Introduction

Health conditions affecting the perinatal period still account for a major contribution to disease burden in sub-Saharan Africa and South Asia despite the significant global shift in disease burden towards non-communicable diseases [1], [2], making the perinatal period i.e. pregnancy, childbirth and infancy, a key period for health intervention. Of this global burden of maternal and neonatal deaths, India contributes the largest share [3]–[6]. India also contributes the largest share in terms of sheer numbers, of maternal and infant under-nutrition, starting with low birth weight infants [7]. Public health approaches to maternal and newborn health over the last decade have emphasized the need for access to services, chiefly skilled attendance and emergency obstetric care, but have paid comparatively less attention to improving family and community practices [8]. A major gap in our knowledge on how to improve perinatal outcomes, is how family and community practices influence maternal/child health care-seeking behaviours [9]. Given India’s significant contribution to global maternal and infant mortality, a focus on this country is integral to any successful global effort [10].

Over the past two decades there has been considerable interest in understanding the socio-cultural milieu of pregnancy and childbirth in low-and middle-income countries so that interventions can be culturally appropriate and have a greater chance of success. The majority of the research has centred on ‘traditional’ or cultural care practices around birth and delivery and the newborn period; and much of it is based on rural populations [11]–[13]. There has been understandable emphasis in the research on potentially harmful traditional practices, particularly in settings such as in rural South Asia and sub-Saharan Africa, where home deliveries are common. We know from recent research in rural India that unhygienic cord cutting, delayed breastfeeding and early bathing [14], and a combination of traditional and modern practices rooted in the concept of inducing heat to facilitate labour, continue to take place [12]. There has also been robust research aimed at describing early infant nutrition, particularly cultural approaches to breastfeeding initiation and duration [15]–[18].

Less understood and described and, we would argue no less important, are the socio-cultural milieu and practices across the whole of the perinatal continuum and in the urban setting. Darmstadt et al. [19] reviewed the literature of antenatal, intra-partum, and postpartum care practices for mothers and newborns in Bangladeshi communities and found a dearth of information. Studies of newborn care practices in the slums of Dhaka [20], and Karachi [21], have found that these were similar to those in rural areas of the South Asia region, including lack of exclusive breastfeeding, bathing the baby soon after birth and applying substances to the umbilical cord. During the 1990s, the MotherCare Project conducted qualitative research to determine the major barriers and facilitators of iron supplementation programs for pregnant women in eight developing countries; beliefs against consuming medications during pregnancy, and fears that taking too much iron may cause too much blood or a big baby, making delivery more difficult were common [22]. In summary, research has been more focused on the potentially dangerous cultural practices during pregnancy, childbirth and newborn period, and less interested in the health promoting aspects of cultural practices.

In 2003 a prospective birth cohort study was commenced at St John’s Medical College (SJMC) Hospital, Bangalore, India, to explore the association of maternal health and nutrition with pregnancy and child health outcomes. Several salient reports and results have already emerged out of this cohort study [23], [24]; in keeping with international research findings, the single most important factor in determining birth weight and hence infant outcomes in this cohort was maternal education level [25]. We situated our qualitative study within this cohort to elicit psychosocial and cultural factors that influence the perinatal period, for mother and infant dyads in urban India. In particular we wanted to explore how ‘cultural’ practices and beliefs influenced women’s pregnancy and childbirth experiences, their pregnancy and family planning choices, their self-care including nutrition through the perinatal continuum.

Empirical Setting, Methods and Data

This paper draws on ethnographic work carried out in greater metropolitan Bangalore, (now Bengaluru), a contemporary urban landscape in India which includes large areas that were until recently considered villages (rural), but have become incorporated into the city. Our previous paper focused on sources of support available to mother-infant dyads [26], we have also reported on the challenges of accessing healthcare in the perinatal period [27]. In this paper we report specifically on the role cultural ideas, beliefs and practices play in influencing the perinatal period in the urban setting.

