Participant Characteristics
The participants’ average age was 37.6 (± 4.7) years. Of the 14 participants, three had a high-school education and 11 had tertiary education. The average length of stay in Bali was 8.8 (± 5.1) years; the majority 10(71%) had been in Bali for over five years. Most of the women’s husbands were Indonesian. {10(71%) were Indonesian, 4(29%) were Japanese}.
Six participants were Muslims, three were Hindu, (they were required to convert when they got married with Indonesian men) and five were adherents of other religions. Over half of the participants could read and write in Indonesian.
Of the 14 participants, 11 had given birth two or more times, and six of the 14 women had also experienced childbirth in Japan. In terms of the choice of birthing facilities, 11 participants had chosen private hospitals and three had chosen a midwives’ clinic (bidan in Indonesian). Six women had given birth vaginally, two had been induced, five had had caesarean sections, and one had experienced a waterbirth. All babies were full-term. The average age of their youngest child was 21 (± 15) months. Only three participants possessed the Indonesian government’s Mother and Child Health (MCH) Handbook, while over half of the women retained the Japanese government’s MCH Handbook (Table 1).
Themes and Categories
We identified 12 categories across five themes, which are described below (Figure 1). During their perinatal period, the participants strongly emphasised safe and satisfying childbirth experiences (Figure 1: I-1). However, they had various worries and concerns regarding issues such as the difficulty of obtaining information pertaining to pregnancy and childbirth (Figure 1: II-1). For this reason, support from family members and Japanese friends who had previously worked as midwives and nurses in Japan, was essential from the beginning of their pregnancy (Figure 1: II-3). Although the participants did not have high expectations of the midwives caring for them (Figure 1: II-2), they did seek comfort and peace of mind (Figure 1: I-3). From the beginning of their pregnancies, they gradually built relationships of trust with the midwives or other caregivers (Figure 1: I-2), but many were disappointed with their childbirth experiences, as they felt that the care provided during labour was not centred on the woman giving birth (Figure 1: III-1). However, through both their own efforts (Figure 1: IV-1) and with the support of family members and the Japanese friends as mentioned earlier (Figure 1: II-3), many women were able to reflect on their childbirth experience positively (Figure 1: IV-2). However, some women could not achieve this, even years after they had given birth (Figure 1: III-2). Additionally, empowerment of mothers during pregnancy, childbirth, and the postpartum confinement was regarded as important (Figure 1: V-1), and participants expressed their hope that perinatal care in Bali, Indonesia would further improve in the future (Figure 1: V-2).
Desire for a satisfying childbirth experience
When the participants were preparing to give birth in Bali, they desired a safe pregnancy and childbirth experience. They had a variety of concerns and worries regarding giving birth at an older age or fears of miscarriage and unpredictability in the onset of labour, and they wanted a high level of maternity care. Consequently, they placed high importance on finding specialist obstetricians and well-equipped health facilities where they could undergo maternity related ultrasound examinations. These women also preferred natural childbirth, to give birth with their husbands in attendance, doula support, kangaroo mother care, and/or exclusive breastfeeding. As a result, they selected childbirth facilities that could provide these services. In effect, these women were expressing the sort of childbirth plans they preferred.
A Japanese friend who had been a midwifery professional said that she would be present for the birth, even if it was in the middle of the night. Also, I kept hearing that hospitals here perform a lot of caesarean sections, so I asked them to perform a caesarean section only if the situation became very bad and with my consent, but, if there were no problems, I said that I would prefer to have natural childbirth. The doctor said that it was his policy was to proceed with a natural childbirth whenever possible (JPN5).
After becoming pregnant, the Japanese women searched for an obstetrician they could trust, underwent regular health check-ups, and then gave birth at the hospital or clinic where their attending obstetrician worked. The women who chose to give birth in midwives’ clinics reported developing trust in their midwives because of the midwives’ attitudes, good listening skills, and their efforts to help the birth occur in a home-like atmosphere, and also because they provided advance explanations of the procedures that were to be undertaken.
The (bidan) staff were wonderful people. They always smiled when they spoke, and if I had diarrhoea when I visited, they would give me lots of advice […], so I kind of depended on them (JPN6).
Almost three-quarters (71%) of the Japanese women’s spouses were Indonesian, and they were based in Bali; consequently, they chose to give birth in Bali rather than travel back to Japan despite their anxiety. Some women sought a feeling of religious solidarity and chose care providers of the same religious faith, while others sought a sense of security and peace of mind at accessible midwives’ clinics (bidan in Indonesian). Women with no experience of childbirth found greater peace of mind in giving birth in familiar surroundings. Moreover, they were grateful that they could, without feeling guilt or embarrassment, ask staff to look after their infants after birth, a common practice in Bali, unlike in Japan.
