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JHLXXX10.1177/0890334417726526Journal of Human LactationPramono and Mariska

Insights in Policy
Journal of Human Lactation

The Role of Licensure in Breastfeeding

The Author(s) 2017
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DOI: 10.1177/0890334417726526

Andini Yulina Pramono, MPH, IBCLC1

and Anna Mariska, MD2

breastfeeding, lactation counseling, policy analysis

As of 2014, the rate of exclusive breastfeeding in Indonesia has healthcare workers. In addition, Roesli, in Shetty (2014),
not reached the national target of 80% (Directorate General of stated that formula companies use underhanded tactics, such
Mother-Child and Nutrition Development, 2012). Based on the as giving rewards to health workers who sell a certain amount
Strategic Plan of Ministry of Health 2015-2019 (Indonesian of formula. This could also be implemented with breastfeed-
Ministry of Health, 2015), the Indonesian government created a ing counselors, as they are not included in the category of
target of a 50% exclusive breastfeeding rate by 2019. It would formal healthcare worker; they could possibly work with
seem that the Indonesian government was decreasing the target WHO Code violators, as they have no regulations regarding
of exclusive breastfeeding; however, only 38% of infants age 0 their profession.
to 5 months were exclusively breastfed (Agency of Health In 2016, Pramono spoke with five mothers who stated that
Research and Development, 2013). There are different data they had received misleading information about breastfeed-
published by the Indonesian Ministry of Health. Only 55.7% ing from the breastfeeding counselors they had visited. This
infants were exclusively breastfed, as published in Indonesian misinformation included giving expressed human milk using
Health Profile (Indonesian Ministry of Health, 2016). Even a bottle instead of at the breast, recommendations to sched-
though it seems that the national target rate was reached, in fact, ule breastfeeding rather than to breastfeed on demand, and
some provinces had very low exclusive breastfeeding rates. misleading information about human milk composition.
Thus, even with the support of breastfeeding counselors, To become a breastfeeding counselor, one only needs to
Indonesia has many barriers to exclusive breastfeeding (e.g., a complete WHO/UNICEFs breastfeeding counseling train-
variety of languages spoken, limited accessibility to education ing module without missing any sessions (a total of 40
and information sources, and differing local beliefs). Currently, hours). There is no education prerequisite for the training.
there are only three authorities (in addition to the government) After completing the training, one must perform a counsel-
that provide the 40 hours of World Health Organization ing assignment within 1 month to obtain the certificate. The
(WHO)/UNICEF breastfeeding counseling training: The official association for breastfeeding counselors in Indonesia
Indonesian Society of Perinatology (Perinasia), Sentra Laktasi is the Indonesian Breastfeeding Counselors Association
Indonesia (SELASI), and the Indonesian Breastfeeding (IKMI); there are approximately 200 members. If a breast-
Mothers Association (AIMI). The frequency of these trainings feeding counselor wants to become a member, he or she will
is increasing every year, which means that the number of breast- be given an ethics code of conduct to follow. Not all breast-
feeding counselors is increasing, although there are no exact feeding counselors want to join, and there is no obligation to
data. Assuming that a single training can have at least 15 partici- become a member.
pants with five trainings in 1 year, a minimum of 75 counselors In Indonesia, breastfeeding counselors have not been
can be trained every year. According to data from Perinasia included in the category of professional health workers. In
(2016), 350 breastfeeding counselors have been trained; how- the Law of the Republic of Indonesia No. 36 of 2014 on
ever, the number of counselors trained by the AIMI and SELASI Health Workers, it is stipulated that those who are considered
has not been recorded, so it remains unknown. health workers are medical staff, clinical psychologists,
The increasing number of breastfeeding counselors in
Indonesia does not equal the rate of exclusive breastfeeding, 1
Advocacy and Law Division, East Java Branch, Indonesian Breastfeeding
which in some provinces still does not reach the national tar- Mothers Association, Surabaya, Indonesia
get. As stated by Torlesse in Shetty (2014), there are other Woman and Child Hospital, Surabaya, Indonesia
barriers. Community-based workers and village health cen- Date submitted: April 14, 2017; Date accepted: July 26, 2017.
ters, known as posyanduan important delivery platform to
Corresponding Author:
reach mothers with information and counseling on breast- Andini Yulina Pramono, MPH, IBCLC, Indonesian Breastfeeding Mothers
feedingare not covered by regulations that protect exclu- Association, Pakuwon City A5 no. 7, Surabaya 60112, East Java, Indonesia.
sive breastfeeding, as these regulations apply only to formal Email:
2 Journal of Human Lactation 00(0)

