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Women’s experience of receiving team-midwifery care in Japan: A qualitative descriptive study

Published:October 08, 2020DOI:https://doi.org/10.1016/j.wombi.2020.09.020

      Abstract

      Background

      Team-midwifery care remains limited in Japan. To introduce changes to the midwifery system, an in-depth understanding of women’s perception of receiving team-midwifery care is crucial.

      Aim

      This study aimed to describe women’s experience of receiving team-midwifery care in Japan and to understand the central essence of this form of care.

      Methods

      This study used a descriptive research design and involved focus group interviews in a birth clinic in central Tokyo. This birth clinic provided continuous team-midwifery care involving five to six midwives in one team from pregnancy to the postpartum period. Interview data were analysed by content analysis. The ethical review board of St. Luke’s International Hospital, Tokyo approved this study (12-R178).

      Findings

      Thirteen women who gave birth within 19 months were included. The women’s experience of receiving team-midwifery care was described as “feelings of becoming closer and connected through a warm mutual relationship” with the midwives. The women felt that the midwives genuinely focused on their care and noticed their desire for their family to be involved. A trusting relationship was built through regular meetings. The women also described their experience as “a lasting feeling of ease and security”. The midwives’ continuity of care empowered the women even after their discharge.

      Conclusion

      The underlying assumption for the women’s empowerment was the continuity of woman-centred care built through a trusting relationship between the women and the midwives. These important elements constitute the central essence of team-midwifery care which can be adopted regardless of the care system.

      Keywords

      Statement of significance
      Problem
      In Japan, the proportion of women receiving team-midwifery care remains small (only 1%), and this form of care is limited to birth centres.
      What is already known
      Studies in Japan reported that women receiving care at birth centres are more satisfied than women receiving care at hospitals and clinics.
      What this paper adds
      This paper describes the experience and clarifies the essence of team-midwifery care at a birth centre in Japan. A mutual trusting relationship and continuity of care fostering a strong connection constitute the central essence of team-midwifery care.