SJMC Hospital is a 1200-bed tertiary healthcare service in Bangalore, which draws patients of diverse socioeconomic status, from urban slums to high-income residential areas. For the in-depth interviews, we identified women from the cohort who had been through pregnancy and childbirth within the last two years. We used maximum variation sampling [28], to ensure a mix of social and cultural groups (i.e. language and religion) from within three education levels from the cohort. These included women with low education levels (primary school-Group 1), women with medium education levels (completed high school-Group 2) and women with high education levels (tertiary education – Group 3). Prior to commencing the interviews, an interview guide was formulated based on a literature review including topics such as home environment, sources of support, pregnancy and childbirth expectations including gender preference, choice and control over reproduction, cultural practices, dietary practices and self-care. Participants were initially contacted by telephone to locate them, as most addresses were incomplete or wrong; the mobile phone proving the most useful method of reaching even the most unreachable. None of the women refused to participate; some were unable to be located due to change in mobile phone number. Participants were interviewed by female researchers (the first author and research assistant) in the location of their choice; most often it was their home, sometimes it was their mother’s house, or their in-laws’ house, occasionally it was their workplace. While the interview subjects were recent mothers, due to the ethnographic approach taken and the reality of conducting qualitative research in India, often the extended family or even friendship network participated. Interviews were continued till a saturation of themes was reached. Each in-depth interview lasted between 1.5 hours to two hours.

Ethnographic observations were carried out during fieldwork by the first author between August 2008 to January 2009 and in December 2010 in Bangalore. Observations were carried out during formal and informal encounters in family homes or workplaces and while interacting with the extended family and friendship network of the participants or during maternal and child antenatal and postnatal healthcare visits in SJMC and a government health centre. The ethnographic approach was influenced strongly by active listening [29], and used a range of methodologies as described by Fitzgerald including observation, participation, formal and informal interviewing and critical self- reflection [30].

Audio taped interviews were transcribed (from the language of interview to English) as soon as possible following the interview either by the first author or the research assistant (RA) and verified by each other. Observation notes were recorded as field notes in a journal and reflective observations entered in Microsoft Word. The transcripts were open-coded manually and re-categorised by the first author and the RA [28]. One other member of the research team in Bangalore independently read all the transcripts and cross-coded the interviews to ensure data integrity Data were analysed using thematic analysis and constant comparative techniques [31]. Overall analysis was iterative, being guided by the principles of grounded theory and phenomenology and incorporating critical reflexivity [32].

Results

In all, in-depth interviews were carried out with 36 women, 13 in group one, 12 in group two, 11 in group three. Table 1 summarises characteristics of those interviewed. The results of the analysis and interpretation of the qualitative data are presented as key themes identified with respect to the research question: how do cultural practices and beliefs impact on the perinatal continuum for maternal-infant dyads in Bangalore? The following themes emerged:

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Table 1. Characteristics of participants, perinatal socio-cultural study, Bangalore.

https://doi.org/10.1371/journal.pone.0111900.t001

1. 1. Pregnancy related expectations and experiences
   • Fertility concerns
   • Gender preference
   • Desire for small family
   • Reproductive choice

1. 2. Traditional cultural practices
2. 3. Dietary practices through perinatal period

Discussion

This qualitative study explores the socio-cultural factors that shape the perinatal period in urban India today. Public health researchers and policymakers are increasingly acknowledging the need to understand pregnancy and childbirth beyond morbidity and mortality statistics [10], [33]. More than two decades ago Cleland and van Ginneken suggested that the intervening role of cultural beliefs and domestic practices may be very important in the explanation of the maternal education-perinatal mortality relationship [34]. We found that while there were many similarities in cultural practices and beliefs in South Asian anthropological studies [35]–[39], there are changing practices and ideas that deserve documenting and recognising. We found in our study that fertility concerns dominate women’s experience of married life; that notions of ideal family size and gender preference are changing rapidly in response to the urban context; that while a rich repertoire of cultural practices persist throughout the perinatal continuum their existence is normalised and even underplayed; and that in terms of diet and nutrition traditional messages are stronger than health messages. Marriage, pregnancy and childbirth are so much part of the norm for women that there is little expectation of individual choice in any of these major life events. The family unit, including extended family, exerts a critical influence throughout the perinatal period, as noted previously [26].

