Running head: INDONESIAN COMMUNITY HEALTH WORKERS

Indonesian Community Health Workers: Roles and Challenges

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

INDONESIAN COMMUNITY HEALTH WORKERS

Abstract
The well-known benefits of breastfeeding led to a number of
regulations launched to ensure women to exclusively breastfeed
from 0 to 6 months postpartum, and to keep breastfeeding
continuously until the babies were 2 years-old, accompanied by
appropriate additional food. On the other side, the regulation
is not followed by good performance. Data from World Health
Organization showed that only 38% of infants aged 0 to 6
months around the world are exclusively breastfed. Almost all
mothers had labor in the hospital reported receiving help with
breastfeeding in the hospital while only slightly more than a
half of them reported receiving help with breastfeeding after
discharge, which means that community health workers as
extension of health professionals in the community have high
opportunity to support and promote breastfeeding. The aim of
this literature review is to identify the role of Indonesian
community health workers in breastfeeding promotion, as well
as challenges faced by them. Selection criteria of community
health workers are explained, as well as job description.
Challenges faced by community health workers are lack of
trainings and unclear division both tasks and households under
responsibility. Some on-going strategies to meet the
challenges are also defined.
Keywords: community health workers, breastfeeding
promotion

INDONESIAN COMMUNITY HEALTH WORKERS

Indonesian Community Health Workers: Roles and Challenges

in Breastfeeding Promotion
Introduction
Considering the benefits of breastfeeding, global
awareness has been raised and regulation has been released to
ensure women to exclusively breastfeed their babies since they
were born until 6 months-old, and it is suggested to keep
breastfeeding continuously until the babies were 2 years-old,
accompanied by appropriate additional food (Yi & Man, 2011).
On the other side, the regulation is not followed by good
performance, both globally and in Indonesia particularly
(Indonesian Ministry of Health, 2010; WHO, 2014).
Early cessation of breastfeeding can be influenced by
many factors, including health education and support from
health professionals (Aidam, Prez-Escamilla, & Lartey, 2005).
Data provided from a study in United States (US) were that
almost all mothers had labor in hospital reported receiving
help with breastfeeding in the hospital while only slightly
more than a half of them reported receiving help with
breastfeeding once discharged from the hospital (Lewallen et
al., 2006), which means that community health workers as
extension of health professionals have high opportunity to
support and promote breastfeeding.
The aim of this literature review is to identify the role
of Indonesian community health workers in breastfeeding
promotion, as well as challenges faced by them.

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Literature Review
Importance of Breastfeeding
Breast milk provides nutrients at the exact composition
according to the needs of the infant for growth and
development. It provides all energy and nutrients needed by
infant for the first 6 months of age, half or more of infant's
energy between 6 and 12 months, and one third of energy needs
between 12 and 24 months (Trajanovska, Burns, & Johnston,
2007; WHO, 2014). Breastfeeding has been associated with
reduced mortality in preterm infants, enhancement of the
infants immunity and protection against gastrointestinal,
respiratory, urinary tract and middle-ear infections and
atopic eczema (Aidam et al., 2005; Beake, Pellowe, Dykes,
Schmied, & Bick, 2012; Britton, McCormick, Renfrew, Wade, &
King, 2007). For long-term effects, breastfeeding helps to
prevent juvenile onset insulin dependant diabetes mellitus,
hypertension and obesity (Britton et al., 2007).
The benefits to the breastfeeding mothers include the
increased likelihood of the burning of body fat deposited
during pregnancy (Yi & Man, 2011), lower incidence of hip
fracture (Britton et al., 2007), reduction in maternal
hemorrhage and reduction in the risk of breast and ovarian
cancer (Aidam et al., 2005). It also helps mothers to space
pregnancies (known as the Lactation Amenorrhoea Method) since
exclusive breastfeeding up to 6 months has a hormonal effect
which often induces a lack of menstruation (WHO, 2014).

