Patterns of Pregnancy Care Based on Indonesian Culture

of antenatal care

In today's society, the myth of pregnancy has always existed, whether consciously or unconsciously.This pregnancy myth may have a positive or negative impact on the behavior of pregnant women.It is common for cultural beliefs and knowledge to have a positive as well as a negative impact.Examples include conceptions of various taboos, causal relationships, and healthy conditions for illness, habits, and ignorance.Moreover, habits that have a negative impact may cause some complications, such as hypertension in pregnancy, bleeding, and impaired fetal growth.According to the research of Ashriady et al. (2022), there is an assumption that some people do not want to consume particular types of fish due to the myth that doing so will affect the condition of their fetus after birth. 5Furthermore, pregnancy check-ups can optimize the physical and mental health of pregnant women so that they can deal with childbirth and the puerperium, as well as preserve the safety of mothers and children during pregnancy.The frequency of pregnant or antenatal health services is required to involve at least six pregnancy checkups and two examinations by a doctor.The lack of optimization of health services for pregnant women has an impact on the late detection of danger signs of infertility in pregnant women, which causes them to be late in making decisions, reaching health facilities, and receiving medical assistance in health services-a situation known as three "late". 6An expectant mother's risk of not being prepared for labor increases by 8.4 times if she misses an ANC visit.Additionally, it may result in a delay in the detection of complications associated with pregnancy.Moreover, complications during pregnancy, childbirth, and puerperium are the causes of maternal mortality.The complications in question are pain experienced directly or indirectly by pregnant women, maternity mothers, postpartum mothers, and or fetuses in the womb, including infectious and non-infectious diseases that pose a risk to the life of the mother and or fetus. 7he initial antenatal visit primarily determines the mother's potential for subsequent antenatal visits, even exceeding the program's recommendations.Antenatal visits to health facilities during pregnancy are important.This visit is intended to monitor the mother's health and the status of her womb through examination, consultation, counseling, and therapy, including iron tablets, in order to ensure that the mother and the baby are both healthy and safe at the time of delivery. 8A medical examination is important for pregnant women to monitor their physical and psychological health, as well as the growth and development of the fetus, and prepare for the delivery process. 9The existence of several beliefs in myths among the Indonesian people made the researchers interested in knowing the pattern of pregnancy care among pregnant women in Indonesia.This study only discussed the pattern of health care for pregnant women in several regions of Indonesia.The researchers have not been able to present the culture of pregnancy care in all regions of Indonesia.Furthermore, it is expected that there will be further research and discussion in various other areas that the researchers have not yet discussed.

METHOD
This study is a literature review on the healthseeking behavior of high-risk pregnant women in Indonesia.The process of conducting article searches entailed looking for several research journal articles that have been published in electronic databases like Scopus, PubMed, Google Scholar, ScienceDirect, and SAGE between 2018 and 2022 using the keywords "health seeking behavior", "pregnancy", "antenatal care", "infant mortality rate", "maternal mortality rate", and "pregnancy care".Article screening was done using the convidence.orgwebsite application to screen duplicate articles.Moreover, the researchers manually screened each article, starting with the title and abstract, then proceeding to exclusion criteria such as completeness and feasibility of the full text of the article, and finally screening the full text of the article using the Mendeley application as a whole.Furthermore, the inclusion criteria in this study are: (1) the most recent five-year journal articles published in 2018-2022; (2) articles provide an overview of pregnancy care behavior of various tribes in Indonesia; and (3) the topic of articles exclusively covers the area of Indonesia.(4) Open access articles.Meanwhile, the exclusion criteria are: (1) not discussing Indonesia; (2) not being fully accessible; and (3) having no link to the topic.In the data identification process, a total of 263 articles were identified and filtered based on inclusion criteria, language, and research location.Afterwards, the relevant research articles were extracted, sequenced, and examined to identify the subtopics and topics.After the screening and eligibility process, 14 relevant final articles were selected.The examination structure can be seen in Table 1, which includes an exploration of health-seeking behavior among pregnant women in Indonesia.

RESULTS AND DISCUSSION
The result showed that regardless of their insurance status, pregnant women sought treatment and went to medical facilities.Every pregnant woman should receive timely and proper treatment.Therefore, the readiness of proper primary services in the hospitals, followed by a referral system, should be balanced with the increasing demand.Moreover, in terms of antenatal care, parity still varies between traditional birth attendants and midwives.As for birth attendants, mothers tend to put their trust in traditional birth attendants rather than midwives.Furthermore, some people continue to follow the advice of traditional birth attendants and use traditional medicine to treat their diseases.However, in the maternity checkup, the traditional birth attendants were only there to check the pregnancy, while the delivery process was carried out by a local midwife or health worker.In addition, people still believe in traditional healing methods through incantations or spells, sacred objects that are considered protectors, and the tiger god as ancestral spirits.Additionally, a good quality of antenatal care tends to be received by mothers who are examined by midwives at the public health center, mothers with higher education, mothers who live in moderate and good neighborhoods, not in slum areas (social environment), and mothers who reside in the Java-Bali Region.This study revealed that the better the culture of pregnant women in their environment and daily life, the more regularly the mother visits an antenatal care or routinely checks on her trimester of pregnancy, while the less good the culture of pregnant women in their environment or daily life, the less regularly the mother visits an antenatal care.A descriptive qualitative approach.

