Lactational Amenorrhea Method as a Contraceptive Strategy in Niger

If used properly, the lactational amenorrhea method (LAM) can be a valuable family planning tool, particularly in low-income countries; however, the degree to which LAM is used correctly and characteristics associated with its use have not been well documented. We therefore sought to use nationally representative data from Niger, where fertility rates are high and women may have limited access to alternative contraceptive methods, to describe the proportion of women who use LAM correctly and the characteristics associated with LAM use. We utilized cross-sectional data from the 2006 Niger Demographic Health Survey. Our sample included all sexually active, non-pregnant, breastfeeding women using some form of contraception (N = 673, unweighted). We used weighted frequencies to describe the correct use of LAM and logistic regression models to describe women who chose LAM for contraception. Among our sample, 52 % reported LAM as their primary method of contraception, but only 21 % of the women who reported using LAM used it correctly. Women who reported using LAM were more likely to live in certain regions of the country, to have no formal education, and to have delivered their most recent baby at home. They were also less likely to have discussed family planning at a health facility or with their husband/partner in the past year. Results indicated that few women in Niger who reported using LAM used it correctly. Our findings reinforce the need to address this knowledge gap, especially given Niger’s high fertility rate, and may inform efforts to improve family planning in Niger and in other low-income countries.     

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.     

Breast-feeding and contraception in Peru

This retrospective study examined duration of breast-feeding and concurrent contraceptive use among 5,648 Peruvian women. Data were gathered during 1986-1992 as part of the Demographic and Health Survey (DHS). The women gave birth to 7,951 infants, 95% of whom were breastfed; 44% of the mothers used contraception while breastfeeding. Consistent with the literature, mothers using oral contraception breastfed for significantly less time than those using other methods. Unexpectedly, mothers using periodic abstinence or withdrawal breastfed longer (15.5 and 15.3 months) than those using other methods or non-contraceptors. Among mothers changing contraceptive methods while breastfeeding the same child, those changing to abstinence and withdrawal breastfed longest (18 months). The relationship of duration of breast-feeding with contraceptive use remained after controlling for other predictors of duration of breast-feeding. Additional data are needed to explain this phenomenon in Peru and perhaps elsewhere.     

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.     

Breastfeeding and contraception]

In the Netherlands many women stop breastfeeding in the first few months postpartum. In 1997, only 16.9% of all 3-month-old babies received full breastfeeding. One of the causes may be insufficient support by the medical profession. A second factor is that often combined oral contraceptives are prescribed to breastfeeding women. As it has been shown that estrogens in these contraceptives inhibit lactation, this is probably one of the reasons why breastfeeding frequently fails in this country. WHO advises not to use estrogens during lactation. According to recent research the lactational amenorrhoea method of contraception (LAM) is highly effective during the first 4 months postpartum. In the 5th and 6th month the effectiveness is strongly dependent on the accuracy by which the conditions are met. The medical profession should pay more attention to the support of breastfeeding and contraception in relation to each other.     

The efficacy of the lactational amenorrhea method (LAM) among working women

The purpose of this study was to assess the efficacy of the lactational amenorrhea method (LAM) for family planning among mothers who are separated from their infants by work. The study population, 170 urban middle class women who planned to return to work before 120 days postpartum, were interviewed monthly for 6 months postpartum and contacted at 12 months. The study population received clinical support for expressing their milk and exclusively breast-milk feeding the infants and for the use of LAM for birth spacing. The cumulative life table pregnancy rate by 6-month was 5.2%, with 3 pregnancies, one at each of months 4, 5, and 6. LAM for working women, as described in this article, might be associated with a higher pregnancy risk than LAM use among non-working women. Therefore, women using LAM should be informed that separation from the infant might increase their risk of pregnancy.     

