Traditional Beliefs in Postpartum Care among Indonesian and Filipino Mothers: A Comparative Study

Traditional Beliefs in Postpartum Care among Indonesian and Filipino Mothers: A Comparative Study Marni Siregar * , Hetty WA Panggabean a , Joseph Peter B. Regondola b , Sri Marasi Aritonang c a Department of Midwifery, Health Polytechnic, Tapanuli Utara, Indonesia b Department of Nursing, Trinity University of Asia, Philippines c Department of Midwifery, Singaper Bangsa University, Karawang, Indonesia


INTRODUCTION
Indonesian women's postpartum beliefs are grounded in religion and long-held health practices. The country is challenged with increasing maternal and neonatal mortality rates, although the recommended reduction strategies are in place [1]. Meanwhile, in the Philippines, postpartum recovery is also surrounded by a wide variety of beliefs, traditional practices, and rituals that involve both mother and infant. Cultural beliefs may be considered implementing maternal care and other health programs that fit their cultural practices [2]. Many cultures have different methods of care during the postpartum period [3]. Some of these cultural practices relate to physical activity levels, taboos and rituals, food and dietary requirements, baths, and purification rituals, among many other approved official routines in nursing care comprised of a varying diet, sufficient amount of fluid intake, self-care and promotion of hygiene practices like sits' bathing, showering, ambulation and exercise. These can seem foreign and very dangerous to a mother with different cultural beliefs [4]. In many societies in the Southeast Asian region, traditional beliefs and practices are believed to be vital to maternal and child health [5]. Deep cultural and social meanings are attached to practices related to behaviors, activities, foods, hygiene, and infant care with variance by regions [6]. There are pretty diverse interpretations of the traditional postpartum beliefs and practices, even in the urbanized communities [7]. For example, in Indonesia and the Philippines, comparative postpartum mothers 'beliefs and practices have not been well documented. The postpartum period is crucial for the wellbeing of a mother and new born baby. Postnatal complications are considered as crucial maternal health problems that should be addressed [8]. During the first postnatal year, postnatal complications could increase the risk of perinatal and infant mortality and other mental problem [9]. The complications also imply negative financial and productivity consequences. In Indonesia, the postnatal service utilization is lower than the skilled birth attendance coverage. Maternal health remains a persisting public health challenge while postnatal care utilization in the rural area of Indonesia is lower than in the urban area, similar to other low-and middle-income countries [10]. Similarly, in the Philippines, low healthcare services utilization in postpartum women contributes to significant maternal deaths during the postpartum period [11]. Unfortunately, most rural or suburban areas do not conform to government services due to perceived traditional beliefs and practices. The postpartum period is an exceptional phase in the life of a newly delivered mother and her newborn. It is filled with strong emotions, physical changes, new and changed relationships, assumptions, and adjustments into the new mother role [12]. The postpartum period is one of the most critical stages for the mother-child dichotomy and has been influenced by multiple cultural beliefs and practices transmitted from generation to generation. While many studies describe the traditional beliefs and practices surrounding the childbearing process, some traditional practices are beneficial to the mother and baby, whereas other practices are not [13]. Many traditional beliefs are grounded in religion and permeate cultural practices, making it challenging to counter long-held health practices based on recent healthcare advances. Use of birth attendants in rural areas remains dominant and women believe that following traditional beliefs leads to health outcomes therefore many mothers follow all relatives' suggestions. Understanding the complexities of local culture is the first step to improving women's awareness of preserving their pregnancy and preventing complications. The purpose of this study is to compare the significant traditional maternal health beliefs and practices carried out by women during a postpartum stage in Indonesia and in the Philippines with emphasis on influence on maternal health utilization. It is hoped that the study results are essential to policymakers to understand the traditional maternal health beliefs and practices and serve as groundwork for any possible intervention aimed at improving the low utilization of maternity care services in the study area.

STUDY DESIGN
This study utilized a descriptive research design, which permitted understanding phenomena, meanings, and personal values related to evaluating traditional beliefs, practices, and wellness in postpartum care among Indonesian and Filipino mothers. Structured survey questionnaires were used to gather quantitative data. This approach afforded the collection of quantitative data about real-life experiences of Indonesian and Filipino mothers who have observed traditional postpartum beliefs and practices passed on from one generation to another. A descriptive approach was used for quantitative analysis, which will provide a clear interpretation of the traditional beliefs and practices of postpartum care in which a cultural-sensitive care program may be developed to enhance maternal and child health.

