Cultural Beliefs and Maternal Health Practices in Rural Bangladesh: A Phenomenological Study

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Zahid Hasan Jibon This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7281727/v1 This work is licensed under a CC BY 4.0 License Status: Under Revision Version 1 posted 14 You are reading this latest preprint version Abstract Background Cultural beliefs and practices have been recognized as prominent determinants of health behavior by modifying the perception of health and illness in developing regions. This is one of the most overlooked areas due to its complexity in countries like Bangladesh. Though several studies addressed this as a pressing issue for advancing maternal health, their primary focus is on antenatal care and pregnancy. This study explored existing beliefs and practices among women during their pregnancy, childbirth, and postpartum period in the Sirajganj district. Methods This study employed a qualitative research strategy accompanied by the phenomenological research design to derive a subjective interpretation of women’s life experiences during this time. Thirty-two study participants with their verbal consent were selected through the purposive sampling method, and in-depth interviews were conducted until data saturation was reached. Results Among all findings, believing an empty stomach causes the fetus to grow large, limiting movement due to avoiding spiritual attention, mostly for evil spirits, using amulets to be protected from these evil spirits, and special arrangements for “Atur Ghor” have been prominent. Conclusions Women in the study area follow a modern approach combined with beliefs and commitment toward their culture that has been transferred from their previous generation, and a willingness to avail modern healthcare facilities. Cultural beliefs maternal practices pregnancy and postpartum phenomenological study spirituality and health Background Maternal mortality is one of the main public health issues in low and middle-income countries. It contributes significantly to the health status of a country. It is driven by multiple factors connected to maternal health, including poverty, food insecurity, inadequate healthcare access, and different socio-cultural factors ( 1 , 2 ). Though Bangladesh has significantly reduced the maternal mortality ratio from 6.48 per 1000 in 1986 to 1.56 per 1000 in 2022, it still faces persistent challenges ( 3 ). 1 Though Bangladesh made remarkable progress, the rate is far above the SDG target of 3.1, which is to reduce the maternal mortality ratio to less than 70 per 100,000 live births. 2 Maternal health is influenced by various biological, environmental, economic, and socio-cultural factors, such as socioeconomic background, gaps in healthcare infrastructure, early marriage, adolescent pregnancy, living conditions, cultural beliefs, etc., ( 4 , 5 ). Cultural beliefs and practices are learned, shared, and passed down through generations, which play a crucial role in shaping overall health behavior, especially maternal health behaviors ( 6 ). These beliefs influence the perception of health risks, eating habits, daily routines, and health-seeking behavior throughout pregnancy and the postpartum period ( 7 , 8 ). Existing theories of health behavior, like the health belief model (HBM) and the theory of planned behavior (TPB), provide a logical framework for a better understanding. For example, the HBM emphasized the perceived cost-benefit analysis for the cue-to-action, while the TBP focused on individuals' intentions, attitudes, perceptions of behavioral control, and cultural approval for understanding their behavior. However, these lack the overall understanding of the interplay between cultural beliefs & practices with the health behavior of individuals ( 9 – 11 ). In contrast, Foggs’ behavioral model (FBM), developed in the early 2000s, offered a comprehensive lens for studying behavior change across generations within the same cultural context. The FBM integrates motivations that enable individuals to learn the intergenerational culture, the ability to perform a certain behavior, and the triggers that serve as cues to action. According to the theory, motivation comes from intrinsic social norms, values, and familial expectations. The ability is influenced by knowledge, skills, access to resources, and societal support systems, enabling individuals' engagement with cultural practices. Finally, family traditions, cultural celebrations, community events, or significant life events reinforce the importance of cultural practices and trigger behavior change across generations ( 12 ). In Bangladesh, especially in rural areas, beliefs like following a specific dietary pattern or relying on traditional care practices for any pregnancy-related issues remain widespread. While some of these align with positive health outcomes, others contribute to delays in seeking medical care or harnessing the benefits of modern healthcare facilities ( 13 ). These include beliefs like the pregnancy is a natural process of reproduction, and women do not need any external help or medical support during this period ( 14 , 15 ). Though different influencing factors like child marriage, power relationships in the family, infrastructures, and husbands’ involvement in maternal care, such as ante-natal visits, have been identified and taken into action, the existence and role of cultural, communal, and personal beliefs and practices, which are the prominent factors influencing maternal health outcome, has not gained enough importance yet and remained overlooked ( 16 , 17 ). Existing pieces of work have focused on the role of cultural beliefs and practices in shaping pregnancy and postpartum care. For example, despite the prevalence of postpartum illnesses, rural women chose to seek help from traditional healers who are believed to possess exclusive curative abilities, and the illness is identified as an effect of supernatural forces ( 18 , 19 ). The persistent beliefs in traditional birth attendants, despite their education and training status, indicate the toughness of ongoing cultural practices. These perceptions highlight the profound influence of cultural beliefs on maternity care, requiring personalized interventions in specific contexts to improve the well-being of mothers and newborns ( 20 , 21 ). The classical pieces of work done by Blanchet and Maloney in the 1980s and recent works on these beliefs and practices have focused on specific beliefs and practices and their impact on health, specifically on antenatal health. Additionally, the Bangladesh Demographic and Health Survey (BDHS) primarily emphasizes quantifiable health indicators, such as antenatal visits and institutional deliveries, while overlooking the qualitative impact of cultural beliefs and practices ( 22 ). These gaps indicate a need for a comprehensive study of the existing beliefs and practices during the total pregnancy to the early postpartum period. This study aimed to explore the existing beliefs and practices among women during their pregnancy, childbirth, and early postnatal period. The findings of this study will provide a deeper understanding of crucial cultural contexts of maternal and child health for developing context-based, effective interventions and policies. Methods and materials Study Design The study employed a combination of qualitative and phenomenological research designs. This research design is the best fit for exploring cultural beliefs and practices from individuals' lived experiences ( 23 , 24 ). Phenomenological research design has been identified as the best fit for this study for the descriptive nature of its aim of exploring the existing cultural beliefs and practices among women regarding their maternity period in Bangladesh ( 25 ). Creel & Tillman in 2008 used this research design to understand the lived experience of spirituality from the never-before-heard voices of ill patients with no religious affiliation, and findings are relevant for the body of knowledge of nursing related to spirituality for persons living with chronic or terminal illness ( 26 ). Another study on study aimed at examining and exploring the meanings, structures, and essence of the lived experiences of Muslim women while seeking to advance knowledge of how Islam, as a religion, can promote gender equality via an Islamic theological (Allah’s Kalam) framework ( 27 ). Empirical researchers have used this study design to delve into personal perspectives, context, and hidden meanings within cultural practices, leading to a deep and empathetic understanding. It helps researchers grasp diverse interpretations, variations, and symbolic significance in a culture, informing culturally sensitive initiatives and policies ( 24 , 28 , 29 ). Settings The study was conducted in the Shahzadpur upazila of the Sirajganj district, which has a cultural setting based on the local Islamic shrines that dates back almost four hundred years. The Shrine plays a special role in developing communal harmony in society. This area of study has been selected for its cultural richness and diverse religious groups ( 30 , 31 ). Study population and sampling strategies The potential participants for the study were mothers with children aged 12 years or younger, with the age limit set to minimize recall bias. Study participants were selected from the women living close to the Mazar, as this vicinity offers a culturally and religiously rich context where cultural and religious beliefs and practices are particularly prominent. The sampling and data collection process was determined by the saturation of the ideas ( 25 ). In this study, we selected 32 mothers who had at least one successful pregnancy or the oldest child under 12 years old using a purposive sampling method. The data collection tool consisted of questions regarding their experiences, the supervision they received, and the practices they followed throughout their pregnancy, childbirth, and postnatal period. Data collection The field interview guide consisted of semi-structured, open-ended questions, was used to conduct in-depth face-to-face interviews with the participants lasting 30 to 45 minutes. The topic guide aimed to explore the mothers' lived experiences, beliefs, practices, and reasons for their actions and beliefs. The tool comprised relevant prompts on the lived experiences surrounding pregnancy, childbirth, and the postnatal period. The topic guide included prompts on participants' beliefs and practices related to protection and diet before and after delivery, workload during pregnancy, and health beliefs and practices. It also explored their first exposure to these beliefs and the reasons for following them. Additionally, the guide covered their perceptions of modern healthcare facilities, the use of modern healthcare services, the place of delivery, and postnatal arrangements for both mother and child. The tools used to collect data were prepared in English, later translated into Bengali, and pre-tested to check their appropriateness to the local context. Since the qualitative study needs an immersion process, the researchers collected data using mobile recorder technology with the verbal consent of the respondents. Additionally, keynotes were taken to complement and contextualize their verbal responses. Maintaining trustworthiness Quality assurance controlling mechanisms were employed throughout the entire research process to ensure trustworthiness. The supervisor monitored and directed the research throughout the entire time, especially during the data collection process. During data collection, the audio recordings were transcribed on the same day of data collection. The verbatim transcriptions were translated into English for analysis. The translated data were read line by line repeatedly to understand the context and meanings used to increase immersion in the data. Data analysis process The translated data were cleaned and imported into NVivo version ten for analysis. Using an open coding system, the data were coded into meaningful contexts. Deeper immersion into data with repeated reading, creating themes, subthemes, categories, and coding was used for data analysis. The codes were combined into different themes and sub-themes. Results Thirty-two participants were selected for the study to explore their lived experiences, beliefs and practices, exposure, and reasons for following those beliefs. The age of the participants