哺乳闭经避孕法对提高产后避孕率的临床观察

观察哺乳闭经避孕法(LAM)中不同喂养方式对产后闭经时间和妊娠率的影响。本研究随机选择1996年5月～1997年5月在天津中心妇产科医院分娩的正常足月初产妇200例,比较不同喂养方式的产后闭经时间和妊娠率。结果:全哺乳组闭经时间(8.77±3.26月)长于部分哺乳组(2.87±1.47月),两组差异有显著性(P<0.05)。部分哺乳组长于非哺乳组(1.95±1.03月),两者差异有显著性(P<0.05)。全哺乳组妊娠率(1.2％)最低,其次为部分哺乳组(5.0％)及非哺乳组(10.0％),三组间差异均有显著性(P<0.01)。结果表明LAM是一种非常可取的避孕方法。     

Differences in the infant-feeding practices in Urban and Rural Nigeria

This study compared the infant-feeding methods of 378 urban mothers and 356 rural mothers. We collected information by means of a questionnaire. The weights of infants were taken by means of an Avery scale and milk intake was assessed by the test-weighing method. The results showed that all mothers breastfed their children and introduced milk formula or other milks at some stage. All urban mothers had stopped breastfeeding by 12 months, but 27.5% of rural mothers breastfed 1 year or more. A majority of the mothers (87.1% rural and 78.6% urban) reported that they stopped breastfeeding when they thought the child was old enough to stop. And although urban and rural mothers said they started weaning their children for similar reasons, 33.9% of urban mothers weaned their babies within the first 9 months of life compared to 6.7% in the rural area. Urban infants were heavier within the period surveyed. This article includes recommendations for increasing the duration of breastfeeding and improving availability of weaning foods.     

Influence of levonorgestrel contraceptive implants, NORPLANT, initiated early postpartum upon lactation and infant growth

This study was undertaken to investigate the effect of use of levonorgestrel contraceptive implants, NORPLANT^R, by breastfeeding mothers on lactational performance and infant growth. NORPLANT^R implants were inserted between days 30 and 42 postpartum in 50 lactating women. Two control groups of breastfeeding mothers, 50 each, were studied in parallel: the first used an intrauterine device (Cu T380-Ag) and the second used either barrier or no contraception. There was no difference in lactational performance among the three groups. The increments in infant weight and height in the three groups were within the normal range for Egyptian infants. However, the rates of weight and height gain in the early postpartum months were slightly, but significantly, lower in the NORPLANT^R group than in the two control groups. However, by the sixth postpartum month, there were no significant group differences in these growth parameters. The possible confusing effect of supplementary feeding is discussed.     

The relation between maternal breast feeding and non-nutritive sucking habits

This study sought to identify the type and duration of breastfeeding received by children and establish the association with non-nutritive suction habits. A retrospective, transversal study was conducted using a questionnaire given to 330 mothers or persons responsible for 3 to 6-year-old children registered in kindergartens in Ara?atuba, State of S?o Paulo, after obtaining their free and informed consent. It was revealed that 86.4% of mothers breastfed their children. With respect to duration, only 33.4% of these mothers breastfed exclusively after 6 months. The average time of exclusive breastfeeding received by children was 3.84 months and complementary breastfeeding was 11.68 months. Of this total, 53.3% reported that their infants manifested non-nutritive suction habits and of these children, 70.45% were not exclusively breastfed for the first 6 months, there being a significant association between both (p<=0.05). Pacifier use was the most frequent habit (44.4%), showing a statistically significant association with breastfeeding time (p<0.0001). It was concluded that breastfeeding was practiced, albeit for a lesser duration than considered indispensable for the baby's development, there being an association between duration and type of breastfeeding and non-nutritive suction habits.     

The effect of a breastfeeding education program on lactational amenorrhea in the Philippines

A study was conducted in two communities in the rural Philippines to determine whether breastfeeding mothers could intensify their nursing enough to increase the period of lactational amenorrhea. Women in one community were exposed to a breastfeeding education program before the birth and during lactation, while women in the other community served as a comparison group. Increased breastfeeding was observed in the group that received breastfeeding education, beginning in the sixth month postpartum. Bottle use began earlier and was more common in the comparison group, but the introduction of solid foods at five to six months was similar. No difference in the duration of postpartum amenorrhea (a proxy for the duration of infertility) was observed between the groups.     

