Beliefs, attitudes and behaviours of pregnant women in Bali.

(1)

(2)

Articles & Issues

1

Articles in Press

Current Issue

Past Issues

Note: After leaving this page to view an article, do not use the back button to return to this Issue. Instead use the Volume/Issue link above the article title to view the Table of Contents again.

Decade:

2010-2013

Year:

2013

Issues:

Vol. 27 No. 6 December, 2011 p.763-888

Search Within This Issue

44 Articles:

View Abstracts Email Abstracts Add to My Reading List Export Citations

Article Title

Author(s)

Pages

Editorial Board

PDF (58 KB)

i

Time to reflect

Preview Full Text PDF (83 KB)

Debra Bick 763

International News

PDF (137 KB)

764-769

United but divided? The need to consider the potential

consequences of devolved UK government on midwifery education

and practice

13 October 2011

Helen Cheyne, Jennifer McNeill, Billie Hunter, Debra Bick

770-774

Advanced Search

Search for

in

All Fields

Go

Articles & Issues

Virtual Issues

For Authors

Journal Info

Special Issues

Writing for Publication Resources

Page 1 of 6

Midwifery - Issues

(3)

Hurdles and opportunities for newborn care in rural Uganda

04 August 2010

Preview Abstract Full Text PDF (168 KB)

Romano N. Byaruhanga, Jesca Nsungwa-Sabiiti, Juliet Kiguli, Andrew Balyeku,et al.

775-780

Risk and safety in context: Medical pluralism and agency in

childbirth in an eastern Moroccan oasis

29 September 2010

Irene Capelli 781-785

A qualitative study exploring student midwives' experiences of

carrying a caseload as part of their midwifery education in England

28 September 2010

Stella Rawnson 786-792

Advanced maternal age and adverse perinatal outcome: A review of

the evidence

01 October 2010

Mary Carolan,

Dorota Frankowska 793-801

Maternal parental self-efficacy in the postpartum period

04 October 2010

Patricia Leahy-Warren, Geraldine McCarthy

802-810

Empowerment in the midwifery context a concept analysis

08 October 2010

Evelyn

Hermansson, Lena Mårtensson

811-816

The use of complementary and alternative medicine by pregnant

women: A literature review

20 January 2011

Helen G. Hall, Debra L. Griffiths, Lisa G. McKenna

817-824

Effects of a pushing intervention on pain, fatigue and birthing

experiences among Taiwanese women during the second stage of

labour

21 October 2010

Su-Chuan Chang, Min-Min Chou, Kuan-Chia Lin, Lie-Chu Lin,et al.

825-831

Effectiveness of an internet-based intervention enhancing Finnish

parents parenting satisfaction and parenting self-efficacy during the

postpartum period

08 October 2010

Anne H. Salonen, Marja Kaunonen, Päivi Åstedt-Kurki, Anna-Liisa Järvenpää,et al.

832-841

Views of Chinese women and health professionals about midwife-led

care in China

08 October 2010

Ngai Fen Cheung, Rosemary Mander, Xiaoli Wang, Wei Fu,et al.

842-847

Page 2 of 6

Midwifery - Issues

(4)

First-time fathers experiences of childbirth A phenomenological

study

21 October 2010

Åsa A. Premberg, Gunilla Carlsson, Anna-Lena Hellström, Marie Berg

848-853

Developing and validating scenarios to compare midwives

knowledge and skills with the International Confederation of

Midwives essential competencies in four European countries

18 April 2011

Valerie Fleming, Jessica Pehlke-Milde Hebamme, Sheila Davies, Teja Zaksek

854-860

Men's involvement in antenatal screening: A qualitative pilot study

using e-mail

12 January 2011

Robert Alan Williams, Sandi Dheensa, Alison Metcalfe

861-866

Beliefs, attitudes and behaviours of pregnant women in Bali

06 December 2010

Luh Putu Lila Wulandari, Anna Klinken Whelan

867-871

Pilot survey of domestic abuse amongst pregnant women attending

an antenatal clinic in a public hospital in Gauteng Province in South

Africa

19 January 2011

L.M. Modiba, O. Baliki, R. Mmalasa, P. Reineke,et al.

872-879

Care and environment in midwife-led and obstetric-led units: A

comparison of mothers and birth partners perceptions

20 January 2011

Andrew G. Symon, Pat Dugard, Maggie Butchart, Val Carr,et al.

