Correlation between subsequent lengths of postpartum amenorrhoea in a prospective study of breast-feeding women in rural Bangladesh.

The relationship between subsequent lengths of lactational amenorrhoea for individual women in a prospective study of breast-feeding women in Bangladesh was studied. The data indicate that previous length of amenorrhoea has significant predictive value for the subsequent length of amenorrhoea. Information on previous experience with lactational amenorrhoea should be therefore incorporated into guidelines for the introduction of family planning during lactation.     

The duration of lactational amenorrhoea in urban Bangladeshi women

The duration of lactational amenorrhoea, and infant feeding patterns and behaviour, were investigated in a sample of 97 mother-infant pairs living in a poor urban area of Dhaka, Bangladesh. A seven-hour time allocation method was used to determine the number of breast-feeding bouts and their duration. The seven-hour observation period was conducted on five occasions: at birth, 1 month, 4 months, 8 months and either 10 or 11 months. The median duration of lactational amenorrhoea was determined to be 24.07 weeks using survival analysis. Mothers who breast-fed their babies for longer and more frequently had, on average, a longer period of lactational amenorrhoea. There was no relationship between sociodemographic characteristics of the mother and duration of lactational amenorrhoea, nor was there any significant relationship between maternal anthropometry and birth weight of the baby and duration of lactational amenorrhoea, but there was a tendency for women with lower body mass index to have longer durations. Using the Cox proportional hazards model, the best predictor of duration of lactational amenorrhoea was the mean of months 0 and 1 durations of breast-feeding, adjusted for the mean frequencies for those months. The introduction of weaning food was also an important predictor.     

Effectiveness of lactational amenorrhoea in prevention of pregnancy in Manila,the Philippines: non-comparative prospective trail.

OBJECTIVE: To determine the contraceptive efficacy of the lactational amenorrhoea method. DESIGN: Non-comparative prospective trial. SETTING: Urban Manila, the Philippines. SUBJECTS: 485 lower income, educated women with extensive experience of breast feeding. INTERVENTION: Women were offered all available contraceptives for use after birth. Those who chose the lactational amenorrhoea method were taught the method, screened for the study, and followed for 12 months to determine the risk of pregnancy when the method was used. MAIN OUTCOME MEASURES: Life table pregnancy rates during correct and incorrect use of the method, censored monthly in the event of sexual abstinence or the use of another contraceptive method. RESULTS: The lactational amenorrhoea method was 99% effective when used correctly (that is, during lactational amenorrhoea and full or nearly full breast feeding for up to six months). At 12 months the effectiveness during amenorrhoea dropped to 97%. CONCLUSIONS: The lactational amenorrhoea method provided as much protection from pregnancy as non-breast feeding women experience with non-medicated intrauterine devices and barrier methods. The contraceptive effect of lactation cannot be attributed to lactational or postpartum abstinence.     

Analysis of postpartum lactational amenorrhoea in relation to breast-feeding: some methodological and practical aspects.

A large multicentre epidemiological study was carried out by WHO between 1991 and 1995 to analyse the duration of lactational amenorrhoea in relation to breast-feeding. The main results of this analysis, which used classical statistical modelling, have been already published. However, some specific aspects of the postpartum fertility amenorrhoea and breast-feeding covariates, and more specifically the observed progressive exhaustion of the breast-feeding inhibitory effect on the reproductive axis, may justify a closer look at the validity of the statistical tools. Indeed, as has already been emphasized, analysis of large longitudinal data sets in reproduction often faces three difficulties: (i) the precise determination of the event of interest, (ii) the way to handle the time evolution of both the studied variables and their effect on the event of interest and (iii) the often discrete nature of the data and the associated problem of tied events. The first objective of the present work was to give additional insights into the estimation and quantification of the dynamics of the effect of breast-feeding over time, considering this covariate either as fixed or time-dependent. The second objective was to show how to perform the analyses using corresponding adapted procedures in widely available statistical packages, without the need for acquiring particular programming skills.     

