In Japan, there has been a decline in family‑supported postpartum care in the home, thought to be linked with women's entry into the workforce (Ministry of Internal Affairs and Communications, 2022), the rise in childbearing age (National Institute of Population and Social Security Research, 2023) and the growth of nuclear families (Ministry of Internal Affairs and Communications, 2020).
In addition, the COVID‑19 pandemic meant that people were raising children in isolation, resulting in negative social impacts such as increases in postpartum depression cases (Matsushima, 2022) and child abuse consultations (Ministry of Health, Labour and Welfare (MHLW), 2021).
There was a decline in the incidence of postpartum depression in Japan from the first recorded rate of 13.4% in 2000 to 9.0% in 2013 (Yamagata, 2013). However, postpartum depression is associated with maternal suicide (Takeda, 2017), child abuse (Mishina et al, 2013; Tokuhiro et al, 2015), prolonged maternal childcare fatigue and associated effects on child development (Nakamura et al, 2021) and depression in the husband and family members (Takehara and Sudo, 2012). In Japan, maternal postpartum suicide is the number one cause of death of expectant and nursing mothers, half of whom had no previous history of psychological conditions, indicating an urgent need to address this issue (Takeda, 2017).
In the UK, mother and baby units provide care for mothers with psychological issues and their infants. In Japan, the government implemented a postpartum care project to supplement public health nurse visits, which all mothers receive, with care by nursing professionals, such as midwives. Building on a 2013 model, these projects aimed to promote postpartum mothers' psychological and physical health, enabling them to raise healthy children by providing seamless support from pregnancy onward (MHLW, 2022).
Care can be provided for a maximum of 1 year postpartum and is given in three forms: residential (inpatient), day service (outpatient), and outreach (home visits). A residential postpartum care facility is a midwifery centre, hospital or other residential (overnight inpatient) facility specialised in providing postpartum care. New mothers and their infants can stay for approximately 1 week and receive care from midwives after the standard 4–5 day stay (6–7 days in the case of caesarean section) at the facility where the mothers gave birth. People who use the facility pay 10–20% of the total cost (paying approximately 6000–12 000 JPY of the 60 000 JPY per night cost), while local authorities and the national government subsidise 80–90% of the cost.
The project guidelines (MHLW, 2017; 2020) specify that psychological care is provided to those who:
However, neither these guidelines nor the Japan Midwives Association (2023) postpartum care guide for midwives specify detailed and definitive recommendations on the psychological care to be provided or on care to prevent postpartum depression. Previous studies have explored care for people at high risk of postpartum depression (Sun et al, 2019; Tateyama, 2022) and where to focus assessments (Kasai et al, 2018), but no clear guidance has been created on postpartum psychological care provided by midwives (Fryer and Weaver, 2014).
Postpartum care services in Japan have only been in existence for a short time and there is little research that focuses on the psychological care they provide. However, there are case reports that show women's mental health recovers as a result of the continual psychological care provided by midwives (Kuwahara and Nakano 2017), indicating the importance of providing this care, especially that intended to prevent postpartum depression. For these reasons, the aim of this study was to explore the psychological care usually provided by midwives at maternity hospitals and other residential postpartum care facilities that admit mothers following discharge from the facilities where they gave birth, and especially focus on care intended to prevent postpartum depression.
Methods
This was a qualitative descriptive study carried out between March and June 2021 at seven residential postpartum care facilities in the Kanto area.
Participants
A total of 14 facilities in the Kanto area where postpartum care was provided were considered for the study. All facilities were sent a letter of request for cooperation, but as a result of COVID‑19 related difficulties, only seven facilities were included.
The participants were a purposive sample of facility directors (or an equivalent level midwife designated by the director). These individuals were deemed to have a good understanding of their facility's care philosophy and policies. Only one individual from each facility participated to avoid potential bias from facility policies, giving a total sample of seven participants.
The inclusion criteria were midwives with experience providing psychological care (including prevention of postpartum depression) at residential postpartum care facilities, who were the facility director or recommended by the director, who understood the purpose of the study and who decided to participate of their own free will. Midwives who experienced any physical or mental strain resulting from completing questionnaires and/or participating in interviews were excluded.
Data collection
Data were collected using pre‑interview questionnaires and semi‑structured interviews. The questionnaire and interview guide used were based on a previous study (Kasai et al, 2018). The questionnaires collected data on the participants' age, years of clinical experience, years of postpartum care experience, total number of postpartum care cases and employment status. The interview guide explored the psychological care typically provided, especially care intended to prevent postpartum depression.
The interviews were held at the facilities or through an online conferencing system between March and June 2021. They were conducted by the first author in Japanese, lasted approximately 60 minutes and were recorded. Quotes were translated into English by the lead author and checked by a native English speaker.
