Benefits of Brest Feeding -What is Exclusive Brest Feeding ? Ways to improve Feeding Practice of infants: Educate College and University girls , Local dignitaries, local political Leaders and Social Leaders and Community Opinion makers benefits of Exclusive Brest Feeding and the immense benefit offered by Exclusive Brest Feeding for first 6 months of lfe.

Disadvantages of LAM method of contraception:

1.      Effectiveness after six months is uncertain Inspite of continued breast feeding.

2.      The words ‘exclusive breastfeeding’ sounds simple but it requires considerable effort and dedication on the part the woman. Frequent breastfeeding, though ideal may be inconvenient or impractical for some women, especially working mothers.

3.      Unlike condoms, there is no protection against sexually transmitted Infections (STIs) including HIV/AIDS. Thus if a woman is infected with HIV and if her partner does not use condom during sexual intercourse she may transmit the HIV through such unprotected sex. Therefore ideally partners of all HIV positive women should use barrier methods of contraception during all sexual intercourses though women can use female condom or newer cervical barrier devices (Leas Shield, Fem Cap) which will be equally effective in prevention of STI. The newer designs of female condom is claimed to be superior in STI prevention e.g. Reddy Female Condom, V-Armour Female Condom, Panty Condom. F-C female condom, Feminine condom (by Medtech Products). Breast milk, however can also can transmit HIV virus to neonate though such chance again is little. Such transmission of virus through breast milk is also applicable for Hepatitis B virus which is also secreted in milk. Most of the credit of newer male and Female condoms(Designer Condoms) goes to “CONRAD”-an organization dedicated to innovation and development of newer condoms including Spring laden Condoms, Inspiral Condoms, Contoured condoms, Sensidot Condoms ,Flared condoms,  Glans-covering condoms,  Oscillating condoms,  Spiral Condoms,  Glow-in-Dark condoms to name a few including invisible condoms(vaginal microbicides) for use of female partners. .

Limitation of breastfeeding as contraceptive:

            Though, breastfeeding is an important and effective means of child spacing, still some uncertainty exists about the extent to which a woman can rely on lactation induced suppression of ovulation for contraception. This is because feeding practice varies from women to women.

When compared to oral contraceptives or sterilization, breastfeeding may not be that effective form of contraception, due to following factors since a) Not all women ovulates as per norms and some  women may occasionally resume ovulation within six months of childbirth while still breastfeeding as per norms. It all depends on b) how frequently the baby is put to breast and above all the total duration of breastfeeding per twenty four hours.

 It is needless to mention that these two factors have great individual variations. What is more important, that there can be day to day variations due to maternal or infant illness or for social or religious reason? Thus if a woman fails to breastfeed as per norms for   couple of days then ovulation can ensure prematurely. All these factors pose a problem in judging initiation of additional contraceptive in an individual woman. Therefore, there is a need of individualization in timing of initiation of contraceptives during breastfeeding period which is at times a difficult task on the part of doctor or HCP (Health Care Provider).

            As stated earlier during lactation amenorrhoea the probability of pregnancy for first six months is initially low i.e. 2%. But chance of pregnancy increases after six months even if the woman concerned remains amenorrhoeic (nonoccurrence of menstruation). All Breastfeeding women should remember that once she regains her menstrual pattern, contraceptive reliability induced by breastfeeding decreases rapidly and hence other means of contraception are always advisable. This applies particularly when the baby is being weaned and solid foods are gradually introduced. As stated, in rural India partial breastfeeding may continue for many months which offers some protection from pregnancy but not hundred percent.

Bellagio Consensus on L.A.M. of Contraception:

            In 1988 a group of reproductive scientists from all over the world met in Bellagio, Italy. They proposed that postpartum women could use lactation amenorrhoea method as a means of family planning. It is these experts who first unambiguously disclosed that women who are fully or nearly fully breastfeeding and amenorrhoeic are likely to experience a risk pregnancy at the rate of less than two percent in the first six months after childbirth. This consensus later came to be known as ‘Bellagio Consensus’. This method of natural contraception, very rightly was soon widely accepted in many countries. The principle of Bellagio consensus as a standard method of natural family planning was reaffirmed by another meeting at Bellagio in 1989 and this consensus was renamed as ‘Lactation Amenorrhoea Method (LAM)’ of contraception.

