The experiences of spirituality during pregnancy and child birth in Indonesian muslim women

Abstract

Objective

To understand the experience of spirituality in pregnancy and labor from the perspective of Indonesian Muslim women.

Method

This study used a qualitative descriptive design and analysis to explore the meaning and experiences of spirituality in pregnancy. Seven Indonesian Muslim women who had a baby under one-year-old participated in this study.

Results

This study found 5 themes related to the Muslim women's experience of spirituality during pregnancy: (1) Submission to God makes it easier for mothers to endure pregnancy and childbirth; (2) Meaning-making through spiritual stories enhances confidence, motivation, and persistence during pregnancy and childbirth; (3) Remembrance of God is a way of self-control, overcoming anxiety and labor pains; (4) Faith in God's help raises self-confidence during labor and delivery; and (5) Faith and close relationship with God can overcome the challenge of pregnancy and childbirth.

Conclusion

Spirituality strongly affects Indonesian Muslim women's behavior in caring for their pregnancy. This study offers insights into the experiences of Indonesian Muslim women in living their spiritual values during pregnancy and labor. Nurses should be sensitive to the spirituality of the women and integrate this element in providing maternal nursing care.

Introduction

Pregnancy is a critical period for women. Women need to adapt to physical changes related to pregnancy while keeping their role in the family.^1–3 Poor adaptation can lead to anxiety and affect women's physical and psychological wellbeing as well as their family processes.⁴ One of the prominent sources to overcome major life changes is spirituality.⁵ Spirituality has been acknowledged as a source of power to guide a person in performing his/her role in any situation in life.^5–9 However, despite the importance of spirituality in holistic care, this aspect remains overlooked in maternal health care which is very body-centric. The lack of knowledge and understanding of spirituality are the major barriers for nurses to address the spiritual needs of women during pregnancy.^4–6

Indonesia is a country with the largest population of Muslim. Islam has a distinct view of spirituality. Spirituality in Islam is defined as the quality of the relationship with God (Allah) encompassing all facets of life and daily activities.¹⁰ The quality of spiritual relationships consists of beliefs, worship, and morals/daily behavior.^11,12 Spirituality also comprises self-concept, the meaning of life, and relationships with others and nature. Islamic worship and canonical law (shariah) aim to put a person to be closer to God as well as to enhance his/her values and self-actualization. Therefore, spirituality is described as having an individual, motivational, and relational ‘face’. The relationship with God is a major theme of spirituality in Islam. Having a conscious and continuous bond with God means living daily life according to the rules set by God in the holy books of Islam (Al Qur’an and Al-Hadith). To be spiritual in Islam also means to be as good as Allah wants in a person.¹⁰

How spirituality is viewed and embodied among women who are in a particularly challenging condition such as pregnancy needs more exploration. Therefore, the objective of this study was to understand the experience of spirituality in pregnancy from the perspective of Indonesian Muslim women.

Method

Study design

A qualitative descriptive design was used in this study. We invited seven muslim women whose youngest child was aged 2 months to 1 year to describe their meaning and experiences on spirituality in their past pregnancy. Eligible muslim women aged 24–31 years agreed to participate, while women having communication and cognitive problems were excluded in this study.

Data collection

Before the interview, the first author explained the aim of this research to each participant to seek informed consent. The first author conducted face-to-face interviews at participants’ homes to maintain privacy and confidentiality. Structured interviews involved open-ended questions such as: “How faith or spirituality affected your pregnancy” and lasted for about 60 min. The interviews were then transcribed verbatim. The transcription was validated by the participants. If a participant had anything else to add or improve, this was done immediately on the transcription, and the answer was verified again. Sociodemographic information including age, educational level, and ethnic groups was also obtained in the interview.

Data analysis

Qualitative data were analyzed completely to represent the cumulative experience of the whole participants.¹³ The collective responses of all participants were analyzed linearly using an inductive process to create categories for organizing data. The analysis steps consisted of interviews, response writing, attendance analysis, meaning, and the relationship between words and concepts. Afterwards, conclusions were drawn from the key messages in the transcripts.

