Breastfeeding care in Japan is in the midst of a great transformation. Traditionally, there were two major breastfeeding care methods in Japan: the Oketani Method originally formalized by a midwife Ms. Sotomi Oketani in 1981 and the Self Mamma Control (SMC) Method developed by an obstetrician, Dr. Yahiro Nezu, in 1986. Both methods aim at the galactopoietic effect (facilitation of breastmilk production) of using unique breast massages techniques. The Oketani Method, which is performed by specially trained midwives, manages breastfeeding trouble such as induration and inflammation in the breasts through a specific breast massage technique and nutritional regimen, while the SMC Method promotes breastfeeding women's regular self-massage of breasts and nipples for breastfeeding preparation and maintanance, from pregnancy through the postpartum period for prevention of breastfeeding problems. When I was an undergraduate student in the late 1990s, the two methods were taught during nurse-midwifery education.

In the past decade then, new approaches for breastfeeding have developed. For example, the BS Care Method, meaning "CARE based on breastfeeding infants' suckling mechanisms," was developed and publicized by Fukuoka Midwives Female & Male (FMFM) Network around 2002. The BS Care Method emphasizes painless, easy breast massage by trained midwives and/or by breastfeeding mothers themselves. The massage imitates breastfeeding infants' suckling motions and deals with both the promotion of breast milk production and the prevention of breast problems.

Furthermore, a Western-based approach by theInternational Board Certified Lactation Consultants (IBCLC) has become popular in Japan in recent years. The credential system for IBCLCs was originally developed in the U.S. in 1985 and has been disseminated internationally. As the qualifying examination and its preparatory seminars became available in the Japanese language, the number of Japanese IBCLCs has increased rapidly in recent years. A major characteristic of the IBCLC approach which contrasts greatly with the traditional Japanese approaches is the focus on an evidence-based, scientific knowledge base regarding breastfeeding. IBCLCs do not include breast massage; rather, they educate breastfeeding women by providing the women with knowledge and counseling. IBCLCs help to get women motivated to breastfeed, praise their efforts, and encourage self-care for breastfeeding.

In addition to the above, peer support groups by breastfeeding mothers, such as La Leche League Japan, and credentialing organizations, such as the Japan Breast Feeding Association that accredits Baby-Friendly Hospitals, have taken important roles in breastfeeding support in Japan. In Japan, many women prefer breastfeeding, and more than 95% of mothers actually initiate breastfeeding, although the rate at 1 month plummets by half and is a challenging point in Japanese breastfeeding care.

When I returned to Japan after six years of graduate study and started to work in a maternity ward in a hospital last fall, I was surprised at first by the fact that breastfeeding care provided by Japanese nurse-midwives had changed in many respects, compared to six years before. Many nurse-midwives go to seminars on breastfeeding care designed by IBCLCs. Many textbooks on breastfeeding care have been written and published by IBCLCs, and current student nurses' and nurse-midwives' curriculums include those books. Some of my colleagues say that "the IBCLC approach is becoming mainstream, rather than the Oketani or SMC methods." Overall, in Japan there is a societal tendency that, whenever a new method emerges, it quickly replaces older ones which become outdated and easily forgotten. The open and flexible attitudes of Japanese people are valuable, but they can be undependable and may overlook something precious in the traditional approaches.

I started noticing some differences between traditional Japanese breastfeeding care and the new methods from the U.S. and other countries. It seems to me that both Japanese nurse-midwives and breastfeeding mothers may be confused by differences between the traditional and new approaches.

The following are examples:
1) Some experienced mothers told me,"When I gave birth last time five years ago, my midwives instructed me that I should breastfeed my baby for 5 minutes on each breast. But, is there a different way now? This time, you midwives encourage me to breastfeed with either breast until my baby is satisfied, and tell me I don't necessarily have to use both breasts at one breastfeeding session." This contradiction is due to new scientific knowledge: breastmilk gradually changes its composition and taste during a feeding time. Earlier breastmilk, called foremilk, is less fatty with low calories, while later breastmilk, hindmilk, contains higher lipid and caloric content. Therefore, babies should intake not only watery foremilk but also richer hindmilk at every breastfeeding session so as to satisfy and provide the babies with enough nutrition (JALC, 2007; Mannel, Martens, & Walker; 2008; Walker, 2010).

2) Some mothers expected nurse-midwives to provide them with breast massage regularly during their hospitalization and they are disappointed and concerned that they may not have enough breast milk without receiving this special massage. Some mothers followed SMC protocol and massaged their nipples during pregnancy to prepare for breastfeeding (so long as the massage did not cause premature labor), and they were surprised to learn after childbirth that breast massage during pregnancy and postpartum is not encouraged at all anymore.

3) Some breastfeeding mothers with flat or inverted nipples or nipple pain would use "nipple shields," synthetic nipples generally made of silicon, to allow the baby to latch on more easily. Although traditionally Japanese midwives have not consistently recommended the use of artificial nipples, IBCLCs seem to be especially concerned that any kind of artificial nipple may create nipple confusion causing the baby to forget how to suckle at the mothers' breast properly, due to the usage of artificial nipples which may inhibit the baby's ability to suckle. As a result, mothers are taught how to feed their babies with a cup as an alternative feeding method (Flint, New, & Davies, 2008; Thorley, 2003).

