Maternal mortality is a significant public health concern, especially in countries with low and middle incomes. According to the World Health Organization (WHO, 2023), in 2020, approximately 287 000 women lost their lives during and after pregnancy and childbirth. The vast majority of these maternal deaths (almost 95%) occurred in low and lower–middle-income countries (WHO, 2023). Approximately 800 women per day died as a result of avoidable factors associated with pregnancy and birth (WHO, 2023).
The provision of healthcare services by proficient healthcare professionals before, during and after childbirth can prevent mortality among women and infants (Ngotie et al, 2022; WHO, 2023). Between 2000 and 2020, the global maternal mortality ratio (maternal deaths per 100 000 live births) decreased by approximately 34% (WHO, 2023). However, maternal mortality is still a significant public health issue in low-income countries, such as Indonesia, which has the highest maternal mortality among countries in the Association of Southeast Asian Nations (UNFPA, 2023). Data from the 2015 inter-census population survey in Indonesia (Badan Pusat Statistik, 2016) showed that the maternal mortality ratio was 305 per 100 000 live births. The sustainable development goals' target is to reduce this to less than 70 by 2030 (WHO, 2018a).
Birth preparedness is an important element of minimising maternal mortality. It facilitates proactive preparation for birth using skilled birth attendants (Markos and Bogale, 2014; Nachinab et al, 2023). It involves women and healthcare professionals strategising for typical childbirth and anticipating necessary actions in an emergency, with the overall aim of reducing obstetric difficulties (Feyisa Balcha et al, 2024). It is essential to ensure that there is adequate staffing to support women with birth preparedness and planning, to prevent the three main delays that lead to maternal death in Indonesia (delays in decision making at the family level, arrival at healthcare facilities and access to healthcare facilities). The role of the community is also important in helping to prevent maternal mortality, especially in ensuring pregnant women do not experience delays in reaching healthcare facilities (Andarge et al, 2017; MacDonald et al, 2018).
Several health facilities in Java have held classes for pregnant women, to inform them about danger signs in pregnancy, prepare them for childbirth and help them prepare for breastfeeding; these classes are organised by community midwives and public health centres. However, they have not been implemented regularly and not all women are able to attend as a result of geographical factors and the distance to midwives or health facilities. Public health and health promotion theories (Thompson, 2023), frequently attribute poor health behaviour to individuals not engaging with health promotion prevention; in this case, meaning that pregnant women do not engage with health services in relation to preparing for childbirth. Researchers have explored the significance of culture in health promotion by integrating it with sociobehavioural variables to create health-related treatments that encourage healthy behaviour (Huff et al, 2015).
However, the results of health promotion operations can be impacted by distinctive patterns of beliefs and perceptions that a culture develops about ‘what health means’. A culture is a system of values, concepts, meanings and associated beliefs that can affect a person's perception, communication skills and conduct (Helman, 2007; Chemuru and Srinivas, 2015). Promoting good behaviour in relation to health, such as preparing for birth, in a positive sociocultural context is crucial to changing health behaviour. Adopting culturally sound health service delivery methods can reduce the gap between culture and health promotion (Salazar et al, 2015).
Studies from low- and middle-income countries have shown that cultural norms significantly impact behaviour during pregnancy, labour and care-seeking (Raman et al, 2016; Lang-Baldé and Amerson, 2018). Additionally, sociocultural barriers can increase the likelihood of obstetric problems for pregnant women and newborns, contributing to maternal mortality (Cheptum et al, 2018). Healthcare professionals must be aware of common cultural practices in the local community, and how they may affect women's behaviour and their preparations for birth.
Indonesian society has its own concepts and values about pregnancy, childbirth, childbirth attendants and the value of children in a family. In Javanese society, which adheres to the patrilineal lineage pattern and family customs, the role of the husband or father is very influential (Lestari et al, 2018). Decision-making behaviour in seeking healthcare during pregnancy is also influenced by factors such as family power hierarchy, family type and family social status (Listiowati et al, 2018). Socio-cultural influences will affect cultural norms and community beliefs in terms of using healthcare services, especially for birth preparedness (Khasanah et al, 2018). This study explored local cultural perspectives of birth preparedness in a rural subdistrict of East Java Province, Indonesia.