            Incidentally, it may be recalled that International consensus conference on Medical abortion i.e. nonsurgical method of abortion was also held at Bellagio city, Italy, 1-5^th November 2004 under the auspices of World Health Organization, Rockefeller Foundation and a NGO (IPAS). Thus Bellagio city is dedicated to reproductive rights and reproductive freedom of woman!

            After Bellagio consensus an International guidelines on ‘Breastfeeding and LAM’ were framed in 1989 and these guidelines were widely circulated in different countries. These guidelines included all three previous standard criteria, all of which must be fulfilled to ensure adequate protection from an unplanned pregnancy i.e. a) amenorrhoea, b) full or nearly full breastfeeding, c) first six months postpartum. The newly issued guidelines however included one additional warning for lactating women. The warning is that if any women who no longer meet all these three criteria, or no longer wish to use LAM, should immediately initiate use of additional family planning method if she intends to avoid pregnancy. It means partial breastfeeding does not offer cent percent protection from pregnancy. The guideline however had another clear message. That is it is the suckling stimulus that results both amenorrhoea and associated protection from pregnancy due to an anovulation (no release of eggs). Hence, adding supplements to the infant’s diet or decreasing the duration of breastfeeding below sixty minutes per twenty four hours and therefore  decreasing total suckling period may hasten the return of ovulation and shorten the efficacy of LAM.

Bellagio consensus also encompass and also  stress on the relevance  on  extended use of LAM?

As an Indian we would be interested to know the effect of extended breastfeeding on contraception i.e. if breastfeeding is continued beyond six months. Many women in rural India breastfeed up to four or five years. What opinion the said experts expressed on breastfeeding-induced natural contraception in such cases? Are they as immune to pregnancy as is enjoyed in first six months? Certainly not. Let us now see what experts say on this issue which is so relevant in Indian context.

Experts opine that it may be possible to extended  LAM beyond six months and there is nothing wrong in this age old practice. But so far as contraceptive effect is concerned their argument was that infants older than six months definitely need some supplemental feeding to maintain their health and development. Naturally, supplementation with other foods decreases breastfeeding frequency considerably. This by reducing suckling duration can result in release of eggs from ovaries. The experts also warned that in such cases ovulation and mistimed pregnancy can follow even if she remains amenorrhoeic. As such, women who continue to breastfeed beyond six months despite supplementation. In fact that is the usual scenario in rural India) the rate of pregnancy during ‘lactation amenorrhoea’ will be higher than that of first six months postpartum. Pregnancy rate however, remains low, than those women who do not breastfed at all. This is called ‘extended use of LAM’.

            Many studies on LAM were conducted since Bellagio consensus. Experts again gathered at Bellagio on 4^th Dec, 1995 and they collectively reviewed all the study reports which were available from different countries. The committee concluded that the Bellagio consensus of 1989 was worthy and appropriate including ‘extended use of LAM.’ Sporadic studies conducted thereafter (1996-2008) to assess the validity of Bellagio consensus have reaffirmed that women who are fully or nearly fully breastfeeding are at very low risk of becoming pregnant in the first six months postpartum or as long as they remain amenorrhoeic.

How can we motivate Indian mothers to accept scientific breastfeeding practices?

There is urgent need to educate all pregnant women (would -be -mothers) about standard breastfeeding practices. Family members and community leaders should also be communicated about benefits of exclusive breastfeeding and other healthy breastfeeding practices. Doctors and health care providers too need updating of their counseling skills on breastfeeding by attending workshops and seminars on this issue. Their noble duty is to part all these scientific knowledge i.e. ‘Dos’ and ‘NOT to dos’ to would be mothers during prenatal visits and also during discharge from hospital or nursing home after childbirth.

a)      Who is responsible for ‘wrong breastfeeding practices’ ? Readers will be shocked to know the results of one Indian survey. This recent study disclosed that of the mothers who decided for early formula feeding 46% were motivated by the suggestions received from family members and neighbors and in 43% such women the decision to start a formula feed was influenced by the doctors and health workers! What an unfortunate scenario! In rest 11% women who started formula feed too early were influenced by different media and advertisements. Now radio talks and TV talks are on to motivate mothers and in- laws.

b)      We can do better: Tips to promote breastfeeding: Breastfeeding and family planning are mutually reinforcing components of any health policy. Many of us understand that early discontinuation of breastfeeding presents considerable health hazards to infant. But we seldom understand that acceptance of standard breastfeeding practice not only benefits the concerned infant but also increase the birth interval by inducing lactation amenorrhoea. Lactation anovulation associated with amenorrhoea resulting from exclusive breastfeeding represents an important child-spacing mechanism in many third world countries. This is because frequent stimulation of the nipple during breastfeeding produce prolactin hormone which in turn reduces some hormones called pituitary ( a gland located in  brain )(pituitary gonadotrophins). It is this prolactin hormone which causes inhibition of menstruation of egg release.

