Women's efforts to solve postpartum problems based on the culture of South Sumatera

Abstract

Objective

This study aims to explore the cultural patterns, habits, and behavior of mothers in overcoming postpartum problems.

Method

The study was of a qualitative design with an ethnography approach. A purposive sampling technique was used, and data were obtained from seven participants who identified with Palembang culture.

Result

The themes which emerged were: (1) Tiredness, drowsiness, and perineal pain were part of the physical problems of postpartum mothers. (2) Sadness and lack of attention were feelings that occur in postpartum mothers. (3) Traditional practices help with breastfeeding problems and perineal pain. (4) Some traditional interventions help mothers reduce physical problems. (5) Postpartum maternal needs are obtained from the family and community through traditional interventions. (6) The expectation of postpartum mothers is the support of husbands, families and health workers.

Conclusion

Mothers’ efforts to solve postpartum problems cannot be separated from habit and the family's culture. Health workers need to facilitate maternal care with a family culture approach.

Introduction

Women's quality of life is difficult to attain because the target of Maternal Mortality Rate (MMR) has not been achieved. In 2015, MMR was 305 per 100,000 live births, and there is a huge challenge for Indonesia to complete the SDGs target by reducing MMR to below 70 per 100,000 live births by 2030.¹ The causes of maternal death can be classified as direct or indirect. Direct causes of maternal death include complications during pregnancy, childbirth and postpartum such as bleeding, eclampsia or disorders due to high blood pressure during pregnancy, prolonged labor, complications of abortion and infection. Indirect causes of maternal death include conditions of cancer, kidney, heart, tuberculosis or other diseases suffered by the mother.¹

The high level of Maternal Mortality Rate places a significant responsibility on health workers to deal with maternal problems. To maintain maternal health, care needs to be taken throughout the reproductive age, especially during the antepartum, intrapartum and postpartum periods. Changes in postpartum mothers occur for forty days, while in health care services are given for only three days. This means a longer period of postpartum care in the home. Until now, the maternal postpartum surveillance system during their stay at home has not been structured, so that habits that occur in the community greatly affect maternal care. The cultural values adopted are usually in accordance with the origin of ethnic groups who influence mothers and families.

Research on customs regarding postpartum maternal care needs to be further explored in order to link maternal care at home with indirect supervision by health workers. Relations between ethnic groups also occur in the interaction of mothers and nurses. Where nurses may have the same or different background or ethnicity from mothers and their families. The Palembang Indonesian community carries out postpartum care in the home involving a traditional midwife. In these conditions, nurses need to understand this diversity and work with mothers and families while respecting cultural values according to ethnic origin.

Method

This was a qualitative study with an ethnographic approach. The researcher interpreted the study results subjectively based on the participants ‘perspectives’ and the researchers’ observations of the care culture of postpartum mothers in South Sumatera. In this study based on ethnography, the researchers observed the cultural rituals of the people of Palembang Indonesia during postpartum care, assessed the meaning and interpreted the results of the study. The study sampling used a purposive sampling technique. The inclusion criteria were postpartum mothers in the range 1–40 days, aged 20–35 years, with multigravida, belonging to Palembang tribes who lived in the city of Palembang, Indonesia and obtained seven participants.

Data was collected through in-depth interviews with informal face-to-face conversations. Interviews were conducted with seven participants, four shamanic massage practitioners and four traditional leaders using a digital voice recorder. Participant responses were documented using note fields note and observations focused on the behavior of participants and the efforts they made when experiencing health problems. This research was conducted over a period of one month, and researchers remained in contact with the participants.

Data analysis was thematically based on keywords arranged into categories. Inter-related categories were defined as one research theme.

