Lactational amenorrhea and the recovery of ovulation and fertility in fully nursing Chilean women

The probability of experiencing the first postpartum bleeding, the first ovulation and the risk of pregnancy during exclusive breastfeeding was assessed in a selected group of urban Chilean women. Admission criteria included having had a normal pregnancy and a vaginal term delivery of a healthy infant and the desire to maintain breastfeeding for as long as possible. The risk of bleeding and the recovery of ovulation was assessed in 48 women selected for being amenorrheic and fully nursing at day 75 postpartum and their willingness to participate in the blood sampling protocol. The first bleeding and ovulation was experienced while fully nursing by 28% and 26% of these subjects, respectively, at day 180 postpartum. The probability of experiencing the first bleeding and the probability of pregnancy during full nursing were calculated for 236 women not contracepting who were enrolled during the first month postpartum. The cumulative probability of bleeding and of pregnancy was 52% and 9.4% at day 180 postpartum, respectively. The risk of pregnancy was less than 2% in the subset of amenorrheic cases. In this urban population selected for having the highest motivation and best breastfeeding performance, the association of breastfeeding with infertility was too weak to serve as an effective birth spacer, except for the period of lactational amenorrhea. When the first postpartum bleeding took place before the sixth postpartum month in fully nursing women, it had a good predictive value to indicate the onset of a higher risk period.     

Breastfeeding pattern and the duration of lactational amenorrhea in urban Chilean women

The influence of the breastfeeding pattern and several clinical variables upon the duration of postpartum amenorrhea was assessed in a group of healthy women selected for having had a normal pregnancy and delivery and being highly motivated for prolonged breastfeeding on demand. 676 women who were fully nursing at the second month postpartum entered the study. Supplements were administered to 11% and 48% of the infants by the end of the 3rd and 6th month, respectively. The first bleeding was experienced before the end of the sixth month postpartum by 57% of the cases. Supplementation had a strong negative influence while nursing frequency had a significant positive influence upon the length of amenorrhea. Notwithstanding, a frequency of 8+ suckling episodes per 24 h could not maintain amenorrhea in around half of the subjects. Age and parity had a moderate negative influence upon the risk of experiencing the first postpartum bleeding. Maternal weight and ponderal index, infant sex, birth weight and growth rate showed no significant influence upon the length of amenorrhea. In this urban population selected for having the highest motivation and best breastfeeding performance, the association of breastfeeding with amenorrhea was weak in comparison with what has been described for other populations. The risk of experiencing the first bleeding was reduced while fully breastfeeding with a high number of nursing episodes per day and night, particularly in older women with higher parity. But even in such situation 25% and 50% of the women had started to cycle by the end of the fifth and eight postpartum month.     

Menstrual Pattern,Sexual Behaviors,and Contraceptive Use among Postpartum Women in Nairobi Urban Slums

Postpartum months provide a challenging period for poor women. This study examined patterns of menstrual resumption, sexual behaviors and contraceptive use among urban poor postpartum women. Women were eligible for this study if they had a birth after the period September 2006 and were residents of two Nairobi slums of Korogocho and Viwandani. The two communities are under continuous demographic surveillance. A monthly calendar type questionnaire was administered retrospectively to cover the period since birth to the interview date and data on sexual behavior, menstrual resumption, breastfeeding patterns, and contraception were collected. The results show that sexual resumption occurs earlier than menses and postpartum contraceptive use. Out of all postpartum months where women were exposed to the risk of another pregnancy, about 28% were months where no contraceptive method was used. Menstrual resumption acts as a trigger for initiating contraceptive use with a peak of contraceptive initiation occurring shortly after the first month when menses are reported. There was no variation in contraceptive method choice between women who initiate use before and after menstrual resumption. Overall, poor postpartum women in marginalized areas such as slums experience an appreciable risk of unintended pregnancy. Postnatal visits and other subsequent health system contacts provide opportunities for reaching postpartum women with a need for family planning services.     

Contraceptive use and pregnancy before and after introducing lactational amenorrhea (LAM) in a postpartum program

There is good evidence that lactational amenorrhea (LAM) is an effective method of fertility regulation during the first 6 months postpartum, provided no other food is given to the baby and the mother remains amenorrheic. However, although breast-feeding is strongly promoted in many maternity hospitals that also run postpartum family planning progams, LAM is rarely included among the contraceptive options being offered.This paper presents the results of an operational study which compared the prevalence of contraceptive use and the cumulative pregnancy rate at 12-months postpartum among 350 women observed before and 348 women studied after introducing LAM as an alternative contraceptive option offered to women following delivery at the Instituto Materno–Infantil de Pernambuco (IMIP), in Recife, Brazil.The percentage of women not using any contraceptive method was significantly lower (p<0.0001) after the intervention (7.4%) than before (17.7%). This difference remained statistically significant after controlling for age, number of living children, marital status and years of schooling. The proportion pregnant one year postpartum was also significantly lower (p<0.0001) after the introduction of LAM (7.4%) than before (14.3%), but the difference was no longer significant after controlling for the same variables. It is concluded that LAM is a useful addition to family planning postpartum programs.     

