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.     

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.     

Contraceptive efficacy of lactational amenorrhea in urban Chilean women.

The contraceptive efficacy of breastfeeding was assessed in 236 healthy urban women who were followed at monthly intervals during the first postpartum year. Proportional hazard models were used to evaluate the influence of time postpartum, menstrual status and breastfeeding pattern upon the risk of pregnancy. Time and menstrual status had a highly significant effect on this risk. Those women who remained in amenorrhea had cumulative probabilities of pregnancy of 0.9% and 17% at 6 and 12 months postpartum, respectively. In those who recovered menstrual cycles, the risk rose to 36% and 55% at 6 and 12 months, respectively. Milk supplementation also increased significantly the risk when considered alone but not when time and/or menstrual status were included in the analysis. However, amenorrheic women who introduced bottle feeding, had a higher risk of pregnancy after 6 months postpartum than those who remained fully nursing. The analysis was unable to detect a significant influence of the nursing frequency. The results confirm that lactational amenorrhea is an effective contraceptive during the first six months postpartum. The first postpartum bleeding marks a great increase in the risk of pregnancy. Supplementation also increases the risk, particularly in amenorrheic women.     

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。     

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.     

The contraceptive effect of breastfeeding

The fertility-reducing impact of breastfeeding, the hormonal mechanism of lactational amenorrhea, the cultural and individual behavioral variables that influence the hormonal mechanism and the duration of amenorrhea, and the policy implications of extending postpartum protection by using lactational amenorrhea as a complementary contraceptive are discussed. Recent studies indicate that the contraceptive effect of lactational amenorrhea is considerable, with use-effectiveness rates comparable to those of oral contraceptives, the condom, or the diaphragm; according to 1 estimate, breastfeeding provides 35 million couple-years of protection annually in developing countries, compared with 27 million provided by family planning programs. The contraceptive effect of breastfeeding is largely lost after the return of menstruation. The physiological processes by which lactation inhibits the ovulatory cycle in humans are poorly understood, although a close association is known to exist between frequent sucking, high prolactin levels, altered LH secretion, and amenorrhea. The length of the breastfeeding period and the timing of the addition of supplementary foods influence both the duration of amenorrhea and the frequency and intensity of nursing. Maternal age and demand vs. scheduled feeding may be secondary factors affecting the duration of amenorrhea. Cultural beliefs and norms regarding breastfeeding practices are of extreme significance in determining the duration of lactational amenorrhea. Flexible family planning programs which encourage the continuation of breastfeeding while promoting the use of appropriate contraceptive methods initiated when they will affect fertility are needed in developing countries.     

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.     

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。     

World population, family planning and development]

The 1991 world population report of the UNFPA projects a world population of 8.504 billion by 2025. The prevalence of the use of modern contraceptives increased from 9% in previous years to an average of 51% at the present time: to 70% in East Asia, to 60% in Latin America, but only to 17% in Africa. 20% of pregnancies are unwanted, the prevention of which would reduce the expected population by 2.2 billion people in 2100. Without birth control programs today there would be 412 million more people in Asia, Latin America, and Africa; and in 2100 1.48 billion would live on Earth instead of 10 billion forecast by the World Bank. The aim of UNFPA is to increase contraceptive prevalence form 51% to 59% by 2000: from 381 million users in 1991 to 567 million acceptors. Only 15% of men use contraceptives, although the prevention of sexually transmitted diseases especially AIDS makes the use of condoms highly advisable. In the report scant mention is made of breast feeding as a family planning method, although the Bellagio Consensus of 1988 states that if a woman almost exclusively breast feeds during lactation amenorrhea a more than 98% protection against pregnancy is offered during the 1st 6 months postpartum. During this period no additional contraception is necessary until the 1st menstruation occurs. Women in Bangladesh taking an oral contraceptive after delivery had shorter birth intervals than women exclusively relying on breast feeding. The Working Group of Medical Development Association issued guidelines concerning contraceptive methods including subdermal implant of levonorgestrel, although excessively strict standards can foil the contraceptive needs of the Third World. Their reproductive mortality is mainly determined by an extremely high maternal mortality rather than by complications from contraceptive use.     

