A hazards model analysis of breastfeeding variables and maternal age on return to menses postpartum in rural Indonesian women

There is mounting research evidence that the duration of lactational amenorrhea is dependent on the infant's suckling input. Multivariate techniques, including the proportional hazards model, offer an effective methodological approach for sorting through the variables that contribute to a process as complex as breastfeeding. This approach was utilized on a sample of 382 mothers who participated in the Ngaglik Study, a longitudinal investigation of maternal health and nutrition, infant development, child spacing, and fertility trends in Central Java, Indonesia. 3 primary breastfeeding variables--average number of nursing episodes during the day, average number of nursing episodes during the night, and average minutes per episode--were obtained from monthly interviews with study subjects, 260 of whom experienced return to menses while breastfeeding. The mean and median durations of amenorrhea were 17.3 and 16.4 months, respectively. The reported total number of suckling bouts per 24 hours averaged 8.85, with an average of 8.23 minutes per nursing episode. Amenorrhea duration ranged from 19.2 months in mothers who nursed 6 or more times during the day-time hours to 12.2 months in mothers who nursed an average of 6 minutes or less per episode. The variable of minutes per nursing bout has the greatest effect on return to menses, while the average number of day-time feeds has the least; the number of night-time feeds is intermediate. When age was introduced into the model, the effects of the nursing variables on return of menses remained constant relative to 1 another but the increment in the risk of menstruating increased with younger age. In summary, this analysis indicates that low intensity breastfeeding with 3 or fewer episodes reported at night, 6 or fewer episodes reported for the day, 6 or less minutes reported per nursing episode, and younger age all increase the risk of early postpartum resumption of menses.     

A biobehavioral model for breastfeeding effects on return to menses postpartum in Javanese women

Abstract

This paper examines the effects of nursing behavior on the duration of lactation amenorrhea in 382 rural Indonesian women who experienced resumption of menses while breastfeeding or were breastfeeding and amenorrheic at the end of a two‐year prospective study. Three primary breastfeeding variables (number of night‐time nursing bouts, number of day‐time nursing bouts, and minutes per bout) were used to develop a behavioral model for breastfeeding. Four breastfeeding patterns were identified for these women. These were designated as: (1) low intensity, (2) medium‐low intensity, (3) medium‐high intensity, and (4) high intensity breastfeeding behavior. Menses resumed at medians of 11.2,16.0,17.6, and 20.8 months, respectively, for these groups. The relationships among the breastfeeding variables in the behavioral model and return to menses were developed and tested by life table and proportional hazards models. Ten per cent of the high intensity breastfeeding group (6 women) delayed menses between 33 and 52 weeks, while 90 per cent (56 women) postponed return of menses for over one year.     

Maternal vitamin D intake and mineral metabolism in mothers and their newborn infants.

Pregnant women receiving daily supplements of 400 IU (10 microgram) of vitamin D2 from the 12th week of pregnancy had plasma calcium concentrations higher at 24 weeks but similar at delivery to those in control pregnant women who did not receive the supplements. Infants of the women receiving the supplements had higher calcium, lower phosphorus, and similar magnesium concentrations on the sixth day of life and a lower incidence of hypocalcaemia than infants of the control women. Plasma concentrations of 25-hydroxycholecalciferol, which showed a seasonal variation, were higher in mothers and infants in the treated group. Cord-blood calcium, magnesium, phosphorus, and 25-hydroxycholecalciferol concentrations correlated with maternal values at delivery. Breast-fed infants had higher calcium and magnesium and lower phosphorus and 25-hydroxycholecalciferol concentrations than artificially fed infants. A defect of dental enamel was found in a high proportion of infants (many of whom had suffered from hypocalcaemia) born to the control women. These results suggest that vitamin D supplementation during pregnancy would be beneficial for mothers, whose intake from diet and skin synthesis is appreciably less than 500 IU of vitamin D daily.     

