Articles in the Update series Les articles de la rubriquegive a concise, authoritative. Le point fournissent unand up-to-date survey of the bilan concis et fiable de lapresent position in the se- situation actuelle dans le
puale , , lected fields, and, over a domaine considere. Des ex-/ / / &~~~~~~~eriodof years, will cover / perts couvriront ainsi suc- /many different aspects oJf cessivement de nombreuxthe biomedical sciences aspects des sciences bio-
/ n{>},/Vll gf ( / and public health. Most oJf mddicales et de la sant /the articles will be writ- publique. La plupart de cesten, by invitation, bY ac- articles auront donc eteknowledged experts on the rediges sur demande par lessubject. specialistes les plus autorises.
Breast-feeding and fertility regulation: currentknowledge and programme policy implications*
A WHO/NRC MEETING
Lactational anovulation associated with amenorrhoea resulting from exclusivebreast-feeding represents an important child-spacing mechanism in many ThirdWorld countries. This is because frequent stimulation of the nipple during breast-feeding produces neural inhibition of the hypothalamus, diminished secretion ofpituitary gonadotropin, and inhibition of ovulation and menstruation.
In places where contraceptive services are available, care should be taken torationalize the use of contraceptive methods together with the lactation-inducedinhibition of ovulation. If prolonged breast-feeding is likely, the early use ofcontraceptives may constitute unnecessary double protection; however, in caseswhere contraception is discontinued and lactation has been reduced or terminated,the mother may be placed at a higher-than-normal risk of becoming pregnant;attention must be given to the type ofcontraceptive method chosen, as well as to thetiming of its introduction. Combined oral contraceptives reduce the volume of milkand may interfere with lactation. However, neither hormonal nor non-hormonalcontraceptive preparations appear to interfere with initiation of milk production.
A consistent policy on lactation and fertility regulation is lacking in manycountries. Policies should be developed according to the national health needs andcircumstances, including local patterns of breast-feeding and weaning, and theduration of lactational anovulation/amenorrhoea. National guidelines shouldinclude the promotion of breast-feeding for at least four months, continuation ofbreast-feeding after supplementaryfoods have been introduced, legislative and socialsupportfor breast-feeding, and preference for non-hormonal contraception duringthe first 4-6 months post-partum.
During the past few years, there has been a rapid increase in knowledge about therelationship of breast-feeding and suckling practices to reproductive function, and aboutthe social and health consequences of unregulated fertility and close birth-spacing onmothers, the family and the community. The steady decline in breast-feeding presents asignificant hazard to infant health, particularly in the developing countries. The main-tenance of breast-feeding, on the other hand, is known to be conducive to increased birth-
* This article is based on the summary report of thc WHO/NRC Joint Workshop and Programme Policy Meeting on Breast-feeding and Fertility Regulation, sponsored by the Special Programme of Research, Development and Research Training inHuman Reproduction and the Division of Family Health of WHO and the US National Research Council, and held in Geneva inFebruary 1982. Requests for reprints should be addressed to Division of Family Health, World Health Organization, 1211 Geneva27, Switzerland. A French translation of this article will appear in a later issue of the Bulletin.
X A full list of participants is given on pages 380-381.
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372 WHO/NRC MEETING
spacing and although contraceptive techniques are a major factor in reducing fertility, theireffect on the continuation of breast-feeding must also be taken into account. Lactation,nutrition, and fertility are clearly interrelated, and any modification of one may well haveunforeseen and possibly deleterious effects on the others.
