PROVISION OF LACTATION CLINIC IN COMPANIES IN SEMARANG CITY: A REVIEW OF POLICY IMPLEMENTATION

Background: As of 2022, Semarang City has 4,083 companies. However, according to the Labor Office of Semarang City, only 109 out of 529 companies provide lactation clinics. In addition, based on previous research in Pedurungan, Semarang City, most of the women (83,3%) who work do not practice exclusive breastfeeding (EBF), one reason being the lack of lactation clinics in companies. Aims: This study examines the implementation of lactation clinic policies in companies in Semarang City. Methods: This study used a qualitative method with a descriptive approach. The research variables included effectiveness, consistency, relevance, organizational structure, resources, sociocultural environment, economic environment, organizational culture, geographic environment, knowledge and skills, communication, and political support. Informants were selected based on purposive criteria, involving eight key informants and 18 supporting informants from eight companies in Semarang City. Results: Lactation clinic policies were ineffective because companies were unaware of their contents and perceived them as recommendations only. On the contrary, working mothers who breastfed recognized the benefits of the policies and considered them relevant. Three out of eight companies provided lactation clinics. The people in charge had yet to be appointed due to the different capacities of the companies. Due to a lack of support from the sociocultural environment, working mothers needed more awareness of the importance of breastfeeding. In addition, most companies do not provide lactation clinics or recommend formula milk. Conclusion: The current policies have not adequately supported the provision of lactation clinics in companies in Semarang City. To address this issue, lactation clinics should be classified according to the companies' capacities. It is also necessary to develop a leading sector that is transparent and responsible for supervising the provision of lactation clinics.


Introduction
The average proportion of female employees in Indonesia between 2020 and 2022 was projected at 35.47% out of 71,570,465 women of childbearing age.(BPS-Statistics Indonesia, 2022).Women of childbearing age may experience pregnancy, childbirth, postpartum, and breastfeeding during employment.One factor that influences the lack of exclusive breastfeeding (EBF) is the type of maternal employment (Rahmawati, 2014).
Mothers employed at companies or other industries often have limited breaks and demanding schedules, which can significantly impact their ability and motivation to breastfeed exclusively due to fatigue.Despite the implementation of workplace policies regarding breastfeeding practices, these challenges persist (Faradila, 2021).Companies can provide lactation clinics to increase the productivity of female employees.Breastfeeding can strengthen children's immune systems, reducing the likelihood of illness.Meanwhile, formula milk can be expensive and affect the well-being of working mothers.
The Government of Indonesia has implemented regulations to support exclusive breastfeeding and provide lactation clinics.These regulations are outlined in the Law of the Republic of Indonesia Number 33  A study conducted in Semarang City showed that most working mothers did not practice exclusive breastfeeding.The study also found that the employment status of mothers was associated with exclusive breastfeeding (Dahlan, Mubin and Mustika, 2013).
According to the government website of Semarang City, the number of companies in Semarang City increased from 4,072 in 2021 to 4,083 in 2022.However, only 20% of the 529 registered companies in the Labor Office of Semarang City provide lactation clinics.According to a preliminary qualitative study, the Health Office of Semarang City lacks standard operating procedures (SOPs) for providing lactation clinics despite the Regulation of the Mayor of Semarang City Number 7 of 2013.In addition, the coordination between the Health Office and the Labor Office of Semarang City has not been established.
Furthermore, there are no clear technical guidelines for providing lactation clinics, and no verbal or written administrative sanctions are imposed on companies that fail to provide them as stipulated in the Regulation of the Mayor of Semarang City Number 7 of 2013.
Based on interviews with three working mothers who breastfed from different companies, only one of the three mothers had access to a lactation clinic at her workplace.However, the condition of the lactation clinic did not meet her needs as the door could not be locked, there were no sink, tables, or chairs, and other employees often used the lactation clinic to rest and sleep.The two remaining mothers expressed breast milk in a prayer room or an unoccupied room separated by a cupboard.None of the three companies provided counseling on breastfeeding or expressing breast milk.
Based on the background above, this study aims to examine the implementation of the lactation clinic policies to meet the needs of working mothers who breastfed in companies in Semarang City.

