Purpose
In this study, the author designed a scale to measure pregnant wives satisfaction with their husbands' supportiveness based on the couples' awareness. The author also tested the content validity.
Method
Participants were couples who were undergoing a single-child pregnancy (divided into groups for early, middle, and last phases of pregnancy). In all, 760 couples were recruited. Among these couples, 437 responded to the questionnaire and 419 were included in the analysis. The questionnaire was designed based on three aspects of husbands' supportiveness of their wives: "Intimacy of couple", "Family system", and "Realization of parenthood". There were 40 questions for the early phase of pregnancy, 46 questions for the middle phase, and 51 questions for the last phase. Couples were asked to indicate if they were satisfied or dissatisfied with various aspects of their relationship related to the pregnancy on a 5-point Likert-like scale.
Results
Wives answered 14, 21, and 24 questions for the early, middle, and last phases of pregnancy, respectively, while husbands answered 17 questions for the early phase, 20 for the middle phase, and 17 for the last phase. Three factors emerged: "Empathy for wives' feelings and health", "Support in doing housework", and "Communication between the couple relating to the birth of their baby". Because the factor structure correspond three aspects of husbands' supportiveness of their wives, the content validity was confirmed. Cronbach's alpha was between .78 and .92, indicating high internal consistency.
Conclusion
This study designed a questionnaire to measure pregnant wives' satisfaction with their husbands' supportiveness. As mentioned above, cronbach's alpha was between .78 and .92, indicating high internal consistency. Because the factor structure correspond three aspects of husbands' supportiveness of their wives, the content validity was confirmed. We succeeded in designing a questionnaire to assess couples' awareness on this topic.

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Objectives
To develop an Assessment Tool that identifies Lactational Mastitis (ATLM) for lactating mothers and to examine its reliability and validity.
Methods
The original "ATLM" was developed based on a descriptive study and a comprehensive review of the literature. After receiving examination on the content validity by the experts who are supporting lactating mothers, we made a preliminary study of ATLM. Based on the results, the present study was conducted, with 16 examination items. The subjects, from whom the lactating mothers with the previous history of breast disease except mastitis were excluded, were 277 pairs of mothers and child, with 554 breasts, during the III stage of lactation. The survey was conducted at 4 institutions in total such as the lactation and child-care center, etc. from April to November, 2010. The survey consisted of filling in the questionnaire for the mothers and children who visited to the survey-cooperating institutions, and measuring their body temperatures. The midwives were asked to fill in the ATLM and LATCH which are being developed. Additionally, 1 week after the survey, the mothers were asked to reply to another questionnaire inquiring of their conditions.
Results
Exploratory factor analysis by principal factor analysis with promax rotation was conducted. The following three factors comprised of 12 items were finally extracted: (1) "Status of milk, (2)" "Production of milk," and "(3) Drainage of milk." A confirmatory factor analysis was conducted by analyzing covariance structures and the hypothesized statistical model was found to fit the actual data. The reliability of the scale was confirmed by a Cronbach alpha's internal consistency reliability coefficient of 0.820 (0.803-0.859 for subscales) and an inter-rater reliability coefficient of 0.490-0.852. The criterion-related validity was confirmed by concurrent validity. The coefficient was r=-0.525** and predictive validity was confirmed with a predictive value of 96.9%. The cut-off point for referral to a physician was 32 points. The sensitivity at this point was 98.0% and the specificity was 87.5%. In addition, the 1st factor scored 11 points higher than the 2nd factor.
Conclusion
The above findings indicate that the "ATLM" is sufficiently valid to improve the quality of identifying lactational mastitis.

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Purpose
The purpose of this study is to carry out a comparative analysis of Japanese women with and without sensitivity to cold (hiesho) during pregnancy with regard to incidence of premature rupture of membranes and infer the causal effects as to whether sensitivity to cold (hiesho) induces premature rupture of membranes.
Method
The study design was a retrospective cohort study. Data was collected for approximately twelve months between October 19, 2009 and October 8, 2010 at six general hospitals with obstetric and pediatric departments in the Greater Tokyo Metropolitan Area. The study was conducted on 2,810 postpartum Japanese women inpatients at those hospitals, and their information was extracted from questionnaire surveys and medical records. In this analysis, confounding factors were adjusted using propensity scores.
Results
Out of 662 women (23.6%) with premature rupture of membranes, 348 (52.6%) had sensitivity to cold (hiesho) and 314 (47.4%) did not. Incidence of premature rupture of membranes is 1.67 times higher (analysis of covariance) or 1.69 times higher (stratified analysis) among pregnant women with sensitivity to cold (hiesho) than those without sensitivity to cold (hiesho) (p<.001).
Conclusions
It was strongly inferred that causal effects exist between sensitivity to cold (hiesho) and premature rupture of membranes.