ranged between 18 to 34, with only 2 having secondary or higher educational qualifications and 1 from the upper economic class. Theme 1: Believing fertility or pregnancy is God-gifted Spiritual beliefs and practices for pregnancy Spiritual beliefs are deeply rooted in the maternal practices of women in the rural areas of Bangladesh, where they often see it as a divine blessing. Women rely heavily on the religious rituals and guidance of spiritual leaders to ensure a successful gestation period. Some claimed to see spiritual entities in their dreams and receive the guidance of getting ‘ Pani Pora ’ (Holy Water), and Jharfuk (Blessings) to be blessed with a child, and later on, they drank and became pregnant with a child. "...One day, Huzur came into my dream and told me that I was doing so much that I still did not have children. Why don't you come to me and take the Pani Pora (Holy water)? Then you will be blessed with children by Allah. Later, I went to Huzur and asked for Pani Pora... After drinking those, I had a child." (33 years old, mother of four) The reliance on spiritual practices is stronger among the women who experienced difficulties in their previous pregnancies. Additionally, participants have expressed their strong intention to make vows to donate materialistic items, livestock, and feed people around specific religious holy places, and nafal prayer for their desired outcome related to the unborn and newborn. "...After my daughter was born, her condition was severe, as she would not survive. After I came back from Sirajganj for five days, one of my aunts said that I should take a vow, a vow for my daughter's life. And I did that. When my daughter was 40 days old, I went to Badal Bari (A local spiritual place) one day and donated two baby pigeons. After a while, when my daughter had diarrhea for 3 months, no medicine helped. I vowed again that if my daughter's diarrhea were cured, I would fast and pray at Badal Bari." (18 years old, mother of one) Beliefs on medical intervention Modern medicine is also acknowledged to play a pivotal role during the pregnancy period, and the local doctors and FWAs were the key distributors of assistance needed. Along with medical intervention for pregnancy, several participants consult with herbal medicine specialists for their problems and seek cures. The participants expressed both approaching modern medicine first, then herbal medicine, and vice versa, if they failed to get any solution in the first attempt. “....We were trying to have a baby for over a year, I took medicine from local doctors and Kaviraj for that. But nothing happened. Then I went to a doctor in Bogura. He gave me some medicine and I got pregnant.” (24 years old, mother of two) “...I went to see many doctors and took so many medicines, but I did not have any children. Then, I went to Kaviraj and had treatment. After that, I had a child. Kaviraj told me to vow that I would give a Pata made of gold the weight of my son’s hair’s weight.” (22 years old, mother of one) A trend of combined beliefs on medical intervention and spiritual practices can be seen among women for getting blessed with a child. Participants' statements about going to the hospital and having faith in vows, blessings from huzur, and pani pora are like healthcare services, and doctors are the medium for spirituality to be fruitful for a successful pregnancy. Theme 2: Certain dietary practices are essential to follow Food patterns during pregnancy Participants had almost similar responses regarding their dietary pattern, followed by avoiding foods that might cause allergic reactions, sweet pumpkin, and different fruits like papaya, pineapple, and extra-sour food, believing these foods might cause miscarriage and pregnancy complications. “...I have had no problem with any food during pregnancy, but the elders had forbidden me to eat papaya and pineapple. They say these are harmful to the unborn child and may cause an abortion if taken.” (27 years old, mother of two) Some avoid nutritious fruits and vegetables to limit the growth of the fetus; on the contrary, eating a full meal, believing in an empty womb, is one of the reasons for the baby to grow larger. “...I ate everything, and I always ate a full stomach because I learned from the elders that the baby will grow larger if the stomach is empty.” (33 years old, mother of three) Food patterns during the postnatal period During the postnatal period, women expressed that they have followed the same dietary practices as during their pregnancy, avoiding allergic foods, dairy products, and intake only nutritious foods, and fruits that increase milk production and hasten the healing of wounds. “...They did not give the puti and prawns. Saying that the son's placenta in the stomach will not heal. For 2 or 3 days, I used to eat these with Kalozira (black cumin) and mach bhorta (Mashed Fish). They also fed me specific fish and pigeons.” (33 years old, mother of four) The participants hardly discussed any rituals or practices other than feeding honey or Misrir Pani (Sweet syrup made with sugar) to the child, believing this action would make the child a sweet talker and of good nature in the future. Furthermore, they expressed their desire to feed mothers’ breast milk as soon as possible. “...Breast milk and honey. Sweet water was also given. It is better to give honey. It is said that the Prophet was fed with honey at first, so it’s a sunnah. My baby got breastmilk after 12 hours. (27 and 33-year-old mothers) After a certain period, Muslims perform the Mukhe Vaat (First Oral Feeding) rituals, where some can celebrate it, and some cannot due to their financial condition. On the other hand, the Hindus are bound to keep a Narayani Puja ceremony to celebrate Mukhe Vaat . It is their religious ritual, and they have to perform this for their child. Theme 3: Health-seeking behavior during pregnancy and delivery Modern healthcare facilities are for troubled pregnancies. Perception of health-related beliefs among the participants depends on their household conditions, preconceptions of health-seeking behaviors, and supervision from the older generations. They believed that healthcare facilities or medical centers were only for complicated pregnancies, and Dais was good enough for them. “...There is no need for doctors or kabiraj (traditional healers) if the position of the baby in the womb is good… In our area, we usually call the Dais (TBAs). But if there is an issue and no solution can be found, then we go to the doctor.” (33 and 35 years old, mother of four and three) Relying on traditional birth attendants for normal delivery The idea of modern healthcare services is only for troubled pregnancies, and also affects their first antenatal care visit, which is somewhere between the 7th and 8th month of pregnancy for most of them. Some of the participants agreed that traditional birth attendants are more experienced, thus, they are good for normal delivery, and the mother doesn't have any kind of complications. “...I have not gone to see a doctor since I was pregnant. When I was 9 months pregnant, I went to do an ultrasonogram, but I did not go there willingly. Apart from that, I did not take any medicine.” (21 years old, mother of two) Experience changes health-seeking behavior. On the contrary, women who have experienced complications, miscarriage, or stillbirth in their previous pregnancies expressed changes in their health-seeking behavior and availed modern healthcare services from the early phase of pregnancy. “...I took health services from the medical staff. As my first pregnancy was a miscarriage, I was scared. I stayed cautious and followed everything the doctor said to me. I did ultrasonography 3/4 times. After doing that, the doctor said that the baby was healthy.” (22 years old, mother of one) This statement is also true for those who have witnessed someone else face a complicated pregnancy and change their health-seeking behavior. Theme 4: Following certain rules is important for both successful childbirth and the newborn child’s future Cultural Precautionary Practices During Pregnancy Interviews have highlighted some seemingly unrelated practices followed by the women, believing these are good for pregnancy. All of the participants believed in the elders’ chaotic nature as the Vari Nissash and always gave the services necessary to please them and their good wishes. Additionally, they believed that unpleasant elders can bring harm to the unborn child. “...My mother-in-law used to say that the delivery process of the baby would be smooth like oil if you gave oiled elders’ hair. So, I did that before I went to my mother’s house.” (33 years old, mother of four) Moreover, some women reported believing that using bandages or tying a petticoat tightly on the upper belly is good for easing delivery and avoiding complications. “...I took the Paat Pora (heated rope tied on the belly softly) because of my stomach ache. My stomach aches so much that I was scared that I would have a miscarriage. That is why I took it.” (21 years old, mother of two) Postpartum practices Though the participants availed of at least one antenatal care visit, the majority of the women believed that they did not need any kind of postpartum care other than resting till postpartum bleeding stopped. Also, those who had institutionalized delivery had an involuntary stay of at least two days to ensure postpartum care access for the mother and newborn child. “...My stomach has been in pain for two days before the delivery. When there was no sign of delivery, but high pain, my husband called an auto to get me to the Shahjadpur Upazila Hospital. I gave birth on the way; the delivery was normal, so we came back.” 22 years old, mother of two) Some participants believe that if the placenta is buried near educational institutions, their child will grow up to be very fond of education and become an educated person. Along with other practices, they also try to perform this one. “...Elders say that if the placenta is placed around schools and madrasas, then the future of the child is bright.” (33 years old, mother of three) Theme 5: Beliefs in supernatural power Pregnant women must be protected from evil spirits. Beliefs in supernatural phenomena are common among women and heightened during their pregnancy period. The participants also believed that only the traditional healers (Ojha, kabiraj, Huzur) could help them overcome the effects of supernatural forces. While most of the participants believed in the effect of supernatural forces, some claimed to have experienced such kinds of events. “...Once, I went through the bamboo bush while pregnant with my son. I felt as if someone was following me from behind. Then I looked back and saw that there was no one. When I came back, my body became very heavy, and after a few days, my baby died. From then on, I would stop walking around these places.” (33 years old, mother of four) Women discussed various initiatives to avoid falling into such kinds of events. These included activities like limiting outside roam, avoiding certain places at certain times, and using amulets and other specific things with them to be protected from Bod Nojor or evil spirits. “...Yes, I took the Rakshi (Hindu amulet). I closed my body (Ga Bondho kora). So that the child in me does not get any harm. So, I took it; I put it on my body and neck. I believed that the child would be healthy if I kept the amulet.” (22 years old, mother of two) Both mother and newborn must be protected. While precautions were taken to protect pregnant mothers from the perceived effects of supernatural forces during pregnancy, these arrangements intensified after delivery. Mothers who delivered in hospitals typically needed to follow fewer safety measures for such concerns, whereas others had to adhere to certain traditional practices to ensure their safety. Both Hindu and Muslim participants discussed a similar traditional post-delivery living arrangement called Atur Ghor . Depending on the economic condition, this might be a separate room or a separate part of a room, covered with materials like written mantras, cow bone, active fireplaces, and many others, to protect the mother and newborn child. According to these beliefs, the mother is considered unholy and susceptible after childbirth, potentially attracting unwanted attention to herself and her baby. To ward off such spirits, she is often required to carry iron objects or matches, which