Pregnancy care for maternal and fetal wellbeing: an ethnography study

Pregnancy care can improve the health of pregnant women and fetuses by increasing awareness of potential serious pregnancy complications. Interventions carried out during pregnancy should be comprehensive, holistic and consider cultural beliefs (Jones et al, 2017).

In some rural communities in Indonesia, women have less agency to determine their needs during pregnancy, and often rely on traditional guidance based on cultural beliefs. Many prenatal, childbirth and postpartum care practices in these communities are based on sociocultural beliefs (Ansong et al, 2022). However, these practices are often incompatible with health science knowledge and can increase the risk of maternal and fetal death (Ariyo et al, 2017). The prevalence of high perinatal mortality and morbidity in certain communities may be linked with some religious and cultural beliefs (Paudel et al, 2018). For example, some communities hold that perinatal mortality and morbidity are the result of divine provision, and such religious–cultural interpretations can lead to a lack of prevention efforts during pregnancy and birth.

Religious and cultural interpretations and practices are common in Sundanese pregnancy care. For example, pregnant Sundanese women do not eat meat, fish or eggs because their religion forbids hurting God's creatures (Adamson, 2015). Such beliefs make it difficult for pregnant Sudanese women to consume enough high‑protein food to prevent anaemia and ensure fetal growth (Dewey, 2016). Some traditional perinatal practices in Indonesia can therefore prevent women from accessing and making use of important healthcare information. Aryastami and Mubasyiroh (2021) noted that the use of traditional practices and community birth attendants can significantly hinder access to modern maternal health services. They reported that the number of traditional birth attendants in an area was inversely proportional to use of maternal health services. There is a widespread belief, particularly in rural communities, that as pregnancy is a natural part of a woman's life cycle, prenatal care must be traditional and carried out only by traditional birth attendants (Agus et al, 2012).

Addressing these beliefs and ensuring access to health services is of the utmost concern for the Indonesian government, as their goal is to decrease maternal and infant mortality across the country. From 2008–2012, the Indonesian maternal mortality rate was estimated to be 359 maternal deaths per 100 000 live births (Riskesdas, 2018). It is important to raise awareness of the importance of receiving pregnancy care from trained healthcare workers. It is also important to recognise that a cultural approach to holistic care can be provided by traditional healers trained in appropriate science‑based interventions.

Appropriate management of maternity care should incorporate cultural considerations, and therefore understand the economic, geographical and social factors that affect ethnic minorities’ attitudes to health services. Healthcare services can encourage community participation in understanding and solving healthcare problems and should aim to develop and build services that that promote respect for all (Jones et al, 2017). Pregnancy care that incorporates the beliefs, values, myths and customs of women and their families contributes to ensuring maternal and fetal health (Sabogal and de Rodríguez, 2019), and traditional perinatal customs should be respected and preserved whenever possible.

Wikberg (2021) found that combining components of care with culture to form ‘intercultural care’ had a positive effect on maternal care. Leininger's transcultural nursing theory is also useful in management of pregnancy care with a cultural approach, and can be modified as needed (Andina‑Díaz and Siles‑González, 2020). Maternity care using Leininger's ‘sunrise model’ is suitable for healthy women who choose to give birth at home (Andina‑Díaz and Siles‑González, 2020). The sunrise model explains that maternal nursing must incorporate awareness of a patient's physiological condition and sociocultural environment (Pratami et al, 2022). However, the provision of nursing care using a cultural approach is made difficult by the number of possible ethnic groups, the size of the population and the number of pregnant women under a nurse or midwife's care (Musie et al, 2022). This ethnography study was carried out to analyse the cultural beliefs of pregnant Sundanese women, related to maternal and fetal wellbeing in Indonesia.

Methods

This research was conducted by a research team, which included a team leader, who was a maternity specialist nurse and researcher, as well as several other members, both male and female, who had attended research and publication training. The study used a qualitative design and an ethnographic approach, which involved observing participants over a sustained time period through direct involvement; this method aims to develop meaningful relationships with participants and their experiences (Reeves et al, 2013). Observations in ethnographic research aim to explain how health beliefs are embedded in culture (Green and Thorogood, 2018).