Data analysis
Recorded interview audio data was transcribed verbatim. The transcripts were read repeatedly, after which speech related to psychological care was extracted and analysed through qualitative induction, as per Berelson (1957). The material was summarised and coded without loss of semantic content. Subcategories and categories were extracted through classification and aggregation based on similarity and heterogeneity. During analysis, the researchers repeatedly reviewed the data to ensure content validity and reliability.
Ethical considerations
This study was approved by the Ethics Committee of the Kitasato University School of Nursing (reference: 2020‑13). The purpose of the study was explained to the participants who gave written informed consent to participate.
Results
The participants' characteristics are summarised in Table 1. Their ages ranged from 40–70 years. They had 17–52 years of clinical experience and had 4–27 years of postpartum care experience. Each participant had handled approximately 100 postpartum care cases or more. Five of the participants were employed full time and two part time.
| Characteristic | Mean ± standard deviation | |
|---|---|---|
| Age (years) | 40–70 | 51.40 ± 13.50 |
| Clinical experience (years) | 17–52 | 30.43 ± 14.70 |
| Experience in postpartum care (years) | 4–27 | 11.14 ± 8.73 |
| Number of psychological care cases | Approximately 100 or more | |
| Employment status | 5 full‑time; 2 part‑time | |
Usual psychological care practices
In terms of usual psychological care practices, seven overall themes were generated, with 21 subthemes, representing 95 codes in total. The themes and subthemes are shown in Table 2.
| Theme | Subtheme |
|---|---|
| Accepting and acknowledging the individual with respect and inclusion | Respect the mother as an individual |
| Value individuality | |
| Accept and acknowledge with inclusivity | |
| Promoting physical and psychological recovery | Relax the body and mind |
| Provide massages and relaxation | |
| Encourage sleep and rest so that the body and mind can recover | |
| Listening through wait‑and‑see care instead of eliciting information | Just listen |
| Use massage and other provided care to listen | |
| Listening for organisation and resolution | |
| Wait for the individual to talk | |
| Pay attention to the recovery stage when asking questions | |
| Reflecting on the birth | Understanding |
| Providing childcare counseling and guidance based on the needs of the individual and their family | Assess needs and provide guidance on breastfeeding support and childcare skills acquisition |
| Support for becoming accustomed to childcare | |
| Guidance that includes the husband and family members | |
| Communicating about relationships and promoting understanding from mother and husband | Being understood by one's husband and family |
| An individual's relationship with their mother | |
| An individual's relationship with their husband | |
| Providing planned continuous and coordinated support | Make effective use of postpartum care |
| Recommend psychological counselling | |
| Provide continuous support |
The first theme was accepting and acknowledging the individual with respect and inclusion. The participants emphasised the importance of taking time to listen and value a woman's individuality so they can grow and develop. They highlighted that everyone had a different personality and lifestyle, so it was important to choose a style that matched this when providing care. The participants also felt that it was important to accept and acknowledge mothers' efforts with inclusivity.
‘We value the personality of each individual and take our time to focus and listen earnestly to what the mother wants to do in order to help her grow in a way she can be satisfied with’. A
‘Each mother and baby is unique and has a different lifestyle, so we offer a variety of options to help them live in a way that fits their lives’. B
‘Some mothers start crying when I acknowledge all their hard work before entering the postpartum care facility’. E
The participants reported on the importance of promoting physical and psychological recovery. They felt it was important to relax the body and mind, highlighting their belief that caring for the body could have a positive effect on the mind. Providing massages for women's feet, backs, shoulders and whole body was thought to promote relaxation. Participants also wanted to encourage sleep and rest so that the body and mind could recover, emphasising that physical recovery was important to allow the mind to recover.
‘When I touch the mother's body during a footbath or massage, their whole body relaxes. That is when they can let out various thoughts’. D
‘I use aroma oil to massage their backs, hips, etc to relax them’. G
‘When the mother is exhausted and unable to think clearly, I encourage her to get some sleep to help her body and mind recover’. A
The third theme was listening through ‘wait‑and‑see’ care, instead of eliciting information. Participants highlighted that it was important to listen to a woman's complaints, incorporating this into the care provided. They emphasised that taking the time to listen to a woman allowed her to become aware of her own thoughts and discover her own solutions. The participants felt that it was better to wait until things were calm, allowing a woman to decide for herself that she wanted to talk to midwives. They also wanted to pay attention to the recovery stage when asking questions, emphasising the importance of observing the recovery stage when caring for women.