880-886

Acknowledgement to Reviewers

07 September 2010

PDF (78 KB)

887-888

International Confederation of Midwives (ICM) 29th Triennial

Conference, Durban, South Africa, 19 23 June 2011

Ann M. Thomson,

Liesbeth Van kelst e179-e180

First ever Report on the State of the World's Midwifery launched at

International Confederation of Midwives 29th Congress in Durban,

South Africa, June 19 23, 2011

Ann M. Thomson e181

An analysis of the meanings of pre-eclampsia for pregnant and

postpartum women and health professionals in Rio Grande do Norte,

Brazil

20 September 2010

Daniela Vasconcelos de Azevedo, Ana C.P.F. de Araújo, Íris C. I.C. Clara Costa

e182-e187

Page 3 of 6

Midwifery - Issues

(5)

Measuring the quality of documented care given by Swedish

midwives during birth

14 September 2010

Linda J. Kvist, Nada Damiati, Johanna Rosenqvist, Ann-Kristin Sandin-Bojö

e188-e194

A randomised controlled multicentre trial of women s and men s

satisfaction with two models of antenatal education

28 September 2010

Malin Bergström, Helle Kieler, Ulla Waldenström

e195-e200

Audits of adolescent prenatal care rendered in Bulawayo, Zimbabwe

28 September 2010

Cynthia N. Chaibva, Valerie J. Ehlers, Janetta H. Roos

e201-e207

Breech presentation and choice of mode of childbirth: A qualitative

study of women s experiences

08 November 2010

Marie-Julia Guittier, Jocelyne Bonnet, Graziella Jarabo, Michel Boulvain,et al.

e208-e213

Postpartum doulas: Motivations and perceptions of practice

08 November 2010

Kimberly Campbell-Voytal, Judith Fry McComish, Joan M. Visger, Carolynn A. Rowland,et al.

e214-e221

Lessons regarding the use of birth kits in low resource countries

08 November 2010

Vanora A. Hundley, Bilal I. Avan, David Braunholtz, Ann E. Fitzmaurice,et al.

e222-e230

Satisfaction with pregnancy and birth services: The quality of

maternity care services as experienced by women

10 December 2010

Josefina Goberna-Tricas, Ma. Rosa Banús-Giménez, Alicia Palacio-Tauste, Sara Linares-Sancho

e231-e237

Prevalence and factors associated with the development of antenatal

and postnatal depression among Jordanian women

06 December 2010

K.I. Mohammad, J. Gamble, D.K. Creedy

e238-e245

Translation and validation of the Breast-feeding Self-efficacy Scale

into Turkish

09 December 2010

Aysun Basgun Eksioglu, Esin Ceber

e246-e253

Women's experiences of perineal pain during the immediate

postnatal period: A cross-sectional study in Brazil

09 December 2010

Adriana Amorim Francisco, Sonia Maria Junqueira Vasconcellos de Oliveira, Flora Maria Barbosa da Silva, Debra Bick,

e254-e259

Page 4 of 6

Midwifery - Issues

(6)

1

et al.

Utilisation of antenatal care in four counties in Ningxia, China

10 December 2010

Zhenghong Ren e260-e266

The timing of interventions during labour: Descriptive results of a

longitudinal study

14 December 2010

Antje Petersen, Gertrud M. Ayerle, Cornelia Frömke, Hartmut Hecker,et al.

e267-e273

Patient safety: A literature review to inform an evaluation of a

maternity service

13 December 2010

Suzanne V. Sinni, Euan M. Wallace, Wendy M. Cross

e274-e278

Midwives and doctors attitudes towards the use of the

cardiotocograph machine

08 February 2011

Sarah McKevitt, Patricia Gillen, Marlene Sinclair

e279-e285

Stay home for as long as possible : Midwives' priorities and

strategies in communicating with first-time mothers in early labour

31 March 2011

Tine S. Eri, Astrid Blystad, Eva Gjengedal, Gunnhild Blaaka

e286-e292

Effects of birth ball exercise on pain and self-efficacy during

childbirth: A randomised controlled trial in Taiwan

04 April 2011

Meei-Ling Gau, Ching-Yi Chang, Shu-Hui Tian, Kuan-Chia Lin

e293-e300

Is

not

testing a major change in clinical practice an ethical dilemma?

10 August 2011

Forster A, Della, Moorhead, Anita, Jacobs, Susan, Amir H, Lisa,et al.

e301-e302

Response to Hood et al. (2010): A story of scrutiny and fear:

Australian midwives experiences of an external review of obstetric

services, being involved with litigation and the impact on clinical

practice

25 January 2011

Kathleen Fahy, Neil Douglas, Jeffery Robinson

e303-e304

Response to Fahy letter Hood et al. paper

18 January 2011

Jennifer Fenwick,

Janice Butt e305-e306

Volume 27 (2011) Index

PDF (125 KB)

e307-e322

44 Articles:

Page 5 of 6

Midwifery - Issues

(7)

The content on this site is intended for health professionals.

Advertisements on this site do not constitute a guarantee or endorsement by the journal, Association, or publisher of the quality or value manufacturer.

Page 6 of 6

Midwifery - Issues

(8)

Beliefs, attitudes and behaviours of pregnant women in Bali

Wulandari, MPH, Dr ,Anna Klinken Whelan, PhD (Associate Professor)

Received 5 January 2010; received in revised form 7 August 2010; accepted 24 September 2010. published online 06 December 2010.

