Redeeming gender imbalances: How biblical interpretations effect women’s health in Indonesia

Several health indicators suggest that the level of women's health globally remains poor. Indicators such as maternal mortality, domestic violence, and stunting, particularly in Africa and Asia, are also linked to poor women's health. There is evidence that the poor quality of women's health parallels the prevalence of gender imbalance. One system supporting gender imbalance is the subjective interpretation of normative gender relations. To address this issue, this qualitative study makes use of the approach developed by Joan W. Scott covering four dimensions of analysis: symbols for both sexes in a culture, normative conceptions that follow these symbols, gender division, and subjective identity. This subjective research took place in the island of Nias, Indonesia where Christianity is the primary religion. The result of this study shows that certain interpretations of biblical verses have negatively impacted women, such as women being considered inferior to men, experiencing loss of opportunity to maintain health due to excessive work responsibilities, and risking mental and physical violence. Certain interpretations of biblical verses are believed and accepted as an absolute and fixed self-identity for Christians. An analysis of gender roles using an approach offered by an historian like Joan W. Scott accurately explains the power of religion-based symbols and norms in maintaining gender imbalance, which in turn, affect women’s health. A way forward is suggested to expand biblical interpretations which could increase equality and improve women’s health.


Introduction
Maternal mortality, poor health of women, and domestic violence against women remain complex global health issues for humanity. Another issue closely related to pregnancy and women's health is childhood stunting. These problems are suspected to be inextricably intertwined with gender inequality. [1][2][3][4][5][6] The issues of women's health are not equally distributed worldwide. After Africa, maternal mortality is concentrated in the eastern region, especially Asia. 7 Indonesia is among the countries with the highest rate of maternal mortality in Asia with the latest data showing 305 deaths per 100,000 live births. 8 In addition, the status of women is also closely related to the health status of children under five years. The Asian region contributed as many Dec 2022. Christian Journal for Global Health 9 (2) as 53 percent of global stunting cases in 2020. 9 Meanwhile, in Southeast Asia, three countries are the ones with high cases of stunting, and Indonesia sits highest on the list. 10 Up to the end of 2021, an official publication by the government revealed that stunting in Indonesia had reached 24.4 percent. 11 Likewise, violence against women occurs on a massive scale with a much higher prevalence in African and Asian regions. 12 The government officially reported that gender-based violence in Indonesia reached 338,000 cases in 2021 alone. 13 The conditions mentioned above reflect the unsettling realities of women's health status, which might be magnified by norms embraced by a particular society. The norms are perceived as social values that should be maintained.
Religion is one among other sources of societal norms. Unfortunately, religion has been proven to maintain and support gender imbalance in society. [14][15][16] These roles are hardly unchallenged since religion is believed to represent a sacred power. Although gender imbalance is not the direct teaching of the Church, the perceptions of some church congregations, derived from the Bible, have been their life inspiration for years. 17 Like a template, the Holy Bible is a life reference of believers' behavior, which Butler called "performativity." 18 Joan W. Scott offers a theoretical framework to understand gender-based imbalance and analyze its religious dimensions. 19 Joan W. Scott argues that gender norms are firmly established in Christianity employing religious symbols. Scott's analysis brings a new perspective on gender analysis, not only on the theoretical level, which was developed after the publication of her essay, 20 but also on the praxis level, something that will also be demonstrated in this paper. Women cannot break the glass ceiling of gender imbalance because the existing power sources do not take sides with them. 21 In addition, religion provides dead, fixed, and solid norms which reject changes.

Systematic
examinations of gender imbalance have indeed been done extensively. However, studies to understand gender imbalance in its subjective biblical interpretation in local contexts remain limited, especially if such a study is linked to women's contemporary issues. Experts tend to understand gender imbalance situations from a general point of view. Interventions based on this generic outlook are often non-parallel to local communities' understanding. As a result, such an approach is most likely to reach a dead end.
Gender imbalance analysis must not be detached from people's daily activities. 22 Therefore, gender imbalance formation should be understood according to its locus, 23 and by doing so, one can comprehend it more accurately and then can offer more contextual changes in the future. The ultimate goal is, of course, to improve women's health.
As far as the author is concerned, Scott's concept has contributed to the interrogation of gender imbalance in the western culture, while in the context of eastern culture, especially Indonesia, it has never been used. This article attempts to explain religious influence on gender imbalance in the eastern context, especially in an Indonesian rural area with a majority Christian faith. This paper attempts to explain how limited interpretations of biblical teachings could contribute to women's health issues in regions with highly complex global health problems like in Asia and, especially, Indonesia.

