RABOAN - Kajian Etika Perawatan Maternal dalam Budaya Lokal

Main ideas / lessons (ethics of maternal care in local culture)

• Indonesia’s cultural diversity shapes pregnancy, childbirth, and postpartum practices—not only through beliefs and customs, but also through day-to-day support for mothers and families.
• Cultural practices can be supportive, offering emotional security, identity, family roles, social solidarity, and transmission of experience across generations.
• But cultural practices can conflict with maternal and fetal safety, autonomy rights, and best interests—creating ethical dilemmas for health workers.
• The core ethical stance presented is: respect culture and local wisdom while making maternal/fetal safety a non-negotiable limit, using evidence-based healthcare.
• Health workers are urged to shift from a judgmental “reject tradition” approach to listening, dialogue, empathy, and risk categorization, then integrating safe cultural elements into healthcare.

Concepts emphasized

• Integration rather than choice: health services should not frame the dilemma as “culture vs. science.” Instead, combine socio-cultural support with modern medical systems centered on the pregnant woman.
• Culture as a strategic partner: tradition is not automatically an enemy; it can be a “social resource” if handled appropriately.
• Maternal safety as top priority
  • WHO data mentioned: around 260,000 maternal deaths due to pregnancy and childbirth (described as ~712 deaths per day).
  • Maternal mortality is described as multidimensional, influenced by interacting determinants such as social/economic factors, access to transportation, decision delays, and clinical conditions.
• Autonomy with support
  • Autonomy is framed as the mother’s right/voice and consent remaining central.
  • Autonomy does not mean isolation; it includes voluntary informed participation supported by family and environment.
• Ethical principles as “compass” (five principles listed):
  1. Autonomy – respect the mother’s right to participate and decide.
  2. Beneficence – focus actions on benefit/good for mother and future.
  3. Non-maleficence / safety efficiency – prioritize safety.
  4. Justice – fairness regardless of social/economic/cultural status.
  5. Respect & dignity – privacy, confidentiality, and humane care.

Methodologies / frameworks / step-by-step instructions (as taught)

A) When tradition meets safety: how to respond (behavioral approach)

• Do not reject all traditions outright.
• Listen first: understand the reasons/meaning behind a practice.
• Use dialogue and empathy to align culture with medical safety.
• Categorize cultural practices by risk:
  • Safe: support/facilitate.
  • Needs modification: negotiate and adjust (e.g., frequency, ingredients, medical compatibility).
  • Unsafe: clearly convey risks and proceed with medical intervention (safety is non-negotiable).

B) Three illustrative clinical cases and how ethics is applied

Case 1: Nutritional taboos (e.g., pregnant women avoiding high-protein foods)

• Ethical dilemma: respect family beliefs without harming fetal health.
• Recommended steps (in the talk’s sequence):
  • Gather facts (what deficiencies occur).
  • Identify nutritional gaps.
  • Find culturally acceptable alternatives that preserve daily nutrition.
  • Continuously monitor nutritional adequacy.
  • Maintain close family communication and involvement.
  • Provide education and a warm, non-judgmental dialogue.
• Key point: provide proper steps rather than simple bans or approvals.

Case 2: Emergency / severe postpartum hemorrhage (or similarly critical conditions)

• Ethical issue: delay from traditional treatments can be fatal.
• Persuasive communication is required while respecting autonomy.
• Five steps for emergency decision-making (as presented):
  1. Explain firmly but without judgment the medical condition.
  2. Report emergencies honestly and responsibly (avoid blaming family).
  3. Explain consequences of delay (increased risk of complications).
  4. Rapid referral: coordinate decisions to save mother and fetus.
  5. Document every decision and maintain continuous care planning.
• Additional note: create agreements/refusals for actions as part of ethical/legal responsibility.

Case 3: Use of herbal/complementary medicine during pregnancy (e.g., herbs for back pain)

• Ethical issue: “natural” does not automatically mean safe/scientific.
• Recommended approach:
  • Listen without judging first.
  • Ask key questions:
    • Purpose of herb use
    • Evidence/scientific basis
    • Potential side effects
    • Whether it conflicts with medical safety
  • Perform risk–benefit assessment.
  • Provide evidence-based education.
  • If used, it must be wise and safe, aligned with evidence-based standards (ingredients and dosage).

C) Seven-step framework for ethical clinical decisions

1. Listening – concerns and hopes, without rushing to judge.
2. Clarification – identify medical facts and the patient’s values.
3. Assess risks – evaluate medical and psychological impacts.
4. Explain evidence – use language the patient can understand.
5. Negotiation – seek win-win options between best medical options and patient preferences.
6. Conscious decisions without coercion.
7. Approval + documentation + continuous evaluation – get agreement from patient/family, document process, and continuously improve.

D) Communication guidance: what to avoid and what to do

• Avoid confrontational rejection phrases, such as:
  • “Mother is wrong” / “If you follow tradition you don’t understand health.”
• Avoid statements that judge or disrespect, because they can close access to care.
• Use a collaboration strategy:
  • Ask reasons for practice.
  • Discuss benefits and risks.
  • Offer safe alternatives.
  • Agree on emergency plans if the condition changes.

E) Maternal care strategy: culture-based service model (six strategic steps)

1. Identify and assess cultural practices (supportive/neutral/risky).
2. Joint design with mothers, families, community leaders (co-create solutions).
3. Communication + information + education (KIE) using understandable language.
4. Prepare referral pathways for fast/safe access while respecting cultural values.
5. Integrate services: combine medical care with traditional/community support when appropriate.
6. Monitoring and evaluation: continuous improvement using feedback.

F) “Non-negotiable” boundaries: reasons certain traditions should not be bargained away (five reasons)

• Non-negotiable safety in serious risk cases.
• Life-threatening risks to mother/baby.
• Violation of women’s rights to their own bodies (human rights concern).
• Structural inequality when women’s voices are muted (reinforcing disadvantage).
• Actions conflicting with safety, including risks of exploitation/psychological trauma.
• Necessity of clinical intervention: standardized safe medical treatment cannot be replaced in certain conditions.

Q&A themes from participants (how collaboration is framed)

• Traditional birth attendants (TBAs/para ji):
  • Not automatically treated as an obstacle.
  • Viewed as providing continuity of care and strong emotional support, especially when modern health workers are less reachable.
  • Recommended stance: collaborate and treat TBAs as partners, provide training/support, and coordinate care rather than immediately prohibiting them.
• Autonomy in extended-family decision contexts:
  • Even when husband/parents/in-laws influence decisions, the mother’s autonomy and consent should remain central.
  • If culture is safe, it may be supported; if unsafe, health workers must be firm and may need to modify practices or override them for safety.

Speakers / sources featured

Speakers

• Moderator: Ika (from CBM UGM / Bioethics and Medical Humanities, UGM)
• Resource person / presenter: Mrs. Tuti Mei Hartati, SST, MKes, PhD
• Father Kusarianto (participant)
• Mr. Joko Murdianto (FK UNISA participant)
• Romokus (participant; requested to be absent/then listen)

Sources referenced

• WHO (World Health Organization) (used for maternal mortality statistics)