Midwifery 27 (2011) 867–871

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Midwifery
journal homepage: www.elsevier.com/midw

Beliefs, attitudes and behaviours of pregnant women in Bali

Luh Putu Lila Wulandari, MPH, Dra,n, Anna Klinken Whelan, PhD (Associate Professor)b
a
School of Public Health, Faculty of Medicine, Udayana University, Denpasar, Bali 80232, Indonesia
b
School of Public Health and Community Medicine, Faculty of Medicine, University of New South Wales, Sydney, Australia

a r t i c l e in fo abstract

Article history: Objective: to explore beliefs, attitudes and behaviours of pregnant women in Bali, Indonesia.
Received 5 January 2010 Design: descriptive qualitative study using in-depth interviews.
Received in revised form Setting: community health-care centre in South Kuta, Bali, Indonesia.
7 August 2010
Participants: 18 pregnant women aged 20–35 years.
Accepted 24 September 2010
Findings: insights into beliefs and attitudes regarding pregnancy emerged from the analysis. Participants
believed that some foods should or should not be eaten by pregnant women. They believed that vegetables
Keywords: are better than meat during pregnancy. Strong beliefs about traditional herbal remedies also emerged.
Health beliefs Complex beliefs on locus of control were also expressed by the majority of the respondents regarding who
Health behaviours
was responsible for the health and well-being of their infant. Women maintained that they themselves,
Pregnancy
health-care professionals, nature and God were all responsible for the health of their infant. In addition,
Culture
some respondents acknowledged the crucial role of the family for support and advice during pregnancy.
Implications for practice: interventions to improve the quality of antenatal care and pregnancy outcomes in
Indonesia should consider these beliefs and attitudes. Counselling by health-care workers, for example,
might explicitly seek women’s complex beliefs on locus of control, and views on preferences for traditional
remedies and food, especially low meat intake. Involvement of husbands and other family members during
pregnancy and birth should also be encouraged and re-inforced by health promotion programmes.
Community and religious leaders should be engaged to support key messages.
& 2010 Elsevier Ltd. All rights reserved.

Introduction importance of beliefs and views towards pregnancy in determining

Reducing maternal mortality remains a major challenge in
low- and middle-income countries, and is the subject of major
global initiatives such as the Millennium Development Goals
(World Health Organization, 2005). However, it is difficult to gain
accurate data for many countries (Lesley et al., 2004). Causes of
maternal mortality are multifactorial (Ronsmans and Graham,
2006) and are related to poverty, inequalities of risk, lack of access
to services, culture, and health beliefs and attitudes. Recent efforts
have focused on ensuring that interventions are evidence based
and comprehensive (Campbell and Graham, 2006). Understanding
health beliefs has emerged as an important concept in developing
behavioural change programmes since the 1980s (Nutbeam and
Harris, 2004), and is an important factor to consider in reducing
maternal mortality (Withers and Abe, 2005).
Pregnancy is a unique phase in life, and it has been proposed
that the beliefs and attitudes of pregnant women towards their
pregnancy influence whether or not they will use healthy behaviours
(Rosenblatt, 1998). Studies have found evidence regarding the
whether or not pregnant women perform recommended health
actions, such as consumption of iron supplements, folic acid intake,
prenatal testing, attendance at prenatal classes, adherence to other
prenatal health guidelines, and health-care utilisation (Labs and
Wurtele, 1986; Tinsley, 1993; Rice and Naksook, 1999; Phoxay et al.,
2001; Haslam et al., 2003). Studies have also documented the role of
beliefs in inducing behaviour that is of medical concern, such as
eating soil during pregnancy (Geissler et al., 1999) and prenatal
smoking (Haslam and Lawrence, 2004).
Although pregnant women’s beliefs and attitudes concerning
pregnancy are very important, few studies have been undertaken in
Indonesia to explore these issues. As part of a study investigating
women’s adherence to iron supplementation in pregnancy in Bali,
health beliefs and attitudes were explored, including diet, traditional
medicines and fetal locus of control. This paper describes findings
from the qualitative interviews with Indonesian pregnant women to
explore their beliefs, attitudes and behaviours regarding pregnancy.