CONTRACEPTIVE EFFECTS OF LACTATION
In many developing countries, the contraceptive effect of breast-feeding, more than anyother method of control, promotes the longer spacing of births.a Recent studies haveshown that lactation exerts a strong contraceptive action because frequent stimulation ofthe nipple, during suckling, leads to neural inhibition of the hypothalamus. The conse-quent decrease in pituitary gonadotropin secretion, in turn, inhibits ovulation andpromotes amenorrhoea.b The contraceptive action of breast-feeding is lessened bydecreased suckling frequency; this may be brought about by such practices as scheduledrather than on-demand feedings (in part, occasioned by separation of the baby from themother during the day or night), reduction in night-feeds, introduction of bottle-feeding,and use of "4pacifiers"s.c
Together with the spread of these practices, less attention has been given to the contra-ceptive effect of breast-feeding especially in areas where women breast-feed infrequentlyand provide their infants with bottle-fed supplements, and thus experience early resump-tion of menstruation and ovulation and are at high risk of pregnancy. Fortunately this hasnot thus far become typical of many developing countries, where traditional breast-feedingpractices have continued and where lactational amenorrhoea for 1-2 years, or even longer,is still common.d
Lactational anovulation associated with amenorrhoea is highly effective in preventingconception. Once ovulation occurs, it will in most cases be followed by menstruation.Conception, without prior menstruation, however, does occur in a small proportion ofwomen. The risk of conception is least during the early postpartum months, but studieshave shown that, even after 18 months, no more than 5-10% of women are likely toconceive prior to resumption of menstruation.e Assuming amenorrhoea lasts a year, onaverage, this 5-10% figure may be regarded as an annual failure rate; as such, it is nohigher than the observed annual failure rate associated with oral contraceptives in manydeveloping countries! It should be emphasized, however, that the time of return ofovulation cannot be accurately predicted and that once it has occurred, lactation no longerhas the same contraceptive effect.Any change in breast-feeding practices in the developing world that reduces the present
high incidence and long duration of breast-feeding and the high frequency of suckling islikely to increase fertility. The current situation in Kenya is an example: here the decline inboth duration of breast-feeding and adherence to postpartum abstinence taboos over thepast decades has brought about increased fertility while the adoption of other contracep-
a ROSA, F. Breast-feeding in family planning. PAG Bulletin, 5 (3): 5-10 (1975).b SHORT, R. The biological basis ofthe contraceptive effect ofbreast-feeding. Paper presented at the WHO/NRC Workshop
on Breast-feeding and Fertility Regulation, Geneva, February 1982.c PREMA, K. Effects of variations in breast-feeding practices and sociocultural factors on the return of fertility during
lactation: a review. Paper presented at the WHO/NRC Workshop on Breast-feeding and Fertility Regulation, Geneva, February1982.
d HUFFMAN, S. L. Maternal and child nutritional status: its association with the risk ofpregnancy. Paper presented at theWHO/NRC Workshop on Breast-feeding and Fertility Regulation, Geneva, February 1982.
e BUCHANAN, R. Breast-feeding: aid to infant health and fertility control. Population reports, Series J, No. 4, July 1975.f SIMPSON-HEBERT, M. & HUFFMAN, S. L. The contraceptive effect of breast-feeding. Studies in family planning, 12:
125-133 (1981).
BREAST-FEEDING AND FERTILITY REGULATION 373
tive techniques has failed to keep pace.! As a result of this rise in fertility and coincidentdecline in mortality, Kenya today has one of the highest population growth rates in theworld, i.e., the population will double in approximately 17 years.
If increases in fertility are to be prevented, any decline in breast-feeding must be offset bya comparable increase in the use of contraceptives, especially in countries where breast-feeding is still an important factor. In Bangladesh, for example, if breast-feeding patternswere to change to those typical of industrialized countries, the already high fertility ratescould be expected to rise by over 50%. To maintain fertility at current levels, a more thanfive-fold increase in contraceptive use -from 9% to about 52% (see Table 1)-would berequired.!
IMPACT OF CONTRACEPTIVE METHODS DURING BREAST-FEEDING
Effect on lactation
For populations wherein lactational amenorrhoea and anovulation are prolonged, earlyuse of contraceptive methods frequently has the effect of providing "double coverage"and may not be justified in terms of efforts and resources involved. Furthermore, insituations where contraceptive discontinuation is common, lactating women may well starta hormonal contraceptive method and abandon it about the time their natural lactationalinfertility has waned, thus putting themselves at risk of pregnancy; this would not havehappened had they commenced the contraceptive method later on in lactation. However, insocieties where the duration of amenorrhoea is relatively short, early introduction ofcontraceptives will obviously reduce the risk of conception.
