Relationship between breastfeeding knowledge and attitude among workers
Our study showed that white-collar workers have a higher percentage of adequate/good knowledge about breastfeeding compared to blue-collar workers, and hence had higher percentage of ‘good attitude’ towards breastfeeding. This might be related to the higher education level of white-collar workers. Pender et al. found that white-collar workers enrolled in workplace promotion programs were more likely to report a healthy lifestyle.10 Galtry et al. found that being blue collar or lower income generally implies lower skill requirements, less flexibility and even less protective working rights hence affecting the health behavior.11
Particularly for the breastfeeding attitude, a study from Malaysia reported that there was a strong correlation between higher education and better knowledge of breastfeeding with the positive attitude and behavior of breastfeeding among women workers.12 According to this study, the greatest incremental of breast feeding and lactating practice occurred among women with at least some secondary education. Ciftci et al. also mentioned that there is a positive effect of women who have an increased awareness and knowledge of the benefits of breastmilk, resulting in a higher frequency of breastfeeding.13 Data from Indonesia confirmed these findings.14
The relationship between knowledge and attitude towards breastfeeding are also reported in studies from Ethiopia,15 Nepal,16 Tunisia,17 and Tanzania18, all indicating that mothers who have an adequate knowledge about breastfeeding have a higher likelihood or probability for exclusive breastfeeding.
However, this study also found that despite the high percentage of inadequate knowledge about breastfeeding among blue-collar workers, this group still had a high percentage of positive attitude towards breastfeeding. A study in Taiwan reported that intention or knowledge alone is not sufficient to overcome barriers to breastfeed.19 A study in Nigeria founded that there was an average decrease in breast feeding duration of 3.2 and 6.6 months correlating with mother’s education to primary and secondary levels, respectively, compared to mothers with no education.20 This finding is similar with the finding of our study that the level of education and knowledge will not necessarily determine the attitude of working women to breastfeed or breast pumping in the workplace.
There were numerous influencing factors including the support of adequate lactation facilities and programs at workplace that potentially improve lactation practices among female workers. Several studies in Indonesia have suggested that apart of knowledge capacity building, a lactation counselor at work, lactation facilities, and support by peers would be critical and hence could help working mothers continue breastfeeding and have a positive breastfeeding attitude.21–23 Family support also plays an important role.6 These factors are key to potentially help mothers to have positive attitude of breastfeeding despite the lower and inadequacy knowledge of breastfeeding.
Work-related determinants toward breastfeeding practice among workers
Another important finding of our study is the lactation or breastfeeding practice, the reasons to not breastfeed and the location of breastfeed in workplace. In this study, there were 15% of white-collar workers and 17% of blue-collar workers were never breastfeed during working hours, for three main reasons; i.e. feel hesitant to take a break during work, an uncomfortable lactation room and not allowed by the supervisors. Studies showed that a dual role of being a lactating mother and an employee at the very same time put them in a difficult situation and brings potential conflict in their daily life.24 In many situations, an employed mother tends to sacrifice the lactation/breastfeeding role in order to pursue career or to meet the job’s target. This is definitely an unfortunate situation for working mothers with infants, since it will affect the health of both mothers and infants.
Although the Indonesian government had issued a series of breastfeeding protection policies at the workplace, such as the Joint Regulation on Promoting and Protecting Breastfeeding at Workplace year 2008 and the Ministry of Health Regulation Number 15/2013 with a technical guideline for a dedicated lactation room and facilities at the workplace, only 21.5% of the female workers had access to adequate lactation facilities in the workplace and only 7.5% of the workers benefitted of breastfeeding promotion support during working hours.6 A study from the USA reports that only 3% of the companies have written policies on breastfeeding at work, even though the majority of companies allow women to express breast milk at the workplace. Only 22% of the companies allowed breastfeeding in the company premises and only 32% provided a designated room solely for breastfeeding or breast pumping.25 Chun Yi et al in Taiwan also found that even if the employer provided a lactation room and allowed an hour break for breast milk pumping, workers found it difficult; and it also could take up to 10–15 minutes to travel between the worksite and the lactation room.19 This might explain the finding of our study why there is still a large number of workers that decided to not breastfeed during working hours and that 50% of the workers decided to pump at the toilet or bathroom instead of the lactation room.
Employers and supervisor’s perception toward breastfeeding practice at workplace
The perception of workers, managers/supervisors and employers towards productivity is another aspect. In our study, 42% of the workers who decided to not breastfeed or pump during working hours mentioned that they felt hesitant to leave their work and 6% of the workers were not allowed by their supervisors. Tsai found that 51.1% of female workers assumed that taking a break for breast pumping two times during working hours could lower their work productivity.26
From the employer point of view, managers and employers consider that breast pumping during working hours might hamper productivity and affect working performance. A survey found that most employers would be willing to institute breastfeeding support at work, although they saw no benefit to support breastfeeding.27 Blue collar workers have their own difficult circumstances in participating in worksite health promotion programs due to the lack of social support by the supervisor. In order to keep the production lines moving, supervisors may refuse to allow workers to attend programs during company time.28 Group leader and the manufacturer’s performance bonus systems may reduce the willingness of women to breastfeed at the workplace. If a group leader disagrees with breastfeeding but the worker continues to breast pump during work hours, it will affect her work performance and bonus.19 Overall, employers do not prioritize providing breastfeeding support at the workplace.29
Based on multivariate analysis, our study found that the working status and level of knowledge are key variables determining the subject’s lactation practice. This was reported in the systematic review by Dinour et al., suggesting that providing a lactation space was the most common employer-based support accommodation studied, followed by breastfeeding breaks and comprehensive lactation support programs targeting the knowledge improvement of lactating workers.30 Mothers report multiple barriers to breastfeeding upon return to work, such as work schedule flexibility and program support in workplace.31
Involvement of a policy maker in the company and a regular promotion program aimed to improve education and breastfeeding knowledge among women worker were put in place to increase lactation practice.32 A workplace-based lactation promotion model, i.e. policy and regulation, facility, education, and human resources are key components to achieve successful breastfeeding and lactation in the workplace.33
Study strengths and limitations
The findings related to the profile of breastfeeding knowledge and attitude between white-collar and blue-collar workers in Indonesia are considered as the strength of this study, as to our knowledge such data had never been reported. The reasons and preferred location of lactation during working hours were also a novel finding and provides significant insight for future improvement of breastfeeding policy. However, designed as a cross-sectional study with self-administered questionnaire, without factor analysis, brings a major limitation of this study outcome, since the subjectivity of the responses cannot be excluded.