Moralising Rhetoric and Imperfect Realities: Breastfeeding Promotions and the Experiences of Recently Delivered Mothers in Urban Yogyakarta, Indonesia

Abstract

Exclusive breastfeeding is embedded in National Health Law and Regulation in Indonesia and is vigorously promoted by health workers, breastfeeding counsellors and religious leaders. This article explores the transformation of state legislation into breastfeeding promotions that are imbued with moralising assumptions directed at expectant women, new mothers and their partners. Drawing on an 18-month ethnographic study, the rhetoric of breastfeeding promotion messages is contrasted with the narratives of urban middle-class mothers in Yogyakarta. This article highlights the challenges women experience in their attempts to breastfeed and the divergence between the moralising rhetoric of breastfeeding promotions and women’s imperfect lived realities. It demonstrates how dominant health promotion messages construct breastfeeding as a moral issue, insist women are obligated to breastfeed their infants, and fail to acknowledge women’s choice, reproductive agency and bodily autonomy. Such messaging assumes the right of infants to be breastfed, and emphasises the developmental problems likely to befall children who are not breastfed. Gendered expectations that all mothers will assume their breastfeeding role selflessly and dutifully are also embedded in breastfeeding promotion messages. We conclude that breastfeeding promotion messages need to be more inclusive and less moralising in their substance and delivery to better serve Indonesian women. Women are likely to feel more supported and less alienated by breastfeeding promotion messages that recognise the possibility of common breastfeeding challenges, such as difficulty establishing successful breastfeeding, the baby blues, the likelihood of suffering discomfort from breastfeeding in public, and issues with the premature cessation of breastfeeding.

Pemberian ASI eksklusif tercantum dalam Undang-Undang Kesehatan dan Peraturan Kesehatan Nasional di Indonesia dan dengan antusias dipromosikan oleh petugas kesehatan, konselor menyusui dan tokoh agama. Artikel ini membahas transformasi legislasi negara menjadi promosi menyusui yang diilhami dengan asumsi moral yang ditujukan pada perempuan hamil, ibu yang baru melahirkan dan pasangannya. Mengacu pada studi etnografi selama 18 bulan, retorika dalam pesan promosi menyusui dirasa kontras dengan pengalaman perempuan kelas menengah perkotaan yang tinggal di Yogyakarta. Artikel ini menyoroti tantangan yang terjadi berkaitan dengan promosi retorik tersebut mengenai moral dalam menyusui dengan kenyataan kehidupan perempuan yang tidak sempurna. Penelitian ini menunjukkan betapa pesan kampanye promosi kesehatan yang dominan menguraikan menyusui sebagai masalah moral, mendesak agar perempuan diwajibkan untuk menyusui bayinya, namun gagal untuk mengindentifikasi pilihan perempuan, 'reproductive agency' dan otonomi atas tubuh mereka. Seperti pesan promosi menyusui yang mengasumsikan bahwa “disusui” atau diberi ASI itu merupakan hak dari si bayi, serta memberikan tekanan bahwa perempuanlah yang bertanggung jawab untuk masalah perkembangan yang mungkin menimpa bayi jika tidak memberikan ASI. Ekspektasi akan gender bahwa semua ibu harus menyusui sang anak dengan tanpa pamrih dan patuh juga ditanamkan dalam pesan promosi menyusui. Kami menyimpulkan bahwa pesan promosi untuk menyusui perlu lebih inklusif dan mengurangi aspek moral secara gender dalam substansi dan penyampaian untuk melayani perempuan Indonesia dengan lebih baik. perempuan akan merasa lebih didukung dan tidak merasa terasing dengan pesan promosi menyusui yang berisi kemungkinan-kemungkinan hambatan dalam proses menyusui yang umum terjadi seperti sulitnya untuk menyusui dengan baik, baby blues, kesulitan inisiasi menyusui, ketidaknyamanan saat menyusui anak di tempat umum, dan penghentian dini menyusui yang bisa diakibatkan oleh kesehatan sang ibu dan faktor-faktor penyebab lainnya.

Keywords:

• Infant feeding
• breastfeeding
• exclusive breastfeeding
• health promotion
• Indonesia
• motherhood

Introduction

Hildred Geertz remarked of her observations of infant feeding and weaning practices in Central Java in the 1950s that “a mother’s nursing, as in her carrying of the child in the womb and giving birth to him, is seen as placing an unrepayable debt on the child’s shoulders” (Geertz, 1961, p. 97). More than half a century later, the national position on infant feeding practices has changed remarkably, with breastfeeding now officially characterised as a maternal obligation. Exclusive breastfeeding, defined by the World Health Organization (WHO) as feeding infants nothing but breastmilk for the first six months, is now enshrined in National Health Law 36 of 2009 (referred to locally as UU 36/2009). Health services are legally bound to promote exclusive breastfeeding, early initiation of breastfeeding (inisiasi menyusui dini or IMD), and the physical co-location of mothers with their infants, known as rooming-in (rawat gabung). All workplaces and public facilities in Indonesia are expected to support breastfeeding through the provision of designated spaces for breastfeeding and expressing breastmilk. These measures are aimed at raising the prevalence of exclusive breastfeeding, currently estimated at between 42 per cent and 54 per cent, to the government’s national target of 80 per cent (BPS, BKKBN, Kemenkes, & ICF International, 2013; Kemenkes, 2014). Across Indonesia’s 34 provinces there is great variation in exclusive breastfeeding prevalence. Rates are lowest in Maluku at 25 per cent and highest in West Nusa Tenggara at 80 per cent (Kemenkes, 2014).

Reducing infant and child mortality and morbidity has been a persistent challenge for historical and contemporary Indonesian governments (Frankenberg, 1995; Mellington & Cameron, 1999). Thus Indonesia’s Exclusive Breastfeeding Program has sound goals from a public health perspective. It aims to improve infant health and nutrition, and to reduce rates of infant mortality, particularly in areas where household incomes are low. Even in the more highly developed areas, access to potable water and refrigeration remain a challenge. While breastfeeding in Indonesia is performed as a normative aspect of early parenting, and is almost universally practised, the same cannot be said for exclusive breastfeeding (Geertz, 1961; Hull, 1979; Iskandar, Costello, & Nasution, 1990; Roshita, Schubert, & Whittaker, 2013; Soekarjo & Zehner, 2011; Susiloretni et al., 2014; Winikoff et al., 1981). According to the most recent Indonesian Demographic and Health Survey, 96 per cent of children aged less than two years are breastfed for some duration (BPS et al., 2013). Exclusive breastfeeding prevalence in Indonesia is higher than in other Southeast Asian nations, namely the Philippines, Malaysia, Thailand and Vietnam (OECD, 2014). At 12 to 15 months of age more than 70 per cent of Indonesian babies are still given some amount of breastmilk (OECD, 2014).