Main concept
Gender imbalance has created inequality and inequity. 24 Instead of creating an understanding of the roles of men and women which should be complementary to each other, [25][26] inaccuracy in understanding the meaning of the Bible has ironically strengthened gender imbalance. 14 Further, as stated by Hwa Yung (2015), church communities in Asia are often only nominal, but lacking in true understanding of the Bible. 27 Dec 2022. Christian Journal for Global Health 9(2) Gender imbalance generally occurs through social processes in society. 28 The social process is formed by various channels, from the birth of a social agent to the end of his or her life. In his book, Bourdieu adds a remark on this by pointing out that the binary system has placed males and females in a vast gap of positions and roles. Men were symbolized by "dry," where their primary activities are outside the house (i.e., in the fields, meeting place, and market) whereas women were symbolized by "wet" (suggesting that they work in gloomy locations and are mostly engaged in housework, yard work, and woodworking). 29 In this paper, I use a concept proposed by Joan W. Scott. She put forth her important idea in her essay entitled Gender: A Useful Category of Historical Analysis. 19 Scott defines gender in historical context. Her first assumption is that "gender is a constitutive element of social relationships based on perceived differences between the sexes." 19 She claims that the primary mechanism for encoding and maintaining power relations is gender. Based on these assumptions, Scott creates a "template" in which she adds four crucial characteristics related to gender. The institutionalization of gender differences, symbols for both sexes in a culture, normative conceptions that follow these symbols, and subjective identity are among these aspects. No one of these four components operates without others due to their interdependence. Scott maintains that these very four aspects build the power interactions that create, sustain, and extend gender disparities.
Scott centered her attention on images like "Eve and Mary" in the Western Christian tradition. An effective and efficient system of control is needed to maintain the gender roles so that men and women behave in accordance with their respective roles. These gender roles function more effectively when the instruments of control are normative. Thus, the binary, which separates the duties of men and women, is justified by social conventions and backed by religious values. Then the division of labour is formed based on the sexual binary. The development of a subjective identity based on sex differences and implemented in daily activities will lead to the subjective self-perceptions of women (and of men as well). According to Scott, the formation occurs through a long process, a personal life history, where women and men both meet what is expected of them within the social system they reside.
In line with Scott, I argue that gender imbalance is manufactured and each culture contains the four aspects proposed by Scott. In this paper, Scott's template is useful in assisting gender research since it explains how gender disparities persist in a given culture in addition to demonstrating the presence of gender inequalities within this society. Making use of the four aspects developed by Scott enables us "to discover the nature of the debate or repression that leads to the appearance of timeless permanence in binary gender representation." 19