城市妇女产后哺乳期闭经和避孕行为的随访研究

为探讨城市妇女在产后1年内的哺乳类型、闭经状况和避孕行为,本研究采用前瞻性随访研究方法,对1996年6月起在山东省淄博市5所区级医院分娩的496名产妇进行登记,并对其中有活产的494名妇女于产后42天、4个月和1年时进行访视。1年访视率为98.8％。被访视对象96.1％为初产妇。访视结果显示,完全母乳喂养妇女产后4个月时月经恢复率为14.7％,而混合喂养者为29.2％(P<0.05)。产后第1个月37.7％的妇女避孕,第2个月为62.3％,前3个月以使用避孕套为主。自产后3个月起宫内节育器使用率逐渐增加。寿命表法分析表明,依产后顺序月为序,完全哺乳概率与产后闭经概率的降低呈一致趋势。在产后4个月时产后闭经概率仍为68.2％,提示提高完全母乳喂养率,有助于哺乳期自然避孕的可行性。为保护母婴健康,防止产后非意愿妊娠的发生,应加强服务网络间联系和适时地为产后妇女提供优质服务。妇幼保健与计划生育服务相结合应成为我国基层初级生殖保健的方向。     

A study of breastfeeding and the return of menses and pregnancy in Karachi, Pakistan

A longitudinal study of breastfeeding women was conducted to determine whether breastfeeding frequency is associated with the length of postpartum amenorrhea. The data are also conducive to testing the guidelines of the "Bellagio Consensus" (i.e., that there is no more than a 2% chance of pregnancy during breastfeeding in the first six months postpartum in the absence of vaginal bleeding and regular supplements). Twenty-eight breastfeeding women were followed-up weekly in Karachi, Pakistan. The frequency of breastfeeding was found to be a poor correlate of the duration of amenorrhea. Thirty-six percent of the women became pregnant during the study. However, all were having menses and/or giving regular supplements before the estimated date of conception, consistent with the Bellagio Consensus. In countries such as Pakistan, where contraceptive use is low, active promotion is needed to prevent the further decline of breastfeeding in order to retain its contraceptive as well as other maternal and child health benefits.     

Progestin-only contraception prevents bone loss in postpartum breastfeeding women

BackgroundThere are an increase in bone loss during the first 6 months postpartum and a complete recovery postweaning. A few studies of steroid contraceptive use during this period provide some evidence towards protection of bone loss with progestin-only contraceptive methods.ObjectiveThe study was conducted to evaluate forearm bone mineral density (BMD) of breastfeeding postpartum women using nonhormonal and progestin-only contraceptive methods.Study DesignA prospective cohort study of postpartum women had an analysis performed at 6 months postpartum correlating BMD with contraceptive use. Forearm BMD was measured 7–10 days, 3 months and 6 months postpartum. Eighty-two women were analyzed, comparing nonhormonal (54) and progestin-only (28) contraceptive methods. Information about breastfeeding duration, amenorrhea and body mass index was collected.ResultsBaseline characteristics of the study population showed no statistical differences between the groups. The median duration of breastfeeding for both groups was 183 days. A significant BMD decrease was observed for the nonhormonal group (p<.001); however, no statistical difference was detected for the progestin-only group. Body mass index, BMD at 7–10 days postpartum and total duration of breastfeeding were positively correlated with BMD at 6 months.ConclusionsOur findings suggest a preventive effect towards postpartum bone loss with progestin-only contraception in breastfeeding women.     