Determinants of breast-feeding and post-partum amenorrhoea in Orissa

A life table analysis is made of the duration of breast-feeding and post-partum amenorrhoea in Orissa, India, taking one variable at a time using data from a baseline survey of fertility and mortality (BSFM) conducted on the lines of the World Fertility Survey. Then a multivariate (proportional hazard) analysis showed that socioeconomic factors including residence, caste status and education influence the breast-feeding and post-partum amenorrhoea periods. There was no effect of maternal age on the length of breast-feeding, but mean length of post-partum amenorrhoea varied with age. The durations of breast-feeding and post-partum amenorrhoea are strongly related.     

Extending lactational amenorrhoea in Manila: a successful breast-feeding education programme.

An experimental breast-feeding education programme conducted at the Philippine General Hospital in Manila demonstrated that women could be motivated to improve their breast-feeding practices and lengthen their period of lactational amenorrhoea in comparison to a control group. Mothers who participated in the programme breast-fed their babies more frequently, delayed the introduction of regular supplements, used fewer bottles and pacifiers and maintained night feeding longer than mothers who were not exposed to the positive breast-feeding messages. The programme was successful in lengthening the period of amenorrhoea among women with elementary, high school, or technical school education, but not among college-educated women. Different educational approaches may be necessary for women of different education levels.     

The recovery of fertility during breast-feeding in Assiut, Egypt

A longitudinal study of twenty-six breast-feeding and twelve non-breast-feeding postpartum women was conducted in Assiut, Egypt in order to determine the time that ovulation resumed after childbirth, and the effect of breast-feeding frequency on the period of lactational anovulation. Breast-feeding women experienced the onset of follicular development, vaginal bleeding, ovulation and pregnancy significantly later than women who did not breast-feed. Ovulatory and non-ovulatory breast-feeders reported similar frequencies of breast-feeding episodes. The introduction of dietary supplements commonly preceded ovulation. An algorithm using three simple variables observable to the breast-feeding mother was found to predict up to 100% of the first ovulations. All breast-feeding women who did not give supplements and did not have a vaginal bleeding episode by 6 months postpartum were anovular by strict criteria for ovulation. Ovulation did not precede bleeding or supplementation in the women who experienced these events before 6 months, yielding a highly effective formula for preventing unplanned pregnancy by the informed use of breast-feeding.     

Lactational performance, consummatory behavior, and suppression of estrous cyclicity in rats suckling underfed pups

The role of pups' appetite in the regulation of maternal consummatory behavior (food intake of nursing mothers), lactational performance and postpartum diestrus was studied over a period of 45 days postpartum in rats chronically exposed to either underfed or normally fed pups. Experimental rats (n = 10) daily received 5 pups, 4-10-days-old, that had been deprived of food for the preceding 24 h while under the care of nonlactating foster mothers. Control rats (n = 10) received normally fed pups obtained daily from lactating foster mothers. Throughout the experimental period, the daily milk yield (estimated by litter weight gain), the intake of food and water by the mother, as well as the ratio of litter weight gain to mother's intake of food and water were all markedly higher in rats nursing underfed pups than in rats nursing normally fed pups. After a peak in lactation around Day 15 postpartum, experimental rats produced the same amount of milk during extended lactation as they did in the beginning of lactation, while control rats produced only half the amount of milk during extended lactation as they did in early lactation. Regardless of the nutritional state of the suckling pups, maternal body weight increased progressively over the first four weeks of lactation and remained unchanged during the time of extended lactation. The postpartum diestrus and the subsequent diestrous phase in the time of extended lactation were considerably longer in duration in rats that nursed underfed pups. On Day 45 of lactation, prolactin levels were higher and the adrenal glands were larger in experimental rats than in controls.(ABSTRACT TRUNCATED AT 250 WORDS)     

Interaction of late pregnancy and lactation in rats.

