Lack of Exclusive Breastfeeding Among Working Mothers in Indonesia

Continuity of breastfeeding process when mothers return to work is a serious issue that immediately must be followed up, so that exclusive breastfeeding program within the first six months can be achieved. Beside providing many benefits for babies, breastfeeding is also beneficial for mothers and entrepreneurs. This study aimed to determine relation of working mothers to exclusive breastfeeding. This study used was cross- sectional design with secondary data of Indonesia Demographic and Health Survey 2012 with samples as many as 1,193 mothers aged 15 – 49 years who had 0 – 5-month-old babies. Based on multivariate analysis, working mothers could decrease opportunity of exclusive breastfeeding in which mother who worked all the time were 1.54 times more likely not to give exclusive breastfeeding than mothers who did not work after controlled by maternal age at childbirth, household wealth index, and antenatal care frequency (p = 0.038; 95% CI = 1.0 to 2.3). Fulltime working mothers are twofold more likely to not be able to give exclusive breasfedding than unemployed mothers after being controlled by counfounder variable.


Introduction
Approximately, five million children in Indonesia are born each year. Food intake, parenting as well as maternal and child health have a major impact on health and well-being in the future. The first thousand days of life, which began from fetus in the uterus until the child aged two years and needs to get the most important period of greatest concern, at that time children who do not receive adequate nutrition can suffer from permanent damage and cannot be recovered at adult. 1 Breastfeeding is a primary stage to get optimum health and growth of the child. Colostrum as dairy starter takes an important role in immunity formation of newborns. In addition to providing vitamins that can be digested by the baby, colostrum is the best food for the newborn gastrointestinal tract. Breastfeeding also plays an important role in preventing the onset of diseases, such as diabetes mellitus, obesity and leukemia among children. Moreover, the bond between mother and her baby is the most amazing relation in the world. 2,3 Breastfeeding may also improve neurocognitive growth, protect against respiratory inflammation and protect the mother from breast cancer. 4 However, the habit of parents to provide prelakteal may obstruck colostrum and continued breastfeeding, also increase the risk of infection. 3 The characteristics of mothers who give exclusive breastfeeding include mothers who do not work, get counseling breastfeeding at antenatal care, get counseling regarding the provision of food for newborns during postnatal care, do not give prelakteal food and have a good knowledge of breastfeeding. 5 Meanwhile, living in urban areas, born in a health facility and a father who has a stable job give positive effects on exclusive breastfeeding. 6 Another study showed that high socio-economic status, maternal employment outside home and status as a single parent had a negative effect on exclusive breastfeeding. 7 Continuity of breastfeeding when mothers return to work is a serious issue that must be followed up in order to achieve exclusive breastfeeding program within the first six months. 8 In fact, this is a quite heavy challenge because there are many workplaces that ignore this, so nursing mothers express breast milk at toilet, emergency stairs, or in their cars. 9 The unavailability of condusive facilities outside home, workplace conflict, family stress, rejection and the need of returning to work will have an impact on exclusive breastfeeding practices. 10 Among women who breastfeed after returning to work, there are only 10% who keep continuing breastfeed until the babies are at the age of six months. The earlier a woman returns to work, she also will stop breastfeeding earlier.
Mothers who work more than 20 hours per week are likely to stop breastfeeding earlier. 8 Likewise, a working mother is likely to breastfeed with a short duration compared to a woman who is unemployed or part time worker. 9 Nursing mother who works in the office every day leaves her baby at home at least 10 hours every day, which is calculated from the time mother goes out of home to the workplace to then back home again. 11 At this time, condition of women has increased due to the transition of women from families of workers into labor. Trends indicate that women's access to formal employment has increased over the time. 12 Human rights commission in 1964 called on to provide protection for breastfeeding women from dismissal or discrimination in the workplace, having special place and standardized to express breast milk and the availability of suitable equipment. 9 Government Regulation Number 33 of 2012 regulates obligations of administrators workplace companies, offices owned by the government, local governments and the private sector to support the success of exclusive breastfeeding program that is by providing special facilities for breastfeeding and/or expressing breast milk according to conditions of company. 13 Law No. 13 of 2013 on Manpower set that women in Indonesia have maternity leave only three months, in which each one and a half months before and after childbirth. Upon their return to work, they face problem of supporting facility for the success of exclusive breastfeeding. 14 Besides, limitations include opportunity to breastfeed during working for women workers, physical fatigue factor and facilities, such as breastfeeding corner and breast milk storage. 15 This study aimed to determine relation of working mother to exclusive breastfeeding.

