Culture, traditional beliefs and practices during pregnancy among the Madurese tribe in Indonesia

Pregnancy and childbirth are critical transitional periods of life. In Asian and African countries, traditional beliefs and practices are often associated with pregnancy, labour and the postpartum period (Aziato et al, 2016; Withers et al, 2018). Historically, some of these practices included praying, rituals or ceremonies, food taboos and recommendations (Aziato et al, 2016; Cukarso and Herbawani, 2020), behavioural taboos, massage, traditional healers, traditional medicine and herbs, and beliefs relating to hot/cold imbalance, magic and superstition (Withers et al, 2018). Such cultural practices are still carried out in many countries (Aziato et al, 2016; Withers et al, 2018; Cukarso and Herbawani, 2020).

The cultural context includes the values, beliefs, morals, customs and practices accepted by a community or group that are often passed on to the next generation by disseminating and implementing the practices (Peprah et al, 2018). They are usually intended to provide an example of good or beneficial behaviour and are expected to have a good impact on one’s life. However, customs or practices that have a destructive effect and are harmful to oneself, family or society must be avoided and may be considered taboo (Kittler and Sucher, 2008).

Indonesia includes thousands of islands with diverse ethnic groups and cultural backgrounds, creating a unique culture. Many rituals are associated with pregnancy and childbirth in Indonesia, including the seventh-month pregnancy ceremony (which symbolises gratitude, the wish for a smooth birth and good health for mother and baby) and the provision of traditional herbal medicine to pregnant and lactating women (Ministry of Health, 2012).

Indonesia has a high maternal mortality rate, recorded as 177 deaths per 100000 live births in 2017 (World Health Organization et al, 2019). In East Java, the rate has been found to be 98 deaths per 100000 live births (East Java Department of Health, 2021). A policy has been put in place that aims to reduce maternal mortality by implementing a partnership between traditional birth attendants and midwives in East Java, including on Madura Island. However, evidence shows that even when healthcare is accessible, not all women use these services (Karavadra et al, 2020). The Madurese still recognise the traditional birth attendant as having a crucial role in antenatal care alongside health workers (Devy et al, 2007), while cultural practices, beliefs and taboos associated with pregnant women are shared among Madurese people who adhere to local culture (Ministry of Health, 2012). Therefore, this study’s aim was to explore pregnant women’s culture, traditional beliefs and practices in the Madurese tribe of Indonesia.

Methods

This qualitative study was conducted in the Sumenep district on Madura Island in Indonesia, between January 2017 and March 2018. Three sub-districts were selected as study sites representing coastal (the Kalianget sub-district) and highland (the Lenteng and Batang-Batang sub-districts) regions; most of the residents of these areas are Madurese.

Participants and data collection

A total of 67 key informants were purposively selected based on inclusion criteria. These criteria were that a participant was either a pregnant woman or her family member (including husbands, mothers-in-law or mothers) provided they were living in the same household, a shaman or religious/traditional leader, or a traditional birth attendant. Participants were also required to have been involved in traditions and cultural practices for pregnancy and childbirth, and be from one of the indigenous tribes of Madura. Those who moved during the study period or could not meet to carry out the study were excluded.

The snowballing technique was used to approach and recruit the participants from the population; pregnant women and their families were asked to refer other pregnant women to the study, as well as contact religious or traditional leaders and traditional birth attendants. A total of 40 participants were involved in in-depth interviews and 27 took part in three focus group discussions. The discussions involved pregnant women’s families, traditional birth attendants and community figures (Table 1).

A semi-structured interview guide was used to collect qualitative data. Two trained interviewers with a bachelor’s and master’s degrees in anthropology conducted the interviews and focus group discussions. The lead researcher ensured data quality and management during data collection. Interviews were carried out in the Madurese language and Bahasa (Indonesian) and transcribed into English by the lead researcher. Two of the researchers were native Madurese speakers. The interviews lasted 45–60 minutes each and were conducted at participants’ homes. The focus group discussions lasted 60–90 minutes and were held in the homes of local health post cadres.

