726526
research-article2017
JHLXXX10.1177/0890334417726526Journal of Human LactationPramono and Mariska
Insights in Policy
The Role of Licensure in Breastfeeding
Support in Indonesia
Andini Yulina Pramono, MPH, IBCLC1
and Anna Mariska, MD2
Keywords
breastfeeding, lactation counseling, policy analysis
As of 2014, the rate of exclusive breastfeeding in Indonesia has
not reached the national target of 80% (Directorate General of
Mother-Child and Nutrition Development, 2012). Based on the
Strategic Plan of Ministry of Health 2015-2019 (Indonesian
Ministry of Health, 2015), the Indonesian government created a
target of a 50% exclusive breastfeeding rate by 2019. It would
seem that the Indonesian government was decreasing the target
of exclusive breastfeeding; however, only 38% of infants age 0
to 5 months were exclusively breastfed (Agency of Health
Research and Development, 2013). There are different data
published by the Indonesian Ministry of Health. Only 55.7%
infants were exclusively breastfed, as published in Indonesian
Health Profile (Indonesian Ministry of Health, 2016). Even
though it seems that the national target rate was reached, in fact,
some provinces had very low exclusive breastfeeding rates.
Thus, even with the support of breastfeeding counselors,
Indonesia has many barriers to exclusive breastfeeding (e.g., a
variety of languages spoken, limited accessibility to education
and information sources, and differing local beliefs). Currently,
there are only three authorities (in addition to the government)
that provide the 40 hours of World Health Organization
(WHO)/UNICEF breastfeeding counseling training: The
Indonesian Society of Perinatology (Perinasia), Sentra Laktasi
Indonesia (SELASI), and the Indonesian Breastfeeding
Mothers Association (AIMI). The frequency of these trainings
is increasing every year, which means that the number of breast-
feeding counselors is increasing, although there are no exact
data. Assuming that a single training can have at least 15 partici-
pants with five trainings in 1 year, a minimum of 75 counselors
can be trained every year. According to data from Perinasia
(2016), 350 breastfeeding counselors have been trained; how-
ever, the number of counselors trained by the AIMI and SELASI
has not been recorded, so it remains unknown.
The increasing number of breastfeeding counselors in
Indonesia does not equal the rate of exclusive breastfeeding,
which in some provinces still does not reach the national tar-
get. As stated by Torlesse in Shetty (2014), there are other
barriers. Community-based workers and village health cen-
ters, known as posyanduan important delivery platform to
reach mothers with information and counseling on breast-
feedingare not covered by regulations that protect exclu-
sive breastfeeding, as these regulations apply only to formal
Journal of Human Lactation
13
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healthcare workers. In addition, Roesli, in Shetty (2014),
stated that formula companies use underhanded tactics, such
as giving rewards to health workers who sell a certain amount
of formula. This could also be implemented with breastfeed-
ing counselors, as they are not included in the category of
formal healthcare worker; they could possibly work with
WHO Code violators, as they have no regulations regarding
their profession.
In 2016, Pramono spoke with five mothers who stated that
they had received misleading information about breastfeed-
ing from the breastfeeding counselors they had visited. This
misinformation included giving expressed human milk using
a bottle instead of at the breast, recommendations to sched-
ule breastfeeding rather than to breastfeed on demand, and
misleading information about human milk composition.
To become a breastfeeding counselor, one only needs to
complete WHO/UNICEFs breastfeeding counseling train-
ing module without missing any sessions (a total of 40
hours). There is no education prerequisite for the training.
After completing the training, one must perform a counsel-
ing assignment within 1 month to obtain the certificate. The
official association for breastfeeding counselors in Indonesia
is the Indonesian Breastfeeding Counselors Association
(IKMI); there are approximately 200 members. If a breast-
feeding counselor wants to become a member, he or she will
be given an ethics code of conduct to follow. Not all breast-
feeding counselors want to join, and there is no obligation to
become a member.
In Indonesia, breastfeeding counselors have not been
included in the category of professional health workers. In
the Law of the Republic of Indonesia No. 36 of 2014 on
Health Workers, it is stipulated that those who are considered
health workers are medical staff, clinical psychologists,
1
Advocacy and Law Division, East Java Branch, Indonesian Breastfeeding
Mothers Association, Surabaya, Indonesia
2
Woman and Child Hospital, Surabaya, Indonesia
Date submitted: April 14, 2017; Date accepted: July 26, 2017.
