Maternity Services and the Role of the Traditional

Birth Attendant, Bidan Kampung, in Rural Malaysia

Aishah Ali and Philippa Howden-Chapman
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his study was undertaken to explore the roles played

by bidan kampungs and understand their contribution to
rural Malay women during pregnancy and childbirth. One
hundred sixteen pregnant women, 13 Western midwives, and 12
bidan kampungs were recruited using convenience and snowball
sampling. Data were collected from focus groups, in-depth
interviews, field notes, and observations. The findings indicated
that although the women were happy to have Western maternity
care, they valued the social and spiritual support received from
bidan kampungs during pregnancy and postnatal care. Western
care was considered useful for modern illnesses. The
traditional maternity care that women received included pantang
or ritual prohibitions that helped them through pregnancy and
helped them achieve better postnatal recovery. The study
indicates that there is a need to combine Western and traditional
care for the benefit of the pregnant women and their infants
health.

fashioned and behind the times because such practices do not fit in with the modern medical technology.
In recent years, Western medical technology has been
accepted as a necessary driver leading to the evident
improvement in maternal and child health indicators.
This acceptance is also enabling clinicians to be more in
control of the medical system in Malaysia. Other maternity providers, particularly traditional birth attendants, bidan kampungs, are no longer commonly used.
This technological advancement is more apparent in
urban areas. Many urban women now prefer to have
medical care and hospital births under the care of specialists in modern facilities. However, women in rural
areas do not have the same opportunity to benefit from
these modern facilities. They maintain strong beliefs in
traditional customary practices. Most rural women still
choose to balance the medicines offered by the Western
providers with the care provided by bidan kampungs.

KEY WORDS: bidan kampung, maternity care, pregnancy,

The work of bidan kampungs was formally recorded in

the 1960s and 1970s, through writings by Chen,1,2 a doctor, and journalists Alhadi3 and Osman,4 who focused
more on spiritual care. Chen1,2 and Abdul Halin,5 an
anthropologist, assessed the work done by bidan kampungs on pregnant women during pregnancy and confinement with a focus on the sociocultural aspects and
collaboration with Western providers at a time when
there was a shortage of trained midwives and when
bidan kampungs conducted 40 percent to 80 percent of

traditional practices

Malaysia is a developing nation undergoing rapid

growth. Over the last two decades, there has been a
significant investment in medical technology and infrastructure, which has improved the health status of
the population. Womens health is one of the priorities
of Malaysias healthcare system. The advancements in
medical technology have in turn changed the status of
traditional customary and ritual pregnancy practices.
The changes have also made homebirth, when most
pregnancy rituals take place, unpopular. Women who
practice pregnancy rituals are embarrassed and reluctant to discuss them in great detail with their medical
providers. Traditional pregnancy rituals are seen as old-

J Public Health Management Practice, 2007, 13(3), 278286

Copyright 
C 2007 Wolters Kluwer Health | Lippincott Williams & Wilkins

278

Bidan Kampungs in Malaysia

Corresponding author: Aishah Ali, PhD, MPH, RN, SCM, PHN, Kulliyyah (Faculty) of Nursing, International Islamic University Malaysia, PO Box 141, 25710
Kuantan Campus, Kuantan, Pahang, Malaysia (e-mail: aaliwnmeds@yahoo.com;
aaliwnmeds@hotmail.com).

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Aishah Ali, PhD, MPH, RN, SCM, PHN, is Lecturer and Assistant Professor,
Kulliyyah (Faculty) of Nursing, International Islamic University Malaysia, Kuantan,
Pahang, Malaysia.
Philippa Howden-Chapman, PhD, DipClinPsyc, is Professor of Public Health,
University of Otago (Wellington), Wellington, New Zealand.