Pregnant women in Java and Bali
A good quality of antenatal care tends to be received by mothers who are examined by midwives at the public health center, mothers with higher education, mothers who live in moderate and good neighborhoods, not in slum areas (social environment), and mothers who reside in the Java-Bali Region.
In general, the results of this study indicated that factors such as maternal education, the workers and the place of antenatal care, the residential environment, and social status have an impact on the selection of good-quality healthcare services.This is in line with the theory of behavioral models and utilization of healthcare services by Andersen (1995).According to him, there are some factors, including predisposing factors, enabling factors, and need factors. 15Moreover, these three factors can be explained as follows: (1) The supporting factors (predisposing) include age, gender, education, occupation, attitudes, and health-related knowledge; (2) The enabling factors include family income and the availability of services; and (3) The need factors (need) include healthcare services.In addition, the utilization of healthcare services depends on external environmental conditions, including physical, political, and economic aspects. 16Furthermore, socioeconomic and cultural factors have an impact on pregnancy outcomes, including maternal mortality.The determinants include health status, women's reproductive status, access to health service facilities, and healthy behavior, including utilization of health service facilities such as: 17

Mother's Health Status
Conceptually, women's status is related to socioeconomic factors, and reproductive status includes the age of the mother, parity, and marital status.The results of ethnographic studies showed that the main causes of pregnancy-related issues are pregnant women at a young age as well as early marriage.

Healthy Behavior and Pregnancy
The norms and culture embraced by a society can shape behavior.Moreover, the mother's health is at risk during pregnancy.Many people believe that being pregnant is a normal and natural occurrence that all married women must deal with.A mother's healthy behavior can be examined by several practices that can demonstrate that a mother is still exposed to traditional practices, including refraining from taking contraceptives for non-medical reasons and traditional umbilical cord care.