are thought to repel malevolent forces. “...Around the room where the mother and the child are kept, elderly people always keep cow bones, sacred prayers are written (Gita path), and iron, matchlight & and fire in the room. I also fear evil things (Atta, Deu-Doitto) and I believe they can bring harm to my baby as well.” (22 years old, mother of two) Many participants believed that if the placenta ( Gorvoful ) is exposed to heat ( Gorom Batash/Sapa Batash ) or dragged by stray animals, it could harm the child, potentially causing vomiting or leading to serious health conditions. To prevent this, they ensure the placenta is properly wrapped in fresh cloth and buried deeply in the earth. “...The placenta has to be put under the ground. If it stays outside, it may harm the baby. The baby will vomit and will have many health conditions, so it is better to bury it under the ground.” (24 years old, mother of two) Source and reason for adhering to the beliefs and practices Beliefs are shaped through various means, with personal experience being the most significant factor. While the sources of information were older generations of the family, most of the participants strongly emphasized their own experiences in believing in vows, amulets, and supernatural phenomena. “...I did not believe in anything during the first child, but when the second child was miscarried and the third child was born, then, I started to believe that I had to be careful.” (27 years old, mother of two) During discussions about the origins of their beliefs, participants explicitly referred to the experiences of others, along with their own. Additionally, they emphasized that elders prescribed many of the restrictions and provisions they followed. These elders warned that failing to adhere to these practices could result in harm to both the mother and the child. “... My Khala (aunt) had a girl first. Then, she was pregnant with a baby boy. One day, while coming back from my grandmother’s house, she felt the Sapa Batash (Hot Wind) on the way, and she started vomiting after coming back to the house. Then, the baby miscarried. Then everyone said there was a road on the way from my grandmother's house, and that road was not good. After that, everyone said that this happened because of that road.” (18 years old, mother of one) These beliefs are shaped through the experiences of their own or someone else’s, and advocacy from the older generation has played a pivotal role in adhering to these beliefs and practices further. Discussion Health, especially maternal health, is shaped by a complex interplay of different determinants like cultural beliefs, social structures, and personal practices ( 20 ). This study explored the existing cultural beliefs and practices surrounding pregnancy, childbirth, and intermediate postpartum care, with a focus on their influences on maternal health outcomes in Sirajganj. Cultural beliefs and practices shape the perception of health and illness. These perceptions, in turn, influence health-related behaviors, which affect maternal health outcomes. Findings suggest that traditional beliefs often dictate the choices women make during pregnancy and childbirth. For example, the beliefs in supernatural causes of illness and reliance on traditional healers (Ojhas & Kaviraj) for remedies reflect deeply rooted cultural norms, which are also evident in previous studies ( 20 , 32 ). Existing studies also shed light on these types of barriers to accessing modern healthcare services, as women perceive traditional practices as more effective or culturally approved ( 19 ). These findings are supported by the Health Belief Model and the Theory of Planned Behavior. They show how cultural beliefs and personal views on risks and benefits affect changes in health behaviors ( 9 – 11 , 33 ). The interplay is further strengthened by the impact of the socioeconomic background of the families. This study found that antenatal care is often prioritized only for high-risk pregnancies, with nutritional choices heavily influenced by family income and cultural norms. Participants also reported relying more on traditional birth attendants and avoiding healthcare facilities as long as they could. The findings are consistent with prior studies, showing that socioeconomic background impacts nutrition and healthcare decisions during pregnancy ( 15 , 18 ). In contrast, findings also suggest that solvent families might incorporate a combination of traditional and modern practices, reflecting a complex dynamic influenced by both economic means, cultural norms, and the decision-making power held by women ( 34 ). The influence of elder family members often overshadows these dynamics, as they uphold traditional beliefs and practices. Such hierarchical structures perpetuate cultural norms that can have both positive and negative impacts on maternal health ( 18 , 20 ). The study shed light on the enduring nature of traditional practices despite advancements in healthcare practices and education. Certain customs like avoiding specific foods, relying on herbal remedies, and using spiritual protections (e.g., amulets) are often reinforced by the older generations, creating a cycle of adherence to traditional practices deeply rooted in familial and communal beliefs. For example, women’s dietary restrictions, such as avoiding papaya and pineapple due to fears of miscarriage, reflect cultural beliefs that prioritize safety over scientific evidence. A study on the Manoshi program participants compared the differences in maternal health indicators between slum and non-slum areas in urban, reported that women tend to maintain practices and behaviors similar to those of rural areas, despite having increased access to health services in the urban areas, marking the cultural concerns might be a substantial barrier in seeking antenatal care ( 13 ). Some of the findings on postpartum rituals from this study, such as the use of “Atur Ghor” (a special confinement space) and the burial of placentas near educational institutions, directly align with work from the 1980s. While some of these may offer psychological comfort, they often delay or substitute essential medical interventions ( 7 , 35 ). Despite the influence of cultural beliefs and practices in shaping maternal health behavior, this study found a gradual shift in those cultural beliefs and practices due to several factors such as increased exposure to education, healthcare services, and urbanization. However, the study also found that past experiences related to pregnancy complications or witnessing adverse outcomes of others as the prominent drivers in this shift. Women with these experiences are more likely to seek modern healthcare services early. This shift reflects a combination of experiential learning and structural improvements in healthcare accessibility. As evident in the existing pieces of literature, the persistence of traditional birth attendants and home-based deliveries indicates that the transition toward modern healthcare is not uniform and largely context-dependent ( 36 , 37 ). Despite these changes, the hesitancy to fully embrace institutional deliveries and postnatal care remains a significant challenge. Integrating these cultural dimensions into the mainstream national health surveys could provide a broader understanding of maternal health dynamics. Conclusion In this exploratory study, findings showed a complex interplay between culturally established beliefs and practices and health-seeking behavior among women during their pregnancy, childbirth, and early postpartum period. The study shed light on the beliefs and practices of fertility, a deeper belief in the heavenly nature of pregnancy, attributing conception to a higher level of spiritual object. Participants also expressed spiritual influence during pregnancy, childbirth outcomes, and postpartum safety, and reported limiting their outdoor activities and performing different activities to ward off evil spirits. These highlight the pervasive influence of spiritual beliefs to protect both mother and child from negative spiritual forces influencing maternal health behavior. After childbirth, different kinds of living arrangements were promoted as it would protect them from any evil spirit trying to harm the impure mother and newborn, similar to the findings of Maloney and Blanchet in the 1980s. They also focused on different kinds of oaths (Manots) to protect themselves from any potential harm from the evil spirit or wish good health and fortune for the child. High attention was paid to the dietary practices, as the participants followed specific food practices. They followed a strict diet of not eating a full stomach during pregnancy, believing this would push fetal growth and might cause pregnancy complications. Though this could potentially be a reason for underweight offspring, their dietary practices during postpartum were focused on the health of the wound and increasing breastmilk. The study also highlighted the gradual shift among the participants, outlining the possibility of future change with proper interventions. Despite advancements in medical care facilities, the participants hold a deepened commitment to their shared spiritual beliefs, perceiving modern healthcare as just a medium for spiritual help for health issues. This sophisticated approach combined both traditional and modern approaches, reflecting a deep connection of the cultural side in shaping maternal health behavior among women. However, the deep-rooted beliefs and practices combined with limited knowledge, accessibility, and affordability hamper the participants' ability to seek medical care, particularly in cases of complicated pregnancy. This study has highlighted a delicate balance between cultural continuity and intention of adaptation in response to changing social, economic, and environmental factors. Despite changes in the social norms and healthcare practices, the participants maintained a strong collaborative approach with their cultural heritage, preserving the beliefs and practices passed down from their previous generations. This flexibility emphasizes the importance of incorporating cultural sensitivity into maternal healthcare interventions, ensuring that healthcare practices align with the beliefs and values of the communities they belong to. This study provides significant insights into the intersection of cultural beliefs, healthcare practices, and maternal health outcomes in the Sirajganj district. By understanding the degrees of these beliefs and practices, healthcare providers and policymakers can develop more culturally sensitive interventions to prioritize community engagement and empowerment, fostering partnerships between healthcare providers and local communities to ensure that maternal healthcare services are readily accessible, acceptable, and effective for all women, not only in Sirajganj district but also everywhere in the country. Limitations of the Study Despite the valuable insight obtained from this study on cultural beliefs and practices surrounding the pregnancy, childbirth, and postpartum period in the Sirajganj district, it is essential to address the limitations inherent in the study design, sample characteristics, and contextual factors. Further studies should aim to mitigate the limitations of this study to enhance the validity, reliability, and applicability of the findings. Declarations Ethics approval and consent to participate The study was conducted in accordance with the Declaration of Helsinki. Ethical approval was granted by the Institutional Review Board (IRB) of the Institute of Health Economics, University of Dhaka. This review board is registered with the Federalwide Assurance (FWA) for the Protection of Human Subjects and is authorized to ensure that research methodologies protect the rights and welfare of all participants. Verbal informed consent was obtained from all participants before the interviews. The research team explained the study's purpose, the voluntary nature of participation, and the right to withdraw at any time. The use of verbal, rather than written, consent was approved by the IRB to suit the local context and potential literacy levels of the participants Consent for Publication Not applicable Availability of data and material The datasets generated and analyzed during this study are the property of the Department of Population Sciences, University of Dhaka. To protect participant privacy and confidentiality, the data are not publicly available. However, data may be available from the corresponding author upon reasonable request, pending formal approval from the Department of Population Sciences. Competing Interests No potential conflict of interest was reported by the authors. Funding No grant received for the study. Author Contribution AHMKH and MZHJ contributed equally to the conception and design of the study, data collection, analysis, and manuscript writing. Both authors read and approved the final manuscript. Acknowledgment The authors express their gratitude to all the mothers who took part in this study. It is noteworthy that this article is an excerpt from a Master’s Thesis. References Khan NU, Asif N, Miraj MA, Khalid H, Awan T, Bin, Khan MA et al. Understanding maternal mortality: A multifaceted analysis of demographic, temporal, and contextual factors. 