Materials and Methods
This qualitative research was conducted in Nias Island, where about 92 percent of the people live in rural areas. Nias Island is dominated by the Nias ethnic group, and the majority are considered Christian. 30 Christian missions entered Nias Island in 1832 and reached their peak with the formation of the local church in the 1930s. 31 More than 95 percent of all people on the island are members of Christian local churches. Therefore, a localized Christian viewpoint will represent the informant's perspective of this study.
In-depth interviews were conducted by the author in 2014 with 25 married husband and wife couples, all of whom claimed to be Christian. To provide additional information, the researcher also conducted in-depth interviews with the couple's mothers-in-law.
Interviews with the wife, husband, or mother-in-law were conducted in separate places to avoid bias, even though they were still at the informant's house. Interviews were conducted at the same time or differently Dec 2022. Christian Journal for Global Health 9(2) depending on the informants' availability of time. Interviews were conducted in the Nias language.
Data were collected using open-ended unstructured questions. The questions were oriented to four fundamental questions as in Scott's concept, namely a) how men and women are symbolized; b) what norms are attached to the symbol; c) what kind of division of labour conforms to the norm for men and women; and d) how women internalize these norms. See the guided questions in Appendix A.
Each informant was informed about the research objectives and given a verbal explanation of the research procedure. Because informants' educational background was not supportive, verbal consent was obtained. For field research, an ethical permit was issued by Health Research Ethical Committee of Medical Faculty, Nommensen HKBP University, Medan, Indonesia. Informants were de-identified by the use of pseudonyms.
When carrying out the research, there was no access to electricity due to limited resources from the government in the research location. Responses were recorded through mobile electronic MP3 devices. Research data were manually analysed for practical purposes in the field since research activities took place in different locations.
After thoroughly listening to the interview recordings, the next step was to code the informants' answers. The final step was to categorize the coded information under the themes of the research goals.
Most of the data collected for this paper come particularly from one of the chapters of the author's PhD dissertation at the University of Amsterdam. The dissertation has been published under the title Gender Inequality Behind Maternal Mortality in Nias Island, North Sumatra, Indonesia, Towards a Gender Audit. 32

Results
In the following sections, the research result regarding the four dimensions proposed by Scott will be presented systematically. The dimensions cover the symbols used to divide gender, the norms represented, and practical implications of the symbols and perceptions of gender roles.

Symbol
To better grasp the correlation between biblical interpretations and the gender imbalance in the given society, the author interviewed both husband and wife to find out how they perceive themselves. Their answers varied, yet they explicitly revealed gender role differences (table  1). The symbolic representations mentioned by the respondents above clearly give contrasting perceptions about men and women. In essence, male and female were represented as dichotomous, binary oppositions. Male was symbolized by something which is "up there," "in front of," or "which comes first." In contrast, female was marked by something "at the rear." Högö, kafalo, and si so föna are symbolic ideologies colouring Niasan daily life. For instance, the head (högö) represents a husband because he is pictured as sitting higher up or in the front, whereas the tail (gi'o) represents his wife since she is pictured as sitting lower down or in the back. Animal heads, Dec 2022. Christian Journal for Global Health 9(2) particularly pig heads, are immensely significant to Niasan culture. Högö is always given to the esteemed person at Nias weddings. Boiling pig heads (högö), which are regarded as the most important and honourable parts of the animal, are always offered during wedding meals.
Different home functions were cited as another description of this symbol. In an interview with a wife, Ina Grace (a pseudonym), she stated that her husband was referred to as a leader (kafalo), the one who had greater responsibility for making decisions, and his wife was a follower (solo'ö), the one who carried out her leader's decisions. As a result, a wife will occasionally assert that she was just hiding in plain sight in a given circumstance, si so furi, while her husband was out in the open, si so föna. The kafalo, who had greater privilege than the other members of the community, was considered to be the highest hierarchical position in the society historically. A kafalo was seen as having greater skills or abilities than common people because they were the focal point of the town. Without the kafalo presence, it was impossible to start a communal gathering or function. The kafalo was recognized for always sitting at the front portion (föna) and in his allotted higher position.
Biological metaphors were cited by some respondents as a way to emphasize gender differences. For instance, a wife, who was born later, was seen as the younger (akhi), but her husband, the firstborn, was seen as the older (ga'a). A girl's duty at home, as "an akhi," was to constantly treat her brother with respect and provide the finest service possible. Again, the older brother (ga'a) had the decision-making authority first, followed by the sisters. Ga'a had the right to take over his parents' role in decision-making as well.
On critical examination of the terms högö, kafalo, si so föna, and ga'a representing male, one can see that they are identical to biblical symbols. These symbolic representations share the idea that male is associated with the head, just like Jesus Christ as the head of the Church or king/leader. In addition, the Old Testament explicitly narrates Adam, a male, as the first human being created (si so föna, ga'a), while female is created afterward.
The symbolization reflects an ideology on the importance of male status, i.e., the husband. He is as significant as Christ himself (a view implied by one informant's response). It is true that the respondents interviewed did not talk about biblical symbols. The juxtaposition of male and Christ can be seen in the poetry of the Nias ethnic group stating that woman as the second creation. 33 The poetry said that in the beginning, was the Creator. The Creator then created woman and made her quite pretty and perfect. A man then took the woman away because he was created earlier than her. The symbol and the poetry are parallel in keeping an ideology that the position of man is higher than that of woman for the latter is merely gi'o, solo'ö, si so furi, and akhi.
Therefore, it is clear from the beginning there had already been a cultural belief in the distinctive positions between man and woman, husband and wife before the advent of Christianity. For the people on the island of Nias, symbols for women had not refered to their status higher than or equal to men. This might explain some of the health issues women experience, as will be discussed in the following section.

