Bulletin of the World Health Organization

Indonesia’s breastfeeding challenge is echoed the world over

The benefits of breastfeeding are clear, yet Indonesia – like the rest of the world – is struggling to improve rates as formula companies maintain their pressure. Priya Shetty reports.

Bulletin of the World Health Organization 2014;92:234-235. doi: http://dx.doi.org/10.2471/BLT.14.020414

Few issues in early parenthood seem as complex and emotionally charged as breastfeeding. Although exclusive breastfeeding is universally acknowledged to be the best form of nutrition to ensure healthy babies, especially in the first six months of life, rates of exclusive breastfeeding remain low the world over, despite government efforts to implement international guidelines.

Since 2001, WHO guidelines have stated that babies should be exclusively breastfed until they are six months old – something most mothers and babies are physically able to do.

Midwife in Indonesia gives advice to a breastfeeding mother
WHO/Budi Chandra
Midwife in Indonesia gives advice to a breastfeeding mother

In the crucial first few months, breastfed children are six times more likely to survive than children who are not breastfed. Yet globally only 36% of infants younger than six months are exclusively breastfed, and in developing countries poor feeding practices – including lack of exclusive breastfeeding until six months and failure to initiate breastfeeding in the first hour –contribute to the deaths of 800 000 children under five years of age each year.

Breastfeeding experts now see an opportunity for galvanizing action. Maternal and child health is riding high on the global health agenda, with nutrition as a core focus. In May 2012, the World Health Assembly adopted six global nutrition targets to be achieved by 2025, one of them on exclusive breastfeeding.

Meanwhile, public–private partnerships, such as the 1000 days partnership, which prioritizes nutrition from pregnancy to the second year of life, and the SUN (scaling up nutrition) movement, have gained enormous international traction and funding. Yet, as researchers and policy-makers are discovering, improving low rates of breastfeeding will mean more than just a focus on nutrition because the reasons behind the low rates are many and complex.

Indonesia is a case in point. In 2009, it enacted a law calling for every baby to be breastfed or to be given breast milk from donors and milk banks exclusively for the first six months of life, unless there are medical reasons not to do so. Yet although rates of exclusive breastfeeding in babies younger than six months increased from 32% in 2007 to 42% in 2012, according to the 2012 Indonesian Demographic Health Survey, health experts in the country say that implementation of the law remains poor and that formula companies continue to push breast-milk substitutes to mothers of very young infants.

The case for breastfeeding is solid. Evidence shows that thanks to protective antibodies, lipids and other elements in breast milk, breastfed babies have fewer episodes of middle-ear infection, diarrhoea and pneumonia. Moreover, the preparation of formula milk in unhygienic conditions that are common in poor countries can lead to diarrhoea or other illnesses, says Marti Van Liere, maternal and child nutrition expert at GAIN Alliance. Since formula milk is expensive, some mothers water it down and, thus, give their babies milk that is not nutritious enough, she adds.

Developmental biologists are also starting to understand that the use of formula milk can have serious long-term health consequences for both mothers and babies, says Dr Alison Stuebe, who studies the effects of breastfeeding at the Division of Maternal-Fetal Medicine, at the University of North Carolina at Chapel Hill, in the United States of America. “Not breastfeeding is linked with higher rates of sudden infant death syndrome, leukaemia and childhood obesity.” Mothers who don’t breastfeed, meanwhile, face an increased risk of premenopausal breast cancer, ovarian cancer and type 2 diabetes.

So what explains the low rates of breastfeeding worldwide? Health workers are one of the key sources of information for mothers, yet “health professionals receive mixed, if any education about breastfeeding during their training and, thus, lack good information to advise women and manage common breastfeeding challenges,” says Stuebe. A lack of support for breastfeeding in the workplace is also a critical factor, she says. “Women who must return to work struggle to maintain their milk supply and earn enough to support their families.”

In Indonesia, “a lack of knowledge and sociocultural, economic and personal reasons mean that many women may choose to bottle-feed with formula milk completely,” says Rustini Floranita, maternal health expert in WHO’s Indonesia office in Jakarta. Although Indonesia’s rates of exclusive breastfeeding before the age of six months have risen in the past seven years, from 32% to 42%, this is only marginally better than the 2003 rate of 40%.