I heard in Japan that if you asked hospital staff to look after the baby at night, they would make a stern face, as if to say: ‘No, you’re the mother, you look after it’. Friends told me that staff would refuse to look after the baby, saying things like, ‘It’s born now; that is the mother’s job’, but in Indonesia, this isn’t the case. I’ve heard that in Japan, the nurses make you feel really guilty (JPN5).
Concerns about local maternity services
Even participants who had no difficulty engaging in everyday conversations in Indonesian had some trouble communicating with midwives, as a result of unfamiliarity with specialist terminology, and many participants reported receiving support from Japanese friends who had also been midwives and other similar health-care professionals who worked in Indonesia. The women experienced difficulty obtaining information related to local maternal and child health services and facilities because of language and technical barriers and were worried that, as foreigners, they could be at a disadvantage. They feared that they would undergo an unnecessary caesarean section without their consent.
Three women were given the Indonesian government’s MCH handbook. Indonesia’s maternal care is unlike Japan’s [2,38], where fourteen maternity check-ups are provided without charge. As this was not the case in Bali, participants felt they had less support provided to them.
Consequently, the local maternity care system added to the participants’ unease regarding giving birth and other pregnancy-related difficulties. The women also felt anxious about the fewer number of examinations conducted during pregnancy in Bali when compared to Japan, and they had doubts regarding diagnoses and prescriptions. Additional differences in the maternity services between Bali and Japan also caused great concern, such as the short duration of postpartum hospital stays, generally one night and two days [39, 40]; when compared with the postpartum hospitalisation period in Japan of 5–7 days [41, 42].
They have many caesareans here. I would hate to have a caesarean. I wanted, if possible, to give birth naturally. Here, there is a tendency to quickly resort to surgery. All of the staff at my company gave birth via caesarean section (JPN3).
I would like them to carry out a few more tests such as urine tests and blood pressure tests before determining that a C section was really necessary for the baby’s and the mother’s sake, (JPN9).
They had adopted an attitude of generally not having high expectations during their social inter- personal encounters and this also extended to health staff, meaning they had fewer expectations from midwives from the beginning. Consequently, even when the level of care they received differed from what they hoped for, they convinced themselves that it could not be helped.
Having no expectations for maternity care is the best way not to get hurt, and my attitude is the same toward some of the other local people. After living here for seven years, you get good at it. But don’t get me wrong, Indonesian people are good people; I love them (JPN3).
Many of the participants had networks of Japanese people they could consult. They were aware of the importance of support from their family and Japanese friends who had been midwives and who also worked in Indonesia. When they, the respondents gave birth, their mothers arrived from Japan to assist them, and Japanese friends who had been midwives living in Indonesia provided support until the postpartum confinement period ended.
For women with Indonesian husbands, there was, on one hand, the added hardship of receiving a large number of relatives who visited after the birth but, on the other hand, family members also provided essential assistance, such as support for breastfeeding and various other aspects of child-raising.
Ms. A. (Japanese friend who had been a midwife) gave me detailed explanations, and I was able to consult Ms. A. about even trivial matters. She was that kind of person. Accordingly, I was not anxious in the least, and it was helpful that she stayed with me during the birth as well (JPN2).
Embarrassment and disappointment
During pregnancy check-ups in hospital by the obstetricians, the Japanese women had virtually no interaction with midwives. Having the belief that health guidance comes from the midwives, based on their knowledge of Japan, this lack of health guidance made them feel anxious. During childbirth, doctors directly assisted with the labour; so the women did not remember any nurses or midwives being present in the birthing room. Comparing this with the situation in Japan, where midwives help during labour, it was understandable the women sensed the extensive authority of the physicians and felt that midwives had an unclear role. Because of this comparison, they were especially discomfited by light level of midwifery and nursing care during labour and birth. When the women entered the hospital with labour pains or after their membrane ruptured midwives checked on them in accordance with their local standards and, since they did not receive clear advice regarding alleviating childbirth pain or actions they should take during labour when compared to their knowledge and experience in Japan, participants felt abandoned and also experienced distress because they perceived that they did not receive the expected support during labour.
Many participants were especially anxious about breastfeeding, unsure about how to treat the umbilical cord when bathing the baby, and they expressed concern about limited guidance provided. Even when the women had the support of family members or friends, they still expected additional health based guidance from professionals. Despite planning for a vaginal birth, women did not feel that they were given enough support from the midwives regarding education on pain management during birth, guidance on breastfeeding, bathing the baby, and so on. Women who had previously experienced childbirth in Japan perceived significant differences in maternity care provided in Bali when compared to Japan that became a source of concern for them.
