Implementation of Breastfeeding Friendly Policy in a Factory: A Qualitative Study among Occupational Health and Safety Coordinators in Indonesia

Friendly Policy in a Factory: A Qualitative Study and Coordinators Abstract Background: Not all mothers are able to breastfeed or pump milk. Return-to-work has been identified as a major and significant barrier to continue breastfeeding, due to improper lactation facilities at the workplace. This study aimed to explore the implementation of breastfeeding friendly policy at factories, from the perspective of Occupational Health and Safety (OHS) coordinators. Methods: A qualitative survey conducted in eight factories, using an adjusted open-ended questionnaire to OHS coordinators in manufacture and garment factories in an industrial area in East Jakarta. The results are presented in a descriptive display matrix and listing, without any statistical analysis. Key and most relevant suggestions and inputs from respondents are presented in the form of quotations to support the pattern found from the survey. and


Introduction
Exclusive breastfeeding is the best nutrition source of infants.
The World Health Organization (WHO) and the Ministry of Health of Indonesia recommend exclusive breastfeeding for the first 6 months of life which should be continued with complimentary food for two years [1][2][3]. WHO defines exclusive breastfeeding as an infant that only receives breastmilk without any other foods, DOI: 10.26717/BJSTR.2020.24.004004 including any liquids, water, formula milk, fruit juice, tea, honey, or any solid food except vitamins and medicines [1,4]. Exclusive breastfeeding is not only beneficial for the infants, but also the mothers. Breastfeeding helps to reduce post-partum body weight and the risk for non-communicable diseases, [5][6][7][8] cardiovascular disease [9]. Breastfeeding improves the quality of life of the mother and her mental health [10]. Breastfeeding prolongs the amenorrhea period [11]. However, not all mothers are able to breastfeed, especially the working mother population. Return to work after maternal leave has been identified as a major and significant barrier for women workers to continue breastfeeding.
Studies show that the breastfeeding rate significantly decreases at the time when mothers return to work [12,13].
The main reasons are related to the distance between home and workplace, improper lactation facilities at the workplace and decreased breastmilk production during working hours [14]. The prevalence of exclusive breastfeeding among factory workers in 2015 was only 19%, significantly lower compared to the national prevalence which was 38% [15]. A study in Taiwan showed that only 10.6% of working mothers continue to breastfeed upon returning to work [14]. An Indonesia study found that 45% of working mothers discontinue breastfeeding because of return-to-work.
Inadequate lactation facilities and support programs in workplace are the main reasons of discontinuation [12]. In Indonesia the breastfeeding and lactation competency is not part of the basic and required competency of corporate physicians, company doctors and Occupational Health and Safety (OHS) coordinators, who in fact are responsible for the health promotion program at the workplace [16,17]. According to Cochrane Reviews in 2012, no randomized controlled trial has been performed to evaluate the effectiveness of a workplace lactation intervention program [18]. The present article is a report of a survey of OHS coordinators in eight factories in the East Jakarta region. This qualitative study aimed to identify the OHS coordinator's perspective about the implementation of national breastfeeding friendly policy and breastfeeding promotion support in their respected factory.

Methods
This is a qualitative survey conducted in eight factories in Jakarta, using an adjusted open-ended questionnaire [19]. The study population were eight OHS coordinators in manufacture and garment factories in an industrial area in East Jakarta. The respondents were asked to fill a questionnaire that consisted

Results
Appendix Tables 1-3 shows that all respondents have worked in the current factory for more than five years and 50% of them

Discussion
To the best of our knowledge, this is the first study reporting on the implementation of the breastfeeding friendly policy in a factory, explored from the perspective of OHS coordinator in Indonesia.
This study reported that the implementation of national or governmental breastfeeding friendly policy in factories is still not optimal compared to what had been suggested by the referenced guidelines and recommendations. The availability of a dedicated and private lactation room is the prioritized facility regulated by the policy, and still there are three out of eight factories that only provide a multi-functional room. The availability of a dedicated and private lactation room is one of the key factors to support the continuation of exclusive breastfeeding among working mothers [19][20][21]. Failure in providing a private and dedicated lactation room at work not only increases the probability of breastfeeding cessation but should also be a non-compliance of employers, hence requiring control and monitoring by the regulator.
Maternal leave is also another indicator explored in this study, and we found that all eight factories only fulfilled the minimum requirements of three months maternal leave and obliged the workers to take leave at least 1.5 months before delivery duedate, which means the workers will need to return to work when the infants are only 1.5-month-old. Although this is not against the policy, it creates a challenging situation for the working mothers.
Previous studies suggested that it is advisable for the employer to lengthen the leave duration whenever possible [19,[22][23][24][25]. Flexible time of breast pumping breaks during working hours is another recommended item by the government policy, endorsed by evidence [21,26,27]. Findings from this study showed that this policy was implemented, although few reiterated the importance of getting permission from a supervisor as well as a suggestion to workers to maximize the lunch break time to pump. The government has made it obligatory to provide a breastfeeding facility in workplace and it was recommended by The Indonesian government through a Joint Regulation since 2008 [28].
Other findings from this study also showed that breastfeeding promotion, education programs, and materials support in workplace were not fully implemented. This finding is similar with another study in Indonesia reporting that only 21.5% of workers have access to proper lactation facilities at work [15].
Most respondents also mentioned that their factories only distributing leaflet and posters related to breastfeeding, while this conservative support was found to be less effective [15,25].
Respondents also admitted that the management and/or factory owners have put the profitability and financial consideration as the key determined parameter in providing breastfeeding facilities and support program at work. This is consistent with findings from the previous study reported that employers do not prioritizing breastfeeding support at the workplace for many reasons [29]. The lack of breastfeeding facilities and support programs will hamper the working performance and productivity of lactating workers [30,31]. All respondents also reported that none of the factories provided a dedicated lactation counsellor at the workplace as it is not clearly recommended by the governmental policy.
A study in Thailand reported that an education co-operation platform of health professionals, the manager and other representatives from the management should be set up, with the support by nurse-midwives and/or lactation consultants within the workplace [32]. Occupational and environmental health nurses trained with specific breastfeeding knowledge also could improve the success of breastfeeding [31] Many studies have shown that an employer could benefit from their female workers' breastfeeding and lactation behaviour which would improve the employee's productivity and motivate mothers to return to work [33][34][35][36][37].
Transforming a workplace to become a breastfeeding friendly environment is critical to support lactating workers [38].

Conclusion
It is evidence based that supporting working mothers to continue breastfeeding at work will be beneficial for the infants, workers, and the employers. Hence, it is recommended by an established governmental policy. However, this qualitative study among OHS coordinators in factories revealed that there is still lack of breastfeeding friendly policy implementation in factories due to misperception of employers toward breastfeeding benefits.

1.
There is a lack of breastfeeding friendly policy implementation in factories.

Employers have an erroneous perception of breastfeeding
benefits on their employees, breastfeeding mothers.

Ethics
This study was approved by The Ethics Committee of Faculty of Medicine, Universitas Indonesia, letter number 786/UN2.F1/ ETIK/2016.

Funding Disclosure
This study received no external funding.