Certain fertility regulating methods are known to influence the quantity and compo-sition of breast milk and the duration of lactation. For example, combined oral contracep-tives that contain as little as 30 iLg of estrogen significantly reduce the volume of milk; h
when used in the first few months of the postpartum period, they can decrease milk volumeby as much as 40% within 3-6 weeks. The concentration of breast-milk constituents isunchanged by combined oral hormonal contraceptives initiated in the first six months.Some progestogen-only hormonal contraceptives, however, are associated with a small butsignificant decrease in total fat.' Although these changes in the quantity and compositionof breast milk have had a small or nonmeasurable impact on the weight gain of infants inthe populations studied, these findings may not be applicable in other situations.
Neither hormonal nor nonhormonal contraceptive preparations have been shown tointerfere with initiation of milk production; however, the duration of lactation is shortenedin a dose-related manner by early implementation of combined oral contraceptives.? Theuse of injectable contraceptives has been associated with increased duration of lactation;the early use of progestogen-only pills and nonhormonal methods has little or no effect onthe duration of lactation.!Nonhormonal contraceptive methods have no effect on either the quantity or compo-
sition of breast milk, with the possible exception that some methods of anaesthesia usedwith sterilization may cause a temporary interruption in lactation. In societies where
g LESTHAEGHE, R. Lactation and lactation-related variables, contraception andfertility: an overview ofdata problems andworld trends. Paper presented at the WHO/NRC Workshop on Breast-feeding and Fertility Regulation, Geneva, February1982.
h KOETSAWANG, S. The effects of contraceptive methods on the quality and quantity of breast milk. Paper presented at theWHO/NRC Workshop on Breast-feeding and Fertility Regulation, Geneva, February 1982.
ZANARTU, J. ET AL. Effects of hormonal and nonhormonal contraceptives on human lactation and re-establishment offertility. Paper presented at the WHO/NRC Workshop on Breastfeeding and Fertility Regulation, Geneva, February 1982.
LAUKARAN, V. H. Effects ofcontraceptives on the initiation and duration oflactation. Paper presented at the WHO/NRCWorkshop on Breast-feeding and Fertility Regulation, Geneva, February 1982.
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Table 1. Use of contraceptives to prevent increased fertility levels due to decreased duration of lactationalamenorrhoea and anovulation to 3 months'
Projecteduse of
Mean contraceptivesMean duration of Current to maintain
Country duration of lactational use of current(year of World breast-feedingb amenorrhoeab contraceptives' birth ratesdFertility Study) (months) (months) (%) (%)
a Adapted from: R. LESTHAEGHE, Lactation and lactation related variables, contraception and fertility: an overview ofdata problems and world trends. Paper presented at the WHO/NRC Workshop on Breast-feeding and Fertility Regulation,Geneva, February 1982.
b Average duration of breast-feeding and amenorrhoea is calculated for mothers with surviving children.c Percentage of married women using any method of contraception (including both efficient and inefficient methods).d Percentage of married women who would need to use contraceptives in order to balance the increase in fertility
resulting from a decrease in the average duration of lactational amenorrhoea and anovulation to 3 months.
lactation is often terminated because of a subsequent pregnancy, contraception initiatedjust before the return of ovulation may actually extend the duration of breast-feeding.k
Effect on infant health
Among breast-feeding mothers using hormonal contraceptives, there is evidence thatabout 0.1% of the maternal dose of certain synthetic estrogens and of most syntheticprogestogens reaches the infant daily.' For most combined oral contraceptives the infant isexposed to nanogram (10- 6 mg) amounts of estrogen and microgram (10- 3 mg) quantitiesof progestogens.m For the newer, high-potency implanted progestogens, the infant isexposed to picogram (10- 9 mg) quantities. These mean levels are very low relative to thequantity of natural sex steroids reaching the infant from either cows' milk or breast milk.Naturally-occurring steroids, however, are rapidly metabolized by the liver in infants incontrast to the longer half-life of synthetic steroids. Infants normally have a brief rise in thecirculating concentrations of testosterone and estrogen in the first four months post-
kThe Danfa Comprehensive Rural Health and Family Planning Project, Ghana. Final report, Accra, University of GhanaMedical School and UCLA School of Public Health, September 1979.