‘I don't say anything unnecessary and focus on letting mothers talk’. B
‘Conversation while providing breast care is a good opportunity to talk’. D
‘It is important for her to accept her current situation and find her own solutions, so I take time to listen, which allows her to become aware of her own thoughts’. A
‘I wait until the mother feels calm and begins to talk’. C
‘As the mother recovers, she turns her attention to the baby and starts talking about things’. E
The fourth theme was reflecting on the birth, which had one subtheme emphasising the importance of reflection for understanding.
‘When the mother begins to talk, we reflect on the birth. This is where you can understand the mother's feelings’. F
The fifth theme explored providing childcare counselling and guidance according to the needs of the individual and their family. Participants assessws needs and provides guidance on breastfeeding support and childcare skills acquisition. They would explain and implement appropriate methods for the individual child, taking into account differences between children. Midwives would provide support for women learning how to care for their baby. For example, they advised women not to leave the baby completely alone, in order to learn their cycles of crying at night. The participants felt that it was important to include a woman's husband in the guidance provided.
‘Guidance is given after the mothers have identified their needs for the kind of childcare they want’. A
‘We recommend that the mother and child share a room, instead of the baby being cared for elsewhere.
This allows the mother to learn their child's rhythm of night-time crying, which can be a source of anxiety for mothers’. E
‘Teach the husband how to bathe the infant and have him practice’. D
The sixth theme explored communicating about relationships and promoting understanding from women's mothers and husbands. Participants felt it was important to explain physiological issues, progressive and regressive phenomena and hormones to a woman's husband and family and gain their understanding. They focused on a woman's relationship with her mother and her husband. Participants noted that a woman's psychological stress may increase when dealing with their mother or anyone with whom they had conflict. Equally, they felt that praising the woman's husband and interacting with them with a sense of gratitude was an important component of care.
‘Explaining and helping husbands and family members to understand changes to the mother's body and hormones after childbirth will improve relationships’. C
‘Those who do not have a good relationship with their biological mothers are supported in preventing mood swings and other mental difficulties’. G
‘I think it is important to interact with husbands with a feeling of gratitude’. C
The final theme was providing planned continuous and coordinated support. Participants felt it was important to make effective use of postpartum care, including creating a care plan. The participants would recommend psychological counselling, and gave continuous support until things were on ‘the right track’.
‘Whether the mother wants to take a break for postpartum care or to practice childcare, the mother's wishes are listened to and a plan is made together’. F
‘I will recommend a psychologist or other specialist for cases that need extra attention’. B
‘We will provide continuous support day and night until childcare is established and then continue to provide long-term support thereafter’. G
Preventing postpartum depression
The category of care intended to prevent postpartum depression had nine themes with 20 subcategories generated from 89 codes. The themes and subthemes are shown in Table 3. Several of the themes from overall care were also reflected in the themes relating specifically to preventing postpartum depression. Additional elements of care in this area included valuing the initial assessment, avoiding negations or impositions and involving a woman's husband and home techniques.
| Theme | Subtheme |
|---|---|
| Value the initial assessment and connection | Value the initial connection to ease tension |
| Value the initial assessment | |
| Acceptance and providing emotional support | Acceptance and approval |
| Emotional support | |
| No negations or impositions | No negations |
| No impositions | |
| No excessive advice or changes | |
| Intentional listening | Taking time to listen closely |
| Earnest listening | |
| Attentively listen about hospital experiences and future plans | |
| Reflecting on the birth | Reflecting on the birth |
| Value the individual and wait patiently to proceed at their pace | Value the individual |
| Wait patiently to proceed at their pace | |
| Encourage rest in a calm environment | Encourage rest |
| Environmental considerations | |
| Provide support in accordance with needs | Assess needs |
| Breastfeeding support | |
| Perform massage | |
| Involve the husband and practice techniques that can be performed at home | Involve the husband |
| Increase familiarity with childcare and practice techniques that can be performed at home |
The participants felt it was important to value the initial assessment and connection, using the initial connection to ease tension through casual conversation and viewing the use of postpartum care as the start of the process.
‘I find that some casual conversation, such as “your feet are swollen,” helps reduce a mother's tension’. C
‘Confirm why the mother wanted to receive postpartum care, as the initial involvement is important’. E
The theme no negations or impositions highlighted that participants wanted to give women a sense of security, ensuring that they would not be viewed negatively for expressing their feelings. It was also important to ensure women did not feel they were an imposition, for example if they needed milk. Participants also reported that it was useful to avoid excessive advice or changes to the woman's way of doing things.