Statement on breast feeding,fertility and contraception

An important part of the human reproductive process, breastfeeding also plays a key role in infant nutrition while protecting the infant from exposure to infection. Breastfeeding also plays a major role in the natural regulation of fertility, but breastfeeding patterns are changing along with urbanization and lifestyle changes. These changes are tending towards a shortening of the duration of breastfeeding, a reduction in the daily frequency of breastfeeding episodes, and an earlier introduction of food supplements. Consequently, the risk of pregnancy during lactation has increased. The literature suggests considerable variability in the length of breastfeeding and postpartum amenorrhea and in the duration of lactational infertility among different populations. Both the return of ovarian activity and fertility depends on the time elapsed since delivery. Variables that play a primary role in the length of amenorrhea and infertility include: the duration of breastfeeding the frequency and duration of suckling; the administration of supplements to the infant; the mother's nutritional status; and geographic, social, and cultural factors. Knowledge of local breastfeeding practices and the associated risks of pregnancy should be a prerequisite for those counseling nursing women. All women should be advised and encouraged to breastfeed fully, as far as is practicable. Women also need to be informed that it is difficult to predict exactly the duration of lactational infertility for each woman. The timing of the introduction of contraception depends on the risk factors and some programmatic aspects, such as the possibility that the woman may not return after delivery or after the 1st postpartum visit as well as the type of contraceptive chosen. Current information on the influence of contraceptive methods -- IUDs, oral contraceptives, injectable contraceptives, norplant, barrier methods, periodic abstinence, and sterilization -- upon breastfeeding are summarized.     

Lactational amenorrhea as a method of family planning in Egypt

Because of the potential importance of the lactational amenorrhea method (LAM) as a family-planning option in Egypt, we analyzed data from the 1995 Egyptian Demographic and Health Survey (EDHS) to study breastfeeding practices, use of contraception, reproductive history and sociodemographic factors for 5504 mothers with children under 3 years. According to the EDHS data, about 80% of Egyptian women breastfed for at least 6 months, and 40% breastfed for 15-18 months. Over half of breastfeeding mothers used no additional contraception. Thirty-six percent of mothers breastfeeding children younger than 6 months who reported using no additional contraception were exclusively breastfeeding and amenorrheic, but only 4% reported relying on breastfeeding for family planning. We also held eight focus group discussions with breastfeeding mothers from urban and rural Upper and Lower Egypt on their use of contraceptive methods, breastfeeding, lactational amenorrhea and LAM. Participants showed strong recognition of the contraceptive effects of breastfeeding but differed widely in their understanding of lactational infecundability and knowledge of LAM as a method. These results suggest that LAM would be widely acceptable to Egyptian women, but that an educational program about the method is needed.     

The contraceptive benefit of breastfeeding

Breastfeeding has long been a means of fertility regulation in traditional communities but only recently have attempts been made to characterize and quantify this attribute. Breastfeeding encompasses behavioral, geographical, and cultural factors, which account for the differences in the prevalence and practice of breastfeeding in different communities. Ovarian activity is suppressed in the breastfeeding mother. Initially the suppression is complete and the woman is amenorrheic. This is followed by anovulatory menstrual cycles or ovulatory cycles that manifest luteal phase deficiency or normal ovulatory cycles. The duration of ovarian follicular suppression is variable and recent work suggests that lactation suppresses ovarian activity by disturbing the pulsatile pattern of luteinizing hormone (LH) secretion. During lactational amenorrhea, prolactin levels are high, LH levels are low to normal. Follicle stimulating hormone concentrations are normal by four weeks postpartum, and estrogen and progesterone levels are low. The degree of ovarian suppression is enhanced by increased frequency of suckling, longer duration of feeds, and more frequent night-time feeds. Introduction of supplementary feeds inhibits ovarian suppression. These and other factors account for variations in the length of lactational amenorrhea in an individual and between populations. The Bellagio Consensus Statement affirms that the risk of pregnancy in a fully breastfeeding, amenorrheic woman in the first six months of lactation is less than 2%. After the sixth month it is increasingly likely that ovulation will precede the first menstruation. The Bellagio Consensus has given scientific validity to birth-spacing in developing countries and the lactational amenorrhea method (LAM) as a means of contraception. If breastfeeding ceases to be full, menstruation resumes, or the baby is more than six months old, alternative methods of contraception should be used. Breastfeeding should feature more prominently in fertility regulation programs and counseling, especially in developing countries.     

Reassessing Unmet Need for Family Planning in the Postpartum Period

Despite renewed interest in postpartum family planning programs, the question of the time at which women should be expected to start contraception after a birth remains unanswered. Three indicators of postpartum unmet need consider women to be fully exposed to the risk of pregnancy at different times: right after delivery (prospective indicator), after six months of amenorrhea (intermediate indicator), and at the end of amenorrhea (classic indicator). DHS data from 57 countries in 2005–13 indicate that 62 percent (prospective), 43 percent (intermediate), and 32 percent (classic) of women in the first year after a birth have an unmet need for contraception (40 percent when including abstinence). While the protection afforded by postpartum abstinence and lactational amenorrhea lowers unmet need, further analysis shows that women also often rely on these methods without being actually protected. Programs should acknowledge these methods’ widespread use and inform women about their limits. Also, the respective advantages of targeting the postnatal period, the end of six months of amenorrhea/exclusive breastfeeding, or the resumption of sexual intercourse to offer contraceptive services should be tested.     