The effect of pregnancy on lactation was studied during the third week of lactational pregnancy in postpartum pregnant rats with a delay in implantation of only 1 day (1d-LP rats). In an experimental design in which the suckling litter was prevented from consuming solid food, lactational performance was estimated by weighing the ten-pup suckling litters on days 16-21 of lactation or by measuring maternal weight loss after a nursing spell on day 21. In 1d-LP rats, food consumption as well as lactational performance was lower than it was in nonpregnant lactating rats (L rats) and pregnant-lactating rats with a normal long delay of implantation of at least 6 days (LP rats). The time spent by the pups sucking at the nipples was not different among the three groups, but the number of milk ejections was diminished in 1d-LP dams. Restriction of daily food supply during days 16 to 21 of lactation diminished lactational performance more strongly in 1d-LP rats than it did in L rats; 1d-LP rats conserved protein stores and mobilized fewer minerals than did L rats. The weight and composition of the litter in vitro were not affected by the food restriction. In pregnant-lactating rats (LP and 1d-LP rats), the number of early resorptions was increased in comparison with pregnant rats, showing that lactation can affect the earlier stages of pregnancy. It was concluded that late pregnancy does not affect nursing behaviour, but suppresses lactation by restricting maternal food intake and mobilization of maternal stores. Measurements in serum indicate a causative role for oestradiol, but not for leptin.     

Impact of lactation upon fertility in the New World primate capuchin monkey (Cebus apella)

In the present paper, we have studied the impact of lactation upon fertility in the capuchin monkey, Cebus apella, under laboratory conditions. Nursing females (ten females, 12 postpartum periods) presented lactational amenorrhea (first menses at 159.2 +/- 9.0 vs 42.6 +/- 5.8 days postpartum in five non-nursing females, seven postpartum periods). Plasma estradiol and progesterone concentrations during lactational amenorrhea were lower than those during the follicular phase of the menstrual cycle. Prolactin was higher than in non-nursing females at 31-60 days postpartum. Interbirth interval, studied in three non-nursing (four intervals) and six nursing females (eight intervals) lasted for 349.5 +/- 11.8 and 613.4 +/- 30.8 days, respectively. In non-nursing females, early recovery of the menstrual cycle was followed by a residual infertility (mating but no pregnancy) lasting 152.8 +/- 7.9 days. In nursing females, recovery of the menstrual cycle was followed by an extended residual infertility of 301.5 +/- 22.7 days. Thus, in the capuchin monkey, nursing prolongs the interbirth interval by inducing lactational amenorrhea and extending the residual infertility period.     

Nutrition, fertility and maternal investment in primates

While the energetics of reproduction have been intensively investigated among women, studies of mother-offspring relationships among non-human primates have tended to neglect the effect of nutrition of the mother on lactational performance and on growth and survival of offspring. Typically fertility has been compared between populations under different nutritional regimes. In this paper, the relations between suckling frequencies, the time of weaning, the survivorship of offspring, the contraceptive effects of lactation and the quality of maternal diets are outlined. Energy transfer from mother to offspring in the form of milk is proposed as a measurable component of maternal investment, and the behavioural causes and consequences of lactational anoestrus are explored using data from free-ranging vervet monkeys. It is suggested that nutrition of the mother is most important during the early phase of rapid infant growth, because at that time the energetic requirements of lactation are high; and that a mother's ability to assess her infant's demands and needs for nutrition for growth leads to alterations in suckling frequencies which result in variation in female fertility.     

Post-partum events and fertility control in Kinshasa, Za?re

Contraceptive prevalence surveys from sub-Saharan Africa typically show low rates of method use. The current study of one zone in Kinshasa, Za?re, provides a more detailed view of fertility control in an urban population by examining the relative duration of breast-feeding, amenorrhoea and sexual abstinence during the post-partum period. While motivations to prevent pregnancy remain high until the youngest child is over 24 months, the average duration of abstinence is only 4 months. This paper describes the methods women use to avoid pregnancy and the changes over the post-partum period.     