nursing staff, midwifery staff, pharmacy personnel, public of the trained professionals who are authorized to provide
health workers, environmental health workers, nutritionists, information and education on exclusive breastfeeding
physical therapists, biomedical engineering personnel, tradi- (Article 13). Breastfeeding counselors do not have a clear
tional health workers, and other such health professionals. mechanism for starting a practice, so they can practice any-
The profession of breastfeeding counseling, or any regula- where without supervision. Other than this, there is no other
tion specific to it, was not stipulated in the other health pro- regulation regarding breastfeeding counseling, including
fessionals category. Therefore, breastfeeding counselors are what types of services may be performed or any obligation to
not tied to any regulation, including what service they pro- comply with the code of ethics.
vide, how they do it, and what kind of information and edu- Breastfeeding counseling in Indonesia needs standards of
cation they give. There are no regulations for breastfeeding practice and a code of ethics in addition to the WHO/UNICEF
counselors as to whether they are allowed to accept any kind standard, 40-hour certification training. To have quality lac-
of donation or sponsorship from any third party, including a tation services, all breastfeeding counselors must champion
human milk substitute producer and distributor or WHO the code of ethics and have supervision that standardizes
Code violator. 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)
Discussion and Recommendation
and should be updated through continuing education require-
The only relevant lactation professional who is globally rec- ments and a written test.
ognized is the International Board Certified Lactation Additionally, as a breastfeeding counselor organization,
Consultant (IBCLC), with an independent regulating body the IKMI should be part of the license-issuing process by pro-
and code of ethics. The IBCLC has a defined body of knowl- viding a recommendation letter for each potential new breast-
edge including college-level courses in basic foundational feeding counselor. Membership in the IKMI would provide
knowledge and lactation-specific knowledge based on the mentorship and a voice to practicing breastfeeding counsel-
best evidence available, which is tested with recertification, ors. A breastfeeding counselor should process his or her prac-
required every 5 years. Other lactation credentials exist in tice license with the City Health Department by submitting
other countries; they require less rigorous criteria that vary the recommendation letter from the IKMI and the WHO/
according to the prerequisite and recertification criteria set UNICEF training certificate, so that monitoring and evalua-
by each education program. There is no international stan- tions can be better performed. This practice license should
dard and little international recognition of these programs. have a validity period that should be renewed regularly.
In Indonesia, the Ministry of Health has regulations per-
taining to breastfeeding and healthcare providers who work Acknowledgments
with breastfeeding families. For example, regulations for pro- The authors would like to thank Lianita Prawindarti, PhD, of the
viding breastfeeding trained staff in every breastfeeding and/ Indonesian Breastfeeding Mothers Association.
or expressing facility are in place (Government Regulation
No. 33, 2012; Ministry of Health Regulation No. 15 of 2013, Authors Note
2013, Article 13). The breastfeeding-trained staff should have The opinions expressed here are the authors and may not necessar-
participated in the standard WHO/UNICEF training held by ily reflect the position of any entity referenced herein.
the federal government, local governments, and/or communi-
ties. In the existing legislation, only health workers are References
mentioned; there is not a term that refers to breastfeeding Agency of Health Research and Development. (2013). Basic health
counselors (Ministry of Health Regulation No. 15 of 2014, research. Jakarta: Indonesian Ministry of Health.
2014). If breastfeeding counselors act in ways that can hinder Directorate General of Mother-Child Health and Nutrition
the success of an exclusive-breastfeeding program, no penal- Development. (2012). Plan of acceleration action of exclusive
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Pramono and Mariska 3

Law of the Republic of Indonesia no. 36 of 2014 on health work- health care provider, health education provider, board of pro-
ers. (2014). Retrieved from Ministry of Health website: http:// fessional organizations in the health sector, as well as manu- facturers and distributors of infant formula and/or other baby
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