The epidemiology of breastfeeding cessation in sub-urban Lagos, Nigeria

Two hundred and forty mothers in a sub-urban community in Lagos were studied. Respondents were women who had children 0 -- 24 months of age. They were largely married women of low educational and socioeconomic background. Breastfeeding is commonly practised in this community. Nearly all the mothers (92.4%) breastfed for longer than six months and a large proportion (71.5%) breastfed up to 12 months. The proportion of male infants who were breastfed for longer than 12 months was higher than that of the female infants (75% vs. 67%) although the difference was not statistically significant (X² = 1.77, p=0.279). Older mothers (#lt35 years) tended to breastfeed for slightly longer period than their younger counterparts. There was a significant inverse association between mothers' level of education and the duration of breastfeeding (p = .035). The major reason for stopping breastfeeding as given by 62 percent (149 mothers) was that the child was old enough. The next important reason for stopping breast feeding was that the mother had to resume work. The “insufficient milk syndrome” as reported from many cultures of developed and developing countries of the world has not yet affected the Nigerian suburban women and was not an important reason for stopping breastfeeding.     

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.     

Frequencies and demographic determinants of breastfeeding and DHA supplementation in a nationwide sample of mothers in Germany

Purpose

German guidelines recommend breast milk as ideal for infant’s nutrition, supporting exclusive breastfeeding for at least 4 months. Moreover, in mothers with insufficient fish intake, DHA status may be improved by supplementation during pregnancy and lactation. However, little is known on current rates of breastfeeding and DHA supplementation in Germany. The objective of this study was to analyse frequencies and demographic determinants of breastfeeding and DHA supplementation in Germany.

Methods

Data derived from a nationwide consumer survey of 986 mothers with children between 5 and 36 months of age in Germany.

Results

78.3 % reported that they ever breastfed their children, and 55.6 % of the mothers exclusively breastfed for at least 4 months. Mothers who did not breastfeed were less likely to be informed by their paediatrician or midwife and were more often not informed at all; 27.8 % of mothers used DHA supplements during pregnancy, 16.8 % postnatal. DHA supplementation was more common in women with a high versus a low fish intake. The social status was the major determinant of breastfeeding initiation and exclusivity and also DHA supplementation.

Conclusion

Breastfeeding initiation and duration of exclusive breastfeeding in Germany need to be improved. Professional counselling and support, with a focus on mothers from lower social classes, appears necessary to increase current rates of breastfeeding initiation, duration, and exclusiveness, but also to ensure a sufficient supply with DHA in pregnant and lactating women, particularly in women with low fish consumption.     

中国西部45县农村2005年3岁以下儿童母乳喂养现状调查

目的了解中国西部10省45县农村<3岁儿童母乳喂养的状况及其影响因素。方法采用横断面调查设计和人口比例抽样法(PPS),于2005年调查了45县获得14 077对母子,通过母亲回顾调查了儿童的母乳喂养情况。结果西部地区农村<3岁儿童母乳喂养率为96.5%。然而,<6个月纯母乳喂养率只有11.4%,优势母乳喂养率为22.0%,完全母乳喂养率为33.4%;及时开奶率为43.5%;母乳持续喂养≥1年的比例是64.9%,母乳持续喂养≥2年的比例仅为9.7%。"应该断奶"和"母亲要参加劳动"是母亲自觉断奶的主要原因。<6个月纯母乳喂养有利于儿童的生长发育,可以降低儿童的2周腹泻患病率。<6个月纯母乳喂养的主要危险因素为母亲受教育程度高、调查地区经济状况差和母亲为少数民族。结论西部地区儿童普遍接受母乳喂养,儿童出生后开奶早,母乳喂养持续时间不长,<6个月纯母乳喂养率一直在较低的水平,尤其是经济状况较差的四类农村以及少数民族地区。     

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.     