Maternity Services and the Role of the Bidan Kampung in Rural Malaysia

the births in rural areas. At that time, the Ministry of

Health realized that bidan kampungs were an essential
part of rural womens health. A training program was
conducted for them in the early 1970s under the initiative of the National Family Planning Board and the
Ministry of Health. Bidan kampungs were registered, received certificates, and given delivery kits on completion of 3 weeks training. Three aspects of care taught in
the training were cleanliness, conducting a proper delivery, and use of family planning methods. They were
asked to encourage rural women to use family planning methods, particularly the pill, and this initiative
was successful.6,7
The training was discontinued in 1979 in most parts
of Malaysia, and gave way to modern medicine. Another reason for stopping bidan kampung services was
the claim that they performed bad practices that
caused harm to pregnant women and their infants.8
One of the factors that cause Western providers to dislike bidan kampungs is that they do not use the germ
theory.9,10 However, bidan kampungs do believe that one
of the causes of illnesses is microorganisms as well
as physical factors such as certain foods that are hot
and cold, physical trauma, air (wind), and supernatural causes.9,10
Today, only selected groups of bidan kampungs or
community aide workers, mainly among the Aboriginal groups and states where population is scarce, are
trained using a guidebook prepared by the Family
Health Development Division. In most instances today, bidan kampungs are not recognized as legal maternity care providers by the medical system. However,
they remain maternity care providers to rural pregnant
women because of the ongoing shortage of health personnel and the social services they provide. Indeed, the
number of bidan kampungs has increased. In 1976, there
were 3,000 bidan kampungs, of whom 1,888 were registered after receiving training.11 The latest figure on
the number of bidan kampungs is from 1997, when they
numbered more than 5,000.12 In most rural areas, bidan
kampungs outnumber the Western-trained personnel.

Bidan Kampungs and Pregnancy Rituals

Bidan kampung practices were strongly influenced by
Hinduism when the Hindu culture was brought into
Malaysia in the early centuries until about 1400. The
Hindu culture was animistic in nature and was well
accepted as the local culture by the Malay. When Islam came, there was assimilation between Islamic beliefs and the Hindu culture. Through these cultures and
beliefs, the traditional healthcare system was developed. The traditional healthcare system practiced by
the Malay used bomoh, a medicine man, for general illness and bidan kampungs for pregnancy and childbirth.

279

Bidan kampungs use herbs and animism to safeguard

their practices and to treat and protect their clients from
evil spirits and ghosts. The animistic practices are usually delivered through incantation. The practice of pantang, prohibitions, and pregnancy rituals are the expertise of bidan kampungs, who remain popular figures.

Maternal and Child Health Statistics

In 1996, Malaysias infant mortality rate was 9.1/1,000
live births, which dropped to 6.3/1,000 live births in
2001.13,14 The maternal mortality rate, which has been
monitored since 1947, has also dropped significantly
over the past decades.15,16 In the 1990s, the maternal
mortality rate was down to 0.2/1,000 live births. It then
rose to 0.53/1,000 live births in 1996 and dropped again
to 0.3/1,000 live births in 2001.14,17 The main cause of
maternal mortality in Malaysia is the same as that in
other developing countries, that is, hemorrhage (postpartum and antepartum).
There have been an increase in the number of hospital births, which the ministry categorizes as safe
births, and a reduction in the number of homebirths.
Women admitted for normal deliveries occupied most
hospital beds in the 1980s and 1990s.13 More mothers gave birth assisted by trained health personnel,
and deliveries conducted by bidan kampungs reduced
markedly.16 Despite the reports of safe deliveries,
complications resulting from pregnancy were the second most common reason for admission to government
hospitals, next to normal delivery at 11.1 percent and
11.9 percent in 1990 and 1995, respectively.13,18

Materials and Methods

The study started in December 1997 and continued until 1999. It was part of the PhD thesis that the first author (A.A.) undertook at the University of Otago, New
Zealand. She visited the project site on three occasions
and spent a total of 8 months in the area. This study was
undertaken to explore the roles played by bidan kampungs and understand their contributions to womens
health in the rural area. Twelve bidan kampungs,
13 government midwives, and 116 pregnant women
participated in the study. Pregnant women were
divided into two groups, 58 in each group. The government group received maternity care from government providers only, whereas the combined group
received care from both government and traditional
providers. Providers were from 11 primary health centers and from community clinics situated in a rural district in the south of Malaysia. Convenience and snowball sampling techniques were used in recruiting the
participants.19 Data collection methods included focus groups, individual in-depth interviews, participant

280 Journal of Public Health Management and Practice

observations, and field notes. A total of 20 focus groups,
each comprising 5 to 10 participants, were conducted,
with 17 pregnant women groups and 3 government
midwives groups. Bidan kampungs were interviewed individually because of dissimilarities in their practices.
Observations were made on the activities at and around
the clinics, bidan kampungs houses, and the women
during their clinic visit and during the interview sessions. These observations were made throughout the
data collection period in every community clinic. The
field notes included the daily activities and events attended and observed. Data were analyzed thematically
using Nudist for the interviews and Epi-Info 6 for demographics of the participants.