Since the introduction of laws supporting Indonesia’s Exclusive Breastfeeding Program there has been a lack of critical inquiry into both their substance and their transformation into health promotion messages. Furthermore, there is limited understanding of the impact of this policy on the lives of Indonesian women. The majority of recent research has been purely descriptive and focused on women’s infant feeding knowledge, attitudes and practices, or has explored exclusive breastfeeding barriers and facilitators (Fauzie, Suradi, & Hadinegoro, 2007; Februhartanty, Wibowo, Fahmida, & Roshita, 2012; Idris et al., 2013; Marzuki et al., 2014; Mufdlilah, Akhyar, Sutisna, & Subijanto, 2016; Nuzrina, Roshita, & Basuki, 2016; Rahmawati, 2016). In contrast, our critique unpacks the substance of Indonesian breastfeeding promotions and their embodiment by women. Thus, our methodology aligns with other feminist critiques of the moralising strains that breastfeeding promotions can place on mothers. This includes scholars who have analysed the health promotion messages of governments and their spokespeople, medical groups and breastfeeding advocacy groups (most notably La Leche League International); as well as those who have considered the lived experiences of women (Beasley, 2010; Blum, 1993; Campo, 2010; Marshall, Godfrey, & Renfrew, 2007; Murphy, 1999; Shaw, 2004; Stearns, 1999; Wall, 2001). Our critique of patriarchal gender ideology in Indonesia is culturally grounded, emphasising how national health promotion efforts continue to construct Indonesian women as self-sacrificing, existing first and foremost to fulfil the needs of others, including the nation (Blackburn, 2004; Ford & Parker, 2008; Newberry, 2010; 2012; Sullivan, 1994; Suryakusuma, 1988; 2004).

In this article we consider the benefits and implications of legislating exclusive breastfeeding for women and children. We explore how women’s exclusive breastfeeding knowledge and intentions are shaped by multiple modes of health promotion – namely, the laws underpinning Indonesia’s Exclusive Breastfeeding Program; religious teachings pertaining to breastfeeding; and some of the key messages disseminated by a community-based breastfeeding advocacy group. We also examine the construction of breastfeeding as natural and a moral imperative for mothers, and explore how this constrains women’s reproductive agency to independently decide to breastfeed. We also reflect upon ways in which the moralising promotions of breastfeeding in Indonesia impact negatively on all women, whether they breastfeed or not.

Ethnographic fieldwork focusing on the reproductive lives and breastfeeding experiences of 20 recently delivered middle-class mothers in urban Yogyakarta was conducted over an 18-month period. We draw on this data, employing a critical feminist perspective to explore the dominant breastfeeding promotions circulating in the lives of urban middle-class women in Yogyakarta and the extent to which they align with their lived experiences. In particular, our focus is on the meanings and values embedded in breastfeeding promotion messages and how they shape expectations of women’s roles in society and impact on their personal subjectivities.

The remainder of this article is divided into seven sections. The next section provides a review of the literature pertaining to the way Indonesian women have understood and embodied breastfeeding, and the Government of Indonesia’s (GoI’s) early breastfeeding promotion efforts. This is followed by a description of the methods used for primary data collection. The National Health Law and the Regulation (known locally as PP 33/2012) underpinning the Exclusive Breastfeeding Program are then outlined. Subsequently we describe how breastfeeding has been portrayed by some Muslim leaders in Yogyakarta. A critique of breastfeeding promotion messages targeted at urban middle-class women follows, drawing predominantly on materials from the Indonesian Breastfeeding Mothers’ Association (AIMI or Asosiasi Ibu Menyusui Indonesia). The article then presents narratives from participants in the ethnographic study to highlight tensions between the rhetoric of various breastfeeding promotions and the lived realities of recently delivered mothers who attempted exclusive breastfeeding. It concludes by juxtaposing the contradictions inherent in contemporary Indonesian breastfeeding promotions and the experiences of urban middle-class women in Yogyakarta.

Literature Review

Performance of and perceptions towards breastfeeding among Indonesian women

Prior studies conducted in Central and East Java that predominantly observed Muslim Javanese women have cultural and methodological pertinence for this study, including research conducted by Geertz (1961), Hull (1979), Winikoff and colleagues (1981) and Margawati (2005). In these studies the majority of women who breastfed tended to do so for durations of longer than six months, and even up to five years, although exclusive breastfeeding was not necessarily practised. During her ethnographic research in the 1950s Geertz (1961) observed that infants were typically nursed on demand for more than a year and then weaned at between 14 and 18 months.¹ Weaning was aided by a ritual meal performed by the traditional midwife (dukun bayi) who was present at the child’s birth (Geertz, 1961).

In Hull’s (1979) study in rural Central Java in the late 1970s, more than 500 women were interviewed monthly during their pregnancies and postpartum.² She found that babies were usually breastfed for up to or beyond two years (Hull, 1979). In the study by Winikoff and colleagues (1981) in Semarang, Central Java, more than 60 households participated in the ethnographic part of the research and 1,358 women were interviewed. They found that almost 80 per cent of children were breastfed for eight months and the median breastfeeding duration was 20 months (Winikoff et al., 1981). Geertz (1961) observed that among mothers who did not work or need to breastfeed other younger children, breastfeeding could continue up to primary school age. Similarly, some of the participants in the study by Winikoff et al. (1981) reported that if a woman had no other children the duration of breastfeeding could be up to five years.

Two recent qualitative studies provide instructive insights into contemporary breastfeeding practices and understandings among Indonesian women (Marzuki et al., 2014; Nuzrina, Bashita, & Basuki, 2016). Marzuki and colleagues (2014) interviewed 36 women in Jakarta, North Sumatra, South Kalimantan and South Celebes with the aim of understanding infant feeding influences. The majority of participants in their study intended to breastfeed and had a positive attitude towards breastfeeding (Marzuki et al., 2014). The participants emphasised the emotional bonding between a mother and her child as a positive aspect of breastfeeding (Marzuki et al., 2014). In Nuzrina, Roshita and Basuki’s (2016) study, 14 women in West Jakarta were interviewed four times between week 36 of their pregnancies and the first 30 days postpartum. Some women in that study first learned about breastfeeding via social media promotions circulated by breastfeeding advocates, including AIMI and Ayah ASI (Nuzrina, Roshita, & Basuki, 2016).

Islam has also shaped the way Muslim Indonesian women have understood breastfeeding and ideal breastfeeding duration. Women in the study by Winikoff et al. (1981) almost unanimously agreed that breastfeeding was a Muslim woman’s destiny and innate responsibility, and that Islam prescribed two years of nursing. Their perceptions are aligned with surah Al-Baqarah 2:233 of the Qur’an, which states: “Mothers may breastfeed their children two complete years for whoever wishes to complete the nursing [period]”.