Participants’ responses depicting spirituality were selected. Then, the coding scheme was designed for participants’ sample contents that expressed positive responses by comparing key phrases with similar words, statements, synonyms, or similar meanings. The first and second authors checked the statements and assigned them to categories. Similar categories were then combined into broader and different themes. We discussed our findings and had our data checked and re-examined to verify that the thematic content was systematic and justifiable on the basis of its response. There were extensive discussions about the basis and logic of classifications, which provided reliability that there was broad agreement on the relevance of the coding system. Dependence between categories and recurring themes was defined as 100% agreement between the researchers.

Rigor

Data were collected using the standard questioning techniques. The concurrent analysis was used to ensure that themes were fully developed in this study. Asking participants some follow-up questions to confirm themes generated were conducted during concurrent analysis to fill any gaps in the data. A detailed audit trail was kept, and verbatim quotes gave adequate context that could enhance the application of findings in similar settings.

Ethical considerations

This study was approved by the Ethics Committee of the Faculty of Nursing, Universitas Indonesia. The objectives of the study, data collection procedures, duration of interviews, and the rights of participants were explained before each interview. Participation in this study was voluntary, and the participants were entitled to withdraw their consent whenever they wished. They were also allowed to interrupt interviews at any time during the process or to refuse to answer the questions if they chose. Interview times and locations were determined based on participants’ willingness and availability.

Results

All participants in this study were Indonesian Muslim women aged between 24 and 31 years. This study found five themes related to spiritual experience during pregnancy: (1) Submission to God makes it easier for mothers to endure pregnancy and childbirth; (2) Meaning-making through spiritual stories enhances confidence, motivation, and persistence during pregnancy and childbirth; (3) Remembrance of God is a way of self-control, overcoming anxiety and labor pains; (4) Faith in God's help raises self-confidence during labor and delivery; and (5) Faith and close relationship with God can overcome the challenge of pregnancy and childbirth

Submission to God makes it easier for mothers to endure pregnancy and childbirth

Of the seven participants involved in the study, six participants professed their belief in the power of God. God gives help to whomever He pleases. Muslim women in this study view spirituality as faith too. Some participants mentioned that the job of a person is to endeavor, and God will ease. Nothing is difficult for Him. This meaning can be seen from the following statements obtained from the participants:

I wanted to have a normal delivery, I tried my best to care for my pregnancy and to avoid anything that endangers labor, the rest was only God who helped (P1, 33 y.o.)

I did my best to give birth normally, and followed the training.... any results later were all the will of Allah (P3)

We did not know when our prayers would be granted by God, and because of that since the beginning of pregnancy I always prayed (P1, 33 y.o.)

Faith in God's power and love motivates women to nurture and try to give birth normally while being ready to accept all the possibilities that occur.

Meaning-making through spiritual stories enhances confidence, motivation, and persistence during pregnancy and childbirth

Two participants shared a spiritual story about motherhood. The story became a model for women in dealing with pregnancy and childbirth. This spiritual story also inspired them to give birth normally, to be patient, and to always pray for the goodness of herself and the child.

I really wanted to have normal labor, I was traumatized by the previous labor. I was traumatized with the doctor; I think Maryam/Mary (mother of Isa/Jesus) gave birth alone... (P1, 33 y.o.).

I tried to learn how I could have a normal delivery by reading books and searching the internet.

We got so influenced by too much fear: if it were not terminated, it would cause calcification, if the time for labor were too long it would cause bla bla bla.... (P1, 33 y.o.)

Imam Bukhori (a prominent Islamic scholar) was very intelligent, but he was not born through a Cesarean section. I always prayed and read surah Maryam (the ‘Maryam’ chapter in the Qur’an) because I wanted to have a baby girl with a best character like Maryam (P2, 29 y.o.)

Participant 1 was a mother who delivered her third baby normally with the help of her husband at home. Two previous babies were born through Cesarean section. The spiritual story of a former holy woman reinforced her belief in God and motivated her to take care of her pregnancy and even to have normal labor. She described that her third baby was born with ease.