New IPPF statement on breastfeeding,fertility and post-partum contraception

The International Planned Parenthood Federation International Medical Advisory Panel drew up the following statement in November, 1989. Breastfeeding is good for the infant. Antibodies passed to it from the mother protect it from infection. Patterns of breastfeeding are changing. Therefore, the risk of pregnancy is increased. Postpartum amenorrhea plays a major role in natural fertility regulation. Studies from around the world show a positive correlation between the length of breastfeeding and the length of lactational amenorrhea. Amenorrhea lasts longer in those who breastfeed more often at night and during the day. There is controversy over the effect of nutrition on postpartum infertility. Pregnancy and the puerperium are a good time for counseling on maternal nutrition, child spacing, breastfeeding, and contraceptive methods. Counseling nursing mothers about potential fertility during lactation should be based on local information. All women should be advised to fully breastfeed. Family planning programs should cooperate with maternity services in providing counseling and education for postpartum women who need contraception, for providing referral services, for producing educational resources, and in training health personnel. Postpartum contraception should be included in the training of traditional birth attendants. Women who do not breastfeed can select any contraceptive method. Mothers who nurse must not hurt success of lactation or the infant's health. Nonhormonal contraception should be the 1st choice for lactating women. IUDs do not harm infant growth or lactation. Postpartum insertions are appropriate, though care must be taken. Female sterilization can be conveniently done at this time. Barrier methods are reliable when used regularly. The failure rate should be lower when used after delivery. Progestagen-only contraception consists of progestagen-only pills, injectables, and Norplant. These do not affect quality and quantity of breast milk or length of lactation. They are suitable for those who do not wish nonhormonal methods. There are possible consequences, however, of the transfer of the steroid to breast milk. Hormonal methods should not be used earlier than 6 weeks postpartum. High and low dose oral contraceptives adversely affect the quality and quantity of breast milk. They also reduce duration of lactation. They should be withheld until 6 weeks after delivery, or until the infant is weaned--whichever comes first. The efficacy or periodic abstinence in nursing women requires further analysis.     

Cox回归模型在产后哺乳与避孕相关关系分析中的应用

应用Cox伴随时间变化变量回归模型来准确的评价产后哺乳与避孕的关系。从天津市河西区随机抽取9个街,344名产后12～18个月的哺乳期妇女进行问卷调查。调查结果表明产后启用避孕措施的时间与哺乳类型无关,但已恢复月经的妇女比仍闭经的妇女更可能选用避孕措施。年轻妇女产后性生活恢复和启用避孕措施的时间较早。建议妇女产后恢复性生活之后,无论完全哺乳还是闭经,都应尽早选择一种适宜的避孕方法。     

Breastfeeding Duration and Development of Dysglycemia in Women Who Had Gestational Diabetes Mellitus: Evidence from the GUSTO Cohort Study

(1) Background: Breastfeeding has been shown to support glucose homeostasis in women after a pregnancy complicated by gestational diabetes mellitus (GDM) and is potentially effective at reducing long-term diabetes risk. (2) Methods: Data from the Growing Up in Singapore Towards healthy Outcomes (GUSTO) study were analyzed to understand the influence of breastfeeding duration on long-term dysglycemia (prediabetes and diabetes) risk in women who had GDM in the index pregnancy. GDM and dysglycemia four to seven years postpartum were determined by the oral glucose tolerance test (OGTT). A Poisson regression model with a robust error variance was used to estimate incidence rate ratios (IRRs) for dysglycemia four to seven years post-delivery according to groupings of the duration of any breastfeeding (<1, ≥1 to <6, and ≥6 months). (3) Results: Women who had GDM during the index pregnancy and complete breastfeeding information and OGTT four to seven years postpartum were included in this study (n = 116). Fifty-one women (44%) had postpartum dysglycemia. Unadjusted IRRs showed an inverse association between dysglycemia risk and ≥1 month to <6 months (IRR 0.91; 95% confidence interval [CI] 0.57, 1.43; p = 0.68) and ≥6 months (IRR 0.50; 95% CI 0.27, 0.91; p = 0.02) breastfeeding compared to <1 month of any breastfeeding. After adjusting for key confounders, the IRR for the ≥6 months group remained significant (IRR 0.42; 95% CI 0.22, 0.80; p = 0.008). (4) Conclusions: Our results suggest that any breastfeeding of six months or longer may reduce long-term dysglycemia risk in women with a history of GDM in an Asian setting. Breastfeeding has benefits for mothers beyond weight loss, particularly for those with GDM.     