' FOTHERBY, K. Transfer of contraceptive steroids in milk. Paper presented a the WHO/NRC Workshop on Breast-feedingand Fertility Regulation, Geneva, February 1982.
m JOHANSSON, E. D. B. & ODLIND, V. Effects possibly related to breast-milk passage of exogenous hormones or theirmetabolites as additionally affected by maternal and infant nutrition. Paper presented at the WHO/NRC Workshop on Breast-feeding and Fertility Regulation, Geneva, February 1982.
BREAST-FEEDING AND FERTILITY REGULATION 375
partum, which leads to the possibility that one or more organs or systems may be especiallysusceptible to the effects of exogenous sex steroids during this period."
Intrauterine contraceptive devices (IUDs), sterilization, and physical barrier methods(condoms, diaphragms, and cervical caps) have not been shown to affect the health ofbreast-fed infants adversely.
Effect on maternal health
Contraception by sterilization or barrier methods has no adverse effects on the health ofbreast-feeding women. Although the spermicidal agent nonoxinol-9 is absorbed from thevagina, no adverse effects have yet been associated with the use of spermicidal creams orsuppositories.'The potential benefits and risks of hormonal contraceptives and IUDs must be assessed
in relation to physiological and metabolic changes that normally occur in the postpartumperiod and during lactation. The difficulties posed by IUDs relate to the postpartumphysiological state of the uterus and antecedent anaemia. There is little evidence thatlactation, per se, aggravates the situation, since the risk of expulsion or perforation isnormally higher during the postpartum period. The greater blood loss associated with theLippes loop may, in situations where anaemia is common, warrant consideration of alter-native IUDs, a matter that may be less important for lactating women, given that lactationprolongs postpartum amenorrhoea and thereby may reduce the blood loss associated withIUDs. Once lactation ceases, however, an alternative to the Lippes loop might be calledfor.The effects of progestogen-only, oral and injectable contraceptives on lactating women
appear to be no different from those on nonlactating women. However, women withlactational amenorrhoea may experience less bleeding associated with progestogen-onlycontraceptives than do menstruating women.' In a small number of women, seriousmenorrhagia, particularly in association with depot-medroxyprogesterone acetate(DMPA), requires therapy; estrogens are effective in this regard but may affect lactationadversely.'Combined oral contraceptives appear to affect lactating and nonlactating women
similarly. There is a slight increased risk of congestive heart failure in lactating women whohave a pre-existing cardiovascular disease condition, such as chronic rheumatic heartdisease, but it is no greater than that associated with pregnancy in comparable women.'Oral contraceptive use during lactation has been associated in some cases with biochemical(but only infrequently clinical) evidence of riboflavin and pyridoxine deficiency amongwomen who were not previously deficient.' Those already showing biochemical evidenceof deficiency showed no further deterioration. However, pyridoxine deficiency in alactating woman is reflected in her breast milk.
EFFECT OF LACTATION ON MATERNAL AND INFANT HEALTH
The case for breast-feeding in the promotion of infant health is reflected in theresolutions adopted by the World Health Assembly.P Breast-feeding is a critical factor in
nHARLAP, S. Are there long-term health and behavioural consequences of exposure to hormonal contraceptives in breastmilk? Paper presented at the WHO/NRC Workshop on Breast-feeding and Fertility Regulation, Geneva, February 1982.
° BELSEY, M. Contraception during the postpartum period and while lactating: effects on the woman's health. Paperpresented at the WHO/NRC Workshop on Breast-feeding and Fertility Regulation, Geneva, Februrary 1982.
" Resolution WHA27.43 (Infant nutrition and breast-feeding). Resolution WHA31.47 (The role of the health sector in thedevelopment of national and international food and nutrition policies and plans with special reference to combatting malnu-trition). Resolution WHA33.32 (Infant and young childfeeding). Resolution WHA34.22 (International code of marketing ofbreast-milk substitutes).
376 WHO/NRC MEETING
infant nutrition and growth, health and survival; this is especially so in low socioeconomicgroups in developing countries. Among other things, it provides protection against gastro-intestinal and other infections not only in developing countries, but also in highlyindustrialized settings as well.