Methods

n
Corresponding author. A comprehensive theoretical model from the World Health
E-mail address: putuwulandari@yahoo.com (L.P.L. Wulandari) Organization (2003) identified five inter-related factors that

0266-6138/$ - see front matter & 2010 Elsevier Ltd. All rights reserved.
doi:10.1016/j.midw.2010.09.005
868 L.P.L. Wulandari, A. Klinken Whelan / Midwifery 27 (2011) 867–871
influence medication adherence behaviour: socio-economic,
health-care related, condition related, therapy related and
patient related. Each of these factors was investigated in a
mixed methods study in Bali, Indonesia in 2007 (Wulandari,
2008). The study was conducted in the subdistrict of South Kuta,
Bali with a population of 32,796 people, and approximately 446
pregnant women recorded in 2007. The area had the lowest
previously reported adherence rate for iron supplementation in
pregnancy among all subdistricts in Bali, with only 3% of pregnant
women taking iron supplements as recommended (Gunung et al.,
2003). Qualitative research is concerned with how people
interpret their experiences and how they use those interpreta-
tions to guide the way they live. As such, it can help to enrich the
facts and figures produced by quantitative research. This paper
reports on the qualitative findings from this mixed methods study
based on in-depth interviews.
In-depth interviews were conducted with 18 pregnant women
exploring their beliefs and experiences regarding healthy preg-
nancy. In-depth interviews were used because this is ‘the most
appropriate method of gathering data when the purpose of the
research is to expose beliefs, perceptions, attitudes, and opinions
that are otherwise hidden in people’s minds’ (Ritchie, 2001,
p. 157). These interviews were used in this study to gain a deeper
understanding and make it possible for the participants to use their
own words to describe these beliefs. It is generally recognised that
in-depth interviews can capture informants’ perceptions in ways
that a survey cannot (Rich and Ginsburg, 1999).
An interview guide was developed prior to the data collection
processes to guide the interview and provide a checklist of topics
that should be asked during the interview. The language and the
sequence of this checklist was not rigid (Mason, 2002), as it was
only intended for use to ensure that all topics to be explored were
covered (Patton, 1987; Ritchie, 2001). The interview guide was
designed with questions around the World Health Organization
model (2003), including information on health beliefs, attitudes
and practices regarding pregnancy, including health-seeking
behaviour and illness during pregnancy, and ideas and practices
about managing healthy pregnancy, focusing on diet and nutrition
as well as fetal health locus of control (Labs and Wurtele, 1986).
Several factors were taken into consideration when choosing
participants for the in-depth interviews in Bali. Although it is
crucial to consider generalisability and representativeness when
planning sampling in quantitative research in this qualitative
study, the sample is chosen to allow the investigator to reach
information-rich cases (Malterud, 2001); thus, purposive
sampling was appropriate. To ensure the richness of the data,
pregnant women with various ethnic backgrounds (i.e. Javanese,
Balinese and Lomboknese) were chosen to participate in
the study.
In-depth interviews took place in the community health care
centre, taking up to one hour. Each interview was audio-recorded
with the consent of the participants, and then transcribed by the
interviewer to protect confidentiality. The transcription was
translated into English and the English version of the transcription
was analysed. The accuracy of translation was improved by
involving the co-investigator with an English-speaking back-
ground who speaks some Bahasa. Content analysis was used to
analyse and interpret the data, which involves ‘identifying,
coding, categorising, classifying and labelling the primary pattern
in the data’ (Patton, 2002, p. 463). The quality of the findings was
improved by member checking at the time of the interview, peer
debriefing with colleagues and the co-investigator, and ensuring
inclusion of contradictory information from participants (Mays
and Pope, 2000; Creswell, 2003), as well as comparison of findings
with previous studies (Geissler et al., 1999). Additionally,
during the coding process, English transcripts were provided to
the co-investigator to cross-check the coding and determine the
consistency of views.
Qualitative research is based on interpretation which necessa-
rily requires input from researchers. The primary researcher
(LPLW) is a young female doctor trained in Bali, who has been
pregnant and received antenatal care in Bali, but has not been
involved in providing care to women in the study sites. The
co-investigator is an English-speaking public health academic
with a midwifery background who speaks some Bahasa.
Written approval was obtained from the Head of the Commu-
nity Healthcare Centre of South Kuta, the Head of the Health
Department of Badung, Bali, and the Human Research Ethics
Advisory Panel at the University of New South Wales, Australia.
Findings
The majority of women interviewed were from Bali, five were
originally from Java and two were from Lombok Island. Most of
the women had been educated to high school level, and their ages
ranged from 20 to 35 years. For most women, the current
pregnancy was not their first. Various issues regarding pregnancy
