |
| Other | 5 (5.2) |
| English proficiency perception | |
| Fluent | 12 (12.6) |
| Daily conversation | 37 (38.9) |
| Limited | 46 (48.4) |
| Financial difficulty | |
| Yes | 5 (5.2) |
| No | 91 (94.8) |
| Participation in group prenatal visit | |
| Yes | 83 (86.5) |
| No | 13 (13.5) |
| Birthing Specialty, N = 75 | |
| Family Physician | 65 (86.7) |
| Obstetrician | 10 (10.4) |
| Birthing type, N = 75 | |
| Vaginal birth | 64 (85.3) |
| Cesarean surgery (planned) | 4 (2.7) |
| Cesarean surgery (unplanned) | 5 (6.7) |
| Assisted Vaginal birth | 2 (2.1) |
| Anesthesia during labor, N = 75 | |
| None | 18 (24.0) |
| Epidural | 57 (76.0) |
| Baby gender, N = 75 | |
| Male | 39 (52.0) |
| Female | 36 (48.0) |
| Primary Care Provider of baby, N = 75 | |
| Same as mother's prenatal care provider | 74 (98.7) |
| Other pediatrician | 1 (1.3) |
| Breastfeeding method, N = 75 | |
| Breastmilk only | 63 (84.0) |
| Breastmilk and breastmilksubstitutes | 12 (16.0) |
Note. SD = standard deviation.
Month in United States at the time of giving birth.
Readiness Score
As one might expect, both readiness for giving birth scores and infant care scores were significantly higher on the postpartum questionnaire than on the prenatal questionnaire (Table 2). Multiparous women had significantly higher scores in both readiness for giving birth and infant care than primiparous women during the prenatal period. Additionally, multiparous women had significantly higher scores in infant care than primiparous women on the postpartum questionnaire.
TABLE 2. Readiness Score for Giving Birth and Infant Care and Knowledge Test.
| Prenatal | Postpartum | p Value | |
|---|---|---|---|
| Readiness for giving birth (0–100) (n = 72) | 54.7 (21.0) | 75.1 (20.8) | |
| Paired Readiness for giving birth (n = 49) | 54.6 (21.2) | 75.8 (19.7) | <.001 |
| Readiness for infant care (0–100) (n = 72) | 51.3 (24.3) | 70.2 (22.6) | |
| Paired Readiness for infant care (n = 49) | 52.9 (24.6) | 72.7 (19.0) | <.001 |
| Knowledge score (0–19) (n = 72) | 12.6 (2.0) | 13.8 (1.5) | |
| Paired knowledge score (n = 49) | 12.6 (1.9) | 13.9 (1.6) | <.001 |
| Prenatal | Nullip (N = 41) | Multip (N = 31) | p value |
| Readiness for giving birth (0–100) | 46.7 (18.6) | 65.3 (19.6) | <.001 |
| Readiness for infant care (0–100) | 39.5 (20.9) | 67.2 (19.1) | <.001 |
| Knowledge score (0–19) | 12.3 (2.2) | 12.9 (1.6) | .212 |
| Postpartum | Nullip (N = 43) | Multip (N = 31) | p value |
| Readiness for giving birth (0–100) | 72.3 (21.2) | 79.5 (20.0) | .160 |
| Readiness for infant care (0–100) | 63.1 (23.0) | 80.7 (17.6) | <.001 |
| Knowledge score (0–19) | 13.6 (1.4) | 14.0 (1.6) | .219 |
Knowledge Score
Knowledge test scores were higher on the postpartum questionnaire compared to the prenatal questionnaire (Table 2). There were no significant differences between knowledge scores for primiparous and multiparous women on either the prenatal or postpartum questionnaires.
Concerns and Satisfaction
Both the results from the JPCQ and JPSQ are shown in Table 3. The questionnaire administered during prenatal period (JPCQ) assessed the level of concern that the women had regarding their prenatal care, giving birth, and newborn care. Women reported a high level of concern about the health of their fetus, pain control during labor, short length of hospitalization, and the availability of breastfeeding support.
TABLE 3. Prenatal Concerns and Postpartum Satisfaction Scores (Scale 1-5).