POPULATION, SAMPLE AND SAMPLING TECHNIQUE
The study population included Indonesian mothers from various localities of North Tapanuli, Indonesia, and Filipino mothers from different suburban districts of Manila. Since the characteristics of the community or population in this study have similarities in cultural beliefs in postpartum care, convenience sampling is theoretically suitable as a sampling technique. Considering the population number of postpartum mothers is more than 1000; therefore, the total sample may be determined by 10% out of the population [1]. Therefore we consider taking 200 participants consisting of 100 Indonesian mothers and 100 Filipino mothers who met the inclusion criteria such as conforming to traditional beliefs in postpartum care and conveniently available in the selected research locales. In contrast, postpartum mothers with complicated pregnancies and over the postpartum stage are excluded from this study. Non-probability sampling was focused on sampling technique where the selection of respondents was based on the judgment of the researcher based on the following inclusion: (1) Indonesian mother who conforms to traditional beliefs and practices in postpartum care. (2) Filipino mothers conform to traditional beliefs and practices in postpartum care (3) willing to participate voluntarily in the study. Exclusion criteria: (1) Postpartum mothers with complicated pregnancy (2) Mothers over the postpartum stage.

RESEARCH INSTRUMENTS
The research study referred to an open-access and validated tools on Postpartum Beliefs and Practices Survey by Shouman and colleagues of the Mansoura University of Egypt, designed to compare beliefs and practices related to postpartum care and being modified in order to align with Indonesian and Filipino mother respondents. The adapted self-administered survey questionnaire consisted of three (3) parts: Profile Characteristics; Traditional Beliefs on Postpartum Care. Profile variables included age, marital status; education; religion; employment; and children. Traditional beliefs on postpartum care were focused on several domains, including technological factors; religious and philosophical factors; kinship and social factors; cultural values, beliefs, and lifestyles factors; political and legal factors; economic factors; and educational factors. A four-point Likert scale was used to measure the responses. In identifying the respondents' perspectives of traditional beliefs in two cultural settings, the modified instruments needed to be translated from English to Indonesian and back to English to ensure items in the questionnaire are adequately aligned to potential respondents originating from Indonesia Philippines. The content of the survey questionnaire in this study needed to be subjected to validation by several experts in traditional postpartum beliefs. All necessary recommendations by the experts were integrated into the internal organization of the research instrument to ensure all the items apply to both Indonesian and Philippine cultural backgrounds. Subsequently, a pilot study was done before conducting the main study to assess the reliability or validity of the data. Furthermore, conducting a pilot had enabled the assessment of the participant's understanding of the questions and the timing required to complete the survey. The pilot study included 10 Indonesian and 10 Filipino mother-respondents who were not part of the actual survey. Internal consistency reliability was tested for each domain not just to examine the reliability and validity of the instrument but also to assess congruence with Leininger's Cultural Care Diversity and Universality Model that forms the theoretical framework of this study. The research instrument had yielded an impressive overall 0.94 Cronbach alpha. An alpha value that is higher than 0.9, the internal consistency is excellent, and if it is at least higher than 0.7, the internal consistency is acceptable.

DATA COLLECTION PROCEDURE
The researcher had initially secured approval from the Graduate School to conduct the study. The researcher further sought administrative approval from the local authorities in selected research locales included in the study. The researcher considered qualified Indonesian and Filipino mother respondents who were deemed principal participants in the study. After all approvals and permission had been secured, the researcher started screening eligible participants based on the inclusion criteria. The purpose of the study was carefully explained to all participants. Voluntary participation was clarified among the qualified respondents and written informed consent was obtained. Confidentiality of all gathered data was assured. Privacy and anonymity of the study respondents were maintained by eliminating all potential identifiers. The researcher had personally facilitated the distribution and collection of completed survey questionnaires and was around to answer any clarification from the respondents. Staff nurse respondents took approximately ten (10) minutes to accomplish the questionnaire. Completed self-administered questionnaires were immediately collected and checked for completeness by the researcher for analysis. Descriptive statistics (frequency and percentage, weighted mean, and t-test, were used to describe and analyze gathered quantitative information. Data collection was carried out between August 2019 and March 2020.