There has been acknowledgement that infertility is an important public health issue [40], [41]; the International Conference on Population and Development Programme of Action stating that reproductive health services should include the prevention and appropriate treatment of infertility [42]. Yet this common problem has received little attention from health policy makers in India. While the World Health Organization recommends the epidemiological definition of infertility, which is the inability to conceive within two years of exposure to pregnancy [43], we found that women in our study felt pressured to demonstrate their fertility soon after they got married, and if that did not occur concerns about infertility dominated family life. We found that the language used to probe about planning for pregnancy was loosely interpreted or misinterpreted, such that the term ‘planning’ has to be understood within its socio-cultural context. Any exploration of pregnancy therefore has to acknowledge the important role of infertility in reproductive health concerns. Indeed, infertility and fertility exist in a dialectical relationship of contrast, such that understanding one leads to a much greater understanding of the other [44]. Much has been written about infertility and its consequences for couples in Africa [45]–[47]; in south Asia the stigma associated with infertility can be seen as a “social response to the breakdown of a conceptual bind that conjoins the sacrament of marriage to the task of producing offspring” [48]. In Hindu families, the very notion of auspiciousness is linked to female fertility [49] across all cultural groups, however infertility is largely blamed on the woman and thought to be due to evil spirits or physiological defects in the woman [50].

The deep-rooted culturally determined beliefs of son preference in Asia are well documented. Much has been written about female foeticide, infanticide, abandonment, out-adoption, under-reporting of female births, and selective neglect of girls leading to higher death rates in South Asia in particular [51]. There are 44 million missing women in India; the sex ratio in second children if the first is a girl is even lower; strongly suggesting sex selective abortions after antenatal sex determination [52]. Given this publicly available knowledge, hearing the very real and current desire of women in Bangalore to have female children was surprising. Equally surprising was the oft repeated desire for ‘small family’ size, even a one child family. This suggests that change is occurring in socio-cultural norms and quite rapidly in certain urban settings. There is growing evidence in China that son preference is on the decline, but a recent study in both rural and urban China revealed that while son preference has weakened considerably in this generation, it has by no means disappeared [53]. Kodzi et al. [54], found the desire to stop childbearing in Ghana is influenced by reproductive life stage; events; perceptions of personal health; the household’s economic welfare; and the overall subjective cost of children. Cost of living concerns were definitely a factor in influencing the desire for small family size; however there was a strongly expressed love and appreciation of the girl child, which has not been documented before to our knowledge. The sociocultural roots of son preference even for non-resident Indians is extremely strong; in our study similarly, women were particularly pressurised to have sons by female in-laws and husbands [55]. This raises the whole question of how much if any reproductive “choice” women do have. We found that there was an ambivalence with which women regarded their own experience of reproductive choice; this began with the lack of choice or control over their marriage and extended through to their ‘planning’, family planning or pregnancy planning. The small minority of women who had had love marriages in our study had the greatest choice in planning their families, as exemplified by the young woman who became pregnant a month after her ‘love’ marriage and proudly proclaimed that she had done “planning”.

