What mental health issues does Indonesia face, and are the drivers similar to other countries?…
Breastfeeding health promotion has the potential to improve the health and wellbeing of many babies and mothers but mainstream health promotion messages in Indonesia are highly moralised and gendered. National maternity leave provisions and breastfeeding laws are out of sync and place significant burdens on mothers who juggle breastfeeding and working.
Exclusive breastfeeding – feeding nothing but breast milk – is recommended by the World Health Organisation (WHO) for the first six months following a baby’s birth and it is enshrined in the Indonesian Health Law (No. 36 of 2009). The law even states that every baby has the right (berhak) to be exclusively breastfed until six months, known as ASI ekslusif.
Breastfeeding health promotion is also legislated in Indonesian health care settings. A 2012 government regulation prevents health workers from providing or promoting formula milk, or offering services funded by formula milk companies. Health workers and facilities that do not promote early initiation of breastfeeding, co-location of mother and baby for the first 24 hours after birth and education and information about breastfeeding may face sanctions, including the loss of licence to practice for health workers.
This regulatory emphasis on exclusive breastfeeding is aligned with WHO exclusive breastfeeding recommendations (which increased from four to six months in 2001) as well as a WHO code concerning formula milk advertising. Historically, formula milk marketing has been extremely aggressive in Indonesia, a trend that continues today in spite of these new regulations. But there are suggestions that the government’s firm approach is starting to make an impact. The 2012 Indonesian Health and Demographic Survey found rates of exclusive breastfeeding in babies under six months increased from 32 per cent in 2007 to 42 per cent in 2012.
According to provincial-level reports, the national rate of exclusive breastfeeding is now 54 per cent, although there is great variance between provinces. In Maluku, just one in four babies receive breast milk exclusively; in Yogyakarta the rate is 68 per cent; and the highest rate is in West Nusa Tenggara, where 80 per cent of babies receive nothing but breast milk.
There is, however, a disconnect between these provincial statistics and data from the 2012 survey, which found that half of all babies are breastfed exclusively for the first three months of their lives and then a significant drop occurs between four to five months, where exclusive breastfeeding tapers to 27 per cent. This decline reflects the fact that the majority of working mothers in Indonesia only have access to three months of paid maternity leave.
My doctoral research is focusing on how urban, middle-class women in Yogyakarta understand and experience breastfeeding and negotiate returning to work or study while maintaining their commitment to breastfeed their babies exclusively. A number of women who participated in this research described the challenges they confronted in balancing the early stages of motherhood, the moral imperative to exclusively breastfeed and returning to work. For first time mothers the learning curve was the steepest.
Despite the fact that all workplaces and public facilities are required by law to have a designated facility for breastfeeding or expressing milk, the majority of working women I interviewed did not have access to such a space. This resulted in some women leaving their offices during their lunch breaks to breastfeed or express their milk. One participant did not have refrigeration facilities at her workplace, nor a private space to express her milk, and went to her sister’s house nearby every lunch break to do so.
Another participant revealed how she lied about her son’s due date to get around her workplace’s inflexibility to allow her to take more of her maternity leave after his birth. She was a government employee, and was required to take one month of maternity leave prior to her baby’s due date. Another first time mother chose to take three additional months of unpaid maternity leave before returning to work.
Pressures on Indonesian women to be “multi-tasking breastfeeding mamas” who simultaneously excel at being mothers, wives, and employees or students, are normalised and idealised through laws and mainstream health promotion messages. The right of mothers to choose whether they wish to attempt to breastfeed exclusively, sometimes, or not at all is absent from dominant health promotion discourses.
Health promotion discourses are often steeped in moral language. Breastfeeding was described by many of my interview and focus group participants as a woman’s destiny (kodrat perempuan), natural, or an obligation as part of Islam. Consequently, women who for health or work reasons are not able to breastfeed are often cast as moral failures. Some of the participants in my research expressed a feeling of guilt when they were forced to supplement their breast milk with formula or packaged infant food or even use a dummy, which is said to discourage baby from the breast.
Further, there is a noticeable gap in raising awareness about the nutritional values of formula milk and helping mothers who do go down that route to distinguish between brands containing fewer harmful additives and flavourings and less sugar. Currently all brands are lumped in the “bad” category, despite the fact that formulations vary widely. Many babies, once they graduate from exclusive breastfeeding, are given formula milk.
The role of men in supporting their wives is recognised as key to exclusive breastfeeding success. Women receive comprehensive and detailed information, designed to educate them about the health and medical benefits of breastfeeding. Men, on the other hand, are being encouraged to support exclusive breastfeeding to enhance their wives’ physical attractiveness (some breastfeeding mothers return to their pre-pregnancy weight faster); for financial reasons (breast milk is free, formula milk is not); and because breastfed kids are purportedly smarter.
These messages reinforce gender roles and stereotypes: women are given detailed medical information and the burden of breastfeeding rests with them; men receive diluted and rudimentary information about aspects of breastfeeding perceived to appeal to them, rather than advice as to how to provide practical support to their partners during this stage of parenthood. Although my study involved middle-class women, not all employed household help. The typically highly gendered nature of housework and childcare in Indonesia means that unless they have strong family support, working women carry a heavy burden.
Breastfeeding is the popular ideal in Indonesia, yet little is known about why some women choose to breastfeed while others do not. Understanding the challenges that mothers face when they juggle breastfeeding with other aspects of their lives can help to identify how their partners and other family members, workplaces and the community can better support women who chose to breastfeed, and ensure that women who chose not to breastfeed are also supported and not stigmatised. The implementation of laws and regulations on breastfeeding-friendly workplaces, though a long and slow process, is a positive step to supporting working mothers. Perhaps the next step for Indonesia will be revising its national maternity leave provisions from three to six months.
Belinda Raintung’s study is supervised by researchers from the Nossal Institute for Global Health, Melbourne School of Population and Global Health and Gadjah Mada University’s Center for Reproductive Health. Funding was provided under the Australia Awards’ Endeavour Research Fellowship Scheme and the Nossal Global Health Scholars Program. The author also collaborates with the Indonesian Breastfeeding Mothers Association (AIMI) and the Yogyakarta Department of Health.