Abstract

Objective

to explore beliefs, attitudes and behaviours of pregnant women in Bali, Indonesia.

Design

descriptive qualitative study using in-depth interviews.

Setting

community health-care centre in South Kuta, Bali, Indonesia.

Participants

18 pregnant women aged 20 35 years.

Findings

insights into beliefs and attitudes regarding pregnancy emerged from the analysis. Participants believed that some foods should

or should not be eaten by pregnant women. They believed that vegetables are better than meat during pregnancy. Strong

beliefs about traditional herbal remedies also emerged. Complex beliefs on locus of control were also expressed by the majority

of the respondents regarding who was responsible for the health and well-being of their infant. Women maintained that they

themselves, health-care professionals, nature and God were all responsible for the health of their infant. In addition, some

respondents acknowledged the crucial role of the family for support and advice during pregnancy.

Implications for practice

Volume 27, Issue 6

, Pages 867-871, December 2011

« Previous

Full Text

PDF

References

Advanced Search

All Fields

Go

&

! "#

Page 1 of 4

(9)

Page 2 of 4

(10)

Page 3 of 4

Beliefs, attitudes and behaviours of pregnant women in Bali

(11)

$% &' ()* +,-./0 1234 56) 5 (789. :33()* + ,4(54 5( 65;. <= () 6 >9 '=%3) 9 '<?5(@4 & $ %8; ) ,) % 84<A55 ;B >9C<: B% D,E 4<F5 3&<$% 8, >9 ,E

?+59% 8 ,58 ,% 8,+) 44 ) ,5) 4)8,58;5 ;G% (+ 5>3 ,+& ( %G5 44 )% 8>34.

:; 65( ,) 45@ 5 8,4%8,+ )44),5;%8%,9%84,) ,D,5>* D>( >8,5 5% (58;% (4 5 @58,B',+ 5H% D (8>3, : 44 % 9) > ,) %8, %(&D B3 )4 +5 (%G,+5ID>3) , '% @> 8DG>9 ,D (5 (J

Page 4 of 4

(12)

Luh Putu Lila Wulandari, MPH, Dr

a,n

, Anna Klinken Whelan, PhD (Associate Professor)

b a_{School of Public Health, Faculty of Medicine, Udayana University, Denpasar, Bali 80232, Indonesia}

b_{School of Public Health and Community Medicine, Faculty of Medicine, University of New South Wales, Sydney, Australia}

a r t i c l e

i n f o

Article history: Received 5 January 2010 Received in revised form 7 August 2010

Accepted 24 September 2010

Keywords: Health beliefs Health behaviours Pregnancy Culture

a b s t r a c t

Objective: to explore beliefs, attitudes and behaviours of pregnant women in Bali, Indonesia.

Design: descriptive qualitative study using in-depth interviews.

Setting: community health-care centre in South Kuta, Bali, Indonesia.

Participants: 18 pregnant women aged 20–35 years.

Findings: insights into beliefs and attitudes regarding pregnancy emerged from the analysis. Participants believed that some foods should or should not be eaten by pregnant women. They believed that vegetables are better than meat during pregnancy. Strong beliefs about traditional herbal remedies also emerged. Complex beliefs on locus of control were also expressed by the majority of the respondents regarding who was responsible for the health and well-being of their infant. Women maintained that they themselves, health-care professionals, nature and God were all responsible for the health of their infant. In addition, some respondents acknowledged the crucial role of the family for support and advice during pregnancy.

Implications for practice: interventions to improve the quality of antenatal care and pregnancy outcomes in Indonesia should consider these beliefs and attitudes. Counselling by health-care workers, for example, might explicitly seek women’s complex beliefs on locus of control, and views on preferences for traditional remedies and food, especially low meat intake. Involvement of husbands and other family members during pregnancy and birth should also be encouraged and re-inforced by health promotion programmes. Community and religious leaders should be engaged to support key messages.

Introduction

Reducing maternal mortality remains a major challenge in low- and middle-income countries, and is the subject of major global initiatives such as the Millennium Development Goals

(World Health Organization, 2005). However, it is difﬁcult to gain

accurate data for many countries (Lesley et al., 2004). Causes of maternal mortality are multifactorial (Ronsmans and Graham, 2006) and are related to poverty, inequalities of risk, lack of access to services, culture, and health beliefs and attitudes. Recent efforts have focused on ensuring that interventions are evidence based and comprehensive (Campbell and Graham, 2006). Understanding health beliefs has emerged as an important concept in developing behavioural change programmes since the 1980s (Nutbeam and

Harris, 2004), and is an important factor to consider in reducing

maternal mortality (Withers and Abe, 2005).