Nutrition, infant feeding and post-partum amenorrhoea in rural Bangladesh

The extent to which differences in the duration of postpartum amenorrhea among chronically malnourished women in rural Bangladesh are related to seasonal patterns of food supply, maternal nutrition, education, and patterns of infant feeding was investigated by application of multivariate hazards models with time-varying covariates. The data were derived from the Birth Interval Dynamics study in Matlab and covered close to 1800 births. Parity, education, season of birth, maternal weight, and infant supplementation all were found to affect the duration of postpartum amenorrhea among these women. Education of 5 or more years had a positive effect on the resumption of menses. Higher parity women, who were older, had longer periods of amenorrhea, as did women who gave birth in October-December. As a measure of nutritional status, the woman's weight at pregnancy termination showed a highly significant positive coefficient, indicating that improved maternal nutrition increased the likelihood of resuming menstruation. Food supplementation, which tends to decrease breastfeeding, also significantly increased the risk of resuming menstruation and had an effect independent of the other variables. When the data were analyzed by season, the most striking finding was the strong influence of education on children born during October-December (who are too young to be directly affected by the larger food supply at birth during the harvest season). The other seasons showed weaker effects of education and a stronger effect of supplementation, perhaps because these infants are older during the harvest season and thus can benefit from supplements.     

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.     

Effect of supplementary food on suckling patterns and ovarian activity during lactation.

Patterns of infant feeding, basal prolactin concentrations, and ovarian activity were studied longitudinally in 27 breast-feeding mothers from delivery until first ovulation. Suckling frequency (6.1 feeds/day) and suckling duration (122 mins/day) reached peak values four weeks post partum and remained relatively constant until the introduction of supplementary food at a mean of 16 weeks post partum. There were subsequently sharp declines in both the frequency and duration of suckling, both of which correlated closely with basal prolactin concentrations. None of the 27 mothers ovulated during unsupplemented breast-feeding, but within 16 weeks of introducing supplements ovarian follicular development had returned in 20 and ovulation in 14 mothers. The mothers who ovulated within 16 weeks of giving supplements had reduced frequency and duration of suckling more quickly and weaned more abruptly than those who continued to suppress ovulation. These data suggest that the introduction of supplementary food may exert an important and hitherto unrecognised effect on the timing of first ovulation by reducing the frequency and duration of suckling episodes.     

Diurnal nursing pattern of wild-type European rabbits under natural breeding conditions

The European rabbit Oryctolagus cuniculus is an important model system in the study of mammalian maternal behavior. This is at least partly due to the rabbit's unusually limited pattern of maternal care, characterized by the mother briefly visiting the young to nurse just once approximately every 24 h. In studies of domestic breeds under laboratory conditions it has been found that females show a rather predictable interval between these once-daily visits. However, as there are reports of considerable inter-individual variation, the aim of our study was to identify factors with the potential to modify the rabbit's diurnal pattern of nursing, such as characteristics of the mother, litter size and also potential changes in the nursing interval length during the early postnatal period. We studied the time course of nursing visits in wild-type rabbits in the natural setting of a large field enclosure in order to obtain results unbiased by laboratory artifacts. Using an automatic portable gas analyzer, we monitored the timing of nursing events by recording the change in oxygen concentration within natural breeding burrows occurring when mothers entered to nurse and calculated the interval length between successive nursing events. During the first nine postpartum days, when our study was conducted, rabbit mothers on average showed a nursing interval of about 24 h. Return intervals remained rather constant in mothers of larger litters but decreased in mothers with smaller litters, resulting in them visiting their young to nurse a little earlier each night. Mothers’ age, day length and season did not affect nursing intervals. In conclusion, our study confirms that under natural conditions rabbits nurse their young only once approximately every 24 h, but that this pattern is not completely fixed and can be modulated by litter size, possibly via the strength of sucking stimulation received by the mother during nursing.     

Prepartum peripherally-induced hyposmia does not reduce postpartum anoestrus duration in nursing goats

Parturient goats rapidly develop exclusive nursing of their own litter that relies on olfactory recognition of the young. They also show a period of postpartum anoestrus whose duration depends on the presence of the kid. In cattle, maternal selectivity is one of the factors that delays the recovery of sexual activity. To investigate the possible influence of maternal selectivity on the duration of postpartum anoestrus in goats, we compared the recovery of estrus behavior by daily estrus detection with an active buck in intact and selective nursing goats (n = 24) with that of dams rendered non-selective by peripheral hyposmia with ZnSO4 (n = 18). Postpartum anoestrus duration was shorter in intact (68+/-7 days) than in hyposmic mothers (93+/-7 days; P < 0.05). However, the cycles of normal duration were less frequent in intact goats (P = 0.03). We conclude that in nursing goats, preventing the establishment of selective nursing by prepartum peripheral hyposmia does not reduce postpartum anoestrus duration. Our results suggest that daily exposure to the buck may result in an earlier recovery of ovarian activity in intact mothers.     