Although breastfeeding has historically been a normative practice in Java and other parts of Indonesia, exclusive breastfeeding has not. This is because breastmilk’s nutritional value has long been perceived by Indonesian mothers to be inadequate as an infant’s sole or even primary food source (Geertz, 1961; Hull, 1979; Winikoff et al., 1981; Margawati, 2005; Marzuki et al., 2014; Nuzrina, Roshita, & Basuki, 2016). Winikoff et al. (1981) found that 46 per cent of infants were breastfed exclusively for the first month, but that this figure fell sharply to 12.5 per cent at three months. Geertz (1961) noted that some infants were given supplementary foods as early as several days old. In Hull’s (1979) study, supplementary foods were introduced in the first weeks of life, despite women’s perceptions that breastmilk was important for infant health. In Margawati’s (2005) study conducted in Semarang involving more than 900 participants, infants whose mothers could not immediately produce breastmilk postpartum were fed alternative foods. Although breastfeeding was considered to be essential for infants by women in the study by Marzuki et al. (2014), exclusive breastfeeding was perceived to be too demanding and unrealistic.

Alongside these infant feeding traditions, the availability, promotion and use of formula milk (susu formula) has proliferated throughout Indonesia (Lim & Kemp, 1994; Shetty, 2014).³ Hull (1979) asserts that formula milk was viewed as a status food in the 1970s, used to incentivise maternal and child health clinic attendance, although women were not fully informed of the positive and negative attributes of formula compared with breastmilk. Women in Margawati’s (2005) study reported that their babies received formula at maternity hospitals and clinics, even though they were producing colostrum. For urban women, formula enabled them to comfortably feed their babies outside the home, as some regarded breastfeeding in public to be a shameful practice (Marzuki et al., 2014; Winikoff et al., 1981). Postpartum women in the study undertaken by Nuzrina, Roshita and Basuki (2016) substituted breastmilk with formula when they were feeling stressed, tired or unwell.

Historical government-led breastfeeding promotion programs

Breastfeeding has long been a concern of the GoI. In 1976 the Ministry of Health Council for Evaluation of Religion issued a fatwa outlining the permissibility of donor breastmilk use in response to concerns raised by Islamic scholars in relation to a Jakarta hospital’s donor breastmilk bank. Further detail on the fatwa is provided below in the section on Islamic breastfeeding promotion. During the early 1990s breastfeeding was embedded in the GoI’s national development program, in response to health officials’ concerns that breastfeeding rates were falling (Lim & Kemp, 1994; Suyono & Thapa, 1990; Hull, Thapa, & Pratomo, 1990). As noted by Iskandar et al. (1990), although breastfeeding initiation was high among Indonesian women and breastfeeding duration was typically lengthy, the benefits of reduced child mortality and illness were undermined by low levels of exclusive breastfeeding. As part of the GoI’s response, the agency BKPP-ASI was established to coordinate national breastfeeding health promotions; Indonesian doctors and nurses were trained in lactation management and counselling; and rooming-in pilots took place in hospitals and clinics in several regions (Suyono & Thapa, 1990; Hull, Thapa, & Wiknjosastro, 1989). During the same period, the National Family Planning Coordinating Board (BKKBN) devised a policy explicitly aimed at promoting and integrating breastfeeding within the Indonesian family planning program (Suyono & Thapa, 1990). The then Chairman stated that the goal of the BKKBN was working towards “formulating legislation to protect women’s rights to breast-feed their babies” (Suyono & Thapa, 1990, p. 155). In a further attempt to publicly strengthen breastfeeding promotion, in 1991 President Suharto handed down a Presidential Decision encouraging women to breastfeed (Lim & Kemp, 1994).

Reformation-era governments have shown increasing interest in breastfeeding promotion in alignment with global health goals to improve infant and maternal health outcomes. The National Labour Law of 2003 sought to protect working women. Article 83 states that: “female workers/labourers whose children are still breastfeeding should be given proper opportunities to breastfeed … if it should be done during work time”. These prior breastfeeding promotions by the GoI and its agencies have set the foundation for the most recent breastfeeding promotion legislation, which is the most comprehensive yet. The key features of the GoI’s breastfeeding promotion via legislative reform are described later in the article.

Methods

This article draws on the first author’s doctoral fieldwork, conducted in Yogyakarta from September 2014 to March 2016. Yogyakarta is a special administrative region physically located on the island of Java and surrounded by the province of Central Java. The ethnographic study employed in-depth interviews (IDIs) with women who had recently given birth, focus group discussions (FGDs) with health workers and breastfeeding counsellors, semi-structured interviews (SSIs) with key community stakeholders, and participant observation. Study participants were recruited from the capital, Kota Yogyakarta, and the two most urbanised regencies within Yogyakarta, Sleman and Bantul. Participant recruitment was facilitated by the Department of Health, Kota Yogyakarta and AIMI Yogyakarta. Ethical approval was granted by the University of Melbourne and Gadjah Mada University. Written informed consent was obtained from all participants.

The first author completed six months of in-country Indonesian language training prior to commencing data collection. The FGDs were co-facilitated by the first author and a local research assistant. All IDIs and SSIs were conducted by the first author. Indonesian language was used in all FGDs and was the primary language used in interviews. The majority of IDIs and all FGDs and SSIs were audio recorded. For the three IDI participants who did not agree to be audio recorded extensive notes were taken.

The FGDs were conducted initially, with the aim of eliciting normative understandings and perceptions about exclusive breastfeeding. The first FGD was with seven health workers from a public primary health clinic (puskesmas) in Kota Yogyakarta. The second FGD was with seven AIMI breastfeeding counsellors.

A total of 31 IDIs with 20 women who had given birth in the last two years were conducted. Interviews aimed to gain a deep understanding of participants’ perceptions and experiences in relation to exclusive breastfeeding, their reproductive health and family planning. The mothers who participated were aged between 21 and 38 years, and all but three were both Muslim and ethnically Javanese. Eight of the women were first time mothers; seven women had one child, eight women had two children, and five women had three children.⁴ All of the women were middle-class and had attained at least a senior high school level education. Four women were undertaking undergraduate or postgraduate studies and two had recently completed postgraduate studies.

Four SSIs with five key community stakeholders were conducted. Informants were from the regency-level Department of Health; the National Family Planning Coordinating Board; the community-based organisation, Ayah ASI; and Muhammadiyah’s ‘Aisyiyah University, Yogyakarta. These interviews were designed to deepen local understandings of breastfeeding from health promotion, religious and gender perspectives.

Participant observation included attending breastfeeding health promotion events conducted by AIMI from February to June 2015. The events were: a prenatal education class; a group discussion on the topic “returning to work after breastfeeding”; a group discussion on introducing foods that complement breastmilk; and a talk show on “breastfeeding from the perspectives of Medicine and Islam”. The intended audience of these events was mothers and expectant mothers, and their partners.