The participants were asked about what cultural traditions for pregnancy and childbirth existed and how they were implemented, what age they were carried out, who would be involved, what the tradition meant and whether there were any beliefs about what would happen if these traditions were not observed. Participants were also asked about community beliefs and practices for pregnant women, including how traditional birth attendants were involved. The questions included asking what acts they felt should be carried out (or avoided) by pregnant women, what purpose pregnancy massage had and how it was done, whether any special food was consumed during pregnancy and any other thoughts they had on traditional beliefs and care practices during pregnancy.

Data analysis

All focus group discussions and in-depth interviews were audio-recorded for transcription and analysis. The transcripts were checked for accuracy and completeness. They were probed for meaning, values, beliefs, experiences and practices. Content and source analysis were used to analyse the data. Similar themes and sub-themes were grouped according to the key findings. Verbatim quotes are used to support the results and allow for transferability in similar contexts. This study used data and sources triangulation to ensure the validity and reliability of qualitative data.

Ethical considerations

The Health Research Ethics Committee, Faculty of Public Health, Universitas Airlangga (approval number: 1-KEPK 2017) issued ethical clearance for this study. All participants signed informed consent forms and could withdraw at any time without consequences. The researcher treated the information on beliefs and practices with respect and kept all data and identities confidential.

Results

The traditional practices frequently performed included fourth-month and seventh-month rituals and pregnancy massage. They were described as being carried out from generation to generation as gratitude to God for the blessings of pregnancy, to ensure the pregnancy was safe, the fetus was healthy and sound and the child was good. Pregnant women feared that if they did not follow existing traditions, it would cause problems during their pregnancy, such as miscarriage, a difficult birth or other negative impacts on the mother and baby.

Two long-standing traditional rituals (fourth- and seventh-months) were frequently carried out. A family’s economic status would determine the festivities carried out, but the ritual stages were the same. In addition to fourth- and seventh-month traditions, there was also a tradition of pregnancy massage usually after four months’ gestation (Figure 1). Traditional beliefs and practices were the same for all three trimesters, and could be divided into 1) taboos and 2) suggestions for pregnant women and their husbands. All traditional beliefs and practices were adhered to and carried out to ensure the mother’s and baby’s health and safety, facilitate birth and ensure the baby becomes a good person.

Fourth-month ritual

The fourth-month ritual was usually held from the gestational age of 3 months and 10 days until the fourth month. This was believed to be the point at which the soul or life was ‘blown’ into a fetus in the womb.

‘When the fetus is in its fourth month, according to Muslims, the soul was blown [into the fetus]. We should pray to [Allah SWT] so that [the child] will be good’. HK, 34 years old

The activities during the ritual included reciting Al-Qur’an, praying and providing food (traditional foods such as yellow rice, tumpeng (nasi rasol), fried chicken, soto, meat, cakes, noodles and traditional cakes such as lemper, porridge and others). The ceremony was held in the pregnant mother’s house, where tahlilan (praising God and prophet) and praying were led by a kyai (a Muslim leader), and neighbors and relatives were invited.

‘Here in this village, we do fourth-month rituals according to my mother, the baby is perfected, provided a mate, given sustenance when it is four months old. So, we pray by inviting our neighbors to be grateful to God’. EK, 30 years old

The ritual was believed to be the right time to ensure ‘goodness’ in the child. Participants believed that God would give every virtue at four months’ gestation and so people should perform ritual activities such as reciting and reading Al-Quran (Surah Maryam, Surah Yusuf and Surah Muhammad) and praying.

‘[At] four months, there was a grateful gathering, only praying together, reciting Surah Maryam, Surah Yusuf, Surah Muhammad’. AZ, 25 years old

The participants also believed that it was necessary to do a variety of good deeds for the fetus to become a good person; this would ensure they were well-behaved, good-hearted and had a good personality. Pregnant women and their husbands felt it necessary to do good deeds such as reading the Qur’an and not killing animals. Reading the Qur’an was thought to provide goodness for the family and child. In contrast, if a parent or husband killed an animal, this evil deed would be passed down to the child. One participants described an incident where a woman’s husband cut off a lizard’s leg while his wife was pregnant; the child was born with a disability in his legs. This example reinforced the belief that bad deeds during pregnancy could be passed to a child, and ensured pregnant women and their families carried on the belief.

