An investigation on the influence of steroidal contraceptives on milk lipid and fatty acids in Hungary and Thailand. WHO Special Programme of Research, Development and Research Training in Human Reproduction. Task Force on oral contraceptives.

A double-blind clinical trial to examine the effects of oral and long-acting injectable contraceptive steroids on milk lipid and its fatty acid content has been done in Szeged, Hungary, and Khon-Kaen, Thailand. In Szeged, a combined and a progestin-only pill did not significantly alter total milk lipid. In Khon-Kaen, treatment with the combined pill was followed by a significant increase in the proportion of milk lipid. In the group treated with the long-acting injectable contraceptive, depot-medroxyprogesterone acetate (DMPA), the milk lipid decreased significantly in the first six weeks in comparison with the control group and the individual pretreatment values. A similar but weaker effect was noticed with the progestin-only pill in Khon-Kaen. Few consistently significant differences were found in the shorter chain fatty acids (myristic, lauric and palmitic acids) during treatment. The percentage proportions were increased during the combined pill treatment in Szeged and Khon-Kaen, and reduced in DMPA and progestin-only treatment in Khon-Kaen milks. The possibility that these reflected a response to a milk volume decrease in the combined pill treatment and a reduction in milk lipid synthesis in association with DMPA and the progestin-only pill is discussed. In Khon-Kaen, linoleic acid (which is not synthesized in the body) was increased by comparison with the controls, as a percentage proportion of the fatty acids in the progestin-only and DMPA groups. Calculation of the amounts of linoleic acid per litre of milk revealed that there had been a significant decrease of linoleic, eicosadienoic, dihommo-gamma-linolenic, arachidonic, docosatetraenoic acids in the w6 family and alpha-linolenic acid in the w3 family in the first two post-treatment visits (3 and 4). This reduction in essential fatty acid output follows the reduction in milk volume. In Khon-Kaen, the combined pill group showed a significant decrease compared with the controls, in the proportions of dihommo-gamma-linolenic acid. The difference in response of the mothers in Khon-Kaen and Szeged is discussed in relation to their different nutritional backgrounds.

Effects of hormonal contraceptives on milk volume and infant growth. WHO Special Programme of Research, Development and Research Training in Human Reproduction Task force on oral contraceptives.

WHO conducted a three-centre study in Hungary and Thailand to evaluate the effects of hormonal contraception on lactation and infant growth. Women choosing oral contraceptives were randomly assigned to a combined oral contraceptive containing 30 micrograms ethinyl estradiol and 150 micrograms levonorgestrel (N = 86) or a progestin-only preparation containing 75 micrograms dl-norgestrel (N = 85). Identical packaging and treatment schedules allowed double-blind observation. One-hundred-and-eleven women using no contraception or non-hormonal methods acted as controls. In the two Thai centres 59 women using depot-medroxyprogesterone acetate formed an additional comparison group. All subjects were healthy women with normal deliveries, whose infants had normal birth weights and satisfactory growth in the neonatal period. Breast milk volume was determined by pump expression using standardized procedures. Information was obtained on nursing frequency and supplementation, infant growth and morbidity. Pretreatment observations at 6 weeks post-partum were used as a baseline, and subjects were followed-up at 9, 12, 16, 20 and 24 weeks post-partum. Women using combined oral contraceptives had a decline in milk volume within 6 weeks of initiating treatment, whereas no significant decrease was observed in the other treatment groups. After 18 weeks of treatment, combined oral contraceptive users experienced a 41.9% decline in milk volume, compared to 12.0% with progestin-only minipills and 6.1% in the non-hormonal controls. The prevalence of complementary feeding and withdrawals due to inadequate milk supply were comparable in the four treatment groups. However, data were not available on the daily amounts of complementary feeds. There were no significant differences in growth of infants between treatment groups. Thus, women may have compensated for declines in milk volume by more supplementary feeding or by more prolonged and intense suckling episodes. We conclude that 30 micrograms estrogen-containing combined oral contraceptives impair milk secretion, but in the selected healthy group of mothers and children studied with the prevailing level of supplementary feeding, this did not adversely affect infant growth.

Postpartum tubal ligation by nurse--midwives in Thailand: a field trial.

PIP: 25 nurse midwives with at least 12 years of schooling, 3 1/2 years of training in nursing and midwifery, and a minimum of 1 year of operating room experience were selected from 18 provincial hospitals in Thailand for training in tubal ligations. During the 12 week course in a maternal and child health center in northeastern Thailand, the nurses received preliminary training and assisted surgeons with 3-5 operations; if their performance was approved, they performed 20 operations under a doctor's supervision. All completed the training and returned to be primarily responsible for postpartum sterilizations at their hospitals under the supervision of a gynecologist. Informed volunteer subjects, apparently healthy women having vaginal deliveries who had requested sterilization before delivery, were screened before the operations. The nurse midwives successfully performed 3549 postpartum tubal ligations in the 1st 12 months. The mean age of the sterilization acceptors was 28.2 years and the mean number of living children was 3.6. Assistance was needed from supervising doctors in 18 cases. After 12 months the average operation time was 14.8 plus or minus .3 minutes. The postoperative complications were similar to those in a pilot study, except that mild pyrexia was more common, occurring in 9.1% of cases. 97.4% expressed complete satisfaction on discharge from the hospital. At 6 weeks postpartum 28 of the 1746 cases returning for checkups had minor local complaints. Attitudes of the doctors at the participating hospitals were generally favorable.^ieng

Post-partum tubal ligation by nurse-midwives and doctors in Thailand.

A shortage of doctors limits the provision of post-partum sterilisation services in rural areas of Thailand. To overcome this problem nurse-midwives with theatre experience were trained to perform post-partum tubal ligation by a mini-laparotomy incision under local anaesthesia. The performance of the nurse-midwives was compared with that of doctors in a controlled, randomised clinical trial. Some operative difficulty was encountered by the nurses in 4.9% of cases and by the doctors in 2.0% of cases. This difference is not statistically significant and arose largely because the nurse-midwife cases were more obese. Nurse-midwives required a significantly longer operating-time (18.5 min) than doctors (11.9 min). However, postoperative morbidity was similar in the two groups (7.0% and 6.0%, respectively). These results suggest that trained nurse-midwives with theatre experience can safely provide post-partum sterilisation services. A further field trial is underway.

PIP: A randomized controlled clinical study of the competence of operating-room nurses in performing tubal ligation as compared with that of doctors was conducted. 5 nurse-midwives with more than 1 year's experience as operating room assistants were selected from the Khon Kaen Maternal and Child Health (MCH) center, and were taught pelvic and abdominal anatomy and the principles of local anesthesia and postpartum tubal ligation. Each of the 5 nurse-midwives was required to perform 30 sterilizations and 3 doctors were required to perform 150 operations. All subjects were healthy volunteers with no history of abdominal surgery; they were randomly allocated to either a trained nurse-midwife or a doctor for the operation. No statistically significant difference in the number of difficult cases were encountered by the 2 operator groups. Average operating time required by nurse-midwives (18.5 minutes) was significantly longer than that needed by doctors (11 minutes) (t=12.7, p 0.001). Thickness of abdominal fat correlated significantly with time required by nurse-midwives (r=0.34, p 0.001). Postoperative complaints and complications were similar for both groups (7.0% and 6.0%, respectively). The findings suggest that postpartum sterilization services can be safely proided by trained nurse-midwives with operating-room experience. Further study should be done to evaluate safety of the nurse-midwife providing sterilization services under usual program conditions in MCH centers and provincial hospitals with operating facilities, as well as cost-effectiveness of such services.