Results

Research themes obtained were:

Theme 1: Tiredness, drowsiness, and perineal pain were parts of the physical problem of postpartum mothers. These themes supported by complaints of weakness, tiredness, and sleepiness, body discomfort, dizziness, cramps and pain while breastfeeding, a lot of blood discharged, breast pain and pain in the wound area were complaints experienced by postpartum mothers. Three of the seven participants responded as follows:

“the complaints were a weakness, dizziness, pain in the place of suture, seven stitches, a lot of blood coming out, stomach cramps after feeding” (P1)

“…., pain near sutures. Lots of stitches. Dizziness complaints due to giving birth” (P2)

“pain in the stomach during the first day, the second day went home from the hospital and was still sick. One week was still sick until squatting. Breast pain after giving birth causes difficult breastfeeding. The nipples are short, so the baby is hard to suckle” (P3).

When under observation, the mother was more lying down and not active. When breastfeeding the mother gets up and sits, but she cannot breastfeed her lying position. Facial expressions show an occasional grimace when feeling pain.

Theme 2: Sadness and lack of attention as feelings that occur in postpartum mothers. These themes supported by: Feelings of sadness, unnoticed and unloved feelings were complaints experienced by mothers. As stated by three of seven participants:

“Mental complaints, high sensitivity, the problem was at home. Alone, it can’t go anywhere so it makes it sensitive, not crying, just daydreaming” (P5)

“there were mental complaints, feeling not in love” (P6)

“Feelings of sadness, no friends, my husband worked, at the time I was happy if I did not know I can ask, but now? I cannot (P2).

Observational results of participants living alone at home, the mother prepared and carried out her own and baby's care. Husbands were away working and did not assist mothers to care for themselves or care for their babies.

Theme 3: Traditional practices help with breastfeeding problems and perineal pain. This theme is supported by the categories below:

• 1.

  Surgical and perineal pain. Two of the seven SC participants stated:

“Complaints of suture pain, sitting on a hot brick. The heat matches our resistance” (P3)

“pain on the stomach the first day, the second day went home from the hospital and still sick. One week was still sick until squatting…” (P5)

During observation, visible surgical scars on the abdominal area began to dry out, tenderness felt but no signs of infection.

Five participants with vaginal delivery also expressed perineal suture pain, as the following participant statements show:

“Pain in sutures, seven stitches, lots of blood coming out” (P1)

“no complaints after childbirth, pain near sutures. Lots of stitches” (P2)

“Pain in sutures, pain near the genitals” (P4)

“there are no stitches, pain in the pubic area in the love of heated bricks on the stove, there is turmeric pounded with lemongrass, then warmed, then wrapped like “pepes” and applied when hot while seated, done for up to 1 week” P7)

Observations of this participant showed the mother walking slowly and grimacing when changing positions.

• 2.

  Breastfeeding was perceived as a problem by participants. Three participants stated the following:

“After bathing in spices brewed in water, the breasts feel full, feel painful, breast milk did not come out because the baby did not want to suckle” (P1).

“Breast pain after giving birth causes difficult breastfeeding. The nipples are short, so the baby is hard to suckle” (P3).

“The nipples were sore, the breast skin was tightened, the nipples protruded, then the breastfeeding was forced if the baby did not want to, the milk was pumped while continuing treatment until the baby suckled directly” (P5).

“the first day the milk did not come out, for a lot of milk, drink banana heart water” (P7).

Observations were made after a steam bath; the breasts looked tight and full, the milk dripped and soaked the mother's clothes. Mothers who experience flat putting problems, nipples become prominent.

Theme 4: Some traditional interventions help mothers reduce physical problems.

Herbs and spices, shamanic massage, and traditional ritual action as traditional cultural themes are supported by the following categories:

• 1.