‘Once here, her husband cut off a lizard’s leg, when the child was born his leg was deformed…that is his house on the edge of the village hall. That was the story when he came home from work there was a monitor lizard next to his house…his husband threw a machete. It was a lizard’s leg broken off’. MN, 29 years old

Seventh-month ritual

The tradition for third-trimester pregnant women was a seventh-month ritual, which was more complex than the fourth-month tradition. Seventh-month routines included reciting Al Qur’an, bathing rituals while carrying coconuts and breaking eggs. These traditions were only carried out for a woman’s first child.

‘For her first child, when the pregnancy is 3 months and 10 days, she is doing selametan [communal feast]. She does not do it for the second child. Usually…there is praying by a kyai [Muslim leader]. Then in the seventh month rituals, if it is the first child, the pregnant mother is bathed, and there are praying rituals and selametan, even though it is simple.’ MN, 60 years old

For subsequent pregnancies, people would recite Al-Quran in the seventh month. The culture placed importance on the first child, the ‘family successor’, which was thought to be special. The second child was assumed to have been represented by the first child, meaning the rituals carried out in the first pregnancy would apply to subsequent pregnancies. Only a prayer would be read for the second child, there was no bath or processions.

The philosophy or meaning behind the seventh-month rituals was purification, facilitating the birth process and acknowledging God in the child’s life from the womb. Bathing rituals were performed to purify the fetus in the womb so it would be clean and holy. Dropping an egg from the lap downwards was a symbolic act that reflected the process of childbirth in the egg sliding and breaking on the soil. It was also thought to symbolise ketaukhidan, the concept of Monotheism in Islam; God is one and single.

‘Well, it is said that the tradition of the people here started a long time ago in order for the baby in her womb to recognise tauhid [affirming God, just one God]’. AS, 55 years old

There was variation in the scale of ritual performed. Whether the practices were elaborate or simple depended on the family’s financial status.

‘Some people do a big ceremony. I am not doing that, just a simple one and inviting the orphans. For this [pregnancy], there is no [third-month ritual]. I do not know; perhaps it will be integrated simultaneously as the celebration of the seventh-month rituals’. MN, 60 years old

The four stages of the rituals were the same, regardless of finances. The first stage was praying and reciting the Al-Quran (pengajian), which helped ensure the child became a good person (well-behaved, good-hearted and a good personality). Neighbours and relatives were invited to pray, recite the Al-Quran and have a meal.

The second stage was bathing, where the expectant father and mother sat and poured water mixed with flowers using a water dipper made of coconut shells. The ritual was carried out by a traditional birth attendant, a Muslim leader (kyai) and relatives. After family poured water on the expectant parents, they would put a dime in a bucket, which was later collected for the traditional birth attendant or midwife. The traditional birth attendant led the bathing process, and the Muslim leader recited Al-Qur’an and prayed.

The third stage was holding or carrying a coconut. Two coconuts (usually yellow) were prepared, one with Arabic letters written on the outside and the other one with Javanese letters. The intention was to introduce Arabic letters, as a basis for reading the Qur’an, and Javanese letters to the child, so they would be intelligent in both religion and education. The expectant mother or father would hold the coconuts in their lap during bathing. They would then be stored in their bedroom until the mother gave birth, after which the coconuts were thrown away or planted. This ritual also reflected the ketaukhidan.

‘A [baby’s] name belongs to the [amanah], [the name] cannot go into [the letters on the coconut]. A name is arbitrary…so it is written with carakan [Javanese letters]’. AS, 55 years old

The fourth stage involved putting an egg in the expectant mother’s lap, who then stood up, causing the egg to fall and break. If the egg did not break when she stood up, she would be encouraged to step on it to break it. This was done to encourage an easy birth.