Participants

This study used purposive sampling via the maximum variation sample size approach (Green and Thorogood, 2018). Maximum variation refers to a sample size that is flexible depending on data saturation. The study was conducted in a Sundanese village in West Java, Indonesia.

Participant selection was carried out by the team leader after discussions with local healthcare workers and community leaders, and was based on inclusion criteria established by the team leader. Participants were required to be either indigenous to the village and pregnant, a reproductive health cadre (a role that serves a liaison between health workers and pregnant women) with more than 1 year's experience, a village midwife who had been working in the village for more than 3 years, a birth attendant with more than 3 years’ experience in the village, or a family member living in the home of a pregnant woman. A total of 16 participants were selected: five pregnant women, three health cadres, two midwives, three birth attendants, and three family members living with a pregnant woman.

Data collection

Data were collected using face-to-face interviews at the participants’ homes. All selected participants consented to take part in the study, and there were no dropouts.

An unstructured interview script was used, allowing flexibility in the data collected. The questions in the script permitted adjustments depending on dynamic and thematic aspects that arose during the interview process. After establishing mutual trust between the researcher and participant, an interview time was scheduled. Interviews were audio and video recorded, with direct quotations and field notes on observations recorded. Each interview lasted a maximum of 1 hour. Observations were carried out in an unstructured manner in the participant's natural social environment, and the researcher acted only as an observer.

Data analysis

Analysis of interview data was carried out in two stages, according to Polit and Beck's (2009) editing analysis style. The first stage included data abstraction, coding, theme creation and memo writing, while the second stage involved data interpretation (DiIorio, 2006). Analysis of observational data began by organising observed events chronologically, identifying critical incidents and key events, describing the place and setting of the research location, and organising the data. Analysis was conducted by focusing on the unit of observation and the main topic being researched. After the data were analysed, data representation was carried out by sorting the data and compiling descriptions.

Trustworthiness

Validity in qualitative research is assessed through credibility, transferability, dependability and confirmability. In the present study, credibility was ensured by allowing for sufficient time to be spent with the participants. Transferability was achieved by critiquing maternal theory. Dependability was ensured by conducting structured data analysis and interpreting study results appropriately. Research confirmation was achieved through audit trails and ideal sampling techniques (King, 1990). An audit trail is a compilation of a researcher's reflections on the process of collecting and interpreting data, and in this study, ideal data sampling was achieved by maximising variation among participants.

Ethical considerations

Ethical approval was obtained from the health research ethics committee of the Institute of Health Science of Dharma Husada Bandung College of Health (reference no: 124/KEPK/SDHB/B/VII/2022). The participants’ identities were anonymised via a coding system.

Results

Table 1 outlines the participants’ characteristics. The participants were aged 20–65 years, and were all married. The highest education among the participants was a midwifery diploma. All healthcare participants had at least 3 years’ experience working in the village.

Analysis of the data revealed seven themes and 15 sub-themes related to cultural beliefs of maternal care and fetal wellbeing (Table 2).

Dietary practices and restrictions during pregnancy

Traditional food taboos

Pregnant women adhered to food taboos rooted in ancestral teachings passed down through generations. They strictly abided by a cultural rule prohibiting the consumption of animal protein sources, such as meat, fish and eggs.

‘Ancestral teachings have long propagated food taboos during pregnancy’. PPW1

‘Pregnant women must adhere to eating taboos for the health of the fetus and to facilitate childbirth’. PBA 1

‘The ancestors prohibited pregnant women from consuming meat, fish and eggs, as it was believed to harm God's creatures and potentially afflict the fetus with curses and illness’. PBA 2

‘Pregnant women have dietary restrictions on animal protein sources, such as meat, fresh fish, sea fish, chicken eggs and duck eggs’. PBA3

Dietary restrictions and portion control

During an observation period, it was noted that pregnant women were also restricted from eating foods believed to cause abortion or containing alcohol. The restrictions included avoiding bananas, pineapples, snake fruit, durian, sticky rice tape and cassava tape. They were also advised to use small tableware to eat, which symbolised the size of the fetus and placenta, and was thought to ensure an easy birth.