  The culture of postpartum care using herbs and spices. All participants stated that they had been treated with herbs and spices. The participants’ statements are outlined below:

“Bathed using boiled water (turmeric leaves, lemongrass, galangal) for 3 days. Then the decoction leaves are tied and rubbed. … bricks are baked, then given turmeric, newsprint, coated with cloth and pounded. Eucalyptus oil is rubbed on the abdomen, sago flour, lemon juice, are then tied to the stomach with a cloth. On the forehead is applied by poultice (turmeric leaves, lemongrass, galangal)” (P3)

“the first day I was bathed with boiled water with turmeric leaves, lemongrass, pandanus, and galangal……then sat briefly on a brick that had been baked and given turmeric coated with a cloth. This was repeated for three days. On the abdomen were eucalyptus oil, sago flour, and lemon juice, tied to the stomach with a cloth. On the forehead, a poultice was applied made of turmeric leaves, lemongrass, galangal. I drank herbs with a composition of 1/2 kg of galingale, 1 kg of turmeric, boiled and drunk for 6 days” (P6), (P7).

When observing, there are herbs and spices available in the room. Spices that have not been processed are stored in the kitchen. The mother was seen using the herbs on her body, and her forehead. The scent of the herbs was evident when I was close to the mother.

• 2.

  Bathing and massage as a technique for postpartum care. Three of the seven participants stated:

“The first day after birth, I bathed with boiled water, this continued for 3 days. I drank herbs for 40 days and applied a baked brick for 1 week” (P6), (P3).

“I was for massaged for one month and applied herbs” (P7)

The mother was observed being massaged all over the body by a traditional healer and an elderly person. This was followed by a warm bath of spices.

Theme 5: Postpartum maternal needs are obtained by the family and community through traditional interventions. Support from parents was obtained during postpartum care. This is supported by the following categories:

• 1.

  Parents prepared all care needs. Two of the seven participants stated the following:

“I feel blessed because my parents and husband always helped me and catered to my needs. I cannot bath the baby by myself, so I needed help” (P3)

“it was important that my mother was always beside me, to help me give breastmilk to my baby” (P1).

Based on observations, parents helped to take care of the baby first, then prepared the ingredients, help the mother to apply them to her body and prepared the herbs to be drunk by the mother.

• 2.

  There is a need to find health workers who can facilitate self-care and assist parents in preparing treatment equipment. Three of the seven participants stated the following:

“my mother called a shamanic massager to care of me and prepare all the herbs” (P1).

“mother called a shamanic massager to care of me for 1 week” (P3).

“I got a shamanic massager from my mom” (P7).

Observational data found that at the participant's home, there was a traditional healer who came every morning to care for the mother.

• 3.

  Actions were taken by the mother by following the shaman's instructions. Three of the seven participants were treated by a shaman and provided the following statements:

“my mother called a shamanic massager to provide care for 1 week. Massage total body” (P1).

“….shamanic massager told my husband to take herbs and spices in our home” (P4).

“Shamanic massager told me that my feet must be straight and should not be bent, eat dry food, and eat coriander so that the breastmilk is smooth” (P7).

Observational data revealed that the shaman is preparing a mixture, then smearing it onto the mother's stomach. Then they attached the skin of an octopus to the mother's stomach. On the forehead, they placed a concoction. After treatment of the body, the shaman made herbal medicine, then the mother drank half a glass of turmeric and ginger.

Theme 6: The wish of postpartum mothers was the support of husbands, families and health workers. This is supported by the following categories:

• 1.

  Expectations of support from husband or family in the form of assistance with care for themselves and their babies. All participants expressed the following:

“the needs after birth was to have people in the house, to help me” (P2).

“I hoped for cooperation from my husband and family to help me” (P3), (P7).

“The first day in the house, I felt tired, and I needed help” (P4).

• 2.

  Expectations of health worker support in the form of giving medicines to overcome postpartum complaints. Two of the seven participants stated the following:

“Traditional care is minimal and lasts for 1 week. Midwives only gave medicine” (P6).

“health workers could do more to help postpartum problems and explain about the medicine” (P7).

Observation results showed that, while smiling, the mother expressed her hope. The mother showed the antenatal book she was reading and the results of the control after removing the umbilical cord.