4) Some transitions in breastfeeding support are due to changes in society, such as increasing lawsuits. For example, to avoid accidents, such as a baby falling off the bed, bed-sharing (co-sleeping) is discouraged and mothers are encouraged to place their babies in baby cots (National Guideline Clearinghouse, 2008; Regional Infant Sleep Committee, 2007). In Japan, women stay in the hospital for five to seven days after a vaginal delivery or for eight to ten days after a Caesarean section. This period is critical for the initiation and establishment of breastfeeding practices, and bed-sharing definitely makes breastfeeding easy and comfortable. Although traditional Japanese bedding is a futon on a tatami mat, western bedding is popular in both homes and hospitals, and the possibility of falling accidents has become a concern, especially for hospital managers who are afraid of being sued by their clients. As a result, in those hospitals, new mothers have to get up and sit up every time they breastfeed their baby, which is frequently when the baby is very young, even in the middle of the night and early morning hours during the earliest postpartum period when most of them have perineal pain. Some institutions prevent falling accidents by putting a cover on the bed railing. Others do not offer a rooming-in system and call mothers to a nursery room for each feeding.

While welcoming and appreciating new knowledge, I sometimes experience difficulties in integrating the new and traditional approaches. How can we take good aspects from both, so that optimum breastfeeding care can be provided for Japanese breastfeeding mothers? How can we avoid confusion and conflict among breastfeeding mothers, as well as among nurse-midwives as much as possible? Above all, how can we value both approaches? Conditions of breastfeeding are diverse in nature, like childbirth, and it is important that the appropriate information for a mother is individually selected from a dependable body of universal knowledge. When new knowledge comes from another culture, at the same time, the cultural appropriateness of the new knowledge needs to be considered. These are difficult but meaningful challenges.

For example:
1) The high-touch care of the Oketani Method made intimate, individualized, one-on-one care by a nurse-midwife for a mother an essential part of breastfeeding care. Breastfeeding women are able to talk and to be listened to by trained nurse-midwives in an empathetic manner during the therapies. Besides, there is a Japanese proverb: "action rather than words; work before talk." Japanese women may not want an educational lecture; they may prefer being touched by their nurse-midwives to heal their breasts on the spot while having their complaints listened to. Above all, the slumbering comfort induced by the warmth of a human hand cannot be obtained without one-on-one massage. Breast massage therapy may be the only time that mothers, who are otherwise always devoting time to care for their babies and others, can be taken care of . (Interestingly, it seems that Japanese women have much less resistance to having their reproductive organs touched by professionals. I have heard that in the U.S., lactation consultants rarely touch their clients' breast directly, whereas Japanese nurse-midwives do so daily. In childbirth, Japanese midwives are traditionally taught how to touch the childbearing women's perineum to prevent it from being torn, while some American nurse-midwives do not.

2) In the U.S. where the initiation rate is not as high as in Japan, the IBCLCs' role in promoting breastfeeding is profound. In that respect, many Japanese mothers are already motivated to breastfeed and may need more practical support to continue their breastfeeding practices. Many Japanese nurse-midwives may want to know why some mothers' physiological transition process after birth is slower than it should be, in spite of their motivation for breastfeeding. They also may want to know how to prevent the problem and how to care for those mothers without pressuring them, using a more holistic approach which includes looking at the entire maternity health care environment and women's emotional health as a whole.

3) The traditional Japanese methods may have facilitated Japanese women's over-dependency on professionals and may have damaged their trust in their own bodies' ability to breastfeed. For example, I have heard multiparous women saying, "My breasts started to produce enough milk after I had breast massage by midwives." As a result, some women are worried whether they can produce enough breast milk without special massage by professionals. The new approaches that value the innate abilities of women and infants can be very helpful for Japanese women to develop more trust in their own bodies. Furthermore, in general, expenses for breast massage are not covered by health insurance. The option of breast massage may not be affordable for low-income women, thus possibly leading to health disparities among mothers in Japan.

4) Foreign research should be critically examined when it is applied in Japan. Dur to the long (1 week or more) postpartum stay in Japanese maternity wards, the research is usually put into practice predominantly by nurse-midwives. Because of the language barrier (most of these studies are not translated into Japanese) and the limited research literacy in general, the findings are often at face value and recommendations followed blindedly rather than applying rigorous analysis regarding their pertinence and application to the particular circumstances found in Japan. For example, ''a method has no evidence'' can indicate two different situations: first, that ''appropriate studies have been done, and those studies reveal that the method has no effect,'' or second, that ''there has been no study done for the effectiveness of the method, therefore no evidence exists yet.'' The reasons for the second situation could be, for example, that its effectiveness is socially regarded as too obvious to conduct a study, or that there have not been enough researchers who are interested in the topic using an internationally acceptable research methodology. These different situations must be treated as different issues, but many clinicians in Japan have limited training in critically analyzing and distinguishing this difference.

This transition process, including the resulting confusion, should reflect the long history and popularity of breastfeeding among Japanese women and the studiousness of Japanese nurse-midwives and other supporters. The popularity of breastfeeding, the high initiation rate, and the long postpartum hospitalization in Japan enable quality breastfeeding studies that can contribute to discussions on optimum breastfeeding care internationally. I look forward to contributing to breastfeeding research so that my current questions can be answered.

Acknowledgement
The author is most grateful to Dr. Tamami Satoh, Professor at Japanese Red Cross Kyushu International College of Nursing, Ms. Brett Iimura, Birth Educator, and Dr. Noboru Kobayashi, Director at Child Research Net for their helpful comments.

More information:
Oketani Method (English): http://www.oketani-kensankai.jp/html/eng.html
BS Care (Japanese): http://bscare.jp/index.html
Lactation Consultant (English): http://www.iblce.org
La Leche League (Japanese): http://www.llljapan.org
Japan Breast Feeding Association (Japanese): http://www.bonyuweb.com
Japanese Association of Lactation Consultants (Japanese): http://www.jalc-net.jp