The first author’s doctoral candidature has been supervised by the second and third authors, and the fourth author had institutional responsibility for the first author while she was undertaking fieldwork. Data analysis was conducted by the first author with input from the second author. The article was prepared by the first author with input from the second and third authors. All of the authors reviewed the final manuscript prior to publication.

Legislative Promotion of Exclusive Breastfeeding

The National Health Law underpinning Indonesia’s Exclusive Breastfeeding Program, introduced in 2009, declares that all infants have the right (berhak) to be breastfed exclusively:

Every baby has the right to be exclusively breastfed from birth up until 6 months of their lives unless otherwise medically indicated … babies should be given only breastmilk for the first 6 months of life and be breastfed for up to 2 years (UU 36/2009, Article 128).

The Health Law was followed by a Regulation in 2012 (PP 33/2012) on exclusive breastfeeding, giving further clarity to the state-imposed responsibilities placed on recently delivered mothers in Indonesia. Article 6 of the Regulation states that “every mother who gives birth must exclusively breastfeed her infant”. Article 11 recommends the use of donor breastmilk as a suitable alternative if the biological mother cannot breastfeed, and Article 12 instructs mothers to refuse (“menolak”) formula milk and other infant food products. Recognition of a woman’s right to choose whether to use her body to breastfeed her baby is absent from the law. The only other endorsed option for women who cannot or choose not to breastfeed is to use milk from a donor, as formula milk and other infant foods are discouraged within the law. However, the use of donor milk can also be difficult to negotiate for some Muslims, as we discuss below. Breastfeeding is thus presented within the current state legislation as the legal obligation of mothers.

The 2012 Regulation attempted to address potential structural and social barriers to breastfeeding by mandating the provision of designated spaces for nursing babies and expressing breastmilk at all workplaces and public venues. However, the provision of lactation rooms has been extremely slow and uneven. Of the women who participated in IDIs, only one had access to a lactation room at the university campus where she was studying. Four other women who were either employees or students of the same institution did not have access to a lactation room in their section of the campus.

Article 37 of the 2012 Regulation implicates the broader community, stating that individuals, groups and organisations must support the GoI’s Exclusive Breastfeeding Program. This support encompasses: the right to early initiation of breastfeeding; rooming-in and exclusive breastfeeding; reporting violations of the WHO’s International Code of Marketing of Breastmilk Substitutes (the WHO Code); providing space and opportunities for breastfeeding at workplaces; supporting women to breastfeed “anytime and anywhere” (“kapanpun dan dimanapun”), including public places; and monitoring breastfeeding in the community.⁵

The notion of monitoring breastfeeding turns infant feeding into a community-level responsibility. This extends the responsibility for the surveillance of mothers to their neighbours, colleagues and bystanders. Plausible consequences of this surveillance are that women who cannot or do not breastfeed face widespread disapproval or, as was the case for Dina whose experience is discussed below, women’s public performance of breastfeeding becomes subjected to uninvited scrutiny.

The Regulation also compels health care providers to reinforce and promote exclusive breastfeeding. Health workers and facilities that do not support and provide opportunities for early initiation of breastfeeding and rooming-in, and do not offer mothers education and information about exclusive breastfeeding, may face sanctions. Penalties include verbal or written warnings, and health workers risk losing their professional licences.⁶ Health workers are also prohibited from receiving, promoting and offering infant milk formula and associated products under Article 17. Even so, the promotion of formula milk by health workers is still occurring, as Nian’s narrative below illustrates.

Placing the child at the centre of these laws creates a moral predicament for parents, especially mothers. Rather than asserting that the biological mother, as the typical source and provider of breastmilk, has the right to choose the best means to feed her child, the legislation infers she is violating her child’s rights if she does not exclusively breastfeed. The legislation employs the language of international human rights, but, problematically, rights are bestowed on infants without any consideration for the rights of mothers regarding the use of their own bodies. The overriding assumption is that women will sacrifice their rights and self-interest for others – in this case their children – a notion that is deeply embedded in postcolonial Indonesian state ideology (Martyn, 2005; Newberry, 2010; 2012; Robinson, 2009; Suryakusuma, 1988). That is not to say that the basis for the GoI’s Exclusive Breastfeeding Program is not sound: if performed universally, breastfeeding is predicted to prevent more than 800,000 childhood deaths annually in children aged under five years (Victora et al., 2016). Of concern, however, are the moralising assumptions embedded in the legislation.

Indonesian Islamic Promotion of Breastfeeding

Religious recommendations pertaining to infant nursing continue to reinforce Indonesian Muslim women’s desire to breastfeed. Several SSI participants clarified that the Qur’an invites mothers to breastfeed and that feeding a baby breastmilk for two years is ideal (“sempurna”). At a talk show event at JIH (Jogjakarta International Hospital) in June 2015, an ustadzah (woman Islamic teacher) shared her understandings of Islam’s appeal for Muslim women to breastfeed their children. She advised attendees that while it is not technically a religious obligation for Muslim mothers to breastfeed for two years, it is a moral obligation (“kewajiban moralitas”). She went on to assert that to decide not to breastfeed would be a sinful (“dosa”) act of maternal neglect (“kezaliman”) that deprived (“menzalimi”) an infant.

Despite the appropriation of Islamic teachings in health promotion discourses in Indonesia, it should be noted that the surah cited above (Al-Baqarah 2:233) also includes a passage implying the possibilities for parents to negotiate and potentially decide to wean earlier. Indeed, the Qur’an does not refer to parental negligence for those who decide not to breastfeed for two years: “... if they both desire weaning through mutual consent from both of them and consultation, there is no blame upon either of them” (Al-Baqarah 2:233). Thus, the notion of choice concerning nursing duration is present in the Qur’an, yet absent in Indonesian Islamic teachings.

In Islam, kinship bonds are established through cross feeding, whereby infants nursed by the same woman become “milk siblings” (saudara sepersusuan) (Cevese, 2015; Geertz, 1961). If the babies being breastfed are the same sex, there is no risk they will marry,⁷ but according to one IDI participant, the child receiving donor breastmilk also becomes the donor’s heir; thus, they are potentially entitled to an inheritance (“warisan”). There is some contention as to how many times the infant has to be fed by the other woman for it to develop into a kin relationship (Republika, 2015). The 1976 fatwa states that the kin relationship is formed only if: i) the child is under two years old; ii) the feeding is performed on five consecutive occasions and to the extent of satisfying the infant’s hunger; and iii) the identity of the woman providing the breastmilk is known (Hooker, 2003).

