TONO, Japan — Since losing its last obstetrician five years ago, this city of nearly 32,000 in rural northern Japan has been desperately seeking a replacement. So desperately, in fact, that it recently promised a horse to any obstetrician willing to come here.
There have been no takers yet. In the meantime, the city has adopted a high-tech measure that may portend the future of child delivery in Japan: pregnant women are examined remotely by obstetricians using real-time data transmitted to the doctors’ cellphones. When the doctors judge that a patient is about to go into labor, the woman heads to the nearest city with a maternity ward — usually Kamaishi, a 40-minute drive east of here, reached by a winding, mountainous, two-lane road that can be treacherous in the winter.
Japan, with a rapidly aging population and a declining birth rate, is grappling with a severe shortage of working obstetricians and places for them to work. With a dearth of babies, hundreds of hospitals and clinics in Japan have shuttered their maternity wards since the beginning of the decade, turning their attention to potentially more lucrative elderly care.
Since 2000, the number of obstetricians in Japan has declined by more than 5 percent to 11,282 in 2004, the most recent year for which figures are available, according to the government. But that figure masks the severity of the shortage, experts say. The number of doctors actually delivering babies was fewer than 8,000 in 2005, according to an estimate by the Japan Society of Obstetrics and Gynecology.
Roughly half of all obstetricians are 50 or older, and overworked; many have given up delivering babies and are focusing only on gynecology. At the same time, the number of medical students choosing obstetrics as their specialty has plummeted since 2004. Turned off by long hours, average pay and a rising risk of malpractice lawsuits in obstetrics, young doctors are gravitating instead toward specialties like dermatology and ophthalmology.
“Young doctors nowadays won’t work just out of a sense of vocation,” said Dr. Kiyoo Tanabe, director of the Japan Association of Obstetricians and Gynecologists. “You have to give them quality of life, a good income and their private time.”
What is more, women make up a majority of obstetricians in their 20s and early 30s. Many retire when they themselves have children, Dr. Tanabe said, because the medical field remains unfriendly to working mothers.
The crisis, he said, “began in rural Japan and reached the major cities in the last year.”
Even in Tokyo, maternity wards are being closed or consolidated, creating a sense of anxiety among pregnant women who are warned to make an appointment for delivery as soon as they learn their due date.
“I was told that places where you can give birth are limited and that everybody is flocking to them,” said Eri Miyasato, 35, who is eight months pregnant and lives in a suburb of Tokyo. “You have to make an appointment for the delivery, and a lot of people are having trouble finding a place.”
Things have changed since the birth of her first child two and a half years ago. “Back then,” she said, “it was all right.”
But the hinterland has been hardest hit as maternity wards have closed one after another. The shortage is so severe that those obstetricians who still practice have few days off. In emergencies, women have been transported by helicopter to maternity wards with available beds. And some women who live far from a maternity ward, as their due dates approach, move to hotels near the hospitals where they are scheduled to give birth.
Tono, once a prosperous trading post known for its horse breeding, is an agricultural municipality that sprawls across a valley and is mostly forestland. As is the case in much of rural Japan, one-third of its residents are over 65.
Each year, 210 to 230 women have children here, said Eisai Kikuchi, a city health official. Since the prefectural hospital here closed its maternity ward in 2002, pregnant women have had no choice but to make the long drive to Kamaishi, or another city with a maternity ward, to give birth.
For Yukie Kikuchi, 38, the city’s sole practicing midwife, that has created worries. A year ago, during a snowstorm, one of Ms. Kikuchi’s patients wondered whether she was going into labor and asked the midwife whether she should go to Morioka, a city more than an hour away.
“But there was a blizzard, you could hardly see, and I was torn whether she should go in this circumstance,” said Ms. Kikuchi, who is not related to the city health official. Eventually, she advised her patient to stay put and was relieved to learn the next morning that it had been a case of false labor.
Ms. Kikuchi said she was pleased and relieved now that obstetricians could remotely examine pregnant women here.
Using the system, Ms. Kikuchi visits patients at their homes or receives them at a clinic in Tono to follow up on their pregnancies. During the examination, a machine hooked to the patient’s stomach records the baby’s heartbeat and sends the information over a cellular network to Ms. Kikuchi’s cellphone and the cellphone of Dr. Toshihiro Ogasawara at Kamaishi Hospital.
Ms. Kikuchi then inputs the patient’s blood pressure, weight and other information on a laptop computer so that the medical record is instantly available to Dr. Ogasawara over the Internet. Using Internet telephony software, the doctor, patient and midwife can talk and see one another on the laptop.
With this system, Dr. Ogasawara can determine whether a patient is in labor. Before, to be on the safe side, a patient would make the 40-minute drive to Kamaishi.
“After a gynecological examination, I’d tell them, ‘Not yet,’ and they’d have to spend another 40 minutes driving back in the middle of the night,” Dr. Ogasawara said. “Now I can talk to the midwife, and if it’s premature, the expectant mother will feel relieved.”
“It’s not only Tono, but many other places have the same problem,” Dr. Ogasawara said in an interview in his office, as he sat at his desk in front of his computer monitor, Webcam and free-standing microphone.
Besides Tono, three other cities adopted the system last fall, said Mr. Kikuchi, the health official. After a three-year evaluation to work out any potential problems, the system is expected to spread elsewhere.
In Tono, 14 women have given birth using the system, and five are currently using it during their pregnancies. “When I was told that there was no place here to give birth, I was, like, ‘What?’ ” said Azusa Furudate, 27, who was undergoing a remote examination 10 days before her due date. “I think this is convenient,” she said of the new system, “though it’s my first time, and I’m not sure what to expect.”
Chieko Asanuma, 28, who delivered her second child five months ago, said she was a little anxious about the new system at first. But as Ms. Kikuchi began visiting her at home and Dr. Ogasawara advised her from Kamaishi, Ms. Asanuma said she found herself preferring the system to going regularly to the hospital, as she had done before giving birth to her daughter, now 5.
“When I’d go to the hospital, I’d have to wait a long time just to briefly see the doctor,” Ms. Asanuma said. “So that only made this better.”
Still, as with any new technology, there are glitches.
As Ms. Kikuchi examined Ms. Furudate on a recent morning at the clinic here, she found her to be a little anemic and recommended eating more seaweed and shellfish.
The machine hooked to Ms. Furudate’s stomach was smoothly sending data to Dr. Ogasawara’s cellphone.
Although a long, blue Internet cable was connected to Ms. Kikuchi’s laptop, the link was down — the first time that had happened since the new system was put in place last fall. So Ms. Furudate spoke to the doctor over the cellphone, instead of seeing his face on the laptop.
Then Ms. Kikuchi got on the cellphone to relay information that the doctor normally would have accessed over the Internet. But the phone’s signal was weak, and the doctor’s voice was unclear.
“Yes, yes,” Ms. Kikuchi said, seconds before the call was dropped. “The signal’s bad. So she should go next week? Moshi-moshi?”