This ritual differed substantially from the fourth-month ritual as it was more closely related to ancient Madurese cultural traditions than the Islamic religion. The materials used included a bucket, comb, drinking glass, shirt and powder, all of which had to be new.

Pregnancy massage

The role of traditional birth attendants was emphasised in pregnancy treatment (pregnancy massage) and postpartum (bathing the baby), rather than childbirth. For labour and birth, it was felt that a woman must be accompanied by health personnel.

A pregnancy massage was frequently practiced according to the participants. The process was first performed on pregnant women at 4 months’ gestation; less than 4 months was considered too young for a massage. The purpose was to improve the baby’s position and reduce the mother’s stiffness and fatigue during pregnancy. It could take up to 30 minutes, and involved the use of olive or coconut oil. If the baby was in an incorrect position, the mother would experience discomfort and difficulty walking and urinating; the traditional birth attendant would ‘fix’ the baby’s position with a ‘junjung’ massage (pushing up). Almost all pregnant women participating in this study had received a massage, and it was thought to facilitate childbirth.

Traditional beliefs

Traditional beliefs and practices during pregnancy were divided into taboos and suggestions, which could apply to the pregnant women, her partner or the couple together. A summary of taboos and suggestions can be seen in Figures 2 and 3. The ideas had been passed down from generation to generation and were implemented to ensure safety and a smooth pregnancy, and wish good for the baby.

Taboos

Several of the taboos were symbolic of difficulties in pregnancy or birth. Pregnant women were forbidden to sit or do activities in a doorway or between the outside and inside of a house. Breaking this taboo was thought to cause a difficult birth. Wrapping a towel or veil around a pregnant woman’s neck was thought to cause the fetus’ neck to be bound by the umbilical cord. Squeezing clothes after they were washed and hanging them on bamboo fences was believed to harm pregnant women and their babies. Pregnant women stepping over or on rope was thought to lead to the umbilical cord wrapping around the baby during birth.

Taboos also applied to pregnant women’s partners. During pregnancy, husbands were forbidden to engage in activities related to nails or nailing objects as this was thought to harm their wife. Husbands also avoided killing or tying up animals. One participants reported on the case of a baby born with its umbilical cord entangled, which was thought to be because the mother draped a towel around her neck during pregnancy.

‘During pregnancy, it is forbidden to cross the rope, wrap the towel around the neck…believe it or not, but I experienced a miscarriage when I was pregnant with my first child because if I wanted to take a bath I put a towel on my neck. The baby was entangled in the umbilical cord and died’. SA, 29 years old

Suggestions

The suggestions for pregnant women mainly advised a massage or repositioning the fetus, to discourage breech birth. A pregnant woman was also encouraged to always carry a sharp weapon, like a small knife, as protection during pregnancy and to avoid interference from supernatural beings. There were also traditional beliefs regarding how to encourage a child of a specific sex. For a daughter, it was thought that they should steal spoons from couples with daughters or exchange clothes with them.

During pregnancy, a pregnant woman’s husband was expected to abstain from taboo activities and recite Al-Quran and sholawat (praising the prophet Muhammad) regularly, for his wife’s safety. This suggestion was thought to keep the relationship between husband and wife intact, so that the wife could obey and serve her husband, which was believed to lead to a smooth and easy childbirth.

Traditional Madurese practices also involved food and drink. It was recommended to drink herbal medicines during pregnancy. Boiled turmeric and tamarind were thought to refresh the body and clean the baby during birth, coconut water was thought to facilitate labour, and boiled Moringa leaves were thought to strengthen the fetus. Herbal medicine (made of turmeric, tamarind and lemon or coconut water) was given in the third trimester, which was believed to be needed for the baby to be born healthy and the mother to be safe during birth.