Despite the fatwa, the supply and use of anonymous donor breastmilk was largely regarded as problematic for both donors and recipients by participants in this study, due to the perceived risk of illicit marriage between kin bonded through breastmilk. The teachings of the ustadzah further reinforced the view that breastmilk donors must be known. She stated that donors must be healthy, cannot be pregnant, and must also be Muslim if the intended recipient is a Muslim infant, but one SSI participant disagreed, saying in interview that there is not yet a fatwa prohibiting the provision of donor milk from a non-Muslim woman to a Muslim infant and vice versa. Further, she stated that Islam teaches its followers to attend to the needs of others, regardless of faith. Thus, donor breastmilk given to Muslim infants needs to be halal (permissible for Muslims), but what it means to be halal in this context is fluid and open to interpretation.

Of the 18 Muslim women who participated in our study, three had donated their breastmilk to other children, and two had given their newborns donated breastmilk (organised through their maternity hospitals) while their own supply was establishing. Yet the lack of visible donor milk banks could limit the ability of Indonesian parents to access a consistent and regulated supply of breastmilk in instances where biological mothers cannot provide it. Online breastfeeding support communities where donors and those seeking breastmilk can connect do exist in Indonesia, but little is known about the popularity of such forums.

Community-based Breastfeeding Advocates’ Promotion of Breastfeeding

The Indonesian Breastfeeding Mothers’ Association (AIMI) is the foremost national group providing comprehensive breastfeeding information and counselling to parents and parents-to-be. The organisation is headquartered in Jakarta and has branches in 13 provinces. In 2015 the Yogyakarta branch of AIMI delivered 20 educational events in Kota Yogyakarta, Bantul and Sleman. In addition, AIMI Yogyakarta offer personal counselling sessions for mothers and expectant women. Of the 20 IDI participants in this study, eight had been counselled by AIMI or attended at least one of their events.

The short film Benar awalnya, lancar menyusuinya (The Right Start will Lead to a Smooth Breastfeeding Experience) is often used to open AIMI events (AIMI & Save the Children, 2013). Narrated in Indonesian with English subtitles, this film delivers a summary of the group’s main breastfeeding promotion messages, as outlined in Figure 1. Emphasised at the beginning of the video is the importance of expectant women familiarising themselves with information from health workers and health facilities that support breastfeeding. The film is targeted at those who attend AIMI events in Yogyakarta – educated, middle-class, urban-dwelling women with access to affordable health facilities – and assumes a reasonable degree of agency. The film describes breastmilk as “the best gift a mother can give her baby” and adds that “there is no other food as perfect as breastmilk” (AIMI & Save the Children, 2013). Point 9 from the video (see Figure 1) stresses that breastmilk cannot be substituted, and infant formula should be avoided. This view is articulated by AIMI counsellors using mainly scientific and medical vernacular, but in some contexts – as noted in the quotes above and below – breastmilk is revered.

Figure 1. ‘Important points about breastfeeding’ from Benar awalnya, lancar menyusuinya (The right start will lead to a smooth breastfeeding experience) (AIMI & Save the Children, 2013).

At a prenatal class in February 2015, following the screening of the film, the case for exclusive breastfeeding was reinforced using the cartoon in Figure 2. The image to the left depicts an aeroplane crash landing; its passengers are toddlers who presumably were not breastfed. The image to the right shows the crash being passed over by another plane that appears to be having a safe take-off. The second aeroplane is emblazoned with the words “IMD” and “Menyusui” (breastfeeding). The accompanying text states: “on a Boeing 777-300 aeroplane filled with Indonesia’s toddlers, salvation is given to those who receive the gold standard food for babies”. One of the key messages is that babies who are not breastfed are in mortal danger, potentially triggering feelings of fear or guilt in mothers who do not, or are unable to, breastfeed. The alarmist tone in this message depicts the moralising prevalent in breastfeeding promotions in Indonesia. It is a metaphoric representation of the women who fail to fulfil their moral duty to breastfeed, in turn compromising their offspring’s safety at the very beginning of their lives, when they are most vulnerable. It portrays a reckless negligence in women who transgress their motherly duty.

Figure 2. Translation: ‘On a Boeing 777-300 airplane filled with Indonesia’s toddlers, salvation is given to those who receive the gold standard food for babies’. From the presentation IMD & rawat gabung (Early initiation of breastfeeding and rooming-in) (AIMI, 2014a).

Subsequent slides in the presentation are less emotive, citing scientific research findings and WHO standards. Parents are advised that it is risky to introduce foods other than breastmilk during the first six months. Infant formula is also explained as risky for baby’s health due to concerns about hygiene and contamination, and the health effects of the additives used in the formulations. At an educational event in Bantul in June 2015 an AIMI counsellor remarked, “we don’t hate infant milk formula, we hate the language of marketing” (“kami tidak benci sufor, kami membenci Bahasa Marketing”); and “breastmilk is from God” (“ASI itu dari tuhan”).

The sum of AIMI’s messages portrays breastmilk as a powerful natural tonic that produces healthier, developmentally superior children. Once armed with this knowledge, to not provide your child with breastmilk is akin to denying them the right to maximise their potential. Breastfeeding thus becomes a parental, and particularly a maternal, responsibility, as morally responsible parents seek to guard the health of their babies (Wall, 2001). The rewards of breastfeeding are not, however, limited to infants; participants in AIMI’s prenatal class are also informed of the potential benefits for mothers and fathers. Moreover, participants are told that women’s employers, the broader community and even the nation can all benefit from breastfeeding – a familiar message propagated in the state discourses discussed above, which have idealised Indonesian women’s sacrifice to their families and the nation.

Although the session facilitator did not go into detail about postnatal mental health, she asserted that breastfeeding mothers have a reduced risk of experiencing postnatal depression and are slightly less likely to maltreat their children. These points are not accompanied by citations, and recent research in the US and England concerning this topic is inconclusive. For example, Hatton et al. (2005) found a greater likelihood of breastfeeding discontinuation in mothers experiencing postnatal depression; while two other studies found initial difficulties breastfeeding may contribute to postnatal depression (Shakespeare, Blake, & Garcia, 2004; Watkins, Meltzer-Brody, Zolnoun, & Stuebe, 2011). An Australian study found that breastfeeding may have helped to reduce the prevalence of child maltreatment by Australian mothers (Strathearn, Mamun, Najman, & O’Callaghan, 2009); however, the relevance of these findings to the Indonesian context is unclear.

Notably, the prenatal class does not cover potential barriers to breastfeeding. Presentations titled “Breastfeeding Challenges” and “Issues with Breasts and Nipples” are delivered during AIMI’s postnatal class, but these messages could conceivably be too late for women who wanted to breastfeed from birth but were unable to. Although the postnatal class has no restrictions on attendance, the omission of detailed information in the prenatal class on the challenges mothers attempting to breastfeed may experience is problematic, because it denies women access to knowledge pertinent to making an informed choice about breastfeeding.

