Indonesian Community Health Workers: Roles

and Challenges
in Breastfeeding Promotion
Ayyu Sandhi - Graduate Institute of Nursing - Taipei Medical
University

Outline
1.
2.

Purpose of the literature review

Literature review
1.
2.
3.
4.
5.

3.
4.
5.
2

Importance of breastfeeding
Global support for breastfeeding
Challenges for breastfeeding continuity
Roles of Indonesian community health workers in breastfe
eding promotion
Challenges faced by Indonesian community health workers
in breastfeeding promotion

Discussion
Conclusion
References

Purpose of the literature review

The aim of this literature review is to identify th
e roles of Indonesian community health worker
s in breastfeeding promotion, as well as challen
ges faced by them.

Importance of breastfeeding
At the exact composition
needed by the baby

Prevent ear
infection

Reduced risk of
getting diabetes

Prevent atopic
eczema
Prevent urinary-tract
infection
Prevent gastrointestinal infection
4

Prevent respiratory
infection

Reduced risk of getting

hypertension and obesit

Importance of breastfeeding

Increased likelihood of th
e burning of body fat dep
osited during pregnancy
Lower incidence of hip fr
acture
Reduction in maternal he
morrhage
Reduction in the risk of b
reast and ovarian cancer
Helps mothers to space p
regnancies (known as the
Lactation Amenorrhoea
Method)

Global support for breastfeeding

Initiate

breastfeeding within the first hour after

delivery
Exclusive breastfeeding for six months
Breastfeeding up to 2 years + complementary fe
eding starting from 6 months

Global support for breastfeeding

Challenges for breastfeeding continuity

WHO, 2014

Indonesian MOH, 2010

29.3
15.
3

Health
profession
als

Communit
y health
workers

Inform all pregnant women about the benefits and management

of breastfeeding Help mothers to breastfeed within half an hour
after delivery
Show mothers how to breastfeed and how to maintain lactation
Practice rooming-in
Encourage breastfeeding on demand
Give no pacifiers to breastfeeding infants
Establish breastfeeding support group for the mothers to be
referred after discharge

A study conducted in United States (US) showed that 92% women had
labor in the hospital reported receiving help with breastfeeding in the
hospital from lactation consultants, nurses or nursing students. But
only 54.8% of them reported receiving help with breastfeeding once
discharged from the hospital (Lewallen et al., 2006).
9

Roles of Indonesian community health wor

kers in breastfeeding promotion
Community health workers (CHWs) are (usually) women
chosen by people in the community and trained to deal
with individual or community health problems.
CHWs are responsible for maternal and child health,
family planning, immunization, nutrition, and
prevention and management of diarrhea in the
community (Indonesian Ministry of Health, 2012).
Selection criteria: literacy, able to carry out their job as
CHW, have their own income, permanently stay in the
village, actively participate in social activities in their
communities, and socially accepted.
10

Roles of Indonesian community health wor

kers in breastfeeding promotion
1. Family members to encourage mothers to exclusively
breastfeed their babies (0 6 months)
2. Mothers to breastfeed immediately after delivery, since
first milk that comes out contains antibody which
protects babies from disease and infection
3. Mothers to take enough rest after delivery in order to
quicken the recovery process and to allow the body
producing adequate breast milk
4. Mothers to breastfeed on demand
5. Mothers to wake up and breastfeed the babies if the
babies sleep for more than 3 hours already
6. Mothers to breastfeed with one breast until they feel
the breast empty, and then move to another breast
7. Mothers to take the babies to the health post once a
month to be weighed, so the growth can be monitored.
11

Anthropometry measurement

Documentation on growth chart

CHWs consult the data to public health nurse and

nutritionist for further intervention

Challenges faced by Indonesian community

health workers in breastfeeding promotion
CHWs are usually highly valued by the communities because
they are considered as people who have higher health
knowledge than average people in the communities.
In fact, most of the CHWs do not have formal education in
health and were not trained prior to beginning their roles
as CHWs. They only receive on-the-job training and learn
independently from other earlier CHWs.
Trainings from public health centre are described as
inconsistent and insufficient due to lack of qualified public
health nurses.
Some medical and nursing schools make efforts to bridge this
gap by sending their students regularly to the community
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Challenges faced by Indonesian community

health workers in breastfeeding promotion
There can be up to 15 CHWs in each village, which
usually has 1200 households. In term of
workload, CHWs consider their job to be
overwhelming since there is no clear division
of tasks among them and no clear
distribution of households under each CHW's
responsibility.
It may lead to some crucial health problems stay
undercover, the service given is not optimal, and
discontinuity of CHWs' active participation.
22

Discussion

Training for CHWs (Condo et al., 2014) :

Pakistan 3 months of initial training, 1 year of supervis
ed fieldwork
India 12 to 18 month distance-learning course
Tanzania 9 months of preservice training
Ethiopia 12 months of training

In Philippines, CHWs with personal breastfeeding experienc

e educate women on exclusive breastfeeding and help to pr
event and manage common breastfeeding problems, and it
was proven to be effective to increase exclusive breastfeedi
ng rate among them (Gilmore & McAuliffe, 2013).
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Discussion

A study conducted in Indonesia previously emphasized urge

nt need for training about the importance of exclusive breas
tfeeding and maintenance of breastfeeding until 2 years of a
ge for the CHWs (Iswarawanti, 2010).