Contraceptive implants and lactation

The safety and efficacy of four contraceptive implants, plant, Implanon, Nestorone and Elcometrine, have been evaluated during use in the postpartum period by lactating women. These implants provide highly effective contraceptive protection with no negative effect on breastfeeding or infant growth and development. Breastfeeding women initiating Norplant use in the second postpartum month experience significantly longer periods of amenorrhea than do untreated women or intrauterine device users. After weaning, the bleeding pattern is similar to that observed in non-nursing women. Norplant use does not affect bone turnover and density during lactation. Norplant and Implanon release orally active progestins while Nestorone and Elcometrine implants release an orally inactive progestin, which represents an advantage since the infant should be free of steroidal effects. The infant's daily intake of steroids (estimated from concentrations in maternal milk during the first month of use) range from 90 to 100 ng of levonorgestrel (Norplant), 75-120 ng of etonogestrel (Implanon), and 50 ng and 110 ng of Nestorone (Nestorone and Elcometrine implants, respectively). Nursing women needing contraception may use progestin-only implants when nonhormonal methods are not available or acceptable. Implants that deliver orally active steroids should only be used after 6 weeks postpartum to avoid transferring of steroids to the newborn.     

Breastfeeding: its relationship with postpartum amenorrhea and postpartum sexual abstinence in a Nigerian community

Breastfeeding, together with its two related postpartum variables--amenorrhea and abstinence--govern both the tempo and quantum of fertility in traditional African societies. Decline in breastfeeding also implies decline in postpartum amenorrhea and abstinence practice. Changes in breastfeeding practices in tropical Africa, therefore, has fertility implications and consequences. This paper examines how breastfeeding is functionally related to postpartum amenorrhea and abstinence in Ilorin, an urban community in Nigeria. Results indicated that the effect of breastfeeding on fertility, through its relationship with postpartum abstinence, might be more important than its effect through lactational amenorrhea in this society. This is more true among women with little or no education than among women with secondary or higher education. The population or family planning implications of these relationships are discussed.     

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.     

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.     

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.     

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.     

Progesterone vaginal ring: introducing a contraceptive to meet the needs of breastfeeding women

Background

The 2012 London Summit on Family Planning called for innovative solutions for increasing contraceptive access for 120 million women and girls by 2020. One way of contributing to this goal is to address the contraceptive needs of postpartum women, who have considerable unmet need especially during lactation. The progesterone vaginal ring (PVR) has been shown to be effective and safe for breastfeeding women and has the potential to enhance contraceptive choice. This user-controlled method reduces dependence on health care providers and has the potential to reduce some access-related barriers that users face. Postpartum women who have used the method have found it easy to use and find it acceptable. A well-designed introductory approach is important to ensure that the PVR is integrated into health systems.

Conclusion

The PVR is a new technology that increases contraceptive options for breastfeeding women and has the potential to improve the health of women and their infants. Careful planning with attention paid to numerous factors can result in its successful introduction.     

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.     

妇女产后月经恢复、避孕与再妊娠概率生命表法分析

本文讨论产后哺乳期闭经作为一种避孕方法纳入计划生育规划中的可行性。基于哺乳期自然避孕的机理,鼓励产后妇女尽可能地延长完全母乳喂养期限,充分发挥哺乳期闭经的避孕作用,既避免了可能的再妊娠,又有益于产妇和婴儿的健康。本研究采用现况调查方法,对山东省淄博市张店区南定镇和沣水乡的2 315例自1993年1月～1995年12月期间凡生育过至少一个活产婴儿的已婚育龄妇女进行了抽样调查。用生命表法分析了产后月经恢复、避孕和再妊娠等事件的发生概率。结果显示,产后三个月时,城乡妇女月经恢复累积概率分别为0.3042和0.3329;避孕累积概率分别为0.5909和0.8700;再妊娠累积概率分别为0.0009和0.0038。数据表明,妇女月经恢复之前,有相当数量的妇女较早使用了避孕方法,意味着哺乳期的避孕作用尚未引起人们的足够重视。因此,建议加强哺乳期闭经可作为一种避孕方法宣传、咨询和培训。