Method
The study design was cross-sectional using secondary data from the Indonesian Demographic and Health Survey (IDHS) 2012. 16 Population of IDHS 2012 was the ever married women aged 15 -49 years within the last five years from the survey and had living babies. Samples in this study were all women in the sample of IDHS 2012 all over Indonesia as within the last five years of the survey had children aged 0 -5 months when the interview took place. Inclusion criteria were having the last baby born alive on January 1 st , 2007 until April 30 th , 2012 and at the time of the interview infants aged 0-5 months, and single birth. Exclusion criteria were pregnant women, mothers who did not know the date of born children for which data was incomplete, and women who worked but did not earn wages. In this analysis, information was from 1,358 single live-born children aged 0-5 months. All of the sample was taken by using the following equation1.
To determine the effect of each variable and to deter-mine the combined effect of several variables simultaneously, multivariate analysis can also be used to detect the interaction between independent variables that resulted in a large or small effect on the effect of each independent variable. In this study, the dependent variable used an ordinal scale with the two categorical analyses using logistic regression. The first multivariate procedure was doing analysis complete model including independent variable and all of confounding variable candidates without bivariate selection process, also interaction variable candidates. The next step was removing the interaction variables that had significant value > 0.05, then assessing the confounding variables by issuing confounding beginning of significant variables that had the highest significant value, but if there was a change exceeding 10%, the the variables were deemed as confounding and must remain in the model. At the end, it would produce final model that includes very important variables, either confounding or interaction variables. IDHS 2012 used a complex sample design that was stratified sampling using two or more methods of sampling, so the analysis process should take design effect and be weighted. Data must be multiplied by the weight of that contained in the sample variance equal to the variance contained in the population. Therefore, the analysis would be conducted using complex sample analysis. Table 1 showed that 43.6% of 1,358 single live-born children aged 0-5 months had exclusive breastfeeding, then showed the getting older age of the baby, the percentage of exclusive breastfeeding decreased. In Table 2, most women in Indonesia did not work (62.5%). Table  3 showed that in bivariate analysis, the largest proportion of mothers who did not exclusively breastfeed was at mothers working full time for someone else (63.6%), p value 0.057; 95% CI 0.98-2.1. In addition, there was a significant relation found between parity and exclusive breastfeeding (p = 0.017; OR = 0.88; 95% CI = 0.8-0.98) ( Table 3).

Results
The bivariate analysis in Table 4 showed that the largest proportion of mothers who did not exclusively breastfeed was at mothers delivered by caesarean section at 66.1% (OR = 1.63; p = 0.030; 95% CI 1.05-2.50, followed by the mothers who delivered their babies by vaginal births (54.5%). In variable the frequency of antenatal visits, the largest proportion of mothers who did not exclusively breastfeed was at mothers doing visits for once to three times (74.5%) (OR = 2.44; p = 0.000; 95% CI 1.5-3.0), followed by mothers doing antenatal visits > four times (54.5%) and a mother never doing antenatal visit (50.2%).
After conducting a multivariate analysis stage, it was obtained that final model was the simplest models that could be generated on this analysis. Based on final model in Table 5, full-time worker women were 1.54 times more likely not able to provide exclusive breastfeeding compared to women who did not work after controlled by maternal age at childbirth, household wealth index, and antenatal care frequency (p = 0.038; 95% CI = 1.0-2.3).

Discussion
This study used cross-sectional design that would make recall bias because the mother forgot about the information of infant's food records before the survey was conducted. However, recall bias in this study could be reduced by asking breastfeeding in the last 24 hours the current survey. By asking about the breastfeeding in the last 24 hours before the survey, it would lead to bias missclasification where various events were, which had occurred between the time of birth until the survey could not be known certainly. Moreover, a possibility might occur that before the last 24 hours the baby had been given food beside breast milk, it would make different classification of exclusive breastfeeding obtained at the time of the survey with the real situation.
Multivariate analysis showed that full-time worker women were 1.54 times more likely not to be able to give exclusive breastfeeding than unemployed women after controlled by confounder variable (p = 0.038; 1-a = 1.96 for 95% confidence interval z 1-b = z value of power test 1-b using 80% P1 = Proportion of exclusive breastfeeding in working mother = 9.5% P2 = Proportion of exclusive breastfeeding in unemployed mother =32% P = mean of P1 dan P2