      1. Introduction

      Midwife-led continuity models are provided in several countries around the world and are reported to have many positive outcomes in women and their infants. These models of care include team-midwifery care, case-load midwifery care, and one-to-one care, according to how the care is provided. The midwife-led continuity of care model is a model of care wherein a known midwife or a small group of known midwives supports a woman throughout the antenatal, intrapartum and postnatal continuum [
      • Sandall J.
      • Soltani H.
      • Gates S.
      • Shennan A.
      • Devane D.
      Midwife-led continuity models versus other models of care for childbearing women.
      ]. Other models of care include obstetrician-provided care, family doctor-provided care, and shared models of care [
      • Sandall J.
      • Soltani H.
      • Gates S.
      • Shennan A.
      • Devane D.
      Midwife-led continuity models versus other models of care for childbearing women.
      ]. Studies have shown that midwife-led care achieves favourable outcomes and creates many positive perceptions. Whatever midwife-led continuity models are provided, midwives are the lead caregivers and are responsible for the care of both the mother and the infant. These models emphasize the important aspect of woman-centredness when providing care as this provides many benefits to women and their infants. Sandall et al. reported that women who received midwife-led continuity of care were less likely to experience regional analgesia, instrumental vaginal birth, amniotomy, and episiotomy than women who received other models of care [
      • Sandall J.
      • Soltani H.
      • Gates S.
      • Shennan A.
      • Devane D.
      Midwife-led continuity models versus other models of care for childbearing women.
      ]. These obstetric outcomes and midwife-led continuity of care models appear to be meaningful to women’s perception of the care that they receive. Forster et al. described that women who received caseload midwifery care reported a higher satisfaction of care from the antenatal period to the postpartum period than women who received standard care [
      • Forster D.A.
      • McLachlan H.L.
      • Davey M.A.
      • Biro M.A.
      • Farrell T.
      • Gold L.
      • et al.
      Continuity of care by a primary midwife (caseload midwifery) increases women’s satisfaction with antenatal, intrapartum and postpartum care: results from the COSMOS randomised controlled trial.
      ]. In addition, the World Health Organization (WHO) recommendations: Intrapartum care for a positive childbirth experience (2018) reported that midwife-led continuity of care models are recommended for pregnant women in settings with well-functioning midwifery programmes [
      • World Health Organization
      WHO Recommendations: Intrapartum Care for a Positive Childbirth Experience.
      ].
      Women’s positive perception of receiving care from a midwife appears to be related to how they build a relationship with each other during the perinatal period. Symon et al. described that women who received caseload midwifery care indicated positive experiences in terms of relationships, tailored care, and effective communication, whereas women who received other models of care indicated more negative experiences [
      • Symon A.
      • McFadden A.
      • White M.
      • Fraser K.
      • Cummins A.
      Using the Quality Maternal and Newborn Care Framework to evaluate women’s experiences of different models of care: a qualitative study.
      ]. Dahlberg et al. reported that women felt safe and cared for from the midwife’s continuous physical and mental presence and support [
      • Dahlberg U.
      • Persen J.
      • Skogås A.K.
      • Selboe S.T.
      • Torvik H.M.
      • Aune I.
      How can midwives promote a normal birth and a positive birth experience? The experience of first-time Norwegian mothers.
      ]. The constant presence of midwives facilitated positive communication between them and the women, enabling the midwives to respond to the women’s needs and help them to be mentally prepared for birth. Petit-Steeghs et al. explained that it was important for women to feel that midwives were responsive to their wishes and needs, which gave them a perception of client-centred maternity care [
      • Petit-Steeghs V.
      • Lips S.R.
      • Schuitmaker-Warnaar T.J.
      • Broerse J.E.W.
      Client-centred maternity care from women’s perspectives: need for responsiveness.
      ]. Bradfield et al. stated that not only women, but also midwives who provide professional care acknowledge that a trusting relationship during pregnancy through childbirth is important for women [
      • Bradfield Z.
      • Hauck Y.
      • Kelly M.
      • Duggan R.
      “It’s what midwifery is all about”: Western Australian midwives’ experiences of being ‘with woman’ during labour and birth in the known midwife model.
      ].
      In Japan, women can choose where to give birth according to their preferences and in consideration of obstetrical risks. This can be at home, birth centres, clinics or hospitals. Although the settings differ, women will receive about 14 antenatal check-ups in total: once in every four weeks until 23 weeks of gestation, once in every two weeks from 24 to 35 weeks of gestation, and once a week from 36 weeks of gestation to birth (Japan Society of Obstetrics and Gynecology, Japan Association of Obstetricians and Gynecologists, 2017) [
      • Japan Society of Obstetrics and Gynecology
      Japan Association of Obstetricians and Gynecologists.
      ]. This allows women to regularly meet their healthcare providers. Home and birth centres are limited to only low-risk women, implying that when a complication occurs, they will be transferred to a hospital immediately.
      To be able to compare women’s perception of receiving care among birth centres, clinics, and hospitals in Japan, we previously conducted a questionnaire survey among 482 women [
      • Iida M.
      • Horiuchi S.
      • Porter S.E.
      The relationship between women-centred care and women’s birth experiences: a comparison between birth centres, clinics, and hospitals in Japan.
      ]. Of the three settings, women who gave birth at birth centres were most satisfied with the care that they received. This was because of the distinctive characteristics of care that the midwives at the birth centres provided, namely, respectful communication and continuity of care. These are considered core elements of woman-centred care (WCC). We also previously compared the health outcomes of low-risk women and infants who received midwife-led care with those who received obstetrician-led care in Japan [
      • Iida M.
      • Horiuchi S.
      • Nagamori K.
      A comparison of midwife-led care versus obstetrician-led care for low-risk women in Japan.
      ]. The outcomes were equal or better in the midwife-led care group similarly to studies that compared midwife-led care models and standard care models: the Apgar scores of infants were similar while women’s perception of receiving WCC was higher; there was less premature rupture of membranes; women were exclusively breastfeeding during hospitalisation and at one-month postpartum; Stein’s maternity blues scale was lower.
      Places where women can give birth in Japan are predominantly in hospitals or maternity clinics, and only 1% of women give birth at birth centres. To overcome these issues, midwives could advocate and promote midwife-led care and enlarge their roles in Japan. The Japanese Ministry of Health, Labour and Welfare is currently promoting hospitals to set up outpatient departments wherein midwives are in charge, as well as in-hospital birth centres in which midwives take care of low-risk pregnancies and childbirths [

