Diastasis of the rectus abdominis muscle is a condition caused by the development of a gap between the rectus abdominis muscles along the linear alba, leading to abdominal wall muscle weakness (Denizoglu Kulli and Gurses, 2022). In the postpartum period, this can occur as a result of hormones and the biomechanical stretching required to adapt to the growth of the uterus and fetus during pregnancy (Hills et al, 2018; Keshwani et al, 2021). It can lead to colorectal-anal symptoms, as well as static and dynamic postural stability (Wu et al, 2021; Denizoglu Kulli and Gurses, 2022).
The time to physiological recovery for diastasis is 6–8 weeks, with a maximum distance between the rectus abdominis of 2cm needed to allow the abdominal wall muscles to support internal abdominal organs and posture, and provide intra-abdominal pressure (Keshwani et al, 2021; Denizoglu Kulli and Gurses, 2022; Skoura et al, 2024). However, not all postpartum women will completely recover, instead experiencing persistent diastasis rectus abdominis after giving birth. In Indonesia, 53% of postpartum mothers experience diastasis rectus abdominis that persists for 3–12 months postpartum (Zulfiani, 2021).
Diastasis rectus abdominis in postpartum mothers is the result of morphological and functional changes to the abdominal muscles (Balasch-Bernat et al, 2021). Several studies have shown that diastasis rectus abdominis contributes to a decrease in the strength of uterine contractions (Deussen et al, 2020; Di Mascio et al, 2021), back and pelvic instability (Hills et al, 2018; Awad et al, 2021; Denizoglu Kulli and Gurses, 2022), and a distended abdomen (van Wingerden et al, 2020; Skoura et al, 2024).
The availability, efficacy and community acceptance of treatments for diastasis rectus abdominis still need to be explored. In the community setting, postpartum women often self care for issues related to the abdominal wall (Gustavsson and Eriksson-Crommert, 2020; Blankensteijn et al, 2023; Fitzpatrick et al, 2024). Some traditional treatments for these issues have been passed down from generation to generation, and are often considered more effective than medical treatments by postpartum women in rural areas, particularly where there is a lack of alternative interventions.
Medical treatments for diastasis rectus abdominis vary from conservative approaches to surgical interventions. Standardised rehabilitation procedures have been shown to significantly reduce the separation of the rectus abdominis muscles and improve the quality of life in postpartum women (Hu et al, 2021). Surgical options include techniques such as abdominoplasty, which may involve repositioning of the rectus abdominis muscles, umbilical transposition and tightening of the abdominal wall, leading to improved aesthetic outcomes and quality of life (Li et al, 2019). In Indonesia, traditional treatment for diastasis rectus abdominis often involves the use of a bengkung or corset (Widaryanti, 2020). Other common treatments include drinking herbal remedies (jamu) and engaging in postpartum exercises (Agustina and Fitrianti, 2020; Fajrin et al, 2022).
Exploring postpartum women's experiences of abdominal wall treatment is important to gaining a deeper understanding of the impact of diastasis rectus abdominis, the effectiveness of treatment, and women's needs and expectations (Creswell and Poth, 2016). This will enable healthcare services to offer care that supports the health and quality of life of postpartum women (Asadi et al, 2022; Benjamin et al, 2023). Nurses and midwives who care for postpartum women need to understand the needs of this community to provide high-quality care. This study aimed to identify the experiences of postpartum women in relation to traditional Javanese cultural care for abdominal wall problems.
Methods
This qualitative study used a phenomenological approach to understand the subjective experiences of postpartum women who experience problems in the abdominal area, as well as those who used traditional Javanese methods to address these problems (Polit and Beck, 2010; Creswell and Poth, 2016; Im et al, 2023). The study was conducted between May and December 2022.
Participant selection
Purposive sampling was used to select 13 postpartum women from Yogyakarta, Indonesia. The inclusion criteria were women who gave birth to full-term babies in the year preceding the study, who could communicate and were not deaf. The exclusion criteria were those with psychological disorders, those unable to participate during the study period and those who had relocated from their residence. Participants were selected from a designated health facility, chosen because the local community practiced traditional treatments. Researchers were assisted by a key local contact who facilitated communication with postpartum women. The participants and researchers had never previously interacted with one another.
