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.     

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.     

Is Maternal Psychopathology Related to Obesigenic Feeding Practices at 1 Year?

Objective: To investigate the relationship between maternal psychopathological symptomatology during pregnancy and at 6 and 12 months postnatally and maternal use of controlling and restrictive feeding practices at 1 year. Research Methods and Procedures: Eighty‐seven women completed a measure of psychological distress during pregnancy and at 6 and 12 months postpartum, and at 12 months postnatally these women reported their usage of controlling and restrictive feeding practices and were observed feeding their infants. Results: General psychological distress, particularly anxious psychopathology, during pregnancy and at 6 and 12 months postnatally was significantly associated with maternal use of restrictive feeding practices at 1 year, even when controlling for length of breast‐feeding and the infants’ weights at 1 year. Contrary to expectations, depression and eating psychopathology as measured by the SCOFF eating disorder measure during pregnancy or at 6 or 12 months postnatally were not associated with the use of controlling or restrictive feeding practices at 1 year. Discussion: These findings indicate that anxious maternal psychopathology may partially explain the development of maternal use of restriction when feeding.     

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.     

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.     

Lactational amenorrhoea in well-nourished Toba women of Formosa, Argentina

The proximate causes of the contraceptive effect of lactation are still a matter of productive debate. This study sought to disentangle the relative impact that intense breast-feeding practices and maternal nutrition have on the regulation of ovarian function in nursing women. A mixed-longitudinal, direct-observational, prospective study was conducted of the return to postpartum fecundity in 113 breast-feeding, well-nourished Toba women. A sub-sample of 70 women provided data on nursing behaviour, daily activities, diet quality and urinary levels of oestrone and progesterone metabolites. Well-nourished, intensively breast-feeding Toba women experienced a relatively short period of lactational amenorrhoea (10.2 +/- 4.3 months) and a high lifetime fertility (TFR=6.7 live births/woman). Duration of lactational amenorrhoea was not correlated with any of the nursing parameters under study or with static measures of maternal nutritional status. The results indicated that the pattern of resumption of postpartum fertility could be explained, at least partly, by differences in individual metabolic budgets. Toba women resumed postpartum ovulation after a period of sustained positive energy balance. As the relative metabolic load hypothesis suggests, the variable effect of lactation on postpartum fertility may not depend on the intensity of nursing per se but rather on the energetic stress that lactation represents for the individual mother.     

Determinants of natural fertility in Sudan

The population of Sudan (North) is at a very early stage of fertility transition and experiences high, stable fertility at a close to natural level. The high observed fertility is found to be a function of the high proportion of married women and ineffective contraceptive procedures. The data used in this study were drawn from the 1979 Sudan Fertility Survey (SUDFS), in which 3115 ever-married women 50 years old from 12,028 households were interviewed. 90% of Sudanese women breast fed for at least 6 months and 80% for at least 12. The main inhibitor of fertility is perceived to be lactational amenorrhea averaging about 11.8 months, which is reported to be high, although among younger women the duration of amenorrhea is shorter due to earlier introduction of supplementary foods. An average of 5.2 months of postpartum sexual abstinence is evidenced, but this is shorter than the period of amennorhea, and therefore has no effect on the birth interval. Neither does marital instability or mean length of separation, which are both close to nonexistent. Sudanese women are comparatively very infecund. 22% gave birth within the 1st year of marriage, 62% within the 2nd, and 83% the 3rd. The proportion of ever-users of contraception is high (e.g. 15.4% among the 25-34 among category), but current use was low (8.1% for the same). The use of contraception is responsible for a reduction of 4.2% of the fertility per married woman. The duration of temporary separation between spouses, due to temporary or seasonal migration of husbands, and the pathological causes of high primary sterility, which contribute to the low fecundability, need further investigation.     

Variability of breast sucking, associated milk transfer and the duration of lactational amenorrhoea.

