Spiritual legitimacy as symbolic infrastructure in maternal health: A cross-cultural ethnography of the Akit Indigenous community in Indonesia

Maternal health in Indigenous communities is often interpreted through biomedical frameworks that under-recognise the moral and spiritual infrastructures shaping care-seeking and referral decisions. This ethnography examines how spiritual legitimacy operates as a symbolic infrastructure in maternal referral pathways among the Akit Indigenous community in Riau, Indonesia, where spiritual and biomedical authorities coexist. An interpretivist ethnography was conducted between September 2024 and March 2025 using in-depth interviews (n = 29), participant observation, and reflexive fieldnotes. Participants included bomoh (spiritual authorities), pregnant and postpartum Akit women, traditional birth attendants, community health workers, biomedical providers, and customary leaders. Data were analysed using Reflexive Thematic Analysis (RTA), emphasising reflexivity and analytic sufficiency. Five interlocking mechanisms constituted spiritual legitimacy as symbolic infrastructure for maternal decision-making: (1) anak inang (ritual kinship bond); (2) bedekeh – libun (ritual cleansing/restorative rite and ritual sealing/opening of pregnancy protection) regulating childbirth readiness; (3) selusuh (ritual blessing mixture) and amulets as material authorisation; (4) the bomoh as a collective decision-maker shaping timing, place, and permissible actions; and (5) a negotiated hierarchy in which biomedical interventions typically require prior spiritual approval. Together, these mechanisms generate moral time, determining when clinical escalation becomes socially legitimate. Maternal referral delays did not primarily reflect rejection of biomedical care but culturally mediated negotiations to secure spiritual safety and moral accountability before clinical escalation, highlighting the need for culturally safe referral governance.