Data collection
In-depth individual interviews were used to collect data, with field notes and video recordings taken (Creswell and Poth, 2016; Van Manen, 2023). The interviews were conducted by the first author, a doctoral candidate in the nursing faculty of the University of Indonesia with 7 years' experience as a maternity nurse.
A question guideline was compiled on the research topic before data collection, and a pilot interview was conducted. Questions asked included ‘how would you describe the changes to your stomach after giving birth, and how did these changes affect your feelings?’ and ‘how did you respond to the changes you felt in your stomach after giving birth? What actions or remedies did you consider or use based on these feelings?’.
Interviews were conducted at women's homes to create an intimate and relaxed environment. Some participants looked after their babies during the interview. Interviews lasted 45–50 minutes and continued until data saturation was reached.
Data analysis
Analysis of descriptive phenomenological data was carried out manually using the Colaizzi (1978) method. The first author transcribed the interviews verbatim, then carried out the following steps (Polit and Beck, 2010; Creswell and Poth, 2016; Alwi and Asrizal, 2018; Alhalabi et al, 2023; Im et al, 2023):
Data validity
Data credibility and trustworthiness were ensured by frequently clarifying the results of analysis with the participants, extending engagement with them. Data transferability was ensured by maximising variation in the participants characteristics, including their age, parity and type of birth. Dependability/reliability was ensured by following a robust analysis method when interpreting participants' statements. Confirmability was ensured by conducting a trial audit, which involved a thorough preliminary review of the research processes and data management practices. This trial assessed the accuracy, consistency and transparency of the study's methodology, data collection and analysis. By identifying and addressing potential issues before the final evaluation, the trial ensured that the study's findings were reliable, valid and grounded in the data (Polit and Beck, 2010; Asadi et al, 2022).
Ethical considerations
This study received ethical approval from the Research Ethics Commission of the Faculty of Nursing, University of Indonesia (approval number: KET-300/UN2.F12. D1.2.1/PPM.00.02/2023). The purpose of the study and its objectives were fully explained to participants, who gave informed consent to participate and were assured of their anonymity and information disclosure.
Results
The participants were 25–40 years old, and had given birth between 3 days and 12 months before the data were collected. All participants had a parity of 1–3, and babies' birth weights ranged from 2900–3500g. Ten of the participants had a vaginal birth, while the remaining three had a caesarean section. Full details are shown in Table 1.
| Code | Age (years) | Time since birth | Parity | Baby's birth weight (g) | Occupation | Mode of birth |
|---|---|---|---|---|---|---|
| 1 | 31 | 3 months | P2A0 | 3100 | Housewives | Spontaneous vaginal birth |
| 2 | 35 | 3 days | P2A0 | 3050 | Housewives | Caesarean section |
| 3 | 27 | 3 months | P3A1 | 3500 | Worker | Spontaneous vaginal birth |
| 4 | 31 | 7 months | P2A0 | 3300 | Employee | Spontaneous vaginal birth |
| 5 | 40 | 9 months | P3A0 | 3100 | Employee | Spontaneous vaginal birth |
| 6 | 34 | 9 days | P1A0 | 2900 | Employee | Cesarean section |
| 7 | 32 | 7 months | P3A0 | 2900 | Worker | Spontaneous vaginal birth |
| 8 | 35 | 12 months | P3A0 | 2965 | Tailor | Spontaneous vaginal birth |
| 9 | 25 | 3 months | P1A0 | 3100 | Employee | Cesarean section |
| 10 | 26 | 7 months | P1A0 | 3200 | Employee | Spontaneous vaginal birth |
| 11 | 33 | 3 days | P3A0 | 2900 | Housewives | Spontaneous vaginal birth |
| 12 | 38 | 21 days | P3A0 | 3100 | Housewives | Spontaneous vaginal birth |
| 13 | 27 | 29 days | P1A0 | 3300 | Housewives | Spontaneous vaginal birth |
Note: P=partus, A=abortus
Data analysis yielded 26 codes, which were organised into 10 categories within 5 themes. The overall themes were symptoms affect activity and appearance, traditional and non-traditional care, benefits and barriers to traditional care, regular use of traditional methods, and the need for and expectation of convenient and practical tools for managing the condition.