Remembrance of God is a way of self-control, overcoming anxiety and labor pain

Five out of seven participants cited that doing dhikr (the act of remembrance of God) and reciting Al Quran as their coping mechanism when they were feeling sad, afraid, and anxious. The participants would feel calm and peaceful by doing so. Five participants did dhikr mostly by uttering ‘astaghfirullah’ (‘I seek forgiveness in Allah’) and by reciting the Qur’an. This theme was illustrated in several sentences expressed by participants.

Whenever I felt worried or scared, I would recite one of the surah/chapters in the Qur’an... I would feel calm afterward... even I would be the one calming the people around me and my husband. (P4, 29 y.o.)

When the pain struck, I would say ‘astaghfirullah’... many times... I didn’t shout, scare or kick the midwife (P4, 29 y.o.).

When I was worried, I prayed to God. I also asked my husband to pray for me. And when I was having food cravings, I also trained myself not to follow all my desires... (P2, 32 y.o.).

Faith in God's help raises self-confidence during labor and delivery

All participants expressed that their faith in God's help had raised their self-confidence through the course of pregnancy and childbirth. Their strong belief in God's power and help was their coping source to overcome the anxiety and trauma of previous labor and to go through the coming labor process. The following excerpts are examples of the participant's statements.

Everything is in God's power, I was just trying to avoid all things dangerous like anemia, bleeding. I had enough trauma with previous labor, so I learned about pregnancy and childbirth and managed to give birth at home (P1, 33 y.o.)

There was information on how the baby is tilted... yes, I just temporarily closed...I trusted in Allah. All of it was just a part of human efforts, wasn’t it?.... And the rest of it, only Allah alone who made it safe... (P1, 33 y.o.)

Faith and close relationship with God can overcome the challenge of pregnancy and childbirth

Almost all participants said that a close relationship with God could overcome the problem of pregnancy and childbirth. Faith and closeness to God are done through prayer. Praying early in pregnancy is believed to make it easier for women to give birth. Of the seven participants, six was highly spiritual as indicated by their statements. In this study, three participants delivered their youngest baby in normal labor and without any complication, while two participants had a cesarean section. However, two women having cesarean section also expressed their strong faith and accepted the procedure as predetermined by God. This case demonstrates the smooth acceptance of women with good spirituality in the given situation. The following is the example of the participants’ expressions:

I asked my husband to pray for me, and then my husband recited some ‘ruqyah’ verse (verses in Al Quran for seeking refuge to God) for me and then..... Alhamdulillah (praise Allah) after Isya (evening) prayer (7.05 pm), I started to feel the contraction pain... at 9 pm I still took care of my other children, after that, I slept for a while, at 11 pm I went to the midwife and gave birth easily. (P2, 32 y.o.)

At the third delivery, it did not dilate well for the labor, but I wondered why I could not… finally, I just prayed... I believed if God's willing, everything would be easy... I just trusted God, and finally, I could have a normal labor (P6, 28 y.o.)

Discussion

The findings of this study show the importance of understanding spirituality as a coping source for Indonesian Muslim women during pregnancy and labor, which is consistent with the former study results. Spirituality in Indonesian Muslim women means to maintain a relationship with God. Spirituality gives them strength, peace of mind, and positive coping mechanism. All of the participants of this study expressed their faith in God. They believed that God is in control and has all the power to help them through challenging times of pregnancy and labor.

The behavior of surrendering to God is not necessarily passive. In Islam, submitting to God is a manifestation of the faith. Faith in God is the source of piety that provides the women a very positive lens of their pregnancy and motivates them to nurture their babies and themselves. Normal labor is generally desirable among Indonesian women, and they trust God to grant them so. In the case when normal delivery could not be attained, the highly spiritual women in this study demonstrated their acceptance as they believed what had happened was God's will. Putting the best efforts is highly encouraged in Islamic teaching yet the result is in the domain of God. Muslims are taught to develop a fine balance of making efforts and surrendering to God for what has been written as the destiny.