Results
Data from the different strands of data collection were
triangulated to test the robustness of the analysis and
any discrepancies noted. Most participants were Malay,
with two Chinese and three Indians. The government
group comprised 90 percent Malay (n = 52), who were
Muslim, and 10 percent Chinese (n = 6) and Indians.
All women in the combined group were Malay. All the
women were married. Most of the pregnant women
were aged between 21 and 35 years, 84 percent (n =
49) in the government group and 91 percent (n = 53) in
the combined group. The youngest was a 19-year-old
woman in the government group. The oldest was
a 45-year-old woman in the government group. No
age difference was identified between the two groups
(P = .75). The longest duration of marriage was 27 years
(2.296; P = .13). More women from the government
group (n = 21, 47%) than from the combined group (n =
10, 17%) (Kruskal Wallis score = 0.04; P = .83245) were
pregnant with their first baby. Most women were expecting their second child. At the time of the interviews,
most women were in their third trimester: 59 percent
(n = 34) in the government group and 67 percent (n =
39) in the combined group (P = .31; 2 = 2.37). Apart
from four women, most women had completed secondary school education, with 62 percent (n = 36) and
50 percent (n = 29) from the government group and
the combined group, respectively. Sixty-nine percent
(n = 40) of the women in the combined group and 48
percent (n = 28) in the government group (P = .0236;
2 = 5.12) were housewives. Table 1 shows a summary
of the demographic backgrounds of the pregnant
women.
The age of the government midwives ranged between 36 and 55, with the majority being 36 or 45
years old. Most of the bidan kampungs were 65 years
and older. Educational levels were higher among the
government midwives. Twelve government midwives
had completed secondary school education, whereas

TABLE 1 Demographics of pregnant women (N = 58)

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Year of marriage
05
610
1115
1621
21
Mean
Number of children
First pregnancy
24
5
Gestational age
First trimester
Second trimester
Third trimester
Occupation
Housewife
Factory worker
Other

Values

Government group

Combined group

35 (59)
10 (18)
10 (18)
2 (3)
1 (2)
5.466

32 (55)
14 (24)
5 (9)
6 (10)
1 (2)
6.621

21 (47)
27 (36)
10 (17)

10 (17)
36 (62)
12 (21)

6 (10)
18 (31)
34 (59)

2 (3)
17 (29)
39 (67)

28 (48)
20 (35)
10 (17)

40 (69)
12 (21)
6 (10)

given are number (percentage).

only three bidan kampungs had some primary education;

the rest had had no formal education. The government
midwives had had 2 years formal training in nursing and midwifery after completing high school education. Bidan kampungs were spiritually trained and
had learnt their skills working alongside other bidan
kampungs.

Antenatal pantang and pregnancy practices

Most pregnant women interviewed practiced a variety of pantang, followed petua, and performed pregnancy ritual ceremony, lenggang perut. The Indians and
the Malays had similar pantang and pregnancy rituals
using somewhat different customs. Although women
practiced pantang and other pregnancy rituals, many
of them believed that the practices conflicted with the
teachings of Islam. However, the women interviewed
felt that they would have better pregnancy outcomes if
pantang were followed. The other reason for following
pantang was to please the elders.
To say I believe in it totally, no, because if I believe in
such a thing is consider syrik. It depends, if I think that
sort of belief can be followed, I will follow, if we can
have good inner strength you dont have to believe in it.
(Pregnant woman, combined group)
If we do not follow (pantang), the elders feel offended
and we will be in difficulty because some pantang are
true. (Pregnant woman, combined group)

Unwritten guidelines about things, activities, and foods that can

or cannot be done/eaten.

Direct translation means swinging of abdomen. It is a pregnancy

ritual performed at the seventh month of pregnancy.

