Lessons Learned from the Great East Japan Earthquake: Birth Outcomes in a Catastrophe in a Highly Aged Society (SpringerBriefs in Population Studies) 9811043906, 9789811043901

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SPRINGER BRIEFS IN POPULATION STUDIES POPULATION STUDIES OF JAPAN

Honami Yoshida

Lessons Learned from the Great East Japan Earthquake Birth Outcomes in a Catastrophe in a Highly Aged Society

SpringerBriefs in Population Studies

Population Studies of Japan Editor-in-Chief Toshihiko Hara, School of Design, Sapporo City University, Sapporo, Hokkaido, Japan Series Editors Shinji Anzo, Tokyo, Japan Hisakazu Kato, Tokyo, Japan Noriko Tsuya, Tokyo, Japan Toru Suzuki, Tokyo, Japan Kohei Wada, Tokyo, Japan Hisashi Inaba, Tokyo, Japan Minato Nakazawa, Kobe, Japan Jim Raymo, Madison, USA Ryuichi Kaneko, Tokyo, Japan Satomi Kurosu, Chiba, Japan Reiko Hayashi, Tokyo, Japan Hiroshi Kojima, Tokyo, Japan Takashi Inoue, Tokyo, Japan

The world population is expected to expand by 39.4% to 9.6 billion in 2060 (UN World Population Prospects, revised 2010). Meanwhile, Japan is expected to see its population contract by nearly one third to 86.7 million, and its proportion of the elderly (65 years of age and over) will account for no less than 39.9% (National Institute of Population and Social Security Research in Japan, Population Projections for Japan 2012). Japan has entered the post-demographic transitional phase and will be the fastest-shrinking country in the world, followed by former Eastern bloc nations, leading other Asian countries that are experiencing drastic changes. A declining population that is rapidly aging impacts a country’s economic growth, labor market, pensions, taxation, health care, and housing. The social structure and geographical distribution in the country will drastically change, and short-term as well as long-term solutions for economic and social consequences of this trend will be required. This series aims to draw attention to Japan’s entering the post-demographic transition phase and to present cutting-edge research in Japanese population studies. It will include compact monographs under the editorial supervision of the Population Association of Japan (PAJ). The PAJ was established in 1948 and organizes researchers with a wide range of interests in population studies of Japan. The major fields are (1) population structure and aging; (2) migration, urbanization, and distribution; (3) fertility; (4) mortality and morbidity; (5) nuptiality, family, and households; (6) labor force and unemployment; (7) population projection and population policy (including family planning); and (8) historical demography. Since 1978, the PAJ has been publishing the academic journal Jinkogaku Kenkyu (The Journal of Population Studies), in which most of the articles are written in Japanese. Thus, the scope of this series spans the entire field of population issues in Japan, impacts on socioeconomic change, and implications for policy measures. It includes population aging, fertility and family formation, household structures, population health, mortality, human geography and regional population, and comparative studies with other countries. This series will be of great interest to a wide range of researchers in other countries confronting a post-demographic transition stage, demographers, population geographers, sociologists, economists, political scientists, health researchers, and practitioners across a broad spectrum of social sciences.

More information about this series at http://www.springer.com/gp/series/13101

Honami Yoshida

Lessons Learned from the Great East Japan Earthquake Birth Outcomes in a Catastrophe in a Highly Aged Society

Honami Yoshida Graduate School of Health Innovation Kanagawa University of Human Services Kawasaki City, Kanagawa, Japan

ISSN 2211-3215 ISSN 2211-3223 (electronic) SpringerBriefs in Population Studies ISSN 2198-2724 ISSN 2198-2732 (electronic) Population Studies of Japan ISBN 978-981-10-4390-1 ISBN 978-981-10-4391-8 (eBook) https://doi.org/10.1007/978-981-10-4391-8 © The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2021 This work is subject to copyright. All rights are solely and exclusively licensed by the Publisher, whether the whole or part of the material is concerned, specifically the rights of translation, reprinting, reuse of illustrations, recitation, broadcasting, reproduction on microfilms or in any other physical way, and transmission or information storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology now known or hereafter developed. The use of general descriptive names, registered names, trademarks, service marks, etc. in this publication does not imply, even in the absence of a specific statement, that such names are exempt from the relevant protective laws and regulations and therefore free for general use. The publisher, the authors and the editors are safe to assume that the advice and information in this book are believed to be true and accurate at the date of publication. Neither the publisher nor the authors or the editors give a warranty, expressed or implied, with respect to the material contained herein or for any errors or omissions that may have been made. The publisher remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. This Springer imprint is published by the registered company Springer Nature Singapore Pte Ltd. The registered company address is: 152 Beach Road, #21-01/04 Gateway East, Singapore 189721, Singapore

Foreword

Japan is known as the country with the fastest aging population in the world with 28.4% of its population over 65 years-old, the lowest percentage of children under 15 years old (12.1% of its population), and smallest prenatal population (0.6% of its population) in 2020. We are in a new stage in the field of maternal and child health, as the number of pregnant women and infants continues to decrease and become a minority and vulnerable population in times of disaster. From a demographic point of view, protecting pregnant women and infants during disasters has a huge impact, thus it is urgently needed to plan and implement better preparedness on disasters especially for maternal and child health. The Great East Japan Earthquake (GEJE) was the most harmful earthquake to have hit Japan, and the fourth most harmful earthquake in the world since modern recordkeeping began. The GEJE revealed two problems—one was the lack of preparedness to acquire the needs of the minority among a highly aged population and the other was the lack of planning for disaster management at the local government level, particularly for mothers and children. Facing GEJE, we Japanese recognized that there were gaps in the provision of specific care during emergencies. As an obstetrician, I know there can be no no-risk pregnant mothers. Even if we have pregnant mothers at low-risk, they easily can turn out to be at risk. Both the psychological stress and the lack of access to health care and medication during a natural disaster bring potentially serious consequences for pregnant women and infants. I realized that we need a cross-organizational approach to address maternal and child health during emergencies. In GEJE, families with children, pregnant and nursing mothers, and infants in shelters constituted a minority, thus making it difficult to assess their condition. Since it was hard for pregnant and nursing mothers to express their opinions in the disaster, their needs don’t reach to the management staff. Moreover, no agreements have existed in any region for treating pregnant women and infants in a disaster in the public sectors and private clinics with prenatal checkups, maternal and child health during pregnancy and delivery. I have started my research and project for emergency preparedness with local governments and focused on building a standard assessment format for maternal and child health to be used at shelters. I was fortunate enough to meet many people in the local governments and private sectors so that we established shelter for mothers v

vi

Foreword

and children in several areas in Japan and found we needed an effort to respond to changes in a society with a declining birthrate. For pregnant mothers facing natural disasters, support of the community through well-designed preventive policy and practices ensures mothers and babies to be safe. We found that being prepared for a disaster helps us connect with everyday people, fosters resilience, and enriches our daily lives. The evidences on disaster preparedness in the context of maternal and child health should be gathered. First, we are all committed to providing the highest quality and the safest care to mothers and children, particularly pregnant mothers and the unborn children during a natural disaster. Second, we can also strengthen our current collaborations and partnerships to provide the best possible healthcare for parents and babies. Finally, I hope that this book will be an opportunity to reconnect established team members and colleagues with new members in the disaster preparedness. I am always trying to be a solid bridge between the two fields: The field of population and reproductive health and the field of disaster and maternal and child health. Both of which are global and significant issues for the next generation and concern the future of our society. It is a privilege for me to write this book along with a distinguished group of medical professionals and population researchers such as Professor Toshihiko Hara (Sapporo City University), Professor Minato Nakazawa (Kobe University Graduate School of Health Sciences), and Dr. Toru Suzuki (the National Institute of Population and Social Security Research). I would like to take this opportunity to thank all our team members in Japan and overseas for the outstanding challenge that they consistently provide. I thank Dr. Kentaro Hayashi and others who provided help at Primary Care for All Team (PCAT) and Primary care for Obstetrics Team (PCOT) project members that include Dr. Hiroshi Ota, Dr. Yumie Ikeda, Dr. Keiko Otsuka, Ms. Yukari Endo, Mw. Shoko So, Dr. Yosuke Fujioka, and Dr. Shinji Tsunawaki who have worked to address the needs of pregnant women from the inception of the PCAT, and Mw. Naoko Nakane, Mr. Yasuhiko Kurano, and Dr. Kayako Sakisaka for their visionary approach to education. The partnership helps ensure that mothers and children will always be treated in the safest manner with great expertise. I would like to express my appreciation for the individuals that have dedicated their time to this book. Foremost, I would like to express my sincere gratitude to my primary supervisor, Professor Emeritus Kunihiko Kobayashi for his support and encouragement and his to-the-point and constructive editing. I would like to thank Dr. Miya Kobayashi for her positive guidance, sincere advice, and great input to the overall study. I am grateful to Dr. Frank Bia and Dr. Peggy Bia, who are my dearest mentors, motivated me to write, and inspired me to share my knowledge in Japan with the rest of the world. Lastly, I would like to thank all of the disaster victims and evacuees who took the time to participate in my study until now. This study would not have been possible without them.

Foreword

vii

Please accept my sincere gratitude on this highly successful series: SpringerBriefs in Population Studies. I would like to thank the outstanding project members—Mr. Yutaka Hirachi, Springer Japan, Senior editor, and colleagues—for coordinating and sharing their knowledge and expertise. The success of this book is a testament to the continued partnership that we build upon with each country’s case, each collaborative disaster experience, and each forum where we have the opportunity to learn from each other. This study was supported by the following research grants: 1. Research on the Development of a Regional Collaborative Disaster Prevention System Including the Operation of Welfare Shelters for Those Who Require Assistance in Times of Disaster with the Central Focus on Pregnant and Nursing Women and Infants. Grant-in-Aid for Scientific Research, Health and Labor Sciences Research Grants (Research on Health Security Control, Research representative: Honami Yoshida, 2013–2015). 2. Maternal and Child Health Required in Times of Disaster—from Research on the Impacts of the Great East Japan Earthquake on Maternal and Child Health. Grants-in-Aid for Scientific Research (Research representative: Honami Yoshida, 2012–2014). 3. Japan Agency for Medical Research and Development, “Personal Health Record (PHR) Research Project, PHR Model for Supporting Pregnancy, Delivery, and Childbearing” (Research representative: Honami Yoshida, 2016–2018). Dr. Honami Yoshida, M.D., Ph.D., M.P.H. Professor Graduate School of Health Innovation Kanagawa University of Human Services Kawasaki City Kanagawa, Japan

Contents

1 Maternal and Child Health History and Public Health System at the Time of Disasters in Japan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 1.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 1.2 MCH in the Period Between the Prewar and Wartime Eras Including the Meiji Era (1868–1912), Taisho Era (1912–1926), and Showa Era (1926–1945) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4 1.3 Postwar Era (1945–1980) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6 1.4 Change in MCH Systems and Healthcare Policy (1980–Present) . . . . 8 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11 2 Support System of Maternal and Child Care on Great East Japan Earthquake . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2.2 The Disaster-Risk Prevention System in Japan and Medical Care for Perinatal Infants . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2.3 The Legal Basis for Providing Support in Times of Disaster . . . . . . . 2.3.1 The Disaster Relief Act (Act No. 118 of 1947) . . . . . . . . . . . . 2.3.2 Disaster Countermeasures Basic Act (Act No. 223 of 1961) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2.3.3 Act on Special Measures Concerning Earthquake Disaster Management (Act No. 111, Established in 1995) . . . 2.3.4 Natural Disaster Victims Relief Law (Act No. 66 of 1998) . . 2.4 Evacuation Sites and Evacuation Process for Maternal and Child Healthcare System . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2.4.1 Shortage of Maternal and Child Healthcare System on the Great East Japan Earthquake (GEJE) . . . . . . . . . . . . . . . 2.4.2 Disaster Effects for Prenatal Care System and Neonatal Mortality in the GEJE-Affected Area . . . . . . . . . . . . . . . . . . . . 2.4.3 Evacuation Site for MCH Care . . . . . . . . . . . . . . . . . . . . . . . . . . 2.5 Preparations for Disaster and Use of International Models to Provide Safe Milk . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2.6 Mother and Child Support and Management of Evacuation Sites . . .

13 14 15 16 16 17 17 18 18 18 20 24 26 27 ix

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2.7 MCH Care and the Growth of a Friendly Society for Mother and Child . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28 2.8 Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30 3 Importance of Cross-Organizational Collaboration for Disaster Preparedness for Maternal and Child Health Care . . . . . . . . . . . . . . . . . 3.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3.2 Initiatives for Personnel Development Research . . . . . . . . . . . . . . . . . . 3.2.1 Progress in a Nationally Applicable Manual for the Operation of Welfare Evacuation Sites and Techniques for Personnel Training . . . . . . . . . . . . . . . . . . . 3.2.2 Development of Training Programs for the Operation of Evacuation Shelters in the Community . . . . . . . . . . . . . . . . . 3.3 Establishing a Collaborative System for the Operation of Next-Generation Evacuation Shelters in the Community . . . . . . . . 3.3.1 Establishment of a Liaison for Pediatric and Perinatal Care During Disasters . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3.3.2 Future Plan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3.4 Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4 Preparations for Maternal and Child Protection in Times of Disaster: Practical Tools for Regional and Multi-Occupational Collaboration . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4.2 Report on Situation of Expectant and Nursing Mothers in the GEJE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4.3 The Role of Administrators Within Governments During Times of Disaster in Providing MCH Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4.3.1 Specific Processes for Establishing Disaster Relief Centers for Mothers and Children . . . . . . . . . . . . . . . . . . . . . . . 4.3.2 Creating an Emergency Response System to Meet the Regional Situation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4.4 Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 Issues to be Solved on Mother and Child Health Care in the Disaster . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5.2 Insufficient Support System for Evacuees at Home . . . . . . . . . . . . . . . 5.3 Issues on Perinatal Medical Support in Disaster Area . . . . . . . . . . . . . 5.3.1 Medical Support by Medical Team in Foreign Countries . . . . 5.3.2 Difficulty on Medical Support for Pregnant Women in the Disaster Area . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

33 34 34

34 35 41 41 43 43 44

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Contents

5.4 Population Dynamics in the Disaster Area: The Role of Local Governments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5.5 Oral History of Mothers Survived from Disasters . . . . . . . . . . . . . . . . 5.5.1 Difficulty of Families with Children Under Elementary School-Going Age Staying in Refugee Facilities . . . . . . . . . . . 5.5.2 Difficulties in Obtaining Supplies and Information for People Who Stayed at Home . . . . . . . . . . . . . . . . . . . . . . . . 5.5.3 Case of Single Parent Families . . . . . . . . . . . . . . . . . . . . . . . . . . 5.6 Equal Support for MCH Care in the Disasters . . . . . . . . . . . . . . . . . . . 5.7 Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6 Personal Health Record (PHR) System for Maternal and Child Health Care in Disaster . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6.2 The Necessity of Constructing a PHR System for MCH Care in Disaster Preparedness . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6.3 The Future of PHR—Establishment of Information and Communication Technology (ICT) System . . . . . . . . . . . . . . . . . . 6.4 Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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72 73 74 75 76 76 77 78 79 80 81 84 87 88

Chapter 1

Maternal and Child Health History and Public Health System at the Time of Disasters in Japan

Abstract Maternal and Child Health (MCH) is one of the pillars of a country. In order to understand MCH during a disaster, it is necessary to know about the state of public health, sanitary conditions, and living standards in the country. The history of MCH tells us the details. In the period between 1868 and 1944, Japan’s MCH policies dramatically developed facing two major World Wars. In the postwar era (1945–1948), MCH was designated as an important field of public health, under the direction and with the assistance of the General Headquarters of the United States Army (GHQ). The Children and Families Bureau was established in 1947 as part of the Ministry of Health and Welfare responsible for preparing MCH policy including mother and child handbooks. Recently, a new trend in MCH was reviewed based on the statistical analysis of national databases including the national census data. The key findings of the statistics were decreased infant mortality rate (IMR), decreased perinatal mortality rate (PMR), and decreased total fertility rates, while low birth weight babies, intellectually handicapped children, and the number of babies conceived through artificial fertilization therapy have increased. Keywords Maternal and child health (MCH) · Infant mortality rate (IMR) · Perinatal mortality rate (PMR) · Total fertility rates (TFR) · MCH handbook

Abbreviations ICT IMR LBW MCH MMR PMR TFR

Information communication technology Infant mortality rate Low birth weight Maternal and child health Maternal mortality ratios Perinatal mortality rate Total fertility rates

© The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2021 H. Yoshida, Lessons Learned from the Great East Japan Earthquake, Population Studies of Japan, https://doi.org/10.1007/978-981-10-4391-8_1

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1 Maternal and Child Health History and Public Health …

1.1 Introduction Although Japan is now an economically developed country, disaster response system and welfare in maternal and child health (MCH) is far behind the other developed countries. Disaster preparedness might be on the lines of a developing country. Disaster response systems need to be continuously adjusted for demographics and healthcare systems. In order to understand MCH during a disaster, it is necessary to know about the state of public health, sanitary conditions, and living standards in the country. The history of MCH may tell us the details. MCH is one of the pillars of a country, and is the most conservative field in Japan because each ethnic group has preserved its culture, social norms, and traditions around pregnancy, delivery, and child-rearing. Many lives had been lost during pregnancy or childbirth even in Japan in the past. Today, Japan boasts one of the highest standards of MCH services [1]. Not only medical progress, but improvement in foundations for MCH services and rise in the awareness of the people led by local governments have contributed to the change. Through these efforts, the idea of MCH services which cover both prenatal and postnatal services had been well-established among the people, especially women in Japan. Instead of achieving one of the world’s lowest infant mortality rates (IMR) and lowest maternal mortality ratios (MMR), Japan is now faced with a highly aged population, and has become the country with the lowest percentage of children in the world [2], low fertility rates, and elevated low birth weight (LBW) infant rates [3]. Thus, a new framework for disaster preparedness with a particular emphasis on MCH is necessary in the twenty-first century. In order to understand the impact of major natural disasters on MCH, we need to understand the history of MCH in Japan. The main measures and outcomes in the field of MCH include IMR, which is the most important indicator. It reflects the state of public health, sanitary conditions, and living standards in the country. It is internationally comparable and is measured as the number of deaths of children aged one year or under per 1000 live births (Fig. 1.1). Currently, the IMR of Japan is 1.9‰, which is one of the lowest rates in the world [4]. Another important indicator is the perinatal mortality rate (PMR), which is measured by late fetal deaths after 28 weeks of gestation plus early neonatal deaths under 1 week, per 100000 live births (or 100000 total births). In Japan, the PMR has shown a rapid decline from 130.6 in 1960, to 3.7 in 2015 [4] due to the promotion of MCH policy. The total fertility rate (TFR) is an important indicator, as well. It reflects the fertility of women during their reproductive ages. After the Second World War, the TFR in Japan declined rapidly from 4.54 in 1947 to 1.34 in 2007 [5]. Figure 1.2 shows the change of IMR, PMR, TFR between 1999 and 2019. It should be important to learn from Japan’s history of healthcare system of MCH field and characteristics of maternal and child health situation to understand a new solution toward disaster preparedness in order to deal with the changes.