Symptoms affect activities and appearance
The participants experienced symptoms that interfered with daily life and altered their appearance. In this theme, the two categories were experiences of pain and distended abdominal walls, and impairments to appearance and daily activities.
The participants reported three distinct types of pain: pain similar to menstrual sensations, pain that felt like a pulled nerve when changing positions, and pain in caesarean section surgery scars. Nine of the participants noted that they experienced pain in their lower abdomen, similar to menstrual pain or labour contractions. Some consulted midwives or doctors, who explained that the pain was natural when the uterus shrank after birth.
‘The pain seemed to be squeezed, but the midwife explained that the pain served to return the uterus to its original condition and showed that it was in good condition’.
‘Like tension, pain in the belly button, lower abdomen … it feels similar to the pain of contractions during menstruation’.
Some participants reported discomfort in their abdominal muscles, which felt like pulled nerves when changing position, standing or coughing. Others reported soreness in their waist or back and the feeling of having a ‘hunched body’, and not being upright.
‘Feeling afraid of changing position from sitting to standing … because this stomach hurts like muscle pull … especially when coughing, spontaneously standing up’.
Those who had a caesarean section experienced pain at the surgical incision site.
‘After the caesarean section, the stitches were still painful. A suture wound from the caesarean section caused the pain’.
Ten of the participants commented that after giving birth, their stomach felt loose, swayed when changing positions and walking, and felt uncomfortable.
‘After giving birth, the stomach feels sagging, especially when walking, causing discomfort’.
Eight participants noted that their bellies looked distended, similar to when they were pregnant, and that they could not wear clothes from before their pregnancy.
‘The belly still looks big, as if the baby is still in it’.
‘Belly still looks like I am 3 months pregnant. It still looks distended’.
‘The stomach has not been able to return to its former state; even the old clothes still can't fit’.
Pain and rocking in their abdomen caused participants to avoid certain activities, such as walking, standing from a seated position, lifting heavy objects and coughing because the movement worsened their pain and discomfort. This hampered their daily lives. Some noted that they wanted their stomach to return to how it was before pregnancy, while others accepted their current condition.
‘I hope it can return to how it was; it is not big anymore’.
Traditional and non-traditional abdominal care
The participants reported using both traditional and non-traditional methods to manage and treat abdominal issues. Traditional care included using ‘bengkung’ or ‘stagen’ (belly fasteners), massage and drinking herbs. Eight of the participants reported using belly fasteners, while six used corsets glued around their stomach and two used ‘gurita’, where ropes were worn around the abdomen.
‘Using a long stagen or bengkung. It is just wrapped around the stomach’.
Bengkung was a belly fastener made of tightly woven cotton thread between 5 and 10 meters long and around 15cm wide. Participants demonstrated wrapping the cloth around their abdomen multiple times without ties, starting from below the abdomen and rising to the top. Some could use it independently, while a few, particularly first-time mothers, needed help from their sisters. Some participants also demonstrated the use of corsets.
Using bengkung was a common practice that had been used for many generations. Participants had been told about it by their mothers, mothers-in-law, sisters and neighbours, who recommended using bengkung so that the stomach would return to its pre-pregnancy state.
Three participants reported that they not only used bengkung or stagen, but also underwent massage performed by a baby shaman during the puerperium, exactly 30 days after birth.
‘Here, there is a baby shaman who usually massages. After conducting a medical examination at the polyclinic, then massaged’.
‘Abdominal pain, like menstruation, goes away after massage’.
Two participants described taking herbal medicine, ‘jamu wale’, purchased at traditional markets.
‘I drank herbal “wale” bought at a special market for mothers after giving birth’.
Non-traditional care included exercise and a particular diet. Two participants adopted these methods. Their exercise included cycling, push-ups, squats, gymnastics and walking. They adjusted their diet by reducing their portion sizes and limiting carbohydrate intake.
‘At least do cycling or push-ups. It is not routine but begins after 40 days of the postpartum period. Doing sports every day from Monday to Friday, along with teaching kindergarten children. The movements performed are usually squatting, standing and jumping for about 15 minutes’.