Maternity Services and the Role of the Bidan Kampung in Rural Malaysia

TABLE 2 Pantang mentioned by participants of four

groups
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Pantang
Physical activities
Food
Total
Values

Government Combined Government

group
group
midwives
59 (77.6)
17 (22.4)
76 (100)

80 (71.4)
32 (28.6)
112 (100)

9 (75)
3 (25)
12 (100)

Bidan
kampungs
36 (66.7)
18 (33.3)
54 (100)

given are number (percentage). Chi-square test; P = .57.

according to Malay belief, is very vulnerable being favored by evil spirits because she has a special fragrance
that they love. Attacks by Satan and evil spirits may
harm the woman and her baby, once he or she is born.
The pregnant woman will be possessed and get sawan,
a fit after being disturbed by the evil spirits and Satan.
If she has to come out, it is necessary for her to
carry sharp metal instruments, such as scissors, a small
knife, or a nail, for defense against hostile supernatural
influences.

The types of pantang practiced

There are 46 different types of pantang that are practiced.
Most of the pantang involve daily activities, including
social aspects of life and household chores (Table 2).
The remainder are concerned with food intake. The results showed a dichotomy of prohibitions practiced between the four groups interviewed. Women who received care from both the government midwives and
bidan kampungs practiced more pantang than did women
who received care from the government midwives only.
Similarly, bidan kampungs gave more pantang to women
under their care than did government midwives
(Table 2). The five most common pantang described
by the women were avoiding (1) sitting at the door;
(2) taking a bath at sunset; (3) visiting the dead; (4)
hitting, hunting, or killing animals; and (5) sewing or
crocheting.

For those that want to follow will listen to me. You are
pregnant, do not go out during sunset. If you want to
go out bring a knife. You are pregnant with your first
child. You have good fragrance. Do not sit at the door;
either you stay in the house or outside the house.
(Bidan kampung)

Avoiding visiting the dead

Visiting the dead, according to Malay women, may lead
to strong consequences in the absence of proper protection. A woman who must visit a dead person is advised
to get protection before or after the visit. The protection
is necessary to avoid badi mayat. An example of protection is the use of a particular kind of plant.
She gives me jerangau. It looks like ginger. It grows
well in a farm and near ditches. Recite prayer three
times, bite the jerangau then rub the bitten jerangau at
your joints before visiting the dead. (Pregnant woman,
combined group)

Avoiding sitting at doors

Anthropologically, doors are considered to have a significant influence on the life of the Malay people, especially so for pregnant women. The women reported
that sitting at and going in and out of the door has a significant influence on the pregnant womens well-being
and is not encouraged. The woman is not only not allowed to sit by the door but also must enter and exit
from a separate door. If she enters a house through the
front door, she should go out through the back door.
Failure to follow this pantang will result in prolonged
labor or the baby having difficulty coming out at birth.

Avoiding taking a bath at sunset

Sunset is the time for prayer. Pregnant women must
not do any activity as the sun sets. Two activities are
specifically not allowed during this period: showering
or bathing and going out of the house. Taking a shower
or bathing at sunset will result in kembar air.
At sunset, evil spirits, including Satan in the form
of pelisit, are out looking for prey. A pregnant woman,

Having excess amniotic fluid at the birth of the baby, something

that is considered unpleasant and an embarrassment for the delivering woman.

A spirit that sucks blood. It is a form of ghost.

281

Another method that a woman can use, according to

the informants, is drawing a mark on the abdomen,
using lime or calcium hydroxide, before or soon after
she returns from the visit.
Husbands who visit the dead do not need protection
before going, but on coming home must take a bath
before entering the house. The bath is taken outside the
house with the clothes on. The clothing has to be thrown
away or washed thoroughly.

Avoiding hitting, hunting, or killing (includes

slaughtering/fishing) animals
In specific circumstances, husbands also have to observe certain pantang. For example, they are discouraged from killing, hitting, or hunting animals, including slaughtering chicken, birds, cows, or sheep and fishing. If they want to eat these animals, they can either
buy them or get someone else to do the hunting and
slaughtering. The women must never, under any circumstances, hit or kill animals. If the husband or wife
kills innocent animals, it is believed that the woman will

An illness sustained by a pregnant woman following a visit

made to a dead body without undertaking any protection.
A herb that grows in the wild and is used as a medicine.

282 Journal of Public Health Management and Practice

deliver a malformed or handicapped child. Fishing is
also discouraged to avoid the same outcome.

Avoiding sewing and crocheting

Most rural pregnant women prepare a new set of bedding, including pillows and bolsters, and new outfits
for the new baby. To do that, many of them want to do
the sewing themselves. This practice is usually not encouraged, because sewing requires stitching and closing of the materials, which is indicative of an unopened
cervix at birth, leading to delay in the delivery process.

