The Last Midwife of Akita: A Prefecture Running Out of Babies

On the wall of Keiko Satō's office, behind a desk cluttered with ultrasound printouts and a ceramic tanuki figurine her mother gave her in 1978, hangs a photograph of a newborn. The baby is wrapped in a white cotton blanket, eyes scrunched against the fluorescent light, mouth open in what might be a yawn or the beginning of a cry. The photograph is dated March 4, 2024. It is the last birth Satō attended at Ōmagari Municipal Hospital.

The maternity ward closed three weeks later. The hospital's obstetrics department had delivered 847 babies in 1990, 312 in 2010, and 41 in 2023. When I visited in February 2026, the ward had been converted into a rehabilitation centre for stroke patients. The pink teddy bears stencilled on the walls remained, visible behind the parallel bars where elderly residents now practise walking.

Satō, who is seventy-one years old and has the careful hands of someone who has caught thousands of falling bodies, still works part-time at a clinic in Daisen City, though the clinic no longer performs deliveries. She does prenatal checkups now. In the past year, she has seen eleven pregnant women. "I used to see eleven in a week," she tells me. She pours barley tea from a thermos that has travelled with her between three hospitals and forty-seven years of practice. "Now I tell the young mothers, 'You are precious. You are doing something almost no one does anymore.'"

The Emptying Province

Akita Prefecture occupies the northwestern coast of Honshu, a region of cedar forests, hot springs, and rice paddies that freeze solid in winter. It was once prosperous—mining, timber, agriculture—and in 1950, the prefecture's population reached 1.31 million. Today it stands at 892,000, and Japan's National Institute of Population and Social Security Research projects it will fall below 600,000 by 2045. The median age is 53.8, the highest of any prefecture. Drive through the villages south of Yokote and you will see houses with collapsed roofs, rice paddies gone to seed, elementary schools converted into senior centres or simply abandoned.

Satō was born in Yokote in 1954, the third of five children. Her father worked for the prefectural forestry department; her mother raised children and kept a small vegetable garden. "There were children everywhere," she remembers. "Every house had three, four, five. The schools were overflowing. We went to class in shifts." She became a midwife in 1979, trained at Akita University Hospital, and returned to her hometown to work at the municipal hospital. In her first year, she assisted with 203 deliveries.

"I have delivered mothers, and then I have delivered their daughters, and in some cases their granddaughters," she says. "That is how long I have been doing this. That is how small this place has become."

"You Are Precious"

Japan's birth rate has been below replacement level since 1974. For decades, demographers warned of the coming crisis; for decades, successive governments announced policies to encourage childbearing—subsidies, childcare expansion, parental leave reforms—and for decades, the birth rate continued to fall. In 2023, Japan recorded 758,631 births, the lowest since records began in 1899. Prime Minister Fumio Kishida called it "now or never" for addressing the crisis. His government pledged ¥3.5 trillion annually for child-related spending. The birth rate fell again in 2024.

The problem, as sociologist Masahiro Yamada of Chuo University has documented extensively, is not simply economic. Japan's marriage rate has collapsed alongside its birth rate; in 2020, 28.3% of men and 17.8% of women aged 30-34 had never married, compared to 21.5% and 10.4% in 1990. Yamada coined the term "parasite singles" in 1999 to describe young adults living with their parents, delaying or foregoing marriage. The phrase was controversial—it implied blame—but it captured something real: the traditional pathway from education to employment to marriage to children had fractured.

In Akita, the trap is particularly vicious. The prefecture loses between 3,000 and 5,000 young people annually to migration, mostly to Tokyo and Sendai. Those who remain are disproportionately male—farmers, factory workers, men who have inherited family businesses or family obligations. In 2023, Akita's sex ratio for residents aged 20-39 was 115 men for every 100 women, one of the most imbalanced in Japan.