1.1 Introduction

3

Fig. 1.1 Changes in infant mortality rate (IMR) per 1,000 live births in the world (1960– 2015) (Source World Bank https://data.worldbank.org/indicator/SP.DYN.IMRT.IN?end=2017& locations=JP-CN-CA-FR-KR-US-GB&start=1960 Estimates developed by the UN Inter-agency Group for Child Mortality Estimation [UNICEF, WHO, World Bank, and UN DESA Population Division] at childmortality.org)

Fig. 1.2 Changes in infant mortality rates (IMR), perinatal mortality rate (PMR), and total fertility rates (TFR) in Japan (1999–2019)

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1.2 MCH in the Period Between the Prewar and Wartime Eras Including the Meiji Era (1868–1912), Taisho Era (1912–1926), and Showa Era (1926–1945) In 1934, a community organization called the “Imperial Gift Foundation Aiikukai,” was established. In 1936, it established and ran the “Aiiku Groups,” which were voluntary groups of married women to promote the welfare and health of mothers and children. It offered a variety of health promotion programs including nutritional education for mothers. In this period, MCH policy is considered to be rapidly established in Japan (Tables 1.1 and 1.2). The Public Health Center Law and Maternal and Child Protection Law were promulgated in 1937, thus establishing the framework of MCH administration [6]. The Ministry of Health and Welfare was established in 1938, and MCH was included within the scope of the duties of the administrative system comprising the local public health centers. From 1939, all infants underwent regular health checkups through mass screening programs. The codification of the rules by Ministry of Health and Welfare, governing the public health nursing profession, secured human resources in the field including MCH in 1941 [5]. In 1942, the “Pregnant Mother’s Handbook,” the precursor of the “MCH Handbook,” was launched (Fig. 1.3) by Ministry of Health and Welfare. In the handbook, the registration of pregnancies and conduct Table 1.1 Chronology of main events in the development of the Maternal and Child Health (MCH) system in Japan in the early Showa and prewar eras Year

Date

Activity

1874

March 12

Promulgation of the Medical System

1876

September 14

Decision to establish midwife school in Tokyo Hospital

1893

September 8

Pediatric department established in Imperial University Medical School

1984

August 1

First Sino-Japanese War begins (ends in April 1895)

1899

July 19

Promulgation of the Midwife Rules

1904

February 10

Russo-Japanese War begins (ends in September 1905)

1911

March 29

Promulgation of the Factories Law

1914

July 28

First World War begins (ends in November 1918)

1916

June 28

Establishment of Health and Hygiene Investigation Committee

September 1

Enforcement of Factories Law

1923

March 30

Revision of Factories Law

1931

September 18

Mukden Incident

1933

April 1

Promulgation of the Child Abuse Prevention Law

1934

March 13

Establishment of Imperial Gift Foundation Boshi-Aiiku-Kai

1937

March 31

Promulgation of Maternal Protection Law

April 5

Promulgation of Health Center Law

July 7

Marco Polo Bridge Incident

1.2 MCH in the Period Between the Prewar and Wartime Eras …

5

Table 1.2 Chronology of main events in the development of the Maternal and Child Health (MCH) system in wartime Japan Year

Date

1938 January 11 April 1 1939 July 28

Activity Establishment of Ministry of Health and Welfare Promulgation of National Mobilization Law Establishment of National Fitness Review Council

September 1 Second World War begins 1940 April 8

Promulgation of National Fitness Law

1941 January 22

Adoption of Guidelines for Formulating Demographic Policies

December 8 1942 February 21

Attack on Pearl Harbor; war with the United States begins Revision of the National Fitness Law

February 25

Promulgation of the National Health Law

June 20

Adoption of Guidelines for Formulating Policies on National Health Guidance

July 13

Promulgation of Ministry of Health and Welfare Ordinance 35 concerning Rules for Expectant Mothers’ Handbooks

1945 August 15

Second World War ends

Fig. 1.3 Primary MCH handbook (1943, “Pregnant Mother’s Handbook”)

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1 Maternal and Child Health History and Public Health …

of regular health checkups was strongly recommended, and various types of MCH services have been established. The services include vaccination, health checks for expectant/nursing mothers, provision of advanced medical care for expectant/nursing mothers and infants, specified treatment support program for women suffering from infertility, guidance and medical care services for raising premature babies, dietary education, etc. [6].

1.3 Postwar Era (1945–1980) In postwar Japan, MCH was designated as an important field of public health, under the direction and assistance of the General Headquarters (GHQ) (Table 1.3). In 1947, the Children and Families Bureau was established under the Ministry of Health and Welfare and the Child Welfare Law was enacted in the same year. The “Pregnant Mother’s Handbook” system, launched during the war, was revised to include infant well-being checkup record by the Ministry of Health and Welfare and renamed as the “Mother and Child Handbook” (Fig. 1.4) in 1948. This was renamed again as the “Maternal and Child Health Handbook” (Fig. 1.5) in 1966, added with childbearing information, education tools, and health checkup record to the age between newborn and seven years old. In 1966, due to enforcement of the Maternal and Child Health Law, MCH services were separated from the Child Welfare Law and MCH policy has been strengthening. Table 1.3 Chronology of main events in the development of the Maternal and Child Health (MCH) system in postwar Japan Year

Date

Activity

1946 November 3

Promulgation of the Constitution of Japan

1947 January

Licensed Agencies for Relief in Asia (LARA) starts distributing milk and food to schools in Tokyo

May 3

Enforcement of the Constitution of Japan

September 5

Revision of Health Center Law

December 12 Promulgation of Child Welfare Law 1948 May 28

Promulgation of Ministry of Health and Welfare Notification 26 concerning the format for Mother and Child Handbooks

1955 November 26 Imperial Gift Foundation Boshi-Aiiku-Kai enters into a contract with the Ministry of Health and Welfare over UNICEF milk deliveries 1956 February

Distribution of UNICEF milk to expectant mothers and preschool children begins

1961 June 19

Revision of Child Welfare Law

1965 August 18

Revision of Maternal Protection Law

1966 May 7

Promulgation of Ministry of Health and Welfare Notification 236 concerning the format for Mother and Child Health Handbooks

1.3 Postwar Era (1945–1980) Fig. 1.4 Initial MCH handbook (1958 “Mother and Child Handbook”)

Fig. 1.5 Current “MCH Handbook” (1966~)

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1 Maternal and Child Health History and Public Health …

These MCH services thoroughly implemented in all municipalities in Japan based on the law [7]. 1. 2. 3. 4. 5. 6.

Health guidance (Article 10) Health examination (Article 12 and 13) Pregnancy notification (Article 15) Maternal and Child Healthcare Handbook (Article 16) Notification of low-birth-weight infants (Article 18) Medical care for premature babies.

1.4 Change in MCH Systems and Healthcare Policy (1980–Present) By 2015, MCH indicators have been largely improved [8]. For example, in 1950, five years after the end of the Second World War, Japan had a high IMR of 60.1 (per 1,000 live births), but this number decreased dramatically to 30.7 in 1960, further down to 13.1 in 1970, and finally to 1.9 in 2015, due to the major efforts taken by the government toward implementing its MCH policy for improving the health of citizens. Moreover, recent research showed a new trend in MCH by a statistical analysis of data from the national database and the national census of the last 50 years [8–11]. It is shown that the average age of a mother at childbirth has risen (Fig. 1.6) [9], the number of low birth weight (LBW) babies has increased (Fig. 1.7) [10], there has been a rise in the number of intellectually disabled children (Fig. 1.8) [11], and a rise in the use of artificial fertilization therapies (Fig. 1.9) [12]. These changes in Japan influenced the childbearing environment. For example, diversity of family may cause fewer opportunities to communicate with each other on the childbearing. The prevailing problems in Japan are as follows: increase in elderly parents with heavy burden of both raising children and caring for their own

Fig. 1.6 Current trends in parents’ ages at childbirth (2008–2016) [9]

1.4 Change in MCH Systems and Healthcare Policy (1980–Present)

9

Fig. 1.7 Current trends in low birth weight babies (1980–2015) [10]

Fig. 1.8 Current trends in intellectually handicapped children (1973–2012) [11]

parents, increase in parents undergoing treatment for infertility, and increase in the care for LBW babies. Moreover, increasing parental stress related to raising and educating children has become a major social problem. Greater emotional support for both parents and children is necessary, due to the lowest rate of children (12.1% of

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1 Maternal and Child Health History and Public Health …

Fig. 1.9 Number of children conceived with fertility treatment (1985–2012) dotted line: number of children born (left), solid line: cumulative number of children born (right) [12]

children under 15 year-old, OECD, 2019) in the world in history [2]. Since we have the MCH handbook, which is a unique tool in Japan and important for promoting health and open dialogue [13], we could find the solution to contribute for other countries to adopt similar MCH programs to solve the similar issues in the future. With this situation, the consideration in MCH should be much more addressed as a big issue in Japan. The Great East Japan Earthquake occurred in 2011. Since the Tohoku area struck by the earthquake suffered from the largest decline in birthrates, rapid aging of the population, and rapid shrinkage of the working population. MCH issues in that area have been neglected because of the idea that mothers and babies constitute the minority in the region. This issue must be kept in mind and such problems should commonly be shared across multiple regions in Japan. Thus, a new solution for disaster preparedness for MCH in Japan should be formulated to address and deal with changes in the environment in which children will be raised. In following chapters, I will mention the evidence from the mega disaster in Japan in Chap. 2, cutting-edge challenge of some local community’s disaster preparedness strategy in Chap. 3, disaster prevention tool in MCH field invented from the experience of disaster in Chap. 4, evacuation management with perspective on MCH in Chap. 5, and information communication technology (ICT) system for disaster management in MCH in Chap. 6.

1.4 Change in MCH Systems and Healthcare Policy (1980–Present)

11

Acknowledgements This study was supported by the following research grants: 1. Health and Labor Sciences Research Grants (Research on Health Security Control) “Research on the Development of a Regional Collaborative Disaster Prevention System Including the Operation of Welfare Shelters for Those Who Require Assistance in Times of Disaster with the Central Focus on Pregnant and Nursing Women and Infants” (Research representative: Honami Yoshida, 2013–2015). 2. Grants-in-Aid for Scientific Research “Maternal and Child Health Required in Times of Disaster - from Research on the Impacts of the GEJE on Maternal and Child Health” (Research representative: Honami Yoshida, 2012–2014). The author thanks Dr. Kentaro Hayashi and others who provided help at the Primary Care for All Team (PCAT), PCOT project members that include Dr. Hiroshi Ota, Dr. Yumie Ikeda, Dr. Keiko Otsuka, Ms. Yukari Endo, and Mw. Shoko So, who have contributed to developing training for rescuing pregnant and nursing women in times of disaster; and Dr. Yosuke Fujioka and Dr. Shinji Tsunawaki who have worked to address the needs of pregnant women from the inception of the PCAT. The author also thanks Mw. Naoko Nakane for her dedicated education in this field.

References 1. Japan International Cooperation Agency (JICA) (2016) Bringing knowledge of Japanese maternal and child health to the world. JICA’s World January 2016:4–5. https://www.jica.go. jp/english/publications/j-world/c8h0vm00009r4edd-att/1601_02.pdf. Accessed 29 Mar 2021 2. Ministry of Internal Affairs and Communications (2019) Number of children in Japan (from population estimation). Statistics Topics No. 120 (in Japanese). https://www.stat.go.jp/data/jin sui/topics/pdf/topics120.pdf. Accessed 29 Mar 2021 3. Miyaji NT, Lock M (1994) Monitoring motherhood: sociocultural and historical aspects of maternal and child health in Japan. Daedalus 123(4):87–112 4. Ministry of Health, Labor and Welfare (2017) Summary of national census, 2016 (in Japanese). http://www.mhlw.go.jp/toukei/saikin/hw/jinkou/geppo/nengai16/dl/gaikyou28.pdf. Accessed 29 Mar 2021 5. Nakamura Y (2010) Maternal and child health handbook in Japan. JMAJ 53(4):259–265 6. Kaminota M (2016) Maternal and child health measures in Japan. In: Ministry of Health, Labour and Welfare (ed) The country report on the 10th conference on maternal and child health handbook 7. Institute for International Cooperation, Japan International Cooperation Agency (JICA) (2005) Chapter 3. Maternal and child health. In: Japan’s experiences in public health and medical systems. JICA. https://www.jica.go.jp/jica-ri/IFIC_and_JBICI-Studies/english/public ations/reports/study/topical/health/index.html. Accessed 29 Mar 2021 8. Yoshida H, Kato N, Yokoyama T (2014) Current status of maternal and child cohorts in Japan, and future prospects from maternal and child health research. J Natl Inst Public Health 63(1):32– 38 (in Japanese). https://www.niph.go.jp/journal/data/63-1/201463010005.pdf. Accessed 29 Mar 2021 9. Ministry of Internal Affairs and Communications (2015) National census at a glance (in Japanese). http://www.stat.go.jp/data/jinsui/topics/topi821.htm#aI-2. Accessed 29 Mar 2021 10. Yoshida H, Kato N, Yokoyama T (2014) Long-term changes in birth weight and related factors analyzed by the vital statistics in Japan. J Natl Inst Public Health 63(1):2–16 (in Japanese). https://www.niph.go.jp/journal/data/63-1/201463010002.pdf. Accessed 29 Mar 2021 11. Okamoto E (2014) Association between intellectually handicapped children and birth weight and mother’s age at birth. Kosei-no Shihyo 61(15):1–7 (in Japanese) 12. Japanese Society of Obstetrics and Gynecology (2014) Results of clinical experience in in vitro fertilization and embryo transfer in Japan. Acta Obstet Gynaecol Jpn 66(9):2455–2481 (in Japanese)

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13. Takeuchi J, Sakagami Y, Perez RC (2016) The Mother and child health handbook in Japan as a health promotion tool, overview of its history, contents, use, benefits, and global influence. Glob Pediatr Health 3:2333794X16649884. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC 4905145/. Accessed 29 Mar 2021

Chapter 2

Support System of Maternal and Child Care on Great East Japan Earthquake

Abstract When a large-scale natural disaster occurs in Japan, the type of support provided is decided based on the demands of the affected prefecture. Moreover, it is necessary for local governments and regions to reach out to mothers and children who cannot contact the governments for the request of support. In particular, it is necessary to pay attention to pregnant and nursing women and infants with sufficient preparation for their obstetric medical needs. The legal basis for providing support such as establishing evacuation sites for pregnant and nursing women is necessary. In recent major disasters, various groups from all over the areas of Japan have provided appropriate support. Cross-sectoral coordination between organizations as well as with the government is essential from the perspective of providing support for maternal and child care. Keywords Legal basis for support · Evacuation sites · Coordination with the government

Abbreviations DMAT DPAT DRM DRR FAO GEJE GHAE HFA ISDR JGSDF MDG PPDML WHO

Disaster medical assistance team Disaster psychiatric assistance team Disaster-risk management Disaster-risk reduction Food Aid Organization Great East Japan Earthquake Great Hanshin-Awaji Earthquake Hyogo framework for action International strategy for disaster reduction Japan ground self-defense force Millennium development goal Pediatric and perinatal disaster medical liaison World Health Organization

© The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2021 H. Yoshida, Lessons Learned from the Great East Japan Earthquake, Population Studies of Japan, https://doi.org/10.1007/978-981-10-4391-8_2

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2.1 Introduction Disasters do not choose a country or region. Natural disasters caused by changes in the global climate trigger increased economic damage worldwide each year. By 2030, it is expected that the cost of such disasters will reach USD 90 trillion. Furthermore, it has been reported that approximately 42 million years of life are lost annually as a result of such incidents [1]. With the aim of reducing the population damage caused by natural disasters around the world, the United Nations Office for Disaster Risk Reduction was established in 2000. This is a national program that was created to replace the International Strategy for Disaster Reduction (ISDR), which was created during the “International Decade for Natural Disaster Reduction” (1990–1999). In 2005, the Hyogo Framework for Action (HFA) was presented at the second UN World Conference on Disaster Risk Reduction, which was held in Kobe City, Hyogo Prefecture. It was mentioned that many supporters are required in times of disaster. Furthermore, provisions requiring consideration (such as the vulnerability of children at times of disaster, women who are prone to injury, gender problems, and the awareness of inhabitants following extensive damage) that acted in concert with the “Millennium Development Goals” (MDGs) that the UN concurrently implemented, were included. In 2015, the third UN World Conference on Disaster Risk Reduction was held in Sendai City, Miyagi Prefecture. Policies for international disaster-risk prevention measures, such as the “Sendai Framework for Disaster Risk Reduction” (DRR), were adopted by 185 countries [2]. In the DRR, by reducing the risks associated with disasters set as the main aim, three basic priorities are presented: First, to secure investments in disaster-risk prevention and related development strategies and plans; second, to strengthen the means of conducting restoration (improved resilience and the adoption of “Build Back Better”); and third, to secure the collaboration of various bodies relating to the government, including local governments and private enterprises, as a means of strengthening public assistance as well as facilitating the occurrence of mutual assistance. In addition to those mentioned above, another important priority was raised, namely “ensuring the safety of people and promoting the participation of women.” This is primarily concerned with women, children, the elderly, and the disabled. In recent times, the effects of climate change are becoming more evident, as can be seen with the frequent occurrence of earthquakes, tsunamis, typhoons, tornados, unexpected floods, and inundations caused by torrential rains. As a result, governments are now faced with major problems regarding appropriate means of securing the disaster victims, as well as means of maintaining sanitary standards.

2.2 The Disaster-Risk Prevention System in Japan …

15

2.2 The Disaster-Risk Prevention System in Japan and Medical Care for Perinatal Infants Disasters are classified into three forms, namely natural, man-made (accidents), and mixed disasters. At the governmental level, responses are framed in accordance with the “Cabinet Secretariat First Action Manual.” If the Deputy Chief Cabinet Secretary for Crisis Management determines that “the Cabinet must take proactive measures,” an “Official Residence of the Response Office” is established and, if it judges that “it is acceptable to tentatively collect information,” an “Official Liaison Office” is established [3]. In addition, at the Central Disaster-risk Prevention Meeting, which is a meeting in which the Cabinet discusses important strategies, the activities described below are performed: 1. 2. 3.

4.

The preparation and implementation of a basic disaster-risk prevention plan and an earthquake-related disaster-risk prevention plan. The preparation and implementation of an emergency-action plan. Deliberation on important items concerning disaster-risk prevention, which is based on advice provided by the Minister of State for Disaster Management (basic policy on disaster-risk prevention, general coordination of policies on disaster-risk prevention, proclamation of a disaster emergency, etc.) The provision of detailed opinions on important matters concerning disaster-risk prevention; these opinions are provided by Cabinet ministers and the Minister of State for Disaster Management [4].

When a large-scale disaster occurs, the type of support is decided based on the demands and needs of the affected prefecture. At the Great East Japan Earthquake (GEJE) in 2011, several prefectures were suffered, and, consequently, coordination was difficult not only within those prefectures, but also between neighboring prefectures. During a disaster, urgent medical care is necessary; disaster-risk reduction of perinatal care system is needed [5]. With regard to the triage stations visited by children and pregnant women, an agreement is now in place to determine the validity of providing experts who can judge whether a station is sufficiently equipped to perform regular triage, and whether diseases unique to perinatal infants can be addressed on an urgent basis at these stations. In order to implement this, the newborn/mother transport network that was established to coordinate the transportation of mothers, etc., in peacetime could also be utilized as an information network during an emergency. Moreover, support systems by experts that can be coordinated from non-disaster regions in times of disaster has also been conducted [6]. Although children, neonates, and pregnant women are the most vulnerable population in disasters, consideration to give full support does not reach them because of the thought that they are a minor population. There were few pediatricians, neonatologists, and obstetricians in Japan DMAT (Disaster Medical Assistance Team), so disaster medical headquarters had limitation to treat perinatal problems.

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2 Support System of Maternal and Child Care …

We trained pediatric and perinatal disaster medical liaison (PPDML) to improve disaster medical managements for children and pregnant women since 2016. During the Kumamoto earthquake in 2016, experts served as PPDML from non-disaster regions. Also, Japan DMAT had annual disaster drills, and PPDML participated in the drill for the first time in July 2017 [7]. In the drill, PPDML coordinated the pediatric and perinatal issues with Japan DMAT and JGSDF (Japan Ground Self-Defense Force) in disaster headquarters. And of this disaster, PPDML coordinated the transport of 22 children and babies with congenital heart disease from damaged National Cerebral and Cardiovascular Center Hospital. The operation was finished within 5 h after transportation. Thus, to protect children and pregnant women, cooperation between disaster medical network and pediatric and perinatal network is absolutely important of any phase in disaster. Because PPDML had attended the disaster drills before the earthquake occurs, the experience could make PPDML achieve good performance in a real disaster. So, we conclude that cooperation between disaster medical network and PPDML is very useful to manage the disaster issues for children and pregnant women, and the most important thing is to cooperate not only in a disaster, but also in ordinary days, which improved medical care system [8]. In recent major disasters, various groups from all over the areas of Japan have provided appropriate support. Cross-sectoral coordination between organizations as well as with the government is essential from the perspective of providing the support for maternal and child care.

2.3 The Legal Basis for Providing Support in Times of Disaster There are 4 main laws related to disasters in Japan, namely the Disaster Relief Act of 1947, the Disaster Countermeasures Basic Act of 1961, the Act on Special Measures concerning Earthquake-disaster Management of 1995, and the Natural Disaster Victims Relief Law of 1998. Each has been established based on the lessons learned from major disasters.

2.3.1 The Disaster Relief Act (Act No. 118 of 1947) This Act was passed following the major Nankai (South Seas) Earthquake that occurred in 1946. The purpose of the Act is to ensure that urgent relevant aid is made available after a disaster occurs in order to protect the victims of the disaster and maintain social order. Although the prefectural government bears the immediate cost of the disaster relief, the national government subsidizes 50–90% of the cost and the rest is paid by the prefectural government. In Article 4, 10 items are documented as types of relief, including a “grant for temporary housing.”

2.3 The Legal Basis for Providing Support in Times …

17

2.3.2 Disaster Countermeasures Basic Act (Act No. 223 of 1961) This Act was passed following the Ise Bay Typhoon that occurred in 1959. It clarified the responsibilities and roles of national and prefectural groups, as well as systems of other public organizations, concerning actions that should be taken to prevent extensive damage during disasters, and also stipulated the basic measures that should be implemented to reduce disaster risks. Mayors, town managers, and village headmen who are familiar with their localities give the power to implement actual evacuation advise and decide the areas for which warnings should be put in place. This is based on the opinion that appropriate action should promptly be taken at the site of a disaster. Relief activities that meet the needs of local inhabitants during a disaster are also developed under this Act. The specific items mentioned in the Act are described below. 1. 2. 3. 4. 5. 6. 7. 8.

Establishing a disaster-risk prevention meeting Establishing an anti-disaster headquarters Preparing a basic and comprehensive disaster-risk prevention plan Disaster-risk prevention activities (maintenance and training of organizations, storage, maintenance of facilities, etc.) Urgent measures (collecting information, issuing warnings, ordering evacuations, etc.) Urgent steps (establishing caution areas, requesting the dispatch of armed forces, etc.) Performing restoration after a disaster Financial measures.