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.     

Aetiological approach of female reproductive physiology in lactational amenorrhoea.

The duration of postpartum amenorrhea and return of ovulation varies on an individual and population basis. In 1980, in Senegal, the relationship of chronic malnutrition and female fertility was investigated for 2 years. The stability of the female body regarding weight and arm circumference despite a heavy annual workload was a surprising finding. The mean female body mass index was higher for lactating women in amenorrhea than required for restoring menstruation in European women. The mean duration of postpartum amenorrhea was 18.2 +or- .6 months. The difference between those who resumed menstruation (20.9 +or- .9 months) and who still had amenorrhea (25.4 +or- 2.2 months) was significant. The duration of breast feeding determined the duration of amenorrhea. Studies have found a link between ovarian dysfunction and women in harsh third world environments and sportswomen under intensive training with both showing irregular menstruation and amenorrhea. Long duration of cycles in New Guinean women, high amount of anovulation in Zairian forest women, and suppression of testosterone and estradiol levels in hunter-gatherers were found. In affluent Europeans and urbanized women in developing countries postpartum amenorrhea dropped drastically. Long distance runners are often vegetarians with low calorie consumption and with a high degree of menstrual trouble owing to low body fat and weight-for-height. The role of beta-endorphins in the hypothalamic blockade of the gonadotropin releasing hormone pulse generator and high stress or physical training is proven. The functioning of the hypothalamo-pituitary-ovarian axis can be hurt by intensive training. Short-term fasting also suppressed the pulsatile luteinizing hormone and testosterone secretion. The protocol and methodology of an etiological study is outlined regarding the factors of this hypothesis on amenorrhea.     

Distribution of postpartum amenorrhea in rural Bangladeshi women

Previous studies of postpartum amenorrhea (PPA) demonstrated distinct subgroups of women with short and long durations of amenorrhea. This phenomenon was attributed to cases where breastfeeding is absent because of pregnancy loss or infant death, or confusion of postpartum bleeding with resumption of menses. We explored these ideas using data from an 11-month prospective study in Bangladesh in which 858 women provided twice-weekly interviews and urine specimens for up to 9 months; 300 women were observed while experiencing PPA. The resulting exact, interval-censored, or right-censored durations were used to estimate parameters of two-component mixture models. A mixture of two Weibull distributions provided the best fit to the observations. The long-duration subgroup made up 84% (+/- 4% SE) of the population, with a mean duration of 457 (+/- 31) days. The short-duration subgroup had a mean duration of 94 (+/- 17) days. Three covariates were associated with the duration of PPA: women whose husbands had high-wage employment had a greater probability of falling in the short-duration subgroup; women in the long-duration subgroup whose husbands seasonally migrated had shorter periods of PPA within the subgroup; and mothers in the short-duration subgroup who gave birth during the monsoon season experienced a shortened duration of PPA within the subgroup. We conclude that the bimodal distribution of PPA reflects biological or behavioral heterogeneity rather than shortcomings of data collection.     

Dietary protein energy supplementation of pregnant Asian mothers at Sorrento,Birmingham. II: Selective during third trimester only.

Unselective dietary protein energy supplementation of Asian mothers at Sorrento Maternity Hospital did not enhance intrauterine growth. The effect of selective supplementation was therefore studied. Forty-five mothers who at 28 weeks were known to be nutritionally at risk (triceps increment less than or equal to 20 microns/week between 18 and 28 weeks) received one of three supplements during the third trimester: (a) vitamins only--a multivitamin sachet daily containing vitamins A, B, C, and D; (b) energy--42-125 MJ (10 000-30 000 kcal), all from carbohydrate, plus vitamins; (c) protein energy--energy and vitamins as before, but with 5-10% of energy from milk protein. Eighty-three mothers regarded as adequately nourished at 28 weeks also received one of the three supplements. In the nutritionally at-risk mothers the protein energy supplement was associated with a heavier crude birth weight and heavier weight for gestational age. Supplementation did not lead to improved intrauterine growth in those mothers who were adequately nourished. The differential effect of supplementation depending on the mothers'' nutritional state during the second trimester may explain apparently conflicting results of other studies where some have shown a substantial effect of supplementation and others only a small effect. This effect of intervention is further evidence that "poor nutrition" contributes to poor intrauterine growth in selected mothers, even in developed countries.     