Normative
Scott places emphasis on the use of symbols having consequences for normative roles. The existing norms ensure that both sexes adjust to the symbols representing their existence. In her narrative, Ina Gayusu (pseudonym) shared her belief as follows: Submissive. Everything we say should be followed. Undeniable In line with the previous statement, Ina Gayusu firmly believed in what the symbols revealed to her. For her, the Bible was a life guide to follow without reserve. She was left with no choice but to obediently uphold this Bible-derived principle because it "has been written in the Bible". Ina Gayusu accepted the notion that men were superior to women as true. Indeed, the respondents in this research often referred to what is written in 1 Corinthians 11: 3.
Ina Gayusu insisted that the Bible's contents had major repercussions in addition to stating her firm religious belief that it was an authoritative source. If a wife does not follow it, she will be a lost soul (elungu). According to Ina Gayusu, this position was not something she had declared, but rather was what God wanted her to be. Her adherence to God's commands was voluntary rather than forced.
Field observations confirm that it had become normative for women to bear physical and non-physical burdens. For a husband, his wife was "a worker," as she was supposed to be. A woman who refused to follow the directions of her husband, and even worse with any public display of resistance, was deemed to be disobeying biblical teachings. A husband once said that a wife's refusal to obey her husband as "… being inappropriate. I have the right not to feed her. And if she keeps on misbehaving, I will give her one beating. It [the beating] is to discipline her." The more we examine gender division in the light of Scott's approach, the more we find out its connection with issues of women's health. The following section shows how symbols and norms are manifested in work division.

Institution
The third dimension proposed by Scott is the implications of symbols and norms.
The implications are generally manifested in the division of labour. In this section, only interviews with wives are present to determine the types of work they perceived as women's jobs, and to discover the coverage of work they had to handle. The results are shown in Table 2. Field observations show that wives fully accept their positions. This collective, absolute obedience is perceived as "normal" and "an identity" that is in line with biblical teachings. In this situation, it is difficult for any member of society to challenge the truth of biblical interpretations and teachings by disobeying their "role." The life experiences shared, especially by Ina Mika, are powerful examples in understanding the subjective identity in Scott's concept. Ina Mika demonstrated how pervasive and intransigent the grasp of subjective identity construction and how it affects women. Their subjective perception of the gender-based symbols-that "men's position is higher than women's"-remains fostered and reinforced throughout their lives.