2024;1–15. Thompson E, Moore J. Addressing Health Inequities in Maternal and Child Healthcare. In Low- Income Communities. 2024;(2):23–7. Bangladesh Bureau of Statistics. Bangladesh Sample Vital Statistics. 2022. Statistics and Informatics Division, Ministry of Planning, Government of the People’s Republic of Bangladesh. 2023. Nour NM. Child marriage: a silent health and human rights issue. Rev Obstet Gynecol. 2009;2(1):51–6. Noor R, Rushdi Saif A. Access to Maternal Healthcare in Rural Bangladesh: A literature-based Analysis on Factors Affecting Maternal Healthcare Utilization in Bangladesh. 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BMC Public Health. 2012;12(1):1. Choudhry UK. Traditional practices of women from India: pregnancy, childbirth, and newborn care. J Obstet Gynecol Neonatal Nurs. 1997;26(5):533–9. Ahmmed F, Ahmed T. Influence of the Socio-cultural Factors in Health-Seeking Behaviour of Women during Pregnancy in Rural Bangladesh. J Exclusion Stud. 2014;4(1):1. Jannat Z, Ali MW, Alam N, Uddin MJ. Factors affecting practices of recently delivered women on maternal and neonatal health care in selected rural areas of Bangladesh. BMC Pregnancy Childbirth. 2023;23(1):1–15. Jahan N, Islam MS. Early Postnatal Care Practices for Mothers and Their Babies in Bangladesh: An Integrative Literature Review. Open J Soc Sci. 2022;10(02):258–70. Goodburn EA, Gazi R, Chowdhury M. Beliefs and practices regarding delivery and postpartum maternal morbidity in rural Bangladesh. Stud Fam Plann. 1995;26(1):22–32. Ayaz S, Yaman Efe S. Potentially harmful traditional practices during pregnancy and postpartum. Eur J Contracept Reprod Heal Care. 2008;13(3):282–8. Ross JL, Laston SL, Nahar K, Muna L, Nahar P, Pelto PJ. Women’s health priorities: Cultural perspectives on illness in rural Bangladesh. Health (Irvine Calif). 1998;2(1):91–109. Nguyen PH, Sanghvi T, Kim SS, Tran LM, Afsana K, Mahmud Z, et al. Factors influencing maternal nutrition practices in a large scale maternal, newborn and child health program in Bangladesh. PLoS ONE. 2017;12(7):1–17. National Institute of Population Research and Training (NIPORT). ICF. Bangladesh Demographic and Health Survey 2022 Final Report. 2024. Badil. D, Muhammad DDM, Zeenaf Aslam ZA, Kashif Khan KK, Anny Ashiq AA, Uzma Bibi UB. Phenomenology Qualitative Research Inquiry: A Review Paper. Pakistan J Heal Sci. 2023;(April):09–13. Neisser HP. The Phenomenological Approach in Social Science. Int Phenomenol Soc Philos Phenomenol Res. 1959;20(2):198–212. Creswell JW. Qualitative Inquiry & Research Design: Choosing Among Five Approaches. Third. Sage; 2013. pp. 7823–30. Creel E, Tillman K. The Meaning of Spirituality Among Nonreligious Persons With Chronic Illness. Holist Nurs Pract. 2008;303–9. Galloway SD. The Impact of Islam as a Religion and Muslim Women on Gender Equality: A Phenomenological Research Study. Nova Southeastern University; 2014. Groenewald T. A Phenomenological Research Design Illustrated. Int J Qual Methods. 2004;3(1):42–55. Bliss LA. Phenomenological Research. Int J Adult Vocat Educ Technol. 2016;7(3):14–26. Wali MA. Antiquity and Traditions of Shahzadpur. J Asiat Soc Bengal. 1904;(33):262–71. Rifat-Ur-Rahman M, Hasan M. Ritualistic Performance of Women Pilgrims in the Makhdum Shah Shrine, Sirajganj. Acad J EXIM Bank Agric Univ Bangladesh. 2021;(August). Uddin J, Hossin M, Mahbub F, Hossain M. Healthcare-seeking behavior among the chakma ethnic group in bangladesh: Can accessibility and cultural beliefs shape healthcare utilization? Int Q Community Health Educ. 2012;33(4):375–89. Ajzen I, Cote NG. Attitudes and the prediction of behavior. Atitudes Atitude Chang. 2008;(January 2008):289–311. Maria L, Dpt W, Ph D. Cultural Barriers To Maternal Health Care In Rural Bangladesh. Online J Heal Ethics. 2013;9(1). Blanchet T. Meanings and Rituals of Birth in Rural Bangladesh: Women, Pollution, and Marginality. University; 1984. Dutta GK, Sarker BK, Ahmed HU, Bhattacharyya DS, Rahman MM, Majumder R, et al. Mental healthcare-seeking behavior during the perinatal period among women in rural Bangladesh. BMC Health Serv Res. 2022;22(1):1–9. Bandura A. Social learning theory. Gen Learn Press. 1971;115–9. Footnotes World Health Organization. (2022). Maternal and perinatal death surveillance and response (MPDSR) in Bangladesh: Progress and highlights in 2022 . WHO SDG Target 3.1 Maternal mortality . (2023). Who.int. https://www.who.int/data/gho/data/themes/topics/sdg-target-3-1-maternal-mortality# Additional Declarations No competing interests reported. Cite Share Download PDF Status: Under Revision Version 1 posted Editorial decision: Revision requested 08 Sep, 2025 Reviews received at journal 06 Sep, 2025 Reviews received at journal 01 Sep, 2025 Reviews received at journal 26 Aug, 2025 Reviewers agreed at journal 19 Aug, 2025 Reviewers agreed at journal 17 Aug, 2025 Reviewers agreed at journal 16 Aug, 2025 Reviewers agreed at journal 15 Aug, 2025 Reviewers agreed at journal 14 Aug, 2025 Reviewers invited by journal 14 Aug, 2025 Editor invited by journal 08 Aug, 2025 Editor assigned by journal 07 Aug, 2025 Submission checks completed at journal 07 Aug, 2025 First submitted to journal 03 Aug, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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Zahid Hasan Jibon","email":"data:image/png;base64,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","orcid":"","institution":"University of Dhaka","correspondingAuthor":true,"prefix":"","firstName":"Md.","middleName":"Zahid Hasan","lastName":"Jibon","suffix":""}],"badges":[],"createdAt":"2025-08-03 07:08:06","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-7281727/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-7281727/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":89260382,"identity":"abf7c6ae-be30-42c0-aa96-9c974e7ce642","added_by":"auto","created_at":"2025-08-18 06:45:28","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":858860,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7281727/v1/f7c1ad7a-c164-49e7-a989-cad77eb2ad2e.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Cultural Beliefs and Maternal Health Practices in Rural Bangladesh: A Phenomenological Study","fulltext":[{"header":"Background","content":"\u003cp\u003eMaternal mortality is one of the main public health issues in low and middle-income countries. It contributes significantly to the health status of a country. It is driven by multiple factors connected to maternal health, including poverty, food insecurity, inadequate healthcare access, and different socio-cultural factors (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e). Though Bangladesh has significantly reduced the maternal mortality ratio from 6.48 per 1000 in 1986 to 1.56 per 1000 in 2022, it still faces persistent challenges (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e).\u003csup\u003e1\u003c/sup\u003e Though Bangladesh made remarkable progress, the rate is far above the SDG target of 3.1, which is to reduce the maternal mortality ratio to less than 70 per 100,000 live births.\u003csup\u003e2\u003c/sup\u003e Maternal health is influenced by various biological, environmental, economic, and socio-cultural factors, such as socioeconomic background, gaps in healthcare infrastructure, early marriage, adolescent pregnancy, living conditions, cultural beliefs, etc., (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eCultural beliefs and practices are learned, shared, and passed down through generations, which play a crucial role in shaping overall health behavior, especially maternal health behaviors (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e). These beliefs influence the perception of health risks, eating habits, daily routines, and health-seeking behavior throughout pregnancy and the postpartum period (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eExisting theories of health behavior, like the health belief model (HBM) and the theory of planned behavior (TPB), provide a logical framework for a better understanding. For example, the HBM emphasized the perceived cost-benefit analysis for the cue-to-action, while the TBP focused on individuals' intentions, attitudes, perceptions of behavioral control, and cultural approval for understanding their behavior. However, these lack the overall understanding of the interplay between cultural beliefs \u0026amp; practices with the health behavior of individuals (\u003cspan additionalcitationids=\"CR10\" citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e–\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e). In contrast, Foggs’ behavioral model (FBM), developed in the early 2000s, offered a comprehensive lens for studying behavior change across generations within the same cultural context. The FBM integrates motivations that enable individuals to learn the intergenerational culture, the ability to perform a certain behavior, and the triggers that serve as cues to action. According to the theory, motivation comes from intrinsic social norms, values, and familial expectations. The ability is influenced by knowledge, skills, access to resources, and societal support systems, enabling individuals' engagement with cultural practices. Finally, family traditions, cultural celebrations, community events, or significant life events reinforce the importance of cultural practices and trigger behavior change across generations (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eIn Bangladesh, especially in rural areas, beliefs like following a specific dietary pattern or relying on traditional care practices for any pregnancy-related issues remain widespread. While some of these align with positive health outcomes, others contribute to delays in seeking medical care or harnessing the benefits of modern healthcare facilities (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e). These include beliefs like the pregnancy is a natural process of reproduction, and women do not need any external help or medical support during this period (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e). Though different influencing factors like child marriage, power relationships in the family, infrastructures, and husbands’ involvement in maternal care, such as ante-natal visits, have been identified and taken into action, the existence and role of cultural, communal, and personal beliefs and practices, which are the prominent factors influencing maternal health outcome, has not gained enough importance yet and remained overlooked (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eExisting pieces of work have focused on the role of cultural beliefs and practices in shaping pregnancy and postpartum care. For example, despite the prevalence of postpartum illnesses, rural women chose to seek help from traditional healers who are believed to possess exclusive curative abilities, and the illness is identified as an effect of supernatural forces (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e). The persistent beliefs in traditional birth attendants, despite their education and training status, indicate the toughness of ongoing cultural practices. These perceptions highlight the profound influence of cultural beliefs on maternity care, requiring personalized interventions in specific contexts to improve the well-being of mothers and newborns (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eThe classical pieces of work done by Blanchet and Maloney in the 1980s and recent works on these beliefs and practices have focused on specific beliefs and practices and their impact on health, specifically on antenatal health. Additionally, the Bangladesh Demographic and Health Survey (BDHS) primarily emphasizes quantifiable health indicators, such as antenatal visits and institutional deliveries, while overlooking the qualitative impact of cultural beliefs and practices (\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e). These gaps indicate a need for a comprehensive study of the existing beliefs and practices during the total pregnancy to the early postpartum period.