      Japan Ministry of Health, Labour and Welfare. Tokyo: [cited 2019.July 17]. Promoting midwife’s performance -establishing in-hospital birth centres and outpatient midwifery departments. Available from: https://www.mhlw.go.jp/file/06-Seisakujouhou-10800000-Iseikyoku/josan_suishin.pdf. Japanese.

      ]. Along this development, the Japanese Nursing Association published a guideline for in-hospital birth centres and outpatient midwifery departments in 2014, which was revised in 2018 [
      • Japanese Nursing Association. Tokyo
      Guideline for in-Hospital Birth Centres and Outpatient Midwifery Departments.
      ]. According to the guideline, the purpose of setting up these midwife-led outpatient departments and in-hospital birth centres is to respond to the various needs of women giving birth and to augment the shortage of obstetricians who manage high-risk pregnancies and facilities handling labour and birth.
      To expand midwifery care in Japan and make a significant difference based on evidence, research focusing on midwifery-led continuity of care has long been awaited. The present study was therefore conducted to describe women’s experience of receiving team-midwifery care in Japan, and to clarify the central essence of such care. As there is a scarcity of research on this area in Japan, the findings are anticipated to provide a more in-depth understanding of women’s perception of team-midwifery care in Japan. A deeper understanding is crucial in creating future opportunities for care providers to further optimize the midwifery care system for women in Japan.

      2. Participants and methods

      2.1 Study design

      This study used a descriptive research design utilizing a qualitative method and involved focus group interviews among women who received team-midwifery care in Japan.

      2.2 Setting

      The focus group interviews were conducted in a birth clinic in central Tokyo, Japan. The birth clinic was selected by purposive sampling because of its distinctive characteristic of providing team-midwifery care. As women in Japan can choose where to receive their antenatal check-ups and give birth, women who were included were those who practiced self-referral. As this birth clinic provides team-midwifery care and specializes in natural childbirth for low-risk pregnant women, they were given information about how the care will be provided, the criteria when they needed to be transferred, and other details at a briefing before they decided to receive care. Antenatal check-ups are provided in private rooms and a full 30 min is given to each woman and her family, checking their health condition, asking their daily life, and providing advice based on their condition. In this clinic, five to six midwives in one team provide continuity of care from pregnancy to the postpartum period. Midwives are the lead caregivers, and women are referred to or transferred to a collaborating obstetrician if any complications occur. In addition, all women visited an obstetrician at least three times to receive blood tests and ultrasound examinations. This is because midwives are the main caregivers in this clinic and midwives in Japan are restricted from performing these procedures independently from obstetricians. Midwives followed a shift-work system, but it was always adjusted so that a known midwife was constantly available for each woman. Every midwifery team held regular meetings to share information about the condition and plans for birth of each woman. The teams also displayed a picture in the clinic to show who the midwives were, and they greeted the women whenever they came to the clinic.

      2.3 Participants and recruitment

      Eligible women were those who received team-midwifery care at the birth clinic from the antenatal period to the postpartum period. Recruitment was conducted by posting a notice on the bulletin board inside the birth clinic, by directly inviting eligible women at midwife-led postpartum classes to participate, or by recruiting eligible women who came from the outpatient clinic to have their breast condition checked.