The value of breastfeeding for Indonesian fathers is promoted via several key points that are not backed up with any tangible evidence. Advantages identified for fathers include economic benefits, because healthier children need fewer clinic visits and fewer medications, and because infant formula is expensive. It is asserted that breastfed children are smarter intellectually, emotionally and socially. There are also physical benefits; it is stated that an advantage of breastfeeding is that it helps mothers to become slimmer, faster (Figure 3). By targeting this message at men, women’s own standards of physical attractiveness are overlooked and their bodies are objectified. As Wall (2001, p. 601) argues, the promotion of breastfeeding as a weight loss strategy “plays to insecurities about the shape of the maternal body”. In the Indonesian context it reinforces cultural notions promulgated by popular media of the ideal feminine form being slim and firm, which is discordant with women’s bodily forms during pregnancy and postpartum. It also positions Indonesian men as arbiters of femininity and beauty.

Figure 3. Translation: ‘Wife returns to her slimmer physical body, faster. Energy used for breastfeeding and the establishment of breastmilk uses the fat reserves stored during pregnancy’. From the presentation Manfaat menuysui dan resiko formula (The benefits of breastfeeding and the risks of formula) (AIMI, 2014b).

Consistent with the findings of Marzuki and colleagues (2014), one point raised almost unanimously by IDI participants as a benefit of breastfeeding was bonding (often referred to as “bonding attachment”), and the closeness between a mother and her infant that can be achieved through skin-to-skin contact during nursing. The health workers in the study also perceived this to be a major advantage of breastfeeding, a point they stress to expectant and recently delivered mothers. Point 3 from Benar awalnya, lancar menyusuinya similarly highlights that the skin contact associated with breastfeeding helps the bonding process, suggesting that women who do not breastfeed cannot have the same closeness with their babies. The video maintains that breastfeeding will help the mother feel happy because she is needed by her baby. As discussed in the section below, breastfeeding does not always diminish feelings of being overwhelmed and exhausted; nor does being relied on constantly by a dependent child always incite feelings of joy and happiness, particularly for new mothers.

One SSI participant from the Department of Health emphasised the feelings of affection (“kasih sayang”) breastfeeding affords women and their babies, and the long-term psychological benefits for children. She explained that children who are not breastfed do not have the same closeness with their mothers and this can manifest in transgressive behaviours, such as drug use, in their later years. Although these claims were not supported by any empirical evidence, they have the effect of emphasising the moral failures of women who do not breastfeed, as well as the moral risks for their children in later life. This perspective further emphasises the Indonesian state’s conscription of women as the moral guardians of their children’s future, which can only be achieved if they dutifully perform breastfeeding as recommended by the dominant health promotion messages.

Tensions between Women’s Experiences and the Moralising Rhetoric of Breastfeeding Promotions

Breastfeeding duration intentions versus realities

As recommended by the dominant breastfeeding promotion messages discussed above, most of the women who participated in IDIs set out to feed their children breastmilk for two years or longer. Exclusive breastfeeding for six months was a stated goal of all participants, regardless of whether this was achieved or not. Women who were not able to breastfeed for their intended duration expressed feelings of sadness, desperation, failure and concern for their children.

Maria (33 years old) desperately sought to exclusively breastfeed, but describes her breastmilk supply as never plentiful. When she returned to work following three months of maternity leave, her supply declined further.⁸ She contacted AIMI for counselling when her son was ten weeks old, but by the time he reached his fourth month, Maria found that she needed to exclusively feed him infant formula, a situation that deeply saddened her:

The first time I fed him infant formula I wanted to cry. Then I fed him in a position that was similar to when I nursed him, so he would feel like he was being breastfed… I had to accept it, it had already happened. The most important thing is that my baby is healthy… This is a specific condition … it’s important to realise that it wasn’t that I didn’t want to breastfeed, I just couldn’t physically do it.

A major concern for Maria was bonding with her son post-breastfeeding. Maria’s aunt, a nurse, helped her to realise that breastfeeding is just one of many means through which mother–child affection is developed.

After 15 months, Alina, the daughter of 33-year-old Melati, stopped wanting breastmilk. Melati had already been using various traditional herbal tonics (jamu, specifically uyup-uyup and daun katuk) to support her breastmilk supply and quality. When Alina began to reject breastmilk, Melati tried to maintain her supply by taking vitamins, and the medication Domperidone. She explained that she eventually gave up breastfeeding with a heavy heart (“berat hati”) when her milk supply diminished.

When at 13 months old Fina bit her mother, 32-year-old Lalita, while breastfeeding, they were both startled (“kaget”). That night Lalita breastfed Fina, but the following day Fina rejected breastfeeding. Lalita’s husband suggested she take Fina to an elder with traditional knowledge (simbok) to see if she could get Fina breastfeeding again,⁹ but the day they went to the simbok’s home clinic it was closed, and by the time she had the chance to return Lalita’s milk supply had declined. Reflecting on this experience Lalita said she felt extremely sad (“rasanya sedih banget”) because she had intended to breastfeed for at least 18 months.

These experiences highlight the reality that breastfeeding does not work out as intended for all mothers, despite the exhortations of the state, health promotion advocates and religious leaders. Women’s breastfeeding struggles are either glossed over or unacknowledged within the dominant health promotion messages. Failure to acknowledge the breastfeeding difficulties experienced by some women can exacerbate their feelings of inadequacy as mothers. Maria’s experience highlights that women can be reassured that breastfeeding is just one of several mechanisms for promoting mother–child bonding. Yet descriptions of strategies for bonding, other than breastfeeding, are absent from breastfeeding promotion messages. This approach further demoralises women attempting to live up to the imperative to breastfeed but who, for various reasons, are unable to do so.

Inconsistent support from health workers

The experience of 36-year-old Nian, a university lecturer and postgraduate student, emphasises that health workers do not always support women seeking to exclusively breastfeed; nor do their practices comply with state legislation. Her eldest daughter, 10-year-old Sinta, was given infant formula by nursing staff without Nian’s consent immediately after she was born and Nian did not go on to establish breastfeeding with her. Thus, when her second child Kirana was born in early 2015, breastfeeding was a new experience for Nian. Following her planned caesarean section, Nian’s breastmilk supply was slow to establish. Both her obstetrician and a paediatrician warned that Kirana’s weight gain was stalling as Nian’s breastmilk supply may have been inadequate.¹⁰ Upon Nian’s discharge she received infant feeding supplies from one of the hospital’s sponsors – an infant feeding equipment company – including a can of formula milk and a bottle with a teat. Nian’s doctor told her that the provision of these supplies did not mean that he did not support the Exclusive Breastfeeding Program. Eventually, with the combination of “breast care” education from the hospital’s physiotherapy section, breastfeeding counselling from AIMI, and self-education, Nian was able to feed Kirana breastmilk for her first six months. This narrative highlights Nian’s high level of health literacy, which enabled her to circumvent the anxieties and mixed messages she received from her doctor, and to seek out alternative support to attain her own breastfeeding goals, but not all women have the level of self-efficacy and confidence required to navigate such an experience. Her case demonstrates that while breastfeeding promotion is the dominant message received by mothers in Indonesia, competition from the formula milk industry remains strong.¹¹ Moreover, it reveals how health professionals are not subjected to moral scrutiny in the same way that mothers are if their actions contradict the national exclusive breastfeeding policy.