2.3.3 Act on Special Measures Concerning Earthquake Disaster Management (Act No. 111, Established in 1995) This Act was passed following the Great Hanshin-Awaji Earthquake (GHAE) that occurred in 1995. It was designed for the purpose of protecting people’s lives and property from damage due to earthquakes. Specifically, it stipulates the preparation of a five-year plan featuring urgent operations that can reduce disaster risks relating to earthquakes, special steps to be taken by the federal government, and the maintenance of a system for promoting research on earthquakes. Based on the above, the main purpose of the Act is to reinforce disaster-risk reduction measures relating to earthquakes, and to contribute to the maintenance of social order and the securing of public welfare (Article 1). In addition, it stipulates appropriate criteria for maintaining disaster-risk reduction facilities, such as evacuation sites, facilities for addressing disasters, and social-welfare facilities.

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2.3.4 Natural Disaster Victims Relief Law (Act No. 66 of 1998) This Act concerns the provision of monetary support to victims to help them rebuild their lifestyles. The amount of funding provided is based on each individual’s income. “The purpose of the Act is to allow individuals whose basic lifestyles have been severely damaged as a result of a natural disaster and who are finding it difficult to rebuild their lives due to economic reasons, etc., to use funds contributed by the prefectural government as mutual aid.” By stipulating measures of supporting the Disaster Victims Lifestyle-rebuilding Support Fund, the Act allows such individuals to receive the support they require to return to living their lives independently (Article 1).

2.4 Evacuation Sites and Evacuation Process for Maternal and Child Healthcare System 2.4.1 Shortage of Maternal and Child Healthcare System on the Great East Japan Earthquake (GEJE) In Miyagi prefecture, 70% of the clinics stopped delivery services (Tables 2.1 and 2.2). Medical institutions in the disaster area tried to collect information on the status of prehospital care for pregnant and nursing women in collaboration with public health nurses. However, finding the situation in peripheral health centers was extremely difficult because, in some municipalities, public health nurses in charge of maternal and child health (MCH) were busy in implementing hygiene control in shelters or working in offices, and could not prioritize MCH care [9–15]. A public Table 2.1 The annual number of deliveries in three prefectures, Iwate, Miyagi, and Fukushima Prefecture

Population (x1,000)*

Number of deliveries** Hospitals

Clinics

Aomori

1,388

11,242

5,168

6,074

54

Iwate

1,347

11,624

6,058

5,566

47.9

Miyagi

2,329

18,536

9,001

9,535

51.4

Fukushima

2,043

18,594

8,068

10,526

56.6

Total

Delivery rate at clinics (%)

Akita

1,105

8,107

5,559

2,548

31.4

Yamagata

1,182

10,437

6,183

4,254

40.8

Ibaraki

2,923

24,483

13,839

10,644

43.5

Source *2011 Vital Statistics **2010 Japan Association of Obstetricians and Gynecologists Facility Information Survey

141

Total

18

51

23 90

31

31

28

52.0

56.6

51.4

47.9

51

23

18

10

Number of hospitals

10

Post-disaster Delivery rate at clinics (%)

Number of hospitals

Number of clinics

Pre-disaster

Source *Japan Association of Obstetricians and Gynecology, 2011

49

54

Fukushima

38

Iwate

Miyagi

Total number of delivery facilities

Prefecture

Table 2.2 Obstetric and gynecologic medicine delivery system in and around the affected area

90

31

31

28

Total

46

17

9

20

Offer delivery services

Number of clinics

44

14

22

8

Discontinued delivery services

49

45

71

29

Percentage of discontinued (%)

2.4 Evacuation Sites and Evacuation Process … 19

20

2 Support System of Maternal and Child Care …

health nurse is assigned to each district, and most of them are in charge of regional health services in 4 categories: the elderly, mental health, adult health, and MCH care. Many public health nurses said that they were worried about mothers and children, but the concern was inevitably set aside because there was no description of MCH in the disaster manual.

2.4.2 Disaster Effects for Prenatal Care System and Neonatal Mortality in the GEJE-Affected Area It is necessary to establish a solid emergency preparedness system and a training system for helping mothers and children. In Japan, MCH was the last on the list in disaster response and preparedness, although it is commonly recognized that vulnerable people who suffered from various types of health issues should have cares from the onset of a disaster. Lessons from recent disasters, however, promoted preparing for MCH care during a disaster, through the establishment of maternal and child shelters and disaster assistant training. There are the reviews of epidemiological research on the GHAE in 1995 [16], global knowledge from around the world [17–22], and the facts of the GEJE [23]. The review revealed a support system for MCH during a disaster. The research team’s statement builds on these principles to emphasize the importance of attending to MCH across all phases of disaster-risk management (DRM): prevention, preparedness, response, and recovery. On the neonatal mortality, clinical data and an analysis of the statistical data on GEJE are presented below. First, the Vital Statistics Survey Death Form was analyzed, which is one of the survey forms from the Ministry of Health, Labor and Welfare to prepare vital statistics. The form is prepared by mayors based on notifications of death and is sent to the ministry via the prefecture. Items on the Death Form include the Notification of Fetal Death, municipality code (1–47), gender of infant (male or female), date of delivery (YY/MM/DD), date of fetal death (YY/MM/DD), place of death, age of mother at the time of infant death, number of children the mother gave birth to prior to this infant, number of weeks of pregnancy, results of earlier pregnancies (number of born children or number of stillborn children at 22 weeks or after of pregnancy), body weight at birth, code of original cause of death, type of place of death (1. Hospital 2. Clinic 3. Elderly-care insurance facility, 4. Birth center, 5. Nursing, 6. Home, 7. Others), and single birth or multiple births. In preparation of this report, the researchers received copies of Vital Statistics Survey Death Forms on magnetic media with the approval of the Minister of Health, Labor and Welfare according to the Statistics Act (Act No. 53 of 2007). The data was used only for infants under 1 year after birth between 1973 and 2013. The Vital Statistics Survey data of two natural mega disasters of GHAE in 1995 and GEJE in 2011 show the impact on infant mortality. The total population of Japan

2.4 Evacuation Sites and Evacuation Process …

21

was 125,570,000 in 1995 when the GHAE occurred and 127,799,000 in 2011 when GEJE occurred. There were 1,062,604 births (0.85% for total population) in 1995 and 1,050,698 births (0.82% for total population) in 2011; there were 3,022 infant deaths (0.28% for total births) in 1995 and 2504 (0.24% for total births) infant deaths in 2011. There were 22 infant deaths due to GHAE and 70 due to GEJE. Among the total infant deaths in both years, the percentage of victims under 1 year is shown in Table 2.3. The table shows that 0.7% of mortality was due to GHAE and 2.8% of infant mortality was due to GEJE. The infant mortality in GHAE was 22, which was 40.7 times higher than the usual infant mortality in one day in 1995, and the infant mortality in GEJE was 70, which was 276.7 times higher than usual in the same year. The analysis of infants aged 0 on GEJE on the Vital Statistics Survey Death Form was as follows: 70 infants aged 0 died in three affected prefectures of which 44 had drowned, 60 were older than 4 months of age, and all died outside the hospital (Table 2.4). The most frequent cause of death for GEJE victims aged 0 was drowning (44: 62.8%) and 23 (32.8%) were unknown. With regard to the place of death, 66 (94.3%) GEJE victims aged 0 died not in hospital or home but someplace else. Among the victims under 1 year in GHAE, 14 were boys and 8 were girls. In GHAE, the places of death included hospital: 3, home: 15, others: 4, and cause of death were choking: 15, burning: 3, and bruising: 4 (data not shown). Table 2.3 Comparison of the effects of the disasters between the GHAE (1995.1.17) and GEJE (2011.3.11) earthquakes Variables

Effects on GHAE Effects on GEJE

Total number of birth of that year

1,062,604

1,050,698

Infant mortality of that year: A

3,022

2,504

Number of total victims by the disaster: B

6,402

15,884

Number of Victim of infants at the day of disaster: C

22

70

Number of Victim in 0–9 year: D

252

391

Rate of infant victims in total victims: C/B

0.3%

0.4%

Rate of infant victims in 0–9 year victims: D/B

8.7%

17.9%

Rate of infant victims in all infant mortality: C/A

0.7%

2.8%

Average infant mortality per day of that year in affected area: E

0.5

0.3

Compared with all infant mortality per day in the affected 40.7 times area of the same year: C/E

276.7 times

Percentage was calculated by the ratio of the number of infant mortality with age range between 0 and 1 year Source National Police Agency, 2014. http://www.npa.go.jp/archive/keibi/biki/mimoto/identity.htm GHAE: Great Hanshin-Awaji Earthquake GEJE: Great East Japan Earthquake

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2 Support System of Maternal and Child Care …

Table 2.4 Comparison between total Japan infant mortality in 2011 and in GEJE infant mortality A: Total infant mortality in 2011

B: GEJE infant mortality

2504

70

2.8

2504

70

2.8

Baby boy

1,289 (51.5)

43 (61.4)

3.3

Baby girl

1,215 (48.5)

27 (38.6)

2.2

Variables, N

B/A (%)

Gender (%) Japan total

Iwate Total

43

19

44.2

Baby boy

27 (62.8)

11 (57.9)

40.7

Baby girl

16 (37.2)

8 (42.1)

50.0 48.2

Miyagi Total

85

41

Baby boy

44 (51.8)

25 (61.0)

0.6

Baby girl

41 (48.2)

16 (39.0)

39.0

Total

35

10

28.6

Baby boy

21 (60.0)

7 (70.0)

33.3

Baby girl

14 (40.0)

3 (30.0)

21.4 14.4

Fukushima

Cause of death (%) Unknown

160 (6.4)

23 (32.8)

Very Low Birth Weight

61 (2.4)

1 (1.4)

Drowned

54 (2.2)

44 (62.8)

Choked

46 (1.8)

1 (1.4)

2.2

Burned

1 (0.04)

1 (1.4)

100.0

Total

322 (12.9)

70 (100)

1.6 81.5

21.7

Place of death (%) Japan total Total

2,504

70

2.8

Hospital

2,140 (85.5)

1 (1.4)

0.05

Home

204 (8.1)

3 (4.3)

1.5

Others

107 (4.3)

66 (94.3)

61.7

Total

43

19

44.2

Hospital

24 (55.8)

1 (5.3)

Home

2 (4.7)

1 (5.3)

Others

17 (39.5)

17 (89.5)

Iwate 4.2 50 100 (continued)

2.4 Evacuation Sites and Evacuation Process …

23

Table 2.4 (continued) A: Total infant mortality in 2011

B: GEJE infant mortality

B/A (%)

Miyagi Total

85

41

48.2

Hospital

40 (47.1)

0

0

Home

4 (4.7)

1 (2.5)

Others

39 (45.9)

39 (97.5)

25 100

Fukushima Total

35

10

Hospital

22 (62.9)

0

28.6

Home

3 (8.6)

1 (10.0)

33.3

Others

10 (2.9)

9 (90.0)

90

0

Percentage was calculated by the ratio of the number of infant mortality with age range between 0 and 1 year

Table 2.5 Comparison between total Japan mortality of the average number of deaths per day in 2011 and 3.11 mortality Year of age Victims of 311 (a) All mortality in 2011 (b)–(a) Mortality per day in (a)/(c) (b) normal days (c) 0

70

162

92

0.25

277

0–9

468

717

249

0.68

684

10–19

425

546

121

0.33

1,279

20–29

520

837

317

0.87

597

30–39

861

1,485

624

1.71

502

40–49

1,137

2,390

1,253

3.44

330

50–59

1,931

5,149

3,218

8.84

218

60–69

3,016

10,231

7,215

19.82

152

70–79

3,898

18,094

14,196

39.00

100

80+

3,482

42,966

39,484 108.47

32

Total

15,738

82,415

66,677 183.18

86

While people were killed mainly by the earthquake during GHAE, people were killed by the tsunami in GEJE. In comparison with GHAE, the rate of infant victims increased for one-day infant mortality in GEJE. How about the number of GEJE victims in other age groups? We analyzed how many times the number of deaths in GEJE (3.11) would be compared to the average number of deaths per day in normal times. Table 2.5 and Fig. 2.1 show that infant mortality was 70 on the 3.11, the day GEJE occurred, and it was 277 times higher than the average number of deaths per day (0.25) in the same year 2011. As of age 0

24

2 Support System of Maternal and Child Care …

Fig. 2.1 Comparison between total Japan mortality of the average number of deaths per day in 2011 and 3/11 mortality

to 9, the number of victims was 468 on the 3.11, the day GEJE occurred, and it was 684 times higher than the average number of deaths per day (0.68) in the same year 2011. Age group of 10–19, it was 1279 times higher than peace time, for 20–29 age group, 597 times higher than normal time, in 30–39 age group, 502 times, for 40–49 age group, 330 times, for 50–59 age group, 218, for 60–69 age group, 152 times, for 70–79 age group, 100 times more, and for 80 and more ages, 32 times more than the normal times. Further, the results indicated that efforts for outreach (reaching out to mothers and children who could not reach out for support) were necessary: In particular, recognizing pregnant and nursing women and infants, making sufficient preparations for obstetric medical needs, providing information on obstetric medicine, informing pregnant and nursing women on medical institutions that could provide examinations and deliveries even if normal communication networks were unavailable, and traveling and visiting clinics and conducting maternal checkups at the region are included. The trial to prepare maternal and child disaster shelters by local governments in Japan is just a small seed.

2.4.3 Evacuation Site for MCH Care Immediately after the GHAE in 1995, a heavy traffic jam occurred. This was because many inhabitants evacuated using their own means, such as personal cars. Above all, it was reported that pregnant women and children who had relatives and acquaintances in the area were supposed to leave the disaster area quickly and did not reside in evacuation sites over a long time [24]. Similarly, after the Chuetsu Earthquake in 2004 and the Chuetsu-Oki Earthquake in 2007, some pregnant women temporarily

2.4 Evacuation Sites and Evacuation Process …

25

escaped to the local elementary and junior high schools, and other similar places, but did not stay there for a long time. On the other hand, during the GEJE, a maximum of 470,000 people escaped to over 2400 evacuation sites nationwide. In the Disaster Rescue Act, a refuge period of seven days is assumed; however, the number of victims peaked at one week after the disaster occurred, and the number of evacuation sites peaked at two months later [25]. Problems relating to the health of mothers and children in evacuation sites when a major disaster occurs are summarized as follows. 1. 2. 3. 4. 5. 6.

Nutrition: Inadequate essential nutrition. Rest: Inability to obtain adequate sleep and rest. Environment: Unhygienic living environment. Exercise: Inadequate physical exercise causing thrombosis. Psychology: Stress and related effects on the mind and body. Information: Lack of information.

In the “Agreement for People Requiring Assistance During a Disaster,” in which the government decreed the development of a support policy in each municipality by 2009, all vulnerable victims of disasters, such as the elderly and patients with serious diseases, can receive essential support at a secondary evacuation site (welfare evacuation site), if they experience significant problems while living in the primary evacuation site. Pregnant women and children under 5 years should also be acknowledged as a group requiring special help. However, capacities for their acceptance into secondary sites differ depending on the municipality. Consequently, it is difficult to provide a common rule as differences exist based on the governing body. Very few measures to help pregnant women were applied after the GEJE [26]. When a disaster occurs, it is preferable for the inhabitants of the affected area to be assessed as quickly as possible by local healthcare nurses or coordinated medical personnel provided by the government. For vulnerable individuals such as the elderly, disabled, chronically ill patients, pregnant women, or infants, the ideal treatment process is to initially determine their location, their physical condition, and the sanitary and transport conditions in the area before stationing government officials, NPOs, or human resources such as volunteers at the location. However, in general, all such operations are commenced concurrently when a disaster occurs and consequently, it is necessary to establish a system where actions are coordinated and information is shared as quickly as possible among various professionals as soon as a chain of command from the government is provided.

26

2 Support System of Maternal and Child Care …

2.5 Preparations for Disaster and Use of International Models to Provide Safe Milk In 2007, the Food Aid Organization (FAO) and the World Health Organization (WHO) jointly announced the Recommended International Code of Hygienic Practice for Food for Infants and Children. In line with this code, the Ministry of Health, Labor, and Welfare in Japan published “Guidelines on the safe preparation, storage, and handling of formulated milk powder for infants.” Here, technology for producing formulated milk powder for infants to prevent infection from the Sakazaki bacteria, whose immixing in milk cannot be completely eliminated, is described, and consumers are warned to use hot water that is at least 70 °C while preparing the formula [27, 28]. The procedure for preparing formulated milk that allows mothers to bottle-feed infants safely is illustrated in Figs. 2.2 and 2.3 [29]. The process shown assumes that the user will be situated in a suitable location with a hygienic environment where drinking water and sewage systems are in place, electricity or gas is guaranteed, and hot water can be obtained quickly. In fact, “wash” and “store” are steps that cannot be ignored. If the utensils are used without being washed properly, it can cause the rapid growth of contaminating bacteria, which will affect the health of the child adversely. Newborns must be fed at least eight times a day. Nursing bottles must be boiled or immersed in a disinfecting solution to maintain their sterility. Many resources, including water and heat sources, are necessary.

Fig. 2.2 Cycle for safe bottle-feeding (Source Nakane N [2015] Support for mothers and infants in evacuees [29])

2.5 Preparations for Disaster and Use …

27

Fig. 2.3 Example of the method of preparing safe milk formula that can be used even at the time of disaster and how to dissolve the milk and adjust the temperature appropriately (Source Nakane N [2015] Support for mothers and infants in evacuees [29])

In a large-scale disaster, it is difficult for a mother to bear the full burden of performing these processes. In order to maintain the health of mothers and children, breastfeeding support must be included in countermeasures against disasters. For the feeding of supplemental milk, medical personnel should have special knowledge in this area [30]. Those who help mothers and their children, must examine the feasibility of stockpiling goods necessary for bottle-feeding, as well as for disposable bottled and liquid milk [31].

2.6 Mother and Child Support and Management of Evacuation Sites Assuming that a real disaster occurs, and preparations relating to self-help are made, mutual and public assistance is fundamental. Previously, when an earthquake occurred with an epicenter directly below Tokyo, the “Investigation Committee for Countermeasures against Disasters and for the Protection of Children” was established in 2006, and “Guidelines for Countermeasures against Disasters and for the Protection of Pregnant Women and Infants” were implemented. The latter is currently undergoing revision [32, 33]. In 2013, Bunkyo-Ku in Tokyo established sites at Tokyo Women’s University as part of its regional disaster-risk prevention plan. The facilities function as evacuation

28

2 Support System of Maternal and Child Care …

sites for pregnant women and infants and are stockpiled with emergency goods, blankets, hypoallergenic milk powder, diapers, wipes and diapers for newborns, emergency baby-delivery sets, etc. To prevent the storage of products that have exceeded their expiry date, contracts have been drawn up with several enterprises and the consumption cycle is monitored continuously. This process is called “running stock,” and this constitutes an epoch-making trial that will be adopted at the national as a model of public assistance. Evacuation routes for the district and neighborhoods have been established, along with evacuation sites, etc., to enable mutual assistance. Since the GEJE occurred, social networking services (SNS) have been drawing attention as a new form of mutual assistance. Moreover, while preparing a manual, etc., of countermeasures for disasters, it is preferable to have a system where the government and individuals can connect, and this process will also allow regions to connect. In urban and district areas, community situations differ greatly, such as age distribution. Therefore, to provide support, age and gender ratios in each area must be investigated. It is necessary to increase disaster awareness and make efforts to ensure that people maintain this awareness for their self-help. Participation in periodical disaster-risk prevention training is recommended, which is effective at both the family and individual levels. It is preferable to practice the way documented in the manual, because defects and contradictions are commonly noticed when drills are performed. In the disaster-risk prevention training conducted by the district, disaster-risk prevention policies and codes of conduct can be shared with participants. With the experience in the training, individuals can be aware of the pregnant and nursing mothers and infants who require special help.

2.7 MCH Care and the Growth of a Friendly Society for Mother and Child Disasters do not choose a time or place in which to occur, and every generation is affected. People who find themselves in an evacuation site never foresee the situation; all the people are forced to live without privacy in all evacuation sites. Such situations make it difficult to discuss any stress-inducing issues. When a mother with an infant endures such a lifestyle for a long time, although they are young and healthy, their burden certainly increases. The availability of medical care for mental health issues temporarily decreases when a disaster occurs. Furthermore, mental problems such as disaster-related stress, psychological trauma (post-traumatic stress disorder), etc., occur commonly, which results in an increased demand for mental health care. So, expert support is very important. In January 2016, the Ministry of Health, Labor and Welfare established Disaster Psychiatric Assistance Teams (DPATs), which receive expert instruction and training. In April 2016, the DPAT formed by the prefecture and cities designated by the Cabinet

2.7 MCH Care and the Growth of a Friendly Society …

29

was active in the disaster area of the Kumamoto earthquake immediately after its occurrence [34]. One of the reasons why pregnant women find it difficult to enter into support networks is that the support staff is clearly ordered to help those who are “gravely affected.” A second reason is “hesitation,” which is a trait peculiar to women. The background for this reason is that mothers, wives, and daughters-in-law put their families first on a daily basis, and are largely unaware that they can “help themselves.” Moreover, pregnant women commonly seem to fail to recognize that they have two lives in one body and also hesitate to adopt the new lifestyle receiving help from others. In the peacetime, reducing the burden of mothers for child-rearing and allowing mothers to have hope in mind are effective. Building a friendly society for woman and child in peacetime is likely to result in friendly society for woman and child in disaster countermeasures [35].

