Challenges and Supports of Breastfeeding at Workplace in Indonesia.

Due to increased number of women workers in Indonesia in the last decade, numbers of women living as a worker and a housewife have increased. This also increases the potential risk of breastfeeding discontinuation. Three months of maternal leave policy and inadequate lactation promotion support in workplace have been identified as factors that hinder lactating practices. The World Health Organization recommendation of 6 months of exclusive breastfeeding and joined regulation of three Indonesia ministers (Ministry of Health, Ministry of Labour, and Ministry of Women Empower) have failed to improve the exclusive breastfeeding rate among female workers in Indonesia due to the lack of a standardized guideline on lactation promotion at workplace. In addition, very limited or no studies have been conducted to evaluate the impact of workplace-based lactation intervention programs on exclusive breastfeeding rate among female workers. This is because the relationship of lactation with working performance and productivity could not motivate employer to invest in workplace-based lactation promotion facility or program.

BACKGROUND

The number of female workers in Indonesia has increased four times in the last decade. The Central Bureau of Statistics in 2014 showed that the number of female workers aged 15 to 44 years who actively participated at work had increased to over 80 million compared to 20 million in 2008 [1]. This upsurge in the number of female workers has increased the number of women living with double roles: as a worker outside the house and as a housewife. According to Triaryati [2], this phenomenon not only creates more pressure to time management and energy spending, but also potentially increases stress and conflicts at home and workplace [3]. One of the main potential risks for working mothers with infants is related to lactation behaviour. Not every working mother is able to breastfeed or pump breast milk at her workplace due to the lack of breastfeeding support and facilities at the workplace. In Indonesia, only 21.5% of outhouse working mothers get access to proper lactation facilities. It has been estimated that 7.5% of women workers have the privilege to have access to an adequate lactation program at their workplace [4]. The prevalence of exclusive breastfeeding among working mothers, especially factory workers in 2015, was only 19%, far behind national prevalence which was 32% [4].

BENEFITS OF BREASTFEEDING

Benefits for babies

It is well-known that exclusive breastfeeding and optimal lactation practice provide benefits for both mother and child's health. World Health Organization (WHO) and the Ministry of Health recommends exclusive breastfeeding during the first 6 months. Breastfeeding should be continued with complimentary food until two years of life [567]. WHO defines exclusive breastfeeding as a baby that only receives breastmilk without any other liquids, including water, formula milk, fruit juice, tea, honey, or any solid food except vitamins and medicines [58].

Research studies have shown that breastmilk provides adequate nutrients for infants. Therefore, they do not require any additional food during the first 6 months of life. The colostrum in the first 24 to 36 hours after delivery contains high concentration of immunoglobulins important for the development of a balanced immune system. It also contains lipase to facilitate fat absorption. In addition, breastmilk contains docosahexaenoic acid and arachidonic acid that are important for brain development [9]. Breastmilk also contains oligosaccharides that can stimulate the growth of healthy gut microbiota. Oligosaccharide components in breastmilk can help strengthen infant's immune system in their early life. Numerous studies have shown the benefit of breastmilk in protecting infants from infections, such as acute otitis media [1011], gastroenteritis [1213], respiratory infections [14], atopic dermatitis, and asthma [151617]. For long-term health, exclusive breastfeeding could reduce the risk of obesity in older children, adolescents, and even adults [18]. Breastmilk also contains probiotics which support the maturation of immune system through gut associated lymphoid tissue [192021]. Exclusive breastfeeding could also decrease the risk to develop diabetes and help stabilize blood pressure and cholesterol level throughout a lifespan [222324]. Psychologically, breastfeeding strengthens the emotional relationship between mother and child [8].

Benefits for mothers

Breastfeeding and lactation practice also benefits the mother. Breastfeeding is one of the strategies to reduce body weight post-partum. After 6 months, the body mass index (BMI) of an exclusively breastfeeding mother will be similar to her BMI before pregnancy. Returning to pre-pregnancy weight is critical to women's health status as retention of post-partum body weight is strongly correlated with higher risk of obesity and its complications, including the risk of non-communicable diseases [25262728]. Exclusive breastfeeding decreases the risk of cardiovascular disease [29]. It also improves the quality of life and mental health. Several studies have shown that lactation for less than 6 months and emotional distress during delivery increase the risk to develop post-natal depression [303132]. Breastfeeding is a natural contraception method as it prolongs the amenorrhea period and helps maintain prolactin concentration known as a lactation amenorrhoea method (LAM). The Bellagio and Kennedy consensus in 1988 and 1996, respectively, resulted in experts to recommend LAM as a family planning option to prevent pregnancy in the first 6 months after delivery. Its effectiveness could reach 98% by giving exclusive breastfeeding for 6 months, resulting in amenorrhoea [28293031].