注射醋酸甲孕酮妇女月经改变的相关因素分析

目的:研究注射醋酸甲孕酮(DMPA)妇女月经改变的相关因素。方法:将390例受试者分为哺乳组和非哺乳组两组,对多种数据进行回归分析。结果:注射DMPA次数越多,体质指数越大,哺乳时间越长,发生问经的可能性越大,而经量多的妇女越容易发生不规则流血。注射期间持续阴道流血不闭经妇女和闭经妇女在初潮、经期、周期、经量、注射次数、是否哺乳六个指标上均有显著性差异。结论:本研究为注射前预测妇女月经改变提供了一定的咨询参考。     

When is breast feeding contraceptive?

Breast-feeding has always been perceived as a contraceptive measure, probably because it is associated with amenorrhea. However, many pregnancies occur during breast-feeding, often quite soon after delivery. A pregnancy occurring 3 months after delivery is considered at risk for both the mother and child. Three conditions are necessary for a 98% contraceptive efficacy of lactation: total amenorrhea; exclusive breast-feeding on demand, both day and night; and occurrence within the first 6 months postpartum. If the three conditions are met, no additional contraceptive method is needed. Beyond 6 months, another method should be used.     

Lactational amenorrhoea and family planning

Scientists and policymakers at an international meeting in Bellagio, Italy, have concluded that the lactational amenorrhea method of family planning (LAM) can be recommended to help women space births. Based on a study of data from several thousand women in more than a dozen countries, including Nigeria and Rwanda, the group decided the following conditions were required to be simultaneously present to achieve a high degree of protection: 1) remaining amenorrheic; 2) being within six months of delivery; and 3) full or nearly full breastfeeding. Used in this manner, LAM was 98% effective. If any of the conditions should change, another method of contraception would have to be used. Infants older than 6 months need supplemental feeding, which typically decreases breastfeeding; however, in many of the reviewed studies, women who continued to breastfeed after 6 months together with supplemental feeding had a low rate of pregnancy, although higher than at six months. This may allow the extended use of LAM. Additional research is needed.     

Drinking and smoking at 3 months postpartum by lactation history

Summary. A spontaneous decrease in maternal drinking and smoking often occurs during pregnancy. The present study was conducted to determine if these lower levels of maternal drinking and smoking during pregnancy persist into the postpartum period, and if so, to determine if they are related to breastfeeding. Drinking and smoking were estimated in three cohorts of postpartum women who had been followed since pregnancy. The first group never breastfed their infants; the second group breastfed for less than 1 month; the third group breastfed for more than three months. (Women who weaned between one and three months were not studied.) Drinking and smoking in all three groups decreased sharply during pregnancy but rose again in the 3 months after delivery, though not to levels that were reported before conception. Usual drinking in the third month postpartum did not differ significantly among the three lactation groups. However, women who were still nursing were less likely to report occasional episodes of heavy drinking (binges) in this month than women who had weaned early or never breastfed. Women nursing in the third month postpartum were also significantly less likely to smoke during the month; if smoking, they were less likely to smoke heavily. These differences in postpartum drinking and smoking were not due entirely to habits before conception or to the influence of other potentially confounding variables.     

Drinking and smoking at 3 months postpartum by lactation history

A spontaneous decrease in maternal drinking and smoking often occurs during pregnancy. The present study was conducted to determine if these lower levels of maternal drinking and smoking during pregnancy persist into the postpartum period, and if so, to determine if they are related to breastfeeding. Drinking and smoking were estimated in three cohorts of postpartum women who had been followed since pregnancy. The first group never breastfed their infants; the second group breastfed for less than 1 month; the third group breastfed for more than three months. (Women who weaned between one and three months were not studied). Drinking and smoking in all three groups decreased sharply during pregnancy but rose again in the 3 months after delivery, though not to levels that were reported before conception. Usual drinking in the third month postpartum did not differ significantly among the three lactation groups. However, women who were still nursing were less likely to report occasional episodes of heavy drinking (binges) in this month than women who had weaned early or never breastfed. Women nursing in the third month postpartum were also significantly less likely to smoke during the month; if smoking, they were less likely to smoke heavily. These differences in postpartum drinking and smoking were not due entirely to habits before conception or to the influence of other potentially confounding variables.