Food pantang
Food pantang were less frequently mentioned in the interviews; nevertheless, they are equally important. The
main reason certain foods are prohibited is because they
are believed to be hot (not spicy), cold, or causative.
These foods are prohibited usually during the early
stages of pregnancy, but some are also avoided throughout pregnancy and during confinement. Unlike the confinement period, when women are encouraged to eat
hot foods to keep the body warm, during pregnancy
women are advised to do the opposite. The common
hot and causative foods mentioned were pineapple, fermented tapioca or rice, bamboo shoot, and sugarcane
juice. The consequences for not following these pantang
are beliefs leading to abortion, prolonged or difficult
birth, disfigurement or malformation of the baby, and
illness.

Lenggang perut
One traditional ceremony that was practiced by all
pregnant mothers in the study, except the two Chinese
women, was lenggang perut with mandi tian. The ceremony is performed on the pregnant woman at the seventh month of pregnancy. Lenggang perut is the time for
the family to get together and say prayers for the couple
blessed with the pregnancy. Seven is chosen because according to the Malay belief, by the seventh month the
fetus is most likely to survive. The ceremony is usually
performed for the first child only. However, in some
families, the same ceremony is carried out for all pregnancies.
The ceremony starts with the pregnant woman (in
some areas the husbands too) being given a mandi tian.

One of the activities of lenggang perut. This is a shower given

to the pregnant woman either alone or with her husband. Seven
types of flowers are usually mixed in the water, followed by the
mixing of water that has been blessed with the recitation of the
verse Yasin from the holy Koran, and finally the juice of a lemon.

After the shower, a bidan kampung or an elderly woman

will make up the prospective mother. The woman will
then be asked to lie on seven layers of batik-sarung, a traditional sarung for Malaysian women. The bidan kampung, together with other elderly women, will grasp the
top of the sarung and swing it from side to side from
under the woman before pulling it a way. While doing
this, the bidan kampung will recite incantation, in white
magic or prayer. This procedure will be repeated until
all sarungs are pulled out.
Traditionally, following the bath, the bidan kampung
using a raw egg or a coconut will check for the babys
sex. The raw egg or a coconut without its husk is placed
on the womans chest or abdomen while she stands or
lies down. The egg or the coconut is then allowed to fall
to the ground. A broken egg or a jagged-cut coconut
shell indicates a girl, whereas an unbroken egg or a
clean-cut coconut shell indicates a boy.
. . .After that she (bidan kampung or elder lady) put raw
egg on her (pointing her chest) and let it drops. If the
egg breaks the baby will be a girl. Mine was not broken
so I have a baby boy [pointing at her child sitting next
to her]. Therefore I believed in that. (Pregnant woman,
government group)

After the ceremony is completed, the family with its invited guests from the community will have a religious
communal gathering. The common food served at the
communal event is a special rice, called ambang, a type
of traditional mixed rice. The significance of this food
is not known. The ceremony today is not as elaborate
as it used to be. It is more Islamic in nature, with less incantation and more prayers using verses from the Holy
Koran.

Bidan kampungs services

Bidan kampungs treat many illnesses that are considered
spiritual in nature. Alongside, they also treat physical
illnesses such as fevers and coughs (Table 3).
For pregnant women, bidan kampungs main roles
are giving advice and petua, including the practice of
pantang.
Women who choose to have a homebirth will usually
have the government midwife conducting the delivery. However, the delivering woman can request that a
bidan kampung also be present. The bidan kampung provides emotional and moral support to the delivering
woman in the form of prayers and also gives massage
to make the woman more relaxed. She also supports
the family. The government midwives stated that pregnant women were much calmer with the adept bidan
kampung sitting next to them:
To me, the services provided by bidan kampung are
useful. For instance, when I conduct a delivery, the

Maternity Services and the Role of the Bidan Kampung in Rural Malaysia

TABLE 3 Tasks performed by bidan kampung as reported

TABLE 4 Mode of delivery (N = 58)

by midwives and pregnant women

qqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqq

Mode of delivery

Legal accepted
roles
Circumcision of
female infant
Body massage before,
during, and after
delivery
Giving advice

Confirmation of
pregnancy

Reported

Unaccepted and
unknown role
Delivery
Treatment of illnesses:
fever, cough,
urinary problems,
bleeding, and falls
Correcting and
manipulation of the
fetus before the
delivery
Provide information on
the use of family
planning methods

Ritual and
complementary
role to government
health services
Performing lenggang
perut
Bathing of female
corpses

Ritual care of placenta

Female ear piercing

Bathing mothers and
infants after delivery
Liaison officer to
government
providers

only by pregnant women.

woman will be safer when the bidan kampung is around.