ETHICAL CONSIDERATIONS
The research study had ensured the voluntary participation of the participants. Anonymity, confidentiality, and privacy of all gathered information from this study were maintained until the completion of the study. Moreover, the study wholly complies with all ethical standards throughout the conduct of the study. A cover letter was attached to the questionnaire to explain the details of the study. Written informed consent was obtained, and it was clarified to all participants that they were under no obligation to accomplish the survey questionnaire. All potential identifiers were eliminated in the questionnaire. The study's research protocol was subjected to the Ethics Review Board of the Trinity University of Asia.

STATISTICAL TREATMENT OF DATA
In realizing the purpose of this study, the numerical data were treated utilizing the Statistical Package for Social Science (SPSS) software. Weighted mean was utilized for the assessment of Indonesian and Filipino motherrespondents on traditional beliefs and practices. Descriptive statistics (frequency and percentage, weighted mean, and t-test, were used to describe and analyze gathered information.

Results
were extrapolated from questionnaires accomplished by the Indonesian mother-respondents (n=110) and Filipino mother-respondents (n=119) in this study. Data collection was carried out between August 2019 and March 2020.
Based on the age characteristic, more Filipino mother respondents are 20 years old and younger (13.4%) than the Indonesian mother respondents (9.1%). However, more Indonesian mother respondents are between 31-40 years old (34.5%) compared to Filipino mother respondents (25.2%). According to their marital status, the more significant proportion of the mother respondents from both countries was married (Indonesian mothers, 96.4% and Filipino mothers (63.9%)). More Filipino mother respondents were single (21.8%) than the Indonesian mother respondents (3.6%). However, more Filipino mother respondents were separated from their spouse (14.3%) in contrast with Indonesian mother respondents (0%). More Filipino mother respondents finished college (37.0%) than the Indonesian mother respondents (16.4%). However, a minimal percentage of Indonesian and Filipino mother respondents have only reached elementary education with 2.7% and 13.4%, respectively. In this study, more Filipino mother respondents are unemployed (36.1%) than the Indonesian mother respondents (15.5%). Interestingly, about a quarter of the Indonesian and Filipino mother respondents were self-employed with 29.1% and 25.2%, respectively. Moreover, a higher percentage of Filipino mother respondents had five children or more (10.1%) than the Indonesian mother respondents (3.6%). Table 1 shows these results. Table 2 summarizes the assessment of traditional beliefs in postpartum care on the dimensions of technological factors; religious and philosophical factors; kinship and social factors; cultural values, beliefs and like ways; political and legal factors; economic factors; and educational factors. With responses of mother respondents to individual dimensions ranging from disagreeing to agree, Indonesian mother respondents presented an overall mean of 2.83 verbally interpreted as agreeing while Filipino mother respondents depicted an overall mean of 2.66 verbally interpreted as agreeing as well. Table 3 supports the analysis in determining a significant difference in the assessment of Indonesian and Filipino mother respondents on their traditional beliefs in postpartum care. t-test was used to compare the seven dimensions of traditional beliefs in postpartum care at a 5% significance level.