2.8 Conclusion While people were mainly killed by the earthquake of GHAE in 1995, people were also killed by the tsunami in GEJE. To compare GEJE with GHAE, the rate of infant victims increased for one-day infant mortality. The disaster-risk prevention system in Japan and medical care for mother and perinatal infants are still developing. Manuals were created for shelters and aid stations with a particular focus on mothers and children. The legal basis for providing support in times of disaster is introduced. To establish evacuation sites and evacuation process for pregnant women, preparations for a disaster and the use of international models to provide safe milk are discussed in this chapter to manage mother and child support in the evacuation sites. Mental health care is also considered for the growth of a friendly society for mother and child. The presence of pregnant women and infants in a disaster region means the inhabitants’ hope, resilience, and belief that the area will recover. If it is feasible to adopt detailed actions that accommodate the diversity of disaster victims, this will become a basic attitude that would underlie future disaster countermeasures. Acknowledgements This study was supported by the following research grants: 1. Health and Labor Sciences Research Grants (Research on Health Security Control) “Research on the Development of a Regional Collaborative Disaster Prevention System Including the Operation of Welfare Shelters for Those Who Require Assistance in Times of Disaster with the Central Focus on Pregnant and Nursing Women and Infants” (Research representative: Honami Yoshida, 2013–2015). 2. Grants-in-Aid for Scientific Research “Maternal and Child Health Required in Times of Disaster - from Research on the Impacts of the GEJE on Maternal and Child Health” (Research representative: Honami Yoshida, 2012–2014). The author thanks Dr. Kentaro Hayashi and others who provided help at the Primary Care for All Team (PCAT), PCOT project members that include Dr. Hiroshi Ota, Dr. Yumie Ikeda, Dr. Keiko

30

2 Support System of Maternal and Child Care …

Otsuka, Ms. Yukari Endo, and Mw. Shoko So, who have contributed to developing training for rescuing pregnant and nursing women in times of disaster; and Dr. Yosuke Fujioka and Dr. Shinji Tsunawaki who have worked to address the needs of pregnant women from the inception of the PCAT. The author also thanks Mw. Naoko Nakane for her dedicated education in this field.

References 1. United Nation (2015) Global assessment report on disaster risk reduction. https://www. preventionweb.net/english/hyogo/gar/2015/en/home/GAR_pocket/Pocket%20GAR_3.html. Accessed 8 Feb 2021 2. Ministry of Foreign Affairs of Japan (2015) The 3rd world congress on disaster prevention. https://www.mofa.go.jp/ic/gic/page3e_000305.html. Accessed 8 Feb 2021 3. Disaster Management Division, Cabinet Office (2016) Disaster management in Japan (in Japanese). www.bousai.go.jp/kaigirep/hakusho/pdf/H28_gaiyou.pdf. Accessed 8 Feb 2021 4. Disaster Management Division, Cabinet Office (2016) Disaster management structure in Japan (in Japanese). http://www.bousai.go.jp/shiryou/taisaku/soshiki2/soshiki2.html. Accessed 8 Feb 2021 5. Watanabe N, Yoshida H (2016) What can we commit for disaster risk reduction of perinatal care system as an obstetrician? J Yamanashi Soc Obstet Gynecol 6(2):2–9 (in Japanese) 6. National Committee on Perinatal Care System, Ministry of Health, Labour and Welfare (2016) Medical care in case of disasters (in Japanese). www.mhlw.go.jp/stf/shingi/other-isei.html?tid= 292852. Accessed 8 Feb 2021 7. Sugawara J (2012) Emergency perinatal medical system and its measures. In: Unno N (ed) Working paper of Health and Labor Sciences Research Grants 2011 “Research on improvement of regional perinatal medical system and adequate allocation of medical resources” (in Japanese) 8. Arimoto H, Furuya S, Yamashita K, Tanaka K, Maruyama T, Takeuchi M, Wada K, Ogita K, Misaki M, Fuke A, Rinka H (2019) Disaster medical management of pediatric and perinatal disaster medical liaison (PPDML) for children and pregnant women in Osaka, Japan. Prehospital Disaster Med 34:s121–s122. https://doi.org/10.1017/S1049023X19002619. Accessed 8 Feb 2021 9. Unno N (2012) Human support for obstetric and gynecologic medicine in affected areas. In: Unno N (ed) Health and Labor Sciences Research Grants in 2011 “Research on improvement of regional perinatal medical system and adequate allocation of medical resources” (in Japanese) 10. Ogasawara T (2012) Obstetric and gynecologic diseases that increases after heavy disaster: discussion from Great East Japan Earthquake, 2011. In: Unno N (ed) Health and labor sciences research grants in 2011 “Research on improvement of regional perinatal medical system and adequate allocation of medical resources” (in Japanese) 11. Yoshida H (2013) Maternal and child health required in times of disaster—From research on the impacts of the Great East Japan Earthquake on maternal and child health. Report of the Grants-in-Aid for Scientific Research, no. 24790626 (in Japanese) 12. Yoshida H, Ikeda Y, Ota H, Fujioka Y (2011) Impacts of support for pregnant and nursing women and infants on reconstruction from the earthquake: issues and the future found through maternal checkups and neonatal visiting activities. Jpn J Disaster Med 16(3):356 (in Japanese) 13. Yoshida H (2011) The prenatal and postpartum care support project in Tsunami-affected areas in Japan: final report submitted to AmeriCares. Tokyo (in Japanese) 14. Yoshida H (2013) Maternal and child health in times of disaster: roles of midwives to protect pregnant and nursing women: (9) Perinatal outcome at the time of Great East Japan Earthquake. Jpn J Midwives 67(9):324–327 (in Japanese)

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15. Tashiro A, Sakisaka K, Okamoto E, Yoshida H (2018) Differences in infant and child mortality before and after the Great East Japan Earthquake and Tsunami: a large population-based ecological study. BMJ Open 8:e022737. https://doi.org/10.1136/bmjopen-2018-022737 16. Hyogo Prefectural Society of Obstetrics and Gynecology (1996) Epidemiological study report on the impacts of stress by Great Hanshin Earthquake on pregnant and nursing women and fetuses (in Japanese) 17. Harris C, Smyth I (2001) The reproductive health of refugees: lessons beyond ICPD. Gender Dev 9(2):10–21. https://doi.org/10.1080/13552070127742. Accessed 8 Feb 2021 18. McGinn T, Casey S, Purdin S, Marsh M (2004) Reproductive health for conflict-affected people: policies, research and programs. Humanit Pract Netw Pap 45:1–36 19. McGinn T (2000) Reproductive health of war-affected populations: what do we know? Int Family Plan Perspect 26(4):174–180 20. The Sphere Handbook (2018) https://spherestandards.org/wp-content/uploads/Sphere-Han dbook-2018-EN.pdf. Accessed 8 Feb 2021 21. HAP Standard (2010) http://www.hapinternational.org/projects/standard/hap-2010-standard. aspx. Accessed 8 Feb 2021 22. Oxfam Japan. http://oxfam.jp/2013/04/post_397.html. Accessed 8 Feb 2021 23. Yoshida H (2012) Earthquakes and children: maternal and child health required after Great East Japan Earthquake. Child Sci 8:87–91 (in Japanese) 24. Disaster Management Division, Cabinet Office (2012) Looking back on Hanshin-Awaji Great Earthquake (in Japanese). http://www.bousai.go.jp/kohou/oshirase/h14/pdf/sankousiryo1-2. pdf. Accessed 8 Feb 2021 25. National Diet Library (2011) Overview of the Great East Japan Earthquake and policy issues 1. Natl Diet Libr Issue Brief No. 708 (in Japanese). http://www.ndl.go.jp/jp/diet/publication/ issue/pdf/0708.pdf. Accessed 8 Feb 2021 26. National Diet Library (2011) Overview of the Great East Japan Earthquake and policy issues 2. Natl Diet Libr Issue Brief No. 712 (in Japanese). www.ndl.go.jp/jp/data/publication/issue/ pdf/0712.pdf. Accessed 8 Feb 2021 27. FAO and WHO (2008) Enterobacter sakazaki (Cronobacter spp.) in powdered follow-up formulae. http://apps.who.int/iris/bitstream/10665/44032/1/9789241563796_eng. pdf?ua=1. Accessed 8 Feb 2021 28. Ministry of Health, Labour and Welfare (2009) Guidelines for treating safety formula (in Japanese). http://www.mhlw.go.jp/topics/bukyoku/iyaku/syoku-anzen/qa/dl/070604-1b. pdf. Accessed 8 Feb 2021 29. Nakane N (2015) Support for mothers and infants in evacuees. Firef 656(8):110–112 (in Japanese) 30. IFE Core group (2008) Infant nutrition in disaster area (in Japanese). http://www.jalc-net.jp/ dl/OpsG_Japanese_Screen.pdf. Accessed 8 Feb 2021 31. Association of Japan Lactation Consultants (2011) Milk feeding in the time of disaster (in Japanese). http://www.jalc-net.jp/hisai/liquid_milk.pdf. Accessed 8 Feb 2021 32. Tokyo Metropolitan Government (2014) Guidelines for supporting mothers and children in disaster (in Japanese). http://www.fukushihoken.metro.tokyo.jp/kodomo/shussan/nyuyoji/sai tai_guideline.html. Accessed 8 Feb 2021 33. Tokyo Metropolitan Government (2013) Guidelines for shelter management (for municipalities), pp 132–135 (in Japanese) 34. Ministry of Health, Labour and Welfare (2016) Rule of disaster psychiatric assistance teams (DPAT) (in Japanese). http://www.mhlw.go.jp/seisakunitsuite/bunya/hukushi_kaigo/shougaish ahukushi/kokoro/ptsd/dpat_130410.html. Accessed 8 Feb 2021 35. Nakane N (2015) Disaster preparedness. In: Japanese Nursing Association (ed) The role of midwife, pp 263–275 (in Japanese)

Chapter 3

Importance of Cross-Organizational Collaboration for Disaster Preparedness for Maternal and Child Health Care

Abstract HUG (Hinanjo Un-ei Game), an evacuation shelter simulation game developed by Shizuoka Prefecture, was adopted as the base for promoting crossorganizational and multidisciplinary collaboration in local communities. HUG is a simulation game in which participants place the cards containing evacuees personal information such as their age, gender, citizenship, and special circumstances into the floor plans assuming the gym and classrooms in the evacuation shelter. Participants experience finding solutions to various events occurring in the evacuation center. The game experience gives participants the opportunity to determine how to assign evacuees to individual rooms while considering the needs of evacuees requiring special assistance. The program also allows public health nurses, disaster prevention managers, and other government employees to gain experience in dealing with more than 100 issues that must be considered in improving the environment and safety of pregnant and nursing women and children. This experience will be useful especially for training voluntary disaster relief organizations that play a central role in operating evacuation shelters. Keywords Hinanjo Un-ei Game (HUG) · Personnel training · Disaster preparedness drill · Simulation game

Abbreviations AHRQ ALSO BLSO DMAT EMIS HUG JTAS MCH STEPPS

Agency for healthcare research and quality Advanced life support in obstetrics Basic life support in obstetrics Disaster medical assistance team Emergency medical information system Hinanjo Un-ei Game Japanese Triage and Acuity Scale Maternal and child health Strategies and tools to enhance performance and patient safety

© The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2021 H. Yoshida, Lessons Learned from the Great East Japan Earthquake, Population Studies of Japan, https://doi.org/10.1007/978-981-10-4391-8_3

33

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3 Importance of Cross-Organizational Collaboration …

3.1 Introduction A disaster-response system for mothers and newborns in the community-specific circumstances should be developed with a solution-focused approach rather than a problem-based one. Personnel training programs were developed to provide the assistance in “Research on the development of a region-based collaborative disasterresponse system involving the operation of welfare evacuation shelters for pregnant/postpartum women and infants and other vulnerable groups in times of disaster” (a health and crisis management research project funded by the Health and Labor Sciences Research Grant for 2013–2015). For 3 years starting in 2013, our research group worked with perinatal care providers and firefighting personnel to develop a practical system to protect the next generation by (1) preparing manuals, action cards, and checklists for post-disaster maternal and child health (MCH) care; (2) facilitating collaboration (among education professionals, neighborhood associations, healthcare organizations, administrative departments, and others) and providing training regularly; and (3) developing brochures and other educational tools to promote self-reliance among pregnant and postpartum women. To organize workshops on post-disaster MCH care and incorporated their feedback to improve the content and tools used in the workshops, we also worked with medical institutions, local governments, midwife associations, local volunteer organizations, and perinatal care providers. We organized over 40 workshops during the three-year period, providing more than 1,500 perinatal medicine specialists, emergency physicians, midwives, paramedics, government officials, public healthcare nurses, and other professionals. The workshops give us an opportunity to collaborate with other professionals on a regular basis. We hope that the knowledge and skills from the workshops are shared among many others and become available as ready-to-use tools to help individuals who need special assistance during disasters.

3.2 Initiatives for Personnel Development Research 3.2.1 Progress in a Nationally Applicable Manual for the Operation of Welfare Evacuation Sites and Techniques for Personnel Training In Japan, there have been little epidemiological surveys or studies on specific disastermitigation measures focusing on people requiring specific assistance [1]. Comprehensive assistance to such groups in medical, healthcare, and welfare facilitates the recovery process following a disaster and plays an important role in helping residents rediscover the will to live and rebuild their lives [2]. For Japan, a disaster-prone nation and faced with population decline, there is a pressing need to develop a region-based

3.2 Initiatives for Personnel Development Research

35

collaborative healthcare system that can effectively accommodate the post-disaster medical needs of pregnant and postpartum women and infants. And to apply and develop the system is needed further for other categories of vulnerable individuals. First, we studied the standards adopted in disaster-response operations in Japan and abroad, and we interviewed various healthcare professionals on the development of a model for a disaster-ready pre-hospital care system. Next, with the cooperation of the Disaster Medical Assistance Team (DMAT) Office of Disaster Medical Center, we audited the DMAT and comprehensive DMAT training programs. We then conducted field exercises and analyzed the content, and organized the specific content of disaster health assistance required for a post-disaster MCH care training program as well as the overall framework of the program. During a course on the Japanese Triage and Acuity Scale (JTAS) offered by the Japanese Association of Emergency Medicine, we learned about pre-hospital emergency care. In the Sphere Project training programs (trainer development programs) on the international standards for humanitarian and emergency assistance, we studied the standards of action that all aid providers must consider while engaging in humanitarian assistance. Further, in Advanced Life Support in Obstetrics (ALSO) and Basic Life Support in Obstetrics (BLSO) courses, we received the training program for physicians and other healthcare professionals to develop and maintain knowledge and skills to effectively respond to perinatal emergency issues [3–5]. Team training is essential in providing high-quality health care that immediately follows a disaster. In the medical field, Team Strategies and Tools to Enhance Performance and Patient Safety (Team STEPPS) were developed in 2005 by the Agency for Healthcare Research and Quality (AHRQ; http://www.ahrq.gov/teamstepps/index/ html) in collaboration with the US Department of Defense. This well-recognized, evidence-based system of team training presents the components of teamwork (leadership, situation monitoring, mutual support, and communication) and tools to be applied by medical professionals.

3.2.2 Development of Training Programs for the Operation of Evacuation Shelters in the Community The basic approach for adults to continue studying is to apply an interactive format in which students use their body movements and senses in their learning, instead of passively listening to lectures. During my study in the US, I learned the principles of adult education and studied facilitation and coaching techniques. I also developed an efficient and effective workshop program by combining the content of the aforementioned ALSO and Team STEPPS courses with various disaster-response training programs in Japan and abroad. I have a chance to study the activity of Team STEPPS and apply the principles of the program to our workshops on assisting mothers and infants during disasters.

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3 Importance of Cross-Organizational Collaboration …

HUG (Hinanjo Un-ei Game), an evacuation shelter simulation game developed by Shizuoka Prefecture (trademark registration number 5308380), was adopted as the base for promoting cross-organizational and multidisciplinary collaboration in local communities. HUG is a simulation game in which participants place the cards containing evacuees’ personal information such as their age, gender, citizenship, and special circumstances into the floor plans assuming the gym and classrooms in the evacuation shelter. Participants also experience finding solutions to various events occurring in the evacuation center. The game experience gives participants the opportunity to determine how to assign evacuees to individual rooms while considering the needs of evacuees requiring special assistance. They can also freely express their views and discuss issues with others, responding to media inquiries, as well as learn about the operation of evacuation shelters (from the website of Shizuoka Prefecture). With the cooperation of Mr. Yasuhiko Kurano, the developer of HUG, I was able to incorporate actual cases involving mothers and newborn babies staying in an evacuation shelter in Ishinomaki to prepare “HUG for Persons Requiring Special Assistance during Disasters” and use it as the foundation for our workshop program. Overview of HUG exercise for people requiring special assistance during disasters is mentioned as follows (Fig. 3.1 and Table 3.1).

Fig. 3.1 HUG for persons requiring special assistance during disasters (evacuation shelter simulation game). Made by Shizuoka Prefecture. Registered trademark no. 5308380, copying unauthorized

3.2 Initiatives for Personnel Development Research

37

Table 3.1 Schedule overview (for a two-hour program) Contents

Theme

Duration

Opening

Self-introduction within groups

10 min

Lecture

Lessons learned in Mega Disaster: Disaster Preparedness in OB/GYN, Child care support, and MCH care

30 min

Drill

Instruction and playing of HUG (Hinanjo Un-ei Game)

30 min

Reflection

What we learned through HUG and what we need to prepare 20 min for disaster with group members

Sharing

Presentation of group discussion

10 min

Discussion and Q&A

Discussion with other groups about disaster response and shelter management

10 min

Closing

Sharing idea: What we want to do from now on

10 min

3.2.2.1

Effectiveness and Significance of HUG

By simulating a specific disaster situation using HUG, the workshop provides participants with an overview of how to operate an evacuation shelter as well as a concrete image of the response and preparation expected for pregnant and postpartum women and infants. The program also allows public health nurses, disaster prevention managers, and other government employees to gain experience in dealing with more than 100 issues that must be considered in improving the environment and safety of pregnant and nursing women and children. This experience will be useful especially for training voluntary disaster relief organizations that play a central role in operating evacuation shelters. Furthermore, by learning about situations and cases requiring a special evacuation shelter for mothers and newborns (secondary evacuation shelter) that is separate from a general evacuation shelter (primary evacuation shelter), participants can make appropriate decisions to develop desirable facilities and management systems. The program allows participants to envision those operations requiring multidisciplinary collaboration among local government employees and perinatal specialists and organizations (e.g., midwives and public health centers) and the framework for cross-organizational collaboration.

3.2.2.2

Exercises of HUG

If you must operate an evacuation shelter, how would you handle the flood of people arriving there and the events occurred in the early stages? What types of decisionmaking skills do you need to ensure that pregnant and postpartum women and infants, who are especially vulnerable during disasters, are evacuated to an appropriate location? The relatively short exercise of about 30–50 min simulates a situation in which evacuees start arriving continuously at a general evacuation shelter such as an elementary school a few hours after an earthquake, and provides participants with a concrete image of what must be prepared during normal times.

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3 Importance of Cross-Organizational Collaboration …

Tools used for the exercise include HUG cards (Figs. 3.2 and 3.3), a checklist (Table 4.1 in Chapter 4), an assessment sheet (Fig. 4.2 in Chapter 4), a list of admitted persons (Fig. 4.5 in Chapter 4), a floor plan of an elementary school designated as a general evacuation shelter, blank A4 sheets of paper, pens, and post-it notes (see Shizuoka Prefecture’s website on HUG: http://www.pref.shizuoka.jp/bousai/e-qua kes/manabu/hinanjyo-hug/game.html). Participants are divided into groups of about six members so that each group consists of a mix of local government employees working in the fields of welfare, disaster preparedness, and health care. If multiple members of the same department from the same local government are participating in the game, they are assigned to different groups. If members of different departments or organizations (e.g., disasterresponse department, public health center, and midwives) from the same local government are participating, they are assigned to the same group. Each participant (acting as an executive member of the organization operating the evacuation shelter) is assigned

Fig. 3.2 Examples of HUG Evacuee Card for people requiring special assistance during disasters

Events Cards [12]

There are no more toilets available !

Events Cards [15]

I'd like to do an interview for the newspaper.

Fig. 3.3 Examples of HUG Event Card for people requiring special assistance during disasters

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to one of the following jobs or responsibilities: General Manager of Operations (in charge of managing evacuees and making decisions), material distribution and meals (in charge of procuring and distributing meals and materials), first-aid assistance and public health (in charge of health management), environment and hygiene (in charge of hygiene conditions in bathrooms and others), evacuation shelter management (in charge of reception and preparation of a list of evacuees), and general affairs and information (general affairs such as handling media inquiries and public relations). The entire team is required to discuss and decide how to assign evacuees to different rooms.