The Role of Culture in the Utilization of Health Services
In rural Indonesian communities, the family generally has a significant impact on the mother's pregnancy status.The results of an ethnographic study showed that the family (not only the husband) still plays a significant role in decision-making, prenatal care, and childbirth.In addition, the central government is constantly developing interventions for maternal health services, however; achievement indicators such as the maternal mortality rate (MMR) are still high.
The myths that characterize the cultural values of a society and are obtained over generations include taboos as well as recommendations on specific foods, behaviors, and rituals.In addition to ensuring optimal growth and health of the mother and fetus, pregnancy care is one of the most important factors in preventing complications and death during childbirth.To know about the health impacts on babies and mothers, it is essential to understand pregnancy care behaviors, especially those related to socio-cultural aspects in a particular region.in the Toraja Tribe, several foods become taboo during the pregnancy process, including banana hearts, pineapple, meat, and salted fish.Furthermore, the recommended foods during pregnancy are vegetables, fruits, fish, and milk. 18In addition, it was discovered that some women during pregnancy preferred not taking drugs, such as Fe tablets, as they were considered to enlarge the fetus in the womb and complicate the delivery process. 5Socio-cultural roles are conditions that are already inherent in certain societies.Indonesia, with a very wide regional geography, has more than 520 ethnic groups and very diverse local wisdoms.This condition requires intervention methods that are locally specific and cannot be generalized nationally.Birth and pregnancy problems are closely related to cultural elements in society.If we look at the vastness of the area, almost all cultures from Sabang to Merauke have traditions in the process of pregnancy, labor, and the birth of a baby. 17he belief of the community to practice taboos based on cultural conceptions is the embodiment of the society concerned as regards a parent's concern for their children, especially posterity as the future generation of the family.Abstinence, or prohibition, was a means for parents in the past to pass on traditional values that are cultural heritage from one older generation to the next.In the past, children as a young generation would be more afraid of supernatural things that did not necessarily happen or the truth than of things that seemed real.Indeed, there are negative and positive sides, both good and bad, to practicing taboos based on traditional beliefs.A problem that has a significant impact on a woman during pregnancy is obeying taboos, especially not consuming particular types of food, which becomes a nutritional problem.The activities of the pregnant women in their daily lives are not reduced; besides, they must undergo taboos so they do not consume the types of food that are actually needed by a pregnant woman for the health of the mother concerned and the growth and development of the fetus they contain.The lack of energy intake from food will certainly have a negative impact on the health of the mother and the fetus she contains, due to trust and taboos around particular foods.In that manner, it is not unexpected that anemia and malnutrition in pregnant women are relatively high, especially in areas where the community firmly upholds traditions and cultural values related to various taboos enforced on women when they are pregnant. 19ach region has different customs for dealing with or controlling pregnant women.Pregnancy and childbirth are considered crisis phases that must be endured.This phase is considered a dangerous one that can be life-threatening, so it is necessary to carry out traditional ceremonies or obey taboos so that babies and mothers are safe.Indirectly, if the individual lives in an environment that has high values and norms of custom, the greater the impact on the shaping of the individual's behavior.Therefore, individuals will become more obedient to the norms and beliefs of the local area.Moreover, customs and culture play a great role in shaping perceptions and attitudes among their adherents.Individuals who adhere too firmly to norms and beliefs may find it difficult to embrace new things, even if the things they adhere to are not in accordance with logic or developments in science and technology.New things that go against culture and customs may be rejected immediately, even if there are theories that can already be accounted for.For example, there are several pregnancy myths, which in this study are divided into four parts: food abstinence, abstinence from deeds, elders, and ceremonies. 19In addition, there is a relationship between food restrictions from culture and the nutritional status of pregnant women; pregnant women who have food restrictions from culture tend to experience malnutrition.This is due to the culture of giving particular food restrictions to pregnant women, especially in the first trimester of pregnancy, in which these taboo foods are nutritious and provide nutrients needed by pregnant women during pregnancy, especially in the first trimester of pregnancy, for the growth and development of the baby.With these restrictions, pregnant women may become malnourished because they do not consume nutritious food. 20Furthermore, there are still pregnant women who believe that if a pregnant woman eats rice crust, it will cause difficulty in the baby's birth during labor; if she eats rice on a small plate, it will cause difficulty in giving birth; and if a mother eats fish, it will cause her breast milk to become fishy. 21ccording to Djonis (2015), there is a relationship between knowledge and utilization of healthcare services, in this case, antenatal care (ANC).Knowledge is something that is needed in order to change the way we think and behave.Moreover, knowledge is a person's ability to reexpress what they know in the form of a response, either orally or in writing.Knowledge is also an important domain in a person's actions or behavior.Behaviors based on knowledge will last longer than those that are not. 16The level of knowledge a pregnant woman has about the importance of antenatal services in preventing and early detecting obstetric health problems affects her thinking patterns about ANC visits.For mothers who have a high level of knowledge, antenatal visits are not merely to fulfill responsibilities but become a necessity. 22The initial antenatal visit on time will be very decisive for the following visit so that the midwife can monitor the health of the mother and fetus properly through the frequency of more frequent maternal visits. 23All inherited cultures tend to change but are sometimes perpetuated.Furthermore, there is a dynamic process that encourages the embracing of new concepts and ideas, and there is another that encourages the preservation of the stability of the existing culture.When change occurs, the process of constructing new ways under the impact of social change happens practically concurrently with the destruction of traditional values, beliefs, roles, and responsibilities in education, family, and others.These new values and rituals replace the old values and rituals.However, compromises occur in some societies when new values and rituals are practiced while preserving older ones. 24he community still uses culturally-based pregnancy care practices, such as food taboos, prohibitions, and recommendations for behavior and rituals or ceremonies during pregnancy.These traditions or cultural aspects are generally inherited from their parents; however, nowadays pregnant women are now allowed to make decisions about what to do or refrain from doing in relation to such myths or cultural traditions.Moreover, health workers must be aware of some local wisdom, such as cultural values, traditions, customs, and beliefs related to pregnancy, in order to provide culturally sensitive care.In addition, it is important to maintain local wisdom that has a positive impact on pregnancy, such as the traditional ceremony commemorating the seventh month of pregnancy, which increases the social interaction factor of the community while serving the social function of monitoring and caring for pregnancy and childbirth. 