On a harsh winter night, November 2, 1995, Itsumi Koga, a Japanese woman living in the Detroit area, arose to her newborn baby son's cries. The sequence of events that followed is not entirely clear, but according to Mrs. Koga, she carried the infant outside and laid him on the bank of a pond. Sometime later, she awoke her husband, who found the infant in the pond, dead from drowning. Mrs. Koga was charged with homicide and incarcerated.

    It soon became clear that Mrs. Koga was suffering from a severe form of post-partum depression with psychotic features. While up to 85 percent of women experience some form of mental illness in the immediate post-partum period, Mrs. Koga was affected by an uncommon, but severe form. The news media picked up on the story and asked, "How might the fact that Mrs. Koga is Japanese have influenced what happened?" Stated in a different way, "Could cultural differences have contributed to baby Tomoyuki's death?" The Koga case became a catalyst for reflecting upon the many cultural differences I have experienced while providing medical care to Japanese patients. I believe that culture almost certainly played a role in this tragedy. The purpose of this article is to highlight critical differences between what a Japanese woman might expect and what she would encounter in the American healthcare system during pregnancy and after childbirth; and to consider how this understanding may shed light on the death of Mrs. Koga's child. In the following, I present intimate examples of differences that I have experienced in the course of providing care to pregnant families and their newborns.

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    A continuous stream of conflicts arise during the prenatal course, delivery, post-partum period, and routine well-baby care visits. While none of these individual differences alone would be of sufficient magnitude to cause profound confusion, these differences, taken as a whole, could render a case of post-partum depression very severe indeed.

    The difficulty first arises when a Japanese patient makes plans to see a doctor in the U.S.. The patient learns that she has to make an appointment for visits, whereas clinic patients in Japan are typically seen on a "first come-first served" basis. The anxiety of having to make an appointment in English over the telephone may be great enough to cause her to delay an appointment, or even not to seek care at all.

    In many cases, Japanese women are dependent on their husbands, who in workplace interactions usually learn to speak better English, to schedule both their appointments and to take time off from work to take them to the clinic. Upon arriving at the office, the staff asks the patient to sign what is typically a several page legal document written in a tiny font in complicated "legalese." Signing a contract to receive medical care is itself an alien concept in Japan; thus the need to sign a contractual agreement without the time or opportunity to understand the content is a disconcerting way to begin a relationship.

    Upon meeting the doctor, the patient may be surprised to learn that pregnancy is diagnosed by a urine test. In Japan, the diagnosis often is made by ultrasound in the doctor's office. In fact, doctors routinely examine the baby with ultrasound during each prenatal visit in Japan. While this practice is of dubious economic efficacy, the failure to perform what is perceived as a most basic test in Japan, and the inability to have the reassurance of visualizing the fetus at each visit may leave doubts in the patient's mind about the quality of care she is receiving in the U.S..

    Yet another shock awaits the patient. For the pelvic portion of the physical examination in Japan, a curtain hangs from the ceiling at waist level that blocks the women and physician from seeing each other. A discussion about the symbolic meaning of the curtain is beyond the purposes of this paper, but suffice it to say that this is a profound difference from the U.S. system. Further, while it is routine for pregnant women to have a Pap smear for cervical cancer in Japan, disclosure that the test has been done is not routine. Thus, when an American doctor explains that a Pap smear is being done for cervical cancer, the Japanese patient may develop unfounded fears that her physician suspects cervical cancer and is doing a diagnostic test rather than a routine screening test.

    During her first doctor visit, the patient receives a prescription for prenatal vitamins, a practice deemed highly important in preventing neural tube defects such as spina bifida and anencephaly. This practice makes sense once explained, but to Japanese women, taught to be suspicious of anything unnatural, especially during pregnancy, it nevertheless feels uncomfortable. In the U.S. the patient will also receive a loose collection of materials about pregnancy, many of which were designed by infant formula companies that promote bottle-feeding (a mixed message, given that breast feeding rates in Japan are well over 90 percent). Prenatal education in Japan, however, is emphasized in part by a government-developed handbook. When a woman becomes pregnant, she registers at a local government office and receives this book which contains information about pregnancy and care of the newborn. Many women are surprised that something similar to this valuable handbook is not widely used in the U.S..