Discussion

Postpartum maternal problems found in this study were impaired movement, tiredness, nausea, body ache, dizziness, cramps, pain while breastfeeding, lots of blood coming out and perineal pain. This is similar to research by Woolhouse, who found that physical health problems most often reported in the first three months postpartum were fatigue, pain, breast problems, perineal pain, and urinary incontinence.²

Psychological complaints can occur in mothers who experience physical problems, and these can even lead to depression when not recognized and addressed immediately.³ This was experienced by the participants of this study, the mothers felt sad, not cared for and unloved. The same results were found by Woolhouse where mothers who reported five or more health problems experience six times the symptoms of postpartum depression.² They then experienced a threefold increase in depressive symptoms at 6–12 months postpartum. Further research conducted by Newbrander in five rural districts in Afghanistan, concerning traditional practices of women, families, and communities related to maternal and newborn care, also showed a high level of postpartum depression.⁴

Mother's efforts to solve the problem of breastfeeding and perineal pain involved in performing traditional practices. One practice that mothers do when experiencing breastfeeding problems is drinking herbs and eating the “katuk” vegetable. The results of this study are in accordance with mothers in the Kajoran village of South Klaten, Indonesia. They also displayed the habits of consuming herbs to maintain a healthy body while breastfeeding.⁵ In the research by Kiani, two risk factors identified for breastfeeding and the lack of exclusive breastfeeding in the state of Nicaragua were pre-lactation feeding and the mother's perception that the baby becomes large at birth.⁶ Most studies show cultural support for breastfeeding, although most traditional societies postpone breastfeeding because colostrum is considered ‘dirty’.⁷

The results of this study found that for maternal perineal pain, mothers were encouraged to sit on heated bricks. This cultural practice is obtained from the mother and in-laws and is derived from the habits taught by their grandmothers or predecessors. Cultural practices are carried out with herbs and spices that can be made by the mother, bought or received through a dukun massage. Unlike the finding of the research done by Seifi, for other physical problems such as urinary tract infections (UTI) in vitro studies have shown the effect of the Rosa Canina fruit in preventing the growth of Escherichia coli.⁸ Rosa Canina fruit capsules can reduce the incidence of UTI in post-op SC patients.

In research conducted by Sari, there were classifications on pregnant women and childbirth grouped into 3 categories, namely behavioral restrictions, food, and drinks.⁹ Various practices in the post-partum period were obtained in Asia, Latin America, and Africa, and the conclusion was a strong cultural understanding of the power of healing through daily food.⁷ One of the population groups in Peninsular Malaysia, held as taboo and avoided certain foods during the postpartum period. There are five prohibited food items that are avoided during the postpartum period: cooking oil, salt, monosodium glutamate, sugar, and meat from game or pets. Dietary restrictions begin immediately after delivery and last for up to one month.¹⁰ There are taboos or myths that are difficult to change even though they are irrational. Postpartum mothers are also discouraged from eating fish, eggs, and meat so that the wound heals quickly. There is also a belief by mothers who refuse to drink a lot after giving birth because of fear about wet birth canal wounds prolonging the healing process.

The traditional intervention carried out by the Palembang people in Indonesia in this study is a steam bath in order to carry out body treatments. In the Indonesian Acehnese community, body care is carried out by means of a postpartum mother undergoing a sale, This is a practice of sleeping on a bed made of wood or a bamboo trunk that has cracks and underneath there is a furnace containing hot charcoal. This tradition is considered to speed up the process of deflating the stomach and uterus, tightening the genitals, and warming the body. Traditional birth attendants in Majene Village, West Sulawesi, Indonesia, handle postpartum mothers based on their knowledge from dreams. The mother must draw water from the well and bring it into the house to restore physical strength.¹¹