Methods
This descriptive study used a qualitative approach to obtain rich, meaningful and detailed information about local cultural perspectives of birth preparedness in a rural subdistrict of East Java (Creswell and Creswell, 2018). Qualitative methods aim to better understand a phenomenon by considering the viewpoints of those with personal experience. Qualitative research explores and offers a profound understanding of practical issues in the real world (Moser and Korstjens, 2017). It gathers data about individuals' experiences, perceptions and behaviour. Qualitative research is fundamentally concerned with asking open-ended questions, focusing on inquiries into ‘how’ and ‘why’ (Cleland, 2017).
The study population was pregnant women domiciled or living in Pacitan, East Java and other key informants of cultural perspectives of birth preparedness.
Participants
Qualitative research standards state that 12–25 interviewees will achieve data saturation (Creswell, 2014; Cropley, 2022). For this study, 16 participants were recruited using purposive sampling, including 10 pregnant women, two community midwives, two pregnant women's parents and two health cadres. Health cadres are community volunteers who assist healthcare professionals in delivering healthcare services to community members.
The inclusion criteria were women of childbearing age (15–49 years old), who were pregnant during the study period, lived in a rural community in Pacitan Regency and had no communication problems. Participants were identified based on data from health centres and information from health cadres in the community. Data saturation was achieved at interview 14. Two further interviews were conducted to ensure saturation.
Data collection
Semi-structured in-depth interviews were conducted face to face with participants, who were asked about how they understood the meaning of pregnancy in a sociocultural context, the danger signs of pregnancy, the meaning of childbirth in a sociocultural context (meaning of birth and preparation for it), and cultural values in pregnancy and childbirth, including taboos. The questions were not pre-tested before data collection.
Each interview lasted 40–60 minutes and was conducted at the participant's home. All interviews were transcribed verbatim and field notes were taken to increase the veracity of data interpretation through triangulation. The field notes assisted in documenting the interviewer's observations and analyses of the data.
Participants' responses were translated from Indonesian to English by certified translators, assisted by research team members. Back-translation was conducted to check the translations' accuracy and a final review of the translation was carried out after the translation was finished.
Data analysis
This study's findings were organised, systematised and described using thematic analysis (Braun and Clarke, 2006). The six steps of thematic analysis are:
The researcher actively participated and immersed themselves in the data by transcribing the exchanges, reading (and rereading) the transcripts and listening to the recordings. Significant components were identified and codes generated, which were then interpretively analysed. Pertinent data excerpts were organised into categories by merging or dividing them according to overarching subjects. Correlations between codes were established and organised into subthemes and themes. Following identifying themes, in-depth analysis was performed to determine whether to incorporate, refine, separate or eliminate original concepts. It was ensured that the information inside each theme was coherent when merged and that there were evident variations among themes. The themes were checked against coded extracts and the entire data set, creating a thematic ‘map’.
Ethical considerations
The study was approved by the Research and Community Engagement Ethical Committee, Faculty of Public Health, Universitas Indonesia (approval number: Ket-444/UN2.F10.D11/PPM.00.02/2022).
All participants were given information about the research background, aims and objectives and what the research would be used for. Participants were asked to give written informed consent, including consent to be recorded during interviews.
One of the researchers lived in the community at the time of the study and participated in activities such as community gatherings, integrated health services activities, wedding ceremonies and other sociocultural and religious activities. She has a PhD and is Muslim.
