The Lactational Amenorrhea Method (LAM): a postpartum introductory family planning method with policy and program implications.

It is well accepted that breastfeeding contributes significantly to child survival and child nutrition. Healthful child spacing is associated with improved birth outcomes and maternal recovery. On a population basis, breastfeeding may contribute more to birth spacing than all family planning use combined in many countries. However, while breastfeeding does provide a period of infertility, until recently, there was no reliable way for an individual woman to capitalize on this lactational infertility for her own efficacious child spacing. The Lactational Amenorrhea Method (LAM) is a new introductory family planning method that simultaneously promotes child spacing and breastfeeding, with its optimal nutrition and disease preventive benefits for the infant. LAM, as it is called, is based on the utilization of lactational infertility for protection from pregnancy and indicates the time for the introduction of a complementary family planning method. LAM is recommended for up to six months postpartum for women who are fully or nearly fully breastfeeding and amenorrheic, and relies on the maintenance of appropriate breastfeeding practices to prolong lactational infertility, with the concomitant delay in menses return. A recent clinical trial confirmed the theoretical 98% or higher effectiveness of the method and field trials are demonstrating its acceptability. Nonetheless, some demographers and family planning organizations continue to debate its value. The development, efficacy, and sequelae of the method are presented using data from several studies by the authors.

Breast feeding and bottle feeding controversies in the developing world: evidence from a study in four countries.

This paper describes some of the findings from a comparative study to investigate infant feeding practices and their determinants in four Third World urban areas: Bangkok, Thailand; Bogota, Colombia; Nairobi, Kenya; and Semarang, Indonesia. The information about developing country urban woman provided by these data allows examination of the interaction of feeding practices with socio-economic and biomedical variables. Through the use of descriptive, bivariate, and multivariate analytic techniques, it is possible to explore some of the questions which have been debated regarding infant feeding practices. Data addressing five major questions are described in this paper: (1) Is breast feeding declining? (2) Is bottle feeding making women breast feed less? (3) Why do women use bottles? (4) How do mothers get the idea of using bottles? (5) How does paid employment affect infant feeding practices and the use of baby bottles? The study documents changes in infant feeding that can be expected to have detrimental effects for child health and for child spacing. Bottle use appears to interfere with breast feeding in all cultures, but more dramatically in more 'modernized' societies. Mothers resort to bottle use for a variety of reasons, but not usually as an attempt to wean. The health care system often provides the first contact between mothers and bottle use, and health care providers frequently encourage the use of artificial feeding. Women who work away from home early in their infants' lives must often use bottle feeding, but the percent of women affected is very small. Many more women use bottles and wean early than work away from home, and most artificially-fed babies do not have working mothers.

Overcoming obstacles to breast-feeding in a large municipal hospital: applications of lessons learned.

A project to overcome institutional constraints to breast-feeding was implemented in a large municipal hospital. Interventions included staff education, intensive training of a team of physicians and nurses, development of user-tested educational materials, and day and evening staffing by a breast-feeding counselor. A nearby hospital served as a control. Project evaluation entailed chart reviews at the intervention site and a control hospital (n = 812); interviews with mothers during their postpartum hospital stay and at return clinic visits (n = 180); and field observations in all areas of the hospital that provided prenatal, intrapartum, postpartum, and pediatric care. Comparisons of the incidence and pattern of breast-feeding were made before, midway through, and after the project. At the intervention site, the incidence of breast-feeding increased from 15% to 56%, and exclusive breast-feeding for more than 3/4 of feedings increased from 0% to 15%. At the control site, the respective changes were from 28% to 41% and from 5% to 7%. Formula use by breast-feeding women decreased but was nonetheless extensive, and the usual reason given by breast-feeding women for supplementation was a perceived insufficiency of breast milk. This may be due, in part, to the fact that bedside assistance to breast-feeding mothers was not integrated into the routine care provided by staff nurses but was relegated to the lactation nurse/counselors who were not available at all times. It is concluded that the process to overcome institutional constraints to breast-feeding is difficult but feasible. Repeated and extensive professional education helps create the context whereby clinical and administrative staff can reassess routines and policies.

Dynamics of infant feeding: mothers, professionals, and the institutional context in a large urban hospital.

