TOKYO — When it comes to women, Japan is an outlier compared with other highly industrialized countries: It lags regarding women’s roles in politics and business, in the salary gap between the genders — and in obstetrics and gynecology.

Many subscribe to the idea that good mothers are forged only through the pain of childbirth.

Less than 3 percent of Japanese women use pain relief during delivery, according to the Ministry of Health and Welfare, compared with 50 percent in the United States and at least 75 percent in France. And only about 3 percent of Japanese women undergo amniocentesis or other genetic screening during prenatal exams, compared with 64 percent in California, according to Eriko Sase, an adjunct professor at the University of Tokyo’s Graduate School of Medicine.

Often, Japanese doctors don’t even mention genetic tests or pain relief. At least one hospital in Tokyo has gone so far as to impose a “no epidural” policy, presumably as part of its emphasis on natural deliveries.

The lack of options for pregnant women is particularly bizarre given Japan’s demographic crisis. The country’s fertility rate has been below the level needed to replace the population since the mid-1970s. Over the next quarter century, the proportion of elderly will rise from nearly one in four to one in three.

Japan’s laggardly status is the result of both supply and demand. Hospitals, including at least one with a neonatal intensive-care unit, have been pulling out of the delivery business altogether. There’s also a shortage of obstetricians and anesthesiologists, as well as of doctors who specialize in newborn care, nurses familiar with newborns, midwives and emergency physicians. The higher risk of lawsuits and longer, more unpredictable working hours drive Japanese medical students into easier lines of work — dermatology and cosmetic surgery, for example.

Salary caps on income earned through the national health care system also discourage students from specializing in women’s medicine. It’s easier to supplement your income by charging more for additional private services as a plastic surgeon than as an obstetrician or anesthesiologist. At the same time, female OB-GYNs often quit or stop delivering babies after they have their own children.

The shortage of OB-GYNs got so bad several years ago that “childbirth refugees” — expectant mothers forced to roam from hospital to hospital in search of a doctor who could deliver their baby — briefly became a national issue. Although the Japan Society of Obstetrics and Gynecology has stepped up its recruitment efforts and is trying to find ways to help female obstetricians keep practicing, the industry association admits that doctor shortages are still a serious problem with deep cultural roots.

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Yasuhiro Tanaka, an OB-GYN and founder of the Tanaka Women’s Clinic in Tokyo, claims to have been the first doctor in Japan to offer epidurals in the 1970s. He believes that the low incidence of pain relief offered to women in Japan is a reflection of the arrogance of the Japanese medical profession. “Medicine is a service industry,” he said. “Doctors here don’t understand that.”

Apparently, some patients may not either. Japanese women refer to their offspring as onaka wo itameta ko (“the child who made my belly hurt”), and many subscribe to the idea that good mothers are forged only through the pain of childbirth. This embrace of pain dovetails with Japan’s nearly universal ethos of gaman, or perseverance during tough times.

“It’s a cult,” said Mika Kanai, a 43-year-old marketing manager of a cosmetics brand and a mother of one who put her son in an international kindergarten in part because of the level of competition and expectation of conformity among the mothers of children in a Japanese kindergarten. “Japanese women consider suffering a virtue.”

Birth practices are always specific to a culture, but in this case culture may be preventing Japan from addressing its economy’s largest structural problem: a shrinking work force. Surely a country that is serious about raising its fertility rate would make it easier for expecting mothers to get proper medical care.