‘Using small plates for meals is recommended for pregnant women to ensure a small placenta and fetus size, promoting easier delivery’. PF2

Hygiene practices

Bathing rituals

Pregnant women actively avoided bathing and shampooing in the afternoon and evening. Instead, they diligently followed a ritual of bathing with water and seven types of flowers only on the night of a lunar eclipse. This practice was believed to prevent events that were perceived to be undesirable, such as the baby having dark skin or unhealthy growth.

‘Bathing in the afternoon or evening is prohibited for pregnant women, [because of] the belief that it can darken the baby's skin’. PBA1

‘Pregnant women are required to bathe with water infused with seven kinds of flowers in the front yard of the house during a lunar eclipse’. PBA2

‘To ward off potential harm to the fetus, I take showers before three o'clock in the afternoon during my pregnancy’. PPW4

Hygiene practices and social norms

Pregnant women in the village performed specific practices related to hygiene during the day, such as shampooing, nail clipping and hair cutting. They held the belief that performing these activities at night could result in birth defects. Pregnant women were also prohibited from going to the bathroom alone in the afternoon and evening because it was believed that ghosts can cause disturbances. Instead, it was advised that family members accompany pregnant women at these times of day.

‘Pregnant women who shower and shampoo in the afternoon or evening will feel fetal contractions and indicate the presence of ghosts’. PBA3

Managing sleep and drowsiness

Napping prohibition

Pregnant women were strictly prohibited from sleeping during the day, which was believed to prevent production of vernix caseosa on the fetus.

‘Pregnant women are advised against taking naps to prevent the baby from being born sticky’. PPW5

However, one family member felt that this restriction was no longer relevant or necessary.

‘There is no valid reason to oppose the prohibition of napping for pregnant women’. PF1

Combating drowsiness

Pregnant women attempted to combat drowsiness and refrained from sleeping or lying down during the day. If they experienced daytime fatigue, a number of strategies were used to help, such as soaking their feet in cold water or consuming sour fruits to alleviate sleepiness.

Sexual intimacy and interactions

Prohibition of sexual intercourse during final stages

During the third trimester, pregnant women abstained from sexual intercourse. If sexual activity did occur, it was carried out without penetration. The belief behind this practice was that engaging in sexual intercourse during the final stages of pregnancy could increase the risk of premature birth.

‘We refrained from having intercourse in the final 4 weeks of pregnancy [because of] the belief that it can harm the pregnancy and fetus, as advised by parents’. PPW3

‘Sexual intercourse is forbidden during the last month of pregnancy’. PBA1

Husband–wife interactions

Interactions between a husband and wife during the third trimester tended to focus on providing attention and care to one other. Husbands reportedly were more attentive to their wives’ health and exhibited a greater sense of responsibility.

‘In the last month of pregnancy, we did not have sexual intercourse’. PPW5

‘As a husband, I am afraid that sexual intercourse in the last month of pregnancy will cause pain in the birth canal or affect the position of the fetus’. PF2

Religious devotion

Pregnancy milestones

This sub-theme highlighted the significant role played by religious beliefs in the Sundanese culture. Pregnant women believed that Allah SWT grants life to a fetus at 4 months’ gestation and that by 7 months, the fetus has fully developed into a human being. Additionally, they believed that bathing in flower water would result in babies with beautiful faces, and that bathing in water containing eels would facilitate an easier labour.

‘The significance of the 4-month event is attributed to Allah SWT granting life to the fetus during this month’. PHC1

‘By the seventh month of pregnancy, the fetus has developed into a complete human’. PM1

‘Taking a bath with flower water is emphasised for pregnant women to ensure the newborn has a pleasant appearance’. PBA3

‘Bathing with eel water is believed to facilitate an easier childbirth’. PBA2

Increased religious devotion and dietary practices

Pregnant women and their husbands engaged more frequently in spiritual activities and worship than those who were not pregnant. This included refraining from slaughtering and consuming meat.