A multidimensional approach was taken to understand the constraints to breast-feeding in a large municipal hospital. Data were collected through direct observation, chart review, and questionnaires to patients and staff. Breast-feeding had not yet begun within 24 hours postpartum in 37% of women who wanted to breast-feed. Chart review revealed that at hospital discharge no woman was breast-feeding exclusively: only 16% of infants had ever been breast-fed and all of these also had been formula fed. The most common reason for the use of supplementary formula and early weaning was the mother's perception or anticipation of insufficient milk. The existing procedures communicated the message to patients that the health care providers expected women to bottle-feed. Some practices that prevented successful breast-feeding were prolonged and/or unnecessary separation of mother and infant, routine provision of infant formula, confusion about drug contraindications for breast-feeding, and inconsistent identification of breast-feeding infants. Staff knowledge about breast-feeding management was inadequate, and staff underestimated mothers' interest in breast-feeding. Recommendations to facilitate breast-feeding include a revision of routines and procedures as well as provision of staff education and expansion of patient education.

Contraceptive use, amenorrhea, and breastfeeding in postpartum women.

Data from a 1981-1982 survey of infant feeding practices in four developing countries are used to analyze the relationship of amenorrhea, lactation, and time since childbirth with contraceptive use. The relationship was first explored using contingency table analysis. Logistic regression analysis was then performed to control for the effects of background variables. Models were tested separately for oral contraceptive users and users of other methods. Analysis showed a strong, independent, and consistent negative relationship between amenorrhea and contraceptive use. Women who were less than four months postpartum were also less likely to use contraceptives. The strength of the association with amenorrhea outweighed all other variables, including demographic correlates of contraceptive use. A negative relationship between breastfeeding and contraceptive use was found only for users of oral contraceptives. It is possible that women in the immediate postpartum period, especially those who are lactating and amenorrheic, are not as highly motivated to use contraception as had been supposed.

Contraceptive choices for lactating women: suggestions for postpartum family planning.

PIP: Both the fertility inhibiting effects of breastfeeding and the lactation inhibiting effects of hormonal contraceptives should be considered in developing postpartum family planning programs for lactating women. Because a high percentage of female contraceptive acceptors discontinue use within a year, the largest birth intervals may be achieved by delaying the initiation of contraception to take advantage of lactational infertility in the first postpartum months. Although evaluation of existing data on the effects of oral contraceptives on lactation is difficult, findings suggest that low-dose progestins may have a less detrimental effect on lactation than combined oral contraceptives. Depo-provera appears to enhance milk volume and duration of lactation, but the unknown side effects of transmission of steroids to the infant and changes in milk composition suggest caution in recommending it for nursing mothers. Results of research on possible effects of IUDs on lactation are conflicting and difficult to interpret, but possible mechanisms through prolactin secretion or oxytocin have been suggested for such an effect. Numerous methodological problems hamper efforts to evaluate evidence of the relationship of contraception to lactation to provide recommendations for family planning programs. The most prudent course where possible is to avoid giving hormonal contraceptives to the lactating woman. Where only hormonal contraceptives are acceptable, the best approach is probably to delay their use for at least 3 months postpartum to allow lactation to become established and the infant to mature.^ieng

The relationship of maternal attitude to pregnancy outcomes and obstetric complications. A cohort study of unwanted pregnancy.

The relationships of maternal attitude to pregnancy outcome and obstetric complications were investigated in a prospective study of a group of 8,000 gravidas, enrolled in the Child Health and Development Studies, who were members of the Kaiser Foundation Health Plan in the San Francisco East Bay Area. Interviews which were conducted early in pregnancy determined the mother's attitude through an open-ended question, "How do you feel about having a baby now?" The responses to this question were categorized as strongly favorable, ambivalent, or negative. Biomedical factors which were related to negative maternal attitude were perinatal death, congenital anomalies, and postpartum infection or hemorrhage. Other factors which were found to be related to maternal attitude toward pregnancy were clinic visits for psychosocial complaints related to anxiety states, and accidental injuries during pregnancy, as well as need for analgesics during labor. Birth weight of the infant, duration of gestation, length of labor, prenatal complications, and intrapartum obstetric complications were not related to maternal attitude. In order to control for the effect of confounding factors, these relationships were analyzed by using a multicontingency table approach and stratifying the data by parity, age of mother, and socioeconomic status.