      2.4 Data collection

      Focus group interviews were conducted three times in March 2013 by one of the researchers. There were four to five participants in each group, and the average time for the interviews ranged from 60 to 90 min. The interviews were recorded using a digital voice recorder and then transcribed verbatim consecutively. An interview guide with the following open-ended questions was used in all the interviews: “What were your expectations of the team-midwifery care?”, “How was the care that you received?”, “Tell me about your care experience here”.
      This study was approved by the ethics review board of St. Luke’s International Hospital, Tokyo (12-R178) on February 25, 2013.

      2.5 Data analysis

      Data were analysed by content analysis. We used the qualitative inductive method to closely assess the data, and grasp and understand fully what women experienced to interpret underlying meanings (Yatsu, 2015) [
      • Yatsu H.
      Start Up Qualitative Nursing Research.
      ]. The authors carefully read through the whole transcribed text to faithfully capture the women’s experience. Then, the contents were summarized, coded, and grouped together under higher-order headings. The analysis was conducted by the researchers who are experts in the midwifery field.

      3. Results

      Thirteen women who gave birth one to 19 months prior to the study were included. Their ages were between 29 to 42 years, of whom eight were primiparas and five were multiparas. Their first visit to receive team-midwifery care was during their 14 to 22 weeks of gestation.
      All the participants were willing to share their experience. From the data analysis, two themes, seven categories, and 16 subcategories emerged. The two themes were “feelings of becoming closer and connected through a warm mutual relationship” and “a lasting feeling of ease and security”. The specific categories and subcategories are described in each theme as shown in Fig. 1.
      Fig. 1
      Fig. 1Women’s experience of receiving team-midwifery care in Japan.

      3.1 Feelings of becoming closer and connected through a warm mutual relationship

      This theme consisted of three categories as follows: “Built a trusting relationship through regular meetings”, “Always focused on me”, and “Noticed that I wanted my family to be involved in my childbearing experience”.

      3.1.1 Built a trusting relationship through regular meetings

      This category consists of three subcategories. As the women had many opportunities to meet their midwives, they built a ‘trusting relationship with the known midwives throughout the prenatal period’. The women described that ‘there was no need to say everything because their preferences were already understood from the start’. The women felt secure during the prenatal period, and they also ‘felt secure with the known midwives during labour’.
      The women shared that they felt a ‘trusting relationship with the known midwives throughout the prenatal period’ because the same midwives who attended to them at their antenatal check-up were at their side during labour:“I was not afraid of my labour because my midwife was beside me. And I knew that I could trust her since she was with me throughout my pregnancy. It was not like this in my last birth, every time I would see a different midwife.”
      As the women were attended to by the same midwives during their antenatal check-up, they developed a comfortable relationship with them. They were able to build a common understanding between each other. The women shared that ‘there was no need to say everything because their preferences were already understood from the start’:“I did not need to say everything every time at my antenatal check-up because they already knew my preferences. My team-midwives understood how I was spending my pregnancy period, so it was easy to communicate. Maybe this is different from [other] hospitals.”
      The women ‘felt secure with the known midwives during labour’ by having the same midwives with them during this period. They were empowered by the midwives and given strength to overcome the labour process. The women were able to experience this sense of security because they were confident that their midwives knew their preferences:“I felt secure when my midwife was with me during labour. We talked a lot during my antenatal period, so she knew what I was thinking about and how I wanted to spend my time during labour. I would not have felt so secure like this if it was not a known midwife.”

      3.1.2 Always focused on me

      This category consists of three subcategories. The women shared that they felt that their midwives ‘showed concern for them as an individual’, and because the midwives knew everything about the women, the women appreciated the way the midwives ‘showed them specifically what to do and what they could do’. After the women had their baby, they shared that they received ‘healing care at the exact time when they needed it most’, which made them feel that they were always cared for.
      The women shared that the midwives ‘showed concern for them as an individual’. The women felt as such because of the warm and comfortable atmosphere that the midwives provided. The women felt that their relationship was genuinely valued and that they were treated as an invaluable person:“They knew everything about me, all my concerns, about my elder children, my husband, my job, everything. They knew when I was so stressed about my job and they would just listen to me with full attention. They were not doing that because it was their job, I could feel that it was from their heart. I was treated as an individual person, not just a woman giving birth.”
      The women appreciated how the midwives ‘showed them specifically what to do and what they could do’ because the care that they received was not just given in a certain mechanical way. Rather, they were provided with care tailored to their needs:“When I said I had low back pain, they suggested me many things I could do. It was easy to understand, and it was not just one way, many ways, so there was always something specifically for me. It was just for me, so I was always positively motivated.”
      The women also shared that they received ‘healing care at the exact time when they needed it most’, which meant that the midwives were there for them exactly when they needed help:“Last time when I had my child at a hospital, I had to say what I wanted the staff to do for me. But here, they asked me and noticed what kind of care I needed from them. They knew just what I needed at the exact time.”