Discussion
This current research shows that Scott's concept is very useful as a framework in explaining the interpretation of verses in the Bible which play a role in shaping and maintaining a gender imbalance in the eastern tradition. The symbols regarding "who is a man" and "who is a woman" clearly reveal that the gender imbalance is supported by the informants' inaccurate understanding of the Bible (see also the questions in Appendix A). It should be recognized that quotes and figures of speech used to represent the husband-and the local people in the research location-as if they are directly derived from biblical teachings are highly questionable. The teachings of Jesus Christ are not meant to create a hierarchy among human beings but that we must love one another indiscriminately. God makes men and women complete and helps each of them to fulfill God's call. No one holds the authority over another (Gen. 1:27, 5:2) since God is the One who possesses the highest and most absolute authority.
However, social realities in this population studied treated biblical interpretations as inflexible truths. Those who adhere to Christianity believed that obedience to gender norms, though the norms bear inequity, is being faithful to their religion. In this light, gender imbalance is more than just a concept; it is a manifestation of the identity of obedient adherents to Christianity. As a result, the demarcation line between men and women and between husbands and wives must be continuously maintained, because that is perceived as the best way to comply with biblical teachings. Though the biblical interpretation is not comprehensively done, the informant's view ( Table 1) that the symbol of Jesus as the head of the church is immediately synonymous with the husband as the head of the household (högö, kafalo), on a practical level, supports the existence of hierarchy in the relationship between men and women and between husband and wife. 14 Thus, what is taking place right now is a tradition justified through symbols, norms and gender divisions, and self-identity formation. The process operates non-physically. Those who undergo the process are not supposed to ask questions; they obediently take it as an undeniable truth. In other words, everyone will assume their given identity because the gender norms are already provided to each one. Gender norms govern not only the mind but also behavior. This internalization process naturally takes place for generations. Each one only plays his or her predetermined role. 18 To ensure the successful operation of the normative regulation, gender norms do provide two things to every social agent. First, important guidelines for behavior so that they continue to carry out existing norms, and second, at the same time, imposing sanctions on those who try to behave outside of these norms. 34 Wives who behave differently will get social sanctions in the form of being called "dishonorable" as informed by Ina Gayusu. She insisted that women's failure to follow biblical teachings meant their denial of Christian virtue, in which one might end up in a Dec 2022. Christian Journal for Global Health 9(2) "chaotic" situation. For Ina Gayusu, the morality of woman is measured with how obedient a wife is to her husband which she believed was explicitly stated in the Bible.
There is no wonder if the jobs that wives should deal with (see Table 2) are more than just daily activities. They are proof of their obedience to the Bible. In this study, a wife was "configured" inflexibly to perform daily work from simple to complex tasks. A wife was expected to prepare and serve meals for the entire home while also being worn out from working in the field. She was also expected to participate in social gatherings like wedding receptions. As mentioned by Moser, women in developing countries like Indonesia hold the triple burden of the productive, reproductive, and social sectors. 35 This division of duties between husband and wife is also supported by interpretations that again come from the Bible. One husband said that "women are able to do all things" (Interview, 6 Augustus 2014). Another husband explained that "women are born with more additional strength than men, and this enables them to handle any kind of works" (Interview, 2 September 2014). These statements are conveyed when interpreting subjectively the meaning of diligent work as written in Romans 12:11, and especially, Titus 2:5, which subjectively was considered only to be done by women. In fact, this subjective view was often used by men to refuse to take part in jobs labelled as women's duties.
When a husband handled a woman's perceived designated chores such as washing clothes or cooking, he would be teased by his peers as "a savuyu of his wife." Savuyu, meaning "slave," is someone follows only his master's instructions and orders. This word, although it has some connection with practices in the past, also refers to the Jews who were slaves in the land of Egypt. So, if a husband helps his wife by doing the work that his wife does daily, he would be humiliated because Christian believers must not be under the concept of savuyu anymore. Husbands who perform "women's jobs" were usually teased by other men.
It is true that these rural men must perform energy-intensive jobs, like clearing trees from a plot of land or working in the family rice crop or garden. However, some men still found time to unwind while working hard. A husband was not instantly given domestic responsibilities, and more importantly, he was not subject to the same types of norm and social expectations as women. These men lived in a system that was more favourable to them. 29 When work divisions are based on gender and there is no option for exchanging roles, especially if supported by religious-based symbols, social agents will accept them as a normative regulation. This rule has been constantly imposed, passed down through the centuries and recognized as normal by social actors. Given that both sexes have a thorough understanding of the range of their respective duties, it makes sense for women (and men) to simply conform to gender roles-a template-created for them. Butler says, "gender is the repeated stylization of the body, a set of repeated acts within a highly rigid regulatory frame that congeal over time to produce the appearance of substance, of a natural sort of being." 18 What is being measured and discussed in this paper cannot be used to establish the direct cause of poor health of women. However, gender imbalance norms can be social determinants of disproportionately poor women's health. Being invisible and difficult to revise, the gender norms play a significant role in maintaining gender imbalance between men and women. Gender norms have become an inseparable part of the existing body of the social agents in the fields of social science and linguistics. 35 The norms are even planted on a solid base, for they contain religious identity wholeheartedly embraced by the religious adherents in this study. The members of society have made their interpretations and lived accordingly for a long period of time. As a result, these biblical interpretations are not questioned.

