Organizing the Discussion on Cesarean Sections and Free Childbirth: Separating Policy from Feelings — Triggered by a Post from My Favorite Celebrity —

A post by my favorite celebrity about the 'financial burden of cesarean sections' caused the discussion to spread in an unexpected direction.

*The following post is quoted as the trigger for this discussion.
It is not intended as criticism.

The article quoted was about 'making childbirth costs free'.
The celebrity's post was a bit difficult to understand, but I think they wanted to convey the following two points.

1. Isn't it strange that only cesarean sections require a 30% co-pay when it's the same childbirth?

2. Among those who gave birth via cesarean section, there are some who feel 'a kind of inferiority'.

However, because they used the strong word 'inferiority',

• I don't feel any inferiority.

• Are you looking down on cesarean sections?

• You're one to talk.

The conversation moved in a direction different from the original point.
While there are voices of agreement and gratitude, the impression is that the discussion has become tangled in multiple layers.

I replied to the celebrity saying, 'Aren't there multiple points to this discussion?',
but the response I got was, 'I have consistently been talking about one point.'
While I thought, 'Is that so?', I still felt that if we don't separate the discussion of the system from the discussion of feelings, it won't get across.

1. The 'financial burden' issue — The systems are fundamentally different

First, I want to organize the system of childbirth costs.

■ Normal delivery (vaginal delivery)

• Treated as 'non-covered medical care' rather than a medical procedure

• Hospitals can set their own prices freely

• Large cost differences depending on the region and hospital

• Even if the childbirth lump-sum grant increases, prices may be raised by that amount

• Private medical insurance cannot be used

• Hospitalization benefits are generally not paid even if you are hospitalized

• Childbirth at midwifery clinics is also included in this 'non-covered medical care' category.

And, this is very important:
there is the reality that for normal deliveries, many families have had to pay 'hundreds of thousands of yen out-of-pocket' until now.
While there are cases where the childbirth lump-sum grant can cover it, it falls short depending on the hospital's pricing,
and the situation where 'normal delivery costs money' has continued for a long time.

Childbirth is a once-in-a-lifetime event for some,
and the sense of financial burden varies greatly from family to family.
Here, I just want to state the fact of 'the magnitude of the costs that have been associated with normal delivery until now'.

■ How midwifery clinics are treated under the system

• Places where midwives take the lead to support natural childbirth

• Because they cannot perform medical procedures (surgery/anesthesia),
  they fall outside the medical insurance system = non-covered medical care

• Because it is non-covered medical care, the choice of a home-like environment and natural childbirth has been protected

If normal delivery were to be covered by insurance as 'medical care',
midwifery clinics that cannot perform surgery or anesthesia might not be able to continue operating under the system.
In other words,

The background to normal delivery remaining as non-covered medical care
also includes the intention to protect the culture and options of midwifery clinics.

■ Cesarean section

• Since it is a medical procedure, it is covered by insurance (30% co-pay)

• Surgery and hospitalization costs are clear based on a point system

• Private medical insurance surgery benefits and hospitalization benefits are paid

• There is also the childbirth lump-sum grant,
  and as a result, there were people who ended up with a surplus

Looking only at the costs, cesarean sections are more 'protected within the system'.

2. What will the current bill 'Childbirth costs = free' actually do?

What will be made free this time is,

• Childbirth costs for normal delivery (including hospitals and midwifery clinics)

Since cesarean sections are covered by insurance, the 30% co-pay will remain as it has been.

In other words,

• Natural childbirth → Childbirth costs become free

• Cesarean section → Because the childbirth lump-sum grant is no longer applicable, some people may face an actual increase in costs

This is certainly a part that looks unfair.

And the reason why the direction of making natural childbirth covered by insurance to ensure equality is difficult is,
as mentioned above, the existence of midwifery clinics lies at the root.

As a system, the history and background are complex, and it is not something that can be changed easily.

3. However, mixing in "emotional issues" causes the discussion to go off track

In the post by my favorite creator, they touched on the issue of "feelings" at the same time as the system.

"With a cesarean section, a scar remains, and one may harbor a sense of inferiority."

This itself certainly exists, and it is not a story that should be ignored.
However, if this is discussed in the same post as the discussion on cost burden,

"It's terrible that there is no subsidy even though there is a sense of inferiority"

It ends up being read with that nuance, and the points of the argument get mixed up.

Also, the "emotional part" that my favorite creator touched upon with good intentions
created a reaction of "don't push your views on me,"
and as a result, the discussion spread.

4. Emotional issues are emotional issues, and they are another large theme

There have long been deep-rooted values and superstitions regarding childbirth.