3.2.2.3

Exercise Procedure of HUG

Two types of cards are used in this workshop: Evacuee Cards and Event Cards. Evacuee Cards (Fig. 3.2) contain about 30 families of the names and other important information on evacuees including those that are particularly vulnerable such as pregnant and postpartum women, infants, persons requiring long-term care, children with disabilities, and persons from abroad. Event Cards (Fig. 3.3) contain descriptions of various events that must be handled by the evacuation shelter operator, including communications from the disaster management headquarters and media inquiries. One group member is assigned the responsibility of reading the cards, and the game proceeds as the person reads out approximately 160 cards. Drawings of a standard gym designated as a general evacuation shelter, the site plan, the floor plan, and classrooms are used. The template included in the HUG set can be adopted as the default conditions for the day of evacuation (intensity of the earthquake, weather conditions, season, time, extent of damage, and general state of the evacuees). As each card is read, the information is shared on the whiteboard and communicated to the other members of the group, giving all participants a chance to act with a sense of urgency.

3.2.2.4

Review of the HUG Results

To allow time for participants to observe, learn from, and look back at their experience of having a difficult time making decisions, not performing well, or struggling to find the correct answer, participants are given about five minutes to complete a review sheet and discuss this with the other group members. About two groups then present their discussions to the other groups.

3.2.2.5

Discussion by Participants of HUG

The exercise provides participants with a clear understanding of what needs to be done and considered in assisting vulnerable persons such as pregnant and postpartum women and their infants in an evacuation shelter operated by non-governmental

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citizens (e.g., voluntary disaster relief organizations) and the specific information to be included in the evacuation shelter operation manual for the community. In addition, the workshops give the participants an opportunity to examine the assistance expected from professionals and administrative agencies (e.g., making rounds and setting up first-aid shelters). And communication methods, equipment, and preparation are also required to provide such assistance. We have been conducting this simulation workshop involving multidisciplinary collaboration among public healthcare professionals, municipal government employees, and firefighting and police personnel in many local communities, and have been improving the program based on feedback on the various tools we developed. In addition, we prepared Evacuee Cards that reproduced actual circumstances involving mothers and their newborns in evacuation shelters based on the postdisaster interviews conducted in areas suffered from Great East Japan Earthquake. In the interviews, evacuees told their impression of severe experiences as follows: “I did not go to the evacuation shelter, because I thought I would not be welcomed there” “I came home from the evacuation shelter, as I felt that I did not belong there, just as I expected,” “I was pregnant at that time, but I did not want to tell my pregnancy to the receptionist.” While, evacuation staffs told us as follows; “Until then, we had never considered these persons who needed special assistance such as women who had just given birth, families with disabled children, and fathers with small children whose mothers had died in the disaster.” In addition, some pointed out that healthy evacuee occupied the best places in the evacuee shelter, leaving no space for persons with mobility restrictions by the time they arrived. We have incorporated these feedback issues and prepared a diagram of a gym filled with evacuees and simulated a situation wherein participants had to assign evacuees to different rooms and identify issues for consideration. After the workshop, the entries in the abovementioned review sheets and workshop surveys are compiled and returned to the local governments hosting the workshop. Many local communities prepared a disaster-response manual based on these reviews and used the manual for workshops on disaster preparedness [6–8]. According to the results of the questionnaire surveys conducted after the workshops, 90% of the participants responded that they were “satisfied” or “very satisfied.” Participants were able to derive the “roles, rules, and stockpiles that needed to be identified and to be prepared during normal times.” They can also derive the necessary “regional collaboration,” and a “manual for assisting mothers and newborns during disasters.” Thus, the results demonstrated that the workshop led participants to engage in actual disaster-response activities in their communities. In addition, some participants brought the program back to their own departments to apply HUG in their workplaces, thus spreading the effect of the program and promoting a collaboration with other departments [9]. (i)

Outline of Measures against Decreasing the Birthrate prepared by the Cabinet Office (effective since April 2015)

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A section titled “Assistance for Newborns and Infants during Disasters” under “Enhancing Safety in Communities” in “Specific Measures” states thus: “Local governments must disseminate knowledge on disaster preparedness, conduct training, and stockpile materials while fully considering individuals requiring special assistance such as infants and pregnant/postpartum women. Communities must also strive to maintain facilities and equipment in designated evacuation shelters and strengthen collaboration among organizations involved in protecting children from disasters.” (ii)

Healthy Parents and children 21 (second phase) (effective since April 2015)

Key issue A: The percentage of prefectures reviewing the system for accepting pregnant/postpartum women when sudden events such as natural disasters occur is used as a reference indicator to provide uninterrupted health care for pregnant/postpartum women and infants. (iii)

Training Program for Opening a First-aid Shelter for Mothers and Infants

This was used as reference material for the “Guidelines for the Operation and Management of Evacuation Shelters” developed by the Working Group for Quality Enhancement, which is a part of the Review Committee for Securing and Improving the Quality of Evacuation Shelters, established by the Cabinet Office.

3.3 Establishing a Collaborative System for the Operation of Next-Generation Evacuation Shelters in the Community 3.3.1 Establishment of a Liaison for Pediatric and Perinatal Care During Disasters Dr. Yuichi Koido, a chief of national disaster medical center, led a research project funded by the Health and Labor Sciences Research Grant for 2016–2018 to promote the development of the foundations for regional medicine. This research project was called “Research on Approaches to the Future Disaster Medical System to Ensure Effective and Efficient Operation of Medical Teams during Large-scale Natural Disasters such as an Earthquake Occurring Directly Underneath Tokyo and a Nankai Trough Earthquake.” A sub-theme of this research was a project titled “Research on Perinatal and Pediatric Care Systems” conducted by one of the members of the project team, Dr. Nobuya Unno. The study focused on the development of a business continuity plan for region-based perinatal medical care after a large-scale disaster. In the study, a plan for providing regional perinatal medical care after a major disaster was prepared in collaboration with professionals working in the field of disaster medicine. The studies conducted by the Perinatal Medical Council and the content of the disaster medical plans prepared by prefectural governments are also needed. In

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principle, the following issues must be addressed in advance and should be included in the plan: 1.

2.

3. 4.

5. 6.

7.

8.

9.

Examine the capabilities of general and regional perinatal medical centers and other core obstetric facilities to continue providing medical services even after large-scale disasters such as earthquakes and tsunamis based on certain clearly indicated criteria. Conduct a study on the organizations needed to establish a system for providing regional perinatal medical care in times of disaster and initiate discussions with related academic societies such as the regional obstetrics and gynecology society, association of obstetricians and gynecologists, association of neonatologists, pediatrics society, association of pediatricians, association of physicians, association of midwives, and nursing association and other related organizations, and develop a system capable of functioning during emergencies that is tailored to the circumstances of the community. Share information on the roles of the liaison for pediatric and perinatal care during disasters. Determine in advance the method of gathering information on medical services offered by facilities during emergencies, and in doing so consider using the Emergency Medical Information System (EMIS) and the information systems of the Japan Society of Obstetrics and Gynecology and others. Determine in advance the basic method of transporting patients during the acute and hyper-acute stages within and out of the region. Determine the policy concerning facilities accepting women giving birth during the hyper-acute phase; within 48 h following the disaster, acute phase; within one week following the disaster, sub-acute to chronic phases; one week or more after the disaster, and make arrangements so that the facilities accepting women giving birth, pregnant and postpartum women, and newborns can be clearly identified when a disaster strikes and the necessary information can be provided to all residents including those living in disaster-afflicted areas. To ensure the availability of medical services in the facilities accepting women giving birth, pregnant and postpartum women, and newborns in different phases, develop measures to secure the necessary personnel such as obstetricians/gynecologists, pediatricians, anesthesiologists, midwives, nurses, as well as personnel necessary for maintaining the functions of the facilities, medical supplies such as related to deliveries and Cesarean sections, and drugs such as including dispatching personnel from non-functioning facilities within the region and support from other regions. Develop measures to secure the means to communicate information concerning the facilities accepting women giving birth and treating pregnant and postpartum women and newborns in all phases. Develop measures for understanding, analyzing, and finding solutions for situations involving pregnant and postpartum women, newborns, and infants at evacuation shelters and other facilities.

3.3 Establishing a Collaborative System for the Operation …

10.

43

Determine the policy of the Perinatal Medical Council regarding acceptance of pregnant and postpartum women and newborns from other disaster-stricken regions.

It is essential that personnel development at the prefectural level reflect these considerations in the future.

3.3.2 Future Plan Based on the results obtained from our research, we developed a disaster prevention system involving regional, administrative, medical, and public-private collaborations for about 20 municipalities. We assisted during liaison meetings hosted by local governments to develop community guidelines to protect people requiring special assistance during disasters, and designed and promoted workshops to help vulnerable groups during disasters [10–12]. Our future plan is to identify the characteristics of people requiring special assistance during disasters (e.g., seniors, persons with disabilities, and persons from abroad) based on the model project for evacuation shelters for pregnant and postpartum women and infants. Our goal is to develop a universal manual to operate welfare evacuation shelters for vulnerable groups during disasters and techniques to train personnel that are also applicable to vulnerable people in other categories and other regions. Furthermore, we aim to enhance public awareness of the importance of disaster preparedness by providing practical training. We also plan to develop and improve a standard national training program and information sharing system to assist vulnerable people during disasters and build foundations to enable their speedy recovery from any disaster in Japan and abroad. We hope that a cross-organizational system for assisting disaster-affected mothers and infants will be developed across the country and that this system will help as many mothers and newborns as possible when the next earthquake strikes.

3.4 Conclusion The Great East Japan Earthquake was a great learning experience particularly in connection with protecting the precious lives of the next generation. I hope that the construction of systems for the regions, governments, and the entire society to protect mothers and children in times of disaster will progress in the future through the lessons learned from the shared experience of this disaster, and by being able to rely on collective wisdom in preparing for the next disaster. Acknowledgements This study was supported by the following research grants: 1. Health and Labor Sciences Research Grants (Research on Health Security Control) “Research on the Development of a Regional Collaborative Disaster Prevention System Including the Operation

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of Welfare Shelters for Those Who Require Assistance in Times of Disaster with the Central Focus on Pregnant and Nursing Women and Infants” (Research representative: Honami Yoshida, 2013–2015). 2. Grants-in-Aid for Scientific Research “Maternal and Child Health Required in Times of Disaster - from Research on the Impacts of the GEJE on Maternal and Child Health” (Research representative: Honami Yoshida, 2012–2014). The author thanks Dr. Kentaro Hayashi and others who provided help at the Primary Care for All Team (PCAT), PCOT project members that include Dr. Hiroshi Ota, Dr. Yumie Ikeda, Dr. Keiko Otsuka, Ms. Yukari Endo, and Mw. Shoko So, who have contributed to developing training for rescuing pregnant and nursing women in times of disaster; and Dr. Yosuke Fujioka and Dr. Shinji Tsunawaki who have worked to address the needs of pregnant women from the inception of the PCAT. The author also thanks Mw. Naoko Nakane for her dedicated education on this field.

References 1. Yoshida H, Nakao H, Arai T, Sugawara J, Tsuruwa M, Kurano Y (2016) Study on the most appropriate way to train disaster medicine for obstetric care worker—the importance and needs. Jpn J Disaster Med 20(3):494 (in Japanese) 2. Yamagishi E, Ishikawa G, Yoshida H, Sugawara J, Nakai A (2016) Construction of regional cooperation system for disaster relief on expectant and nursing mothers. The 21st Annual Meeting of Japanese Association for Disaster Medicine. Jpn J Disaster Med 20(3):492 (in Japanese) 3. Yoshida H, Arai T (2015) The strategies for developing a cross-sectional network by disaster preparedness in maternal and child health. The 1st Annual Meeting of Advanced Life Support in Obstetrics (ALSO)-Japan, p 8 (in Japanese) 4. Dateoka K, Yoshida H, Uchida K, Hidaka T, Ito Y (2015) The effectiveness evaluation of BLSO course questionnaire. The 1st Annual Meeting of Advanced Life Support in Obstetrics (ALSO)-Japan, p 7 (in Japanese) 5. Yoshida H, Arai T, Watanabe N, Hirata S (2015) The possibility of establishment of the crosssectorial network by analysis of the prenatal epidemiology in disaster. J Kanto Obstet Gynecol 52(3):357 (in Japanese) 6. Yoshida H (2015) Disaster preparedness in maternal and child health (MCH). Clin Res 505:33– 38 (in Japanese) 7. Yoshida H (2015) Disaster preparedness in maternal and child health (MCH). Firef 53(1):118– 120 (in Japanese) 8. Yoshida H, Hayashi K, Oota H, Ikeda Y, Ootsuka K, Harada N, Arai T, Fujioka Y, Haruna M, Nakao H (2015) Perinatal outcome in Great East Japan Earthquake (GEJE) and rescue project in maternal and child health (MCH). J Gen Family Med 38(1):1–6 (in Japanese) 9. Yoshida H (2015) Lessons learned in mega disaster. Firef 53(11):114–115 (in Japanese) 10. Yoshida H, Watanabe N (2016) Disaster preparedness in obstetrics and gynecology. J Yamanashi Univ 6(2):2–9 (in Japanese) 11. Yoshida H (2015) Child care support in disaster preparedness and maternal and child health (MCH). Child Health 18(7):6–11 (in Japanese) 12. Yoshida H (2017) The significance of tackling disaster response- to transcend vertical divisions and bring out the kindness of the community. Matern Child Health Inf Mag 2:15–20 (in Japanese)

Chapter 4

Preparations for Maternal and Child Protection in Times of Disaster: Practical Tools for Regional and Multi-Occupational Collaboration

Abstract It is important to provide appropriate aid and support for expectant and nursing mothers after a disaster. The role of administrators within governments is to establish relief centers for them in advance. For urgent preparation, it is necessary to create a concrete action plan, as well as a concrete system design, and an emergency response system. The number of expectant and nursing mothers should be precisely counted. Support tools for maternal and child health by local governments when disaster strikes include awareness-based pamphlets for maternal and child disaster relief and shelter assessment sheets. The sheet was created from the perspective of those who need special accommodation, which contains a checklist to determine the risks relating to maternal and child health after a disaster. Keywords Relief center · Action plan · Awareness-based pamphlets · Shelter assessment sheet

Abbreviations CBR GEJE GHAE IDP MCH OB/GYNs OCHA PCAT UNFPA

Crude Birth Rate Great East Japan Earthquake Great Hanshin-Awaji Earthquake Internally Displaced Person Maternal and Child Health Obstetricians and Gynecologists Office for the Coordination of Humanitarian Affairs Primary Care for All-Team United Nations Population Fund

© The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2021 H. Yoshida, Lessons Learned from the Great East Japan Earthquake, Population Studies of Japan, https://doi.org/10.1007/978-981-10-4391-8_4

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4.1 Introduction Just after the Great East Japan Earthquake (GEJE) on March 11, 2011, I was sent to Miyagi Prefecture and the coastal area of Iwate Prefecture, specifically Ishinomaki City and the town of Minamisanriku, to assess the prevailing maternal and child health conditions as a dispatch doctor for the Japan Primary Care Association-Disaster Relief Project, Primary Care for All Team (PCAT). Immediately after a disaster struck, the local governments and health centers often fall into a state of paralysis. It is especially important to have a direct response from vulnerable people, including mother and children, for their support. However, the assessment of the condition of expectant and nursing mothers is difficult. In the society of increasing aging population with a declining birthrate, expectant and nursing mothers are considered minor population in the community. So, it is hard for mothers to ask help in times of disaster. Pregnancies and births are not an “illness” and “natural” phenomenon and treated as “usual” issues. So, many mothers hesitate to ask help. Owing to the difficulty in accessing medical facilities and the responsibilities within the family, mothers are often unable to evacuate with their infants; their physical and mental health are greatly damaged. I resigned from the position as a clinical doctor working in the field of perinatal care for 10 years and became a researcher in a national institute of public health in 2012. Subsequently, I engaged with over 30 local governments, such as the city of Tokyo to develop mother and child health (MCH) policies in the disaster and received two research grants to aid to raise the projects. Professionals from a variety of fields such as medical experts, policy maker, firefighters, researchers, dietitian, and people from educational fields have come together to collaborate and provide support in this project. In this chapter, the role of administrators within governments during times of disaster will be mentioned based on the report by expectant and nursing mothers suffered from disaster.

4.2 Report on Situation of Expectant and Nursing Mothers in the GEJE After the GEJE, I teamed up with midwives to provide aid and support to expectant and nursing mothers around the towns of Ishonomaki, Minamisanriku, Onagawa, and the city of Higashi-Matsushima in Miyagi prefecture. We often found that many expectant and nursing mothers did not explain their feelings on their fears and anxiety about their young children. At the shelters, we found many women suffering from sleep deprivation and dermatological problems. Women who were breastfeeding their babies had stopped lactating due to the shock of losing their spouses or other

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family members. In some cases, they could no longer think of or feel affection for their children. On television and other news outside disaster-stricken areas, survivors were often praised for their patience, which was reported as a “virtue.” People who could not exhibit patience were considered as either weak or spoiled, and those who lacked the ability to endure were shameful. However, endurance and patience are not a virtue at all, which give bad influence on the health of expectant mothers and infants. Usually, postpartum mothers and their infants need both medical and governmental support. However, both governmental systems fall into a state of paralysis as a result of the confusion if earthquakes and other natural disasters strike the area. In addition, their capacity of physical activity often reduced. To create a place to provide for MCH in times of disasters, each entity should operate efficiently without any gaps. In the disaster area, many obstetricians, gynecologists, midwives, pediatricians, and family doctors participated in expanding the support for MCH as part of disaster relief operations. Some people say that “Young children don’t seem to have any worries.” Some often asked, “With the youngest of these babies, in particular, we wonder to what extent they could understand the changes that have taken place due to such natural disasters!” They seem to imply that the children experiencing natural disasters suffer no ill effects. To this, one pediatrician replied saying, “For the babies, their mother is their shelter. They can sense their mother’s mental and emotional state. If the mother feels uncomfortable and lonely, their babies are affected as well.” Those words left deep impression on me. It made sense to me. Mother is a shelter of her child. Children as well as their mothers should be protected from any disasters. It has been demonstrated clearly that in developing countries, when a mother passes away, the infant mortality rate increases by 20–30 percent. This is a painful reminder that for a healthy development of children, it is essential that they have someone to raise them with love. Further, the Convention on the Rights of the Child guarantees the rights of all children to receive a good environment for life and indicates no child should be left behind. After the GEJE, I wondered why there were no considerations for perinatal, neonatal, or pediatric experts and staff, and for that matter, anything to do with providing MCH care as part of disaster responses and disaster medical treatment plans in Japan. During disasters, many people need rescuing and those who were seriously wounded required medical assistance. However, there was no acknowledgment that women experiencing pregnancies and childbirths required assistance, as well. It is assumed that pregnancies and births are not an illnesses, and, thus, are to be treated as usual issues. Childbirths are considered as a social and natural phenomenon based on a QOL model not being serious issue like illnesses are, which required the intervention of advanced medical technology. Since expectant women are rare in an aging society with declining birthrates, preventative care does not reach expectant women during disasters.

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After GEJE, my colleagues and I focused on children and mothers, whether they were among the rubble or in scattered shelters. We expressed our anxiety that expectant and nursing mothers were left in cold, hungry, and in unsanitary situations, which would worsen their health. However, the shelters, and the city governments had no time to hear them out. The standard responses were related to the belief that there were “other priorities here” or that they were “talking about more important matters during disasters.” Since there was no list of expectant and nursing mother evacuees, we organized the list by walking around in the shelters and interviewing expectant and nursing mothers about their medical status. This became the only dataset available for expectant and nursing mothers in the disaster-stricken areas of GEJE. While obstetricians and gynecologists (OB/GYNs) visited these sites to attend the needs of expectant and nursing mothers as well as of the infants, nothing much could be done. A cross-occupational support system connecting pre- and postpartum mothers with a support network, such as public health nurses, midwives, nurses, OB/GYNs, pediatricians, child care workers, school nurses, child consultation centers, psychiatrists, clinical psychologists, police officers, and various other professional occupations is essential to develop a support system. Most importantly such a system must be put in place well before a disaster strikes. At the time of GEJE I worked on the field, there was no information on how to connect mothers in need of pre- and postpartum support to individuals close to them or to other people in the community that could offer them such support. There were many mothers and children in need, but public health nurses and local government staff were already busy and worn-out and could not do much for them. It became clear that social resources such as counseling centers and hotlines for mothers and children should be utilized to help them access support. Organizations of community member and NPOs should have collaborative relations and share information during peacetime, to make a system in which each of their activities could be linked to the other during a disaster. Many reports have been published in other countries in relation to expectant and nursing mothers and some of them have drafted guidelines that are considered a global standard for maternal and child disaster relief [1–10]. As the support system for maternal and child aid during the Great Hanshin-Awaji Earthquake (GHAE) has been reported [11], lessons must be learned from GHAE in building support for survivors of GEJE.