    Thus, during the course of the first visit, it becomes clear to Japanese women that the medical management of her pregnancy in the U.S. will be very different, something that is reinforced throughout the pregnancy. If she develops a urinary tract infection, she might be concerned that the powerful medications used by doctors here will be too strong for her body and her developing baby. Patients often comment to me that they want the lowest dose possible because their bodies are smaller, and they believe that Japanese people are more susceptible to adverse effects from excessive doses. Indeed, basic research illustrates that metabolism of certain drugs differs by ethnic group.

    As the delivery date approaches, many Japanese patients are excited about the prospect of having a baby "Made in USA," but cultural differences continue to surface. In Japan, a woman often will return to her parents' home several weeks prior to her due date in order to have the assistance of her mother at the time of delivery, and in the exhausting post-partum period. Because of costs, this is usually not feasible for a Japanese expatriate woman in the U.S.. The somewhat strange alternative is for her husband to come to the delivery — a practice nearly unheard of in Japan. While some are eager to participate, others complain that they are pressured to participate. At the time of delivery, patients may be pleased about the option of painless delivery secondary to epidural anesthesia, though this option is rarely available in Japan. The generally aggressive nature of U.S. obstetrics practice, including high Cesarean section rates, is a source of fear for patients.

    After the delivery, the patient and her husband will be shocked to learn that she may be discharged within 36 hours. In Japan, women typically spend five to seven days in the hospital after a normal delivery, and usually three weeks after a Cesarean section. It is common to have a breast feeding room where all the newborn mothers sit together and breast feed; the more experienced help the less experienced mothers learn. On several occasions, Japanese patients have asked to stay an extra day in the hospital, even if it means that they have to pay for it out of pocket.

    Also, if she has a male baby, the new mother will be asked if she would like to have her son circumcised. This is a virtually unknown practice in Japan, and surprises Japanese people no less than Americans when they first learn of female circumcision practices (often referred to as female genital mutilation) in Africa. In Japan, it is customary to present the umbilical cord to mothers in a box at the time of discharge, though most patients are cognizant that this a Japanese custom and do not expect this here.

    While population-based screening of all newborns for hypothyroidism and phenylketonuria by a blood test is required in the U.S., some prefectures in Japan also conduct neuroblastoma screening of all newborns. What is standard care in Japan is not standard here and in some cases not available, often leaving the parent confused and anxious.

    Immunization practices also differ. First, each country routinely administers vaccinations not commonly given in the other. For example, Japanese babies are routinely immunized for Japanese encephalitis, and against tuberculosis with the BCG vaccine. In contrast, U.S. babies are immunized for hepatitis B and Haemophilus influenza B.

    Second, babies usually do not receive more than one injection at a time in Japan, though it is common for a baby in the U.S. to have two or even three injections at one visit. Moreover, Japanese mothers commonly believe that babies should not be given an immunization when the baby has an illness, whereas in the U.S., clinicians are encouraged to immunize babies in spite of mild illness.

    Finally, in Japan doctors and nurses advise mothers not to bathe babies on the day of immunizations, as it is believed that they may be more vulnerable to sickness. A U.S. physician, unaware of this practice, might casually dismiss this question with an answer that she need not be concerned. This gap in assessment about what is good for her baby will at minimum leave her confused and possibly leave her wondering whether her U.S. physician is practicing good medicine.

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    It is clear to me that cultural differences in medical practice can be pronounced enough to exacerbate a severe medical condition. Taken in total, these differences can add insult to injury when a patient has a very debilitating problem like post-partum depression with psychotic features. I believe it is unlikely that Mrs. Koga's post-partum depression would have been as severe if baby Tomoyuki had been born in Japan. There, the fundamental cultural supports might have been sufficient to prevent the death of her son. Her family and friends would have been better able to mobilize support for her, her doctors would have been more familiar with the symptoms of post-partum depression as they manifest in Japanese women, and she would have been better able to cope with her illness.

    Can the balance of justice weigh these cultural factors, and adequately assess their impact? A mobile symbolizes for me a patient's delicate balance in her new U.S. environment. In spite of her resiliency the strings of support for her are thin, and even minor events can have sufficient force to send her reeling out of balance. It is perhaps not "culture" as such that is implicated in this tragedy, but the insufficient awareness of cultural differences in medical practice, and the crucial role they play in many aspects of medical treatment.

    Michael Fetters is a faculty member in Family Practice. He regularly provides care for Japanese patients in his clinical practice, and his research focuses on the interface of clinical medicine, anthropology and ethics.