‘Pregnant women and husbands need to pray for a healthy pregnancy, an easy birth and a healthy fetus’. PF3

‘If the wife is pregnant, the husband is not allowed to slaughter animals for food because that means hurting God's creatures and causing a curse’. PBA1

Family participation

Parental involvement and decision-making authority

The interviews highlighted that parents played a crucial role in decision making for their adult children. Pregnant women and their husbands regularly sought advice from their parents, believing that they possessed valuable experience of pregnancy care.

‘Husbands and wives should consult their parents before making decisions’. PHC2

‘It is prohibited to take action without informing parents’. PF3

Involving mothers-in-law in prenatal care decision making

Pregnant women's mothers-in-law were reported to be highly protective of pregnant women, with parents assuming a significant role in making decisions related to prenatal care. A woman's husband often sought and followed the advice of his mother-in-law regarding care of his wife during pregnancy.

‘As a husband, I usually ask my parents and in-laws about pregnancy care. They have experience about it. They also always provide support to us’. PF2

Challenges in monitoring fetal wellbeing

Lack of knowledge and awareness of fetal wellbeing and monitoring

The interviews revealed a lack of attention and understanding from pregnant women in terms of monitoring fetal movement. Additionally, they showed a lack of interest in receiving antenatal care, which included an examination of fundal height to estimate fetal weight.

‘Pregnant women are unaware that the number of daily fetal movements indicates fetal wellbeing’. PPW1

‘Pregnant women are unaware that fundal height can estimate fetal weight’. PPW3

‘The health worker explained that pregnant women in this village, on average, do not monitor fetal movements daily as advised by health workers’. PM1

Fetal movement

The interviews revealed that pregnant women did not regularly monitor fetal movement, only consciously paying attention to movement on nights with full moons. They were not aware that movement was an indicator of fetal wellbeing.

‘Pregnant women feel the fetus moving intensely during bathing rituals on full moon nights, but generally neglect monitoring fetal movements’. PPW2

‘The health worker explained that fetal movement in the womb can indicate the baby's health’. PM1

Lack of enthusiasm for monitoring fetal wellbeing

Based on the observations, it was evident that pregnant women in the village lacked interest in monitoring fetal wellbeing. They were unaware of the importance of monitoring fetal wellbeing through daily fetal movements and measuring uterine fundal height to estimate fetal weight.

Discussion

The present study was conducted to explore pregnancy care and fetal wellbeing from a cultural perspective for pregnant Sundanese women from a village in West Java, Indonesia. This ethnographic study found discrepancies and disparities between cultural beliefs and scientific research.

Dietary practices and restrictions during pregnancy

The participants were found to hold strong beliefs related to taboos associated with traditional foods, dietary restrictions and portion control. These included prohibition of consumption of protein sources, such as meat, fish and eggs. Pregnant women also avoided consuming fibre sources from fruits, which were deemed harmful to the womb, and were advised to limit the size of their food portions. These beliefs are at odds with a scientific understanding of the importance of adequate nutritional intake for the health of both the mother and fetus during pregnancy (Kilpatrick et al, 2017).

It has been established that a minimal increase in protein intake of approximately 1g/day is needed in the first trimester of pregnancy. However, protein requirements increase by an average of 21g/day in the second and third trimesters, resulting in a higher estimated average requirement of 0.88g/kg body weight/day (Trumbo et al, 2002; Murphy et al, 2021). A belief restricting consumption of protein sources and limiting food portions can significantly impact the health of both the mother and fetus.