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Purpose
The aim of this study was to clarify the changes of oxidative stress and antioxidant potential in maternal plasma and total antioxidant capacity in human milk to investigate whether those indices may be associated with perinatal data.
Method
Fifty postpartum women were followed for one month after delivery. We measured reactive oxygen metabolites (d-ROMs) and biological antioxidant potential (BAP) in maternal plasma, and total antioxidant capacity (OXY adsorbent) in human milk by F.R.E.E. (Free Radical Elective Evaluator), as markers of oxidative stress and antioxidant potential, respectively.
Results
Oxidant stress decreased significantly to 393.2±71.9 U.CARR, but antioxidant potential increased significantly to 2288.8±252.1 μmol/L in one month postpartum (p<.001). The rate of change of oxidant stress correlated significantly with the rate of change of antioxidant potential (from 0~2 days to 4~5 days postpartum: r=.467, p<.01, from 4~5 days to one month postpartum: r=.337, p<.05). Total antioxidant capacity levels of human milk in one month postpartum were significantly lower than in 4~5 days postpartum (p<.001). High groups of total antioxidant capacity levels of human milk in 4~5 days postpartum (n=23) were correlated with antioxidant potential postpartum (p<.01).
Conclusions
Oxidant stress decreased in one month postpartum, however, it was still higher than the normal range. A significant increase was observed in antioxidant potential by one month postpartum. High groups of total antioxidant capacity in human milk were associated with antioxidant potential in maternal plasma. Evaluation of oxidative stress and antioxidant capacity in the postpartum period is considered useful as indices of health care.

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Purpose
Based on a questionnaire survey to mothers three to four months after childbirth, we examined how mothers acquire maternal roles, perceive a gap between their antenatal assumptions regarding their postpartum life, physical changes and child rearing and their actual postpartum conditions, and we identified other related factors, considering the measures to be introduced during pregnancy to support acquisition of maternal roles.
Methods
The study was conducted on mothers three to four months after childbirth, timing when mothers are considered increasingly eager to acquire maternal roles, and to gradually become relieved of the postpartum anxieties. A questionnaire sheet requesting anonymous, handwritten responses, was sent to 348 mothers, who had participated in checkups for infants aged three to four months, which were conducted at six health facilities in two cities. The responses were collected by post from 113 mothers (collection rate: 32.5%). After excluding invalid responses, the responses from 107 mothers were analyzed in this research.
Results
The mean age of enrolled respondents was 32.0 years (SD: 4.0), and those mothers comprised 77 primiparous women (72.0%) and 30 multiparous women (28.0%). The primiparous women had no clear assumptions about the postpartum wound pains and breast pains. Even if they had any assumptions, they perceived that the actual postpartum pains were greater than their antenatal assumptions. Positive correlations were found between afterpains greater than antenatal assumptions and negative acceptance of the maternal roles, between anal prolapse milder than antenatal assumptions and positive acceptance, and between severe fatigues and/or afterpains and heavy perceived loads of child rearing. Adjustment with husbands regarding child rearing positively correlated with positive acceptance. Adjustment in other aspects of life did not correlate with acquisition of maternal roles. Positive correlations were found between positive acceptance of maternal roles and satisfaction with childbirth, and between negative acceptance and heavy loads of housework and child rearing.
Conclusion
We clarified that the difficulties in acceptance of maternal roles correlated with a gap between the antenatal assumptions of the mothers regarding their postpartum physical changes and their actual postpartum conditions, particularly when the actual pains and loads were greater than their antenatal assumptions. A positive correlation was found between adjustment with husbands during pregnancy regarding child rearing and acceptance of maternal roles. These findings suggested the necessity for introducing supporting measures during pregnancy, such as filling the gaps in the mothers' assumptions.