Available evidence indicates that the energy and protein levels in breast milk are littleaffected by maternal nutritional status; the volume of milk may be reduced, but it isgenerally adequate to maintain infant growth during the first few months.' Most studiesshow that substantial differences in maternal nutritional status account for a difference ofonly a few months or less in the duration of lactational amenorrhoea and are thus of littledemographic importance in terms of natural birth-spacing. Maternal undernutritionduring pregnancy, however, affects birthweight, and low-birthweight babies face a greaterrisk of morbidity and early death.
Milk synthesis and secretion nevertheless involve a considerable nutritional demand onthe mother. Women whose dietary intake is inadequate during pregnancy often havelimited physiological reserves with which to support these additional nutritional demands.However, the available data suggest that although some deterioration in maternalnutritional status may occur if diets during pregnancy and lactation are inadequate,adaptive mechanisms appear to increase the efficiency of food utilization and preventmarked deterioration in maternal nutritional status as assessed by anthropometric indices.rMalnourished women often succeed in producing viable, albeit smaller, babies and inbreast-feeding them successfully.
PROGRAMME POLICY IMPLICATIONS
In many countries, there are no consistent policies on lactation and fertility regulation.Given the scientific evidence presented at the workshop, it is clear that maternal and childhealth and family planning policies should be more closely integrated. Thus the inter-relationship of lactation and fertility regulation, as well as the unique role of breast-feedingand lactational amenorrhoea and anovulation in child health, birth-spacing, and fertilityregulation should be taken into account.As a way of incorporating the most recently available scientific information into
programme policies appropriate to a given set of health systems and socioculturalconditions, the following common principles are generally applicable:
(a) Infant and young child health, nutrition and fertility regulation are factors influ-encing the achievement of any significant improvement in maternal health.
(b) Education of health workers and dissemination of general information to othersectors of society can play a supporting role in infant and young child feeding, and theimportance of breast-feeding and lactational amenorrhoea should be an integral compo-nent of any programme designed to enhance the health and wellbeing of mothers andchildren.
(c) Social and health support systems that favour and encourage frequent suckling,including on-demand and night-time feedings, contribute to the prolongation oflactational amenorrhoea and its effectiveness as a means of birth-spacing, and shouldtherefore be promoted.
q NUTRITION COMMITTEE OF THE CANADIAN PEDIATRIC SOCIETY AND COMMITTEE ON NUTRITION OF THE AMERICANACADEMY OF PEDIATRICS. Breast-feeding. Pediatrics, 62 (4): 591-601 (1978).
rWHITEHEAD, R. G. Maternal diet, breast-feeding capacity, and lactational infertility. Report of a UNU/WHO/IPPF/UNICEF Workshop, Cambridge, England, March 1981. Tokyo, United Nations University, 1983.
BREAST-FEEDING AND FERTILITY REGULATION
(d) Health service routines and social practices which unnecessarily interfere with thepromotion and maintenance of breast-feeding should be identified and modified, dis-couraged or discontinued.
(e) Lactational amenorrhoea is a highly effective contraceptive. However, when the riskof conception during amenorrhoea is considered too high, other contraceptive techniquesshould be initiated as close as possible to the expected termination of lactational amenor-rhoea. Unfortunately, the duration of amenorrhoea varies among different social groups,and so no time can be specified that will apply to all population groups. The appropriatetime for introducing other contraceptive techniques must, therefore, be set by familyplanning and health officials on the basis of what they know of breast-feeding andlactational amenorrhoea patterns in the specific situation at hand. The policy could be, forexample, that contraception should be initiated at the time when a quarter to one-half oflactating women resume menses (the 25 percentile or the median) or at the resumption ofmenses, whichever time comes first.
(f) Nonhormonal contraceptives are preferable during lactation; they reduce the likeli-hood of a new conception and may thus prolong lactation. IUDs should be used in theimmediate postpartum period only where follow-up facilities are available to ensure thatthe IUD is in its proper position and for reinserting those that are not.
(g) Combined hormonal contraceptives should be discouraged in the early months oflactation, because they diminish the yield of milk. When a woman prefers to use hormonalcontraceptives in the early months of lactation, progestogen-only contraceptives -oral orinjectable should be made available.
