What France Prescribes and Japan Does Not

A woman gives birth in France and, some weeks later, receives a prescription for pelvic-floor rehabilitation: a course of sessions with a physiotherapist or midwife, reimbursed, offered as a matter of routine to essentially everyone. It is so ordinary there that women discuss it the way they discuss a dental cleaning.

A woman gives birth in Japan and receives a one-month check, at which the baby is examined thoroughly and she is asked how she is. After that, for most women, there is nothing. The difference between those two countries is not biological, and it is not that one of them cares more. It is that one health system classified the pelvic floor as a muscle group that has just undergone a traumatic event, and the other classified what follows as a fact of life.

Describe it in the language used for any other injury and the neglect becomes obvious. A sheet of muscle has been stretched to several times its resting length over hours. It may have torn, or been cut. Connective tissue and fascia through the abdomen have been progressively loaded for months and then abruptly unloaded. Nerves have been compressed. The rib cage, the diaphragm and the breathing pattern have all been displaced and have not automatically returned.

Any of that happening to a shoulder would produce a referral, a plan and a course of treatment. Happening here, it produces the sentence everyone has heard: it is normal after a baby. Leaking when she sneezes is common; common is not the same word as normal, and it is certainly not the same word as untreatable. Pelvic floor muscle training has some of the strongest trial evidence in conservative medicine for exactly this, and the evidence has been strong for decades.

The pelvic floor is not the only structure that was loaded and left. The two bands of abdominal muscle that run down the front of the torso are joined by a strip of connective tissue, and in pregnancy that strip stretches and the bands move apart. This is 腹直筋離開, and it is not a rare complication — measured by palpation in one well-known cohort it was present in six women in ten at six weeks after birth, about four and a half in ten at six months, and roughly a third at twelve months.

What makes this worth a section of its own is not the frequency. It is what happens in the absence of anyone naming it. The visible result is a lower abdomen that does not flatten, and with no other explanation available it gets read as fat and treated as a discipline problem. So it is attacked with restriction and with sit-ups — and sit-ups are close to the worst available response, because the movement drives pressure forward against exactly the tissue that has already given way. A woman can spend two years working hard at the one thing that keeps the problem open, while being congratulated for her effort.

Two facts sit underneath that and they pull in opposite directions, which is why both need saying. It does not reliably close on its own: the same line of research finds a measurable separation still present in a substantial minority of women at three, five, ten and twenty years. And precisely because it does not close on its own, the door does not shut either. There is no window that expired at six months. A woman eleven years past a birth who assumed she had missed her chance did not miss it; what she missed was being told there was anything to attend to.

Look at what the French prescription is attached to and the shape of the gap changes. It is written at a postnatal consultation six to eight weeks after the birth — an appointment for the mother, at which somebody examines the structure in question and then writes a plan. Ten sessions, reimbursed in full, with a further ten or fifteen available if the result at the end is judged insufficient. The reimbursement is the part people repeat. The assessment is the part that does the work.

In Japan the corresponding appointment is oriented to the baby, who is examined in detail, and to the acute complications of the mother — bleeding, infection, blood pressure, mood. A pelvic floor assessment is not a routine part of it. And at the end of it she is told, in one form of words or another, that she is fine now and may resume normal activity.

That sentence is the one a great many women carry for years, and it is worth being exact about what it means. It is an administrative statement, not a clinical finding about the pelvic floor, because the pelvic floor was not assessed. Nothing was found to be fine; nothing was looked at. So when something is not fine afterwards — leaking, pain, a heaviness low down — the conclusion available to her is that she was cleared and is nonetheless failing, which points the whole problem inward. It is not that she was told something untrue. It is that a sentence about the absence of infection was heard, reasonably, as a verdict on everything.

Pain with sex after childbirth is extremely common and very often persistent, and it is one of the most consistently misattributed symptoms in the whole field. It gets explained as tiredness, as low mood, as the relationship having changed, as her not being interested any more.

A large share of it is mechanical. Scar tissue that has healed short and tight. Muscles that have learned to guard and will not release on request. Tissue changes driven by the hormonal state of breastfeeding, which produces dryness that has nothing whatever to do with desire and which responds to the same simple measures dryness always responds to. These are things a pelvic health physiotherapist and a 婦人科 treat as routine.

The cost of getting this wrong is not only physical, and this is the part that deserves to be said slowly. Picture two people lying in the dark, a few feet apart, not speaking. She is thinking: something is wrong with me, and if I say it out loud it becomes real, and he will think I am broken. He is thinking: she does not want me any more, and I am not allowed to ask twice. Both of them are wrong. The actual answer is a band of scar tissue that healed a centimetre too tight, and it is treatable in six weeks by somebody whose entire job this is. They will not find that out, because the one sentence that would unlock it is the one sentence neither of them can say. Marriages have ended in that silence — not over anything either person did, but over a mechanical fact nobody was ever given the words for.

Go back to the two people in the dark, because the silence there has a structure and the structure can be undone. It holds because every sentence available to her is a sentence about desire, and a sentence about desire cannot be said in that room without landing as a verdict on him. I don’t want to is heard as I don’t want you. Not tonight, said four times, becomes a position. She is not staying quiet out of shame alone; she is staying quiet because she can see what the words will do when they arrive.