Quantitative relationships between physical parameters of sucking, milk transfer and the duration of amenorrhoea were examined in normal mother-baby pairs under exclusive breastfeeding. Sucking pressures were recorded twice on the second and once on the fifth month after birth, during complete breastfeeding episodes, by means of a catheter attached to the nipple and connected to a pressure transducer, the signals of which were analysed by computer. Babies were weighed before and after each sucking episode to estimate milk transfer. In the first nursing episode after noon, 2-month-old babies sucked from 140 to > 800 times during 4-15 min from the first breast, obtaining from 20 to > 100 g milk. The physical parameters of sucking and milk transfer exhibited high inter-individual but low intra-individual variabilities. There were significant differences in the physical parameters of sucking and milk transfer efficiency between first and second breast and between the second and fifth months after birth. Milk transfer efficiency was inversely correlated with time occupied by non-sucking pauses > or = 1.5 s, and was directly correlated with mean intersuck intervals in the first breast and with duration of the sucking episode, number of sucks, mean pressure and area under the pressure curve in the second breast. There was no correlation between the physical parameters of sucking and duration of lactational amenorrhoea (n = 62). However, significantly more mothers had amenorrhoea lasting > 180 days among those whose babies spent a longer proportion of the nursing episode in non-sucking pauses > or = 1.5 s. This finding indicates that sensory stimulation of the nipple produced during a nursing episode by stimuli other than sucking itself may have an important role in sustaining lactational amenorrhoea. It is concluded that nursing episodes have a complex structure that allows the development of a breastfeeding phenotype in each mother-baby pair, exhibiting important inter-individual variability. The present analysis does not support the contention that this source of variability accounts for the variability in the duration of lactational amenorrhoea.     

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.     

Vaginal rings for contraception in lactating women

Contraceptive methods for breastfeeding women should be safe for the mother and infant and should not interfere with lactation. Progestin-only methods meet these conditions and can be used from the sixth week postpartum. Because all progestins are excreted in milk, those that are insufficiently active by the oral route are preferable to avoid any possible effect on the baby. These steroids, however, must be administered to the mother by a non-oral route. Initially, progesterone was administered subdermally to test this concept. Subsequently, a progesterone vaginal ring was developed to be used continuously for 3 to 4 months and replaced with a new device, as needed, until weaning. Clinical trials have shown a high contraceptive efficacy (over 98.5%) and safety. The gross continuation rate of this method is approximately 40% at 12 months of use, with use-related problems being the main reason for discontinuation (26.8%). Currently, a Nestorone vaginal ring is under development, delivering 50 microg of Nestorone per day. It may be used continuously for up to one year, even if weaning occurs earlier. Both of these progestin-only rings prolong lactational amenorrhea to 10 to 12 months, which represents a health benefit and convenience for many women. The registration of the progesterone vaginal ring, developed as a contraceptive method to be used exclusively during lactation, has been approved in Chile and Perú. The fact that it is a user-controlled long-term contraceptive that delivers a natural hormone makes it an attractive option for many women.     

Comparing the effectiveness of copper intrauterine devices available in Canada. Is FlexiT non-inferior to NovaT when inserted immediately after first-trimester abortion? Study protocol for a randomized controlled trial

ABSTRACT: BACKGROUND: We describe the rationale and protocol for a randomized noninferiority controlled trial (RCT) to determine if the Flexi-T380(+) copper intrauterine contraceptive device (IUD) is comparable in terms of effectiveness and expulsion rates to the most common Canadian IUD currently in use, NovaT-200, when placed immediately after a first-trimester abortion. METHODS: Consenting women choosing to use an IUD after an abortion for a pregnancy of less than 12 weeks of gestation will be randomized to device-type groups to receive immediate post-abortion placement of either a Flexi-T380(+) IUD, a device for which no current evidence on expulsion or effectiveness rates is available, or the Nova-T200 IUD, the only other brand of copper IUD available in Canada at the time of study initiation. The primary outcome measure is IUD expulsion rate at 1 year. Secondary outcomes include: pregnancy rate, method continuation rate, complication rates (infection, perforation), and satisfaction with contraceptive method. A non-intervention group of consenting women choosing a range of other post-abortion contraception methods, including no contraception, will be included for comparison of secondary outcomes. Web-based contraception satisfaction questionnaires, clinical records, and government-linked health administrative databases will be used to assess primary and secondary outcomes. DISCUSSION: The RCT design, combined with access to clinical records at all provincial abortion clinics, and to information in provincial single-payer linked administrative health databases, birth registry, and hospital records, offers a unique opportunity to determine if a novel IUD has a comparable expulsion rate to that of the current standard IUD in Canada, in addition to the first opportunity to determine pregnancy rate and method satisfaction at 1 year post-abortion for women choosing a range of post-abortion contraceptive options. We highlight considerations of design, implementation, and evaluation of the first trial to provide rigorous evidence for the effectiveness of current Canadian IUDs when inserted after first-trimester abortion.Trial registrationClinicalTrials.gov Identifier NCT01174225.     

Breast-feeding patterns, maternal milk output and lactational infecundity.