Methods
This study used a qualitative method with a descriptive approach through in-Indonesian Journal of Health Administration (Jurnal Administrasi Kesehatan Indonesia) p- ISSN 2303-3592, e-ISSN 2540-9301 10.20473/jaki.v12i1.2024.139-149Original Research depth interviews.It was conducted in Semarang City between July and December 2023.Eight companies were included, with criteria for large and small companies in the mountain and coastal areas that have and don't have lactation clinics.These companies were selected based on the number of workers and accessibility based on geographic condition consideration.Informants were selected based on purposive criteria with consideration of being directly or indirectly involved and knowing information about providing lactation clinics in Semarang City companies.
The eight main informants handled the implementation of the policy of providing lactation clinics in each company, which consists of the person responsible for managing the lactation clinic or HRD (Human Resource Development) in the company.Meanwhile, the triangulation informants were 18 with criteria of company leaders and working mothers who breastfed in the eight companies, the Health Office of Semarang City, and the Labor Office of Semarang City.
Weimer and Vinning's theory on policy implementation was used to analyze the data, which analyzed policy effectiveness, consistency, relevancy, the organizational structure of companies and institutions, resources of companies and institutions, the social environment of companies, the organizational culture of companies, and communication and political support from companies' perspectives.

Policy Implementation
Semarang City has implemented policies regarding the provision of lactation These policies support the exclusive breastfeeding program, which ensures that newborns have the right to receive breast milk and that mothers have the obligation to breastfeed.However, many large and small companies have not yet fully implemented these policies due to a lack of awareness of the policies regarding the provision of lactation clinics in companies.Often, these policies are perceived as recommendations only, as opposed to mandatory policies.
According to Table 1, not all large companies have lactation clinics; most workers use laboratories or prayer rooms to express breast milk.All companies have no internal regulations related to lactation clinic implementation, although some of them offer breastfeeding opportunities.This condition will make working mothers doubtful and confused about expressing breast milk without clear regulations.
The availability of lactation clinics, infrastructure, equipment, and transparent company policies are the main factors supporting working mothers in expressing breastmilk.This support is needed so that working mothers can express breast milk in peace and obtain legal or policy protection (Suciati, 2020).This support is needed so that working mothers can freely express breast milk and obtain legal or policy protection.
The gender of workers at the company does not affect the provision of lactation clinics.This can be seen in the fact that there are still companies that do not have lactation clinics, even though almost 80% of their workers are women.

Policy Effectiveness
Based on the study of eight companies, the Regulation of the Minister of Health Number 15 of 2013 and the Regulation of the Mayor of Semarang City Number 7 of 2013 have not been implemented effectively.This condition can be affected by content, actor, and context.In the research, only three of eight companies provided lactation clinics, none established internal regulations, and only one hired a breastfeeding counselor.In general, the companies were unaware of their obligation to provide lactation clinics and were unfamiliar with the policies stipulating the provision of lactation clinics.The provision of lactation clinics can be adjusted to the conditions and capabilities of the company.However, no regulations specify the facilities of lactation clinics based on the classification of large and small companies.The three companies with lactation clinics did not meet the minimum requirements outlined in the regulations due to a lack of familiarity with the contents, a small number of female employees, and limited company budgets.These issues are not unique to Semarang City.A study conducted in South Kalimantan Province showed that most institutions or companies did not provide lactation clinics.In addition, none of the companies received any guidance or supervision (Henderawaty et al., 2014).
However, the regulations clearly state that guidance and supervision should be provided through advocacy, dissemination, technical guidance, monitoring, and evaluation by relevant agencies.In addition, the Mayor of Semarang City's Regulation stipulates that companies that do not provide lactation clinics should be subject to verbal or written administrative sanctions.
Nevertheless, the five companies without lactation clinics claimed that they were never sanctioned.
Workplace managers are the policy actors responsible for providing lactation clinics in companies.Meanwhile, the Health Office serves as the implementation coordinator.Unfortunately, companies were unaware of the implementation coordinator of these policies and never received any form of dissemination regarding lactation clinic policies from any institution.This is due to a lack of a leading sector related to these policies in Semarang City.
Furthermore, the Labor Office of Semarang City only monitors the availability of lactation clinics and not the provision of facilities within them.According to the Health Office and the Labor Office of Semarang City, the coordinators of the implementation of these regulations are the Minister of Women Empowerment and Child Protection, the Minister of Manpower and Transmigration, and the Minister of Health as outlined in the Joint Ministerial Decree or the Joint Regulation of the three Ministers.A similar case was found in South Kalimantan Province, where the Women Empowerment and Child Protection Agency, the Office of Manpower and Transmigration, and the Health Office of South Kalimantan Province were unaware of the division of tasks and responsibilities among the offices.This resulted in a lack of communication, leading to no dissemination and monitoring of companies (Henderawaty et al., 2014).
Several environmental factors influence policies and their implementation (O'Brien et al., 2020).For instance, companies without lactation clinics are often influenced by employees who are not accustomed to expressing breast milk at work and company leaders who do not provide adequate support in terms of facilities, flexible pumping time, and internal regulations.In addition, working mothers face challenges in maintaining their breastfeeding productivity due to limited opportunities to express breast milk.
A study in Surakarta City found that psychological factors significantly impact breast milk production.Mothers who experience prolonged stress, sadness, lack of confidence, and various emotional distress were more likely to have reduced or no breast milk production (Satino and Setyorini, 2014).Another study showed that the lack of dedicated spaces for expressing breast milk and unsupportive company leadership regarding breastfeeding often lead to stress for working mothers.
Additionally, the cleanliness of alternative lactation rooms cannot be guaranteed, which can lead to breast milk contamination (Thepha et al., 2018).