emerged from the respondents. Major themes which emerged
included beliefs around preferences for foods, preferences for
traditional remedies, a range of views on fetal locus of control,
health-care professionals versus ‘dukun’ (traditional birth atten-
dants), and the role of their husband and other family members
for support and advice during pregnancy.
Beliefs on food preferences in pregnancy
A wide range of beliefs about what types of food should and
should not be eaten during pregnancy was stated. A particularly
important belief was that vegetables are better than meat because
they increase the production and ‘freshen’ the taste of breast milk:
It is better if we eat lots of vegetables. (Woman 13)
Ehmm.. not very frequent [eat meat]. People said that if we are
pregnant, it is better for us to eat fruits and vegetables rather
than eat meat. The breast milk will taste fresh if you eat lots of
vegetables and the baby will like it. If you eat meat a lot, your
breast milk will become a bit sour and of course the baby will
not want it. (Woman 7)
Although vegetables are good for pregnant women, beliefs about
the disadvantages of meat may put pregnant women at greater risk
of developing anaemia in pregnancy, a major problem in Indonesia,
because meat provides easily absorbed iron and promotes iron
absorption in the body (Tapiero et al., 2001; World Health
Organization/Food and Agriculture Organization, 2002). In
addition, diets containing a large amount of certain vegetables,
such as a vegetarian diet, may reduce iron absorption (Schümann
and Solomons, 2007) because the form of iron contained in those
vegetables is relatively difficult to absorb, and some vegetables may
contain factors which inhibit iron absorption (Thompson, 2007).
Beliefs on traditional herbal remedies
In addition to beliefs about food, beliefs about traditional
herbal remedies also emerged. Two respondents expressed strong
beliefs about traditional and modern medicine, and stated a
preference for traditional herbs as being more natural and
without side-effects:
I think both [iron pills and herbal medicine] are important,
aren’t they? I take the herbals regularlyy and I feel that my
 L.P.L. Wulandari, A. Klinken Whelan / Midwifery 27 (2011) 867–871
baby is healthyy that was also what I did in my first
pregnancy. I regularly took the herbalsy and nothing’s wrong
with my baby. In fact, he was very vigorous. (Woman 6)
I believe in both traditional as well as modern medicine. What
I‘ve known is that modern medicine sometimes bring about
side-effects, but traditional herbal doesn’t. It is because
traditional herbal contains bahan alami [natural ingredients].
(Woman 7)
Traditional tamarind and turmeric do no harm to our baby. In
fact, it makes both of us healthier. (Woman 7)
One woman held strong beliefs about taking traditional herbal
remedies during pregnancy because the practice has been passed
down for many generations, and she believed that there were no
associated side-effects:
My mother, my grandmother, my great grandmother had used
this herbal to make us healthier. And it works, without any
side-effects. (Woman 7)
Some of the beneficial traditional herbal treatments men-
tioned included tamarind, turmeric, cinnamon, clove and coconut.
This woman also stated that health-care professionals did not
understand the practice of taking traditional herbal remedies:
I think the midwives might prohibit me to drink it [traditional
herbal]. Health-care workers are always sceptical about
traditional herbal. I know that. (Woman 7)
Health-care workers are always thinking that it is medicine
that will keep us healthy. The truth is, there are many
alternatives we can use to make us healthy. One of them is
traditional herbs. (Woman 7)
Despite their strong beliefs regarding traditional herbs,
respondents admitted that they did not talk openly about this
practice to their midwives, as they believed that the health-care
staff would be sceptical and forbid them from taking the herbs.
Fetal locus of control
Women were asked about fetal locus of control (Labs and
Wurtele, 1986) to provide insights into the design of broad health
promotion interventions. Surprisingly, the women were unable to
express strong views on internal or external factors. When
probed, a range of beliefs was expressed by the majority of the
respondents regarding who was responsible for the health of their
infant. Women said that they themselves were responsible for the
health of their infant (i.e. internal locus of control), but also
believed that God or faith determined the infant’s health. Internal
and external loci of control were indicated as equally important in
maintaining pregnancy. In essence, the women believed that in
order to maintain their infant’s health, they needed to take good
care of themselves, follow health-care recommendations, follow
traditional rituals and pray to God. In many ways, this is
consistent with observed adherence to traditional Balinese
rituals:
We have to take care of our baby ourselves, and we should
follow the recommendation from health expertise, but it is
God who will determine the fate, the health of our baby.
(Woman 4)
Our baby will be healthy if we are taking good care of our baby
during pregnancy. It also depends on how good the health-care
facilities. And last and most importantly, God will determine
whether our baby will be born healthy or not. So I think the
three of them are important. (Woman 2)
869