Pregnancy is a unique phase in life, and it has been proposed that the beliefs and attitudes of pregnant women towards their pregnancy inﬂuence whether or not they will use healthy behaviours

(Rosenblatt, 1998). Studies have found evidence regarding the

importance of beliefs and views towards pregnancy in determining whether or not pregnant women perform recommended health actions, such as consumption of iron supplements, folic acid intake, prenatal testing, attendance at prenatal classes, adherence to other prenatal health guidelines, and health-care utilisation (Labs and Wurtele, 1986; Tinsley, 1993; Rice and Naksook, 1999; Phoxay et al.,

2001; Haslam et al., 2003). Studies have also documented the role of

beliefs in inducing behaviour that is of medical concern, such as eating soil during pregnancy (Geissler et al., 1999) and prenatal smoking (Haslam and Lawrence, 2004).

Although pregnant women’s beliefs and attitudes concerning pregnancy are very important, few studies have been undertaken in Indonesia to explore these issues. As part of a study investigating women’s adherence to iron supplementation in pregnancy in Bali, health beliefs and attitudes were explored, including diet, traditional medicines and fetal locus of control. This paper describes ﬁndings from the qualitative interviews with Indonesian pregnant women to explore their beliefs, attitudes and behaviours regarding pregnancy.

Methods

A comprehensive theoretical model from the World Health

Organization (2003) identiﬁed ﬁve inter-related factors that

Contents lists available atScienceDirect

journal homepage:www.elsevier.com/midw

Midwifery

n

Corresponding author.

E-mail address:putuwulandari@yahoo.com (L.P.L. Wulandari)

(13)

influence medication adherence behaviour: socio-economic, health-care related, condition related, therapy related and patient related. Each of these factors was investigated in a mixed methods study in Bali, Indonesia in 2007 (Wulandari, 2008). The study was conducted in the subdistrict of South Kuta, Bali with a population of 32,796 people, and approximately 446 pregnant women recorded in 2007. The area had the lowest previously reported adherence rate for iron supplementation in pregnancy among all subdistricts in Bali, with only 3% of pregnant women taking iron supplements as recommended (Gunung et al., 2003). Qualitative research is concerned with how people interpret their experiences and how they use those interpreta-tions to guide the way they live. As such, it can help to enrich the facts and figures produced by quantitative research. This paper reports on the qualitative findings from this mixed methods study based on in-depth interviews.

In-depth interviews were conducted with 18 pregnant women exploring their beliefs and experiences regarding healthy preg-nancy. In-depth interviews were used because this is ‘the most appropriate method of gathering data when the purpose of the research is to expose beliefs, perceptions, attitudes, and opinions that are otherwise hidden in people’s minds’ (Ritchie, 2001,

p. 157). These interviews were used in this study to gain a deeper

understanding and make it possible for the participants to use their own words to describe these beliefs. It is generally recognised that in-depth interviews can capture informants’ perceptions in ways that a survey cannot (Rich and Ginsburg, 1999).

An interview guide was developed prior to the data collection processes to guide the interview and provide a checklist of topics that should be asked during the interview. The language and the sequence of this checklist was not rigid (Mason, 2002), as it was only intended for use to ensure that all topics to be explored were covered (Patton, 1987; Ritchie, 2001). The interview guide was designed with questions around theWorld Health Organization

model (2003), including information on health beliefs, attitudes

and practices regarding pregnancy, including health-seeking behaviour and illness during pregnancy, and ideas and practices about managing healthy pregnancy, focusing on diet and nutrition as well as fetal health locus of control (Labs and Wurtele, 1986). Several factors were taken into consideration when choosing participants for the in-depth interviews in Bali. Although it is crucial to consider generalisability and representativeness when planning sampling in quantitative research in this qualitative study, the sample is chosen to allow the investigator to reach information-rich cases (Malterud, 2001); thus, purposive sampling was appropriate. To ensure the richness of the data, pregnant women with various ethnic backgrounds (i.e. Javanese, Balinese and Lomboknese) were chosen to participate in the study.

In-depth interviews took place in the community health care centre, taking up to one hour. Each interview was audio-recorded with the consent of the participants, and then transcribed by the interviewer to protect confidentiality. The transcription was translated into English and the English version of the transcription was analysed. The accuracy of translation was improved by involving the co-investigator with an English-speaking back-ground who speaks some Bahasa. Content analysis was used to analyse and interpret the data, which involves ‘identifying, coding, categorising, classifying and labelling the primary pattern in the data’ (Patton, 2002, p. 463). The quality of the findings was improved by member checking at the time of the interview, peer debriefing with colleagues and the co-investigator, and ensuring inclusion of contradictory information from participants (Mays

and Pope, 2000; Creswell, 2003), as well as comparison of ﬁndings

with previous studies (Geissler et al., 1999). Additionally, during the coding process, English transcripts were provided to

the co-investigator to cross-check the coding and determine the consistency of views.

Qualitative research is based on interpretation which necessa-rily requires input from researchers. The primary researcher (LPLW) is a young female doctor trained in Bali, who has been pregnant and received antenatal care in Bali, but has not been involved in providing care to women in the study sites. The co-investigator is an English-speaking public health academic with a midwifery background who speaks some Bahasa.