\u003c/p\u003e\u003cp\u003eThis study aimed to explore the existing beliefs and practices among women during their pregnancy, childbirth, and early postnatal period. The findings of this study will provide a deeper understanding of crucial cultural contexts of maternal and child health for developing context-based, effective interventions and policies.\u003c/p\u003e"},{"header":"Methods and materials","content":"\u003cp\u003e\u003cb\u003eStudy Design\u003c/b\u003e\u003c/p\u003e\u003cp\u003eThe study employed a combination of qualitative and phenomenological research designs. This research design is the best fit for exploring cultural beliefs and practices from individuals' lived experiences (\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e). Phenomenological research design has been identified as the best fit for this study for the descriptive nature of its aim of exploring the existing cultural beliefs and practices among women regarding their maternity period in Bangladesh (\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e). Creel \u0026amp; Tillman in 2008 used this research design to understand the lived experience of spirituality from the never-before-heard voices of ill patients with no religious affiliation, and findings are relevant for the body of knowledge of nursing related to spirituality for persons living with chronic or terminal illness (\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e). Another study on study aimed at examining and exploring the meanings, structures, and essence of the lived experiences of Muslim women while seeking to advance knowledge of how Islam, as a religion, can promote gender equality via an Islamic theological (Allah’s Kalam) framework (\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e). Empirical researchers have used this study design to delve into personal perspectives, context, and hidden meanings within cultural practices, leading to a deep and empathetic understanding. It helps researchers grasp diverse interpretations, variations, and symbolic significance in a culture, informing culturally sensitive initiatives and policies (\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e, \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003cb\u003eSettings\u003c/b\u003e\u003c/p\u003e\u003cp\u003eThe study was conducted in the Shahzadpur upazila of the Sirajganj district, which has a cultural setting based on the local Islamic shrines that dates back almost four hundred years. The Shrine plays a special role in developing communal harmony in society. This area of study has been selected for its cultural richness and diverse religious groups (\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e, \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003cb\u003eStudy population and sampling strategies\u003c/b\u003e\u003c/p\u003e\u003cp\u003eThe potential participants for the study were mothers with children aged 12 years or younger, with the age limit set to minimize recall bias. Study participants were selected from the women living close to the Mazar, as this vicinity offers a culturally and religiously rich context where cultural and religious beliefs and practices are particularly prominent.\u003c/p\u003e\u003cp\u003eThe sampling and data collection process was determined by the saturation of the ideas (\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e). In this study, we selected 32 mothers who had at least one successful pregnancy or the oldest child under 12 years old using a purposive sampling method. The data collection tool consisted of questions regarding their experiences, the supervision they received, and the practices they followed throughout their pregnancy, childbirth, and postnatal period.\u003c/p\u003e\u003cp\u003e\u003cb\u003eData collection\u003c/b\u003e\u003c/p\u003e\u003cp\u003e The field interview guide consisted of semi-structured, open-ended questions, was used to conduct in-depth face-to-face interviews with the participants lasting 30 to 45 minutes. The topic guide aimed to explore the mothers' lived experiences, beliefs, practices, and reasons for their actions and beliefs. The tool comprised relevant prompts on the lived experiences surrounding pregnancy, childbirth, and the postnatal period. The topic guide included prompts on participants' beliefs and practices related to protection and diet before and after delivery, workload during pregnancy, and health beliefs and practices. It also explored their first exposure to these beliefs and the reasons for following them. Additionally, the guide covered their perceptions of modern healthcare facilities, the use of modern healthcare services, the place of delivery, and postnatal arrangements for both mother and child. The tools used to collect data were prepared in English, later translated into Bengali, and pre-tested to check their appropriateness to the local context. Since the qualitative study needs an immersion process, the researchers collected data using mobile recorder technology with the verbal consent of the respondents. Additionally, keynotes were taken to complement and contextualize their verbal responses.\u003c/p\u003e\u003cp\u003e\u003cb\u003eMaintaining trustworthiness\u003c/b\u003e\u003c/p\u003e\u003cp\u003eQuality assurance controlling mechanisms were employed throughout the entire research process to ensure trustworthiness. The supervisor monitored and directed the research throughout the entire time, especially during the data collection process. During data collection, the audio recordings were transcribed on the same day of data collection. The verbatim transcriptions were translated into English for analysis. The translated data were read line by line repeatedly to understand the context and meanings used to increase immersion in the data.\u003c/p\u003e\u003cp\u003e\u003cb\u003eData analysis process\u003c/b\u003e\u003c/p\u003e\u003cp\u003eThe translated data were cleaned and imported into NVivo version ten for analysis. Using an open coding system, the data were coded into meaningful contexts. Deeper immersion into data with repeated reading, creating themes, subthemes, categories, and coding was used for data analysis. The codes were combined into different themes and sub-themes.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eThirty-two participants were selected for the study to explore their lived experiences, beliefs and practices, exposure, and reasons for following those beliefs. The age of the participants ranged between 18 to 34, with only 2 having secondary or higher educational qualifications and 1 from the upper economic class.\u003c/p\u003e\u003cp\u003e\u003cb\u003eTheme 1: Believing fertility or pregnancy is God-gifted\u003c/b\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003eSpiritual beliefs and practices for pregnancy\u003c/b\u003e\u003c/p\u003e\u003cp\u003eSpiritual beliefs are deeply rooted in the maternal practices of women in the rural areas of Bangladesh, where they often see it as a divine blessing. Women rely heavily on the religious rituals and guidance of spiritual leaders to ensure a successful gestation period. Some claimed to see spiritual entities in their dreams and receive the guidance of getting ‘\u003cem\u003ePani Pora\u003c/em\u003e’ (Holy Water), and \u003cem\u003eJharfuk\u003c/em\u003e (Blessings) to be blessed with a child, and later on, they drank and became pregnant with a child.\u003c/p\u003e\u003cp\u003e\u003cem\u003e\"...One day, Huzur came into my dream and told me that I was doing so much that I still did not have children. Why don't you come to me and take the Pani Pora (Holy water)? Then you will be blessed with children by Allah. Later, I went to Huzur and asked for Pani Pora... After drinking those, I had a child.\" (33 years old, mother of four)\u003c/em\u003e\u003c/p\u003e\u003cp\u003eThe reliance on spiritual practices is stronger among the women who experienced difficulties in their previous pregnancies. Additionally, participants have expressed their strong intention to make vows to donate materialistic items, livestock, and feed people around specific religious holy places, and nafal prayer for their desired outcome related to the unborn and newborn.\u003c/p\u003e\u003cp\u003e\u003cem\u003e\"...After my daughter was born, her condition was severe, as she would not survive. After I came back from Sirajganj for five days, one of my aunts said that I should take a vow, a vow for my daughter's life. And I did that. When my daughter was 40 days old, I went to Badal Bari (A local spiritual place) one day and donated two baby pigeons. After a while, when my daughter had diarrhea for 3 months, no medicine helped. I vowed again that if my daughter's diarrhea were cured, I would fast and pray at Badal Bari.\" (18 years old, mother of one)\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003eBeliefs on medical intervention\u003c/b\u003e\u003c/p\u003e\u003cp\u003eModern medicine is also acknowledged to play a pivotal role during the pregnancy period, and the local doctors and FWAs were the key distributors of assistance needed. Along with medical intervention for pregnancy, several participants consult with herbal medicine specialists for their problems and seek cures. The participants expressed both approaching modern medicine first, then herbal medicine, and vice versa, if they failed to get any solution in the first attempt.\u003c/p\u003e\u003cp\u003e\u003cem\u003e“....We were trying to have a baby for over a year, I took medicine from local doctors and Kaviraj for that. But nothing happened. Then I went to a doctor in Bogura. He gave me some medicine and I got pregnant.” (24 years old, mother of two)\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003e“...I went to see many doctors and took so many medicines, but I did not have any children. Then, I went to Kaviraj and had treatment. After that, I had a child. Kaviraj told me to vow that I would give a Pata made of gold the weight of my son’s hair’s weight.” (22 years old, mother of one)\u003c/em\u003e\u003c/p\u003e\u003cp\u003eA trend of combined beliefs on medical intervention and spiritual practices can be seen among women for getting blessed with a child. Participants' statements about going to the hospital and having faith in vows, blessings from huzur, and pani pora are like healthcare services, and doctors are the medium for spirituality to be fruitful for a successful pregnancy.\u003c/p\u003e\u003cp\u003e\u003cb\u003eTheme 2: Certain dietary practices are essential to follow\u003c/b\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003eFood patterns during pregnancy\u003c/b\u003e\u003c/p\u003e\u003cp\u003eParticipants had almost similar responses regarding their dietary pattern, followed by avoiding foods that might cause allergic reactions, sweet pumpkin, and different fruits like papaya, pineapple, and extra-sour food, believing these foods might cause miscarriage and pregnancy complications.\u003c/p\u003e\u003cp\u003e\u003cem\u003e“...I have had no problem with any food during pregnancy, but the elders had forbidden me to eat papaya and pineapple. They say these are harmful to the unborn child and may cause an abortion if taken.” (27 years old, mother of two)\u003c/em\u003e\u003c/p\u003e\u003cp\u003eSome avoid nutritious fruits and vegetables to limit the growth of the fetus; on the contrary, eating a full meal, believing in an empty womb, is one of the reasons for the baby to grow larger.\u003c/p\u003e\u003cp\u003e\u003cem\u003e“...I ate everything, and I always ate a full stomach because I learned from the elders that the baby will grow larger if the stomach is empty.” (33 years old, mother of three)\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003eFood patterns during the postnatal period\u003c/b\u003e\u003c/p\u003e\u003cp\u003eDuring the postnatal period, women expressed that they have followed the same dietary practices as during their pregnancy, avoiding allergic foods, dairy products, and intake only nutritious foods, and fruits that increase milk production and hasten the healing of wounds.