Equation 1.
95% CI=1.0-2.3). This result was in line with finding that unemployed mothers were more likely to give exclusive breastfeeding 1.98 times higher than working mothers. 5 Mothers working more than 20 hours per week had higher risk to stop breastfeeding. 8,9 A study reported that on antenatal care, the pregnant women would gain knowledge of exclusive breastfeeding. As the number of antenatal visits, the mother would be increasingly exposed to the information of exclusive breastfeeding from a midwife or other health professionals. 4 Breastfeeding mothers who received counseling about breastfeeding during antenatal care were 2.44 times more likely to give exclusive breastfeeding than those who did not receive counseling about breastfeeding. 17 Working mothers who kept giving exclusive breast-feeding would face many problems. This would affect them to have low confidence for giving exclusive breastfeeding. 8,9 Maternal employment had a negative correlation with the success of exclusive breastfeeding. 18 That problem could affect the let down reflex in the establishment and expenditure of milk. As a result of incomplete let down reflex, there would be accumulation of milk in the alveoli clinically visible as breasts enlarged. The pain would increase, so that stress would increase. Reduced stimulation of breastfeeding from the babies, such as when the power and frequency were less and short of feeding time means the release of prolactin from the pituitary was reduced, so that the manufacture of milk diminished. 19 Families with higher economic status tend not to give exclusive breastfeeding. This was supported by the af- fordability to buy extra food, such as milk formula that could be given to infants in addition to breast milk. The study also revealed that welfare of the family played an important role in the breastfeeding habit. 17 Infants from families with higher economic status rarely got exclusive breastfeeding because of exposure to formula milk and financial support. 20 Although the businesses or employers already knew about the benefits of breastfeeding, but there were still no efforts made to support the success of breastfeeding programs in the workplace. Some barriers to the success of exclusive breastfeeding programs in the workplace included the unavailability of private lactation areas to express the milk, the absence of a flexible schedule, bad relation with the employer or supervisor, declining productivity and financial concern. Influence of employers or businesses took an important role in the success of exclusive breastfeeding for mothers who had a regular job outside the home, then programs that could give support the exclusive breastfeeding were required, at least providing time for nursing mothers to express the breast milk. Flexibility of break to express milk needed a range every three or four hours, therefore it needed to make the difference between nursing mothers and the other workers. 9 Availability of private lactation areas and other supporting facilities today do not fully comply with legislation in Indonesia. It requires a daycare as a complement of the private lactation areas, so the nursing mothers may bring their babies to workplace that will enhance the success of exclusive breastfeeding. 21 There remain companies that do not provide lactation space, so that working mothers express their milk in the toilets or female praying room and store it in the pantry refrigerator along with food and beverage of other workers. 22 There are some policies that specifically accommodate the needs of working mothers to breastfeed in accessing rights. According to Government Regulation No. 33 of 2012 on Clause 30, businesses or employers shall give support on exclusive breastfeeding program and provide private lactation areas in workplace. 13 Minister of Health has issued the Regulation of the Health Ministry of the Republic of Indonesia No. 15 of 2013 regarding the procedure for the provision of private lactation area, but not all businesses or employers provide lactation room convenient with the Government Regulation. 23 Indonesian Government also issues other regulations.  24 However, in practice, the rules get less exercise control or supervision with related parties, such as government or private agencies, beside the lack of enforcement of sanctions/rewards for those who have to enforce the rules properly or not as a form of appreciation for the governments that have contributed to an increase in exclusive breastfeeding in Indonesia. The penalty for corporates and individuals who dissuade exclusive breastfeeding program is included in Clause 200 and 201 of Health Regulation No. 36 of 2009 with arrangement of sanction in forms of imprisonment and fine. 25

Conclusion
Participation of mothers in the family economy can lower the chances of exclusive breastfeeding, full-time working mothers are 1.54 times more likely not be able to give exclusive breastfeeding than unemployed mothers after being controlled by counfonder variable.

Recommendation
Health Ministry of the Republic of Indonesia can enhance the role of health workers in providing health counseling for pregnant mothers, particularly about the necessity of exclusive breastfeeding and balanced diet. Moreover, the authority should provide working mothers information concerning on management of exclusive breastfeeding, such as techniques of expressing milk and storing breast milk properly, beside the needs to enhance cross-sectoral cooperation in providing information about benefits of exclusive breastfeeding for the mother and her baby as well as the benefits for the businesses and employers. Manpower Ministry of the Republic of Indonesia can conduct monitoring to businesses and employers to ensure the availability of private lactation room and the facilities that support for working mothers to continue exclusive breastfeeding. It is expected that the businesses or employers can arrange flexibility of break schedules, especially for full-time employees, so that working mothers can express milk with a quiet and comfortable condition. Also, the employers can create a comfortable working atmosphere that does not result stress or pressure for working mothers, especially for the employees who work throughout the year, as well as provide adequate daycare facilities.