Insufficient nutritional intake during pregnancy can lead to adverse outcomes such as premature birth, conditions such as anaemia and even maternal or fetal death (Wood and Gordon, 2001; Rosnani and Mediarti, 2022). It can also cause impaired growth and developmental issues for the child (Yunitasari et al, 2021). Given the findings of the present study, health workers, particularly nurses, midwives and obstetricians, are likely to need to address nutrition-related beliefs, which can be challenging. However, with an appropriate approach, it is possible to address cultural beliefs that do not align with scientific research, ultimately promoting the wellbeing of pregnant women and fetuses. By rectifying misconceptions, healthcare professionals can contribute to improving health outcomes for both mothers and babies. Aryastami and Mubasyiroh (2021) argued that traditional birth attendants can support maternal health during childbirth, encouraging support for programmes aimed at reducing the maternity mortality rate. Similarly, Ansong et al (2022) highlighted that community leaders and cadres, chosen by local residents, can be empowered to deliver nursing care with a cultural approach. This underscores the significance of involving community figures in healthcare initiatives, aligning with cultural perspectives to enhance the effectiveness of nursing care.

Hygiene practices

The results of the present study showed that pregnant women in the village adhered to hygiene practices based on cultural beliefs, such as refraining from showering at night or performing bathing rituals during a full moon. These practices are rooted in the belief that such rituals ensure a child's physical wellbeing. However, maintaining cleanliness during pregnancy is important. Studies have shown that bathing at night does not have a negative impact on pregnant women, as long as the water temperature is not excessively cold and the duration is reasonable (Agopian et al, 2013). Taking a warm bath before bedtime has been shown to promote relaxation, reduce stress and aid in rejuvenation (Lee et al, 2013; Taşkın and Ergin, 2022). However, bathing in a yard during a full moon may increase the risk of premature contractions and hypothermia in pregnant women (Rosenthal et al, 2020). Healthcare workers can play a vital role in educating community members on the potential risks associated with such cultural practices, significantly influencing a person's understanding of the link between hygiene and health (DeLaune and Ladner, 2011).

Managing sleep and drowsiness

The interviews showed that the Sundanese people believed that napping during pregnancy could cause the fetus to become attached to the uterus and lead to labour complications. From a scientific standpoint, this belief is unfounded.

Rest and sleep are vital components of overall wellbeing during pregnancy (DeLaune and Ladner, 2011; Durham and Chapman, 2013). Pregnancy involves physiological changes that necessitate adaptation and external support (Soma-Pillay et al, 2016), and pregnant women require more rest and sleep than non-pregnant women because of the physiological and metabolic alterations that take place (Littleton and Engebretson, 2002). Adequate rest and sleep increase relaxation, suppress anxiety and prevent disturbances to the body's circulation (Hashmi et al, 2016). It is important that healthcare workers encourage pregnant women to get the rest and sleep that they need (Sasaki et al, 2021). Given this, the cultural belief that pregnant women should be prohibited from sleeping or lying down during the day poses a significant challenge for healthcare workers, as this contradicts established health science facts and does not benefit maternal or fetal wellbeing.

Sexual intimacy and interactions

Littleton and Engebretson (2002) noted that beliefs, culture, values and gender roles influence sexual activity, and changes in sexual activity during pregnancy are common (Malary et al, 2021). The present study revealed that Sundanese culture prohibits sexual intercourse during the third trimester of pregnancy. However, there is evidence that engaging in sexual activity in the final trimester can be beneficial (Chang et al, 2011; Blumenstock and Barber, 2022; Janssen et al, 2023). According to DeLaune and Ladner (2011), sexual intercourse during the third trimester should be comfortable for both partners and does not compromise the wellbeing of the fetus. Ansong et al (2022) highlighted that participating in sexual activity during pregnancy ican assist with a smooth birth. This perspective underscores the importance of understanding and addressing cultural beliefs surrounding sexual practices during pregnancy.

Cultural beliefs and religious devotion

A holistic perspective on healthcare encompasses all aspects of an individual, including their physiological, psychological, social, cultural, cognitive and spiritual health (DeLaune and Ladner, 2011). A synergistic relationship between physical, psychological and spiritual factors during pregnancy positively and significantly influences labour outcomes (Tork Zahrani et al, 2020). In Indonesian society, spiritual practices are commonplace; for example, pregnant women and their spouses are encouraged not to dwell on others’ flaws and imperfections to prevent accumulation of negative karma, which is thought to affect the fetus (Rofi'i, 2013). Pregnant women and their partners are expressly prohibited from passing judgment on others, as this is believed to negatively influence the baby's temperament.