Written approval was obtained from the Head of the Commu-nity Healthcare Centre of South Kuta, the Head of the Health Department of Badung, Bali, and the Human Research Ethics Advisory Panel at the University of New South Wales, Australia.

Findings

The majority of women interviewed were from Bali, ﬁve were originally from Java and two were from Lombok Island. Most of the women had been educated to high school level, and their ages ranged from 20 to 35 years. For most women, the current pregnancy was not their ﬁrst. Various issues regarding pregnancy emerged from the respondents. Major themes which emerged included beliefs around preferences for foods, preferences for traditional remedies, a range of views on fetal locus of control, health-care professionals versus ‘dukun’ (traditional birth atten-dants), and the role of their husband and other family members for support and advice during pregnancy.

Beliefs on food preferences in pregnancy

A wide range of beliefs about what types of food should and should not be eaten during pregnancy was stated. A particularly important belief was that vegetables are better than meat because they increase the production and ‘freshen’ the taste of breast milk:

It is better if we eat lots of vegetables. (Woman 13)

Ehmm.. not very frequent [eat meat]. People said that if we are pregnant, it is better for us to eat fruits and vegetables rather than eat meat. The breast milk will taste fresh if you eat lots of vegetables and the baby will like it. If you eat meat a lot, your breast milk will become a bit sour and of course the baby will not want it. (Woman 7)

Although vegetables are good for pregnant women, beliefs about the disadvantages of meat may put pregnant women at greater risk of developing anaemia in pregnancy, a major problem in Indonesia, because meat provides easily absorbed iron and promotes iron absorption in the body (Tapiero et al., 2001; World Health

Organization/Food and Agriculture Organization, 2002). In

addition, diets containing a large amount of certain vegetables, such as a vegetarian diet, may reduce iron absorption (Sch ¨umann

and Solomons, 2007) because the form of iron contained in those

vegetables is relatively difﬁcult to absorb, and some vegetables may contain factors which inhibit iron absorption (Thompson, 2007).

Beliefs on traditional herbal remedies

In addition to beliefs about food, beliefs about traditional herbal remedies also emerged. Two respondents expressed strong beliefs about traditional and modern medicine, and stated a preference for traditional herbs as being more natural and without side-effects:

I think both [iron pills and herbal medicine] are important, aren’t they? I take the herbals regularlyyand I feel that my

(14)

baby is healthyy that was also what I did in my ﬁrst

pregnancy. I regularly took the herbalsyand nothing’s wrong

with my baby. In fact, he was very vigorous. (Woman 6) I believe in both traditional as well as modern medicine. What I‘ve known is that modern medicine sometimes bring about side-effects, but traditional herbal doesn’t. It is because traditional herbal contains bahan alami [natural ingredients]. (Woman 7)

Traditional tamarind and turmeric do no harm to our baby. In fact, it makes both of us healthier. (Woman 7)

One woman held strong beliefs about taking traditional herbal remedies during pregnancy because the practice has been passed down for many generations, and she believed that there were no associated side-effects:

My mother, my grandmother, my great grandmother had used this herbal to make us healthier. And it works, without any side-effects. (Woman 7)

Some of the beneﬁcial traditional herbal treatments men-tioned included tamarind, turmeric, cinnamon, clove and coconut. This woman also stated that health-care professionals did not understand the practice of taking traditional herbal remedies:

I think the midwives might prohibit me to drink it [traditional herbal]. Health-care workers are always sceptical about traditional herbal. I know that. (Woman 7)

Health-care workers are always thinking that it is medicine that will keep us healthy. The truth is, there are many alternatives we can use to make us healthy. One of them is traditional herbs. (Woman 7)

Despite their strong beliefs regarding traditional herbs, respondents admitted that they did not talk openly about this practice to their midwives, as they believed that the health-care staff would be sceptical and forbid them from taking the herbs.

Fetal locus of control

Women were asked about fetal locus of control (Labs and

Wurtele, 1986) to provide insights into the design of broad health

promotion interventions. Surprisingly, the women were unable to express strong views on internal or external factors. When probed, a range of beliefs was expressed by the majority of the respondents regarding who was responsible for the health of their infant. Women said that they themselves were responsible for the health of their infant (i.e. internal locus of control), but also believed that God or faith determined the infant’s health. Internal and external loci of control were indicated as equally important in maintaining pregnancy. In essence, the women believed that in order to maintain their infant’s health, they needed to take good care of themselves, follow health-care recommendations, follow traditional rituals and pray to God. In many ways, this is consistent with observed adherence to traditional Balinese rituals:

We have to take care of our baby ourselves, and we should follow the recommendation from health expertise, but it is God who will determine the fate, the health of our baby. (Woman 4)