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Global Support and Challenges for Breastfeeding Continuity

Because of the extensive evidence of well-known
advantages of breastfeeding, international awareness about
this issue has been raised. Global support for the
encouragement, commencement, and continuation of breastfeeding
has been initiated. In 2003 the WHO together with UNICEF
recommend breastfeeding immediately within the first hour
after baby delivery, breastfeeding exclusively for the first
six months of life and continuation of breastfeeding for up to
two years of age along with nutritionally-adequate and safe
complementary (solid) foods (Yi & Man, 2011). Far in advance,
in 1992 the WHO and UNICEF launched Baby Friendly Hospital
Initiatives, a global program which works with health
providers, clinicians, and women to ensure all women and their
babies receive the benefits of breastfeeding. A 10-steps
program to successful breastfeeding has been developed to
promote and support breastfeeding, which includes specific
practices and indicators that each maternity service should
able to achieve (Beake et al., 2012).
In spite of the massive structured program to promote and
support breastfeeding, some countries still have to deal with
reduction in breastfeeding rate. Centers for Disease Control
and Prevention in 2003 showed that only 36% of women continue
breastfeeding until 6 months (Lewallen et al., 2006). WHO
provided data that up to February 2014, only about 38% of
infants aged 0 to 6 months around the world are exclusively

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breastfed (WHO, 2014). In the United Kingdom (UK), statistics

showed that in 2005 breastfeeding initiation rate was 69% and
declined to 25% in term of exclusive breastfeeding at six
months postpartum. In Japan, it is reported that 96% of
mothers intend to exclusively breastfeed, but the number of
exclusive breastfeeding was just 42% at four weeks postpartum.
Chinese mothers were no different. Statistics showed that only
50% of Chinese mothers exclusively breastfeed for the first
six months postpartum (Yi & Man, 2011). In Indonesia, data
from Ministry of Health in 2010 revealed that breastfeeding
initiation rate was 29.3% and declined to 15.3% in term of
exclusive breastfeeding at six months postpartum (Indonesian
Ministry of Health, 2010).
Community Health Workers : Roles in Breastfeeding Promotion
Active participation of health professionals is needed
since lack of health education and support from health
professionals is one among many factors that might influence
the early cessation of breastfeeding. Health professionals
were highly regarded in the communities as a credible source
of health information (Aidam et al., 2005). As stated in the
10-steps to successful breastfeeding published by the WHO in
1989, health professionals should inform all pregnant women
about the benefits and management of breastfeeding. Once the
baby is delivered, health professionals should help mothers to
breastfeed within half an hour after delivery, show mothers
how to breastfeed and how to maintain lactation even when the

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baby and the mother are separated, practice rooming-in,

encourage breastfeeding on demand, give no pacifiers to
breastfeeding infants, and establish breastfeeding support
group for the mothers to be referred after discharge (Beake et
al., 2012). Health professionals should recommend breast milk
(human milk) for all infants in whom breastfeeding is not
specifically contraindicated and provide parents with
comprehensive, current information on the benefits and
techniques of breastfeeding (Cadwell, 2007).
A study conducted in United States (US) showed that 92%
women 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). This data indirectly shows the importance of
having community health workers who will help to disseminate
information from the formal health system to the community.
Community health workers also have a great chance to help the
mothers dealing with breastfeeding problems and improving the
breastfeeding outcomes.
Community health workers (CHWs) play important roles in
primary health care delivery, particularly in the delivery of
interventions for maternal and child health in settings of
health professionals shortages (Condo et al., 2014). Serving
as liaison between the community and the formal health system,
CHWs have been found to be effective in implementing

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interventions to prevent under-five deaths, including malaria

prevention, health education, psychosocial support, essential
newborn care, and breastfeeding promotion (Gilmore &
McAuliffe, 2013).
In Indonesia, CHWs are (usually) women chosen by people
in the community and trained to deal with individual or
community health problems. They are serving as the extension
of public health centre and later becoming the closest health
functionary to the people in the community. 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).
Indonesian CHWs' messages for breastfeeding mothers as
stated in the CHWs guidebook among others (Indonesian Ministry
of Health, 2012): 1) Family members to encourage mothers to
exclusively breastfeed their babies from 0 to 6 months of age;
2) Mothers to breastfeed immediately after delivery, since
first milk that comes out (colostrum) 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, at least 8 times a day; 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

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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.
Once a month, after gaining data about mothers'
breastfeeding state, babies' height and weight, and other data
related to community health status, CHWs will go to public
health centre to deliver these results and discuss about
further intervention with nutritionist and public health
nurse. CHWs will visit mothers at home if needed, accompanied
by a public health nurse. Referral to health facilities, in
this case if mothers face any difficulties in breastfeeding
(such as engorgement, inadequate milk supply, sore nipple,
etc.) is also made based on CHWs' consideration.
Community Health Workers : Challenges in Breastfeeding
Promotion
Indonesian CHWs are generally chosen by their communities
based on criteria including 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. 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. However, 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.