      3.1.3 Noticed that I wanted my family to be involved in my childbearing experience

      This category consists of three subcategories. The women were grateful because the midwives ‘showed concern to their elder children during pregnancy’, and they had ‘nothing to worry about having their elder children with them during labour’, which was different from their last experience at other birth settings. They also said that they ‘received antenatal care for their husband’:“Every midwife knew my elder children and showed concern for them. They explained how my baby was doing in easy words so they could understand.”
      The women said that there was ‘nothing to worry about having their elder children with them during labour’, and they were happy to see their elder children involved in the moment of having their new born sister/brother:“I was able to have my elder children with me during labour. And right after birth, my elder children were able to meet their new born sister/brother. It was not through windows like other hospitals usually do, so they were so happy and felt so involved.”
      The women’s antenatal check-up was not just for them. They shared that they also ‘received antenatal care for their husbands’. The midwives knew that the women wanted their husbands to be involved, so they actively payed attention to them. By doing so, the midwives tried to motivate the husbands and made them involved in their wife’s labour process:“The midwives explained the labour process to my husband so precisely. If it was not for that, I think he would not have had a chance to learn, so sometimes the antenatal care was for my husband.”

      3.2 A lasting feeling of ease and security

      This theme consists of four categories: “always warm and comfortable atmosphere”, “could just be myself”, “I could do it myself”, and “wanted to be connected”.

      3.2.1 Always warm and comfortable atmosphere

      This category consists of three subcategories. The women shared that they ‘could ask anything without hesitating’ and ‘were able to ask any small things’. Therefore, the birth clinic was a ‘peaceful and comfortable place’ for them.
      The women said that the midwives were like their mothers because they were so reliable and that they ‘could ask anything without hesitating’. This was because the midwives gave plenty of their time to the women, which made it easier for the women to communicate their feelings:
      “It was like having many reliable mothers. I could talk and ask anything, so I looked forward to meeting them. We could talk about big things and small things and it became easier and easier to discuss because of the plentiful time the midwife took for me.”
      As the midwives were very intimate and understanding, the women felt very close to them. The women shared that they ‘were able to ask any small things’ which reassured and comforted them:
      “The midwife was such an empathetic listener, when I had a little trouble, I knew I could ask for help to them. I did not have to worry about anything.”
      The women enjoyed the ‘peaceful and comfortable place’ that the midwives prepared for them. They enjoyed the place from their antenatal check-up until their time of labour. They were certain that they could overcome the labour process because their midwife is always with them:
      “Every time I came, the midwives welcomed me in a warm atmosphere. This place is such a peaceful and comfortable place, when I came here for labour, I had nothing to worry about. I knew I would be okay. I would want to have my next baby here at this same place.”

      3.2.2 Could just be myself

      This category consists of two subcategories. The women said that they ‘were able to express their desire’ and ‘were able to depend on the midwives because they knew them’, allowing them to be just themselves.
      As the women developed a close relationship with the midwives, they shared that they ‘were able to express their desire’ which enabled them to overcome the labour process. They did not feel supressed in expressing what they wanted to do:“Since this was my second time to give birth, I told my midwife that I want to do this and I do not want to do that. And she was there for me at my labour, so I could handle the labour process.”
      The women did not hesitate to ask their midwives for help, and they shared that they ‘were able to depend on the midwives because they knew them’. The women had the assurance that their midwives will come to them any time they needed help, even when they felt that they were being self-centred. They did not have to worry about being seen as an annoying person because of the trusting relationship with their midwives:“I felt free to say whatever was in my mind. Even if I was self-centred, I knew my midwife will accept it. When I had trouble calming down my baby during hospitalization, I could call her and ask for help and she would come right away and help me. That eased me so much.”