The Mathematics of Disappearance

I spend a morning with Takeshi Kudō, who runs the Daisen City Hall's population policy office. His department has a staff of four and an annual budget of ¥180 million. "We have tried everything," he says. He lists the programmes: subsidies for young families who relocate to Daisen (¥1 million), subsidies for wedding expenses (¥300,000), free fertility treatment, free childcare, matchmaking events. The city organised forty-seven matchmaking events in 2023. They resulted in four marriages. "The mathematics are against us," Kudō says. "If you have 100 young women leaving every year and 100 young men staying, after ten years you have a city with no young women."

The national government has begun to acknowledge what prefectures like Akita have known for years: some communities may be beyond saving. In 2024, the Ministry of Land, Infrastructure, Transport and Tourism published a report on "regional compaction"—the consolidation of shrinking communities into sustainable clusters, the managed abandonment of the rest. The report does not use the word "abandonment." It speaks of "strategic withdrawal" and "service concentration."

Satō knows these numbers intimately. She recites them without notes: the forty-three municipalities in Akita that no longer have maternity facilities, the average age of the prefecture's remaining obstetricians (58), the distance a woman in Yokote must now travel to give birth (62 kilometres, to Akita City). "When I started, every town had a midwife," she says. "Every town had babies. Now the babies go to the city to be born, and then they grow up and they leave for Tokyo, and they never come back."

The Question of Immigration

In the global context, Japan's demographic crisis is not unique—South Korea's fertility rate is lower, Italy's population is older in some regions—but Japan's policy response has been distinctively insular. Immigration, which has stabilised or reversed population decline in much of Europe and North America, remains politically constrained. Japan admitted 321,000 new permanent residents in 2023, up from 184,000 in 2018, but the numbers remain modest compared to the scale of natural population decline. The government prefers technical intern programmes and specified skilled worker visas—temporary categories that assume eventual departure.

In Akita, foreign residents constitute just 0.7% of the population—roughly 6,200 people, mostly technical interns from Vietnam and Indonesia working in manufacturing and agriculture. The prefecture has made modest efforts at integration: Japanese language classes, cultural exchange programmes. But the assumption remains that these workers will leave. "We are grateful for their help," says Kudō, carefully. "But we cannot build a future on temporary workers. We need families. We need babies."

I ask him whether the prefecture has considered more aggressive immigration recruitment—campaigns in Southeast Asia or South America to attract permanent settlers, not just temporary workers. He pauses for a long time. "That is a conversation for Tokyo," he finally says. "We in the regions cannot make that decision."

The Last Shift

Keiko Satō will retire at the end of this year. There is no one to replace her. The clinic where she works will stop offering prenatal care; women in Daisen will drive to Akita City, an hour away, for their checkups. She is at peace with this, she says, or at least she has made her peace. "I did my job. I helped bring life into the world. I cannot force the world to keep wanting life."

On my last afternoon in Daisen, Satō takes me to see the abandoned elementary school where she was educated. The building is structurally sound—red brick, built in 1958—but the windows are dark and the playground equipment has been removed. A caretaker comes twice a month to check for water damage. Inside, the small wooden desks remain in rows, as if the children might return at any moment. Satō walks through the corridors slowly, touching the walls. "There were 400 students when I was here," she says. "By the time it closed in 2018, there were twelve."

We return to her office before I leave. She shows me her records—handwritten logs of every birth she has attended, dating back to 1979. The early years are thick with entries, ten or fifteen names per page. The recent years are sparse. She turns to the final page, the one with the photograph on the wall: March 4, 2024, a boy named Haruki, 3,200 grams, born at 6:47 a.m. to a mother who had driven from Yokote because there was nowhere closer.

"I told his mother what I tell all of them now," Satō says. "I told her: you are doing something rare. You are doing something brave. You are bringing a new person into a world that is forgetting how to make them." She closes the logbook. Outside, the snow has begun to fall again, covering the empty streets of a city that once believed it would last forever.