Results
Table 1 outlines the characteristics of the 16 participants. Three themes were generated from the interviews: the meaning of pregnancy in the sociocultural context, the meaning of childbirth and cultural values in pregnancy.
| Participant type | ID | Age (years) | Gestational age (weeks) | Gravida | Education | Occupation |
|---|---|---|---|---|---|---|
| Pregnant women (n=10) | P1 | 21 | 23 | Primigravida | Senior high school | Housewife |
| P2 | 24 | 14 | Primigravida | Senior high school | Housewife | |
| P3 | 37 | 30 | Grande multigravida | Junior high school | Housewife/farmer | |
| P4 | 19 | 32 | Primigravida | Junior high school | Housewife | |
| P5 | 34 | 28 | Multigravida | Bachelors | Teacher | |
| P6 | 17 | 28 | Primigravida | Junior high school | Housewife | |
| P7 | 30 | 14 | Multigravida | Junior high school | Housewife | |
| P8 | 22 | 8 | Multigravida | Senior high school | Housewife | |
| P9 | 34 | 35 | Multigravida | Bachelors | Teacher | |
| P10 | 44 | 28 | Grande multigravida | Primary school | Housewife | |
| Midwives (n=2) | P11 | 48 | - | - | Midwifery diploma 3 | Civil servant |
| P12 | 39 | - | - | Midwifery diploma 3 | Civil servant | |
| Parents of pregnant women (n=2) | P13 | 56 | - | - | Junior high school | Housewife |
| P14 | 42 | - | - | Primary school | Housewife | |
| Health cadres (n=2) | P15 | 49 | - | - | Junior high school | Health cadre |
| P16 | 49 | - | - | Junior high school | Health cadre |
Meaning of pregnancy in the sociocultural context
Meaning of pregnancy
Several participants described pregnancy as a blessing or a gift to be grateful for.
‘Pregnancy is a blessing for me. I am happy because I have been waiting for almost a year, for a fortune. Yes, it is true, pregnancy is a blessing, a gift, so I am grateful’.
One participant considered pregnancy a gift even though it was unplanned.
‘Pregnancy for me is a gift, even though I have not planned to have children. For the past two years, I have not had family planning, only calendar birth control, but how come I'm pregnant, even though I've never had sex during intercourse? Pregnancy is a gift from God Almighty. My current condition is weak, nauseous, but uncertain, usually early every morning’.
Knowledge of danger signs of pregnancy
Some participants were able to name danger signs during pregnancy, such as a lack of active baby movements, spotting, bleeding, high blood pressure (hypertension) or amniotic fluid discharge.
‘Maybe it is better to check the baby's movements, whether they are more active, if there are spots or if bleeding continues … Sudden heartburn, bleeding, excessive dizziness, amniotic fluid coming out, when [I had] my first child, my waters broke first. Yes, bleeding’.
However, some did not know about danger signs.
‘I don't know yet. Once, I read from a book but forgot … I don't you know yet; the important thing is you can't work hard’.
Meaning of childbirth in the sociocultural context
Meaning of childbirth
Some participants felt that childbirth was extraordinary, even, for example, in the case where labour had to be induced because of a lack of labour signs.
‘Delivery is an extraordinary thing, full of struggles. My experience with my first child was that I had not experienced any signs of labour, for example, mucus coming out’.
Pregnant women indicated that a discharge of amniotic fluid usually marked labour. Some thought that a stomachache and discharge marked labour.
‘Labour is usually marked as stomachache…Labour is usually marked as pain and rupture of membranes. Also, delivery is usually marked by mucus discharge … Labour is usually marked by a discharge of amniotic fluid’.
Preparedness for childbirth
Several pregnant women noted that they had not prepared supplies for their birth.
‘No, there is no preparation, but usually clothes and baby equipment, but that's usually when you've given birth. So far, we have thought about, for example, baby clothes, God willing, enough clothes, but they have not been prepared, later when it is nearing delivery. So, there is no preparation, later when you want to give birth’.
Others confirmed that preparation for childbirth was usually done close to the due date. Healthcare professionals, especially midwives, recommended preparation.
‘Preparation for childbirth can be funded…if the clothes have not been prepared, later if it is approaching delivery, in addition to the identity card and essential papers’.
One participant said that preparation for childbirth focused on health issues, including a mother's health.
‘Preparation for childbirth focuses more on health issues, maybe preparation related to a mother's health, if Allah is pleased. I want to give birth typically, but it turns out that my [hemoglobin] is lacking because the risk is that if hemoglobin is low, there are many risks to others’.
Participants who were mothers of pregnant women stated that preparations for childbirth were generally carried out when the mother had already given birth or shortly beforehand, and described common preparations, influenced by the available financial support.