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Purpose
The purpose of the present study is to clarify whether or not there is any difference in scores of the various factors comprising a sense of satisfaction gained from child rearing in the groups of primiparas who had high and low assessments of their Marital relationship during the initial stage of childrearing.
Methods
The subjects were 100 primiparas who gave birth at general hospitals in Tokyo, and were mothering an infant that was 2~3 months old. The survey comprised (1) demographic data (age, number of hours of sleep per night, EPDS, etc.); (2) scale measuring assessment of the relationship between husband and wife (Marital Love Scale); and (3) questionnaires and scales measuring various factors comprising the sense of satisfaction gained from child rearing [fatigue (inquiring about subjective symptoms), self-efficacy (general self-efficacy scale), self-efficacy pertaining to childcare (primary factor of the scale measuring positive feelings toward child rearing during puerperal period), questionnaire assessing husband's social support, acceptance of the maternal role (maternal consciousness scale), parental behavioral index (PBI)].
Results
The results of the 93 subjects providing valid responses (93%) were analyzed statistically. When the group having a high evaluation score of the Marital relationship was compared against the group having a low evaluation score, sleep time was significantly shorter, but other background elements were almost the same. When the group having a high evaluation score of the Marital relationship was compared against the group having a low evaluation score, of the six factors comprising a sense of satisfaction gained from child rearing, the evaluation scores for the husband's social support (mental support; p=.000, informational support; t=3.81, p=.000, and instrumental support; p=.006), self-efficacy score (p=.040), and the score for positive and affirmative acceptance of the maternal role (p=.004) were significantly higher.
Conclusion
When the mother's feeling of satisfaction gained from child rearing during the child rearing period is viewed from the perspective of how the Marital relationship is assessed, if the mother has high regard for the Marital relationship, it is believed that she will then have highly positive feelings toward child rearing. Consequently, it is regarded as necessary that nurses not only provide instruction in specific child rearing methods, but that, along with the coping ability which the mother had developed, nurses need to take an interest in the Marital relationship, and convey the importance of communication between husband and wife within the context of childcare support.

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Purpose
To verify the outcomes of care provided by midwives for the purpose of building maternal confidence in new mothers.
Methods
This research was designed as a sequential, quasi-experimental study targeting an intervention group of 27 new mothers and a comparison group of 35 new mothers. Confidence-building care was given to the intervention group at 2-weeks postpartum (by phone) and 3-weeks postpartum (by interview). This care consisted of a midwife listening to a mother talk about the kinds of experiences that made her feel capable of taking care of her baby, and the kinds of experiences that made her feel as if she was doing her best, or has done her best, to care for her baby. The midwife then recognized the mother’s efforts, and communicated assurances and a positive assessment. The Japanese version of the Maternal Confidence Questionnaire (hereafter, J-MCQ) was administered 4-5 days postpartum (pre-test) and 1-month postpartum (post-test). A t-test was conducted to validate the intervention outcomes.
Results
The average J-MCQ score for the pretest was 34.2 points (SD=8.3) for the intervention group and 34.5 points (SD=7.9) for the comparison group. No significant difference was seen between the groups (t=0.191, p=.849). The average J-MCQ score for the posttest was 46.3 points (SD=9.1) for the intervention group and 42.8 points (SD=7.5) for the comparison group. No significant difference was seen between the groups (t=1.663, p=.101). Both groups scored significantly higher in the post-test than the pre-test (intervention group: t=9.446, p=.000; comparison group: t=6.28, p=.000).
Conclusion
The confidence-building care for first-time mothers conducted by midwives was not demonstrated to be effective, but whether or not the intervention was implemented, this study clearly showed that mothers at 1-month postpartum possessed more confidence that at 4-5 days postpartum.

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Purpose
To identify the process by which mothers who have given birth to a premature baby acquire a maternal role through the experience of breastfeeding, and to consider directions for breastfeeding support that facilitates the development of a relationship between the mother and premature baby and the mothers' role achievement.
Methods
The research design was a qualitative descriptive study. Seven mothers who had given birth to a premature baby at 23-28 weeks gestation and were currently breastfeeding participated in semi-structured interviews focused on their experiences and thoughts regarding breastfeeding. Data were analyzed using a qualitative inductive approach.
Results
In the 'complex psychological situation of experiencing loss through premature birth', and while dealing with 'delays in recovering strength after the birth due to prolonged enforced rest during pregnancy', mothers received 'support from midwives to start breastfeeding' from immediately after the birth, and started expressing milk with 'the conviction to breastfeed precisely because the baby was premature'. In the process of expressing until it became possible to breastfeed directly, participants repeated 'continuing expressing they could do for their baby' and 'seeking a role by expressing' with 'the existence of support from family and nurses as they kept on expressing'. When mothers could start breastfeeding directly, they were conscious of 'a dramatic surge of sense of really being a mother through breastfeeding'. In this process, 'revision of the image of childcare that had been interrupted through premature birth' occurred recurrently. Before the baby's discharge from hospital, mothers felt 'heightened love for the baby with a sense of reality'. While they achieved 'enhanced self-efficacy as the mother' through breastfeeding, they also experienced 'anxiety about the future as they could imagine caring for their baby extensively'.
Conclusion
The present findings demonstrate the importance of nursing that supports mothers' motivation to breastfeed and emphasizes the meaningfulness of breastfeeding in maternal role achievement through the experience of breastfeeding among mothers who have given birth to a premature baby.

