In 2015, the Indonesian maternal mortality ratio (MMR) was 305 per 100,000 live births, according to the Intercensus Population Survey (SUPAS) 2015 (1). Although it has remained high compared to neighboring countries (an average 240) in 2012, the Indonesian MMR dropped from 359 maternal deaths per 100,000 live births (2). The three common delays which adversely affect maternal mortality include: delays in family decision making due to mothers’ inability to recognize danger signs in pregnancy; delays in accessing care at a healthcare facility related to geographic barriers and problems with transportation; and delays in receiving care because of the health service quality in healthcare facilities (3). These three types of delays together caused 85.7 percent of maternal deaths. An analysis in Aceh province, Indonesia found that vaginal bleeding (59.7%), eclampsia (25.5%), and other problems (14.8%) were significant factors in the increased risk of maternal mortality (4).
Traditional beliefs and practices are prevalent in Indonesia similarly to other Asian countries and are known to influence maternal and child health (6, 7). Several studies, especially in Asia and Africa, have used quantitative and qualitative approaches to identify traditional beliefs and practices for pregnancy, which have included special dietary rules, personal hygiene, daily activities/isolation of pregnant women, taboo on informing about pregnancy, and prohibition of sexual intercourse (6,8–10). Traditional childbirth and postpartum practices include the choice of delivery place, fear of exposure to hospital equipment, rituals of cutting the umbilical cord and removing the placenta, breastfeeding and even the tradition of isolating the mother after childbirth and the baby (6,8,10–12).
Previous studies found the key risk factors associated with reduced use of antenatal care (ANC) and facility-based deliveries (FBDs) included low household wealth index, inability to pay for services, low maternal education level, sociocultural factors, low involvement of mothers in the decision-making process, mothers’ limited exposure to mass media, far distance to health facilities, and adequate access to and quality healthcare (13–16). Other research examining factors that influence the use of skilled birth attendants (SBAs) for delivery has found that Jaminan Kesehatan Nasional (JKN), Indonesia’s national health insurance, has significantly increased the use of SBAs for poor pregnant women. This analysis also found that education and supply-side factors, including the ratio of primary health centers per 1,000 people, significantly influenced SBA use in maternal health care utilization (17).
Indonesia’s varied cultures and ethnic group practices underlie health-seeking behavior, particularly for maternal and neonatal health (MNH) services, whether or not these influences are recognized (18). These include the number of TBA in population, the use of traditional practices, and family composition. A study in Uganda found that cultural factors inhibit mothers in using modern ANC. Beliefs and myths often enforce the mothers to give birth at home and implement the practice of traditional umbilical cord cutting (UCC) (19).
Childbirth at home remains prevalent in rural areas in Indonesia. It is related to the presence of and preference for TBAs at the village level. Data from several small qualitative studies in Jakarta, Banten, and West Java found that TBA use was a major sociocultural barrier to MNH utilization (20), and that the traditional beliefs underlying TBA preference were particularly pervasive among low-income families (21). Research also showed that women tended to prefer TBAs because they believed it was easier to interact, have more experiences, are more accessible, and are more likely to encourage natural birth compared to midwives (22). Many types and styles of services performed by TBAs could result in unexpected maternal and newborn complications; such practices include ngolesi (to wet the vagina using coconut oil in the perception to ease the baby’s delivery), kodok (the TBA inserting a hand into the uterus to take out mother’s placenta), nyanda (having the mother sit in a straight-legged position for hours, with a consequent risk of bleeding and swelling) (23).
Traditional UCC using tools such as bamboo knives—sembilu—or unsterilized razors or scissors, is another traditional practice associated with maternal and newborn complications. It is widely practiced among the Dayak’s ethnic group who mostly live in Senggau, West Kalimantan. Improper UCC may cause bleeding in the newborn. Similarly, cutting the placenta with the use of a bamboo knife may cause infection for the mother. Other risk factors associated with traditional UCC is the use of mixed kitchen dust or coffee and the saliva of a betel chewer as an antiseptic, also increase the risk of maternal and newborn complications (24).
Evidence of the influence of family composition on the use of maternal health services is very limited in Indonesia. A small qualitative study in the Klaten district of Central Java found that the social influences of the extended family were associated with increased use of postnatal care (25). Another study that used Indonesian Demographic and Health Survey data found that familial support was associated with a significant increase in the use of ANC services (13).
With regard to family planning methods, problems relating to unmet need are found in many countries. A number of cultural barriers exist, such as religious prohibitions, resistance from men, and misperceptions of the side effects of contraceptives (26–29). This study aims to analyze the evidence of traditional practices that influence the uptake of comprehensive maternal health service use in Indonesia.