(h) Promotion of improved maternal health and nutrition is an essential component ofany breast-feeding and fertility-regulation policy. Improvement of the maternal diet duringpregnancy decreases the risk of low-birthweight infants, perinatal mortality, and infantmorbidity. Even where maternal nutrition is less than optimal, women can provideadequate nourishment to sustain infant growth in the first months of life. However,because lactation also poses nutritional demands on the mother, it is important to improvethe maternal nutritional status during pregnancy and lactation.
(i) In order to prolong maternal amenorrhoea and provide adequate nutrition for theinfant, both mothers and health workers should be given information on when and how tointroduce additional, locally available foods so as to meet the infant's nutritional needswithout diminishing the frequency and intensity of suckling.
The appropriate approach to infant nutrition and health, maternal wellbeing, andfertility regulation will depend upon a variety of social and health care factors. Forexample, in highly industrialized societies, where women tend to work away from homeand are subject to rigid time schedules, frequent on-demand breast-feeding may be imprac-tical beyond the period allowed by postpartum maternity leave. In these societies, anyadverse health implications of shorter durations of breast-feeding are often minimized byready access to health care, including family planning services.
In less industrialized societies, where women still tend to work at or close to home andwhere there is opportunity for frequent contact between mother and infant, breast-feedingmerits active support. Emphasis should be given to the importance of breast-feeding notonly as a source of nutrition and a protection against infection, but also as an effectivecontraceptive under appropriate conditions. Developing countries all too often have butlimited health and family planning services; large rural populations lack services adequateto ensure the continuity of care essential for effective family planning and follow-up.Fortunately, child-bearing women in these circumstances frequently have a relatively longpostpartum lactational amenorrhoea which provides natural contraceptive protection untilshortly before the return of menses.
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WHO/NRC MEETING
In the determination of how best to combine the promotion of breast-feeding, appro-priate addition of other foods, and family planning, a number of issues dealing with healthand the social and health care system must be taken into account. Various combinations ofstrategies will be called for, depending on the nature of the community, its health profile,and the extent to which it is served by a health care system that will provide maternal andchild health care and family planning support. The important information to be consideredincludes: the customary pattern of breast-feeding in the community, the duration andfrequency of breast-feeding, the age at which supplementary foods are usually introduced,prevailing birth-spacing intervals, and the mean duration of lactational amenorrhoea.Patterns of breast-feeding and of lactational amenorrhoea commonly vary from one socio-economic group to another. Lifestyle, female work and employment patterns, and healthcare system support are among the factors that influence both the behavioural component(breast-feeding) and the resultant physiological responses (lactational amenorrhoea). Morethan any other factor, the duration of lactational amenorrhoea determines what type offamily-planning strategy should be employed and what contraceptive methods are to berecommended.Whenever decisions cannot be based on individual histories, and when the variation in
patterns of breast-feeding and lactational amenorrhoea is relatively slight, it is possible tofollow a general strategy to arrive at the optimal time for starting a contraceptive method.Such a strategy is applicable to amenorrhoeic women only, since all menstruating womenwho desire contraception should be offered protection.
Fig. 1 illustrates the different times at which two different populations (A and B) wouldrequire contraceptive protection. Population A, with a relatively short period of amenor-rhoea, should have contraception introduced at about time Al. But to recommend the
100
C0 ~~~~~~POPULATION A \POPULATION BE
50
3.1 50~~~~~~~~~~~~~
Age of infant
Fig. 1. The duration of lactational amenorrhoea, shown here in two populations (A and B), as a factor deter-mining the appropriate time for the introduction of another contraceptive method (see text).
378
BREAST-FEEDING AND FERTILITY REGULATION
introduction of contraceptives at time Al for population B would be wasteful of resources,since virtually none of the women would as yet be at risk of pregnancy. Also if dis-continuation of contraceptives is common in population B, many women could terminatetheir use at a time when they might be at risk of pregnancy. To initiate contraception at timeBI would provide unnecessary coverage for some women in population B, but would covervirtually all those likely to become pregnant during lactational amenorrhoea. To initiatecontraception at time B2 is a compromise: some women would be at risk of becomingpregnant but there is less unnecessary use of contraceptives overall.