\u003c/p\u003e\u003cp\u003e\u003cem\u003e“...They did not give the puti and prawns. Saying that the son's placenta in the stomach will not heal. For 2 or 3 days, I used to eat these with Kalozira (black cumin) and mach bhorta (Mashed Fish). They also fed me specific fish and pigeons.” (33 years old, mother of four)\u003c/em\u003e\u003c/p\u003e\u003cp\u003eThe participants hardly discussed any rituals or practices other than feeding honey or \u003cem\u003eMisrir Pani\u003c/em\u003e (Sweet syrup made with sugar) to the child, believing this action would make the child a sweet talker and of good nature in the future. Furthermore, they expressed their desire to feed mothers’ breast milk as soon as possible.\u003c/p\u003e\u003cp\u003e\u003cem\u003e“...Breast milk and honey. Sweet water was also given. It is better to give honey. It is said that the Prophet was fed with honey at first, so it’s a sunnah. My baby got breastmilk after 12 hours. (27 and 33-year-old mothers)\u003c/em\u003e\u003c/p\u003e\u003cp\u003eAfter a certain period, Muslims perform the \u003cem\u003eMukhe Vaat\u003c/em\u003e (First Oral Feeding) rituals, where some can celebrate it, and some cannot due to their financial condition. On the other hand, the Hindus are bound to keep a \u003cem\u003eNarayani Puja\u003c/em\u003e ceremony to celebrate \u003cem\u003eMukhe Vaat\u003c/em\u003e. It is their religious ritual, and they have to perform this for their child.\u003c/p\u003e\u003cp\u003e\u003cb\u003eTheme 3: Health-seeking behavior during pregnancy and delivery\u003c/b\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003eModern healthcare facilities are for troubled pregnancies.\u003c/b\u003e\u003c/p\u003e\u003cp\u003ePerception of health-related beliefs among the participants depends on their household conditions, preconceptions of health-seeking behaviors, and supervision from the older generations. They believed that healthcare facilities or medical centers were only for complicated pregnancies, and \u003cem\u003eDais\u003c/em\u003e was good enough for them.\u003c/p\u003e\u003cp\u003e\u003cem\u003e“...There is no need for doctors or kabiraj (traditional healers) if the position of the baby in the womb is good… In our area, we usually call the Dais (TBAs). But if there is an issue and no solution can be found, then we go to the doctor.” (33 and 35 years old, mother of four and three)\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003eRelying on traditional birth attendants for normal delivery\u003c/b\u003e\u003c/p\u003e\u003cp\u003eThe idea of modern healthcare services is only for troubled pregnancies, and also affects their first antenatal care visit, which is somewhere between the 7th and 8th month of pregnancy for most of them. Some of the participants agreed that traditional birth attendants are more experienced, thus, they are good for normal delivery, and the mother doesn't have any kind of complications.\u003c/p\u003e\u003cp\u003e\u003cem\u003e“...I have not gone to see a doctor since I was pregnant. When I was 9 months pregnant, I went to do an ultrasonogram, but I did not go there willingly. Apart from that, I did not take any medicine.” (21 years old, mother of two)\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003eExperience changes health-seeking behavior.\u003c/b\u003e\u003c/p\u003e\u003cp\u003eOn the contrary, women who have experienced complications, miscarriage, or stillbirth in their previous pregnancies expressed changes in their health-seeking behavior and availed modern healthcare services from the early phase of pregnancy.\u003c/p\u003e\u003cp\u003e\u003cem\u003e“...I took health services from the medical staff. As my first pregnancy was a miscarriage, I was scared. I stayed cautious and followed everything the doctor said to me. I did ultrasonography 3/4 times. After doing that, the doctor said that the baby was healthy.” (22 years old, mother of one)\u003c/em\u003e\u003c/p\u003e\u003cp\u003eThis statement is also true for those who have witnessed someone else face a complicated pregnancy and change their health-seeking behavior.\u003c/p\u003e\u003cp\u003e\u003cb\u003eTheme 4: Following certain rules is important for both successful childbirth and the newborn child’s future\u003c/b\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003eCultural Precautionary Practices During Pregnancy\u003c/b\u003e\u003c/p\u003e\u003cp\u003eInterviews have highlighted some seemingly unrelated practices followed by the women, believing these are good for pregnancy. All of the participants believed in the elders’ chaotic nature as the \u003cem\u003eVari Nissash\u003c/em\u003e and always gave the services necessary to please them and their good wishes. Additionally, they believed that unpleasant elders can bring harm to the unborn child.\u003c/p\u003e\u003cp\u003e\u003cem\u003e“...My mother-in-law used to say that the delivery process of the baby would be smooth like oil if you gave oiled elders’ hair. So, I did that before I went to my mother’s house.” (33 years old, mother of four)\u003c/em\u003e\u003c/p\u003e\u003cp\u003eMoreover, some women reported believing that using bandages or tying a petticoat tightly on the upper belly is good for easing delivery and avoiding complications.\u003c/p\u003e\u003cp\u003e\u003cem\u003e“...I took the Paat Pora (heated rope tied on the belly softly) because of my stomach ache. My stomach aches so much that I was scared that I would have a miscarriage. That is why I took it.” (21 years old, mother of two)\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003ePostpartum practices\u003c/b\u003e\u003c/p\u003e\u003cp\u003eThough the participants availed of at least one antenatal care visit, the majority of the women believed that they did not need any kind of postpartum care other than resting till postpartum bleeding stopped. Also, those who had institutionalized delivery had an involuntary stay of at least two days to ensure postpartum care access for the mother and newborn child.\u003c/p\u003e\u003cp\u003e\u003cem\u003e“...My stomach has been in pain for two days before the delivery. When there was no sign of delivery, but high pain, my husband called an auto to get me to the Shahjadpur Upazila Hospital. I gave birth on the way; the delivery was normal, so we came back.” 22 years old, mother of two)\u003c/em\u003e\u003c/p\u003e\u003cp\u003eSome participants believe that if the placenta is buried near educational institutions, their child will grow up to be very fond of education and become an educated person. Along with other practices, they also try to perform this one.\u003c/p\u003e\u003cp\u003e\u003cem\u003e“...Elders say that if the placenta is placed around schools and madrasas, then the future of the child is bright.” (33 years old, mother of three)\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003eTheme 5: Beliefs in supernatural power\u003c/b\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003ePregnant women must be protected from evil spirits.\u003c/b\u003e\u003c/p\u003e\u003cp\u003eBeliefs in supernatural phenomena are common among women and heightened during their pregnancy period. The participants also believed that only the traditional healers (Ojha, kabiraj, Huzur) could help them overcome the effects of supernatural forces.\u003c/p\u003e\u003cp\u003eWhile most of the participants believed in the effect of supernatural forces, some claimed to have experienced such kinds of events.\u003c/p\u003e\u003cp\u003e\u003cem\u003e“...Once, I went through the bamboo bush while pregnant with my son. I felt as if someone was following me from behind. Then I looked back and saw that there was no one. When I came back, my body became very heavy, and after a few days, my baby died. From then on, I would stop walking around these places.” (33 years old, mother of four)\u003c/em\u003e\u003c/p\u003e\u003cp\u003eWomen discussed various initiatives to avoid falling into such kinds of events. These included activities like limiting outside roam, avoiding certain places at certain times, and using amulets and other specific things with them to be protected from \u003cem\u003eBod Nojor\u003c/em\u003e or evil spirits.\u003c/p\u003e\u003cp\u003e\u003cem\u003e“...Yes, I took the Rakshi (Hindu amulet). I closed my body (Ga Bondho kora). So that the child in me does not get any harm. So, I took it; I put it on my body and neck. I believed that the child would be healthy if I kept the amulet.” (22 years old, mother of two)\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003eBoth mother and newborn must be protected.\u003c/b\u003e\u003c/p\u003e\u003cp\u003eWhile precautions were taken to protect pregnant mothers from the perceived effects of supernatural forces during pregnancy, these arrangements intensified after delivery. Mothers who delivered in hospitals typically needed to follow fewer safety measures for such concerns, whereas others had to adhere to certain traditional practices to ensure their safety.\u003c/p\u003e\u003cp\u003eBoth Hindu and Muslim participants discussed a similar traditional post-delivery living arrangement called \u003cem\u003eAtur Ghor\u003c/em\u003e. Depending on the economic condition, this might be a separate room or a separate part of a room, covered with materials like written mantras, cow bone, active fireplaces, and many others, to protect the mother and newborn child. According to these beliefs, the mother is considered unholy and susceptible after childbirth, potentially attracting unwanted attention to herself and her baby. To ward off such spirits, she is often required to carry iron objects or matches, which are thought to repel malevolent forces.\u003c/p\u003e\u003cp\u003e\u003cem\u003e“...Around the room where the mother and the child are kept, elderly people always keep cow bones, sacred prayers are written (Gita path), and iron, matchlight \u0026amp; and fire in the room. I also fear evil things (Atta, Deu-Doitto) and I believe they can bring harm to my baby as well.” (22 years old, mother of two)\u003c/em\u003e\u003c/p\u003e\u003cp\u003eMany participants believed that if the placenta (\u003cem\u003eGorvoful\u003c/em\u003e) is exposed to heat (\u003cem\u003eGorom Batash/Sapa Batash\u003c/em\u003e) or dragged by stray animals, it could harm the child, potentially causing vomiting or leading to serious health conditions. To prevent this, they ensure the placenta is properly wrapped in fresh cloth and buried deeply in the earth.\u003c/p\u003e\u003cp\u003e\u003cem\u003e“...The placenta has to be put under the ground. If it stays outside, it may harm the baby. The baby will vomit and will have many health conditions, so it is better to bury it under the ground.” (24 years old, mother of two)\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003eSource and reason for adhering to the beliefs and practices\u003c/b\u003e\u003c/p\u003e\u003cp\u003eBeliefs are shaped through various means, with personal experience being the most significant factor. While the sources of information were older generations of the family, most of the participants strongly emphasized their own experiences in believing in vows, amulets, and supernatural phenomena.\u003c/p\u003e\u003cp\u003e\u003cem\u003e“...I did not believe in anything during the first child, but when the second child was miscarried and the third child was born, then, I started to believe that I had to be careful.” (27 years old, mother of two)\u003c/em\u003e\u003c/p\u003e\u003cp\u003eDuring discussions about the origins of their beliefs, participants explicitly referred to the experiences of others, along with their own. Additionally, they emphasized that elders prescribed many of the restrictions and provisions they followed. These elders warned that failing to adhere to these practices could result in harm to both the mother and the child.\u003c/p\u003e\u003cp\u003e\u003cem\u003e“... My Khala (aunt) had a girl first. Then, she was pregnant with a baby boy. One day, while coming back from my grandmother’s house, she felt the Sapa Batash (Hot Wind) on the way, and she started vomiting after coming back to the house. Then, the baby miscarried. Then everyone said there was a road on the way from my grandmother's house, and that road was not good. After that, everyone said that this happened because of that road.” (18 years old, mother of one)\u003c/em\u003e\u003c/p\u003e\u003cp\u003eThese beliefs are shaped through the experiences of their own or someone else’s, and advocacy from the older generation has played a pivotal role in adhering to these beliefs and practices further.