‘What are the preparations? There are also no free insurance people, baby clothes and other stuff later. When I give birth, I also call baby shaman … so preparing for childbirth. Usually, baby clothes, sarongs and mother's clothes are prepared when they give birth, if insurance is obtained from the government’.
There was an assumption that preparations for labour being carried out earlier in pregnancy was taboo.
‘Sometimes, according to villagers and parents, preparing for childbirth during pregnancy is not good or something that is considered taboo’.
The community midwives highlighted that one of the main problems in rural areas was related to finances. Many pregnant women were not prepared for the associated costs at the time of birth.
‘Many people when they are about to give birth but don't hold any funds at all, I think how to do it later if the pregnant woman who is about to give birth doesn't have a crash, and doesn't take care of her. I mean how do I make the community self-sufficient?’
Healthcare professionals provided some education and information to women, but the lack of education in the community was highlighted.
‘Until there was a delivery that 2 years ago had not been paid for, that's why I'm applying for funds to the village. If you get pregnant, you have to prepare for the pregnancy because the socioeconomic community is lacking, especially if the delivery is not desired so the delivery preparation is lacking. It isn't just during delivery but after delivery also still need to be prepared, because of the socio-economic community and the level of education are lacking, support is needed if there is a case like this’.
Cultural values
Pregnancy and childbirth preparation
Participants described some of the cultural values regarding pregnancy and childbirth preparation in rural areas, including traditional ceremonies.
‘You can't sleep too long during the day, and you usually perform ceremonies after giving birth, such as the brokohan [traditional ceremony in Java]. You can't take too long a nap. There will be a 7-month traditional ceremony … When cleaning or sweeping, you have to throw it away. You can't sew often, you can sit at the door, you go out immediately, you cannot stagnate’.
According to the health cadres, there were a range of opinions and preferences regarding pregnancy and preparation for childbirth across several cultures locally. For example, most pregnant women undertook preparations after giving birth, as previously highlighted.
‘From a cultural point of view, for example, preparing clothes and so on, they are only prepared when they are in labor because during pregnancy … it is not permissible. For the man [husband], he has to change his attitude; his wife is pregnant, and she has to pray a lot’.
Abstinence during pregnancy
Some participants reported special restrictions during pregnancy, including abstinence from certain foods, such as pineapple, tape, durian, grapes, papaya chicken and eggs.
‘At sunset you are not allowed to leave the house … There are only a few dietary restrictions, for example, pineapple, tape, durian, grapes, pineapples that have never been eaten so far, and papaya because they fear these [fruits] are said to be bad’.
‘When my first child was not allowed to eat chicken, was not allowed to eat eggs, at Maghreb [sunset prayer] was not allowed to go outside … This means that when cooking, you cannot wear shells, you can't make fun of people, you can't eat anything’.
The health cadres confirmed that these beliefs were held by pregnant women in the community.
‘If the women are pregnant for the first time, they can't do this … for example, you can't eat pung petung [bamboo roots], vegetables, you cannot sit at the door, you cannot eat pineapple, tape’.
Discussion
This study explored cultural perspectives of birth preparedness in a rural subdistrict of East Java, Indonesia. Cultural norms were found to significantly impact pregnancy, labour, and care-seeking behaviour, including practicing certain behaviours and observing taboos. Pregnancy can be influenced by several elements, including a couple's intentions, social support and the community's perspective of pregnancy, which is influenced by the sociodemographic and sociocultural aspects of the area (Soltani et al, 2017).
Cultural beliefs and values associated with birth provide perspective on the meaning of childbirth for women who give birth. A woman can identify the experience as positive or negative, with some women reporting negative or traumatic births (Viirman et al, 2022). One of the participants in the present study stated that childbirth is an extraordinary thing but full of struggles. Childbirth is a unique event and experience, and is associated with pain (Laney et al, 2014). Several studies have found that many women experience fear of childbirth. The results of the study show that the prevalence of fear of childbirth is 24% overall, with a high level of fear of 31.5% occurring in nulliparous women (Toohill et al, 2014).