      3.2.3 I could do it myself

      This category does not have any subcategories. The women were able to feel and enjoy the natural labour process, which made them satisfied with their experience:“The labour process was natural, I did not have to use any medication. They did not direct me to push so I was on my own pace, and my baby’s pace. I could really feel my baby coming out. So, I am 200% satisfied with my labour.”

      3.2.4 Wanted to be connected

      This category consists of two subcategories. For the women, receiving team-midwifery care meant not just the care provided in the birth clinic. They shared that they ‘wanted to be connected even after their discharge’ and that they felt a ‘sense of security of having a place to rely on after their discharge’.
      The women expressed that they became very close to the midwives and they said that they ‘wanted to be connected even after their discharge’:“I miss the midwives so much. It is so sad that I do not have a chance to come here and meet them. I would want to make an excuse to come and have them see my grown baby. We have become so close to each other.”
      As the women built a very close and trusting relationship with their midwives, they had a ‘sense of security of having a place to rely on after their discharge’. They knew that they could rely on their midwives even after their discharge from the clinic. This was a secure and reliable place for them to come back to:“I feel so secured that I have a place to rely on even after discharge. There is a clinic near my home but I know I will come here if I need help.”

      4. Discussion

      This study elucidated women’s experience of receiving team-midwifery care in a birth clinic in Japan. The women freely expressed their experience regarding the care they received from their midwives. They willingly shared their experience of how a close relationship with their midwives was established and strengthened, how much this caring relationship meant for them and their families, and to what extent such relationship influenced them over time. These valuable experiences were categorized into two notable themes: “feelings of becoming closer and connected through a warm mutual relationship” and “a lasting feeling of ease and security”.

      4.1 Woman centredness

      The close relationship established between the women and the midwives reflected WCC. Meeting regularly and spending precious time together enabled the women and midwives to know each other more deeply. The women could feel the midwives’ warm caring attitude and that the care was always organized and individualized. The women felt that the midwives ‘always focused on them’ and they were at ease that they ‘could just be themselves’ because of the constant ‘warm and comfortable atmosphere’ provided by the midwives. These provisions of safe care, respect for women, and treating women as a whole person constitute the essence of WCC as described by Horiuchi et al. [
      • Horiuchi S.
      • Kataoka Y.
      • Eto H.
      • Oguro M.
      • Mori T.
      The applicability of women-centered care: Two case studies of capacity-building for maternal health through international collaboration.
      ]. This is the underpinning philosophy of providing care to women.
      Effective communication is the underlying assumption for building a ‘warm mutual relationship’ and providing WCC. As stated in the WHO recommendations: Intrapartum care for a positive childbirth experience (2018), effective communication is recommended between maternity care providers and women [
      • World Health Organization
      WHO Recommendations: Intrapartum Care for a Positive Childbirth Experience.
      ]. To achieve effective communication, the midwife regularly meets the woman, which reflects continuity of care, enabling the midwife to appropriately respond to the woman’s needs. This leads to a better understanding of the woman. Bradfield et al. reported on midwives’ experiences and indicated that their being ‘with a woman’ places the woman and her family in the centre of the care they experience [
      • Bradfield Z.
      • Hauck Y.
      • Kelly M.
      • Duggan R.
      “It’s what midwifery is all about”: Western Australian midwives’ experiences of being ‘with woman’ during labour and birth in the known midwife model.
      ]. Symon et al. described that women who received care from the continuity of midwifery care model reported effective communication compared with other models of care [
      • Symon A.
      • McFadden A.
      • White M.
      • Fraser K.
      • Cummins A.
      Using the Quality Maternal and Newborn Care Framework to evaluate women’s experiences of different models of care: a qualitative study.
      ]. Women giving birth at birth centres in Japan reported respectful communication and continuity of care during antenatal check-ups which were related to their satisfaction with the care that they received [
      • Iida M.
      • Horiuchi S.
      • Porter S.E.
      The relationship between women-centred care and women’s birth experiences: a comparison between birth centres, clinics, and hospitals in Japan.
      ]. The theme “feelings of becoming closer and connected through a warm mutual relationship” describes the strengthening of relationship between the women and the midwives through effective communication similarly to previous studies.