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eHealth, especially maternal health, is shaped by a complex interplay of different determinants like cultural beliefs, social structures, and personal practices (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e). This study explored the existing cultural beliefs and practices surrounding pregnancy, childbirth, and intermediate postpartum care, with a focus on their influences on maternal health outcomes in Sirajganj.\u003c/p\u003e\u003cp\u003eCultural beliefs and practices shape the perception of health and illness. These perceptions, in turn, influence health-related behaviors, which affect maternal health outcomes. Findings suggest that traditional beliefs often dictate the choices women make during pregnancy and childbirth. For example, the beliefs in supernatural causes of illness and reliance on traditional healers (Ojhas \u0026amp; Kaviraj) for remedies reflect deeply rooted cultural norms, which are also evident in previous studies (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e). Existing studies also shed light on these types of barriers to accessing modern healthcare services, as women perceive traditional practices as more effective or culturally approved (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e). These findings are supported by the Health Belief Model and the Theory of Planned Behavior. They show how cultural beliefs and personal views on risks and benefits affect changes in health behaviors (\u003cspan additionalcitationids=\"CR10\" citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eThe interplay is further strengthened by the impact of the socioeconomic background of the families. This study found that antenatal care is often prioritized only for high-risk pregnancies, with nutritional choices heavily influenced by family income and cultural norms. Participants also reported relying more on traditional birth attendants and avoiding healthcare facilities as long as they could. The findings are consistent with prior studies, showing that socioeconomic background impacts nutrition and healthcare decisions during pregnancy (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e). In contrast, findings also suggest that solvent families might incorporate a combination of traditional and modern practices, reflecting a complex dynamic influenced by both economic means, cultural norms, and the decision-making power held by women (\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eThe influence of elder family members often overshadows these dynamics, as they uphold traditional beliefs and practices. Such hierarchical structures perpetuate cultural norms that can have both positive and negative impacts on maternal health (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e). The study shed light on the enduring nature of traditional practices despite advancements in healthcare practices and education. Certain customs like avoiding specific foods, relying on herbal remedies, and using spiritual protections (e.g., amulets) are often reinforced by the older generations, creating a cycle of adherence to traditional practices deeply rooted in familial and communal beliefs. For example, women\u0026rsquo;s dietary restrictions, such as avoiding papaya and pineapple due to fears of miscarriage, reflect cultural beliefs that prioritize safety over scientific evidence. A study on the \u003cem\u003eManoshi\u003c/em\u003e program participants compared the differences in maternal health indicators between slum and non-slum areas in urban, reported that women tend to maintain practices and behaviors similar to those of rural areas, despite having increased access to health services in the urban areas, marking the cultural concerns might be a substantial barrier in seeking antenatal care (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e). Some of the findings on postpartum rituals from this study, such as the use of \u0026ldquo;Atur Ghor\u0026rdquo; (a special confinement space) and the burial of placentas near educational institutions, directly align with work from the 1980s. While some of these may offer psychological comfort, they often delay or substitute essential medical interventions (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eDespite the influence of cultural beliefs and practices in shaping maternal health behavior, this study found a gradual shift in those cultural beliefs and practices due to several factors such as increased exposure to education, healthcare services, and urbanization. However, the study also found that past experiences related to pregnancy complications or witnessing adverse outcomes of others as the prominent drivers in this shift. Women with these experiences are more likely to seek modern healthcare services early. This shift reflects a combination of experiential learning and structural improvements in healthcare accessibility. As evident in the existing pieces of literature, the persistence of traditional birth attendants and home-based deliveries indicates that the transition toward modern healthcare is not uniform and largely context-dependent (\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e, \u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eDespite these changes, the hesitancy to fully embrace institutional deliveries and postnatal care remains a significant challenge. Integrating these cultural dimensions into the mainstream national health surveys could provide a broader understanding of maternal health dynamics.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eIn this exploratory study, findings showed a complex interplay between culturally established beliefs and practices and health-seeking behavior among women during their pregnancy, childbirth, and early postpartum period.\u003c/p\u003e\u003cp\u003eThe study shed light on the beliefs and practices of fertility, a deeper belief in the heavenly nature of pregnancy, attributing conception to a higher level of spiritual object. Participants also expressed spiritual influence during pregnancy, childbirth outcomes, and postpartum safety, and reported limiting their outdoor activities and performing different activities to ward off evil spirits. These highlight the pervasive influence of spiritual beliefs to protect both mother and child from negative spiritual forces influencing maternal health behavior. After childbirth, different kinds of living arrangements were promoted as it would protect them from any evil spirit trying to harm the impure mother and newborn, similar to the findings of Maloney and Blanchet in the 1980s. They also focused on different kinds of oaths (Manots) to protect themselves from any potential harm from the evil spirit or wish good health and fortune for the child.\u003c/p\u003e\u003cp\u003e High attention was paid to the dietary practices, as the participants followed specific food practices. They followed a strict diet of not eating a full stomach during pregnancy, believing this would push fetal growth and might cause pregnancy complications. Though this could potentially be a reason for underweight offspring, their dietary practices during postpartum were focused on the health of the wound and increasing breastmilk.\u003c/p\u003e\u003cp\u003eThe study also highlighted the gradual shift among the participants, outlining the possibility of future change with proper interventions. Despite advancements in medical care facilities, the participants hold a deepened commitment to their shared spiritual beliefs, perceiving modern healthcare as just a medium for spiritual help for health issues. This sophisticated approach combined both traditional and modern approaches, reflecting a deep connection of the cultural side in shaping maternal health behavior among women. However, the deep-rooted beliefs and practices combined with limited knowledge, accessibility, and affordability hamper the participants' ability to seek medical care, particularly in cases of complicated pregnancy.\u003c/p\u003e\u003cp\u003eThis study has highlighted a delicate balance between cultural continuity and intention of adaptation in response to changing social, economic, and environmental factors. Despite changes in the social norms and healthcare practices, the participants maintained a strong collaborative approach with their cultural heritage, preserving the beliefs and practices passed down from their previous generations. This flexibility emphasizes the importance of incorporating cultural sensitivity into maternal healthcare interventions, ensuring that healthcare practices align with the beliefs and values of the communities they belong to.\u003c/p\u003e\u003cp\u003eThis study provides significant insights into the intersection of cultural beliefs, healthcare practices, and maternal health outcomes in the Sirajganj district. By understanding the degrees of these beliefs and practices, healthcare providers and policymakers can develop more culturally sensitive interventions to prioritize community engagement and empowerment, fostering partnerships between healthcare providers and local communities to ensure that maternal healthcare services are readily accessible, acceptable, and effective for all women, not only in Sirajganj district but also everywhere in the country.\u003c/p\u003e\u003cp\u003e\u003cb\u003eLimitations of the Study\u003c/b\u003e\u003c/p\u003e\u003cp\u003eDespite the valuable insight obtained from this study on cultural beliefs and practices surrounding the pregnancy, childbirth, and postpartum period in the Sirajganj district, it is essential to address the limitations inherent in the study design, sample characteristics, and contextual factors. Further studies should aim to mitigate the limitations of this study to enhance the validity, reliability, and applicability of the findings.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study was conducted in accordance with the Declaration of Helsinki. Ethical approval was granted by the Institutional Review Board (IRB) of the Institute of Health Economics, University of Dhaka. This review board is registered with the Federalwide Assurance (FWA) for the Protection of Human Subjects and is authorized to ensure that research methodologies protect the rights and welfare of all participants. Verbal informed consent was obtained from all participants before the interviews. The research team explained the study\u0026apos;s purpose, the voluntary nature of participation, and the right to withdraw at any time. The use of verbal, rather than written, consent was approved by the IRB to suit the local context and potential literacy levels of the participants\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for Publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and material\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets generated and analyzed during this study are the property of the Department of Population Sciences, University of Dhaka. To protect participant privacy and confidentiality, the data are not publicly available. However, data may be available from the corresponding author upon reasonable request, pending formal approval from the Department of Population Sciences.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting Interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNo potential conflict of interest was reported by the authors.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNo grant received for the study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor Contribution\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAHMKH and MZHJ contributed equally to the conception and design of the study, data collection, analysis, and manuscript writing. Both authors read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgment\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors express their gratitude to all the mothers who took part in this study. It is noteworthy that this article is an excerpt from a Master\u0026rsquo;s Thesis.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eKhan NU, Asif N, Miraj MA, Khalid H, Awan T, Bin, Khan MA et al. Understanding maternal mortality: A multifaceted analysis of demographic, temporal, and contextual factors. 2024;1\u0026ndash;15.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eThompson E, Moore J. Addressing Health Inequities in Maternal and Child Healthcare. In Low- Income Communities. 