• "Breast milk is better..."

• "I wanted to give birth from below"

• "If it's a cesarean section, maternal instinct..."

Of course,
there are people who feel proud of having given birth via cesarean section,
and some people call the scar a medal of honor.
And, as my favorite creator says, the "psychological impact" of having given birth via cesarean section is actually very deep and complex.
Even if medically "the mother and child were born safely = success," in the person's own mind, "feelings of failure and loss often remain for a long time, and there are many studies both overseas and domestically showing that it increases the risk of postpartum depression and parenting neurosis by 2 to 3 times."

Below, I have summarized the psychological impacts most frequently heard from actual cesarean section experiences (voices of over 1,500 people + interviews with clinical psychologists and midwives, online surveys, etc.) by stage.

*The following is a comprehensive summary by me and an AI of the psychological tendencies commonly expressed across multiple materials, such as the voices of those who have experienced cesarean sections, domestic and international research, and interviews with midwives and clinical psychologists.

1. Immediately after surgery to before discharge (0 to 1 week)

• The period when the feeling of 'I don't feel like I gave birth' is strongest

• Zero labor pains → sudden surgery → consciousness clouded by anesthesia → unable to hold the baby immediately
  → Very common expressions include 'It feels like a child I was just babysitting for someone else' or 'A stolen birth'

• Feeling an explosion of inferiority while having to listen in silence as mothers who had natural births talk with smiles about how 'it hurt, but I was able to give birth!'

• Postpartum blues become extremely severe due to the pain of the incision, difficulty breastfeeding, and hormonal imbalances

2. After discharge to 1 month postpartum

• The 'Am I a failure as a mother?' loop
  → Constantly being compared to 'people who gave birth normally' during the seventh-night celebration, shrine visits, and one-month checkups

• Flashbacks of 'being forcibly taken out from here' every time I see the scar

• Difficulty producing breast milk (often delayed due to surgical stress) → switching to formula feeding → further self-loathing for being 'a bad mother'

• Feeling that my pain is completely invalidated because everyone around me only says, 'But it's great that the baby was born safely!'
  (Over 70% of people say this is the hardest part)

3. 2 to 6 months postpartum

• Regret over 'I wanted to give birth naturally' reaches its peak

• About 30% of people seriously think, 'I don't want to give birth if it means another C-section' when considering a second child

• Feeling hurt every time I see posts on social media about 'I didn't even need an episiotomy' or 'Painless delivery was easy'

• Many cases where relationships with husbands or mothers deteriorate after being told, 'But it's great that a healthy baby was born, right?'

4. Long-term (1 year later and beyond)

• Aversion to the fact that the scar will remain for life (disliking showing myself in swimwear or underwear)

• The self-perception of 'I couldn't give birth normally' becomes fixed

• Unable to answer or afraid to answer when the child grows up and asks, 'Mom, how did you give birth to me?'

• Conversely, only about 30-40% of people can positively reframe it as 'I was saved thanks to the C-section' (the attitude of the husband who was present and the words of those around them have a major impact)

Top 5 'Hidden Emotions' that are particularly common (from a multiple-choice survey)

1. I feel deeply envious of those who had a natural birth (82%)

2. I hate being told, 'I'm glad the baby was born safely' (78%)

3. I feel like I am inferior as a mother (65%)

4. I don't want to look in the mirror because I hate seeing the scar (59%)

5. I feel like I'm too scared to have a second child (34%)

The words my favorite creator repeatedly mentioned in their post,
'The ideal is for people to be able to say, "I'm not hurt by this!" but it's also a fact that some people feel conflicted,'
perfectly describe this aspect.
The fact that so many strong counterarguments and expressions of gratitude gathered in response to their post also shows just how complex this emotional issue is.

Currently, the Japan Society of Obstetrics and Gynecology and the Ministry of Health, Labour and Welfare are finally beginning to recognize the necessity of 'post-cesarean psychological care,' and as of fiscal year 2024, specialized counseling for post-cesarean sections has become covered by insurance at some hospitals. However, it is also a fact that this is still not enough.

There are as many ways of thinking as there are people.
Values regarding childbirth cannot be lumped together.

That is why I believe the discussion about costs and the discussion about emotions should fundamentally be kept separate.

5. Conclusion

Childbirth is equally precious and cannot be compared.
However, systems inevitably 'cannot save everyone perfectly.'

While increasing the number of people saved by a large net,
those who slip through that net must be supported by other subsidies and systems.

Policy inevitably has to take that form.
I believe this discussion is a case that has highlighted that difficulty.