A sentence about tissue does not do that, and this is the practical centre of the page. There is a place that hurts, physically, and I am going to have it looked at. It reports a fact rather than a feeling. It asks him for nothing, so there is nothing for him to fail at. It cannot be misheard as rejection, because it is not about him at any point. And it can be said by a woman who is not yet able to say anything larger — which matters, because the larger conversation is the one that keeps being postponed until a better evening, and the better evening does not come.

What it does on his side is the part worth noticing. It replaces a story in which he is no longer wanted with a fact about an injury — and an injury is a thing a person can be on the side of. Very few men would choose the first story if the second one were offered to them. Most of them are not choosing it now; they simply have not been handed anything else.

The gap is real but it is not total, and the most useful thing on this page is a service a great many women do not know exists in their own city. 産後ケア事業 is now a duty of municipalities under the amended 母子保健法. It comes in three formats — a short stay, a day visit, and a visit to the home — and it is subsidised, often heavily. It exists to give a new mother rest, feeding support, and someone to ask.

It is chronically under-used, and the reason is almost never cost. It is that using it feels like admitting to not managing. Which is the same 我慢 mechanism arriving at the single worst possible moment — a woman at eight weeks, not sleeping, declining a subsidised service designed precisely for her, in order to avoid appearing to need it.

Two other things worth knowing. 産後うつ affects roughly one in ten new mothers, is a medical condition rather than a failure of feeling, and has treatment that works — the one-month check now routinely screens for it, and an honest answer there is worth more than a composed one. And if no local pelvic physiotherapy is available, asking the 婦人科 directly about 骨盤底筋 and about scar tissue by name will get further than describing a general sense of not being right.

The single most useful adjustment is to ask for an assessment rather than for reassurance, because reassurance is what has already been tried and it is what failed. Am I all right invites a kind answer and closes the appointment. Is there a separation, how wide is it, and where — that is a question with a measurement at the end of it, and a measurement can be acted on.

Name the structures rather than describing a general sense of not being right. 骨盤底筋 for the muscle group. 腹直筋離開 for the abdominal separation. 会陰切開の瘢痕 or 裂傷の瘢痕 for scar that healed short and tight. 性交痛 for pain with sex, which is a clinical term and not a confession. A 婦人科 that hears the specific words will reach for the specific answer; the same 婦人科 hearing that she has been feeling a bit off since the baby will, quite reasonably, reassure her.

And ask the question that is almost never asked, which is who does this locally. Pelvic health physiotherapy exists in Japan and is unevenly distributed; a 婦人科, a midwife, or the staff running the municipal 産後ケア service will often know who in the area actually does it, and that piece of information is not in any leaflet. It is worth asking even where the answer turns out to be nobody, because the nobody is then a fact about the district rather than a fact about her.

There is a second thing happening alongside the tissue, and it is not medical. For a year or more the body has been handled constantly and almost never on its own account: examined, measured, fed from, climbed on, woken. It has been useful without interruption. A great many women describe emerging from that stretch feeling not injured but vacated — as though the body were equipment they administer rather than somewhere they live.

The repair for that is not more effort. It is contact that asks for nothing — touch with no feeding, no examining and no outcome attached, in which the only question being answered is what she notices. That capacity comes back reliably and faster than most women expect, but it does not come back by being waited for, and it does not come back during a task.

One qualification, because the comparison is doing a lot of work on this page and it should not be doing more than it can carry. The French pathway is not flawless and has been argued about at home. Some of what is delivered under its heading rests on weaker evidence than the core of it does; the best-supported element is supervised pelvic floor muscle training, and not every session everywhere is that. Nothing here requires France to be right about every technique.

What the comparison actually establishes is narrower and harder to argue with. One country has a route: an appointment at which the structure is examined, a prescription that follows from what is found, a named professional whose job this is, and a second look at the end to decide whether more is needed. The other has no route. That is a difference in provision, not in technique, and it is the difference that decides whether a woman with a treatable problem ever meets anybody who treats it.

Which is also the encouraging half of it. A Japanese woman does not need the French system in order to get most of the benefit, because the component with the best evidence behind it is the one she can ask for by name, from a 婦人科 she can already reach, without a reform, a referral pathway or a change in the law. The gap is in provision, and a gap in provision closes for one person at a time, from her side, the moment she knows what to ask for.

Moonlight does not treat pelvic floors, scar tissue, incontinence or postnatal depression, and would be doing real harm by implying otherwise. Those belong to a 婦人科, to pelvic health physiotherapy, and to a municipal 産後ケア service. Saying which door a thing belongs behind is not this house deflecting. It is the part of the work that protects you.

What is inside this house’s boundary is the last section and only that: unhurried attention to a body that has spent a long time being useful, with nothing asked of it. Not before the medical questions are answered — alongside them, or after, and never instead.

A French woman and a Japanese woman go through the same enormous event, and one of them is handed a rehabilitation plan and the other is handed a leaflet about the baby. Everything downstream of that — whether she leaks at forty, whether sex hurts at thirty-five, whether she spends a decade quietly believing her body simply stopped working properly — follows from a decision taken by a health system, in a meeting, years before she was in the room. Your body did not fail. It was not offered the aftercare that the same body would have been given six thousand miles away, and then it was asked to be grateful. That is worth knowing on its own, because it takes a verdict about you and turns it back into a gap in provision — and a gap in provision is something any woman can walk around, the moment somebody finally tells her it is there.