Friday, January 11, 2013

Sushi, Onsen and Other Unexpected Pregnancy Customs

Following a recent NYT story regarding the very low use of epidurals in Japan (3% in Japan versus about 50% in the US), a friend asked about the differences in pregnancy advice in Japan. 

The most surprising things are that sushi and onsen (natural hot spring baths) are generally considered ok. None of the medical professionals I have spoken with in Japan have advised against these things (3 Japanese doctors, 1 British doctor, 1 American nurse with 20 years of labor and delivery practice in Japan). Both of these are no-nos in the US.  To quote a friend, “asking if you can eat sushi or enjoy a bath is like asking if you can even be pregnant in Japan.”

Standards for handling raw fish, and possibly food safety standards in general, are higher than in the US. While I wouldn’t eat convenience store/grocery store sushi and I have not sought it out, I have eaten it when it has been served to me from a source I would consider high-quality. Jason and I were amused when a Japanese couple invited us out to dinner and they pre-picked the sushi course dinner. Not just sushi, but multiple courses of it. They knew I was pregnant and they also have children, but I doubt it occurred to them that US medical advice would be to avoid it. In all fairness, while sushi is more common here,  the sushi course dinner probably featured less raw fish than you might order at a Japanese restaurant in the US. Portions are simply smaller and there is a greater focus on presentation, quality, and a variety of dishes, including cooked dishes.

Due to rising levels of mercury in large fish, there are similar recommendations to limit consumption of certain kinds of fish, whether cooked or raw. 

Onsen and bathing
One person after another, Japanese families take a hot bath every single night. During my language homestay, my hosts would take a hot bath even after returning home from dinner at 11 pm in the middle of a summer heat wave. Another friend mentioned that her very traditional parents do not like to travel overseas because people take showers in the bathtub and they cannot relax in the bath knowing that other people have had their dirty bodies in the tub (you always wash first while outside of the tub). And they can’t imagine not enjoying their hot bath every night. Family trips and company retreats often center around destination trips to famous onsen towns and a good Japanese inn always features a hot spring bath. All of this is to point out that bathing as relaxation is a very important part of Japanese culture.

Again, none of the medical professionals have advised against bathing. In fact, my doctor recently recommended that I increase the amount of time I spend in the bath because of pelvic pain. My reaction, and seconded by Japanese friends, has been to approach it with common sense. Since we can preset our tub, we fill it at a reasonable temperature. If I go to an onsen where the temperatures are hotter, I get in briefly and then sit on the edge of the tub soaking my legs. If mama is relaxed, baby is relaxed, ne?

Other food issues
I have not been told to avoid other foods. While available here, cold cuts and soft cheeses (recommended against in the US) are not part of a regular Japanese diet. I have not specifically asked about it since we rarely encounter either.

On the other hand, there are old-wives tales about eating “warm” winter vegetables (carrots, squash, etc.) and avoiding “cold” summer vegetables and certain fruits (tomatoes, etc.). This is not medical advice in Japan, just advice from women of a certain age, along with admonishments to keep your belly warm. The American nurse mentioned that these preferences may stem from traditional Chinese medicine, where keeping the belly warm through certain foods and wraps is thought to improve organ function.

Oddly enough, I’ve developed an aversion to uncooked tomatoes and kabocha squash (Japanese pumpkin) is one of my favorites. On the other hand, I eat fruit constantly.  

Caffeine and alcohol
Medical advice is consistent with the US, but Japanese women seem to be more diligent in avoiding both. A coffee-loving American friend, who gave birth in Hong Kong, tells a story that she had to stop visiting a friend who began to insist beforehand that she only have non-caffeinated beverages. Perhaps stricter avoidance of caffeine during pregnancy is more common throughout Asia.

Japanese women receive paid prenatal and postnatal leave. They receive 6 weeks at 67% of leave before the baby is due and 8 weeks after. Following the 8 weeks after birth, either the mother or the father can continue maternity or paternity leave for up to one year at 50% pay. Since I'm covered by American employment law during the fellowship, I do not receive these particular benefits.

As a result of this policy and other cultural norms, women simply do not work as late into pregnancy as their American counterparts. I recently decided to leave work at 38 weeks due to pelvic/hip problems and both the British doctor (sort of our second opinion/family doctor) and my Japanese Ob/Gyn seemed surprised that I would even still consider working at this stage.

Just before I stopped working, I learned that a staff member was already on maternity leave. Her baby is due in June! This is not uncommon here where women leave work much earlier and tend to not return to work. Surveys of women suggest they generally want to return, but there are various cultural and practical barriers. As a result, women's labor force participation is much lower in Japan than in other comparable nations. It seems there must be a better balance between the scant time most American women take off and the difficulties of returning to the workforce in Japan. While these are ultimately personal decisions, these choices are surely shaped by both cultural preferences and public/corporate policies.

If you've read this list and think some things sound crazy or even medically negligent, keep in mind that Japan has excellent maternal and infant health outcomes. Japan usually ranks first with the lowest rates of infant mortality, whereas the US lags behind most other industrialized nations. Perhaps those outcomes are related to better diets and more active lifestyles (obesity is not a problem here). Perhaps they are related to women leaving work earlier and being able to focus on a healthy pregnancy. Perhaps they are related to other factors like lower levels of poverty. But these statistics suggest that I am receiving good medical care and not to overly worry about these differences. Most importantly, having this experience here has forced both of us to think more critically about the sometimes conflicting and ever-changing guidance for pregnancy, childbirth and beyond and be more willing to trust our own instincts. 

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