The bidan kampung can massage the womans hand, leg
and wash the placenta afterwards. (Government
midwife)

The presence of a bidan kampung is usually complementary to that of the government midwife. She usually arrives first at the womans home and prepares the
hot water and the delivery space. She helps the government midwife by holding a torch light during the
delivery and if and when stitching is required. She will
also do the ritual for cleaning the placenta. After delivery, she will help to clean the mother and bathe the
baby.
With her help our work is a little bit lighter. Bidan
kampung also helps to sponge bath the mother after
delivery. (Government midwife)

Home delivery is very rare today, except in an emergency, or in the absence of trained midwives when bidan
kampungs do attend to delivery. The health authorities do not approve many of the tasks performed by
them, as shown in Table 3. One of the practices that was
strongly disapproved was manipulation of the fetus before the delivery. However, I observed this procedure
to be harmless. A manipulation method used by bidan
kampungs is a gentle body massage using oil, repeated
over a period of 2 or 3 days, or using symbolic gestures
and holy water. Most other tasks were also treated in
the same manner.

283

qqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqq
Spontaneous vaginal delivery
Cesarean section
No record/not delivered

Government group

Combined group

31 (53)
12 (21)
15 (26)

43 (74)
5 (9)
10 (17)

Values given are number (percentage). Chi-square test; P = .047.

Most of the missing numbers were from women who had moved to

other clinics in

different areas or went home to their parents for delivery.

Bidan kampung and pregnancy outcomes

The outcomes of birth with respect to the mode of delivery were better for the combined group. Fifty-three
percent (n = 31) from the government group and 74 percent (n = 43) from the combined group gave birth by
vaginal delivery. The proportion of cesarean births was
higher in the government group (n = 12, 21%) than in
the combined group (n = 5, 9%) (P = .0466; 2 = 3.096)
(Table 4). The positive birth outcomes, however, did
not remove conflicts between the bidan kampungs and
the Western practitioners. This conflict arose because
the bidan kampungs were not formally trained; they just
had spiritual training.
It was after [receiving the ring] that I got the signs from
my grandmother from Sumatra, Pelembang. I did not
see her face, but it was during this time [in the dream]
that she told me, I do not want to give it to others, only
you could bear it.

Discussion
The paucity of published evidence about bidan kampungs practices and positive outcomes has been a
source of conflict about their status in Malaysia. Bidan
kampungs, through their cultural practice, provide emotional and physical support during pregnancy and at
birth. These practices are still an integral part of pregnancy, and many women believe that they help them
emotionally and physically in easing the birth process,
which thereby reduces the use of medical interventions.
Their physical support, including bathing the mother
after childbirth, is necessary to relax the mother and
make her more comfortable after the long hours of labor. The women who used these services found the traditional practices helpful for psychological well-being
and believed they improved birth outcomes. The fieldwork described here has shown that the people in the
community trust the old beliefs. Modern medicine cannot change or remove them but can work with them
in a complementary way to make modern medicine accepted by the community.20 Lau20 says, the combination
of cultural, social, and religious beliefs with modern
medical procedures has a significant role in promoting
good health outcomes.