Anytime and anywhere? Breastfeeding and discretion

Although the 2012 Regulation directs the community to unconditionally support women to breastfeed “anytime and anywhere”, the majority of Muslim IDI participants stated that they did not feel comfortable breastfeeding outside of their homes or private vehicles, for those who had cars. This was the case for both women who routinely wore an Islamic veil (jilbab) and those who did not. In the excerpt below, Melati (who wears a jilbab) describes how she negotiated breastfeeding in instances she was away from home:

I’m not comfortable if I’m out because there aren’t designated places for breastfeeding. So, if I have to go out I usually bring the car because, for example, if I have to breastfeed, I can return to the car to do it. In many public places and tourist sites there aren’t breastfeeding rooms yet.

Harum (28 years old) similarly feels most comfortable breastfeeding at home. In the following passage she describes the challenges of breastfeeding in public places that do not have lactation rooms available:

Belinda:

Where do you feel comfortable breastfeeding if you are not at home?

Harum:

Well usually … if there is a nursing room, I’ll use it. If I cannot find a nursing room, I wear a nursing apron. Only if I use an apron it’s a pain ya. My baby gets too hot and then he gets cranky, because he’s covered.

As Harum’s experience reveals, when nursing facilities are not available, breastfeeding discreetly in public can be difficult and uncomfortable. Harum is a Muslim who does not usually wear a jilbab, but her desire to be covered while she breastfeeds reflects Javanese notions of being sopan (polite) and modest. Although women who do not cover their breasts can be seen publicly breastfeeding in Yogyakarta, breasts in Indonesian culture are increasingly being codified as sexual. Indonesian censors have taken to blurring and pixelating women’s bare chests and cleavage in talent contests, foreign music videos, films and other visual media (see, for example, Hoesterey, 2016; Pausacker, 2015; Sapiie, 2016), and this may have the effect of making women more uncertain about the propriety of breastfeeding in public. As Wall (2001) and Campo (2010) argue, the body of the breastfeeding woman transgresses the boundaries and ideals between the maternal body and the sexual body, and to simply assert that the breastfeeding breast is different from the sexual breast is problematic. Fuelling the collective moral panic about public exposure of breasts, AIMI facilitators opened the prenatal class with the disclaimer that images would be used, but that those breasts should not be mistaken for pornography, “banyak foto bukan pornografi”.

Another participant, 29-year-old Dina, was breastfeeding her daughter at a supermarket in a local mall. Dina’s daughter became hungry and it was bothersome (“terlalu ribet”) to leave the supermarket to breastfeed in one of the mall’s nursing rooms.¹² Dina did not think it was impolite to breastfeed in the supermarket as she wears a jilbab, and her chest and breasts are fully covered when she breastfeeds. Despite this level of modesty, a woman who saw Dina reprimanded her; she explains her frustration:

The woman in the jilbab told me “Mbak, in the mall there’s a nursing room”. It’s up to me if I want to use the nursing room or not. So I told her “ya Bu, but she was already thirsty”. But it’s none of her business. If, for example, my breasts were exposed, sure it would have been sinful of me. Why was she making a fuss?

These experiences are also reflective of the continued Islamisation of Indonesia and the subsequent narrowing boundaries of Islamic modesty for and among Indonesian women (Allen, 2007). Although the study field site, Yogyakarta, is renowned for its diversity and tolerance compared with other parts of Java, the narratives presented in this article demonstrate the strong concern of some Muslim women to protect their physical modesty while breastfeeding. These narratives also highlight the tensions between the dual moralities of breastfeeding and Islamic modesty, which can be difficult for breastfeeding Muslim women to reconcile.

Breastfeeding and postpartum mental health

Although breastfeeding is often characterised by breastfeeding promotions as innate, natural and critical for bonding between mother and baby, women in this study did not always express these sentiments. Breastfeeding is promoted by AIMI as a way to alleviate postnatal depression, but for some women the exhaustion associated with being constantly in demand for feeding required some adjustment. Dina revealed that she experienced mild depression for the first one to two months following her daughter’s birth:

It was like I didn’t entirely realise beforehand what it meant to have a child. When we’re pregnant and we give birth, we’re overjoyed, and of course we understand we’re becoming a mother. But at the time [following her daughter’s birth] I was like, “wahhh … how do I have to be?” I was so exhausted. Babies have a pattern of their own, and we already have our own sleeping pattern; we sleep through the night, but babies sleep then wake up, sleep then wake up. It’s so tiring.

Another first time mother, 26-year-old Susi, had a difficult birthing experience. She had planned a vaginal, “natural” delivery with her twins, but she ended up having a caesarean birth. Susi’s son was also born with jaundice so he needed ultraviolet treatment for the first 24 hours. Susi’s breastmilk was slow to establish and she was concerned there was not enough. Susi found the advice and instructions provided by the hospital overwhelming. She describes feeling frightened, afraid and depressed:

Because I had the baby blues, I was thinking: “why isn’t my breastmilk coming out?”… I felt depressed early on, about my children, “why is only my daughter rooming-in?”, “my son is sick”… maybe because I had two children at the same time for my first time … they had so many needs, so I was confused … the first time I tried to breastfeed them both at the same time, I was confused about the position, my arms were hurting.¹³

These narratives highlight that first time mothers experience difficulties establishing and adjusting to breastfeeding and their new role as a parent. While breastfeeding is portrayed as perfect for babies, women’s experiences are often far from easy or perfect. More supportive and realistic approaches to breastfeeding promotion would integrate detailed information about how different women experience and may overcome the challenges of breastfeeding so that if problems occur, those women feel less like moral failures. Ideally, a comprehensive prenatal education would discuss potential breastfeeding challenges alongside other useful information, such as tips for settling a crying baby, routine duties of new parents, coping with lack of sleep, and postpartum recovery for new mothers.

Discussion and Conclusions

As has emerged in other analyses that juxtapose breastfeeding promotions and the lived experiences of women, a dominant theme in this study was the construction of breastfeeding as an inherent motherly duty, and not at all a debt of the child to their mother as observed by Geertz (1961). The moralising rhetoric of the breastfeeding promotions analysed in this article takes women’s bodies and subjectivities for granted in its attempt to promote exclusive breastfeeding compliance. The promotions by community breastfeeding advocates and religious leaders in particular seek to educate women and their husbands about exclusive breastfeeding, but their approaches are biased, as the sole emphasis is on reinforcing the merits of breastfeeding. The perceived need to educate pregnant women and mothers is described by Bartlett (2002) as “headwork”, constructing infant nursing as a practice to be learned and managed rather than embodied. She asserts that women are viewed by biomedicine as needing training and management, rather than being permitted bodily autonomy. In the Indonesian context, women’s headwork is further complicated by a narrative that situates the teaching and supervision of women within a paradigm that prioritises infants’ rights, while silencing women’s rights.