| Concern (SD) | Satisfaction (SD) | ||
|---|---|---|---|
| 1 | Procedures and special tests will be clearly explained to you before they are done. | 2.59 (1.14) | 4.00 (0.92)d |
| 4 | Someone can be reached by telephone to answer questions. | 2.70 (1.08) | 4.11 (0.90)d |
| 5 | The physicians and staff are available to talk to you at your visits. | 2.27 (1.23) | 4.39 (0.79)d |
| 9 | Other health-care providers are consulted about your care appropriately. | 1.90 (0.87)a | 3.63 (1.24) |
| 10 | Your provider has knowledge and skill about your health. | 1.56 (0.92)a | 4.12 (0.90)d |
| 11 | Your privacy is protected. | 1.47 (0.69)a | 4.38 (0.84)d |
| 12 | You will be treated with respect. | 1.53 (0.82)a | 4.32 (0.84)d |
| 14 | Your questions are answered honestly and openly. | 1.73 (0.87)a | 4.07 (0.91)d |
| 15 | You are allowed choices in your care. | 1.9 (0.94)a | 3.99 (0.90) |
| 16 | Your wishes are taken into consideration about your pregnancy care and infant care. | 1.97 (1.04)a | 4.05 (0.88)d |
| 17 | You are allowed to actively participate in your own care. | 1.68 (0.86)a | 3.79 (1.03) |
| 18 | You could voice your opinions about your care. | 1.76 (0.91)a | 3.90 (1.02) |
| 19 | You don't receive ultrasound at each visit. | 2.51 (1.20) | 3.32 (1.19) |
| 20 | Your baby is healthy and growing well | 3.14 (1.11)b | 3.52 (1.14) |
| 21 | Communication with providers and staffs during prenatal care. | 2.18 (1.14) | 4.03 (0.92)d |
| 25 | About the pain control during your labor and birth. | 3.25 (1.16)b | 3.74 (1.21) |
| 26 | You will have enough social support giving birth. | 2.42 (1.19) | 4.28 (0.86)d |
| 27 | You will have enough social support after giving birth. | 2.48 (1.20) | 4.24 (0.92)d |
| 29 | Your stay at the hospital after giving birth will be short. | 3.49 (1.30)b | 2.87 (1.11)c |
| 30 | You can get enough support/help in breastfeeding. | 3.07 (1.25)b | 3.60 (1.09) |
Low concern.
High concern.
Low satisfaction.
High satisfaction.
The postpartum questionnaire (JPSQ) was designed to assess the women's level of satisfaction corresponding to each item they had been concerned about during the pregnancy, giving birth, and newborn care. The only item with a low satisfaction score was the short length of hospital stay.
DISCUSSION
This study aimed to quantitatively measure the concerns of immigrant Japanese women during pregnancy as well as their level of satisfaction with prenatal care, giving birth, and preparation for infant care.
Even though there were several areas in which women identified a high level of concern, this did not lead to poor satisfaction with their care. These concerns were either addressed during the prenatal period or they were concerned but satisfied because overall the birthing process and their baby care experience was satisfactory.
The only topic where women reported a significant level of concern and then subsequent low level of satisfaction was regarding the short hospital stay. We believe the high level of concern regarding the short hospital stay is related to the high level of concern that women have regarding breastfeeding support. The typical length of hospital stay after vaginal birth in Japan is 7 days, while it is 24–48 hours in United States. A longer duration of hospital stay in the United States is not possible due to the high cost of hospital care. In Japan, women receive inpatient breastfeeding support for 7 days. Approximately 80%–90% of Japanese women in Japan are exclusively breastfeeding at 1 month postpartum (Awano & Shimada, 2010; Kitano et al., 2015). According to the Centers for Disease Control and Prevention (CDC), about 59% of women in the United States are exclusively breastfeeding at 1 month postpartum (CDC, 2019). In the JFHP, we aim to provide strong breastfeeding support to our patients so they can be as successful at breastfeeding as they would be in Japan. Close outpatient care is provided to the lactating women with breastfeeding support in the first week after hospital discharge. Instead of being provided over the course of 7 days in the hospital, the care is provided by trained nurses during the shorter hospital stay and then additional support is given over the phone by Japanese speaking nurses. In this study, all of the women who came to their postpartum visits were breastfeeding to at least some degree, 84% were exclusively breastfeeding. The satisfaction score for breastfeeding support was 3.6, reflecting that despite their concern, overall they were moderately to highly satisfied by the time they came to their postpartum visit. This is likely due to the efforts we have taken to ensure that women are able to get breastfeeding support once they leave the hospital.
Concerns regarding the health of the fetus are common among all pregnant women (Huizink et al., 2004; Yali & Lobel, 1999). In Japan, it is a standard practice that the obstetrician performs a quick ultrasound at each prenatal visit (Yeo et al., 2000). While women in this study reported a high level of concern regarding the health of their baby, the concern score related to not having ultrasound every time was not particularly high. This may be due to the detailed anatomical survey done in the United States during which high resolution images are shared with the patient. It is unclear if this is equally reassuring to women compared to the multiple quick ultrasounds done without a formal report or a detailed discussion on findings that are done in Japan.