Corresponding Author:
Andini Yulina Pramono, MPH, IBCLC, Indonesian Breastfeeding Mothers
Association, Pakuwon City A5 no. 7, Surabaya 60112, East Java, Indonesia.
Email: andiniyulina@yahoo.co.id
2 Journal of Human Lactation 00(0)
nursing staff, midwifery staff, pharmacy personnel, public
health workers, environmental health workers, nutritionists,
physical therapists, biomedical engineering personnel, tradi-
tional health workers, and other such health professionals.
The profession of breastfeeding counseling, or any regula-
tion specific to it, was not stipulated in the other health pro-
fessionals category. Therefore, breastfeeding counselors are
not tied to any regulation, including what service they pro-
vide, how they do it, and what kind of information and edu-
cation they give. There are no regulations for breastfeeding
counselors as to whether they are allowed to accept any kind
of donation or sponsorship from any third party, including a
human milk substitute producer and distributor or WHO
Code violator.
Discussion and Recommendation
The only relevant lactation professional who is globally rec-
ognized is the International Board Certified Lactation
Consultant (IBCLC), with an independent regulating body
and code of ethics. The IBCLC has a defined body of knowl-
edge including college-level courses in basic foundational
knowledge and lactation-specific knowledge based on the
best evidence available, which is tested with recertification,
required every 5 years. Other lactation credentials exist in
other countries; they require less rigorous criteria that vary
according to the prerequisite and recertification criteria set
by each education program. There is no international stan-
dard and little international recognition of these programs.
In Indonesia, the Ministry of Health has regulations per-
taining to breastfeeding and healthcare providers who work
with breastfeeding families. For example, regulations for pro-
viding breastfeeding trained staff in every breastfeeding and/
or expressing facility are in place (Government Regulation
No. 33, 2012; Ministry of Health Regulation No. 15 of 2013,
2013, Article 13). The breastfeeding-trained staff should have
participated in the standard WHO/UNICEF training held by
the federal government, local governments, and/or communi-
ties. In the existing legislation, only health workers are
mentioned; there is not a term that refers to breastfeeding
counselors (Ministry of Health Regulation No. 15 of 2014,
2014). If breastfeeding counselors act in ways that can hinder
the success of an exclusive-breastfeeding program, no penal-
ties are imposed.
In Indonesia, the government has no clear regulations
specifically for practicing breastfeeding counselors. Breast
feeding counselors are defined as trained persons, both health
professionals and nonhealth professionals, who have com-
pleted training and acquired certificates in breastfeeding
counseling (Government Regulation No. 33, 2012; Ministry
of Health Regulation No. 39 of 2013, 2013). The job descrip-
tion of a breastfeeding counselor is counseling, educating,
and motivating the workers in the rooms where breastfeed-
ing is being practiced (Ministry of Health Regulation No. 15
of 2013, 2013, Article 15). A breastfeeding counselor is one
of the trained professionals who are authorized to provide
information and education on exclusive breastfeeding
(Article 13). Breastfeeding counselors do not have a clear
mechanism for starting a practice, so they can practice any-
where without supervision. Other than this, there is no other
regulation regarding breastfeeding counseling, including
what types of services may be performed or any obligation to
comply with the code of ethics.
Breastfeeding counseling in Indonesia needs standards of
practice and a code of ethics in addition to the WHO/UNICEF
standard, 40-hour certification training. To have quality lac-
tation services, all breastfeeding counselors must champion
the code of ethics and have supervision that standardizes
care. A practice test and final written test should be required
for one to be certified as a breastfeeding counselor.
Certificates should be given a validity period (e.g., 3 years)
and should be updated through continuing education require-
ments and a written test.
Additionally, as a breastfeeding counselor organization,
the IKMI should be part of the license-issuing process by pro-
viding a recommendation letter for each potential new breast-
feeding counselor. Membership in the IKMI would provide
mentorship and a voice to practicing breastfeeding counsel-
ors. A breastfeeding counselor should process his or her prac-
tice license with the City Health Department by submitting
the recommendation letter from the IKMI and the WHO/
UNICEF training certificate, so that monitoring and evalua-
tions can be better performed. This practice license should
have a validity period that should be renewed regularly.
Acknowledgments
The authors would like to thank Lianita Prawindarti, PhD, of the
Indonesian Breastfeeding Mothers Association.
Authors Note
The opinions expressed here are the authors and may not necessar-
ily reflect the position of any entity referenced herein.
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