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10

Trainings from public health centre are described as

inconsistent and insufficient. Public health centre is aware
of this issue but at some point, lack of qualified public
health nurses becomes barrier to arrange a regular training
for CHWs. Some medical and nursing schools make efforts to
bridge this gap by sending their students regularly to the
community despite there is no official collaboration between
school and public health centre. The medical and nursing
students will have opportunity not only to learn from the
community, but also to implement their knowledge in the
community, one among many ways is by conducting some trainings
for the CHWs.
Author's experience in 2010 was to train 35 CHWs in the
area of the lowest breastfeeding rate in the city, so they
have deeper understanding about breastfeeding and able to
teach mothers about breastfeeding techniques. Subtopics
delivered were about exclusive breastfeeding, breastmilk
production, benefit of breastmilk, benefit of breastfeeding,
effective breastfeeding techniques, handling obstacles during
breastfeeding, and breastfeeding management for working
mothers. Another author's experience in conducting training to
the CHWs in 2011 was not only limited to particular health
topic the CHWs needed to know, but also about developing selfconfidence and communication skills necessary to promote
behaviour change in the community.

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11

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. So it seems like each CHW should
master all information in all health fields and they should
know the health status of all 1200 households. It may lead to
some crucial health problems stay undercover, the service
given is not optimal, and discontinuity of CHWs' active
participation.
Discussion
There are some previous studies which emphasize the
importance of training for the CHWs. In Pakistan, each CHW
receives 3 months of initial training and 1 year of supervised
fieldwork. In India, civilian health professionals should pass
12 to 18 month distance-learning course. In Tanzania, CHWs
receive 9 months of preservice training, while CHWs in
Ethiopia receive 1 year of training (Condo et al., 2014).
In Philippines, CHWs with personal breastfeeding
experience educate women on exclusive breastfeeding and help
in prevention and management of common breastfeeding problems
and it was proven to be effective to increase exclusive
breastfeeding rate among them (Gilmore & McAuliffe, 2013).
However, since there are some cultural practices that do not
conform with breastfeeding promotion and many erroneous
practices in the community, personal breastfeeding experience

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12

should also be supported by empirical evidence, which can be

obtained through appropriate training. A study conducted in
Indonesia previously emphasized urgent need for training about
the importance of exclusive breastfeeding and maintenance of
breastfeeding until 2 years of age for the CHWs (Iswarawanti,
2010). Submaterials delivered in the training should be based
on phenomena usually faced by CHWs, if not then data about
common breastfeeding problems may be used, such as
insufficient milk supply, painful nipples, latch problems,
returning to work/school, drug/illness of mother or baby, and
any other personal reasons (Lewallen et al., 2006).
In Indonesia, there have been many studies exploring
effectiveness of training conducted for CHWs on their
knowledge and skills about malaria prevention, DHF prevention,
and balance nutrition. So far there is no study exploring
effectiveness of training for CHWs on their knowledge and
skills about breastfeeding promotion, which is worth
investigating.
Division of tasks and number of households which become
responsibility of each CHW are important things to do. Rwanda
locates 3 CHWs per village: One CHW who is responsible for
community health, nutrition, and HIV/AIDS prevention; one CHW
who is responsible for infant and maternal health; and one
more is responsible for social affairs and community wellbeing (Condo et al., 2014). Clear job destinction and
distribution of the number of households that are the

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responsibility of each CHW will help CHWs to be more focus,

doing more accurate assessment of health problems, giving more
optimal service, and maintain active participation of CHWs.
Conclusion
CHWs play important roles in improving community health
status in general and breastfeeding outcomes in particular.
Support and education from CHWs will help mothers dealing with
breastfeeding problems once discharged from the hospital. Some
challenges faced by CHWs are lack of adequate training, lack
of self-confidence and communication skills, and high workload
due to unclear job destinction and distribution of the number
of households. Adequate training programs as well as clear
division of tasks and distribution of the number of households
are expected to help CHWs to be more focus, effective, and
stay active. In case there is lack of human resources to
conduct training, official collaboration between public health
centre and medical/nursing school should be considered.
Materials related to breastfeeding should be based on real
phenomena often faced by CHWs or based on common breastfeeding
problems from the studies. Study about effectiveness of
training on CHWs about breastfeeding is further to be done.

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