      4.2 Empowerment of the women

      The women receiving care from the midwives were empowered by their close relationship with the midwives. They felt a growing trust to their midwives and at the same time an increasing confidence in themselves. They realized that they ‘could do it by themselves’ and they felt ‘a lasting feeling of ease and security’. Karlstom et al. reported that when women have a trusting and supportive relationship with the midwife, they gain the ability and strength to overcome the challenges of the birthing process because of the midwife’s continuous presence and support [
      • Karlström A.
      • Nystedt A.
      • Hildingsson I.
      The meaning of a very positive birth experience: focus groups discussions with women.
      ]. Dahlberg et al. similarly reported that the continuous presence and support of midwives promote their responsiveness to the women’s needs which empowers the women and their family [
      • Dahlberg U.
      • Persen J.
      • Skogås A.K.
      • Selboe S.T.
      • Torvik H.M.
      • Aune I.
      How can midwives promote a normal birth and a positive birth experience? The experience of first-time Norwegian mothers.
      ]. Receiving constant and reliable care from the midwives accumulated positive experiences during the women’s pregnancy because the midwives’ care was always focused on the women. Focused care means that the midwives were always at the women’s side and were responsive to their needs. Petit-Steeghs et al. emphasized that maternity care services should be responsive to women’s needs to achieve client-centred care [
      • Petit-Steeghs V.
      • Lips S.R.
      • Schuitmaker-Warnaar T.J.
      • Broerse J.E.W.
      Client-centred maternity care from women’s perspectives: need for responsiveness.
      ]. Even after their discharge and when they faced difficulties in child rearing, the women had the confidence to overcome because of their ‘sense of security of having a place to rely on after their discharge’.

      4.3 Strengths and limitations

      This research is one of the first studies to highlight women’s perception in receiving team-midwifery care in a birth clinic in Japan. The present findings remain a valuable contribution to this model of care as there has been very little work conducted on midwifery continuity of care in Japan. Although not all birth settings in Japan can provide a team-midwifery care system, some important elements that can be adopted regardless of the care system were identified in the present study. The first element is building a warm and trusting relationship between the women and the midwives. The second element is providing constant and genuine care so that the women can feel a sense of connection. The third element is assuring the women of support even after discharge. Even when midwives are not the main caregivers such as in obstetrician-led care, greeting women and letting them know that a midwife is always present and ready to care for them will provide a sense of reassurance. Sharing and carefully handing over information of women among midwives will ensure sensitivity to their hopes and responsiveness to their needs. It is strenuous to institute changes in settings and systems in a short period of time. Having recognized this issue, there is currently a movement of establishing ‘my-midwife system’ in some areas in Japan (i.e., Mamanone Project) []. This system shares a similar feature to New Zealand’s ‘Lead Maternity Carer system’ which coordinates pregnant women’s maternity care (New Zealand College of Midwives) [

      New Zealand College of Midwives. [cited 2020. Aug 26]. Available from: https://www.midwife.org.nz/women/about-midwives/about-lead-maternity-carer-lmc-services/.