Our baby will be healthy if we are taking good care of our baby during pregnancy. It also depends on how good the health-care facilities. And last and most importantly, God will determine whether our baby will be born healthy or not. So I think the three of them are important. (Woman 2)

If we eat enough food, get enough rest, checking our pregnancy regularly, hopefully everything will be normal. But we have to also remember that God is one who makes the decision. So it means that we also have to pray a lot so that everything will be just ﬁne. (Woman 7)

I think both of them. We have to believe in God; however, we do have to try our best as welly. (Woman 16)

Don’t forget to check your pregnancy regularly, eat lots of vegetables so that your milk will taste fresh. Drink traditional herbals to make you feel healthier, get lots of walking so that it will be easier for you to give birth, lots of prayer so that God will help you throughout your pregnancy. (Woman 18) Respondents believed that some traditional rituals that should be avoided were funerals, weddings and going outside at night.

Interestingly, although they did not understand the real meaning of the rituals, they followed them without question for the sake of their infant. One woman indicated that she felt uncomfortable if she disobeyed these rituals:

Yesyof course we have to believe ity in our culture, it is

forbidden for pregnant women to attend marriage ceremonies. Whether I don’t know whyybut I think it is better if we just

follow what our parents sayy. (Woman 1)

Furthermore, because these rituals have been passed on from generation to generation, pregnant women believed that unless they were followed, the health of their infant would be adversely affected.

All these views around pregnancy seemed to inﬂuence pregnant women’s decisions about how to manage healthy pregnancy.

Midwives versus traditional birth attendants

Another theme that emerged during the interviews was about choice of birth attendant. Although women expressed positive views about traditional herbal medicines, none of them were using traditional birth attendants. Two women mentioned their positive views about midwives rather than traditional birth attendants:

I only go to midwives. I never believe in dukun [traditional birth attendant]. (Woman 9)

Of course to the midwives. I never believe in dukun. Some-times they have strange methods to handle our pregnancy. It’s better if we just believe in health-care professionals. (Woman 7)

However, this ﬁnding should be interpreted with caution as women not attending midwives’ clinics were not included in the study.

Important role of husband and other family members

Some respondents indicated the crucial role played by the family for support and advice. This advice ranged from informa-tion about the signs of impending labour to tips for caring for the infant:

I ask my parents about what the symptoms of in labour arey

and then they told me the signs like pain in the backy, blood

or ﬂuid from vaginay. (Woman 1)

It will be a lot easier for me, because they [parents] have more tips about caring the baby. (Woman 7)

(15)

Sometimes when he [husband] ask me to take the iron tablets and explain that it’s for the sake of the baby’s health, that’s when I thought that I have to take the tablets so that my husband might feel happy about it. (Woman 8)

Pregnant women admitted that they took their family’s advice without question because they trusted them. They also admitted that they followed their advice because they wanted their family to be happy with them.

Discussion

Limited attention has been paid to pregnant women’s beliefs about healthy pregnancy in Indonesia. By conducting in-depth interviews, various beliefs about managing pregnancy emerged from the current study. Participants believed that there were some foods that should or should not be eaten by pregnant women. Although some of these beliefs were culturally understandable, unfortunately some of them implied a lack of understanding of the diversity and quantity of food needed to provide the required level of iron in pregnancy. For example, some participants reported a preference for vegetables over meat, but the opposite is recom-mended, particularly where anaemia in pregnancy is prevalent. Meat is recommended during pregnancy because it contains haem iron which can be absorbed easily. Although some vegetables are iron rich (such as broccoli and spinach), certain vegetables may contain non-haem iron which is less well absorbed and may contain factors which inhibit iron absorption.

Similarly, some pregnant women also expressed a preference for herbal remedies over modern medicine as they were more ‘natural’ and less likely to have side-effects. This ﬁnding contra-dicts research ﬁndings in Pemba Island, Africa (Young and Ali, 2005) in which pregnant women feared traditional medicine and considered that it might have adverse effects on their infant. In the current study, although not all women acknowledged the use of traditional herbal remedies, all were familiar with them, and argued that these remedies were natural and without side-effects. This preference for traditional medicine is a concern in this study, as it has been suggested as a factor that contributes to non-adherence to recommendations given by health-care providers

(Galloway et al., 2002). It is also a concern that women believed

that health-care workers would be sceptical about their use of traditional herbs, resulting in their not being able to discuss this openly with their health-care providers.

The ﬁndings about avoidance rituals were similar to a previous ﬁnding in Pemba Island, Africa in which pregnant women believed that staying at home after dark would protect them from bad spirits which could harm their infant (Young and Ali, 2005).

Pregnant women expressed difficulty in choosing between an internal and external locus of control in determining the health of their infant. They believed that they themselves, plus God and nature were all responsible for the health of their infant. Putting a significant value on the role of nature in the health of an infant is a concern in this setting due to the fact that it may have a negative influence on decision making during pregnancy. The role of beliefs about fate and nature which negatively influence decisions to engage in healthy behaviour during pregnancy is reported in a qualitative study among Thai women (Rice and Naksook, 1999). This study found that strong beliefs about the role of chance in determining the health of an infant had discouraged pregnant women from undergoing prenatal testing. However, in the present study in Bali, women also acknowledged that their own behaviours influenced the health of their infant, rather than external factors alone.