The ontogeny of nursing in Babyrousa babyrussa and a comparison with domestic pigs

The nursing behavior of eight babirusa (Babyrousa babyrussa) infants was studied. Four were from single births and four were from twin births. The age at weaning, the time of day and number of nursing bouts per day, the mean duration of nursing bouts, and whether the offspring or the dam ended nursing bouts were all examined. It was found that although twins are weaned earlier than single offspring, there were no other statistically significant differences in nursing behavior of single and twin offspring. The ontogeny of nursing behavior in this species is described and some comparisons are made between the nursing behavior of babirusa and nursing in the domestic pig (Sus scrofa) and selected suids. Babirusa dams take longer to wean their offspring, allow them to nurse longer, and end nursing bouts less often than domestic pigs. The differences in behavior between babirusa and domestic pig nursing behavior may be related to differences in the number of offspring produced by the two species and the amount of parental investment in each offspring. Zoo Biol 19:253–262, 2000. © 2000 Wiley‐Liss, Inc.     

Daily supplementation with iron increases lipid peroxidation in young women with low iron stores

The aim of this study was to determine whether women with low iron stores (plasma ferritin 相似文献   

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.     

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.     

Prevalence of periconceptional folic acid use and perceived barriers to the postgestation continuance of supplemental folic acid: survey results from a Teratogen Information Service

BACKGROUND: Fewer than 40% of U.S. women are taking folic acid supplements periconceptionally at a time when the risk of neural tube defects (NTDs) can be reduced by supplementation. A better understanding of the vitamin-taking habits of childbearing-age women and effective methods for improving periconceptional supplement use are needed. METHODS: A telephone survey conducted through the California Teratogen Information Service (TIS) between August 2003 and January 2004 assessed the prevalence and characteristics of pregnant callers who did not use folic acid supplements in the periconceptional period, and explored attitudes toward advice to continue vitamin use following pregnancy in order to be protected in a future pregnancy. RESULTS: A total of 327 pregnant women who called the TIS for information agreed to participate in the survey. More than half (53.2%) were not taking folic acid-containing supplements in the periconceptional period. Predictors of lack of use included a higher prepregnancy body mass index, younger maternal age, non-white race/ethnicity, lower education level, and unplanned pregnancy. One-quarter of the women said they would be willing to continue taking vitamins after the pregnancy if advised to do so by a physician. The remainder identified obstacles to following that advice--notably, not planning to become pregnant again and the belief that enough folate is derived from diet alone. CONCLUSIONS: More than half of the callers to the TIS were not compliant with recommendations regarding periconceptional folic acid supplementation. This represents an opportunity for TIS specialists and physicians to intervene in a current pregnancy to encourage maintenance of supplement use in the subsequent interpregnancy interval.     

Brief description of WHO protocol for data collection.

WHO Simplified Methodology (1987) is being applied in several studies: the Task Force on Methods for the Natural Regulation of Fertility of the Special Program on Human Reproduction in centers in Chendu, China; Guatemala City, Guatemala; New Delhi, India; Sagamu, Nigeria; Santiago, Chile; Uppsala, Sweden; and Westmead/Sydney, Australia. 550 lactating mothers who can read and write were examined in order to provide a better understanding of the relationship between breast-feeding duration and lactational amenorrhea, and to determine whether the longitudinal study results are applicable to the general population. Protocol involved data collection of breast-feeding frequency, timing, and duration; supplementary feeding characteristics and timing; and maternal and infant health. WHO protocol is also being examined in studies in Colombo, Sri Lanka, and Sagamu, Nigeria. The study objective was to examine the effect of maternal nutritional supplementation with skimmed milk powder in Colombo and a high protein biscuit in Sagamu on the duration of lactational amenorrhea in moderately malnourished breast-feeding mothers. Followup studies are expected. Optimally, the end product should be a measure of the presence of ovulation, however, the logistics prevented this from occurring. Instead, weekly urine samples were collected and tested for the presence of estrogen and pregnanediol glucuronide. Motivation is a key determinant in the success of these projects, since detailed record keeping over a prolonged period of time is required. Motivational interventions vary between centers and may involve social contact with investigators or health care support for the mother and infant. Some preliminary results indicate that the higher the percentage receiving supplementation, the earlier the return of the menses.