Fear of childbirth and pain is also common among all women (Huizink et al., 2004). In this study, there was a high level of concern regarding pain control in labor. Epidural anesthesia is not widely available in Japan and knowledge of epidural anesthesia among Japanese women is limited. Japanese women learn about epidurals while they are in Japan and positive re-enforcement comes from friends living in the United States who had positive experiences with epidural anesthesia (Yoshioka et al., 2012). We have been trying to address anxiety about epidural anesthesia by providing education during prenatal visits. In this study, 48 of 66 (72%) women who gave birth vaginally received epidural anesthesia, which is higher than national average of 61% (Osterman & Martin, 2011). There was a relatively high satisfaction score for pain control. This likely reflects the availability of epidural anesthesia in the United States and a higher level of comfort with epidural anesthesia due to education during prenatal visits.
There were several items that were previously reported to be stressors (Ito & Sharts-Hopko, 2002) but women in this study did not report a high level of concern. These include: inability to obtain cord segment as they do in Japan, inability to submerge the newborn in water until the cord falls off, language barriers in the hospital, lack of routine use of episiotomy, lack of ultrasonography at each prenatal visit, and lack of social support. This may be related to changes in the standard of obstetric care that have evolved in Japan since previous data was collected (some of the practices are now more similar to those in the United States). It may also be due to the additional education and support provided to Japanese women through our patient centered health program.
Our current program has been offering group prenatal care for Japanese women since 2011. This program provides additional support and education, tailored to the pregnant Japanese women's needs (Little & Fetters, 2018; Little et al., 2013), as demand for prenatal education is very high. It is standard for first time parents to participate in education classes for childbirth and newborn care in Japan. All of the primiparous women in the study chose to participate in group prenatal care. The group prenatal care allows for education about pregnancy, giving birth, newborn care, and education about the differences between standard practices in Japan versus the United States. Group prenatal care also allows social support for expectant mothers. Most of the women had been in the United States for a short period of time and they often did not have the family support that they would have had during this time period if they were in Japan. This makes the social support provided during group prenatal care even more valuable. We believe that the education and social support provided through group prenatal care is the reason that women ultimately reported high satisfaction despite initially having a lot of concerns about pregnancy and giving birth. Unfortunately, we could not evaluate the effectiveness of the group prenatal care since all of the primiparous women participated and most of the multiparous women participated so we did not have an adequate control group.
IMPLICATIONS FOR PRACTICE
Prenatal stress is known to have negative impacts on both maternal and infant well-being. This stress is increased in women living in foreign countries. Many obstetric providers are caring for women with different traditions, cultures, and beliefs than their own. In order to support these women and help them to have a safe and healthy birth, we need to understand which of the cultural differences are the most important to them. Our study uniquely examined Japanese women's prenatal concerns and subsequent satisfaction with prenatal care, giving birth, and postpartum care. The findings of this study highlight the importance of asking women which cultural differences are the most concerning to them. Japanese women had the highest level of concerns regarding the well-being of their baby during pregnancy, pain control during labor, a short hospital stay, and lack of breastfeeding support. All of the concerns except the hospital stay can be addressed with education. The JFHP has been successful in providing additional outpatient breastfeeding support that would be provided during a 7-day postpartum hospital stay in Japan. So, despite their high level of concern about breastfeeding support, the women were ultimately satisfied with breastfeeding in the United States.
We cannot know which parts of prenatal, intrapartum, and postpartum care are the most important to our patients, particularly those with backgrounds different from our own, if we do not ask them. An understanding of these differences can be used to structure education for pregnant women and potentially advocate for system changes to accommodate women from diverse backgrounds. This is the best way to decrease the stress associated with giving birth in a different country and ensure that all women are able to have a safe and healthy birth.
ACKNOWLEDGMENTS
We thank Dr. Micheleen Hashikawa, Ms. Etsuko Inohara, Tomomi Sano, and Hitomi Wild for facilitating collection of the surveys.
Biographies
SAHOKO H. LITTLE is an Assistant Professor, University of Michigan, Department of Family Medicine. She provides prenatal care and inpatient pregnancy care. Fluent in Japanese, she cares for many Japanese patients at Livonia Health Center.
SATOKO MOTOHARA is a Project Manager of Mixed Methods Program and Project Coordinator of SMARTER FM Project, University of Michigan, Department of Family Medicine.
MELISSA PLEGUE is a Statistician Expert, University of Michigan, Department of Family Medicine.
CHRISTINE MEDAUGH is a Clinical Lecturer, University of Michigan, Department of Family Medicine. She is the medical director of Livonia Health Center and she provides prenatal care and inpatient pregnancy care.
ANANDA SEN is the Lee A Green Collegiate Research Professor and Research Professor, Family Medicine and Biostatistics, University of Michigan.
MACK T. RUFFIN is Professor Emeritus, University of Michigan, Department of Family Medicine, and Professor and Chair, Department of Family and Community Medicine at Penn State Hershey Medical Center.
DISCLOSURE
The authors have no relevant financial interest or affiliations with any commercial interests related to the subjects discussed within this article.
FUNDING
This study was supported by the University of Michigan Center for Japanese Studies Faculty Research Grant “Stress of Japanese pregnant women in the United States,” 5/2011- 4/2012.
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