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4.3 The Role of Administrators Within Governments During Times of Disaster in Providing MCH Care 4.3.1 Specific Processes for Establishing Disaster Relief Centers for Mothers and Children 4.3.1.1

Urgent Preparation for Disaster Mitigation

In 2011, when I was thinking about applying the lessons learned from the GEJE to help the next generation, there were numerous opportunities to share reports on assistance activities at the local midwife association and elementary schools, as well as in other disaster struck areas through support events in Bunkyo District, Tokyo. The “Future Bunkyo Festival—Thinking about Recovery and the Future as a region” (2012, Bunkyo District, Tokyo Junior Chamber Committee) was one such event, where I held a panel discussion with three mothers who had survived the earthquake in Ishinomaki City, Miyagi prefecture. Each discussed their experience of the earthquake and the aftermath and expressed their views on the preparedness required in dealing with disaster. The mayor of Bunkyo District, the district’s employees, and approximately 100 people in the child-rearing age attended the event. Upon hearing the stories shared by expectant and nursing mothers in the disaster-stricken areas, participants were able to imagine the consequences of delays in food delivery, the lack of access to medical care, and the lack of privacy. This was a unique opportunity for medical doctors and others who worked in the disaster-stricken areas to exchange thoughts and make recommendations to the district. In disaster-stricken areas, the risk of perinatal diseases, the rise of infectious diseases, and the risk of premature births, miscarriages, and postpartum depression are major causes for concern. The local disaster prevention plan of Bunkyo District has learned from those mentioned above. Before GEJE, no provision provided the special care during disasters for expectant and nursing mothers and infants. No specific measures had ever been discussed or set up. This then led to the revision and signing of a new agreement on disaster relief [12]. As part of the agreement, Bunkyo District signed documents with four women’s colleges within the district that agreed to provide shelter for expectant and nursing mothers, as well as infants during a disaster. The Tokyo Midwives Association and university hospitals within each district had agreed to support and assist such people. The content of the agreement reads as follows: When an earthquake of an intensity on the Japanese seismic scale of 5 occurs within Bunkyo District, based upon the decision of the district’s Disaster Countermeasures Headquarter, a shelter will be made for expectant and nursing mothers and infants (age 0) including those who are visitors to the district whose homes have collapsed or burned down by fire and thus lost a place to live. [13]

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Along with these documents, the “Local disaster prevention plan of Bunkyo District (2012)” was updated. This plan clarified the actions that needed to be taken to support expectant and nursing mothers and infants during a disaster.

4.3.1.2

Creating a Concrete Action Plan

Ninety-nine % of all maternal deaths occur in most developing countries, especially in rural areas and among poorer communities. Young adolescents under 15 years face a higher risk of complication and deaths as a result of pregnancy than other women [14]. According to the United Nations Population Fund (UNFPA), 61 percent of preventable maternal deaths take place in countries affected by humanitarian crises or fragile conditions. In 2015, the Office for the Coordination of Humanitarian Affairs (OCHA) estimated that 507 women and adolescent girls died every day from complications in pregnancy and childbirth in emergency settings [15]. In Japan, a plan to specifically address maternal health care during a disaster is poor. We need to establish learning community on global health expertise including a formula to calculate these vulnerable population to utilize disaster preparedness plan. Emergencies force people to flee their homes and to become internally displaced persons (IDPs) or refugees for an indefinite period of time [15]. Approximately 4 percent of the total refugee population may be pregnant—which means that out of a population of 100,000 people, 4,000 women will be pregnant in one year. Out of these 4,000 pregnancies, approximately 15 percent will end in a serious, potentially life-threatening complication. Japan’s crude birth rate (CBR) expressed per 1,000 population is 8.3 (in 2011) [16], which means that out of a population of 100,000 people, 800 women will be pregnant in one year. Out of these 800 pregnancies, approximately 15 percent need cesarean sections or an assisted birth technique and 1 percent will end in a serious and potentially life-threatening complication in emergency situation. To better prepare for disasters in the future, a formula is necessary to calculate the number of expectant and nursing mothers and infants that will need such services to admit to the shelters (Table 4.1). The next issue is to identify the amount of space necessary to accommodate these women and their children. If each evacuee would ideally require a space of 3.3 m2 , how much space would be necessary in all, and where would the emergency supplies be stored? The Bunkyo District administrative officer suggested signing an agreement with Women’s Colleges within the district. There are many benefits of using women’s colleges. First, it provides an excellent opportunity for their students to learn about the attitudes prevailing in and contributions made by the community and to learn about motherhood in general. Second, the disaster response system established would be connected to the district directly. Finally, the presence of sufficient emergency supplies and the installation of the communication network would benefit the colleges as well. In addition to the colleges that agreed to help, local government officials began to support this initiative by securing a budget.

4.3 The Role of Administrators Within Governments …

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Table 4.1 Estimated number of evacuees in need of care of maternal and child health Target population

Number of people

Annual number of births in a year (total number of births in the region): A

A

(1) Number of births per day at the time of the disaster daily number of births (B)

A ÷ 365

(2) Number of pregnant women Number of pregnant women pregnancy to full term

B x 280 days (gestation period)

Number of pregnant women from 37 to 40 weeks, and number B x 28 days of newborns (3) Postpartum mothers Number of postpartum mothers within 6 weeks of childbirth

B x 42 days

Number of newborns

B x 42 days

4.3.1.3

Design of a Concrete Social System

The manual and documents relating to the opening and operation of the shelter were articulated by the Bunkyo District and groups such as the Tokyo Midwives Association. The operators clearly defined each role and responsibility in writing. The universities that agreed to house evacuees are expected to constantly check on the safety of their facility and conduct regular inspections and appropriate maintenance operations. They must prepare to accept evacuees in the event of a disaster and help direct the students appropriately. The district offices must send a few women staff members to each shelter to act as liaisons between the shelter and the Disaster Countermeasures Headquarters. Additionally, they are responsible for overseeing communications. The Tokyo Midwives Association should visit each of the shelters and provide mental and physical care, triage, and respond to deliveries. The evacuees themselves should also volunteer to help run the shelter. It was also decided that firefighters and police, as well as neighboring citizens, would provide support in the operation of the shelter [17, 18]. Pregnant and postpartum women in Bunkyo District received a Maternal and Child Health Handbook and a “Maternal and Child Health kit,” as well as a flyer listing out all the mother and child shelters nearby. When this trial became a reality, I was tremendously happy and gratified to all of the efforts and ideas previously paid off. Many districts provide MCH Handbooks, other novelties, gifts, and smaller textbooks on MCH as a set to pregnant and postpartum mothers. However, they were not given a list of emergency shelters for mothers and children near them, so this measure helped raise awareness in favor of disaster preparedness. Since the establishment of the agreements and guidelines, the universities, the Tokyo Midwives Association, medical facilities, and district personnel from each area of responsibility decided to share and exchange their ideas and opinions together in one place to discuss activities conducted by the associated institutions at least once a year. This helps to create a sense of familiarity with one another in peacetime that will facilitate greater interaction during times of crisis. Additionally, once a year, associated institutions collaborate and undergo training for the acceptance of

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evacuees, on checking emergency supplies, reviewing maintenance, and altering system designs. Associated institutions also review the manual by evaluating the training to ensure that the lessons learned in the previous disaster are not forgotten. A detailed list of the emergency supplies necessary for the emergency shelter to provide for expectant and nursing mothers and infants, and the shelter layout are shared in reference item [17].

4.3.2 Creating an Emergency Response System to Meet the Regional Situation 4.3.2.1

Estimation of the Number of Expectant and Nursing Mothers

When one is going to create a resource like “Regional Medical Health Demand and its Resources,” there are several issues to consider in finding ways to handle a disaster. First, it is important to visualize the number of residents that will need special accommodation or assistance within one’s municipality when a disaster strikes. In addition, knowing the number of facilities and medical institutions available to support these people as well as the capabilities of each medical institution must be assessed. Even when there may be not enough time to have a detailed review, it is important to consider the number of people within the region that would require special accommodation or consideration, in order to gain an understanding of the situation. There are several issues to be considered while estimating such a number. For example, the following checklist may be used to determine the number of vulnerable people within a medical district: 1. 2. 3. 4. 5.

People with physical or mental disabilities (those with limited mobility, intellectual disabilities, internal disabilities, visual, or hearing disabilities). Elderly with dementia or physical weakness. Otherwise healthy infants who do not have the capacity to understand or make decisions. Foreigners who do not understand Japanese well enough to save their lives. Expectant and nursing mothers who have temporary limitations in their physical activities.

Based on these categories, it is possible to estimate the number of people and their population size and share that information within one’s department or within the area to provide support (Table 4.2) [12].

4.3.2.2

Information for Expectant and Nursing Mothers

If there are not enough plans for support at the municipal level, to start a maternal and child disaster relief project will be difficult [18, 19]. Based on interviews conducted

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Table 4.2 Calculation of the number of expectant and nursing mothers in Bunkyo District [12] Population of Bunkyo District

Approximately 200,000 people

Number of evacuees

The number of survivors of the disaster in the district: approximately 40,000 people (20% of the population)

Annual birth rate

Approximately 1,600 people per year Number of infant evacuees: Annual birth rate (1,600 people) x (2) Evacuation rate (20%) Evacuees of each type of mother (pregnant and postpartum): number of infant evacuees x 2

Total within the district

960 people

Estimated number of evacuees

Pregnant mothers: 320 infants: 320 mothers and infants: 640

among the staff of multiple municipalities, I received requests to create pamphlets targeted toward offering encouragement and awareness to mothers and children on disaster preparedness that could be used in parenting classes and parenting support salons [20–23]. As such pamphlets were not created ever by medical professionals specifically targeting health management facing a disaster, two awareness-based pamphlets were published for maternal and child disaster relief titled, “Disaster preparedness book for mother and baby” (Fig. 4.1), and the pamphlet titled “Asking for help,” based on my experience of visiting the shelters within disaster-stricken areas. Moreover, health checkups based on my research conducted among OB/GYNs are also provided [24, 25]. These pamphlets focused on two primary areas, namely, preparations to be made before a disaster strikes and health management after a disaster. One section of the pamphlets to which many responded positively was the concept of the “capacity to receive help,” not only in the moments of disasters, but by connecting the concept to one’s daily life, and by establishing ties with others, thus forming communities. This resulted either in lectures or the availability of information that were then used in workshops in approximately 30 municipalities so far.

4.3.2.3

Tools for Maternal and Child Support Provided by Local Governments During a Disaster

In addition to the above items, a shelter assessment sheet was created from the perspective of those who need special accommodation. Specific attention was paid to the establishment of a checklist to determine the presence of risks relating to mothers and children. The checklist was developed by the study team and was funded by the Ministry of Health, Labour and Welfare. This checklist can be used easily by both municipality personnel and medical staff even if they do not have any prior knowledge relating to disasters. They are simple enough to be customized to suit local situations and have been made available to the public (Figs. 4.2–4.7) [18].

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Fig. 4.1 Mother and baby disaster preparedness book for awareness-raising for mothers and children

Fig. 4.1 (continued)

4.3 The Role of Administrators Within Governments …

Fig. 4.1 (continued)

Fig. 4.1 (continued)

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Fig. 4.1 (continued)

Fig. 4.1 (continued)

4 Preparations for Maternal and Child Protection …

4.3 The Role of Administrators Within Governments …

Fig. 4.1 (continued)

Fig. 4.1 (continued)

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Fig. 4.1 (continued)

Fig. 4.1 (continued)

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Fig. 4.2 Special needs assessment for maternal and child health standard assessment form at the shelters [18]

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Figure 4.2 is the assessment sheet for those who need special accommodation. Recognizing those who need special considerations can help the municipal government personnel, midwives, and nurses predict and determine how they should be providing support and how to allocate medical resources. This assessment form was created with the support of the Health and Labor Sciences Research Grants (Research on Health Security Control) titled “Research on the Development of a Regional Collaborative Disaster Prevention System Including the Operation of Welfare Shelters for Those Who Require Assistance in Times of Disaster with the Central Focus on Pregnant and Nursing Women and Infants” in 2015 (Research representative: Honami Yoshida). The research group worked using the information gathering tool that was suggested at “A Workshop on MCH Function in Public Health in Time of Disaster” as a national standard for understanding the problems of MCH that affect the maintenance of the health of evacuees. The form is useful for not only by obstetricians and specialists in MCH but also by administrative staff members and supporters at the shelter. Notes for information gathering (assessment) using this form: • Prior preparation 1.

2. 3.

Gather information at great speed by paying full attention to the situation prevailing in the target shelter. In particular, try not to place an extra burden on the evacuees where the evacuees help each other. Information should be collected within 72 hours after the disaster and when life under evacuation is expected to be prolonged. If the form is used by persons outside the shelter, ask them to follow the instructions. To make arrangements is available at the site from the headquarters whenever possible and collect information through the form after obtaining preliminary information on the shelter.

• Procedure for Assessment 1.

2.

3.

Introduce yourself to the person responsible for the shelter or person in charge of health management. Show the ID and explain the purpose of your visit. Collect information after obtaining consent and cooperation of the person responsible. Choose a method to collect information that suits the situation of each shelter (hearing, observation, etc.). Understand and describe the information generally within a short period of time so that burdens are not placed on evacuees and administrative staff. At the end of information gathering, present an overview of the results to the person responsible (or person in charge of health management, etc.), review the information by submitting a copy of the form, if possible, tell him/her that the results will be utilized in providing necessary support, and indicate that you will

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4.

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visit the shelter continuously to gather additional information. You may hand in leaflets for dental and oral health management for shelters, as well. Specify unknown information in this form as “Unknown,” or in another similar manner to distinguish from information that has been “omitted” and report the information to the MCH department of the headquarters at site (public health and welfare office or dental association).

Note that “Shelters, etc.” in this assessment form refers to a place to accommodate people after a disaster by providing overnight stay and meals. Therefore, welfare shelters are for those who encounter difficulties in their normal lives and require assistance, including the elderly, the disabled, and sickly people. In a broader sense, welfare facilities to respond to disaster-related impact and accommodation, including homes, are included. Figures 4.3 and 4.4 present the mother and child profile questionnaire. After each individual fills the form with details on the required items, these data will be placed together on a mother and child evacuee list which will be mentioned in later. Mothers and children who enter this information will be given room assignment as seen in Fig. 4.6. When this tag is displayed, they are given priority in terms of access to space and items that are being distributed. Consultant staff are present to help make it easier to indicate which items are in short supply or if there are an issue that needs to be resolved. Systems were created, by two midwives, Ms. Akemi Nakama and Ms. Mayumi Tsuchiya. They are in charge of the disaster management project in the Tokyo Midwives Association. The evacuee list in Fig. 4.5 is particularly significant because in past disasters caused by earthquakes, no such list used by evacuation shelters was drawn out. In the direct aftermath of a disaster in which there is much confusion, it is understandable that the municipal government staff may have a short time generating a list of mothers and children in need of help. However, if a questionnaire such as the one shown in Figs. 4.3 and 4.4 (patient profile questionnaire) are to be distributed and filled out by the mothers themselves, waiting time of mothers could be reduced. Having a system that operates before disasters strike in which mothers could be requested to fill their patient profile questionnaire would allow these women to receive a room and access care immediately after a disaster. Mothers and children would then be able to receive various considerations and assistance, leading to an incentive for the mothers to fill out the forms. Consequently, this would also make it easier for them to reach out for help whenever they need it. Further, the room assignment chart in Fig. 4.6 will be useful in understanding those who need special accommodation in the shelter, such as mothers and children requiring separate spaces from other evacuees. Lastly, the medical check list for perinatal care in Fig. 4.7, for expectant and nursing mothers, would be useful when mothers and children moved from the disaster-stricken areas. It would also be useful for those in municipal governments and shelter operational staff members who have little knowledge of MCH.

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Fig. 4.3 Mother and child patient profile questionnaire (Mother) [18]

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Fig. 4.4 Mother and child patient profile questionnaire (Infant) [18]

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Fig. 4.5 Evacuation shelter evacuee list [18]

To keep these tools ready before any disaster strikes can help take quick action to assess the status of the most vulnerable people in society, namely, mothers and children. Public health nurses can connect them to appropriate support during a disaster.

4.4 Conclusion There are several hurdles in the path of creating a relief system for mothers and children. To overcome those hurdles, many professionals have collaborated within a research group to improve the system. Seminars have also been useful in informing the health management system. Support tools that have proved to be useful have been shared and such information will be used along with existing policies in each region to improve the response to MCH needs. When the next disaster strikes, the information provided here will help save as many expectant and nursing mothers, fetuses, newborns, and infants as possible.

4.4 Conclusion

Fig. 4.6 Room assignment table and accommodation chart [18]

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Fig. 4.7 Medical check list for perinatal care [18]

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Acknowledgements This study was supported by the following research grants: 1. Health and Labor Sciences Research Grants (Research on Health Security Control) “Research on the Development of a Regional Collaborative Disaster Prevention System Including the Operation of Welfare Shelters for Those Who Require Assistance in Times of Disaster with the Central Focus on Pregnant and Nursing Women and Infants” (Research representative: Honami Yoshida, 2013–2015). 2. Grants-in-Aid for Scientific Research “Maternal and Child Health Required in Times of Disaster - from Research on the Impacts of the GEJE on Maternal and Child Health” (Research representative: Honami Yoshida, 2012–2014). The author thanks to Dr. Kentaro Hayashi and others who provided help at the Primary Care for All Team (PCAT), PCOT project members that include Dr. Hiroshi Ota, Dr. Yumie Ikeda, Dr. Keiko Otsuka, Ms. Yukari Endo, and Mw. Shoko So, who have contributed to developing training for rescuing pregnant and nursing women in times of disaster; and Dr. Yosuke Fujioka and Dr. Shinji Tsunawaki who have worked to address the needs of pregnant women from the inception of the PCAT. The author also thanks to Mw. Naoko Nakane for her dedicated education on this field.

References 1. Anwar J, Mpofu E, Matthews LR, Shadoul AF, Brock KE (2011) Reproductive health and access to healthcare facilities: risk for depression and anxiety in women with an earthquake experience. BMC Public Health 11:523 2. Biddinger P, Savoia E, Massin-Short SB, Preston J, Stoto MA (2010) Public health emergency preparedness exercises: lessons learned. Public Health Rep 125:100–106 3. Collaghan WM, Rasmussen SA, Jamieson DJ, Ventura ST, Farr SL, Sutton PD, Mathews TJ, Hamilton BE, Shealy KR, Brantley D, Posner SF (2007) Health concerns of women and infants in times of natural disasters: lessons learned from hurricane Katrina. Matern Child Health J 11:307–311 4. Dole N, Hertz-Picciotto I, Siega-Riz AM, McMahon MJ, Buekens P (2003) Maternal stress and preterm birth. Am J Epidemiol 157:14–24 5. Glynn LM, Wadhwa PD, Dunkel-Schetter C, Chicz-DeMet A, Sandman CA (2001) When stress happens matters: effects of earthquake timing on stress responsivity in pregnancy. Am J Obstetric Gynecol 184:637–642 6. Yamaji K (2011) Institutional design of individual units and family units on disaster victim directory in Japan. Inst Res Disaster Areas Reconstr Kwansei Gakuin Univ 3:73–84 (in Japanese) 7. Emarson E, Fothergill A, Peek L (2006) Gender and disaster: foundations and directions. In: Rodriguez H, Quarantelli EL, Dynes R (eds) Handbook of disaster research. Springer, New York 8. Women’s Commission for Refugee Women and Children (2007) Minimum initial service package (MISP) for reproductive health in crisis situations: a distance learning module, p 93 9. American Red Cross (2002) Standards for hurricane evacuation shelter selection. ARC4496. 2002.1, p 2 10. Japan Society of Obstetrics and Gynecology & Japan Association of Obstetricians and Gynecologists (2011) Low risk pregnancy and birth treated by birth center with midwives. In: Guideline for obstetrical practice in Japan, pp 214–221 (in Japanese) 11. Hyogo Prefectural Society of Obstetrics and Gynecology (1996) Epidemiological study report on the impacts of stress by Great Hanshin Earthquake on pregnant and nursing women and fetuses (in Japanese) 12. Suzuki H (2012) Notice on concluding disaster prevention agreements in local government. Preced Local Gov 361:106–120 (in Japanese)