If we eat enough food, get enough rest, checking our pregnancy
regularly, hopefully everything will be normal. But we have to
also remember that God is one who makes the decision. So it
means that we also have to pray a lot so that everything will be
just fine. (Woman 7)
I think both of them. We have to believe in God; however, we
do have to try our best as welly. (Woman 16)
Don’t forget to check your pregnancy regularly, eat lots of
vegetables so that your milk will taste fresh. Drink traditional
herbals to make you feel healthier, get lots of walking so that it
will be easier for you to give birth, lots of prayer so that God
will help you throughout your pregnancy. (Woman 18)
Respondents believed that some traditional rituals that should
be avoided were funerals, weddings and going outside at night.
Interestingly, although they did not understand the real
meaning of the rituals, they followed them without question for
the sake of their infant. One woman indicated that she felt
uncomfortable if she disobeyed these rituals:
Yesyof course we have to believe ity in our culture, it is
forbidden for pregnant women to attend marriage ceremonies.
Whether I don’t know whyy but I think it is better if we just
follow what our parents sayy. (Woman 1)
Furthermore, because these rituals have been passed on from
generation to generation, pregnant women believed that unless
they were followed, the health of their infant would be adversely
affected.
All these views around pregnancy seemed to influence
pregnant women’s decisions about how to manage healthy
pregnancy.
Midwives versus traditional birth attendants
Another theme that emerged during the interviews was about
choice of birth attendant. Although women expressed positive
views about traditional herbal medicines, none of them were
using traditional birth attendants. Two women mentioned their
positive views about midwives rather than traditional birth
attendants:
I only go to midwives. I never believe in dukun [traditional
birth attendant]. (Woman 9)
Of course to the midwives. I never believe in dukun. Some-
times they have strange methods to handle our pregnancy. It’s
better if we just believe in health-care professionals.
(Woman 7)
However, this finding should be interpreted with caution as
women not attending midwives’ clinics were not included in
the study.
Important role of husband and other family members
Some respondents indicated the crucial role played by the
family for support and advice. This advice ranged from informa-
tion about the signs of impending labour to tips for caring for the
infant:
I ask my parents about what the symptoms of in labour arey
and then they told me the signs like pain in the backy, blood
or fluid from vaginay. (Woman 1)
It will be a lot easier for me, because they [parents] have more
tips about caring the baby. (Woman 7)
870 L.P.L. Wulandari, A. Klinken Whelan / Midwifery 27 (2011) 867–871
Sometimes when he [husband] ask me to take the iron tablets
and explain that it’s for the sake of the baby’s health, that’s
when I thought that I have to take the tablets so that my
husband might feel happy about it. (Woman 8)
Pregnant women admitted that they took their family’s advice
without question because they trusted them. They also admitted
that they followed their advice because they wanted their family
to be happy with them.
Discussion
Limited attention has been paid to pregnant women’s beliefs
about healthy pregnancy in Indonesia. By conducting in-depth
interviews, various beliefs about managing pregnancy emerged
from the current study. Participants believed that there were some
foods that should or should not be eaten by pregnant women.
Although some of these beliefs were culturally understandable,
unfortunately some of them implied a lack of understanding of the
diversity and quantity of food needed to provide the required level
of iron in pregnancy. For example, some participants reported a
preference for vegetables over meat, but the opposite is recom-
mended, particularly where anaemia in pregnancy is prevalent.
Meat is recommended during pregnancy because it contains haem
iron which can be absorbed easily. Although some vegetables are
iron rich (such as broccoli and spinach), certain vegetables may
contain non-haem iron which is less well absorbed and may
contain factors which inhibit iron absorption.
Similarly, some pregnant women also expressed a preference
for herbal remedies over modern medicine as they were more
‘natural’ and less likely to have side-effects. This finding contra-
dicts research findings in Pemba Island, Africa (Young and Ali,
2005) in which pregnant women feared traditional medicine and
considered that it might have adverse effects on their infant. In
the current study, although not all women acknowledged the use
of traditional herbal remedies, all were familiar with them, and
argued that these remedies were natural and without side-effects.
This preference for traditional medicine is a concern in this study,
as it has been suggested as a factor that contributes to non-
adherence to recommendations given by health-care providers
(Galloway et al., 2002). It is also a concern that women believed
that health-care workers would be sceptical about their use of
traditional herbs, resulting in their not being able to discuss this
openly with their health-care providers.
The findings about avoidance rituals were similar to a previous
finding in Pemba Island, Africa in which pregnant women believed