The tendency for rural South Indian women to prefer smaller babies and the relationship of this preference to dietary behaviour and quantity of food consumed during pregnancy have been well described by Nichter and Nichter [39]. We found that traditional, cultural messages about food and diet, including bewildering notions of hot and cold foods versus body habitus which have been well described, still hold meaning and relevance [56]. However curtailing diet consumed in order to have a small baby was never mentioned; the nutritional content of the food was also not a preoccupation for our mothers. A recent qualitative study of pregnant women in Mumbai similarly found that despite the knowledge that the best solution for anaemia in pregnancy was a nutritious diet, respondents did not consume appropriate diets, nor provide details of dietary regimens that would help improve iron content [57]. Breastfeeding, indeed prolonged breastfeeding, was universally practiced; other studies from this region have confirmed that prolonged breastfeeding is the norm and complementary feeding commences around four months [58]. Interestingly the ‘drink boiled water’ message, especially for baby, had translated into practice; this is clearly a change in behaviour over practices from decades ago [59]. Delayed breastfeeding, the early feeding of substitutes such as honey and ghutti to the newborn, which have been described in other studies from rural and urban settings [21], [60], appears to be changing in this urban setting. Cultural and religious practices from pregnancy through to the first year of life clearly have meaning, even though they were normalised (maamuli) and diverse in nature. Rodrigues’ study from Goa found that the failure to observe rituals and dietary practices associated with childbirth, such as the use of special diets and body massages with oil, was associated with perinatal depression [61]. Similarly women in our study who did not have a pregnancy ceremony, or were deprived of a culturally sanctioned celebration for whatever reason were unhappy.

These findings should be interpreted with certain limitations in mind. Although our study provides in-depth qualitative insight into cultural practices and beliefs throughout the perinatal period in Bangalore, it cannot be generalised beyond the urban South Indian population. Urban populations are by nature fluid and dynamic, the particular mix of cultural groups that reside in urban South India may not be similar to urban populations elsewhere. We did not specifically interview husbands, however the nature of doing field-based qualitative research in India means that the interview is with more than just the woman so that often family or friends participate, with husbands and fathers-in-law regularly attending the interviews.

In conclusion, in the great melting pot of metropolitan Bangalore, traditional and cultural practices and beliefs do strongly influence the perinatal continuum, but they are morphing and moulding according to the socio-environmental context. Kesterton and Cleland [14], from their qualitative study of birthing practices in rural Karnataka also found that movement away from traditional practices is already taking place, particularly amongst the more educated and better off. We would argue that the sometimes accusatory gaze with which ‘traditional’ practices in pregnancy and childbirth have been described, needs to be re-positioned to encompass the health and wellbeing-enhancing practices that continue to play a role for today’s mothers. There also needs to be an acknowledgement that culture is dynamic and that change is a constant. Clearly some health messages are getting through such as the need to have clean water and early attachment to the breast, while others are not. We know from research in India that community-based intervention, targeted at certain high-risk newborn-care practices, can lead to substantial behavioural modification and reduction in neonatal mortality [62]; however not all domestic behaviours change easily as our study illustrates. Further research is required to elucidate the nexus between receipt of health information and desired behaviour change. We would suggest that ethnographic research, which is multi-methodology research par excellence [30], should be given more importance both in understanding the socio-cultural contexts and in helping shape public health interventions.

We call for a greater understanding of the dynamic factors influencing and shaping the perinatal period in urban India. This includes acknowledging the critical importance of the family both in supporting and in disrupting perinatal wellbeing. It also includes acknowledging the health promoting as well as potentially harmful perinatal practices and beliefs, to result in better targeting of culturally appropriate public health interventions throughout the perinatal continuum. Behaviour change interventions to improve maternal and newborn health need to address potentially harmful practices through appropriate training of healthcare providers, changing their perceptions and attitudes, and arming them with the skills to promote positive, culturally sanctioned behaviour. Beyond merely targeting ‘practices’, healthcare providers also need to understand the socio-cultural contexts which influence beliefs and practices. This can only be achieved by involving the extended family and community in the perinatal journey.

Acknowledgments

We gratefully acknowledge the invaluable support and help provided by Dr Sumithra Mutthayya and members of the Nutrition Research team from St John’s Research Institute, St John’s Medical College, Bangalore. The first author is particularly grateful to all the women and families who so freely gave their time to this research.