Policy Consistency
Companies did not provide lactation clinics based on their classification, although they had different capacities.

Indonesian Journal of Health Administration
(Jurnal Administrasi Kesehatan Indonesia) p- ISSN 2303-3592, e-ISSN 2540-9301 10.20473/jaki.v12i1.2024.139-149Original Research Some companies believed that the provision of lactation clinics conflicted with the ability of working mothers to express breast milk, which overlaps with the Labor Law regulating a seven-hour workday.The lack of consistency is evident due to the lack of a transparent leading sector and conflicting policies.Policy actors and stakeholders must have clearly defined and synchronized roles in overseeing, nurturing, supervising, monitoring, and evaluating the implementation to address this issue.Additionally, policy actors should conduct intensive and consistent dissemination to avoid multiple interpretations of different policies.
Both policy actors and stakeholders must work together and share a common understanding.Moreover, the effective enforcement of policies requires firmness in implementing applicable sanctions (Lobubun, Raharusun and Anwar, 2022).However, the main obstacle to implementing policies is the lack of enforcement of applicable sanctions (Setiyowati and Ispriyarso, 2019).To ensure policy consistency, it is necessary to establish a shared understanding among policy stakeholders, the leading sector, and policymakers.This can be achieved through specific policies related to exclusive breastfeeding.

Policy Relevancy
The policies regarding the provision of lactation clinics remain relevant in promoting exclusive breastfeeding.Three companies reported benefits for mothers who breastfed, felt comfortable, respected their privacy, and maintained hygiene while expressing breast milk.In other words, the provision of lactation clinics in companies can enhance the success of exclusive breastfeeding for employees and serve as a profitable investment for companies by potentially increasing the productivity of female workers (Basrowi et al., 2015).
However, there might be a discrepancy between the company's position and that of working mothers.For instance, due to the small number of mothers who breastfed, the company suggested using alternative facilities, such as prayer rooms, instead of providing a lactation clinic.Nevertheless, working mothers expressed concerns about a lack of privacy and compromised hygiene when using other spaces to express breast milk.
In another company, lactation clinic policies were considered irrelevant because most working mothers provided formula milk and expressed breast milk using their equipment.However, the availability of lactation clinics is crucial because the equipment that mothers bring to express breast milk requires support from a lactation clinic to ensure hygiene (Sari and Prameswari, 2019).

Organizational Structure of Companies and Institutions
This study found only one company that hired a designated staff member, a qualified nurse responsible for the lactation clinic.The company considered the management of the lactation clinic crucial to providing and maintaining facilities, especially since most of the employees were women, and the company prioritized their health.The company also emphasized that a certified breastfeeding counselor should oversee the management of the lactation clinic.This could ensure that the lactation clinic meets the needs of breastfeeding mothers.
However, other companies did not have a specific position for this role due to employee efficiency and budget constraints.Instead, they delegated responsibilities to the human resources department (HRD).In some newly established companies, employees had dual roles, leading to work-related stress and reduced productivity.Therefore, a collaboration between the Health Office of Semarang City and public health centers near these companies is necessary to train the HRD personnel to understand the management protocols for lactation clinics, procedures for breastfeeding at work, and the necessary facilities, thereby meeting the needs of working mothers who breastfeed.