The role of a spouse and/or family member in managing pregnancy was also apparent. Pregnant women acknowledged that

emotional support and advice from their spouse and parents were among the factors that contributed to their intention to manage healthy pregnancy. This is supported by studies in Malawi (Aguayo

et al., 2005), Nigeria (Ejidokun, 2000) and Vietnam (Aikawa et al.,

2006), which found that the majority of pregnant women were encouraged and supported by their husbands or other family members during pregnancy. In fact, a meta-analysis on adherence

by DiMatteo (2004) noted a strong correlation between the

presence of practical and emotional support from family members and adherence to health recommendations.

Despite the small number of participants, this study provides a deeper understanding of women’s views and experiences about pregnancy, as the information was gained through their own opinions and expressions. Some women reflected a lack of ‘modern scientific’ knowledge about healthy pregnancy, which is a concern due to the possible counter influence on recommended health behaviours during pregnancy. Strategies to enhance the quality of care for pregnant women and improve pregnancy outcomes should address this conflict in knowledge systems. Counselling by health-care workers might explicitly seek women’s views on preferences for traditional remedies and food, especially low meat intake. It should account for, and tap into, women’s views on what is perceived as healthy food during pregnancy. Counselling should also include information about side-effects that might result from the use of natural herbs. The importance of an internal locus of control in influencing pregnant women in managing healthy pregnancy should be encouraged and re-inforced, while not denying the value of external beliefs. Tailoring client-centred education programmes with regard to women’s views on managing healthy pregnancy could enhance the quality of antenatal care programmes and women’s adherence to health recommendations during pregnancy. Considering the significant involvement of husbands and parents, health promotion programmes targeting them would also be useful. Involvement of husbands and other family members during pregnancy should be encouraged and re-inforced by health promo-tion programmes. In addipromo-tion, due to the fact that many pregnant women expressed the importance of faith and religion in their pregnancy, involving community and religious leaders in the health promotion programme for pregnant women could improve the effectiveness of behavioural change campaigns. Community and religious leaders should be engaged to support key messages.

This study is not without limitations. The main limitations of this study are those that generally exist in conducting in-depth interviews with small numbers, although all attempts were made to minimise the impact of these factors. Although the findings [regarding preferences for specific foods, preferences for tradi-tional remedies, complex locus of control, midwives versus dukun (traditional birth attendants), and the role of husband and other family members for support and advice during pregnancy] cannot represent perceptions of all pregnant women in Indonesia due to the limited sample size and qualitative methods used to elicit the information, it is not the aim of qualitative inquiry to provide generalisable findings. However, the qualitative findings of this study provide a deeper understanding of women’s views and experiences about managing healthy pregnancy. Further studies may find it useful to quantify these beliefs and attitudes. In addition, considering the wide popularity of herbal remedies, such practices warrant further investigation.

Acknowledgements

The authors would like to thank the pregnant women who participated in this study, and the Community Healthcare Centre of South Kuta, Bali. The authors would also like to acknowledge the meticulous qualitative expertise of Associate Professor Jan

(16)

Ritchie and Ms Sally Nathan from the School of Public Health and Community Medicine, the University of New South Wales, and thank them for their assistance and comments on this study. This study was supported by an Australian Development Scholarship kindly provided by the Government of Australia.

References

Aguayo, V.M., Diallo, B., Signe´, P., et al., 2005. Acceptability of multiple micronutrient supplements by pregnant and lactating women in Mali. Public Health Nutrition 8, 33–37.

Aikawa, R., Jimba, M., Nguen, K., Zhao, Y., Binns, C., Lee, M.K., 2006. Why do adult women in Vietnam take iron tablets? BMC Public Health 6, 144.

Campbell, O., Graham, W., 2006. Strategies for reducing maternal mortality: getting on with what works. Lancet 368, 1248–1299.

Creswell, J.W., 2003. Research Design: Qualitative, Quantitative, and Mixed Methods Approaches, second edn. Sage Publications, Thousand Oaks. DiMatteo, M.R., 2004. Social support and patient adherence to medical treatment:

a meta-analysis. Health Psychology 23, 207–218.

Ejidokun, O.O., 2000. Community attitudes to pregnancy, anaemia, iron and folate supplementation in urban and rural Lagos, south-western Nigeria. Midwifery 16, 89–95.

Galloway, R., Dusch, E., Elder, L., et al., 2002. Women’s perceptions of iron deﬁciency and anemia prevention and control in eight developing countries. Social Science and Medicine 55, 529–544.