In an individual case, health and family-planning workers should ascertain, during theprenatal period, whether the mother intends to breast-feed and, if so, for how long. Healthworkers should then arrange for a postnatal follow-up at about the time supplementalfoods are introduced, bearing in mind that the duration of lactational amenorrhoea will beaffected by this introduction of supplemental foods, the pattern of day- and night-feeding,and the termination of breast-feeding. The selection of a contraceptive method prior toweaning, as indicated above, should be governed by the following:- the extent to which it does not interfere with breast-feeding;- its reliability and acceptability;- the extent to which the mother can be expected to return for regular consultation;- the availability of family planning services.
If the mother has breast-fed previously, it is wise for the health worker to inquire abouther history of lactation and lactational amenorrhoea, in order to determine an appropriatetime for initiation of an additional contraceptive method.
SUMMARY GUIDELINES FOR PROGRAMME POLICY
1. Breast-feeding and family planning should be mutally reinforcing components of anyhealth policy, which should itself be tailored to local needs.
2. In the promotion of breast-feeding, information on its effect in increasing birthintervals by inducing lactational amenorrhoea, the nutritional benefit to the infant, and itsprotection against infection should be included.
3. Information on the contribution of lactational amenorrhoea to birth-spacing shouldbe disseminated to the public and all health sector personnel and be incorporated into thecurricula for training of health workers. Emphasis should be given to the followingmeasures which promote lactational amenorrhoea:- breast-feeding exclusively for four months, with frequent suckling on demand, both
by day and night;- continuation of breast-feeding after supplemental foods have been introduced at 4-6
months.
4. The most appropriate time for introducing other family planning methods should beestablished, for each situation, on the basis of breast-feeding patterns and trends, and theduration of lactational amenorrhoea.
5. In order to realize optimal benefits from breast-feeding in relation to family planning,it is essential that social and health programme policies should be strengthened by thefollowing actions:- Protect and promote breast-feeding through maternity legislation and social support
systems, the provision of education and information, as well as implementation of otherlegislative and social actions.
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- Provide fertility regulating methods and services appropriate for lactating women;encourage the use of nonhormonal contraceptives for 4-6 months postpartum; for breast-feeding women who desire hormonal contraceptive protection, provide progestogen-onlyhormonal contraceptives during the period of lactational amenorrhoea, and a warning onthe effect of combined oral contraceptives on the quantity of breast milk.- Encourage, by providing information on fertility-regulating techniques and services,
the timely initiation of family planning shortly before the return of menses.
6. Health workers and the community require information on the interrelations betweenmaternal nutrition, breast-feeding, and fertility, including the following:- Optimal benefits of breast-feeding with respect to infant nutrition, protection from
infection, and birth-spacing may be realized without significant deterioration in thenutritional status of the mother.- Changes in breast-feeding practices are among the more important factors that affect
the duration of lactational amenorrhoea and consequent birth intervals, in contrast tovariations in maternal nutrition, which have only a marginal impact on birth-spacing.- Optimal health of the mother, and hence of the family, can best be assured by pro-
viding locally available foods that are good sources of energy and other nutrients duringpregnancy and lactation, preventing and alleviating nutritional deficiencies such asanaemias, and identifying and using local social and physical support systems that canreduce maternal work loads and thus reduce maternal morbidity.- Infant survival and longer intervals between births are promoted by providing the
infant with supplemental food from locally available sources in a manner and at a time thatfavours continued and frequent breast-feeding.
7. Development of simple methods to enable women to identify the resumption ofovarian function is important in order to maximize the fertility-regulating impact of breast-feeding.
LIST OF PARTICIPANTS
A. Akin, Institute of Community Medicine, Hacettepe University, Ankara, TurkeyR. Apelo, National Family Planning Office, Ministry of Health, Manila, PhilippinesD. Ashley, Ministry of Health, Kingston, Jamaica
*J. Bale, Food and Nutrition Board, National Academy of Sciences, Washington, DC,USA
S. Bhatia,International Centre for Diarrhoeal Disease Research-Bangladesh, Depart-ment of Population Dynamics, Johns Hopkins University, Baltimore, MD, USA
*J. Bongaarts, The Population Council, New York, NY, USAP. Cholnoky, Szombathely, HungaryH. Cruz-Ruiz, Ministry of Health, Lima, Peru.R. Rivera-Damm, Institute of Scientific Research, University of Juarez, Durango,Mexico
H. L. Delgado, Division of Human Development, Institute of Nutrition of CentralAmerica and Panama (INCAP), Guatemala City, Guatemala.