‘Eat not as much as before, so try to reduce the portion of carbohydrates and eat more vegetables and fruit’
Benefits of and barriers to traditional treatments
Participants highlighted the benefits of traditional treatments, including pain relief and having their stomach comfortably supported. Using the bengkung or corset enabled women to move more actively, allowing them to care for children and holding their baby without fear or doubt. Some participants wore a bengkung or corset when travelling to support more active mobility.
‘Wearing that corset helps endure the pain, so it feels better’.
‘Comfortable actually, no soreness or anything’.
They also appreciated that the tools helped to reduce the size of their stomach, which they felt improved their appearance.
‘The stomach feels tighter, like being tied up’.
‘If you wear a stagen, the belly becomes smaller, and the clothes fit’.
Participants who underwent massage experienced significant benefits, including the cessation of pain. Only one participant reported benefits from a daily exercise routine, which was that the abdomen gradually returned to its pre-pregnancy condition.
‘I exercise regularly every day. As a result, the pain has decreased, and my stomach is starting to look smaller’.
However, there were also disadvantages to using traditional medicine. The participants highlighted that using a bengkung or corset for more than 2 hours could cause heat, itching and tightness, eventually necessitating removing the item. In addition, the corsets were unstable and sometimes changed position, causing discomfort.
‘Prolonged use of a bengkung or corsets causes heath [issues]’.
‘Feeling sultry and short of breath’.
Some participants felt the bengkung was too complicated, making them take longer to undress. It could also be difficult to put on, especially for first-time mothers. Some felt they did not have the time to wear bengkung or corsets, especially when caring for their baby or when no one could assist them.
‘When going to the bathroom, the time becomes longer because we have to take off the corset, which is quite troublesome’.
‘Sometimes lazy to use … Hurry up what you don't have time to do’.
Some participants needed help accessing massage services because the healers were located far from where they lived. Others had to return to their parents' places of origin because of the increasingly scarce presence of ‘baby shamans’ in urban areas.
‘I only got a massage once because it was far away. The journey took about 3 hours’.
Other barriers to treatment included not liking herbal medicine because of its bitter taste.
‘It tastes bitter and unpleasant; I don't like herbal medicine’.
Regular use of traditional methods
Not all of the participants used traditional methods regularly or for long periods. Eight of the participants noted that they did not regularly wear stagen or corsets, only when they had time, were travelling or felt like using them. They typically wore them for 2–3 hours per day for 5–7 days during the puerperium. As noted previously, wearing them for longer led heat, itching and tightness, which discouraged longer use, and they were not easy or quick to put on and remove, which was not convenient.
‘The use of bengkung/stagen or corset for 7 days during childbirth, sometimes used, sometimes not’.
Only three participants regularly used traditional care. These women used a bengkung or corset every day from morning to noon and in some cases until night for 30–40 days. They removed the stagen/corset when bathing, then immediately put it back on. These participants felt that regular use yielded greater benefits and did not face significant obstacles.
‘The bengkung/stagen or corset is used daily, at any time, for 40 days after delivery’.
The need and hope for more effective, comfortable and practical tools
Participants highlighted the need for interventions to manage their symptoms and their expectation of effective, convenient and practical tools. In particular, they wanted a method that would reduce shock, especially during activity and that would enable their abdomen to return to its original condition, reduce abdominal pain, overcome strain on the stump and waist, and improve posture.
‘I need a scaffold or corset to be safer, not shaky, move safer and [be] more comfortable’.
The participants highlighted that they wanted tools to manage their condition that were comfortable, and did not cause heat, itching and tightness. They wanted to use a tool regularly, so they wanted one that was easy and practical to use and did not interfere with daily activities or cause side effects.
‘Desire that the … stomach can be tight again’.
‘The desire for the … stomach to shrink, try to be able to return’.
‘I want to use a tool but one that is comfortable’.
‘A practical tool that can restore the condition of the stomach’.
Discussion
This study explored postpartum women's experiences of diastasis rectus abdominis and the traditional and non-traditional methods they used to manage their symptoms. Their symptoms included pain and altered appearance, which affected their daily lives. Traditional treatments included stomach wraps and corsets, while modern methods used included a diet and exercise regime.