284 Journal of Public Health Management and Practice

Bidan kampungs like many other traditional birth
attendants in many developing countries have been
shown to improve the health of those under their
care,7,8,21,22 if proper training is given to them. In
Pakistan, for example, properly trained traditional birth
attendants managed to significantly improve immunization coverage for infants and women and the usage of contraceptive methods.22 This success occurred
because the community responded positively to the female health workers, who were selected from their own
community.
There are many other cultures that use and take the
traditional practices seriously. Chinese, Hispanic, Filipino, Hawaiian, Portuguese, Japanese, and Samoan,
for example, are among the societies that have strong
beliefs in the traditional pregnancy practices.2328 Although each culture has its own identity and unique
practices, there are also similarities. Hispanic people,
for example, believe that an eclipse can harm the growing fetus. To safeguard the fetus, pregnant women use
metal objects such as keys, a practice similar to that
found in the Malay culture, where women carry a sharp
instrument to protect themselves when going out at
sunset. Attending a funeral is discouraged in Japanese
culture, another similarity with the Malay culture. Pregnant Filipino women are discouraged from looking at
ugly pictures to ensure a good-looking baby. The Filipinos, together with the Hawaiian, Samoan, and Portuguese pregnant women, are discouraged from using
necklaces during pregnancy. Failure to do so is believed
to cause the umbilical cord to wrap around the babys
neck, thus choking the baby. The Filipinos believe that
the sex of the baby can be determined traditionally
without using any medical technology. A needle on a
string that swings across the wrist of a pregnant woman
is believed to signal a boy. If the needle spins in a circular motion, the baby is said to be a girl. The Hawaiians
determine the sex of the baby by looking at the shape of
the abdomen and the pregnant womans complexion.
A pointed abdomen and a clear complexion indicates
a boy, whereas a rounded stomach with a bad complexion indicates a girl, who is believed to have taken
on the beauty of the mother. The Hawaiians believe
that frequent prayers in the form of chanting done by
Kapuna will ensure easy labor without complications.
Portuguese pregnant women are discouraged from attending a funeral, as it can lead to malformed infants.
Japanese pregnant women are encouraged to think positive thoughts, visualize positive imagery, and listen to
music.
Western research looking at psychosocial needs during pregnancy and birth has also been extensively
explored.29,30 Oakleys30 work on cross-cultural practices of childbirth looked at different styles of pregnancy and birth in both developed and developing

countries. Issues touched by Oakely were the control of

childbirth by medical men instead of midwives and the
comparison between biomedical and traditional maternity care and birth. Schott and Henley29 discuss the
importance of understanding womens social and religious backgrounds by Western providers when delivering maternity care.
In Malaysia, though there are many pregnancy practices in the Malay culture, there are relatively few
Malaysia-based studies.8,5,7,21,31 Some studies took place
in the 1970s and the 1980s and showed that the sociocultural needs of pregnant women are as important as
biomedical care. All these authors state that incorporation and understanding of the sociocultural needs of
pregnant women by Western-trained providers allow
the women to be more receptive of biomedical care.
Women in this study, despite being culturally modest
and submissive, did have social and cultural needs. It
is therefore important for health providers to acknowledge and respect these needs by allowing them to practice these rituals as long it does not harm the mother
and the unborn child. The available medically trained
health personnel (doctor and midwives) in rural areas
are less able to meet these needs. The (new) westernized
maternity care system focuses more on womens bodies, neglecting their psychological, spiritual, cultural,
and religious needs. Lenggang perut, pantang, and other
pregnancy rituals are a part of pregnancy care for rural Malay and some Indian women but are losing their
place in most parts of Malaysia.
There are two reasons why traditional practices are
losing their place in the Malay culture. First, the Western providers do not believe that these practices are
beneficial to the health of the women and their unborn
infants. Women who practice these would, therefore,
not discuss these with their providers. Heggenhougen32
describes how rural people who practiced or visited
traditional healers for treatment felt that the traditional
method of care was not modern, so were reluctant to
acknowledge it to the Western provider.
The second reason is the role of Islam in Malay society. The original intention of performing lenggang perut was to get rid of evil spirits, which are part of
Hindu culture. This purpose is syrik, according to fatwa
from the Islamic Department, Selangor. Syrik can be divided into two categories, minor and major. The term
syrik referred in this study is major syrik when jampi
or incantations are used. It is associating in supplication, which involves directing ones supplication
to someone other than Allah as a means of gaining
provisions or being cured from a sickness or obtaining help during a crisis or for any other purpose.

Rulings on Islamic issues set by an Islamic scholar.