25ccording to Amdad (2018), because of their previous experiences, pregnant women seek midwives' assistance with childbirth.Pregnant women who get pregnancy assistance from midwives will continue to get assistance from them.Moreover, pregnant women do not consider whether or not their current pregnancy is high-risk.Furthermore, pregnant women choose public health centers over midwives as their second option for delivery services, and the last one is hospitals.If the results of observations and follow-up examinations performed by the midwife and public health center do not indicate any improvement, then they must be referred to a hospital.At the public health center, midwives or health workers provide pregnant women and their families with information and some medical measures to minimize the risks. 26In addition to these actions, there are three methods of treatment, including: lay sector treatment (self-medication) carried out by pregnant women against complaints of illness during pregnancy is to buy medicine at stalls or markets and rest at home; traditional sector treatment, which is traditional birth attendant treatment, involves touching the pregnant woman's belly to find out and improve the location of the fetus and the condition of the baby and giving prayer water; and medical professional sector treatment, which is a treatment carried out by health workers at public health centers and hospitals.Due to the trust factor and being considered experienced, pregnant are more likely to seek sources of treatment information from their parents or in-laws. 27In addition, some pregnant women still do not follow the procedure for antenatal care when looking for health services in the traditional sector (traditional birth attendants) or the professional sector (health workers), which has an impact on the quality of health services for pregnant women. 28regnant women tend to adhere to traditional beliefs without knowing the logical reasons behind these restrictions.These beliefs or prohibitions are believed to protect mothers and babies during pregnancy, but they can also put mothers and babies at risk of deficiencies in essential nutrients such as protein, fat, vitamins, and calcium.For example, iron is essential for fetal growth and development, as is nutrition for pregnant women.Adherence to traditional birth attendants and a lack of knowledge lead to low utilization of antenatal care and a tendency to not receive it. 29Moreover, the early detection of various abnormalities associated with pregnancy makes antenatal examination or supervision beneficial.Therefore, steps can be taken into account and prepared for childbirth assistance.Furthermore, antenatal care has significant advantages since it can identify various risks and complications of pregnancy so that pregnant women can be directed to get referrals to hospitals.The benefits of antenatal care for mothers include reducing and enforcing early pregnancy complications, maintaining and improving the mental and physical health of pregnant women to face childbirth, improving maternal health after delivery, and facilitating breastfeeding.In addition, counseling on the use of family planning contraceptives, providing advice and instructions on different pregnancy-related problems, and attempting to classify pregnancies with risk factors or high risk will determine safe delivery assistance. 30n important factor that has an impact on the utilization of antenatal care services is the support from the surrounding environment for seeking health care services.Moreover, people still hold the prevailing belief that men have the right to make all family decisions since they are the head of the household.Women's opinions are often disregarded in making decisions related to medical action due to the condition of women who are considered weak (because of their pregnant physiques).Therefore, a mother must get the approval of her husband or inlaws before having any antenatal care examinations.The autonomy of married women in making decisions about seeking and utilizing health services is still very low.Mothers must obey the decision-makers in the family with regard to sources of financial and logistical support.Therefore, the need to seek health care must first be acknowledged by the head of the household.In addition, permission from at least two family members, specifically the husband and parents-in-law, is required before seeking and utilizing health services. 31omen's pregnancies are considered natural and normal.Some people are unaware of the risks to the mother's and fetus's health; thus, the mother continues to carry out strenuous activities without paying attention to her condition.In addition, there is also the myth that it is better to conceal young pregnancies since doing so increases the possibility of a miscarriage.Furthermore, the number of traditional birth attendants is still large in certain areas because women choose to give birth with one because they feel more comfortable and have an advantage.The practice of midwives monitoring pregnant women who still give birth with traditional birth attendants has to be addressed.There is still a large number of non-medical workers (traditional birth attendants) in society that cannot be ignored; instead, they must be empowered in aspects that do not conflict with medicine.For example, being companions for pregnant women (if the pregnant woman desires), accompanies them for examinations, and refers them to midwives, forming a mutually beneficial symbiotic relationship between midwives and traditional birth attendants.In addition, it is necessary to increase health promotion activities and improve effective communication between health workers and traditional leaders in order to bridge the acceptance of health programs and integrate cultural beliefs with professional health practices through the search for alternative problems rooted in socio-cultural factors.

CONCLUSION
The health-seeking behavior of pregnant women in Indonesia is influenced by factors such as maternal education, health professionals, the place of antenatal care, the residential environment, and social status.Some of the methods used by the community to seek treatment include self-treatment, traditional treatment, and medical treatment.Furthermore, some pregnant women are still comfortable choosing traditional birth attendants as their healthcare providers.In addition, it is necessary to optimize the health service programs for pregnant women equally and conduct public education regularly to increase knowledge and improve the health status of the community, especially pregnant women's health.Moreover, in order to make changes in attitudes and behaviors related to pregnancy and childbirth health, health workers must adopt an effective communication approach that is implemented synergistically and continuously.Service providers and health workers need to understand the symbolic meaning contained in each element of culture so that they can make changes in an appropriate and adaptive way while still respecting the good values contained in every aspect of culture.It is also necessary to improve the competence of health workers in order to communicate effectively when providing health services.It is expected that with effective communication, health workers would be better able to maintain an intensive approach to foster public trust and educate the public about myths or traditions that may or may not be followed.

Table 1 .
The summary of the included studies