Breast feeding can serve as a contraceptive up to 6 months after birth with 98% effectiveness. The so-called suckling reflex arc is a sensitive mechanism conveying messages about nutritional needs of the child, stimulating the release of prolactin responsible for milk production, suppressing ovarian activity by hypothalamic beta-endorphin production leading to reduction in the pulsatile release of gonadotrophic hormones. Increased suckling produces more milk, but only in well-fed women. In Bangladesh, malnourished children required more suckling time than better-fed infants. Increasing the amounts of weaning food lowers feed urgency and suckling intensity thereby relaxing ovarian suppression. Breast-milk consumption can be measured by test weighing the infant before and after feeding, but it is subject to error, especially in developing countries where up to 20 feeds are required to deliver 800 ml of milk. Thus, weighing over 2-5 days is more accurate. The method of giving deuterium oxide tracer to the mother, and measuring its disappearance from the mother's milk and the infant's saliva for 2 weeks is precise and noninvasive. The Doppler ultrasound technique measures milk flow through an artificial teat for research purposes. Manual or mechanical pump measurement of milk transfer separates the mother from the child, thus it is not useful for normal conditions. It can be used for estimating the amount of milk left and the rate of milk secretion by using a breast pump along with oxytocin for full emptying of milk. Accurate estimation of suckling intensity and milk transfer is essential for the determination of the relationship of breast feeding and lactational infecundity.     

Correlates and implications of breast-feeding practices in Bas Zaire

A sample of 1871 women having a child under 3 years old in Bas Zaire was studied to determine the correlates of breastfeeding practices and to examine the interrelationships among breastfeeding, contraceptive practices and desire for pregnancy. The methods of analysis applied were life table analysis and its multivariate extensions. Most of the findings in this analysis are consistent with current literature on the correlates of the duration of breastfeeding. Maternal education, economic status, age, parity, urban residence, pregnancy, and sex of the index child were significantly related to the length of breastfeeding. Among non-pregnant women, current desire for pregnancy was also related to breastfeeding status when the length of time since birth of the last child was taken into consideration. Rural women were reportedly ready for another pregnancy sooner after the birth of their last child than were urban women. Breastfeeding appears to be the most important means of contraceptive protection in the study population. The effective traditional method of extended postpartum abstinence is not widely prevalent, particularly among the urban sample, and indeed seems to be on the decline. The data presented here also suggest that breastfeeding pratices are changing in this area of Africa where little economic development has occurred in the past 20 years. This research suggests that if current trends continue, fertility levels are likely to increase significantly. The findings also indicate that Bas Zairian mothers want to space their births and for this reason may be receptive to family planning programs that use appropriate strategies.     

Fine needle aspiration of benign and malignant breast masses associated with pregnancy.

Of 1,612 fine needle aspirates (FNA) of breast lesions performed over a seven-year period, 25 cases (1.5%) were identified as breast masses associated with pregnancy. Patients ranged in age from 16 to 46 years, with a mean of 27. Gestational age at the time of FNA ranged from three months to three months postpartum or following breast-feeding. Cytologic diagnoses of these pregnancy-associated breast masses were: galactocele (5 cases, 20%), lactating adenoma (9 cases, 36%), fibroadenoma with lactational change (7 cases, 28%), juvenile fibroadenoma with lactational change (1 case, 4%), atypical reactive duct cells with lactational change (1 case, 4%) and infiltrating duct carcinoma (2 cases, 8%). The degree of lactational change varied proportionately with gestational age. None of the 22 patients with benign cytologic diagnoses of galactocele, lactating adenoma or fibroadenoma subsequently developed carcinoma. The mean clinical follow-up for these 22 patients was 27 months. Three cases of fibroadenoma and the case of juvenile fibroadenoma were confirmed by surgical excision. Biopsy of the lesion cytologically diagnosed as atypical reactive duct cells with lactational change revealed infiltrating duct carcinoma (IDC). All three patients with IDC had involvement of multiple axillary lymph nodes, and 1 patient had widely metastatic disease. In two cases of IDC the background lactational breast epithelium exhibited marked cytologic atypia that closely resembled the IDC. Pregnancy-related cellular atypia potentially results in a false-positive diagnosis of breast carcinoma on FNA. FNA is useful in distinguishing benign breast masses of pregnancy from those with marked cytologic atypia requiring surgical biopsy and may minimize the delayed diagnosis of carcinoma associated with pregnancy.     

When ancient meets modern: the relationship between postpartum non-susceptibility and contraception in sub-Saharan Africa

Extended durations of postpartum non-susceptibility (PPNS) comprising lactational amenorrhoea and associated taboos on sex have been a central component of traditional reproductive regimes in sub-Saharan Africa. In situations of rising contraceptive prevalence this paper draws on data from the Demographic Health Surveys to consider the neglected interface between ancient and modern methods of regulation. The analysis reports striking contrasts between countries. At one extreme a woman's natural susceptibility status appears to have little bearing on the decision to use contraception in Zimbabwe, with widespread 'double-protection'. By contrast, contraceptive use in Kenya and Ghana builds directly onto underlying patterns of PPNS. Possible explanations for the differences and the implications for theory and policy are discussed.     