Resources of Companies and Institutions
Resources are crucial to program implementation, serving as a driving force Indonesian Journal of Health Administration (Jurnal Administrasi Kesehatan Indonesia) p- ISSN 2303-3592, e-ISSN 2540-9301 10.20473/jaki.v12i1.2024.139-149Original Research and policy implementer.However, this study found that lack of space continued to be a barrier for some companies with lactation clinics.Limited space in a company is the primary reason for the absence of lactation clinics.Interestingly, among working mothers in companies equipped with lactation clinics, 75% practiced exclusive breastfeeding, citing the comfort and convenience provided by these facilities (Subratha, 2019) However, many companies did not prioritize the provision of lactation clinics due to budget constraints for facilities, infrastructure, and breastfeeding counselors.The lack of lactation support facilities is often attributed to its perceived high cost, making it infeasible to set up lactation support facilities (Kusumaningrum et al., 2017).
This study found that only one company was willing to hire a designated lactation clinic supervisor certified as both a nurse and a breastfeeding counselor.Research shows that training more breastfeeding counselors can effectively increase exclusive breastfeeding rates in a region (Sari and Prameswari, 2019).Therefore, to address the shortage of breastfeeding counselors, one potential solution involves leveraging support from the work environment, such as colleagues acting as breastfeeding facilitators in the workplace or introducing breastfeeding support groups (Ickes et al., 2023).

Sociocultural Environment of Companies
Many working mothers hesitated to express breast milk if no lactation clinic was available.As a result, they often left their children with their grandmothers, who provided them with formula milk.
Furthermore, some individuals in particular companies in Semarang City paid less attention to their health, particularly regarding exclusive breastfeeding.This is primarily influenced by a workforce dominated by millennials and Gen Z individuals who were unmarried and, therefore, did not breastfeed.Company culture and colleagues also play a significant role.The demands of production quality control could cause working mothers to rush to express breast milk, resulting in less milk production and supplementation with formula milk.In addition, formula milk promotions diverted their attention from breastfeeding to providing their children with formula milk.
Extensive formula milk promotions can create the perception that it contains essential nutrients for infants, is necessary as an alternative to breast milk, and is a practical and efficient choice.However, long-term formula milk feeding can increase health risks in infants, including diarrhea, asthma, ear infections, allergies, obesity, sudden infant death syndrome (SIDS), diabetes, and impaired cognitive development (Kera et al., 2023).
Furthermore, some mothers lacked knowledge of proper breast milk expression techniques and lactation terminology.In addition, some mothers were unfamiliar with breastfeeding equipment, such as cooler bags, and discarded expressing breast milk before receiving counseling.In some companies, working mothers were found to introduce formula milk to their children before returning to work after maternity leave.Some other working mothers faced challenges in providing exclusive breastfeeding due to nipple confusion experienced by their infants.
Counseling or education can be delivered through technology, such as creating WhatsApp groups and sending daily broadcasts.Workplace breastfeeding counselors should also be available 24/7 to answer questions and help motivate female employees who are currently breastfeeding.This emphasizes the importance of interventions aimed at motivating working mothers to breastfeed (Basrowi et al., 2015).

Organizational Culture of Companies
Companies that provide lactation clinics suggest that their organizational culture highly prioritizes the health and hygiene of their employees, predominantly female employees.This was evident in the food and beverages, garment, and telecommunications industries, where more than 300 females were employed.Health programs, such as regular check- of 2012 on Exclusive Breastfeeding and the Regulation of the Ministry of Health Number 15 of 2013 on the Procedures for Providing Special Breastfeeding Facilities and Expressing Milk.These regulations require all workplaces and public spaces to provide lactation clinics that meet established standards.These facilities should enable working mothers to breastfeed and express milk during working hours.Semarang City has also implemented regulations to support exclusive breastfeeding and provide lactation clinics at workplaces, such as the Regional Regulation Number 2 of 2015 on Maternal and Child Safety and the Regulation of the Mayor of Semarang City Number 7 of 2013 on Increasing the Provision of Breast Milk.
clinics.These policies are outlined in the Regulation of the Ministry of Health Number 15 of 2013 on the Procedures for Providing Special Breastfeeding Facilities and Expressing Breast Milk and the Regulation of the Mayor of Semarang City Number 7 of 2013 on Increasing the Provision of Exclusive Breast Milk.