The most memorable episode was that when I was giving birth in Japan to my first child, a midwife supported me during labour to avoid push with each contraction, but I didn’t have such specific support here (in Bali) (JPN1).
If the staff had knowledge, I wish they had shared it with me. Rather than leaving the breastfeeding process after birth to the mother, I would have liked it if they had provided a little more guidance.…I thought that they probably don’t provide guidance for how to bathe the baby and every little thing because there are family members to do that (JPN9).
Those experiences left women dissatisfied with their experiences during and after birth, and hoped they could have better experiences in the future. Women who were unable to bear the labour pains and underwent caesarean sections felt regret that they could have perhaps borne the pain if they had received help and encouragement.
I was in the throes of birth, I couldn’t cope with labour pain, I asked help from the midwife, but she just said ‘Not yet’. I felt increasingly sad and neglected because no one did anything for me during labour. Finally, I said, ‘Please perform caesarean’ (JPN8).
Women’s potential strength
After giving birth, many of the participants did not receive clear guidance about breastfeeding or caring for the infant and consequently taught themselves instead. This is the way it is culturally done in Bali because of the available family support structures. While they were in hospital, they watched internet videos and referred to Japanese leaflets and childcare books since many of these were in Japanese and therefore understandable. Furthermore, those who had experienced childbirth in Japan drew on their previous and existing knowledge of labour and child-rearing to use in their situation.
They didn’t teach me anything about how to care for the baby, even how to change a diaper. […] I didn’t really expect the hospital staff to teach me these things, and so I read various (Japanese) books on child-raising. (JPN7).
Even though some of the women were dissatisfied with various aspects of the perinatal care they received, they were relieved that their babies had been born healthy. They did not regret their decision to give birth in Bali and were able to regard their pregnancy and labour experiences as positive.
I had really strong feelings about ‘What if it had been a natural birth’? but all of a sudden they decided I needed a caesarean and I just said something like, ‘OK, as long as the baby is born healthy’. Ultimately, I felt that it was more important that the baby was born healthy than whether I wanted to do this or that. And so, in the end, I was just happy that the baby was born healthy, and that we were able to leave the hospital and that the baby grew healthily (JPN11).
Future hope
At Japanese childbirth facilities, healthcare guidance is provided through mothering classes and individual instruction from midwives, but only a few of the participants received similar guidance in Bali. Many of the women studied these things on their own, using the internet and other resources. During pregnancy check-ups, they felt that information and explanations were not actively being provided to expectant and nursing mothers; for instance, regarding examination results, they were simply told if there were any problems but they were not given additional detailed information to reassure the mother. The women also reported that information was not offered on topics such as weight gain and foods to be avoided during pregnancy. The participants knew that excessive weight gain during pregnancy can increase the risk of gestational diabetes, macrosomia, and/or hypertensive disorders of pregnancy, and they felt that they needed to take the initiative to obtain relevant information. This was probably due to the fact that the advice given to the local Balinese pregnant may not be appropriate for the Japanese participants. The participants also thought that the care and limited information provided to the local expectant mothers by their doctors who were in charge of their maternity care as problematic when compared to their knowledge and experiences in Japan. This highlighted the need for childbirth preparation and education for foreign expectant women that can help broadens their options.
My hands and feet were really swollen and puffy; my blood pressure was elevated. I was worried, so I did a search on the Internet, and I found quite a number of diseases/conditions I would probably have been diagnosed with in Japan, such as hypertensive disorders of pregnancy. That was my situation, but here I didn’t receive any particular explanation or advice (JPN5).
In contrast to Japan, Indonesia has a high birth rate. Some participants thought that their obstetricians and gynaecologists would have a great deal of experience, and that there were also veteran midwives who had established their own practices. The participants wanted to receive care from experienced professionals. Some participants who experienced discomfort during pregnancy found relief after receiving treatment at midwives’ clinics, while other participants were pleased to receive breast massages after birth, which improved milk production.
When I went to my husband’s parents’ after childbirth, I got breast massage from an elderly traditional midwife, it helped me with exclusive breast-feeding. There are many midwives’ clinics here, they shared with us useful pieces of maternal health trivia, and they were friendly (JPN10).
It may be that in Indonesia having children is almost too routine; pregnancy and childbirth are not treated as big and special events. But I think the process could be made a little more enjoyable. As a mother, there are only a limited number of times you can experience childbirth in your lifetime, aren’t there? That’s why I think there could be more opportunities for enjoying the childbirth process (JPN7).
I think the care provided for childbirth is OK as far as locals are concerned, but I think that health-care professionals at health facilities where foreigners are treated need to provide more information and support about postpartum care and caring for pregnant women. (JPN13)