It is essential to maintain ceremonial cultural practices that commemorate the fourth and seventh months of pregnancy as part of pregnancy care underscored by a cultural approach. Engaging in these spiritual practices can contribute to pregnant women's mental wellbeing (Mutmainnah and Afiyanti, 2019). However, further study is needed to explore beliefs where their health impact is unclear, such as bathing using water containing eels, considering issues of cleanliness.

Family participation

The findings related to the involvement of family members in a pregnant couple's decision making are a testament to the importance of family support, which plays a crucial role in optimising prenatal care (Wiradnyani et al, 2016). Family support has been shown to enhance self-esteem and confidence for pregnant women (Wardani Diadjeng et al, 2022) and can manifest in different forms, including providing information, affection, acceptance and positive motivation (DeLaune and Ladner, 2011). Engaging pregnant women's parents and their in-laws in important decisions regarding prenatal care can be beneficial, both in terms of having a positive impact on health and wellbeing and aligning with cultural values. Parents can draw from their own experiences, offer valuable perspectives to pregnant women and their spouses and enable them to make informed decisions.

Challenges monitoring fetal wellbeing

Pregnant women in the village lacked knowledge and were both unaware of the importance of monitoring fetal wellbeing and therefore unmotivated to do so. They were not aware of the importance of fetal movement as an indicator that can be used to assess fetal wellbeing (Jain and Acharya, 2022). Regular monitoring is crucial to identify and prevent conditions that hinder a fetus’ development and growth (Widiasih et al, 2021). These results highlight the importance of healthcare workers engaging pregnant women in their own care and ensuring that they understand the importance of fetal monitoring. This can be accomplished through a cultural approach to health education that promotes a mother's empowerment by providing her with the ability to monitor the wellbeing of her baby.

Implications for practice

Culture-based healthcare interventions are an effective approach to enhancing maternal and fetal wellbeing. Nurses and healthcare professionals should be attentive to patients’ cultural backgrounds and beliefs in order to provide comprehensive interventions. Additionally, successful communication and collaboration among healthcare workers, traditional leaders and families are crucial for providing effective healthcare to pregnant women. In Indonesian culture, biological mothers and mothers-in-law play significant roles in providing information and interventions to pregnant women and their husbands. Nurses and midwives should not only focus on pregnant women and their fetuses but also involve extended family members, particularly mothers and parents-in-law.

Conclusions

This study examined cultural beliefs related to pregnancy care for maternal and fetal wellbeing in a Sundanese village in West Java, Indonesia. The findings reveal disparities between cultural beliefs and practices, and scientific research, in areas such as dietary habits, hygiene practices, sleep, and challenges in monitoring fetal wellbeing. It also explored cultural beliefs and practices that can be incorporated into medical pregnancy care, such as family involvement. Recognising the positive and negative impacts of culture on pregnant women and their babies is crucial. Effective communication among community leaders, healthcare workers and families plays a vital role in addressing the negative elements and improving overall care. Healthcare workers should adopt a holistic approach to pregnancy care, encompassing education and interventions while considering cultural factors. Collaborating with community leaders and birth attendants is essential to ensure the wellbeing of both the mother and fetus throughout pregnancy.

Key points

• It is important to consider cultural context when providing maternity care to pregnant women.
• A culture-based approach is necessary to ensure provision of holistic healthcare that improves maternal and fetal wellbeing.
• An integrated care plan involving health workers, cultural leaders and families is likely to improve maternal and fetal wellbeing

CPD reflective questions

• Why and how does culture influence maternal and fetal wellbeing?
• What can happen if healthcare providers ignore a patient's cultural beliefs?
• Is it appropriate to modify or change a community's cultural beliefs, as they relate to pregnancy care?