‘Almost all pregnant women here drink [herbal medicine], so it’s quick and easy at birth. Most of the time, it’s tamarind, turmeric, coconut water or lemon water. They say the child will be clean…and the delivery process is easy…. If it’s tamarind, sometimes it’s made by yourself, sometimes it’s made by a traditional birth attendant’. NN, 24 years old

Discussion

The findings of the present study highlight that the Madurese still practice deep-rooted cultural traditions during pregnancy. These practices include four- and seven-month rituals and pregnancy massage, as well as taboos for pregnant women and their partners and suggestions for how to behave. The strongest motivation for such rituals is the belief that failing to perform these practices will lead to negative consequences, such as miscarriage, difficulty during childbirth or a baby born with a disability. Most of the traditional beliefs and practices outlined by the participants are harmless to pregnant women and their babies, while several can positively affect a mother’s psychological and physical condition, such as baby repositioning and praying.

The traditional practices were largely based on religious and cultural beliefs. Such beliefs and practices have been documented in many studies worldwide (Aziato et al, 2016; Karahan et al, 2017; Withers et al, 2018). Two rituals were outlined by the participants, conducted at four and seven months’ gestation. The four-month ritual involved prayer and gratitude to God, inviting relatives and neighbours, distributing food and drink and collection coins. Prayer and collection for charity in traditional pregnancy birth practices can also be seen in other cultures (Cassaigne 2008). The seven-month ritual in Javanese culture is believed to facilitate the birth process and have a positive impact on pregnant women (Hanafie et al, 2022).

The four- and seven-month rituals involve thanksgiving or gratitude to God, while also attempting to ensure that a pregnant woman will have a comfortable pregnancy, smooth labour and birth, and that the baby will become a good and religious person (Ratih Indraswari, 2018). These rituals continue to be practiced because they are felt to be meaningful; they are also followed by Javanese people elsewhere in Indonesia (Cukarso and Herbawani, 2020). Behavioural taboos and suggestions continue to be carried out to ensure the safety of mothers and their babies, to protect against evil spirits, and to ensure an uncomplicated pregnancy and birth and maintain peace and harmony in the family (Kaphle et al, 2013). Some beliefs related to attempting to ensure having a child of a particular sex; similar beliefs have also been reported in Istanbul, Turkey (Karahan et al, 2017).

The use of traditional birth attendants is influenced by cultural traditions, as they are thought to perform critical services and respect local customs (Koblinsky et al, 2000; Titaley et al, 2010). In the Sumenep district, a policy has been implemented to promote birth in health facilities through a partnership of traditional birth attendants and midwives (Rofika and Hariastuti, 2020). The partnership is essential to decrease maternal mortality. This partnership has led to a change in the role of the traditional birth attendant. Traditional birth attendants are not allowed to perform a birth in Indonesia; instead they escort pregnant women in labour to health facilities and their own role is emphasised in pregnancy and postpartum treatment.

The partnership was established in the 2000s through collaboration between the health office and village heads throughout the Sumenep district. Village heads informed traditional birth attendants in their areas about the policy, which states that health personnel (doctors and/or midwives) must carry out all labour and birth processes. Traditional birth attendants are forbidden to conduct a birth by themselves, or they can be fined IDR 500000 (equivalent to approximately £27.95).

At first, there was refusal from traditional birth attendants but over time, with frequent outreach to both the attendants and the community, they eventually agreed to cooperate with health personnel (Ribeiro Sarmento, 2014). In addition, training for traditional birth attendants was provided. The Department of Health coordinates the partnership policies for traditional birth attendants at the district level. Healthcare centres, as institutions under the Health Service located in the sub-districts, coordinate with the district head to invite traditional birth attendants to the working area, where they are provided with an explanation of the benefits of the partnership. After the partnership agreement is signed, regular meetings are held at the health centre every month to provide education about the role of traditional birth attendants in pregnancy care.