Geissler, P.W., Prince, R.J., Levene, M., et al., 1999. Perceptions of soil-eating and anaemia among pregnant women on the Kenyan coast. Social Science and Medicine 48, 1069–1079.

Gunung, I., Arhya, I., Wirakusuma, I., Indraguna, G., Supriyadi, 2003. Survei Anemia Ibu Hamil di Provinsi Bali [Survey of Anaemia among Pregnant Women in Province of Bali]. Faculty of Medicine, University of Udayana, Denpasar, Bali. Haslam, C., Lawrence, W., 2004. Health-related behaviour and beliefs of pregnant

smokers. Health Psychology 23, 486–491.

Haslam, C., Lawrence, W., Haefali, K., 2003. Intention to breastfeed and other important health-related behaviour and beliefs during pregnancy. Family Practice 20, 528–530.

Labs, S.M., Wurtele, S.K., 1986. Fetal health locus of control scale: development and validation. Journal of Consulting and Clinical Psychology 54, 814–819. Lesley, M., Graham, S., Nargiz, T.-M., Julia, H., 2004. Safe motherhood program

evaluation: theory and practice. Journal of Midwifery and Women’s Health 49, 338–344.

Malterud, K., 2001. Qualitative research: standards, challenges, and guidelines. Lancet 358, 483–488.

Mason, J., 2002. Qualitative Researching, 2nd edn. Sage Publications, London. Mays, N., Pope, C., 2000. Qualitative research in health care: assessing quality in

qualitative research. British Medical Journal 320, 50–52.

Nutbeam, D., Harris, E., 2004. Theory in a Nutshell: A Practical Guide to Health Promotion Theories. McGraw-Hill, Australia, Sydney.

Patton, M.Q., 1987. How to Use Qualitative Methods in Evaluation. Sage Publications, Newbury Park.

Patton, M.Q., 2002. Qualitative Research and Evaluation Methods, 3rd edn. Sage Publications, Thousand Oaks.

Phoxay, C., Okumura, J., Nakamura, Y., Wakai, S., 2001. Inﬂuence of women’s knowledge on maternal health care utilization in southern Laos. Asia Paciﬁc Journal of Public Health 13, 13–19.

Rice, P.L., Naksook, C., 1999. Pregnancy and technology: Thai womens’ perceptions and experience of prenatal testing. Health Care for Women International 20, 259–278.

Rich, M., Ginsburg, K.R., 1999. The reason and rhyme of qualitative research: why, when, and how to use qualitative methods in the study of adolescent health. Journal of Adolescent Health 25, 371–378.

Ritchie, J., 2001. Not Everything can be reduced to numbers. In: Berglund, C.A. (Ed.), Health Research. Oxford University Press, Melbourne.

Ronsmans, C., Graham, W., 2006. Maternal mortality: who, when, where, and why. Lancet 368, 1189–1200.

Rosenblatt, D., 1998. Adherence in pregnancy. In: Myers, L.B., Midence, K. (Eds.), Adherence to Treatment in Medical Conditions. Harwood Academic Publish-ers, Amsterdam.

Sch ¨umann, K., Solomons, N.W., 2007. Safety of interventions to reduce nutritional anemias. In: Kraemer, K., Zimmermann, M.B. (Eds.), Nutritional Anemia. Sight and Life Press, Basel, pp. 285–314.

Tapiero, H., Gate, L., Tew, K.D., 2001. Iron: deﬁciencies and requirements. Biomedicine and Pharmacotherapy 55, 324–332.

Thompson, B., 2007. Food-based approaches for combating iron deﬁciency. In: Kraemer, K., Zimmermann, M.B. (Eds.), Nutritional Anemia. Sight and Life Press, Basel.

Tinsley, B.J., 1993. The signiﬁcance of women’s pregnancy related locus of control beliefs for adherence to recommended prenatal health regimens and pregnancy outcomes. Journal of Reproductive and Infant Psychology 11, 97–102.

World Health Organization, 2003. Adherence to Long Term Therapies: Evidence for Action. WHO, Geneva.

World Health Organization, 2005. The World Health Report 2005: Make Every Mother and Child Count. WHO, Geneva.

World Health Organization/Food and Agriculture Organization, 2002. Human Vitamin and Mineral Requirements. WHO/FAO, Bangkok.

Withers, M.H., Abe, D., 2005. How traditional beliefs about pregnancy and childbirth in Bali may affect maternal mortality. In: Poster presented at the American Public Health Association’s 133rd Annual Meeting and Exposition, Philadelphia, PA.

Wulandari, L.P.L., 2008. Kurang Darah: a mixed method study of anaemia and iron supplementation in pregnant women in South Kuta, Bali. Unpublished Master’s Thesis. University of New South Wales, Sydney.

Young, S.L., Ali, S.M., 2005. Linking traditional treatments of maternal anaemia to iron supplement use: an ethnographic case study from Pemba Island, Zanzibar. Maternal and Child Nutrition 1, 51–58.