Symptoms of diastasis rectus abdominis
The participants experienced various symptoms, including saggy abdominal walls, the appearance of a distended stomach and pain. These findings challenge the current literature that has yet to reach a consensus on the relationship between diastasis recti and physical complaints (Blankensteijn et al, 2023). The participants noted three distinct types of pain: cramping in the lower abdomen, pain like muscles being pulled when moving or changing position and pain in caesarean incision wounds.
Deussen et al (2020) reported that painful sensations, similar to menstrual cramps, were related to decreased abdominal muscle function, resulting in diastasis rectus abdominis. Weakening of muscle function in the abdominal wall, including in the rectus abdominis, obliquus internus, obliquus externus, transversus abdominis and fascia, results in decreased intra-abdominal pressure, meaning the uterus has to work harder with intermittent contractions during uterine involution, leading to pain (Deussen et al, 2020).
The present study's participants also highlighted pain when coughing or changing position, with some adopting a hunched position and experiencing soreness in the lower back, waist and pelvis. Diastasis rectus abdominis is known to be related to static postural stability and torso rotational strength (Hills et al, 2018; Denizoglu Kulli and Gurses, 2022). Biomechanical and pelvic dynamic theories note functional and anatomical interactions between the muscles of the diaphragm, abdomen, lumbar spine and pelvic floor. Diastasis rectus abdominis results in decreased abdominal muscle contractions, limiting the function of the rectus abdominis muscle. This specifically affects lateral muscles, such as the external abdominis, internal abdominis and transversus abdominis, which impact torso mobility, control of lumbar-pelvic bone stability and posture formation. As a result, women with diastasis rectus abdominis often experience pain when changing position and soreness in the back and pelvis (Eriksson Crommert et al, 2020; van Wingerden et al, 2020; Denizoglu Kulli and Gurses, 2022).
The present study's participants also experienced a rocking sensation in their abdominal wall, especially when moving, and felt that their stomachs looked as if they were still pregnant. Protrusion in the midline of the abdominal wall along the gap between the rectus abdominis muscles is caused by weakness of transverse abdominis muscle tone that is unable to tense the posterior rectus abdominis sheath, resulting in decreased abdominis wall resistance to intra-abdominal increase (van Wingerden et al, 2020). This transverse muscle weakness causes a bulge between the rectus abdominis muscle and abdominal invagination, resulting from distortion of the posterior linea alba. These protrusions and invaginations are compounded by changes in the angle of muscle pull that can alter body mechanics and impair the ability of the abdominal muscles to generate force, as well as the fascia's ability to transfer loads across the midline (Skoura et al, 2024). These effects all lead to the appearance of a distended stomach.
Physical symptoms can have a significant psychological impact for women who experience diastasis rectus abdominis. The distended appearance of the stomach can impact women's self-image (Skoura et al, 2024). Some try to accept this by understanding that they have changed because they have given birth (Eriksson Crommert et al, 2020). The sensation of rocking and pain can hinder women's daily activities. Some women develop kinesiophobia as a result of the pain felt when moving (Balasch-Bernat et al, 2021).
Traditional care
Most of the present study's participants used traditional abdominal fasteners and elastic corsets to manage the symptoms of their condition. Different cultures endorse various traditional practices to facilitate the physical recovery of postpartum mothers. Bengkung involves wrapping rigid cotton fabric around the torso from under the breasts to the pelvic bone (Dennis et al, 2007; Fadzil et al, 2016; Azmi et al, 2019), and is often recommended in countries such as Malaysia, Singapore, Thailand, Vietnam, Cambodia, Mexico and Guatemala, as well as by the Hmong, to speed up uterine involution and improve the shape of the stomach. Mothers, mothers-in-law, sisters and neighbours of postpartum women may recommend their use (Ahuja et al, 2023).