2024;(2):23\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eBangladesh Bureau of Statistics. Bangladesh Sample Vital Statistics. 2022. Statistics and Informatics Division, Ministry of Planning, Government of the People\u0026rsquo;s Republic of Bangladesh. 2023.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eNour NM. Child marriage: a silent health and human rights issue. Rev Obstet Gynecol. 2009;2(1):51\u0026ndash;6.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eNoor R, Rushdi Saif A. Access to Maternal Healthcare in Rural Bangladesh: A literature-based Analysis on Factors Affecting Maternal Healthcare Utilization in Bangladesh. J Armed Forces Med Coll Bangladesh. 2021;16(1):69\u0026ndash;75.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eKılı\u0026ccedil;oğlu EA, Ergin B, Ergin E. Transmission of Family Culture The Case of Grandmother, Mother and Granddaughter. Int J Progress Educ. 2023;19(5):26\u0026ndash;40.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMaloney C, Aziz KMA, Sarker PC. Beliefs and Fertlity in Bangladesh. ICDDR,B. 1981.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eAnsong J, Asampong E, Adongo PB. Socio-cultural beliefs and practices during pregnancy, child birth, and postnatal period: A qualitative study in Southern Ghana. Cogent Public Heal. 2022;9(1).\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eBecker MH. The Health Belief Model and Sick Role Behavior. Health Educ Monogr. 1974.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eRosenstock IM. The Health Belief Model and Preventive Health Behavior. Health Educ Monogr. 1974;2(4).\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eAJZEN I. Theory of Planned Behavior. Organ Behav Hum Decis Process. 1991;50(1):179\u0026ndash;211.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eFogg B. Fogg-persuasive behavior. Behav Model Persuas Des. 2009;7.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eChoudhury N, Moran AC, Alam MA, Ahsan KZ, Rashid SF, Streatfield PK. Beliefs and practices during pregnancy and childbirth in urban slums of Dhaka, Bangladesh. BMC Public Health. 2012;12(1):1.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eChoudhry UK. Traditional practices of women from India: pregnancy, childbirth, and newborn care. J Obstet Gynecol Neonatal Nurs. 1997;26(5):533\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eAhmmed F, Ahmed T. Influence of the Socio-cultural Factors in Health-Seeking Behaviour of Women during Pregnancy in Rural Bangladesh. J Exclusion Stud. 2014;4(1):1.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eJannat Z, Ali MW, Alam N, Uddin MJ. Factors affecting practices of recently delivered women on maternal and neonatal health care in selected rural areas of Bangladesh. BMC Pregnancy Childbirth. 2023;23(1):1\u0026ndash;15.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eJahan N, Islam MS. Early Postnatal Care Practices for Mothers and Their Babies in Bangladesh: An Integrative Literature Review. Open J Soc Sci. 2022;10(02):258\u0026ndash;70.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eGoodburn EA, Gazi R, Chowdhury M. Beliefs and practices regarding delivery and postpartum maternal morbidity in rural Bangladesh. Stud Fam Plann. 1995;26(1):22\u0026ndash;32.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eAyaz S, Yaman Efe S. Potentially harmful traditional practices during pregnancy and postpartum. Eur J Contracept Reprod Heal Care. 2008;13(3):282\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eRoss JL, Laston SL, Nahar K, Muna L, Nahar P, Pelto PJ. Women\u0026rsquo;s health priorities: Cultural perspectives on illness in rural Bangladesh. Health (Irvine Calif). 1998;2(1):91\u0026ndash;109.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eNguyen PH, Sanghvi T, Kim SS, Tran LM, Afsana K, Mahmud Z, et al. Factors influencing maternal nutrition practices in a large scale maternal, newborn and child health program in Bangladesh. PLoS ONE. 2017;12(7):1\u0026ndash;17.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eNational Institute of Population Research and Training (NIPORT). ICF. Bangladesh Demographic and Health Survey 2022 Final Report. 2024.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eBadil. D, Muhammad DDM, Zeenaf Aslam ZA, Kashif Khan KK, Anny Ashiq AA, Uzma Bibi UB. Phenomenology Qualitative Research Inquiry: A Review Paper. Pakistan J Heal Sci. 2023;(April):09\u0026ndash;13.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eNeisser HP. The Phenomenological Approach in Social Science. Int Phenomenol Soc Philos Phenomenol Res. 1959;20(2):198\u0026ndash;212.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eCreswell JW. Qualitative Inquiry \u0026amp; Research Design: Choosing Among Five Approaches. Third. Sage; 2013. pp. 7823\u0026ndash;30.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eCreel E, Tillman K. The Meaning of Spirituality Among Nonreligious Persons With Chronic Illness. Holist Nurs Pract. 2008;303\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eGalloway SD. The Impact of Islam as a Religion and Muslim Women on Gender Equality: A Phenomenological Research Study. Nova Southeastern University; 2014.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eGroenewald T. A Phenomenological Research Design Illustrated. Int J Qual Methods. 2004;3(1):42\u0026ndash;55.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eBliss LA. Phenomenological Research. Int J Adult Vocat Educ Technol. 2016;7(3):14\u0026ndash;26.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eWali MA. Antiquity and Traditions of Shahzadpur. J Asiat Soc Bengal. 1904;(33):262\u0026ndash;71.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eRifat-Ur-Rahman M, Hasan M. Ritualistic Performance of Women Pilgrims in the Makhdum Shah Shrine, Sirajganj. Acad J EXIM Bank Agric Univ Bangladesh. 2021;(August).\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eUddin J, Hossin M, Mahbub F, Hossain M. Healthcare-seeking behavior among the chakma ethnic group in bangladesh: Can accessibility and cultural beliefs shape healthcare utilization? Int Q Community Health Educ. 2012;33(4):375\u0026ndash;89.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eAjzen I, Cote NG. Attitudes and the prediction of behavior. Atitudes Atitude Chang. 2008;(January 2008):289\u0026ndash;311.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMaria L, Dpt W, Ph D. Cultural Barriers To Maternal Health Care In Rural Bangladesh. Online J Heal Ethics. 2013;9(1).\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eBlanchet T. Meanings and Rituals of Birth in Rural Bangladesh: Women, Pollution, and Marginality. University; 1984.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eDutta GK, Sarker BK, Ahmed HU, Bhattacharyya DS, Rahman MM, Majumder R, et al. Mental healthcare-seeking behavior during the perinatal period among women in rural Bangladesh. BMC Health Serv Res. 2022;22(1):1\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eBandura A. Social learning theory. Gen Learn Press. 1971;115\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"},{"header":"Footnotes","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003e World Health Organization. (2022). \u003cem\u003eMaternal and perinatal death surveillance and response (MPDSR) in Bangladesh: Progress and highlights in 2022\u003c/em\u003e. WHO\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003e \u003cem\u003eSDG Target 3.1 Maternal mortality\u003c/em\u003e. (2023). Who.int. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.who.int/data/gho/data/themes/topics/sdg-target-3-1-maternal-mortality#\u003c/span\u003e\u003cspan address=\"https://www.who.int/data/gho/data/themes/topics/sdg-target-3-1-maternal-mortality#\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-pregnancy-and-childbirth","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"prch","sideBox":"Learn more about [BMC Pregnancy and Childbirth](http://bmcpregnancychildbirth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/prch/default.aspx","title":"BMC Pregnancy and Childbirth","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Cultural beliefs, maternal practices, pregnancy and postpartum, phenomenological study, spirituality and health","lastPublishedDoi":"10.21203/rs.3.rs-7281727/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7281727/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e\u003cp\u003eCultural beliefs and practices have been recognized as prominent determinants of health behavior by modifying the perception of health and illness in developing regions. This is one of the most overlooked areas due to its complexity in countries like Bangladesh. Though several studies addressed this as a pressing issue for advancing maternal health, their primary focus is on antenatal care and pregnancy. This study explored existing beliefs and practices among women during their pregnancy, childbirth, and postpartum period in the Sirajganj district.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e\u003cp\u003eThis study employed a qualitative research strategy accompanied by the phenomenological research design to derive a subjective interpretation of women\u0026rsquo;s life experiences during this time. Thirty-two study participants with their verbal consent were selected through the purposive sampling method, and in-depth interviews were conducted until data saturation was reached.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e\u003cp\u003eAmong all findings, believing an empty stomach causes the fetus to grow large, limiting movement due to avoiding spiritual attention, mostly for evil spirits, using amulets to be protected from these evil spirits, and special arrangements for \u0026ldquo;Atur Ghor\u0026rdquo; have been prominent.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e\u003cp\u003eWomen in the study area follow a modern approach combined with beliefs and commitment toward their culture that has been transferred from their previous generation, and a willingness to avail modern healthcare facilities.\u003c/p\u003e","manuscriptTitle":"Cultural Beliefs and Maternal Health Practices in Rural Bangladesh: A Phenomenological Study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-08-18 06:21:18","doi":"10.21203/rs.3.rs-7281727/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-09-08T15:01:35+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-09-06T16:00:50+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-09-01T05:20:11+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-08-26T06:53:09+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"135577292662615550143150480009911206181","date":"2025-08-19T23:43:42+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"165233638026330996772726485332074704085","date":"2025-08-18T03:34:56+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"201180408854250751451863306277054853030","date":"2025-08-16T04:40:36+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"279018705575077738585129210484335086674","date":"2025-08-15T10:18:58+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"168210846306088125483759609811566010635","date":"2025-08-15T01:32:34+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-08-14T18:24:40+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-08-08T08:29:08+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-08-07T04:06:36+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-08-07T04:05:44+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Pregnancy and Childbirth","date":"2025-08-03T06:54:42+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-pregnancy-and-childbirth","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"prch","sideBox":"Learn more about [BMC Pregnancy and Childbirth](http://bmcpregnancychildbirth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/prch/default.aspx","title":"BMC Pregnancy and Childbirth","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"285ba30f-d10a-4be4-9bd0-c45668025ea0","owner":[],"postedDate":"August 18th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"in-revision","subjectAreas":[],"tags":[],"updatedAt":"2026-05-11T12:36:15+00:00","versionOfRecord":[],"versionCreatedAt":"2025-08-18 06:21:18","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7281727","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7281727","identity":"rs-7281727","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}