Improving rates of breastfeeding depends, among other things, on reducing the reliance on formula milk, and yet this has proved difficult. In 1981, the International Code of Marketing of Breast-milk Substitutes was adopted by countries at the World Health Assembly to ensure that formula was not promoted to mothers, for example, through free samples, subsidies or other means, and that all formula labels and information stated the benefits of breastfeeding and the health risks posed by substitutes.

However, uptake of the code has been dismal. According to a 2011 WHO report, only 37 (19%) of the 199 countries reporting to WHO have fully implemented the recommendations. Indonesia is no exception. According to the WHO report, Indonesia has seen “many provisions into law, with voluntary and other national measures” but not full implementation.

The problem is that the code is “unevenly endorsed and not consistently enforced,” says Stuebe. “Every time a baby goes to breast, a formula company loses a sale, so formula companies aggressively promote their products and work to undermine a woman’s confidence in her ability to meet her baby’s needs.”

And there are other barriers. Community-based workers and village health centres – known as posyandus – an important delivery platform to reach mothers with information and counselling on breastfeeding – are not covered by regulations that protect exclusive breastfeeding as these only apply to formal health-care workers, says Harriet Torlesse, head of nutrition at UNICEF’s Indonesia programme.

What’s more, she says, “formula companies operating in Indonesia regularly market follow-up formula milk for children aged one year and above,” which falls well short of the International Code of Marketing of Breast-milk Substitutes and subsequent World Health Assembly resolutions that prohibit marketing such products for children younger than two years.

Formula companies can use underhand tactics, says Dr Utami Roesli at the Indonesian Breastfeeding Center. “Midwives who sell a certain amount of formula are rewarded by formula companies with gifts such as cell phones, computers, motorcycles or even holidays.”

Pressure from formula companies is not the sole explanation for low breastfeeding rates in Indonesia. GAIN’s work in the country suggests that a key barrier to breastfeeding is a poor understanding of nutrition, says Van Liere, and not realizing that using formula milk can interrupt breast-milk production.

Baby is fed milk from a bottle in Ethiopia
WHO/Petterik Wiggers
Baby is fed milk from a bottle in Ethiopia

Roesli says that cultural mores are at work too. “Breastfeeding rates do not seem to correlate with the mother’s education, whether they are urban or rural, or whether they are wealthy; instead, breastfeeding decisions are heavily influenced by older family members – often grandmothers – and by health-care workers.”

All this suggests that a multipronged approach is needed to improve breastfeeding. The WHO–UNICEF Baby Friendly Hospital Initiative goes some way towards encouraging health workers – both midwives and physicians – to support breastfeeding. Since 1991, 15 000 hospitals in 134 countries have joined the initiative.

In Indonesia, research last year by Aristiati Susiloretni, from the Semarang Health Polytechnic, and colleagues suggests that if the government were to invest in a robust implementation plan of its new legislation, it might see a radical shift in breastfeeding rates.

They found that a holistic approach – one that involved voluntary health workers, traditional birth attendants, Muslim scholars and heads of villages and used advocacy, training, media promotion and home visits – increased breastfeeding enormously.

In their 2013 randomized controlled study, published in the American Journal of Health Promotion, of 163 families in Demak district, Central Java, exclusive breastfeeding rates at 1, 8, 16 and 24 weeks for the intervention group which benefited from this holistic approach versus the control groups, which did not, were: 75.3% versus 28.0%, 64.2% versus 14.6%, 50.6% versus 8.5%, and 37.0% versus 3.7%, respectively.

Both UNICEF and Save the Children published major reports on the state of breastfeeding worldwide last year, both making urgent calls for action. The UNICEF report concluded that a key factor in returning breastfeeding to the global agenda would be embedding it in international nutrition initiatives such as the SUN movement. Save the Children, meanwhile, is calling for better enforcement of legislation, and crucially, is taking action against formula companies that sidestep international codes of conduct.

“It is devastating that something as simple and crucial as breastfeeding is still not happening for so many mothers and infants around the world,” says Frances Mason of Save the Children. “No child is born to die because they don't get the basic nourishment they need.”