In a similar vein, the GoI’s breastfeeding legislation obligates women to perform what is constructed as their natural moral duty to their families and the nation. It essentially strips away notions of a woman’s corporeal autonomy to make decisions about whether or not to use her body to breastfeed, and to what extent. Furthermore, these laws give licence to members of the broader community to scrutinise the breastfeeding practices of women. Regulation by community members does not always have the effect of affirming women’s breastfeeding practices, as was evidenced when Dina breastfed in the supermarket. A dialogue that considers women’s rights to choose how, when and where they feed their children is absent. Indonesian women’s breastfeeding compliance is assumed in national legislation, even though the laws continue to be undermined by some health workers, as was experienced by Nian, and the visibility of formula milk remains ubiquitous.

The religious breastfeeding promotions described in this article constitute a highly moral interpretation of the Qur’an, which infers irresponsibility on the part of women who do not breastfeed. This is despite the fact that the Qur’an states that the provision of donor milk to an infant is acceptable. The notion of choice and autonomous parental decision making is entirely absent in these particular interpretations of Islam. The breastfeeding promotion approach in AIMI’s educational sessions attempts to strike the balance between the provision of biomedical evidence and what Blum (1993) refers to as the maternal approach to breastfeeding promotion, in which motherhood and the maternal–child bond are celebrated. Yet AIMI’s materials and their delivery impose moral responsibility on mothers and fathers to prioritise exclusive breastfeeding, and offer no alternative feeding options. Little recognition is given to women who cannot or do not wish to breastfeed. Furthermore, the emphasis on the positive aspects of breastfeeding during prenatal education sessions does not adequately prepare women for the difficulties they may encounter. The emphasis on the physical benefits of breastfeeding targeted at husbands also reinforces persistent gender stereotypes.

Women are increasingly reliant on support from their peers, health workers, lactation counsellors and groups such as AIMI to negotiate the breastfeeding challenges they encounter (see also Marshall, Godfrey, & Renfrew, 2007). Yet these support mechanisms may do more harm than good if they continue to perpetuate inherently moralising ideologies and overlook the pluralistic and messy nature of breastfeeding as experienced by real women. What is evident from the experiences of mothers in this study is the struggle between the day-to-day challenges of performing breastfeeding and the underlying pressures placed on women by dominant breastfeeding promotions. The moralising rhetoric of these messages has the effect of ignoring the reproductive agency of women and their right to autonomous decision making pertaining to their bodies and the way in which they feed their babies. Moreover, the key messages contained in the three breastfeeding promotions analysed in this article gloss over the fact that it is perfectly normal and natural for mothers and babies to experience difficulties breastfeeding.

It would better serve the needs of Indonesian mothers if breastfeeding promotion messages took an even-handed approach, acknowledging the physical and emotional demands of infant feeding, and emphasising also that women should have the ability to decide to breastfeed or not. Infant feeding is just one of numerous responsibilities of parents, and need not be a burden or the exclusive responsibility of one parent. Chastising women who do not and cannot breastfeed using alarmist language of blame, shame, failure and moral peril, along with narrow gendered ideals and expectations, should be avoided in breastfeeding promotion messages and materials if they are to be truly supportive of Indonesian women.

Disclosure statement

No potential conflict of interest was reported by the authors.

Funding

The first author is the recipient of an Australian Postgraduate Award scholarship, a Nossal Global Health Scholars Program studentship and a Graduate Women Victoria Bursary in Memory of Feminist Fathers. An Endeavour Research Fellowship was also awarded to the first author in 2014 to support the fieldwork.

Acknowledgments

This special issue came to fruition amidst great joy and great loss. Just before submitting her article, Belinda and her partner Aditya welcomed their beautiful daughter Juno into the world. Literally days too before submitting his article, Teguh and his partner Julian welcomed their beautiful daughter Pax. Of immense sadness and loss, however, was the passing of Hanny Savitri Hartono (Vitri), just a week after submitting her final version. Vitri suffered a stroke while on campus and left behind three children and a husband. Vitri was an example of someone who truly sought to live a moral life and always treated others with kindness and respect – she was caring, compassionate and generous. She left this world far too early and with far too much still to contribute but her faith in Allah made her transition easier for loved ones to bear. We dedicate this special issue to Juno, Pax and Vitri.

Notes

1. The duration of a Javanese year is 420 days (Geertz, 1961).

2. Today the study site, Ngaglik, is an urban district within Yogyakarta’s Sleman Regency.

3. As occurred in other lower income nations. The predatory promotion of formula to women in lower income countries came under fierce scrutiny by activist groups in the 1970s and provided the basis for current global limitations on the marketing of formula and other breastmilk alternatives (see Muller, 1974; Krasny, 2012; Boswell-Penc, 2006).

4. One of the participants was a first time mother with twins.

5. The WHO Code is a health promotion strategy recommending restrictions on the marketing and distribution of breastmilk substitutes (such as infant formula), and the equipment used to prepare and serve breastmilk substitutes. There is an inherent contradiction between the Indonesian legislation and the fact that formula milk has long been and still is promoted heavily in medical and retail outlets of all sizes and in mainstream media throughout the country (Lim & Kemp, 1994; Shetty, 2014).

6. Although it has been anecdotally reported that some health services and workers have been issued warnings, the authors are not aware of any health workers or facilities that have had their licences revoked under the Regulation to date.

7. In Indonesia same sex relationships are not recognised by the state.

8. For women working as public servants or in the formal private sector, the length of paid maternity leave is typically three months. Four to six weeks of the leave must usually be taken prior to the due date.

9. Similar to the role of the dukun bayi in infant weaning observed by Geertz (1961), simbok are still called upon by some women to help with weaning and other infant feeding challenges.

10. It is not uncommon for neonates to lose weight during their first week after birth. Compared with formula fed babies, breastfed infants lose more weight initially and take longer to regain their birth weight (Macdonald, Ross, Grant, & Young, 2003).

11. Hull and colleagues (1990) found that almost half the university-educated postpartum women in their study perceived a need to feed infants formula during the first six months of life.

12. Ribet is the slang form of the Indonesian repot (bothersome).

13. The term “baby blues” was commonly used by participants and is the term used in Indonesian language health promotion articles targeted at expectant mothers. It refers to the mild depressive symptoms that many mothers experience in the postpartum period that typically dissipate after several days to two weeks.