Effects of food restriction on the length of lactational diestrus in rats

The effect of food restriction (60% of an ad lib ration) for the first 14 days postpartum on serum progesterone levels and the duration of lactational diestrus was determined in rat dams nursing litters of eight pups. Food restricted dams showed a longer period of lactational diestrus than ad lib fed dams. Food restriction also caused an increase in progesterone levels that was maintained beyond the period of food restriction itself. Treatment with the dopamine agonist bromocryptine mesylate (0.5 mg/day) either from Day 1 or Day 9 postpartum onward induced early termination of lactational diestrus in both ad lib and food restricted dams but the effect was more rapid in the ad lib fed than in the food restricted females. In both cases, however, the effects of bromocryptine administration on milk delivery showed a similar time course providing indirect evidence that prolactin suppression was equivalent under both diet conditions. These data suggest that food restriction during lactation results in increased progesterone levels that most likely result from increased prolactin release. Further, while prolactin suppression in food restricted dams reduces the duration of lactational diestrus, the latency to do so is somewhat longer than that seen in ad lib fed females, suggesting that some other mechanism may also be operating to suppress ovulation in the food restricted female.     

Postpartum lactational amenorrhoea as a means of family planning in the Sudan: a study of 500 cases

The lactational histories of 500 Sudanese women were studied retrospectively to examine postpartum lactational amenorrhea as a method of family planning. Particular attention was given to the factors affecting postpartum lactational amenorrhea, including supplementary feeding and the use of modern contraceptive methods. Breast-feeding was overwhelmingly practised (90%) among this sample, which was roughly representative of the Sudanese population as a whole. The prevalence of amenorrhea among this group of lactating women was quite high (73%). Duration of lactational amenorrhea ranged from 2 to 36 months with a median of 12 months. Introduction of supplementary feeding had little effect on lactational amenorrhea up to the 9th month of breastfeeding. Beyond the 12th month of breastfeeding, lactational amenorrhea was significantly prolonged by postponing the introduction of supplementary feeding until the 4th month or later. Ovulation, and hence conception, during lactational amenorrhea was unpredictable. It occurred as early as the 3rd or as late as the 36th month postpartum. Conceptions interrupting lactational amenorrhea soon after delivery (3-9 months) were more frequent among primiparous women. The failure rate of lactational amenorrhea as a contraceptive was 8.4%. Though extremely high compared to that of the pill, lactational amenorrhea was more useful as a fertility control mechanism because, in this study, a high proportion of women initiated pill use, but soon discontinued it because of side effects. Modern contraceptive practice was not prevalent. Amenorrheic mothers accepted the pill after the 6th month postpartum (41%, compared to lactating mothers whose menses had returned who started much earlier. 49% of the women studied relied completely on the protection of lactational amenorrhea. 57% of all lactating women who used the combined pill reported a reduction in milk production. Knowledge of modern contraception was poor and incorrect in many cases, leading to several policy implications, including usage of sterilization.     

Changes in leptin levels during lactation: implications for lactational hyperphagia and anovulation

In these studies we investigated the time course of changes in circulating leptin levels in lactating rats and the dependence of these changes on the energetic cost of lactation and evaluated the contribution of changes in leptin levels to lactational hyperphagia and infertility. In the first experiment, plasma leptin levels were measured on Days 5, 10, 15, 20, and 25 postpartum in freefeeding lactating rats and age-matched virgin females. Retroperitoneal and parametrial fat pads weights were obtained from the same females. In the second experiment the same measures, together with plasma insulin and prolactin levels, were taken on Days 15 and 20 postpartum from galactophore-cut and sham-operated females. In Experiments 3 and 4, the effects of exogenous leptin administration, either subcutaneously (sc) or intracerebroventricularly (icv), on lactational anovulation, maternal food intake, and dam and litter weights were examined. Circulating leptin levels decreased in lactating rats. Leptin levels were highly positively correlated with fat pad weight. Eliminating the energetic costs of lactation by preventing milk delivery induced dramatic increases in plasma leptin and insulin levels and also increased adiposity. Exogenous leptin administration did not affect length of lactational anovulation but reduced food intake, maternal body weight, and litter weight gain when given centrally and maternal body weight when given systemically. Together, these data show that the energetic costs of lactation are associated with a fall in circulating leptin levels but that these do not make a major contribution to the suppression of reproduction in lactating rats; however, they may be permissive to the hyperphagia of lactation.     