The Muslim women in this study also make meaning of their pregnancy from the stories related to pregnant women and child birth in Islamic scripture. They internalize the story of Maryam (Mary the mother of Jesus) in the Al Quran. There is a chapter named Maryam in the Qur’an which depicts her virtues as a pious and noble woman and her story during tribulation of her pregnancy and labor. This story provides a narrative of faith, strength, and persistence that our participants found compelling. They can relate to the struggle of Maryam during the pregnancy and child birth to frame the spiritual experience of their pregnancy and labor.

Another theme found in this study is regarding spirituality's role in developing women's self-control. In Islam, awareness of God is the best method of self-control. The results of this study are also substantiated by previous research results. Participants feel serenity after reciting the Qur’an or doing dhikr. Dhikr is also performed at the time of delivery. This self-control practice helps conserve energy and lower anxiety during labor. The highly spiritual women in this study also refrained themselves for being lazy or craving food excessively while being pregnant. They had some rest and kept their food intake reasonably. Such positive self-control that has been stemmed from their piety in their daily life was maintained throughout their pregnancy.

In addition, the women in this study rely on God's help so that they had higher self-confidence during pregnancy and childbirth. They believe that they always have God's back as their ultimate source of strength. They also obtain the strength from reading, pondering, and reciting the Qur’an which they solidly believe in as the words of God and apply the guidance on it in their daily life. They find consolation in the verses of Qur’an, one of the most resonating verses being: “Do not grieve, if you are a believer, do not despair to God's grace”. They also believe that Al Qur’an has the power to heal not only the physique but also their soul. Hence, it is an ultimate source of coping mechanism.

The faith and close relationship with God help women overcome the challenges in pregnancy and childbirth.¹¹ The power of the relationship with God can be deduced from the participants’ expression of their beliefs and worship activities, such as “God will provide help to His pious servants”. This theme is in accordance with Islamic teaching in Al Qur’an. Spirituality can greatly affect women in pregnancy. A participant of this study even gave birth on her own with the help of her husband at home after two previous cesarean sections that made her very traumatized. She educated herself about the process of pregnancy and childbirth and care for her pregnancy according to Islamic teachings. Other participants also strongly believe that God will provide help and facilitate labor.

Worship is an effort to get closer to God. The types of worships done by the participants during pregnancy include prayers (the compulsory and extra prayers), dhikr, supplication, reciting Al-Quran and memorizing verses of Quran. The acts of worship helped participants adapt to pregnancy while maintaining their daily activities. Worships and spirituality were also cited as making their pregnancy and labor more meaningful. They also help the women maintain a positive relationship with the fetuses, husbands, children, and other family members. Information from this study provides insights on how spirituality manifests and affects Indonesian muslim women through pregnancy and childbirth.

Conclusions

The results of this study indicate that the aspect of spirituality affects women's behavior in caring for their pregnancy. Almost all participants said that during pregnancy, God was the source of strength that facilitated their pregnancy and delivery process. Spirituality is highly important for Indonesian muslim women, so health care professionals should encompass this aspect in providing care. Nurses are encouraged to see women through comprehensive ‘lenses – physical, emotional, psychological, social, and spiritual.¹⁴ Health care practitioners should integrate the spiritual dimension of pregnancy into a holistic care approach, and educators should discuss spirituality in pregnancy in their teaching programs. Assessments should not be confined to questions of religion or religious status in order to identify what religion means for mother and family.¹⁵ Health care professionals should appreciate the spiritual source and be able to assess the client's level of spirituality in the same manner as assessing risks and other protective factors in pregnancy, such as medical and family history or social support. Health care professionals should ask open questions to find out how important spirituality or religion for pregnant women¹³ and how it affects them during pregnancy. This study describes the importance of spirituality during pregnancy and childbirth for Indonesian Muslim women. Future studies should explore nursing care to promote spirituality among pregnant women in Indonesia.

Conflict of interests

The authors declare no conflict of interest.

Acknowledgments

This work is supported by Hibah PITTA 2017 funded by DRPM Universitas Indonesia No. 391/UN2.R3.1/HKP.05.00/2017.