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13. Suzuki H (2012) Risk management on disaster vulnerable population. Local Gov Res 88:105– 126 (in Japanese) 14. WHO (2019) Maternal mortality. http://www.who.int/en/news-room/fact-sheets/detail/mat ernal-mortality. Accessed 9 Feb 2021 15. United Nation’s Population Fund (2015) Maternal mortality in humanitarian crises and in fragile settings. https://www.unfpa.org/resources/maternal-mortality-humanitarian-crisesand-fragile-settings. Accessed 9 Feb 2021 16. World bank (2018) Birth rate, crude (per 1,000 people)—Japan. World Bank Open Data. https:// data.worldbank.org/indicator/SP.DYN.CBRT.IN?locations=JP. Accessed 29 Mar 2021 17. Tokyo Metropolitan Government (2013) Guidelines for shelter management (for municipalities), pp 132–135 (in Japanese) 18. Yoshida H (2016) Research on the development of a regional collaborative disaster prevention system including the operation of welfare shelters for those who require assistance in times of disaster with the central focus on pregnant and nursing women and infants (Health and Labor Sciences Research Grants, 2013–2015, number 22761296) (in Japanese) 19. The Sphere Project (2018) The sphere handbook 2018. https://spherestandards.org/handbook2018/. Accessed 29 Mar 2021 20. Disaster Management, Cabinet Office (2015) Report on the 3rd working group of improvement of the security and quality of shelter review meeting (in Japanese). http://www.bousai.go.jp/ kaigirep/kentokai/hinanzyokakuho/wg_situ/dai3kai.html. Accessed 29 Mar 2021 21. Nakaita I (2015) Roadmap of mental health care booklet. http://www.bousai.go.jp/kaigirep/ kentokai/hinanzyokakuho/wg_situ/pdf/dai3kaisankou3.pdf. Accessed 29 Mar 2021 22. Haruna M, Yoshida H (2013) Mother and baby disaster handbook (in Japanese). http://www.bou sai.go.jp/kaigirep/kentokai/hinanzyokakuho/wg_situ/pdf/dai3kaisankou4.pdf. Accessed 29 Mar 2021 23. Yoshida H (2013) Asking for help handbook (in Japanese). http://www.bousai.go.jp/kaigirep/ kentokai/hinanzyokakuho/wg_situ/pdf/dai3kaisankou5.pdf. Accessed 29 Mar 2021 24. Tokyo Metropolitan Government (2014) Guidelines for disaster management on saving maternity citizens and children (in Japanese). http://www.fukushihoken.metro.tokyo.jp/kodomo/shu ssan/nyuyoji/saitai_guideline.files/guideline.pdf. Accessed 29 Mar 2021 25. Yoshida H, Hayashi K, Ota H, Ikeda Y, Otsuka K, Harada N, Arai T, Fujioka Y, Haruna M, Nakao H (2015) Perinatal outcomes in aftermath of Great East Japan Earthquake and the way how maternal child health support team (Primary Care for Obstetrics Team: PCOT) responded. J Jpn Primary Care Assoc 38:136–142 (in Japanese)

Chapter 5

Issues to be Solved on Mother and Child Health Care in the Disaster

Abstract For mothers and children facing the disaster, three perspectives must be taken into account: the perspective of aid providers, the perspective of local governments, and the perspective of the person experiencing the disaster. How to design a systematic approach to evacuations affecting mothers and children should be considered based on evacuee’s real experiences. For example, families with younger children could not stay in refugee facilities because children frequently cried and were noisy. Supplies were not given for evacuees at home. Thus real statements of evacuee tell us what should be done. Consideration for the safety needs of families with women and infants is still insufficient, which may cause population declines in the disaster area. An increasing number of municipalities in Japan now construct the system to offer effective services based on evacuees’ demands. Keywords Evacuee at home · Sphere project · Population dynamics

Abbreviations DMAT GEJE MCH PCAT RQ WASH WE

Disaster Medical Assistance Team Great East Japan Earthquake Maternal and Child Health Primary Care for All Team Citizens Disaster Relief Network Japan Water Supply, Sanitation, and Hygiene Promotion Women’s Eye

© The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2021 H. Yoshida, Lessons Learned from the Great East Japan Earthquake, Population Studies of Japan, https://doi.org/10.1007/978-981-10-4391-8_5

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5.1 Introduction On April 1, 2011, three weeks after the Great East Japan Earthquake (GEJE), I began running medical examinations for pregnant women around the evacuation center based on the information received from Dr. Fujioka, a primary care physician of Japan Primary Care Association, Disaster Relief Project, and Primary Care for All Team (PCAT). I visited the refuge facilities in the area, carefully keeping a copy of the pregnant women’s medical charts. Since refuge facilities were situated apart from each other, it took three hours to reach each site by car. I noticed that there were no medical records on emergency for pregnant women in the shelters; no pregnancy checklist, questionnaires, and notes nor the charts specific to pregnant women were prepared in the Japan Red Cross, disaster medical assistance team (DMAT), and any other disaster relief team. The risk assessment sheet or checklist for pregnancy process might raise concerns for risk management in perinatal care. Moreover, many mothers lost their Maternal and Child Health (MCH) handbooks. In the facilities, neither copy machines nor computer devices were used to save medical questionnaires and create datasets. The health care of mothers and children, especially pregnant women, should be recognized by an understanding of the status of regional medical and home healthcare activities, such as obstetric examinations and childbirth visits. It was necessary to alert the local government on the establishment of a system to prevent pregnant evacuees from being left underserved. However, there were so many issues to manage in public health system or policy after the disaster, so the local government couldn’t provide aid for MCH care. After several dispatches to disaster area, my colleagues developed an assessment sheet to use exclusively for pregnant women to unify the interview items, as seen in Chapter 4. These pregnancy risk assessment sheets became a prototype for the development of the pregnancy and child care tool. In the Ministry of Health, Labor and Welfare (MHLW) policy and notice about disaster prevention, there were no words of pregnant mothers, and families with newborns. This chapter explores the problems and obstacles of mothers and infants facing a disaster based on their real experiences.

5.2 Insufficient Support System for Evacuees at Home Here we intend to clarify the issues encountered while providing support for mothers and children who take refuge in their own homes during a disaster. The research was led by Ms. Megumi Ishimoto with gender perspective, who was a leader of a nonprofit called Women’s Eye (WE) and she raised three points based on statements made by disaster volunteer groups that worked during the emergency support period after the GEJE. They visited the disaster evacuation shelter and supported women evacuees [1]. The points are as follows:

5.2 Insufficient Support System for Evacuees at Home

1.

2.

3.

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Families with children under elementary school-going age left the uncomfortable refuge facilities, and sought refuge in their own homes because they could not manage to live in the evacuation shelter. It is difficult to provide supplies and information to families taking refuge in their own homes, since there was no local system to get the information of evacuees who have left the shelter. The unfairness on the degrees of support provided at refuge facilities and in homes caused an adverse impact on the community. The reason of unfairness was simply because there were no support systems for evacuees at home: they were considered to be able to live in their own house, but they needed food and daily necessaries because of no resources. However, current rule of emergency shelter, the relief supplies, and food are only for people in the shelter, not for evacuees at home.

5.3 Issues on Perinatal Medical Support in Disaster Area 5.3.1 Medical Support by Medical Team in Foreign Countries We have little experience to be supported by foreign government until this disaster, GEJE. The village of Minami Sanriku accepted medical support of pediatrics and obstetrics from foreign countries after the GEJE. Mr. Sato, a governor of Kuriharacity has a private relationship with Israel medical team and help match accepting the international medical support team and the village of Minami Sanriku [@Israel medical team activity overview on medical support in GEJE: https://www.mofa. go.jp/mofaj/saigai/iryou_israel.html] Medical teams from Israel were fully selfcontained and specialists in internal medicine, surgery, pediatrics, obstetrics and gynecology, otolaryngology, and other fields offered help on ground. They brought their own “mobile clinics” to provide support to people affected by the disaster. This well-experienced team was dispatched to provide support during other disasters in the world, too, such as the Haiti earthquake, and had access to abundant equipment, particularly for obstetric care. This team brought with them portable ultrasound devices, examination tables, delivery tables, and neonatal resuscitation facilities. Dr. Fujioka and Dr. Tsunawaki, both of whom were Japanese physicians were impressed by the Israeli team and its work. Since maternal care had deteriorated during the disaster, they consulted a pregnant woman from Onagawa, to gather information on the support received from the Israeli team.

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5.3.2 Difficulty on Medical Support for Pregnant Women in the Disaster Area Enough obstetricians and gynecologists were dispatched from university hospitals nationwide through academic societies in disaster hospitals in the affected areas, and the manpower was sufficient for the smooth conduct of hospital operations. However, these obstetricians could not arrive at the shelters and clinics because the roads were cut off. As no connection existed between local communities and pregnant women who were left in the area, they could not get sufficient perinatal care because of the difficulty in accessing the hospital. Moreover, there were no obstetrics experts in the rescue team that visited the shelter in the area. It is necessary for the prefectural office to be aware of the importance of treating pregnant women appropriately, and to ensure that there is no disruption in the flow of information from the municipal office and public health nurses to mothers. Obstetricians and gynecologists should provide information on the state of pregnant women to the regional hospitals who can understand the situation, and can confirm whether women can be admitted immediately after going into labor and remain hospitalized postpartum for two to three days. A follow up has begun to see that the pregnant women and newborns are taken care of by interacting with the municipal health and welfare division to provide postnatal care and undertake neonatal visits. We asked humanitarian support from the midwife association and provided data concerning the presence of pregnant women or infants in refuge facilities and details of examinations performed in the shelter each day. The healthcare workers from the neighboring town were asked to provide support and to share the information with local government. However, developing measures to ensure the health and safety of pregnant women and infants at risk in disaster situations were critical for the management of refuge facilities and shelters. It is essential from the perspectives of both aid providers and the survivors themselves, that pregnant women and newborns must be gathered in the same room for being provided adequate support even in disaster. Perinatal care, supplies, and information could be shared with local mothers and infants.

5.4 Population Dynamics in the Disaster Area: The Role of Local Governments A survey was conducted by Gender Equal Society Division in Miyagi Prefecture targeting 35 municipalities in Miyagi Prefecture in 2012, one year after the GEJE. The questionnaire surveys were conducted from mid-June to early July 2012 and interviews were conducted from late July to September 2012. The findings were published in a report titled “Study report on the formation of gender equality for the disaster sufferer support in the GEJE affected area.” The report was valuable as it

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offered insights on the status of gender equality in providing aid for survivors of the GEJE, which appears in the report [2]. In these municipalities, people tended to believe that consideration for the safety needs of families with women and infants was insufficient, and exhibited population declines of approximately 20–40% according to the national census of five years after the earthquake. Other factors such as major property damage due to the tsunami, the absence of women’s hospitals, and the rise in the elderly population since the earthquake are considered to be related to this population decline. It became clear that the careful consideration of mothers and children during the acute stage and aftermath of a disaster was necessary. Currently, many local governments in the affected areas are trying to rejuvenate their hometown through redevelopment projects, ward development projects, and reconstructed public housing. However, various indicators of restoration show that population dynamics remain in lower level. The Japanese Population Association stated that the declining birth rates and the shrinking population were the manifestation of the mindset pertaining to raising children. The demographic theory [3] that “the declining birthrate is an adaptive response: the public’s assessment of modern society (birth rate = referendum)” and the results of the survey examining whether the social environment was supportive of young people and the child-rearing generation in the event of a disaster may arrive at the same conclusions. To provide a support and assessment of the conditions of survivors in the disasters needs developing predictions and plans in advance and preventing the loss of the region’s inheritors by cultivating an environment. The tools necessary to manage refuge facilities were described in Chapter 4 in this book. Municipalities throughout the nation have started to use these tools since 2013 [4].

5.5 Oral History of Mothers Survived from Disasters After the GEJE, the statements concerning mothers and children, focusing on their anxiety were recorded by the volunteer group of Citizens Disaster Relief Network Japan (RQ) (http://www.rq-center.net/wp/lang/en.html). They worked in the Sanriku coastal area of Miyagi Prefecture during the emergency support period from the report on shuttles to refuge centers, report on delivery vehicles, aid supplies request sheets, women’s request sheets, and delivery reports. In addition, sections concerning investigations on evacuee mothers were extracted from the reports, homepage, and internal documents of RQ. This contained in the activity records of WE (Women’s Eye), a group that operated in the Sanriku coastal area of Miyagi Prefecture during 3 years immediately after the earthquake in May 2011 until February 2014. We handled this personal information carefully and obtained the informed consent of the interviewees regarding the publication of the content of their interviews.

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5.5.1 Difficulty of Families with Children Under Elementary School-Going Age Staying in Refugee Facilities Families with children younger than the elementary school-going age leave refuge facilities earlier than the other families. Many families with children in this age group tend to decide to stay at home because of lack of privacy and noisy attitude by their kids and babies. The interviews conducted by RQ volunteers with families who left shelters because of their children’s needs have revealed the statement as follows: “Family with children aged one year and five years and elderly people suffering from dementia left the refuge after a month.” “There are no homes, no workplace of my husband. I live in my parents’ house. Two children aged one year and three years live with us. We have a car, but I cannot receive supplies, because I don’t stay in a refuge facility.” “My son’s wife went with her two-year-old son to my parents’ house. She is expected to give birth in August.” “My family fled to my wife’s parents’ home (in Akita) with children aged one year and five years.”

According to a women survivor from Kesennuma, Miyagi Prefecture, who lived in a shelter for one week and then returned home to support the community, some families were told that their children were noisy and began to feel that they were no longer welcome to stay in the refuge facility. Families with children in refuge facilities are forced to be calm, which give them much stress. Some children were hurt by abuse and complaints by adults around them, and in some cases, the children and their family were obliged to leave the area. Before the disaster, there were approximately 30 children in the area (aged less than 20 years); however, only about 10 were left a month after the earthquake, and since then, children have gradually moved from the area. In addition, young mothers could not request help, even when they needed diapers or milk. Even though refugees had various needs, communication with other people was poor, and that made providing adequate responses difficult. According to the “Major statistics by prefecture/municipality” and “Population rankings by municipality and number of households” sections of the 2010 national census data, 31% of the households in the area comprised children in 2010 (households consisting of a married couple and children, male parent with children, or female parent with children) (Ofunato: 28%, Rikuzentakata: 29%, Kesennuma: 31%, Minami Sanriku-cho: 30%, Ishinomaki: 35%). However, this figure assumes that children are unmarried and aged less than 20 years. In addition, the average demographic proportion of children aged less than 14 years in the area in 2010 was 11.9% (0~14 years-old population: Ofunato: 11.9%, Rikuzentakata: 11.7%, Kesennuma: 11.9%, Minami Sanriku-cho: 12.6%). Although it is difficult to compare the number of households with children below the elementary school-going age before and after the earthquake, few households had children in this age group before the disaster, and it is speculated that the number of these households rapidly increased among those taking shelter at home after the earthquake.

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5.5.2 Difficulties in Obtaining Supplies and Information for People Who Stayed at Home The results of our interview with RQ mainly concerning supplies provided to homes between March 24 and April 9 evoked the following responses: “There was an infant aged eight months. The house where the baby was staying did not have enough blankets.” “While large-scale refuge facilities receive supplies daily, almost no supplies were provided to small refuge facilities.” “Supply provision does not reach the people in isolated areas or homes that could not make it to refuge facilities. Futons, rice, water, baby supplies; one person is tasked with delivering these supplies to about 50 homes.” “It is possible that food and supplies are accumulating at refuge facilities. It is impossible for people who take shelter at home to access it.” “When I go to the refuge facilities, people there glare at me and say, ‘You still have your home, is that not enough?’ I feel uncomfortable, but we need water for our infants.”

In an interview with all the municipalities in Miyagi Prefecture on support for people taking shelter at home, it was heard that there was a complaint that only people in refuge facilities received supplies, while those taking shelter at home did not. The ward administrator came to provide necessary supplies to people taking shelter at home. The commissioned welfare volunteer members understood people’s needs, but it was difficult for the staff to attend to home evacuees, because of insufficient manpower. RQ distributed information to pregnant women and infants taking shelter at home on flyers labeled “To pregnant women and mothers with babies.” In addition, Peace Jam (a non-profit providing supplies to meet childcare needs) provided support and RQ provided request sheets for women’s needs. During our interviews with these groups, they indicated, “There are pregnant women (expected to give birth by the end of June). There are almost no supplies for newborns, and there is a lack of childcare support information.” “If you can provide a temporary place for infant care, we would be grateful. We request people’s kindness and support for children and parents.” During the interviews conducted in each municipality in Miyagi Prefecture, some of the remarks received included: “Pregnant women said that to stay in refuge facilities was good. Medical cares by nurses were carried out, but no one knows the situation of pregnant women who remained at home.” When asked about their understanding of infants’ status and childcare support, it was stated that “out of 34 cities, towns, and villages, only one town responded saying that it was able to provide support” and one town indicated that they “were able to receive pregnant women, provide obstetric examinations, and offer obstetric care.” According to a disaster victim from Kesennuma in Miyagi Prefecture, mental health care for children was also necessary immediately after the earthquake to address issues such as mental instability, flashbacks, and somatic disorders after seeing the horror of bodies washing away.

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In interviews and seminars at WE, an NPO which promote gender perspective in disaster support, many voices were reported about conflicts between those in refuge centers and those who stayed at home, as those who took shelter at home were bullied for going to refuge facilities for baby supplies, food, and drinking water. This occurred immediately after the disaster and continued for about three years thereafter.

5.5.3 Case of Single Parent Families Single parents were not provided with much support or attention at refuge facilities or at home. The statements are as follows: “My friend is a single mother and I am concerned that she is depressed and her personality has changed.” “A mother and a child need mental care.” “My daughter lost her husband and lives in temporary housing with two children of elementary school-going age. They come once a week to parent’s home.”

Originally in Japan, single mother families had very low-income levels. After the disaster, information concerning special supports for them were insufficiently provided.

5.6 Equal Support for MCH Care in the Disasters The Sphere Project [6], which is an international effort to improve the quality and accountability in humanitarian assistance activities carried out after disasters indicated that survivors have three key rights, namely (1) the right to life of dignity, (2) the right to receive humanitarian assistance, and (3) the right to protection and a safe environment. In particular, water and sanitation are important elements that impact survival during the early stages of disasters. Thus, all groups will fairly and safely provide water supply, sanitation, and hygiene promotion (WASH) resources to disaster-affected populations, and we are working on activities that can use the provided facilities and reduce public health risks. Ultimately, “design and response” guidance, one of the core standards, is important. Assistance should be provided without discrimination to all people in need and equal accesses are necessary.

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5.7 Conclusion The research project, Investigation of the shelter for mothers and children in disaster, comprises experts in various related fields such as disaster medicine, obstetricians, gynecologists, and midwives and considers the types of resources and support needed to operate a specialized refuge facility for pregnant women and infants [6]. Factors concerning the stockpiling of supplies, fostering public awareness, and disseminating information were identified using key phrases such as “a place where supplies are provided” and “a place where mothers can have friendly exchanges and restore their support systems” [7–9]. Even in the case of mothers who take refuge in their own homes or mothers who leave the refuge facilities out of necessity, their families must be able to receive subsequently provided support comfortably as they continue to be “people who are prioritized during disasters.” In addition, providing a list of goods stocked at the refuge facility for mothers and children in Tokyo’s Bunkyo Ward, a layout diagram of rooms, and a list of disaster support activities would be helpful [10]. In “The Sphere Project Handbook” mentioned above, the promotion of breastfeeding in refuge facilities after disasters, establishing nursing rooms, a method of calculating the minimum necessary nutritional value for mothers and children, coordinating the ratio of men’s to women’s toilets as 1:3, and prevention of sexual harm are necessary in order to provide maximum support and protection to mothers and children. From the perspective of rebuilding and supporting the local community, attitudes toward mothers and children must not stop at consideration, but become more aggressive and offer protection, respect, and lifestyle support. Acknowledgements This study was supported by the following research grants: 1. Health and Labor Sciences Research Grants (Research on Health Security Control) “Research on the Development of a Regional Collaborative Disaster Prevention System Including the Operation of Welfare Shelters for Those Who Require Assistance in Times of Disaster with the Central Focus on Pregnant and Nursing Women and Infants” (Research representative: Honami Yoshida, 2013–2015). 2. Grants-in-Aid for Scientific Research “Maternal and Child Health Required in Times of Disaster—from Research on the Impacts of the GEJE on Maternal and Child Health” (Research representative: Honami Yoshida, 2012–2014). The author thanks to Dr. Kentaro Hayashi and others who provided help at the Primary Care for All Team (PCAT), PCOT project members that include Dr. Hiroshi Ota, Dr. Yumie Ikeda, Dr. Keiko Otsuka, Ms. Yukari Endo, and Mw. Shoko So, who have contributed to developing training for rescuing pregnant and nursing women in times of disaster; and Dr. Yosuke Fujioka and Dr. Shinji Tsunawaki who have worked to address the needs of pregnant women from the inception of the PCAT. The author also thanks to Mw. Naoko Nakane for her dedicated education on this field.

