Issue:
February 2025 | Japan Media Review
Tokyo’s epidural subsidy highlights the medical sector’s struggle to address the low birth rate
The Tokyo Metropolitan Government has announced that it will offer a subsidy for the use of epidurals during childbirth starting in October. The plan follows up on a campaign promise made by Tokyo Governor Yuriko Koike last summer to "reduce the financial burden of childbirth" and thus help increase the fertility rate in the capital, which dipped below 1.0 in 2023. The money is only available to residents of Tokyo who give birth at a medical institution located in Tokyo. It is the first subsidy for epidurals offered by a prefecture, though one town in Gunma Prefecture also pays for epidurals.
National health insurance does not cover pregnancy and childbirth unless there is a complication that requires remedial medical care. An epidural is a procedure that can be administered during childbirth to alleviate the pain of labor, and thus is not considered remedial medical care. According to a report in the January 6 issue of the Yomiuri Shimbun, epidurals in Japan for childbirth normally cost between ¥100,000 and ¥150,000, which, as an option, is in addition to the fee charged by the medical institution for delivering a baby. The cost of giving birth in Japan varies depending on the location, but the average nationwide in 2023 was ¥506,000, according to the health ministry. The highest average fee is in Tokyo, ¥625,372, and the lowest is in Kumamoto, ¥388,796. The central government offers a grant of ¥500,000 (more precisely, ¥488,000, since ¥12,000 is withheld for obstetricians' liability insurance) to women who give birth and paid after delivery through local governments.
Epidurals are still relatively uncommon in Japan owing to various factors. The Yomiuri reports that in some countries, epidurals are administered during as much as 80% of births. One reason the procedure has not caught on as well in Japan is the strong belief that the pain of labor, in the words of the Yomiuri, "fosters a stronger mother-child connection". However, other, more practical reasons for the paucity of epidurals in Japan is the cost and lack of anesthesiologists, who are needed to administer the procedure. The use of epidurals has increased in recent years, especially in Tokyo, where there are more medical facilities equipped to offer it. In 2018, epidurals were administered during 45,558 childbirths nationwide, a number that increased to 89,044 by 2022, or 11.6% of all childbirths that year, the first time the rate had exceeded 10%. According to a survey conducted by the maternity magazine Zexy Baby, 60% of respondents who said they wanted to use epidurals during the birth of their children did not because of the expense.
Another matter that may hinder the use of epidurals has to do with the perception that they are risky, though most obstetricians worldwide say it is not only a safe procedure but offers both physical and mental health benefits. Epidurals not only alleviate pain during childbirth, but mitigate much of the accompanying anxiety. Women who undergo epidurals tend to recover from labor more quickly and are thought to be less susceptible to post-partum depression, so there may be attendant financial benefits in terms of postnatal care.
One of the problems related to the childbirth subsidy is that it is paid after the fact, meaning all fees related to a woman's pregnancy and labor are paid up front by the patient, who only later receives ¥488,000 in compensation. Women of limited means may not be able to pay up front and so the subsidy is not quite as effective in removing a financial obstacle for these women. A recent Asahi Shimbun article profiled a non-profit organization called Florence that helps such women, the purpose being to provide them with medical care so that they can see their pregnancies to term. Florence works with clinics and pays for everything, from examinations to delivery, through private donations. But the program is only for low-income women who are already pregnant. Similarly, some local governments pay for childbirth services, but only after the expectant mother has been examined by an obstetrician. And in many cases, in addition to having insufficient funds, some low-income women may also not be enrolled in a national insurance plan and so do not undergo prenatal exams, which they would have to pay for themselves. A significant aspect of national health insurance coverage is that when the subscriber misses a certain number of payments, they lose that coverage, regardless of how many years they've already paid into it. So in addition to not being able to afford the process of giving birth in a hospital or clinic, lower income women may not be able to afford recommended prenatal examinations.
Although the average cost of an epidural in Tokyo stands at about ¥124,000, the subsidy will be capped at ¥100,000 per birth, so the prefecture estimates it would need ¥1.1 billion for the program in fiscal 2025. In that light, there is speculation that costs could still go up as a result of the subsidy. Another Asahi article that appeared on November 24 reported that in 2022, in 41 prefectures the handout could not cover the average cost of delivery, so it was increased nationally from ¥420,000 to ¥500,000 the following year. When that happened the average cost of having a child increased by 7%, or about ¥24,000, indicating that medical institutions would increase their fees whenever the government decided to subsidize anything connected to pregnancy and childbirth. After the health ministry queried hospitals and clinics as to why they had increased their fees automatically once the handout increase went into effect, 90% said it was due to "increased overheads," implying that the institutions were already absorbing these expenses and took the government increase as a cue to increase their fees. In any case, since pregnancy and childbirth are not covered by national insurance, the government has no say with regard to related fees.