Infant feeding practices and socio-demographic factors in Ottawa-Carleton

Parents of 320 infants 6-18 months of age were interviewed to determine infant feeding practices and socio-demographic factors contributing to parental choices. 76% of women breastfed initially. Social class was directly related to the incidence of breastfeeding. 50% of the women who started breastfeeding continued to do so at 6 months, a figure which is higher than that previously reported in Canada. Although social class was a major determinant in parents' choice of infant feeding, cultural factors were also very important. A higher proportion of mothers who spoke languages other than English or French in the home (including mainly Polish, Italian, Spanish, and East Indian) breastfed their infants than did mothers who spoke French, even though more of them were in the lowest socio-economic group. The reason for the relatively low incidence of breastfeeding by Francophone mothers is unclear.     

上海市产后妇女避孕方法选择的定性研究

目的:了解上海市产后妇女避孕措施的选择及其影响因素,并了解妇幼保健和计划生育机构对产后避孕服务提供情况。方法:采用个人访谈和小组讨论的研究方法,对上海市分娩1年内的产妇以及参与产后家庭访视的妇幼保健和计划生育工作人员进行访谈。结果:妇女产后早期倾向选择对身体康复和哺乳没有影响的避孕套和安全期避孕,一段时期之后倾向选择避孕效率更高的方法。选择避孕方法的种类受妇产科医生的建议和亲戚朋友避孕经验的影响较大。产妇避孕知识整体水平不高,普遍不了解哺乳避孕法以及口服避孕药、皮下埋植剂等避孕方法。由于产后访视员避孕知识的不足使得产后访视几乎未开展有效的避孕指导。结论:采取多种措施,提高产妇避孕知识,扩大产后避孕方法的选择,改善产后访视的避孕指导。     

Breast-feeding and postpartum ovulation

This paper reviews the evidence for the contraceptive effects of breastfeeding on postpartum ovulation. In developing countries breastfeeding prevents more pregnancies than all the other methods of contraception. In a detailed Edinburgh longitudinal study of 27 breastfeeding and 10 bottlefeeding mothers, the return of ovarian follicular development and ovulation was determined by several estimations of total urinary estrogen and pregnanedial excretion, respectively. In the bottlefeeding mothers the patterns of events after delivery was consistent. Basal prolactin levels fell to non-pregnant levels within 2-3 weeks postpartum. By 15 weeks all bottlefeeding mothers had resumed ovulation and menstruation. By contrast, all breastfeeding mothers who breastfed for a mean of 40 weeks maintained elevated basal prolactin levels for longer than the bottlefeeders. The mean time to 1st ovulation was 36 weeks with a range between 15-66 weeks postpartum. The infant feeding patterns showed striking differences between these mothers (33% of the whole group) who suppressed ovulation for more than 40 weeks postpartum and the rest of the mothers (67%) who ovulated before that time. The mothers who suppressed ovulation for more than 40 weeks not only maintained breastfeeding for the greatest number of weeks, but also suckled more frequently, breastfed for a longer total time each day, and maintained 1 or more night feeds for a longer time. After supplementary food was given there was a rapid increase in the number of mothers with evidence of ovarian activity and within 16 weeks of starting, 71% had evidence of follicular activity and 52% had ovulated. Mothers who introduce weaning food abruptly and reduce sucking rapidly will be more likely to experience an early return of ovulation and potential fertility. The mechanism of lactational infertility is not clearly understood. 45% of the completed menstrual cycles during lactation were anovular and of the 55% which were ovular, many were associated with defective luteal phases. The birth spacing effect of lactation is of great importance in communities where alternative contraceptive devices are not available or not acceptable. Breastfeeding is a complementary form of contraception.