Abdominal binding supports weak abdominal wall muscles. The pressure from the binding is detected by nerve receptors, which further signals the brain to induce muscle contractions (Szkwara et al, 2019). Abdominal binders have been shown to effectively increase intramuscular pressure on the rectus abdominis muscle, contributing to stabilisation of the lumbar spine (Miyamoto et al, 1999). In addition, an abdominal binder can play a role in reducing postpartum bleeding by applying gentle pressure to the uterus that supports the process of uterine involution (Ghana et al, 2017; Di Mascio et al, 2021; Kara and Nazik, 2021). Abdominal binding has also been shown to reduce pain, such as menstrual cramps, as it can increase intra-abdominal pressure to help the uterus contract (Di Mascio et al, 2021).
Meta-analyses have shown that the use of abdominal binders after a caesarean section plays a significant role in reducing pain, especially in the first two days postpartum (Abd-ElGawad et al, 2021; Di Mascio et al, 2021). The application of a wide elastic compression belt fitted around the abdomen after surgery serves as a complementary therapy, reduces the need for analgesics, supports wound healing and allows early mobiliaation after a caesarean section (Ghana et al, 2017; Abd-ElGawad et al, 2021). It induces abdominal compression, which regulates blood circulation and reduces inflammation in the incision area, facilitating faster tissue recovery (Abd-ElGawad et al, 2021).
Several of the present study's participants also received abdominal massage, a tradition also found in Malaysia, India and Hawaii, which aims to increase strength, relieve tension and muscle pain, support sleep after birth and maintain health (Dennis et al, 2007; Fadzil et al, 2016). Some women also took herbal treatments, which are used by most postpartum women in Java and Sumatra in Indonesia for healing and restoring health (Agustina and Fitrianti, 2020). This traditional postpartum maternal care is usually recommended by older women in the family. Herbal medicine is affordable and accessible (Agustina and Fitrianti, 2020). In Malaysia, herbal medicine is used to increase endurance, and some hospitals provide traditional services, such as massage and herbal medicine, for postpartum mothers (Fadzil et al, 2016). Massage and herbal medicine can contribute to physical fitness, helping postpartum women manage discomfort (Dennis et al, 2007; Fadzil et al, 2016; Benjamin et al, 2023).
Barriers to using traditional care
Despite benefiting from using traditional care, the participants also reported that using traditional bengkung or corsets could lead to itching and shortness of breath, and they could be difficult to use, particularly given the time it took to put on and remove traditional stomach wraps or corsets. Grigoriadis et al (2009) also highlighted postpartum women's accounts of perceived adverse effects from traditional treatments, where women expressed dissatisfaction with the care received for physical issues. As a result of these challenges, the present study's participants were often inconsistent in their use of either traditional or modern care methods. Few of the participants reported consistently caring for their abdominal area.
The need for new care tools
The participants spoke about the desire for management options that were more effective, comfortable and practical. Eriksson Crommert et al (2020) highlighted that postpartum women seek to understand and develop strategies to cope with diastasis, while Asadi et al (2022) reported that they needed additional therapies, support groups or personalised treatment plans and recovery through self-conditioning. The complex physical and psychological concerns that result from changes in the abdominal wall require special interventions to improve postpartum women's health and wellbeing. Many of the traditional methods of care were felt to be ineffective, uncomfortable and impractical for postpartum women. Care of the abdominal wall for postpartum women would benefit from the development of tools that combine aspects of culture and modern technology (Asadi et al, 2022; Ahuja et al, 2023).
Implications for practice
Healthcare professionals working in maternity could improve care for postpartum mothers by thoroughly assessing their needs, including evaluating the effectiveness of traditional care methods being used. Further research is needed to develop innovative tools combining culture and technology that can be used by postpartum women and are effective, comfortable and practical when considering their needs.
Limitations
This study has several limitations. It was conducted in a single setting, which restricts the findings' applicability to other areas and may not fully capture the diversity of experiences and practices related to diastasis rectus abdominis. The study also provides limited information on traditional treatments from other regions. Furthermore, the study did not include insights from traditional birth attendants, who play a significant role in postpartum care and may offer unique and valuable perspectives on managing the condition.
Conclusions
Postpartum women exper ience physical and psychological consequences from diastasis rectus abdominis. Traditional and non-traditional care methods can be beneficial, but can also present challenges. As a result, abdominal wall care is often inconsistent. Postpartum women need treatment that is effective, comfortable and practical.