In actuality, the central government began discussions on whether to allow pregnancy and childbirth to be covered by national health insurance as early as fiscal 2026, in accordance with a Cabinet proposal adopted in 2023. The Asahi reported on the proposal last summer after a study group of medical professionals and academics was assembled by the health ministry to debate the ramifications. As with Tokyo's epidural subsidy, the purpose is to alleviate the financial burden of childbirth in order to boost the birth rate. However, national coverage means the government would become involved in setting prices for pregnancy care and childbirth, actions that the Japan Society of Obstetrics and Gynecology (JSOG) opposes. One obstetrician who runs a clinic in Fuchu no Mori, Tokyo, told the Asahi that if the services he offered were covered by national health insurance, he would probably close down, pointing out that since 2013, the number of annual deliveries he's performed has decreased by about 40%. He has tried to keep his fees low and as a result his business is in the red, so if the government further restricts what he can charge, it will not be worth his while, especially as utility and food costs continue to go up. Moreover, equipment and personnel must be maintained at certain prescribed levels. As it stands, he had to hire a part-time physician to be on overnight duty once a week. It's the only time he can take time off. "We cannot perform all the tasks [related to pregnancy and childbirth] within the financial framework dictated by the government," he told the Asahi.
In a sense, there's a chicken-egg dynamic at work here. As the birth rate falls the average age of obstetricians increases, since medical students don't see any point, financially speaking, in entering the field. According to the JSOG, there were 1,818 ob-gyn medical facilities in Japan in 2006. In 2023, there were 1,090. Unsurprisingly, most of the loss was in rural regions. These numbers include both clinics (fewer than 20 beds) and hospitals with ob-gyn departments. One solution would be to promote medical centers that focus on perinatal care, referring to a woman’s needs tarting from the time she discovers she is pregnant to one year after giving birth. But at present there is an average of only one such center per prefecture, so such promotion would be an uphill battle. Another idea is to consolidate what is available in outlying regions so that more services can be offered in fewer locations, a process that could be accelerated with the application of national health insurance. But that wouldn’t solve the problem of access.
In addition, the average age of a woman who gives birth in Japan has increased over the last several decades, and with that comes an increase in medical risk, both for the mother and the child. Facilities must be better prepared for complications, and that means higher costs.
If the government wants to get involved in the medical side of the birth rate problem, it has to decide whether it wants to support women who want to have babies through subsidies or through insurance. If it decides the former, it is going to have to increase the subsidy to have the desired effect, and if it chooses the latter, it may also have to adjust the system in some way so as not to over-burden the child-bearing infrastructure. Either way, it is going to be expensive, and insurance premiums will have to be increased, since even the childbirth subsidy is funded through the national health insurance system.
If epidurals are to be covered by insurance, more clinics and hospitals will need to upgrade their facilities and hire more anesthesiologists. But as one anesthesiologist, Fumi Tsutsui, noted in an article published in the January 10 edition of President Online, there is a danger of medical institutions hiring unqualified people, such as cosmetic surgeons who tend to be trained in anesthesiology but don't necessarily have experience in administering epidurals, which requires a specific set of skills. And because Tokyo is the only prefecture offering the epidural subsidy, it may mean that more anesthesiologists will move to the capital, depriving other areas of their services. But the most important consideration that must be addressed with the adoption of the subsidy is the unpredictability of childbirth. Labor cannot be scheduled, though some obstetricians do what they can by inducing labor or performing caesarean sections. Otherwise, if the mother wants an epidural, an anesthesiologist must be on hand 24 hours so that when labor does begin, they are available to administer it. For this reason alone, Dr. Tsutsui doesn't think there will be an increase in epidurals just because there is a subsidy to pay for it. She should know since, like many anesthesiologists, she is a freelancer. She can turn down jobs at her own discretion.
The good news is that anesthesiologists are younger than the average physician and well over half are women, meaning they tend to have more in common with the people they are treating and so provide more sympathetic care, especially if they have given birth themselves. In fact, most obstetricians in Japan are also women, and the government might want to solicit their opinions with regard to increasing the birth rate. The reluctance to have children isn't always just based on financial considerations.
Philip Brasor is a Tokyo-based writer who covers entertainment, the Japanese media, and money issues. He writes the Japan Media Watch column for the Number 1 Shimbun.