Zaluchu
Dec 2022. Christian Journal for Global Health 9 (2) The gender division has been accepted as an identity and used to build what is perceived as a well-managed life. In a normal situation, efforts to change gender norms will encounter a "patriarchal bargain," 37 not only from men but also from women themselves. Resistance is even greater when gender norms are attached to religion.
The above series of processes is the social landscape behind the poor quality of women's health in various parts of the world, especially in the Eastern region. Gender norm-based identities are forcibly distributed to women, and as a result, they lose their autonomy. On physical and mental levels, many women have no chance to take care of their pregnancy, consume nutritious food, and manage pregnancy spacing. After giving birth, a woman cannot fully focus on providing healthy food for her baby. Women are loaded with so many other jobs that they have no room to fulfill their maternal responsibilities. Husbands may impose more burdens by committing violence against their wives.
To sum up, the approach offered by Joan W. Scott helps to investigate a particular social phenomenon, namely, the presence of gender imbalances which lead to injustices behind the poorer conditions of women's health. This investigation hopefully offers new insight into women's health interventions in the future.

Conclusion and Recommendation
The gender imbalance still survives so strongly because it supports the social agent's interpretation of the meaning of the Bible. With these interpretations, symbols, norms, division of work, and subjective identity are maintained in society, and women, including pregnant women, women with babies, and even children, pay the price for this practice.
This social conditioning must be overcome because it is very detrimental to women's health. First, the local church should give more accurate interpretations of the relationship between men and women. Instead of using only biblical verses that favor men, the Church should offer holistic, balanced biblical interpretations. The Church must highlight the importance of a husband's love and sacrifice to his own wife (Ephesians 5:25-33), in the same way Jesus Christ sacrificed and emptied Himself to redeem God's chosen people. This message should be routinely delivered to the congregation in religious activities, such as Sunday services in Church, weekly activities, and especially home worship activities. For the Church leaders in the eastern hemisphere, where gender norms still favor men over women, they need to initiate a dialogue to shed light on the interpretations of pertinent biblical verses. Through dialogue, church leaders may be able to correct the personal biblical interpretations that may cause gender injustices, especially the ones against women.
Given the fact that women's health is related to long-held traditions, the Church is required to develop teachings that argue that Jesus Christ does not only sacrifice Himself to redeem human beings from their sins but also save them from any oppressive or harmful traditions. The blood of Christ should also redeem every deep cultural practice which promotes gender injustices. A redeemed cultural practice encourages the congregation to love and serve one another (Mark 9:35), create reciprocity, and submit to one another as redeemed people (Ephesians 5:21). The Church should play an active role in fostering a healing community as a manifestation of her responsibility in this world. 38 Allowing gender injustices to happen means paving the way for human tragedy to occur before the Church's eyes. It should be recognized that many churches are insensitive to gender injustice. In these circumstances, activists, health practitioners, and health researchers need to urge church leaders to scrutinize whether their church plays direct or indirect roles in encouraging gender inequalities that cause negative consequences to women's health. Church leaders in Nias Island may show resistance, but if logical explanations of gender inequality offered by Scott's concept are given, they could join hands to address gender inequality which has disadvantaged women for so long. Future studies could be in the form of action research aimed to understand the possible changes as an effect of people's education, and of course, by using social channels suitable to the people.
This research was conducted on Nias Island with only individual members of several congregations. The results therefore may not reflect the views of other church members or the synod leaders. In addition, there may have been different dynamics if it was carried out in urban areas. Though gender differences can be accepted as a gift of God, unjust gender imbalances remain a challenge to be resolved because of the global health problems they produce in God's creation. As a man, I see so many things that should be fixed in this very patriarchal culture, but would encourage a better understanding of the justice and human dignity expressed as truths written in the Bible.