Submaterials delivered in the training should be based on p

henomena usually faced by CHWs, if not then data about co
mmon breastfeeding problems may be used, such as insuffi
cient milk supply, painful nipples, latch problems, returning
to work/school, drug/illness of mother or baby, and any oth
er personal reasons (Lewallen et al., 2006).

Effectiveness of training for CHWs on their knowledge and s

kills about breastfeeding promotion should be investigated.
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Discussion

Clear job destinction and distribution of the number of hous

eholds that are the responsibility of each CHW will help the
m to be more focus, doing more accurate assessment of hea
lth problems, giving more optimal service, and maintain acti
ve participation of CHWs.

Rwanda locates 3 CHWs per village: One CHW who is respon

sible for community health, nutrition, and HIV/AIDS preventi
on; one CHW who is responsible for infant and maternal hea
lth; and one more is responsible for social affairs and comm
unity well-being (Condo et al., 2014).

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Conclusion
1.
2.

3.

4.

5.

6.

Support and education from CHWs will help mothers dealing with breastfe
eding problems once discharged from the hospital.
Challenges faced by Indonesian CHWs are lack of adequate training, lack o
f self-confidence and communication skills, and high workload due to uncl
ear job destinction and distribution of the number of households.
Adequate training programs as well as clear division of tasks and distributi
on of the number of households are expected to help CHWs to be more fo
cus, effective, and stay active.
In case there is lack of human resources to conduct training, official collab
oration between public health centre and medical/nursing school should b
e considered.
Materials related to breastfeeding should be based on real phenomena oft
en faced by CHWs or based on common breastfeeding problems from the
studies.
Study about effectiveness of training on CHWs about breastfeeding is furth
er to be done.
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References
Aidam, B. A., Prez-Escamilla, R., & Lartey, A. (2005). Lactation counseling increases exclusive
breast-feeding rates in Ghana. The Journal of nutrition, 135(7), 1691-1695.
Beake, S., Pellowe, C., Dykes, F., Schmied, V., & Bick, D. (2012). A systematic review of structure
d compared with nonstructured breastfeeding programmes to support the initiation and d
uration of exclusive and any breastfeeding in acute and primary health care settings. Mate
rnal & child nutrition, 8(2), 141-161.
Britton, C., McCormick, F., Renfrew, M., Wade, A., & King, S. (2007). Support for breastfeeding
mothers (Review). Cochrane Database Syst Rev, 1, CD001141.
Cadwell, K. (2007). Latchingon and suckling of the healthy term neonate: breastfeeding asses
sment. Journal of Midwifery & Womens Health, 52(6), 638-642.
Condo, J., Mugeni, C., Naughton, B., Hall, K., Tuazon, M. A., Omwega, A., . . . Ngabo, F. (2014). R
wanda's evolving community health worker system: a qualitative assessment of client and
provider perspectives. Human resources for health, 12(1), 71.
Gilmore, B., & McAuliffe, E. (2013). Effectiveness of community health workers delivering prev
entive interventions for maternal and child health in low-and middle-income countries: a s
ystematic review. BMC public health, 13(1), 1-14.
Indonesian Ministry of Health. (2010). Situasi dan Analisis ASI Eksklusif. Retrieved December 2
5, 2014, from
http://www.depkes.go.id/resources/download/pusdatin/infodatin/infodatin-asi.pdf.
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References
Indonesian Ministry of Health. (2012). Buku Pegangan Kader POSYANDU. Retrieved December
25, 2014, from http://www.depkes.go.id/download.php?file=download/promosi-kesehatan/
buku-saku-posyandu.pdf
Iswarawanti, D. N. (2010). Kader posyandu: peranan dan tantangan pemberdayaannya dalam
usaha peningkatan gizi anak di Indonesia. Jurnal Manajemen Pelayanan Kesehatan, 13(04).
Lewallen, L. P., Dick, M. J., Flowers, J., Powell, W., Zickefoose, K. T., Wall, Y. G., & Price, Z. M. (20
06). Breastfeeding support and early cessation. Journal of Obstetric, Gynecologic, & Neonat
al Nursing, 35(2), 166-172.
Trajanovska, M., Burns, S., & Johnston, L. (2007). A retrospective study of breastfeeding outco
mes in an Australian neonatal intensive care unit. Journal of Neonatal Nursing, 13(4), 150-1
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WHO. (2014). Infant and young child feeding. Retrieved December 25, 2014, from http://www.
who.int/mediacentre/factsheets/fs342/en/
Yi, C. M., & Man, H. S. (2011). The effectiveness of breastfeeding education on maternal breast
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