BREASTFEEDING AT THE WORKPLACE

Breastfeeding at the workplace is a great challenge for a working mother [323334]. Studies have revealed that the breastfeeding rate decreases strongly when mothers return to work [35363738]. The main reasons are the distance between home and workplace, unavailability of lactation facilities at the workplace, and decreased milk production during working hours [353637].

According to data from Taiwan, only 10.6% of mothers continue to breastfeed after returning to work [35]. Data from Indonesia are better. According to the Ministry of Health, 62.5% of mothers continue to breastfeed after having returned to work. Data collected in a private company in Jakarta are similar (56.7%) [36]. However, Basrowi et al. [4] have found that 45% of working mothers in Indonesia have stopped to breastfeeding at their infant's third month of age because of return-to-work. Limited lactation facilities and support programs in workplace and inadequate knowledge about how to do breastmilk pumping and store breastmilk are the main reasons of discontinuation [363738]. The Indonesian's Breastfeeding Mother's Association has suggested that a lactation counsellor at work, lactation facilities, and support by peers would be critical to help working mothers continue breastfeeding [394041]. Adequate lactation facilities and program at the workplace can improve lactation incidence by three-fold and increase exclusive breastfeeding rates by six times (odds ratio, 5.93; 95% confidence interval, 1.78–19.79; p<0.050) [4]. However, managers and employers consider that breast pumping during working hours might hamper productivity and affect working performance [42]. However, no research on this topic has been performed.

BREASTFEEDING FRIENDLY POLICY AT WORKPLACE

The Indonesian government issued a Joint Regulation among the Minister of Women Empowerment, Minister of Labour, and the Minister of Health to promote and protect working mothers to breastfeed and pump milk at the workplace [43]. The Government Regulation on Exclusive Breastfeeding in 2012 obliges every citizen, including employers, to promote success of exclusive breastfeeding. Every workplace is mandatory to support dedicated lactation room in the workplace with standardized facilities (Table 1). In 2013, the Ministry of Health issued a technical guideline about the presence of a lactation room at the workplace [4445]. However, this regulation was not supported with a standard labour regulation at the workplace. Occupational health and safety management systems such as the Guideline for the implementation of Occupational Health and Safety Zone 18001 in 2007 or the Guidelines on occupational safety and health (OSH) management systems International Labour Organization (ILO)-OSH in 2001 did not include any clausal on the availability of lactation facilities and program at the workplace. Government regulation on occupational health and safety has a section on the prohibition of employment termination during maternity leave as well as a suggestion clausal of lactation facility at workplace. However, these articles do not include a clear guideline on promotion, education, or counselling aspects of breastfeeding and lactation [46]. Therefore, the joined regulation between three ministers failed to improve exclusive breastfeeding rate among female workers in Indonesia due to the lack of a standardized guideline on lactation promotion at workplace.

Table 1

General Criteria for a Lactation Room

Lactation promotion is not part of the core tasks of corporate physicians or company doctors. Practical lactation promotion guidelines are unavailable in the workplace [4748]. Lactation promotion programs at the workplace have been applied in many countries. However, very limited to no studies have been conducted to evaluate the impact of workplace-based lactation intervention programs on exclusive breastfeeding rate among female workers and the relationship of such programs with working performance and productivity. According to Cochrane Reviews in 2007 and 2012, no randomized controlled trial has been performed to evaluate the effectiveness of a workplace lactation intervention program [49].

BREASTFEEDING SUPPORT IN WORKPLACE

An employer could benefit from their female workers' breastfeeding and lactation behaviour as a study has shown that friendly policy and regulation supporting a lactation program at workplace could improve employee's productivity and motivate mothers to return to work [50515253].

A lactation counsellor is a healthcare provider trained and certified in breastfeeding and lactation. It is appointed by the company to provide continuous support. The counselling aims to help mothers breastfeed and motivate and educate working mothers on its benefits. Education is recommended to be given during pregnancy and after mothers return to work. Education materials include methods to breastfeed, breast pumping methods and hygiene, benefits of exclusive breastfeeding and early initiation, reproductive health, and nutrition for breastfeeding mothers. Several studies have highlighted the importance of education since there are many barriers to continue breastfeeding at the workplace. Education and counselling at the workplace do have positive impact [414344].

BREASTFEEDING SUPPORT FROM FAMILY

Family also plays an important role in the success of breastfeeding and lactation practice, especially in providing information, moral support, and facilities. Family could help find information about breastfeeding. Mothers could ask help for simple and practical aspects related to breastfeeding problem. Emotional support from family is necessary for mothers as they require motivation for breastfeeding [5455].