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References 1. Ishimoto M (2013) Disaster victims support activity of women’s eye (WE). In: Yoshida H (ed) Report of the Grant-in-Aid for Scientific Research (no. 22761296) “Research on the development of a regional collaborative disaster prevention system including the operation of welfare shelters for those who require assistance in times of disaster with the central focus on pregnant and nursing women and infants” (in Japanese) 2. Miyagi Prefecture (2012) The promotion of the formation of gender equal society division in Miyagi prefecture (in Japanese). http://www.pref.miyagi.jp/uploaded/attachment/222031. pdf. Accessed 29 Mar 2021 3. Kaneko R (2014) Demographic perspective—structure and trends of declining birthrate. The Population Association of Japan 66th Annual Meeting Abstracts (in Japanese). http://paj66th. web.fc2.com/abs/sym1.pdf. Accessed 29 Mar 2021 4. Yoshida H (2013) Research on the development of a regional collaborative disaster prevention system including the operation of welfare shelters for those who require assistance in times of disaster with the central focus on pregnant and nursing women and infants. Grant-in-Aid for Scientific Research (no. 22761296) (in Japanese) 5. The Sphere Project (2018) The sphere handbook 2018. https://spherestandards.org/wp-content/ uploads/Sphere-Handbook-2018-EN.pdf. Accessed 29 Mar 2021 6. Disaster Management, Cabinet Office (2015) Report on the 3rd working group of improvement of the security and quality of shelter review meeting (in Japanese). http://www.bousai.go.jp/ kaigirep/kentokai/hinanzyokakuho/wg_situ/dai3kai.html. Accessed 29 Mar 2021 7. Nakaita I (2015) Roadmap of mental health care booklet (in Japanese). http://www.bousai.go.jp/ kaigirep/kentokai/hinanzyokakuho/wg_situ/pdf/dai3kaisankou3.pdf. Accessed 29 Mar 2021 8. Haruna I, Yoshida H (2013) Mother and baby disaster handbook (in Japanese). http://www.bou sai.go.jp/kaigirep/kentokai/hinanzyokakuho/wg_situ/dai3kaisankou4.pdf. Accessed 29 Mar 2021 9. Yoshida H (2013) Asking for help handbook (in Japanese). http://www.bousai.go.jp/kaigirep/ kentokai/hinanzyokakuho/wg_situ/pdf/dai3kaisankou5.pdf. Accessed 29 Mar 2021 10. Tokyo Metropolitan Government (2013) Guidelines for shelter management (for Municipalities), pp 132–35 (in Japanese)

Chapter 6

Personal Health Record (PHR) System for Maternal and Child Health Care in Disaster

Abstract Promoting relationships with neighbors and creating an environment that encourages people to help one another during disasters and in normal times are effective way in supporting mothers and children. Medical personnel should consult with municipalities during normal times to determine ways in which they can support mothers and children during a disaster. Maternal and child health (MCH) policy that promote maternal and child well-being after disasters, such as maternity checkups and vaccinations, should be designed. If data on medical facilities, municipalities, and child-rearing parents can be gathered, shared, and utilized in a personal health record (PHR) system, the quality of support for pregnancies, births, and child-rearing can improve significantly. Today, there are multiple businesses and entities involved in maternal and child health care. However, while they are interconnected in complex ways, their businesses, institutions, and administrative tasks are neither cooperative nor well integrated. For this reason, the merits of users carrying their own data are being discussed, and it has become a pressing need to create a tool for data sharing and communication for stakeholders. The PHR system is created with the goal of enabling individuals to personally own their information and to protect their lives and health through a collaborative network. Keywords Information and communication technology (ICT) · Personal health record (PHR) system · My Me-Byo record

Abbreviations EMIS GEJE ICT MCH PHR

Emergency medical information system Great East Japan Earthquake Information and communication technology Maternal and child health Personal health record

© The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2021 H. Yoshida, Lessons Learned from the Great East Japan Earthquake, Population Studies of Japan, https://doi.org/10.1007/978-981-10-4391-8_6

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6.1 Introduction A solid emergency preparedness system and a training system to help the life of mothers and children are needed. In Japan, maternal and child health (MCH) was the last item on the list in disaster response and preparedness, although it is commonly recognized that the most vulnerable people suffer from various types of health issues right from the onset of disaster until several decades later. Lessons from the recent disasters, however, have promoted the necessity to connect each mother with local MCH care system in disaster response and preparedness, including an emphasis on maternal and child shelters. In this chapter, the construction of a personal health record (PHR) system will be presented to protect the next generation and to facilitate regional collaborations in times of disaster. As we mentioned in the previous chapter, Japan is one of the world’s most disasterprone countries and has experienced all kinds of disasters, from natural disasters such as earthquakes, tsunamis, floods, and snow disasters, including infectious diseases, to human disasters such as nuclear accidents, chemical weapons (sarin gas), and train accidents. During the global pandemics such as Severe Acute Respiratory Syndrome (SARS) in 2002, Middle East Respiratory Syndrome (MERS) in 2012, and H1N1 Influenza in 2009, various laws and systems have been put in place to prevent and contain the spread of infection in Japan. The December 2019 outbreak of a new coronavirus infection (COVID-19) affected all social systems, including health care, economy, transportation, and lifestyle, and was so devastating that it has been described as a syndemic. As of the end of 2020, 8.334 million people worldwide (230,000 in Japan) have been infected and 1.81 million people (3,400 in Japan) have been reported to be killed. What is the impact of infant health checkups and vaccination rates on maternal and child health policies in Japan? In Japan, as a result of the declaration of a state of emergency on April 7, 2020, infant health checkups and vaccinations were cancelled or postponed by local governments for more than half year nationwide [1]. From now, we will require to replace face-to-face checkups with telephone checkups, consultations via social networking services, remote support and information provision to infants and young children using online calling systems and smartphone applications, and recommendations for vaccinations, while ensuring that we take the most reliable methods available. In fact, in Kanagawa Prefecture, the healthcare ICT (Information and Communication Technology) tool system has been implemented. By linking Kanagawa Prefecture’s health management application, “My ME-BYO Chart,” with a private smartphone application, “Maternal and Child Health Handbook Application (booklets with health record about pregnancy, delivery, and child-bearing until 7 years old provided by telecommunications company),” it is possible to manage vaccination and medical checkup records, as well as medications and allergies in one place. Each municipality has its own interactive communication function with residents (Fig. 6.1).

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People record health informa on in ordinary mes MY ME-BYO Record Database

Children / Family

Data sharing

Efficient support given with the current status accurately

Disaster ApplicaƟon

Supporters PHN

DMAT (Medical Teams)

Emergency Response HQs by Municipali es

Health informa on

New Disaster Response System

Evacua on Shelter Informa on i.e. Number of evacuees, hygene status

Fig. 6.1 Supporting for vulnerable people in evacuation shelters by using PHR app (MY MEBYO record) (PHN: Public Health Nurses, DMAT: Disaster Medical Assistance Team, HQs: Headquarters) Courtesy of Healthcare New Frontier Promotion Headquarter Office, Policy Bureau of Kanagawa Prefectural Government, 2018

6.2 The Necessity of Constructing a PHR System for MCH Care in Disaster Preparedness The importance of the MCH Handbook, mentioned in Chap. 1, is fully recognized to help after the Great East Japan Earthquake (GEJE). It would be useful to add an instruction to the MCH Handbook to save the lives of children as well as those of expectant and nursing mothers in the disaster. Promoting relationships with neighbors and creating an environment that encourages people to help one another by thinking about disaster preparedness in normal times are effective in supporting mothers and children. In the aftermath of the GEJE, many individuals in child-rearing generation were reminded of the importance of having supportive relationships with other child-rearing parents. Within the scope of the disaster prevention awareness activities for pregnant women, it is important to be connected with local governments, thinking about the time of disasters that led to the reconsideration of social capital such as relationship with neighbors and their communities. For example, in addition to the items that the child-rearing generation should prepare their emergency supplies, they can also take steps to identify people they can rely on and identify multiple ways of contacting them. It would be useful to have information from the MCH Handbook stored in cell phones and as pictures in smartphones, and to save all this information in the internet site such as the cloud, and to encourage the periodic verification of sources of medical consultation. Doing

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Back-up system for maternal child care handbook GPS can detect where the mothers and babies are le Fig. 6.2 Back-up system for maternal and child care handbook (GPS: Global Positioning System)

so would help foster supportive relationships that can continue during normal times and lead to support during a disaster. Medical personnel should consult with municipalities before a disaster to determine how best they can support mothers and their children during such times, and design proper measures that can promote maternal and child well-being after disasters, such as maternity checkups and vaccinations. Cross-organizational engagement related to pregnancy, birth, and child-rearing can also allow for a deeper exploration of health-related concerns and disease prevention methods, by analyzing school-going children and adults using mother and child cohort studies. These actions will not only help gather medical and health-related data from municipalities in one place, but also, by creating a sustainably manageable system, help provide comprehensive health care that takes into consideration mothers who are raising children. Our research group has developed a smartphone application (Fig. 6.2) that is currently in the stage of pilot study. This app can be downloaded onto smartphones, where it uses the phone camera function to record and upload the content of the MCH Handbook onto the phone. The app extracts information from the captured images, such as remarks from doctors, the progressions, and contact and primary physician information. This app borrows from the structure of the MCH Handbook and includes the following contents: (1) a medical questionnaire, (2) tips and advice for times of disasters, (3) records of the MCH Handbook, (4) display of geographic information at the time of a disaster, and (5) data management (tally). It is designed to function as a backup for the MCH Handbook data during normal times, and can be utilized to verify maternal and infant safety providers during a disaster. The medical questionnaire screen is used in firstaid stations during a disaster; for example, to enter and track (1) the current maternal physical conditions, (2) the number of expectant women, (3) the number of infants under age one year, (4) any wounds to the mother, and (5) the status of pregnancy, etc.

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Once the data is sent, it will automatically be tallied. On the tips and advice screen, one can learn ways to prepare for possible disasters physically and mentally, including the items they must keep handy and the actions they must take when a disaster occurs. The aim here is to increase attention to the possibility of the occurrence of and response to disasters, and thereby reduce the impact of a disaster if one occurs. On the MCH Handbook record screen, once the Handbook is issued after pregnancy, each expectant mother who has the app downloaded on her smartphone will, at normal times, take pictures of the MCH Handbook to keep a record. The information from the captured images specific to the expectant mother, such as the remarks from the doctor, the progression of pregnancy, the contact information, and other details of the primary physician, will be placed on record. If the users’ smartphone location information features are turned on, the GPS will help locate where the expectant women are, and in turn, will help medical professionals determine how many expectant and nursing mothers are located within the vicinity of a particular shelter area, where they will be taken in the event of a disaster. The data management (tally) screen will help automatically tally the abovementioned and write it out in a comma-separated value format, allowing individuals to save their information. If this information is backed up onto the free cloud, even when the Handbook is lost, the records will be retained and can thus help determine suitable emergency response mechanisms when a disaster occurs. At present, the manual and training content are being distributed to various local governments in Japan, and “mother-and-child shelters” are being planned for times of disasters at the municipality-level. Furthermore, the guidelines for reversing the declining birth rates passed by the Cabinet Office, which came into effect in April 2015, state that, “the local governments must promulgate disaster mitigating knowledge, which keeps infants, expectant and nursing mothers, and other vulnerable individuals who require extra consideration in mind, and must conduct training, store supplies, work toward improving the equipment of facilities at the designated shelters, and strengthen collaborative ties with related institutions whose aim is to protect children from disasters.” The Ministry of Health, Labour and Welfare’s second campaign “Healthy Parents and Children 21” (April, 2015), determines the direction of the maternal and child health initiatives. It states that, “the percentage of prefectures that are considering a system in which expectant and nursing mothers can be sheltered when unexpected events such as disasters occur,” and may be used as one index to determine how to provide uninterrupted MCH care. Thus, there is a greater demand for people to be engaged in methods that protect infants and expectant and nursing mothers at times of disasters [2–7]. Using the system to gather information on expectant and nursing mothers, we plan to create a tentative scenario to test the system for usage in situations like disaster training. If the system does indeed automatically gather information on expectant mothers, such as location, weeks of pregnancy, presence or absence of complications, and history of pregnancy, at the time of a disaster, the system will make it possible for specialists on obstetrics and gynecology to visualize and consolidate their medical needs when a disaster strikes, and help them improve the efficiency of their medical support. While this system specializes in providing for expectant

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mothers, it may be possible to use it in connection with the current Emergency Medical Information System (EMIS), someday. This would mean that even in cases where the communication infrastructure is not functioning well outside, as long as there is Wi-Fi inside the first-aid stations, the computers set up at each of the clearing or first-aid stations would be able to tally information. This will allow for the collection of information on expectant mothers in disaster-stricken areas. This method is not only limited to use for expectant mothers, but may be applied to the general management of the needs of other survivors of disasters.

6.3 The Future of PHR—Establishment of Information and Communication Technology (ICT) System Maternal and child health services are established at the municipality-level because of the increase in the number of older pregnancies, infertility treatment, complications in pregnancy, low birth weight babies, and babies with disabilities. Further, because the conditions for current pregnancies, births, and child-rearing are diverse, regional communities cannot address them with a single, monolithic approach. Given that only 0.8% of women are expectant mothers, and just 15.2% are mothers with children, the needs of these minorities do not appear clearly. Therefore, we can expect that if we manage to design a system to provide supportive services that match the specific needs of individual situations, including pregnancies, birthing, and child-rearing, we are able to respond to each individual with their feedback, and may reduce people who have difficulties in raising children. Today, there are multiple businesses and entities involved in MCH care, and they are interconnected (Fig. 6.3). However, the businesses, institutions, and administrative tasks are neither cooperative nor well integrated. For this reason, the merits of users to carry their own data are being discussed, and it has become a pressing need to create a tool for data sharing and communication among stakeholders. The merits of the app for users are proposed as follows: • It allows health diagnostic data to be visualized easily in growth curves and charts (currently, the users and municipalities need to plot the data onto a chart) • While it may have insufficiencies as a tool for data representation, it can manifest the viewpoints of the users • It enables the input of data that reflect the feelings and perceptions of the users, including their worries and concerns, and can allow for further developments and additional extensions with the software; and in doing so, such information can be reflected in the measures that are to be taken • It creates a common language among the stakeholders to enable the identification of the items necessary for support and proper timing. This way, a collaborative structure that supports mothers and children can be put in place, and a system that promotes MCH can operate more smoothly.

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Fig. 6.3 Multiple businesses and entities involved in maternal and child health care (Source the second report of “Healthy parent and child” by Ministry of health and Welfare, 2014)

Mothers, children, and families are all key factors in the formation of an efficacious regional foundation. More effective support to mothers and children will help connect and regenerate families and regional communities. An effort is currently underway in maternal health facilities by local government to reinforce a comprehensive and longterm support system that covers pregnancies, deliveries, and the child-rearing period. It is important to create a society in which more and more women can receive pre- and postnatal self-care and child-rearing support in a safe and comfortable environment. Such services are ideally tailored to suit each individual, and whole society should be supportive of the growth and independence of children, starting from the prenatal period. There are also various efforts being made to develop apps to collect diagnostic data on expectant and nursing mothers from the municipalities and medical and health facilities such as gynecological departments and pediatrics, and to preserve such records in the form of a PHR [8]. So far, there have been insufficient efforts to support expectant women, nursing mothers, and infants. Data in PHR apps include medical and diagnostic information on mothers and fetuses and infant immunization records, such as those recorded in the MCH Handbook, obtained from the local governments or municipalities, medical facilities such as gynecological departments or pediatric departments. Mothers or other guardians can share these data, which can be used by local governments,

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Public health nurse

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Naonal social number

user Informed consent Nursery school Child consultaon center

Electronic maternal and child health handbook Family

cooperaon of data from governments cooperaon of data from obstetric clinics automac gain of vital informaon

Private company

University and research instute

Fig. 6.4 Shared information communication Tool (ICT) maternal and child health handbook (PHR: personal health record)

medical facilities, and other businesses, so long as they have consent. Researchers now have the ability to create a model in which a variety of supportive services for pregnancies, births, and child-rearing (Fig. 6.4). It may also now become possible for expectant and nursing mothers and other guardians to utilize such PHR apps to examine and verify regional collaborative and reciprocal systems and environments, to review technical issues, and to utilize PHR information (big data) to promote clinical practice and research relating to pediatric health. Such apps can be used not only to provide information to the child-rearing generation, but as a portal for individual consultations where parents can express their concerns and feelings, to provide check sheets for physical and mental health to assess healthcare needs, and to connect individuals with specialists for face-to-face dialogue, as necessary. This way, people in need can receive the support they require. Check sheets can also accommodate preferred modes of communication such as face-to-face conversations, newsletters, emails, SNS, or the collective café method, which may make it possible for respondents to provide better descriptions of their opinions. This will hopefully make it easier to connect individuals to the support they need. We hope that the MCH Handbook is not only useful in keeping health records but is also used as a tool to promote interactions among the locals as well as mothers and children, so that children and those who raise them feel at ease with the people and communities around them. In the past, medical and health facilities only

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recorded numerically data describing cases as either normal or abnormal. However, now, smartphone apps have the potential to become exchange diaries. For example, if the mother writes, “The things I feel tired about,” or “Matters of recent concern,” then during a checkup, the medical staff may read this and respond by showing appreciation and encouragement by saying, “I see you are trying very hard. We are all on your side.” Or, perhaps, the medical staff may reply by sending a message saying, “You are doing just fine the way you are doing it. It is not about how you raise the child, but rather the fact that you are raising your child with love itself is the most precious act.” Used properly, this could create an environment for conversations in which parents feel comfortable sending out an “SOS signal” when they face a crisis.

6.4 Conclusion If the data managed separately by medical facilities, municipalities, and child-rearing parents can be gathered, shared, and utilized in a PHR system, then the quality of support for pregnancies, births, and child-rearing can improve significantly. If we are able to visualize the connections and support networks, it will contribute to the security of the child-rearing generation in normal times by increasing the mothers’ ability to call for help. Members of the child-rearing generation are able to manage their own information, as well as that of their children, and independently decide how to raise their children. These are the signs of the dawning of a society in which policymakers and health and medical staff are not pushing their desires upon individuals, and the child-rearing generation is able to express its own wishes directly to and on an equal footing with municipalities and communities. The goal of this project is for individuals to obtain not only the ability to manage their own health but also to make choices about their lives in general, without any excuse for making such decisions. The PHR system was created with the goal of having “individuals personally own their information and protect their lives and health through a collaborative information network” based on experiences from disasters in the past. It is hopeful that the system will act not only as a risk management tool but will also make life easier for people in normal times, and help connect people with each other. Acknowledgements This study was supported by the following research grants: 1. Health and Labor Sciences Research Grants (Research on Health Security Control) “Research on the Development of a Regional Collaborative Disaster Prevention System Including the Operation of Welfare Shelters for Those Who Require Assistance in Times of Disaster with the Central Focus on Pregnant and Nursing Women and Infants” (Research representative: Honami Yoshida, 2013–2015). 2. Grants-in-Aid for Scientific Research “Maternal and Child Health Required in Times of Disaster - from Research on the Impacts of the GEJE on Maternal and Child Health” (Research representative: Honami Yoshida, 2012–2014). 3. Japan Agency for Medical Research and Development, “Personal Health Record (PHR) Research Project, PHR Model for Supporting Pregnancy, Delivery, and Childbearing” (Research representative: Honami Yoshida, 2016–2018). The author thanks to Dr. Kentaro Hayashi and others who provided help at the Primary Care for All Team (PCAT), PCOT project members that include Dr. Hiroshi Ota, Dr. Yumie Ikeda, Dr.

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Keiko Otsuka, Ms. Yukari Endo, and Mw. Shoko So, who have contributed to developing training for rescuing pregnant and nursing women in times of disaster; and Dr. Yosuke Fujioka and Dr. Shinji Tsunawaki who have worked to address the needs of pregnant women from the inception of the PCAT. The author also thanks to Mw. Naoko Nakane, Mr. Yasuhiko Kurano, and Dr. Kayako Sakisaka for their visionary approach to education. The partnership helps ensure that mothers and children will always be treated in the safest manner with great expertise.

References 1. Yoshida H (2021) Infants and child checkups in pandemic in Japan. Bi Ken J Tomo 44(1):3–8 (in Japanese) 2. Yoshida H, Hayashi K, Ohta H, Ikeda Y, Otsuka K, Harada N, Arai T, Fujioka Y, Haruna M, Nakao H (2015) Perinatal outcomes in aftermath of Great East Japan Earthquake and the way how maternal child health support team (Primary Care for Obstetrics Team: PCOT) responded. J Jpn Primary Care Assoc 38:136–142 (in Japanese) 3. Yoshida H (2014) The increase of low birth weight infant and effective health promotion to mothers. Ibaraki J Matern Health 32:39–42 (in Japanese) 4. Yoshida H (2015) Save the infants and pregnant mothers in disaster area. Clin Res 505:33–38 (in Japanese) 5. Yoshida H (2012) Earthquakes and children: maternal and child health required after Great East Japan Earthquake. Child Sci 8:87–91 (in Japanese) 6. Yoshida H (2016) Research on the development of a regional collaborative disaster prevention system including the operation of welfare shelters for those who require assistance in times of disaster with the central focus on pregnant and nursing women and infants (Health and Labor Sciences Research Grants, 2013–2015, number 22761296) (in Japanese) 7. Yoshida H (2015) Maternal and child health required in times of disaster—from research on the impacts of the Great East Japan Earthquake on maternal and child health (Grants-in-Aid for Scientific Research, 2012–2014, number 24790626) (in Japanese) 8. Moriichi A, Toyoshima K, Itani Y, Yoshida H (2019) Development of an information sharing system with caregivers using personal health records (PHRs) that enables automatic extraction of clinical information necessary for supporting the care of extremely low birth weight infants from hospital systems. J Jpn Soc Telemed 15(1):25–30 (in Japanese)