      ]. For future programs, attention will also be focused on midwives who provide team-midwifery care and those who work as ‘my-midwife’. It may also be possible to include midwives who work at midwife-led outpatient departments and in-hospital birth centres, and midwives who have high hopes and strive to make valuable contributions to further improve the maternity healthcare system in Japan. By doing so, both promoting factors and interfering factors can be fully grasped.
      The limitations of this study include the limited setting and data collection period. The setting is limited because team-midwifery care in Japan is still a very minor system. The places where team-midwifery care is mostly provided are in birth centres at about 1% and in in-hospital birth centres at 13.2%, which limited our recruitment. These proportions have not changed significantly from the data collection period (Japanese Nursing Association, 2019) [
      • Japanese Nursing Association. Tokyo
      Report on the Effect of in-Hospital Birth Centres and Outpatient Midwifery Departments.
      ]. Also, the data collection period in 2013 may not exactly describe the present situation. The national campaign ‘Healthy Parents and Children 21’ (Japanese Ministry of Health, Labour and Welfare) [

      Japanese Ministry of Health, Labour and Welfare. Tokyo: [cited 2020. Aug 16]. Healthy Parents and Children 21(Second Phase). Available from: http://sukoyaka21.jp/about, Japanese.

      ] entered its second phase in 2015, aiming to further improve the health standards of mothers and children. One of the basic agenda of this campaign is to improve seamless health measures for pregnant women and infants that ensure comfortable and safe pregnancy, childbirth, and child rearing. Importantly, the ‘Maternal and Child Health Act’ was revised in 2017 and the Comprehensive Support System for Children and Child-rearing (Japanese Ministry of Health, Labour and Welfare) [

      Japanese Ministry of Health, Labour and Welfare. Tokyo: [cited 2020. Aug 16]. Guideline for Comprehensive Support System for Children and Child-rearing. Available from: https://www.mhlw.go.jp/file/06-Seisakujouhou-11900000-Koyoukintoujidoukateikyoku/kosodatesedaigaidorain.pdf. Japanese.

      ] has been established by law. With these changes, related organizations are able to share information and cooperate to support the child rearing generation. These developments may have effects on women’s pregnancy and child-rearing experiences.
      However, we believe that women’s experiences of receiving team-midwifery care are consistent because the underlying beliefs of midwives do not change. Therefore, despite these limitations, the results demonstrate the essential features of women’s experiences of receiving team-midwifery care. We hope that team-midwifery care which takes into account the central essence of midwifery care throughout their perinatal period can be fully implemented not only in Japan, but also in countries and settings that have restrictions of perinatal support to women.

      5. Conclusions

      Team-midwifery care enabled the women to become closer and connected to the midwives through a warm mutual relationship and the feelings of ease and security. The underlying assumption for the women’s empowerment was the continuity of WCC built through a trusting relationship and communication between the women and the midwives. This relationship empowered the women and provided them with strength to overcome the difficulties of child rearing even after their discharge.

      Author contributions

      Dr. Mariko Iida (https://orcid.org/0000-0002-3426-0965) was responsible for data collection, data analysis, and writing the initial daft of the article, and assisted in preparing the research proposal. Dr. Kumiko Nagamori was responsible for the research proposal development, ethics approval, and data analysis assistance. Dr. Shigeko Horiuchi (https://orcid.org/0000-0001-7412-3941) was responsible for finalizing the research proposal and data analysis. All authors have read and approved the final manuscript.

      Funding

      This study was funded by Japan Society for the Promotion of Science KAKENHI Grant-in-Aid for Early-Career Scientistss (No. 18K17578, Principal Investigator Dr. Mariko Iida), and Japan Society for the Promotion of Science KAKENHI Grant-in-Aid for Scientific Research (A) (No. 17H01613, Principal Investigator Dr. Shigeko Horiuchi).

      Ethical statement

      The ethics review board of St. Luke’s International Hospital, Tokyo, Japan approved this study (approval number 12-R178; approval date February 25, 2013).

      Conflict of interest

      The authors declare that they have no conflicts of interest associated with this manuscript.

      Acknowledgments

      The authors are grateful to all the women who participated in our research.
      We are sincerely grateful to Dr. Edward Barroga (http://orcid.org/0000-0002-8920-2607), Medical Editor and Professor of Academic Writing at St. Luke’s International University, Tokyo, Japan for reviewing and editing this manuscript.

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