DISCUSSION
Assessment of two groups of respondents showed varied views on modern technology regarding information dissemination, access, and its impact on traditional medicines. Nevertheless, both cultures have a common perception of the impact of the internet on their stand on traditional postpartum practices in which several pieces of information, education, and communication materials are readily accessible. While Indonesian mothers view the internet as an excellent place to browse and validate cultural beliefs, Filipino mothers avert that idea as they may have sources other than the internet to validate acquired beliefs on postpartum care. The previous study has stated that providing information concerning the effectiveness of an internet-based intervention, mothers' and fathers' parenting experience during the postpartum period and parents as users of online parenting support [15]. Previous studies indicate that internet-based interventions improve parents' knowledge, attitudes, and/or motivation [16][17][18]. The ubiquitous nature of technology use among postpartum women represents an opportunity to deliver support and education to women who may not otherwise receive it in the traditional setting of a physician's office. Most postpartum women have access to technology and smartphones, which they used to access information at least a few times per week throughout postpartum. The most common technologies used are apps, internet search engines, parenting websites, and e-mail [19,20].
Both cultures have a common perception of trusting various traditional therapies that offer spiritual comfort towards postpartum recovery. Moreover, both Indonesian and Filipino mothers believe in using religious artefacts to drive away evil spirits away. In line with previous research, most Thai women adhered to traditional postpartum practices related to the notion of regaining 'heat.' These included 'lying by fire,' food restrictions, taking hot baths, and consuming hot drinks. Other activities involved not exposing the body to heat loss by keeping covered, not shampooing the hair, avoiding the wind, and sexual abstinence [21]. Other studies have found that many Asian women continue to practice a wide range of traditional beliefs and practices during pregnancy, childbirth, and the postpartum period, included massage, the state of pollution after childbirth, the use of traditional healers and traditional medicine and herbs, beliefs relating to hot/cold imbalance, behavioral taboos, magic, and superstition [22]. The assessment of the two groups of respondents showed the same view toward the importance of obtaining support from relatives and friends who realize the importance of rest and providing support during the postpartum period, and they shared the same opinion on the positive effect of social support on the mother's physical, emotional and mental health during the postpartum recovery. However, on the other hand, the influence of relatives, especially husband and mother or mother-in-law, is quite dominating, particularly in practicing local culture, which has been carried out for generations to accelerate postpartum healing [23], thereby increasing non-compliance with health workers such as midwives [8], For example, the Marapi ritual in Manunggang Jae Village is carried out with the intention that mothers who have just given birth are strong and recover quickly [24]. Assessment of two groups of respondents showed contrasting views on adherence to government-initiated programs on postpartum care should be mandatory. While most Indonesian mothers comply with their governmentinitiated health programs, most Filipino mothers cannot wholly adhere to available health programs offered by government agencies. Furthermore, both cultures think formal health care programs provided by the government significantly improve maternal and child outcomes and consider government's outreach services and home visits of community health workers make a difference in maintaining continuity of care and supporting healthy behavior.
In order to address these needs, postnatal care programs should consistently adapt to both the physical and psychosocial needs of the mother depending on standard cultural practices and beliefs to maximize the utilization of postnatal health care services. Postnatal practices could achieve a higher quality of care by maintaining more comprehensive support and involvement between health care providers and the mother. With this, the wellbeing and emotional health of both the mother and newborn can be promoted [25]. A low ratio of utilization of healthcare services in postpartum women may contribute to maternal deaths during the postpartum period. Financial and environmental barriers might hinder healthcare services in women who deliver at home in the Philippines [11]. In many low and middle-income countries, women are encouraged to give birth in clinics and hospitals to receive care from skilled birth attendants. The birth attendant is also trained to identify, manage, and refer any health problems that arise for mother and baby. The skills, attitudes, and behavior of birth attendants and how they work in an enabling working environment impact the quality of care. If any of these factors are missing, mothers and babies will likely receive suboptimal care [11]. Poor teamwork and lack of trust and collaboration between health workers negatively influenced care [26,27]. In line with previous studies, it was found that, on average, mothers from low-income families in Indonesia decided to give birth at home [8]. In Indonesia and other low-and middle-income countries, there could be similarities and differences in the barriers to postnatal care utilization with that of antenatal care. For example, the lack of knowledge among mothers is common for antenatal and postnatal care [8]. However, low education and financial barriers were the more dominant factors for the utilization of antenatal care [28]. Each group has different knowledge of postpartum mothers' signs and dangers, where postpartum mothers in the Philippines have a better understanding than postpartum mothers in Indonesia. Community's literacy on the postnatal period and care most of the mothers Indonesian in our study lacked health literacy, including knowledge, skills, and awareness of the postnatal period.
Another study in West Java, Indonesia, also highlighted awareness of postnatal care [29]. Other studies also reported a very low proportion of mothers with sufficient knowledge and awareness about the danger signs during pre- [30] and postnatal care [31].

CONCLUSIONS
These findings indicate that traditional practices towards maternal care in the postpartum period are commonplace that have been practiced for generations in countries in Southeast Asia, especially Indonesia and the Philippines. However, the respondents in this study showed different assessments in assessing culture in maternal care postpartum. t-test was used to compare the seven dimensions of traditional beliefs in postpartum care at a 5% significance level. Four dimensions, including technological factor (p-value 0.000); kinship and social factors (p-value 0.024); cultural values, beliefs, and like ways factors (p-value 0.000); and educational factor (pvalue 0.002), showed a statistically significant difference in the assessment of mother respondents on their traditional beliefs in postpartum care. Current research has not characterized all postpartum cultures in all corners of the country compared with the culture of postpartum mothers in the Philippines.

RECOMMENDATIONS
Postpartum mothers utilize technology in accessing various information, education, and communication materials regarding traditional postpartum practices that can be downloaded through the internet, and postpartum mothers do not entirely rely on religious traditions, superstitious beliefs, and other postpartum rituals. Then next, postpartum mothers reach out for support from family members, including mother, mother-in-law, other female relatives during the recovery period.