Nursing behaviour and its relation to duration of post-partum amenorrhoea in an Andean community

Nu?oa is a high altitude rural Peruvian community characterized by socioeconomic stratification and differential access to the market economy. Nursing practices and the effects of nursing are also stratified; this translates into a risk of menses at 12 months post-partum nearly seven times greater in wealthier than in poorer women. Most nursing occurs in the morning, among those who practice on-demand breast-feeding. Nursing episodes are clustered into sessions; the amount of breast-feeding is regulated by varying the number of episodes per session rather than by changing the duration of suckling episodes or the frequency of sessions per hour. Thus, resumption of ovulation is not dependent on the variable spacing of nursing episodes or sessions. The components of nursing activity most likely to be responsible for variation in the duration of post-partum amenorrhoea in these nursing women are mean session duration and mean number of episodes per session. The mean duration of morning nursing sessions is negatively associated with infant's age, reflecting the greater reliance of younger children on breast-milk. The mean duration of afternoon nursing sessions is positively associated with mother's age, independent of infant's age, possibly reflecting maternal age-related variation in milk production capabilities. Baby minding by older daughters may also help to explain variation in afternoon nursing.     

Fertility transition in Bangladesh: understanding the role of the proximate determinants

Bangladesh has been passing through a crucial phase of fertility transition. The level of fertility declined dramatically during the early 1990s without any remarkable improvement in socioeconomic and health status, and then remained constant at a high level of 3.3, despite the increased use of contraception. Such fertility transition can be traced to variations in one or more of the proximate or direct determinants of fertility. This paper critically analyses the fertility levels in Bangladesh with a view to exploring the possible explanations of fertility decline in the 1990s and then its stabilization. The main focus of the study is to examine the role of the major proximate determinants of fertility in bringing about the change in fertility level in Bangladesh. The data for the study come from a series of nationally representative surveys over the period of 1975 to 1999-2000. The analysis indicates that fertility has temporarily ceased to decline in recent years due to the 'tempo' effect of high past fertility, but in general a declining trend in fertility is underway. The analysis suggests that the fall in fertility is consistent with the underlying trends in most important proximate determinants of fertility. In recent years contraception has emerged as the highest fertility reducing factor in Bangladesh and its effect is greatest in middle and older age groups. Although until the early 1990s postpartum lactational infecundability was the most important and strongest fertility reducing factor in Bangladesh, in recent years its fertility inhibiting effect has gradually decreasing owing to the declining trend in the lactational infecundability period. The analysis reveals that although the fertility reducing effect of the marriage pattern is increasing, its effect is offset by the declining trend in the lactational infecundability period. A review of these two variables suggests that their effect cannot be raised much for prevailing socioeconomic and cultural reasons, and any future reduction in fertility in Bangladesh may be largely dependent on increased use of effective birth control methods.     