Although not all of the present study's participants had planned their pregnancy, many perceived it as a blessing or a gift from God, for which they must be grateful. Studies have shown that pregnant women see pregnancy as a responsibility and a process that fosters healthy connections between partners; it can also be seen as the foundation for marriage and starting a family (Eddy and Fife, 2021). Pregnancy is also seen as more significant when planned and desired (Lestari et al, 2018). Some women have claimed that being pregnant is a miraculous phenomenon that every woman should go through and that a child is the most priceless possession they will ever own (Yilmaz et al, 2021).
The pregnant women who participated in the present study demonstrated a low level of knowledge about danger signs during pregnancy. Most answered that they did not know about danger signs. Similarly, a study in Papua New Guinea reported that only 60% of 246 pregnant women could remember one danger sign (Vallely et al, 2019). A study in Madagascar reported that 81% of 326 women knew only one danger sign in pregnancy (Salem et al, 2018). Signs that women should be aware of include vaginal bleeding, seizures, severe headaches with impaired vision, fever, inability to get out of bed, severe abdominal pain and quick breathing or difficulty breathing (Teng et al, 2015). Awareness of danger signs is one of the most important elements of preparing for birth, in order to promote positive outcomes (WHO, 2018b; Feyisa Balcha et al, 2024).
Birth preparedness and complication readiness are essential in ensuring women can access skilled healthcare providers at the onset of labour (Feyisa Balcha et al, 2024). The pregnant women who participated in the present study noted that they had not prepared for birth during their pregnancy, and midwife participants highlighted that many pregnant women in the community did do so. This lack of preparation was because of a cultural belief that preparing for birth during pregnancy, for example by gathering clothes and blankets for mother and baby, was taboo. Similar cutural beliefs have been reported elsewhere, with a study in Kenya noting the belief that preparing for labour before a baby was born could cause neonatal mortality or bring bad omens (Cheptum et al, 2018). In West Ethiopia, it was reported that only one in five women prepared well for birth (Wudu and Tsegaye, 2021). A study in India highlighted that among other reasons, women gave birth at home because they had not planned transportation (55%) or prepared their finances (48%) (Wilcox et al, 2016). Improving birth preparedness and readiness through community-based awareness and promotion initiatives is imperative to effectively address and overcome complications (Wudu and Tsegaye, 2021).
Pregnant women in the present study reported that certain activities were considered taboo while pregnant, such as travelling at certain times and consuming certain foods. Jayadi et al (2020) conducted a similar study in Kaili Tribe Palu City, and found that a number of foods were considered off-limits for pregnant women, including the majority of fruits. A study in Ethiopia found that almost half of 147 respondents abstained from one or more foods during pregnancy (Tela et al, 2020). The reasons for avoiding certain foods during pregnancy include beliefs that the foods would make the baby fat and difficult to birth, or lead to an abortion or fetal abnormalities.
Foods may be forbidden for ethical, religious or cultural reasons. Food taboos are prevalent in practically all communities. However, they can have a negative impact, potentially leading to malnutrition among pregnant women (Jayadi et al, 2020). Poor maternal nutrition can impact both pregnancy and birth, especially in rural areas (Tela et al, 2020).
Implications for practice
The results of this study can be used to develop midwifery and public healthcare practice. They can be used as a basis for creating an intervention to educate pregnant women about the importance of preparing for childbirth.
Limitations
The main limitation to this study was that the participants only represented a single setting in Indonesia and the study's sample was small, meaning the results cannot be generalised. Another limitation was that one of the researchers lived in the same area as the participants, which could impact participant responses. This was addressed by ensuring participants were aware of the concern before data collection, and were asked to respond objectively based on their experiences and views.
Conclusions
Pregnancy and childbirth are heavily influenced by sociocultural factors, including in rural areas of Indonesia. In this study, many pregnant women regarded certain foods as taboo and avoided preparing for labour during pregnancy. Education interventions are necessary, exploring taboos and the significance of continuous birth preparation from healthcare professionals, such as midwives. Innovation is needed to empower the community to promote preparation for childbirth, such as preparing for costs, exploring public health funds and providing information on birth preparedness, especially for pregnant women in rural areas.