‘To get the mother to open up, accept her expressed ideas without denial’. D
‘The mother may reject methods imposed by a midwife, so we let a mother choose her own methods’. B
‘I try not to unnecessarily improve, advise or change too much of what the mother is currently doing’. F
Involving the woman's husband and practicing techniques that could be performed at home was viewed as an important component of preventing postpartum depression. Participants felt it was important to include a woman's husband in instruction provided before discharge from the facility and increase their familiarity with childcare as well as supporting techniques that suited the mother and child, rather than methods deemed ‘proper’.
‘It is important to involve the husband in childcare by providing him with bathing and facility discharge guidance’. E
‘We support the way that is appropriate for mother and child, not “the right way”. It works better if you let mothers practice how they will raise their child at home and allow them to experience success’. D
Discussion
This study explored psychological care practices typically provided by midwives in residential postpartum care facilities, especially those intended to prevent postpartum depression. These practices were generally characterised by accepting and attentive listening, approval, waiting and matching pace with the mother, encouraging rest, reflecting on the birth, matching individual needs and working with the family.
The authors assert that the many similarities between the overall psychological care provided and the care intended specifically to prevent postpartum depression result from the midwives' fundamental belief that any postpartum mother could experience postpartum depression. The findings from the present study are reflected in the postpartum care guide for midwives published by the Japan Midwives Association (2023), which advises midwives to ‘listen carefully to the mother's thoughts on what kind of childcare is preferred’, ‘support the mother in discovering a childcare method that suits their child’ and ‘listen to the mother's stories about their pregnancy and childbirth’ (Japan Midwives Association, 2023). The findings emphasise that, in addition to interactions with the mother, midwives make adjustments for family and provide psychological care in conjunction with other professionals. Establishing support systems can reduce a woman's psychological burdens (Sakano and Nakanishi, 2018), meaning that the provision of psychological care that includes family members during the postpartum period is key.
A finding from the present study that is not evident in previous guidelines is that care was frequently provided for mothers at residential postpartum care facilities when they had given birth at a different facility, making their attendance the start of their experiences of postpartum care. The participants highlighted that midwives were intentional in their initial interactions with mothers, to reduce tension and allow them to express their thoughts. A midwifery diagnosis is necessary to provide healthcare guidance as part of an individually tailored postpartum depression prevention programme. As such, patient interviews and assessments are essential (Japan Midwives Association, 2023). The authors believe that midwives value initial assessments that allow them to explore a mother's needs through attentive listening and communication. Midwives can also make observations, instead of relying on information provided by sources such as the birthing facility or public health nurses.
A lack of confidence in childrearing and childcare anxiety can be a risk for postpartum depression (Sato, 2006; Enya and Kabeyama, 2018; Nakamura et al, 2023). The present findings highlighted that midwives practiced interactions designed to increase mothers' childrearing confidence by establishing trust and avoiding heightened anxiety. Midwives avoided discouraging childcare techniques performed at the birthing facility or at home, excessively changing or imposing childcare styles, providing excessive advice or drastically changing approaches. The absence of trusted individuals or a lack of support are risks for postpartum depression among new mothers (Nakamura et al, 2023). Support from family and maintaining relationships with others can mitigate this risk, but may be insufficient alone. The present findings suggest that mothers should be supported to play an active role in action and communication, and assistance should be provided to allow key individuals, such as husbands and partners, to be involved in childcare.
Implications for practice
There is an urgent need to strengthen cooperation among governmental entities, such as public health centres, local midwifery centres and other facilities, in order to provide timely support to mothers and families in need of psychological care to prevent postpartum depression. In Japan, postpartum care services are available to mothers who have applied at public health centres to receive care from midwives. If public health centres are able to smoothly carry out procedures for use of the service and strengthen the pipeline leading to midwife involvement at an early stage, both mother and child benefit from a midwife's care, including psychological care, before any decline in their condition.
Future research should explore midwives' competencies in postpartum care, establishing the skills needed to enable midwives to confidently engage in postpartum care by addressing perceived issues such as dependence on experience and the ability to determine if a case can be handled by midwives alone.
Limitations
One limitation is the possibility of bias, as the participants were taken from a small number of geographical regions, meaning the results may not be generalisable.
Conclusions
This study found that the psychological care provided in residential postpartum care facilities in Japan is generally focused on acceptance, listening and approval. Care practices are founded on respect for mothers and proceeds at their pace, promoting rest, allowing for reflection on childbirth and providing health guidance and family interactions that match mothers' needs. Care specifically intended to prevent postpartum depression is focused on initial assessments and prioritises relationships, avoids negations and impositions and involves a woman's husband and family members. These practices build trusting relationships and help mothers gain confidence in childrearing without contributing to anxiety. The authors believe that these findings will be useful in clinical practice when implementing psychological care intended to prevent postpartum depression.