* Member of the Committee on International Nutrition Programmes, National Research Council(NRC) Subcommittee on Nutrition and Fertility. The Subcommittee also includes Gretchen Berggren(Harvard School of Public Health, Boston, MA) and Carl Taylor (The Johns Hopkins University,Baltimore, MD).
BREAST-FEEDING AND FERTILITY REGULATION 381
K. Fotherby, Department of Steroid Biochemistry, Royal Postgraduate Medical School,Hammersmith Hospital, London, England
M. T. Hamamey, Basic Health Services Department, Ministry of Health, Cairo, EgyptS. Harlap, Department of Medical Ecology, Hebrew University of Jerusalem, Jerusalem,
Israel*S. Huffman, School of Hygiene and Public Health, Johns Hopkins University, Balti-
more, MD, USA (Co-Secretary)V. J. Hull, Department of Demography, The Research School of Social Sciences, The
Australian National University, Canberra, AustraliaS. Jafery, Jinnah Postgraduate Medical Centre, Karachi, PakistanE. D. B. Johansson, University Hospital, Department of Obstetrics and Gynaecology,
Uppsala, Sweden*J. B. Josimovich, Department of Obstetrics and Gynaecology, College of Medicine and
Dentistry of New Jersey, New Jersey Medical School, Newark, NJ, USAS. Koetsawang, Family Planning Research Unit, Department of Obstetrics and
Gynaecology, Siriraj Hospital, Bangkok, ThailandV. Height Laukaran, The Population Council, New York, NY, USAR. Leke, Central Hospital, Yaounde, United Republic of CameroonR. Lesthaeghe, Inter-University Programme on Demography, Brussels, Belgium
*J. Menken, Office of Population Research, Princeton University, Princeton, NJ, USAB. Muntasser, United Nations Fund for Population Activities, Geneva, SwitzerlandK. Prema, National Institute of Nutrition, Hyderabad, AP, IndiaJ. Rooks, United States Agency for International Development, Washington, DC, USAB. Saxena, Indian Council of Medical Research, New Delhi, IndiaP. Senanayake, International Planned Parenthood Federation, London, EnglandR. Short, MRC Reproductive Biology Unit, Medical Research Council, Edinburgh,
ScotlandA. R. Soerano, Family Planning Services, Ministry of Health, Jakarta, IndonesiaK. Sundstroem, The National Board of Health and Welfare, Stockholm, SwedenM. Q. Talukder, Institute of Postgraduate Medical Research, Dhaka, Bangladesh0. Thanangkul, Research Institute for Health Sciences, Chiang Mai University, Chiang
Mai, ThailandJ. Vince, Port Moresby General Hospital, Port Moresby, Papua New GuineaH. L. Vis, Paediatric Clinic, University Hospital of St Pierre, Free University of Brussels,
Brussels, BelgiumR. Whitehead, Dunn Nutritional Laboratory, Cambridge, EnglandB. Winikoff, The Population Council, New York, NY, USAS. Zacharias, Department of Obstetrics and Gynaecology, Faculty of Medicine, Uni-
versity of Chile, Santiago, ChileZhang De-wei, Shanghai Institute of Planned Parenthood Research, Shanghai, China
WHO Secretariat
M. A. Belsey, Special Programme of Research, Development and Research Training inHuman Reproduction (Co-Secretary)a
M. Carballo, Maternal and Child Health, Division of Family Health (Co-Secretary)A. Kessler, Special Programme of Research, Development and Research Training inHuman Reproduction
A. Petros-Barvazian, Division of Family HealthB. Underwood, Consultant, Nutrition Unit, Division of Family Health
a Currently Maternal and Child Health, Division of Family Health.
382 WHO/NRC MEETING
ACKNOWLEDGEMENTS
Funding support for the workshop and meeting was provided by theWHO Special Programme ofResearch and Development and Research Training in Human Reproduction, by the Division ofFamily Health from resources provided by the United Nations Fund for Population Activities(INT/79/P46), and by the US National Research Council.