BREASTFEEDING POLICY AND SUPPORT FOR FEMALE WORKERS AMONG COUNTRIES

The WHO collected data from 182 countries and concluded that there were many variations in breastfeeding and lactation regulation at the workplace. Differences in policies include duration of maternal leave, break time for breast pumping during working hours, and duration of break time. Around 45 countries do not allow breastfeeding breaks during working hours while 130 countries protect female workers regarding milk pumping with flexible time. Seven countries have unpaid breaks [56].

The United States of America (US) and the United Kingdom (UK) have introduced lactation programs for employees that are more advanced compared to other countries in providing technical guideline in workplace. US Centers for Disease Control and Prevention has issued regulations for company or business owners to include a written policy that a lactation program is part of the company's standard operational procedure and corporate accreditation. Workers have the right for maternity and breastfeeding leave for 3 to 6 months. It can be prolonged up to one-year post delivery. The availability of lactation facilities at workplace and consultation service from counsellor are the company's responsibility. Another special regulation is paternity leave so that husbands also have the opportunity to take leave.

Most Asian countries have not strictly implemented these policies, although several countries are increasingly paying more attention to these aspects (Table 2). Taiwan urges companies to provide maternity leave for 8 months. In addition, Taiwan asks industries to implement breastfeeding and lactation friendly policy by protecting mothers so that they have flexible breastfeeding break time. Companies are obliged to provide dedicated lactation room. However, companies do not have obligations to provide breast pump device. Workers should bring the pump by themselves [57]. Hong Kong also supports workers to continue breastfeeding after returning to work. Workers who plan to pump breastmilk during working hours should discuss this with their supervisor to set the schedule. Their supervisor should support them by providing a comfortable environment, such as giving permission for having breastfeeding breaks (e.g., two times within 8-working hour, each for 30 minutes break) until their child reaches the age of one year, providing a dedicated space for lactation with a comfortable chair, electric pumping, and storage facilities for breastmilk. Every worker should support their colleagues to breastfeed as it is proven to increase lactation practice among working mothers [58].

Table 2

Workplace Breastfeeding Policy in Different Countries

NA, not available.

Scandinavian countries are arguably the best in breastfeeding protection and promotion policy in the world. In many Scandinavian countries, the legislation on breastfeeding and maternity protection in workplace goes beyond ILO standards [59]. The fifteen Save the Children's State of the World's Mothers Report in 2014 stated that three Scandinavian countries (Finland, Sweden, and Norway) were the top ranked among 178 countries in Mother's Index assessment for the wellbeing of mothers and children in which maternity protection for working women was part of the report [60]. Partnerships among government, health association, and non-government organization are found to have common objectives to support and protect breastfeeding in all aspects. In Norway, due to the Norwegian Association of Breastfeeding, “Ammehjelpen”, government policy has gradually increased the length of maternal leave to be one year with 80% pay or 46 weeks with full pay. Labour market regulations in Norway also entitle women to take necessary break if they breastfeed or to shorten their working day by one hour [61]. In Finland, the government regulation entitles all pregnant mothers, be it working or non-working mothers, to use maternity healthcare clinics for free on regular basis [62]. The Swedish legislation on parental leave and maternal protection is very comprehensive, with a large collection of acts and regulations. Most importantly, it provides parental leave (maternity, paternity, and child-care leave) with a total combined duration of 480 calendar days (almost 69 weeks or >17 months) for both parents until the child is 18 months old. Female employees are also entitled to nursing breaks without specific duration of times. This means breastfeeding breaks during working hours can be taken as long as the female employee continues to breastfeed [60].

BREASTFEEDING AND WORKING MOTHERS' PRODUCTIVITY

To the best of our knowledge, direct relationship between working mothers' breastfeeding/lactation behaviour and their productivity has not been assessed. Previous assessments were limited to conventional parameters such as presence and absenteeism. Breastfeeding is often perceived as a behaviour that may potentially hinder their productivity. Tsai [40] found that 51.1% of female workers assumed that taking break for breast pumping two times during working hours could lower their work efficiency. Breastfeeding at the workplace could actually improve productivity and decrease days of absenteeism since infants are healthier than children receiving formula milk [49].

CONCLUSION

The exclusive breastfeeding rate and lactation practice is still low among female workers. This could increase the risk of many health-related problems, resulting in an increase in the number of children who could receive protective health benefits from being exclusively breastfed. Additionally, mothers who did not lactate would not receive health benefits from lactation. Female workers do not obtain adequate information or support about breastfeeding and continued lactation after returning to work. Workplace lactation facilities and programs are still insufficient which could hinder lactation practice. Therefore, it is of key importance to prioritize research to develop an ideal workplace-based lactation promotion model and evaluate its impact on female workers' health status and productivity.