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Purpose
Using five locations in Japan that are taking the lead in establishing in-hospital birth centers as model cases, we are developing factors for the establishment of in-hospital birth centers.
Subjects and Methods
We surveyed midwives at five general hospitals that have established in-hospital birth centers (one midwife at each facility). We collected data using a structured interview survey, focusing on the preparations that were made to establish the in-hospital birth center. To conduct our analysis, we recorded the interviews, transcribed the inter-views, and then integrated the transcribed data using the KJ method.
We examined and diagrammed the relationships between the categories chronologically.
Results
The data sampled from the transcriptions was ultimately combined into groups: "Background behind the es-tablishment of an in-hospital birth center," "Infrastructural system creation," "Skills development of midwives," and "Staff placements and cooperation". When these four elements were expressed in a structural drawing, the path toward the establishment of an in-hospital birth center promoted by midwives was shown to be comprised of two phases: (1) an uphill portion reflecting the "Background behind the establishment of an in-hospital birth center," and (2) a flat portion, reflecting the "Infrastructural system creation," "Skills development of midwives," and "Staff placements and cooperation." Moving toward the establishment of an in-hospital birth center required the presence of midwives dedicated to the development of such a facility. When these midwives moved forward in their efforts, the uphill slope expressed in the "Background behind the establishment of an in-hospital birth center" was impor-tant. Some of the factors that facilitated the progress made by these midwives as they struggled uphill toward their goal included "positive reasons for establishing the facility" and "the involvement and support of key persons." The factors impeding their progress included "negative reasons for establishing the facility." When the supporting fac-tors won out over the impeding factors, forward progress could be made. Progress along the flat road that followed the uphill slope could then proceed smoothly.
Conclusions
Making progress toward the establishment of in-hospital birth centers requires the strong dedication of mid-wives to this cause, as well as an environment that is supportive of their efforts.

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Objective
With child rearing starting immediately after childbirth, there is a strong possibility of postnatal depression due to inexperience of the mother combined with irregular rhythms of the newborn to create perception of a large burden for the mother. This study used the Nursing Child Assessment of Feeding Scale (NCAFS) to observe the infant's behavioral state, cues during breastfeeding, and mother's responses on the fourth day after birth, and recorded the interactions of the mother and infant. This study also evaluated use of the NCAFS as an early postnatal measurement tool.
Methods
A descriptive study was conducted to elucidate early postnatal mother-infant interactions and cues for these interactions in accordance with the component observation items (NCAFS). Subjects were primiparous mothers and infants hospitalized in a medical institution on the fourth day after birth. Observation was conducted using a network camera and microphone fixed inside the mother's room, with a digital video camera used for recording after breastfeeding started. Analysis was applied by evaluating the scenes from the start until the end of breastfeeding in accordance with the 76 NCAFS items (score range 0-76). Also, the actions of the mother and infant were written down. This study was approved by the Ethical Review Committee of the authors' institution and the institution where the study was conducted.
Results
Breastfeeding scenes of 10 mother-infant dyads were recorded and observed. Breastfeeding frequency during the recorded period was a mean of 2.1 times (SD=0.7), with a mean duration of breastfeeding of 11.3minutes (SD=4.2). The NCAFS mean score was 54.1 points (SD=6.1). mother-infant dyads were chosen who scored lower compared to other subjects (Conclusions
NCAFS was applied to observation of breastfeeding interactions between the primiparous mother and infant on the fourth day after birth, elucidating the characteristics of mother-infant interactions such as the infant's cues and the mother's responses. The possibility of setting a NCAFS cut-off score for mother and infant within 1 week postnatal, and using Japanese NCAFS in longitudinal follow-up of mother and infant was suggested.

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The Japan Academy of Midwifery has developed the Evidence-Based Care During Childbirth Guideline for Midwives (2012 edition) containing care policies for healthy low risk women and newborns. In order to disseminate the guideline, contents of the guideline are introduced for midwives through the current paper. A total of twenty nine clinical questions were included in the guideline. For each clinical question, evidence statement, its explanations and references were prepared. Evidence-based and women-centered care would be promoted if midwives adopt care policy in the guideline at hospitals, clinics and independent midwives.

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