The recovery of ovarian function during breast-feeding

The pattern of breast-feeding was daily recorded and the serum concentrations of prolactin (PRL), FSH, LH, estradiol (E2) and progesterone (prog) were measured at weekly intervals in 26 breast-feeding mothers from the time of delivery and up to the resumption of regular ovulation or to the end of the first postpartum year. Twelve postpartum non-breast-feeding women were similarly studied as controls. An algorithm was used to characterize ovulatory events into three types: the first, with evidence highly suggestive of normal ovulation (EHSO), the second, with evidence of probable ovulation (EPO) and the third with evidence indicating questionable ovulation or deficient corpus luteum function (QO/DCT). Pregnancy preceded the first menstruation in one woman in each of the breast-feeding and control groups. Of the 19 breast-feeding women who started to menstruate during the first postpartum year, five had EHSO, one had EPO, 5 had EQO/DCL and 7 had anovulatory (AO) menstruation. The corresponding figures in the 11 controls were 6, 2, 3 and 0. Pregnancy occurred before a second menstruation in one woman in both the study group and the controls. In 18 breast-feeding women observed, the second menstruation was preceded by EHSO in 7, by EPO in 3, by EQO/DCL in one and AO in 7. In 10 controls the corresponding figures were 7, 3, 0 and 0. Out of a total of 79 menstruations observed during breast-feeding the incidence of AO was 30% and of QO/DCL was 15%. In actively breast-feeding mothers, hyperprolactinemia persisted for more than 1 yr. However, menstruation and ovulation occasionally occurred before the drop of PRL to concentrations seen during the normal menstrual cycle. In the majority of women, low E2 levels were present during lactational amenorrhea, but with occasional spikes in some. A few women maintained somewhat high values of E2 for several weeks before the resumption of menstruation. The implications of these hormonal findings to the attempts to improve on the contraceptive effect of breast-feeding are discussed.     

The effect of initiation of child supplementation on resumption of post-partum menstruation

The effects of initiation of solid and liquid supplementation on resumption of post-partum menstruation are examined, using data from a 2-year prospective study of birth interval dynamics from central Java, Indonesia. The sample analysed consisted of 444 women who experienced resumption of menses while breast-feeding, women who were breast-feeding and amenorrhoeic at the end of the study, or women who resumed menstruation or were censored after infant mortality and weaning which preceded the resumption of menses. Multivariate hazard model analysis was used to assess the significance of supplementation, various breast-feeding covariates, and age and parity of the dependent variable. Because the timing of supplementation varies, the supplementation variables were introduced into the analysis as time-varying covariates. For the mothers in the sample, solid and liquid supplementation was initiated at medians of 2.1 and 8.0 months respectively. The former had a significant effect on resumption of menses, while the latter was only marginally significant. Earlier supplementation meant shorter durations of amenorrhoea for the majority of women. However, the effect was not consistent across all categories of women. For the small group of mothers who were low intensity breast-feeders (less than or equal to 6 minutes per nursing episode) or as low frequency day-time breast-feeders (less than or equal to 6 nursing episodes per day-time), earlier supplementation had no additional effect on their rate of resumption of menses post-partum.     

High lactation index is associated with insulin sensitivity

The aim of the study was to evaluate the contribution of lactation to insulin sensitivity in women 12 to 18 month postpartum using an oral glucose tolerance test (OGTT). Mean lactation index (LI), a scoring system that considers the establishment and maintenance of the lactation was used. Lactation index was calculated according to the number of months of breast-feeding per child with a maximum of 72 points. The mean LI was calculated by dividing the total number of points by the number of children. A cutoff point of 72 was considered for the LI. We investigated the inverse of the homeostasis model assessment (HOMA_Sens) and the Cederholm index. Healthy women went through standardized interview and anthropometry. After a 10- to 12-h overnight fast, a 2-h OGTT was performed. Multiple regression analysis was performed with HOMA_Sens and Cederholm index, which were adjusted for parity, percentage body fat, LI and presence/absence of breast-feeding. Both HOMA_Sens and Cederholm index were negatively associated with percentage body fat (P<.01), and Cederholm index was positively associated with LI (P=.01). Mean 120-min insulin levels were significantly lower in women with LI=72 when compared with LI<72 women. Insulin sensitivity measured by the Cederholm index is positively associated with prolonged and sustained lactation, while percentage body fat presented a negative association. In this way, sustained lactation-associated metabolic changes are considered protective to women's health.