Use of periodic abstinence in Bangladesh: do they really understand?

Data from a nationally representative study in Bangladesh (BDHS 1996-97) were analysed to identify significant predictors of use of periodic abstinence, in comparison with other modern contraceptive methods. The study found that women in Bangladesh mostly use modern methods during their peak reproductive years, after which some of them switch to periodic abstinence. These women tend to be more from educated and from higher socioeconomic backgrounds and with at least one living son. Another set of data from the Matlab DSS was analysed and the results were in the same direction. Focus group discussions found that women were using the periodic abstinence method incorrectly, abstaining for more days than is necessary. For Bangladeshi contraceptive users to reach a higher degree of use-effectiveness for period abstinence, more IEC materials need to be developed.     

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.     

Formula feeding can help illuminate long-term consequences of full ectogenesis

Breastfeeding is analogous to pregnancy as an experience, in its exclusiveness to women, and in its cost and the effects it has on equitable share of labor. Therefore, the history of formula feeding provides useful insights into the future of full ectogenesis, which could evolve into a more severe version of what formula feeding is today: simplify life for some women and provide couples with a more equitable share of work at the cost of stigma, guilt and a daily diet of studies purporting to show the benefits of natural pregnancy. Making pregnancy an optional route to motherhood would make women's life trajectory more similar to men's and thus put pressure on women to compete with men on the ground shaped by men's preferences. Despite being a treasured experience of many women today, bearing children could become the luxury of the few, the province of the very poor and a choice working women will pay a high price for as women who choose pregnancy become stigmatized as self-indulgent or unprofessional and penalized for it in the workplace. At the same time, scarce societal resources that could be used to support pregnant women and working mothers would instead be directed toward proving to women or even forcing them to gestate children “the right way.” While not necessarily threatening on its own, when added to formula feeding, IVF, stem-cell produced ova and sex robots, full ectogenesis could diminish men's stake in women's wellbeing and even existence.     

Maternal Obesity and Breast‐feeding Practices Among White and Black Women

Despite the increase in obesity among women of reproductive ages, few studies have considered maternal obesity as a risk factor for breast‐feeding success. We tested the hypothesis that women who are obese (BMI = 30–34.9) and very obese (BMI ≥35) before pregnancy are less likely to initiate and maintain breast‐feeding than are their normal‐weight counterparts (BMI = 18.5–24.9) among white and black women. Data from 2000 to 2005 South Carolina Pregnancy Risk Assessment Monitoring System (PRAMS) were used. The overall response rate was 71.0%; there were 3,517 white and 2,846 black respondents. Black women were less likely to initiate breast‐feeding and breast‐fed their babies for a shorter duration than white women. Compared to normal‐weight white women, very obese white women were less likely to initiate breast‐feeding (odds ratio: 0.63; 95% confidence interval (CI) = 0.42, 0.94) and more likely to discontinue breast‐feeding within the first 6 months (hazard ratio (HR) = 1.89; 95% CI: 1.39, 2.58). Among black women, prepregnancy BMI was neither associated with breast‐feeding initiation nor with breast‐feeding continuation within the first 6 months. Because very obese white women are less likely to initiate or continue breast‐feeding than other white women, health professionals should be aware that very obese white women need additional breast‐feeding support. Lower rates of breast‐feeding among black women suggest that they should continue to be the focus of the programs and policies aimed at breast‐feeding promotion in the United States.     

Sequence of events following adoption of contraception: An exploratory analysis of 1973 fertility history data

Abstract

Fertility histories from the 1973 United States National Survey of Family Growth are analyzed in the context of a model of contraceptive use based on a Semi‐Markov processes. This model provides a means of constructing data‐based estimates of probabilities of pregnancy following initial acceptance of a contraceptive method. The algorithm used to construct these estimates recognizes multiple intervals of contraceptive used prior to the events: pregnancy, marital dissolution, or sterilization.

Estimated probabilities of the events marital dissolution and pregnancy for women seeking to delay pregnancy are presented, as are probabilities of contraceptive sterilization for women seeking to prevent subsequent pregnancy. These estimates are compared to one‐step transition probabilities and directly observed NSFG data on pregnancy, marital dissolution, or contraceptive sterilization in an attempt to judge the validity of the model and to assess biases which may result from its use.