Maternity Services and the Role of the Bidan Kampung in Rural Malaysia

There are three more categories of major syrik. First

is association in the intention, which refers to performing deeds that may be good in themselves but
that are done for the sake of this worldly life and
not for the sake of Allah. The next syrik is association in loving Allah, which refers to loving someone
or something else more than or as much as one loves Allah. Lastly, these practices involve association in obedience, which means to obey people when they make
unlawful things lawful, and to believe that it is permissible to follow those who make such legislation. The
lenggang perut and pregnancy rituals classified here are
major syrik, which are categorized as Bidaah Dholalah.
However, when the practices are intended to get the
family together, cleaning of the pregnant womens bodies to make them feel good and using prayers and
sayings from the Holy Koran, they are categorized as
Bidaah Hasanah and are accepted. The rural women or
bidan kampungs knew their actions were wrong and categorized as Bidaah Dholalah, but they were not given
an explanation as to how these were wrong and no alternative was given to them.
Both lenggang perut and pantang have three significant meanings to mothers-to-be. First, women can tell
their families and communities that they have successfully conceived and will soon be mothers. Inviting family members and people in the community is a way to
show that in the months to come, they are not alone
in their new roles as mothers. Second, to acknowledge
that they can count on all the support and help that they
need. Third, it is to boost womens morale by giving
them external strength to improve their inner strength.
Malaysia as a developing country with a shortage
of nurses and trained medical personnel cannot ignore
the care provided by bidan kampungs. Western countries have successfully accepted and supported traditional (indigenous) practices in the medical system
following the 1977 Thirtieth Health Assembly of the
World Organization, which passed a resolution promoting the development of training and research in
traditional systems of medicine.33 Recently, the World
Health Organization launched the First Global Strategy
on Traditional Medicine and Complementary Alternative Medicine (TM/CAM), which further shows the importance of TM/CAM including practitioners such as
bidan kampungs.34

Actions, words, and activities involving animistic elements that

can deviate from belief in the oneness of Allah. These actions,
activities, and words are not accepted and discouraged not only
during pregnancy but also in daily lives.

The opposite of Bidaah Dholalah, which contains practices, or

phrases, specified and stated in the Holy Koran, and Hadith. Hadith is the term used to describe the actions and sayings done
and said by the Prophet Muhammad (pbuh).

285

The training of bidan kampungs should continue to

ensure the safety of pregnant women, especially when
performing procedures that are delicate and can be
life-threatening and could be in conflict with Western
medicine. Adequate and consistent training for bidan
kampungs will also keep their skills and knowledge updated. Efforts made in the 1970s and 1980s by the Ministry of Health to control, reduce, and stop the work
of bidan kampungs have not been completely successful,
because there are increasing numbers of them. There
is shortage of government providers to serve women
in rural areas and demand from rural women for bidan
kampungs is high.1,5,6,8,21 Moreover, the available Western
providers services are not well distributed, are scarce,
and are available mostly in urban areas. The blurred
policy that allows training for some bidan kampungs
enables them to continue providing services to women
antenatally, intranatally, and postnatally without supervision. This can be unhealthy to women, especially
when untrained bidan kampungs are serving the pregnant women.
Policy makers in Malaysia have taken steps for looking at how best the TM/CAM practices can be incorporated into the biomedical system. When this policy
eventuates, trained bidan kampungs, who are a useful
group of TM practitioners in maternity services, can act
as a bridge between women and biomedical practice, by
allowing them to provide psychosocial and traditional
services to pregnant women. In comparison with some
traditional birth attendants of other developing countries, bidan kampungs in Malaysia have a high status and
are respected by the rural community. By promoting an
official role for bidan kampungs, Malaysia can join other
Asian countries, such as Indonesia, Thailand, and Vietnam, to use and integrate traditional practices into the
medical system by recognizing traditional practitioners
with regular supervision.
It would be very wise for the medical profession if
it could look at the work of bidan kampungs more objectively and appreciate the contribution they make.
Systematic and regular training is necessary and comparison should be done between trained and untrained
bidan kampungs. Western providers before rejecting or
accepting traditional care may require proof of the harm
and good of their practice. Western providers can continue to provide the Western care, but they also need
to accept traditional medicine by bringing themselves
to the level of traditional medicine and understanding the contribution made by bidan kampungs. When
bidan kampungs are employed, the probability of people accepting their advice is higher because of the cultural similarity. Disrespect for culture means failure for
any healthcare delivery. If services of a well-trained
bidan kampung are properly utilized, it will continue to
have a positive impact on maternal and child services,

286 Journal of Public Health Management and Practice

leading to continuous reduction in mortality and morbidity rates.
Much has been said in the analysis of health development programs about the necessity to change or update traditional medical systems so that they will be in
line with the modern medical view. Little, however, is
heard about the need to modify modern medical systems to bring them in line with the views of the target
population.5(p233)
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