that staying at home after dark would protect them from bad spirits
which could harm their infant (Young and Ali, 2005).
Pregnant women expressed difficulty in choosing between an
internal and external locus of control in determining the health of
their infant. They believed that they themselves, plus God and
nature were all responsible for the health of their infant. Putting a
significant value on the role of nature in the health of an infant is a
concern in this setting due to the fact that it may have a negative
influence on decision making during pregnancy. The role of beliefs
about fate and nature which negatively influence decisions to
engage in healthy behaviour during pregnancy is reported in a
qualitative study among Thai women (Rice and Naksook, 1999).
This study found that strong beliefs about the role of chance in
determining the health of an infant had discouraged pregnant
women from undergoing prenatal testing. However, in the
present study in Bali, women also acknowledged that their own
behaviours influenced the health of their infant, rather than
external factors alone.
The role of a spouse and/or family member in managing
pregnancy was also apparent. Pregnant women acknowledged that
emotional support and advice from their spouse and parents were
among the factors that contributed to their intention to manage
healthy pregnancy. This is supported by studies in Malawi (Aguayo
et al., 2005), Nigeria (Ejidokun, 2000) and Vietnam (Aikawa et al.,
2006), which found that the majority of pregnant women were
encouraged and supported by their husbands or other family
members during pregnancy. In fact, a meta-analysis on adherence
by DiMatteo (2004) noted a strong correlation between the
presence of practical and emotional support from family
members and adherence to health recommendations.
Despite the small number of participants, this study provides a
deeper understanding of women’s views and experiences about
pregnancy, as the information was gained through their own
opinions and expressions. Some women reflected a lack of ‘modern
scientific’ knowledge about healthy pregnancy, which is a concern
due to the possible counter influence on recommended health
behaviours during pregnancy. Strategies to enhance the quality of
care for pregnant women and improve pregnancy outcomes should
address this conflict in knowledge systems. Counselling by health-
care workers might explicitly seek women’s views on preferences
for traditional remedies and food, especially low meat intake. It
should account for, and tap into, women’s views on what is
perceived as healthy food during pregnancy. Counselling should also
include information about side-effects that might result from the
use of natural herbs. The importance of an internal locus of control
in influencing pregnant women in managing healthy pregnancy
should be encouraged and re-inforced, while not denying the value
of external beliefs. Tailoring client-centred education programmes
with regard to women’s views on managing healthy pregnancy
could enhance the quality of antenatal care programmes and
women’s adherence to health recommendations during pregnancy.
Considering the significant involvement of husbands and parents,
health promotion programmes targeting them would also be useful.
Involvement of husbands and other family members during
pregnancy should be encouraged and re-inforced by health promo-
tion programmes. In addition, due to the fact that many pregnant
women expressed the importance of faith and religion in their
pregnancy, involving community and religious leaders in the health
promotion programme for pregnant women could improve the
effectiveness of behavioural change campaigns. Community and
religious leaders should be engaged to support key messages.
This study is not without limitations. The main limitations of
this study are those that generally exist in conducting in-depth
interviews with small numbers, although all attempts were made
to minimise the impact of these factors. Although the findings
[regarding preferences for specific foods, preferences for tradi-
tional remedies, complex locus of control, midwives versus dukun
(traditional birth attendants), and the role of husband and other
family members for support and advice during pregnancy] cannot
represent perceptions of all pregnant women in Indonesia due to
the limited sample size and qualitative methods used to elicit the
information, it is not the aim of qualitative inquiry to provide
generalisable findings. However, the qualitative findings of this
study provide a deeper understanding of women’s views and
experiences about managing healthy pregnancy. Further studies
may find it useful to quantify these beliefs and attitudes. In
addition, considering the wide popularity of herbal remedies,
such practices warrant further investigation.
Acknowledgements
The authors would like to thank the pregnant women who
participated in this study, and the Community Healthcare Centre
of South Kuta, Bali. The authors would also like to acknowledge
the meticulous qualitative expertise of Associate Professor Jan
 L.P.L. Wulandari, A. Klinken Whelan / Midwifery 27 (2011) 867–871
Ritchie and Ms Sally Nathan from the School of Public Health and
Community Medicine, the University of New South Wales, and
thank them for their assistance and comments on this study. This
study was supported by an Australian Development Scholarship
kindly provided by the Government of Australia.
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