Postpartum maternal behavior to overcome health problems according to the results of the study Sari, showed that in the Banjar tribe in East Martapura District Indonesia, mothers are grouped into 3 categories in obtaining care, namely from a traditional birth attendant, customs and from health workers. Health worker activities according to Cwikel who evaluated the Mom to Mom program (M2M) found that it can help women overcome the first year of care through home visits to mothers.¹² It had the potential to overcome challenges in the postpartum period among women of diverse cultures. Ideally, these interventions must build behaviors that support and include recognized cultural life such as breastfeeding, postpartum counseling, rest and recovery. Then improve them by modifying potentially harmful aspects of other cultural practices during the perinatal period.⁷ Inaccessible and inadequate programs promoted a culture of mistrust and suspicion among mothers from the Black and Minority Ethnic (BME) about perinatal health services.¹³

Differences occur with South American mothers who migrated to Italy. In the context of migration, immigrant mothers are powerless to understand the meaning of postpartum rituals.¹⁴ As found by Turner, neonatal community interventions must be adapted to existing population practices and knowledge.¹⁵ Village leaders no longer impose traditional views. In the populations studied, traditional practices in period partum are no longer common. Ideally, these interventions should establish behaviors that support recognized cultural life such as breastfeeding and promoting post-partum rest and recovery while modifying potentially harmful aspects of other cultural practices in the perinatal period.⁷ Multidimensional assessments of acculturation can prove to be useful in better adjusting breastfeeding interventions for the future.¹⁶ Actions are carried out according to the severity of the patient, who may need counseling, social support and may sometimes need to be hospitalized in severe cases. There are a number of traditional methods around the world which are sometimes useful and sometimes dangerous for mother and baby.¹⁷

The results showed that the ability of mothers to resolve postpartum health problems was strongly influenced by the support system of their husbands, parents or the community. Mothers become more adaptable to body changes. Psychologically, the mother does not feel alone when experiencing health problems. As the results of a study in British Columbia, for 396 first-, fourth- and eighth-week postpartum mothers, results showed that partner support was positively correlated with social support.¹⁸ This is consistent with the results of another study that found that it is very important for mothers to get support from their husbands, mothers-in-law, village midwives, village cadres and leaders as well as the presence of a culture that plays a role.¹⁹

Cultural practices carried out by mothers during postpartum require the help of health workers to bridge the needs of mothers and the support of husbands, families, and communities in order to achieve maternal and infant health. As the results of this study show, the expectation of mothers to care for themselves need the involvement of husbands, families, and health workers. The support that mothers need takes the form of understanding and assistance from their husbands, parents and health workers in providing fulfillment of their care needs.²⁰ This is consistent with the results of quantitative and qualitative research on the involvement of professionals in helping maternal health problems during childbirth at home.²¹ Health workers need to provide intervention to postpartum mothers through health education packages because these are proven to increase knowledge, improve behavior and self-efficacy in parenting.²² Socio-cultural barriers to maternal health and the inability of mothers to seek care without being accompanied by male relatives can lead to serious health problems.⁴ Conversely, the advice of health care workers and access to available health services brings better conditions after giving birth.²³ In accordance with research Cwikel, family-centered care requires recognition of the role of relatives and other members of the mother's social network as a guide in the health care process. Mothers tend to seek help through family and religion, rather than through medical services.²⁴

Conclusion

Postpartum mothers overcome their health problems by asking for help from their husbands and parents. This makes it easier for the mother to get self-care and care for her baby while at home. Husbands and parents provide care for mothers by imitating family habits or culture. Cultural practices include the use of herbs or spices, baths and massages, and advice given by massage shamans. Treatment received by mothers can reduce maternal complaints, so that adaptation to physical and psychological changes is more easily experienced by mothers. Husband, parent and health worker cooperation occurs during the care of postpartum mothers. Therefore, health workers are required to provide care for postpartum mothers within the cultural context of of home life.

Conflict of interests

The authors declare no conflict of interest.

Acknowledgements

This work is supported by Hibah PITTA 2018 funded by DRPM Universitas Indonesia No. 1855/UN2.R3.1/HKP.05.00/2018.