Traditional birth attendants were found to play a role in providing traditional massage during pregnancy, as has been highlighted in previous studies of traditional practices (Tobing et al, 2019). The systematic touching and manipulation of the body’s soft tissues is increasingly being used as adjunctive therapy for stress relief and to promote relaxation and wellbeing during pregnancy, and can also be used as an alternative to pharmacologic or invasive forms of analgesia during labour (Pachtman Shetty and Fogarty, 2021). Most pregnant women in the present study had received a pregnancy massage to ensure the baby was positioned correctly in the womb. This can positively affect a mother’s physical condition (Lau 2012), as they relax and find it easier to walk and urinate. In addition to baby repositioning, midwives may encourage traditional birth attendants to use pregnancy massage therapy (Diana et al, 2018). Although pregnancy massage can be beneficial, and is not harmful to mother or baby, the process must be done carefully by an expert (Banul and Halu, 2020).

Massage therapy can effectively reduce pregnant women’s anxiety, stress hormones, sleep disturbance (Aswitami et al, 2021) and back pain, as well as helping mitigate against obstetric and postnatal complications, depression, anxiety and leg or back pain during pregnancy (Field et al, 2004). This is likely the result of reduced cortisol levels and, in turn, excessive fetal activity in depressed women (Field 2010; Dobernecker et al, 2023). In studies of the effect of such massage therapy, the rate of prematurity is lower in those who practice massage (Field 2010; Hall et al, 2020).

Relaxation techniques during pregnancy can affect maternal, fetal and neonatal outcomes (D’Souza et al, 2021). Relaxation can improve a woman’s emotional state, which can reduce the need for admission to a hospital, minimise the risk of obstetric complications and lead to a longer longer gestation, reduced risk of caesarean section and fewer postpartum complications (Fink et al, 2012). Maternal stress and depression can increase fetal heart rate and motor activity through an increase in corticotropin-releasing hormone, adrenocorticotropic hormone, cortisol and noradrenaline (DiPietro et al, 2021). Relaxation can improve a woman’s emotional state by increasing dopamine and serotonin levels, while decreasing cortisol and norepinephrine levels (Dieter et al, 2001; Fink et al, 2012). Relaxation has also been shown to lead to a greater neonatal birth weight, improved performance on the neonatal behavioral assessment scale, reductions in maternal physiological and endocrine measures and salutogenic effects, including regulating emotional states and physiology (Fink et al, 2012; Moraes et al, 2020).

Identifying pregnant women at higher risk of complications and treating these early in pregnancy can improve obstetric and developmental outcomes for both a mother and fetus (Fink et al, 2012). Pregnant women participant have reported that therapeutic massage can relieve pregnancy discomforts such as headache, backache, muscle cramp, sleep disturbance and anxiety (Xue et al, 2022). Therapeutic massage is an effective method for reducing discomfort-related pain and can be clinically advised as an alternative, safe and affordable method of pain relief during pregnancy. Raising midwives’ awareness awareness of the use of massage therapies for pregnant women has been recommended as part of routine antenatal care (El-Hosary et al, 2016).

Studies show that many cultures’ beliefs make some activities taboo during pregnancy, including avoiding killing animals, seeing wild and frightening animals, hating someone, behaving rudely to others, cutting hair and fishing (Koeryman 2019). One tradition in the present study was for pregnant women to consume coconut and lime water. In the Madurese culture, coconut water is thought to clean the baby’s skin (Rian et al, 2018).

Conclusions

Traditional beliefs and practices for pregnant women of the Madura Tribe in Indonesia include fourth- and seventh-month rituals, massage and behavioural taboos and suggestions. These traditions are carried out to show gratitude to God and are believed to help ensure that the child becomes a good and religious person, that the mother and her baby have a safe pregnancy and uncomplicated birth, and to maintain peace and harmony in the family. Pregnancy massage by traditional birth attendants can help women be more comfortable during pregnancy.

Most practices outlined in the present study are harmless for mothers and babies. Healthcare providers should be respectful of prevailing traditional beliefs and practices when providing care.

Key points

• The Madurese have several beliefs and traditions that celebrate pregnancy, including pregnancy massage and four- and seven-month ceremonies.
• Some activities are considered taboo because they are believed to interfere with pregnancy and childbirth for pregnant women and their husbands.
• There are also recommended activities that are believed to facilitate birth; these activities include pregnant women and their husbands.