Never be happy with the status Quo: The contribution of lactation amenorrhoea to birth spacing should be categorically disseminated to mothers especially during the prenatal visits. Basic information on ideal breastfeeding practice should also be c6tedcommiased to family members, in laws, and opinion leaders in the community.

The following globally accepted practice should repeatedly be communicated while the mother is still in hospital or nursing home these are a) exclusively breastfeeding for first six months, with frequent suckling on demand, both day and night. b) Continuation of breastfeeding even after supplemental foods has been introduced after 6 months. C) The most appropriate time for introducing other family planning methods should be established, for each individual based mainly on breastfeeding patterns and trends, and obviously on the duration of lactation amenorrhoea. The couple should also be made aware of the available fertility regulating methods, for lactating women. The couple should preferably use nonhormonal methods of contraception e.g. IUD (Intra-uterine devices) or condom. In the authors opinion these two are ideal contraceptives from four to six months postpartum.

But those breastfeeding women who desire hormonal contraceptive protection they can choose progesterone only hormonal contraceptives e.g. minipill or Inj. Progesterone i.e. quarterly shots. This hormonal method also has a track record good efficacy and safety. If none of these four methods are selected the combined oral contraceptives may be started only after six months of childbirth as it adversely affects quality of breast milk (WHO category 2 risk so long baby is breastfeeding).

However to initiate and promote breastfeeding important of personal support is very relevant. Personal contact and support really helps breastfeeding to succeed. This may be from health workers, counselors, family members, or from other breastfeeding mothers in the community. Radio broadcasts, newspaper articles and lectures can increase people’s knowledge, but they may not change what mothers do. Person-to-person help is necessary to convince mothers to put the ideas into practice.

Support for a breastfeeding mother means a kind person who can:

-          See her often, help with practical tasks, and avoid saying anything critical.

-          Reassure her that she cans breastfeed and that her milk is perfect and sufficient.

-          Praise her for what she is doing right.

-          Explain what is normal.

-          Advise her if she does not know what to do.

-          Help her if she was a problem.

-          Encourage her to persist.

What points need to categorically discuss during antenatal period.

1.      Her breast milk is always the best food for her baby. The quality of the milk will always be good whatever her diet.

2.      The size and shape of the breasts does not matter. Small breasts and large breast both produce milk in sufficient quantity, and a baby can suckle from any of them.

3.      Breastfeeding does not spoil her figure. It should help her to lose weight after the baby is born. Having a baby always alters the breasts – whether or not the mother breastfeeds. Most changes that are seen in older women are partly due to age. If she wears a well fitting brassiere or other support while she breastfeeds, her breasts will have a good shape.

4.      Bottle feeding is dangerous. If family and friends urge the use of a bottle, explain that this practice is no longer recommended because it causes much illness. Baby –Friendly Hospitals have come up since early 1990s.

5.      Let the baby suckle soon after delivery – within an hour if he is willing. She should keep the baby with her and let him suckle whenever he wants to from the first day. This helps the mother’s milk to come in.

6.      She can make one or two of her dresses open at the front so that the baby can reach the breast easily. This helps her to breastfeed modestly, without exposing the breasts.

7.      All mothers feel more emotional and sensitive than usual for a few weeks after delivery. It helps to know that these feelings are normal and that they will pass. (Adopted from: “Helping mothers to breastfeed” by felicity savage king, published by ACASH publication, Post Box No. 2948, Mumbai 400 002, India. Author pays a big salute to such a publishing authority. This is like a patriotic duty.

Current Breastfeeding practice in India: Have we made any progress?

a)      Early resort to artificial feeds: To our astonishment a recent survey in India revealed that only thirty percent of infants are ‘wholly breast fed’ at the end of five months. Rest seventy percent infants are allowed to take supplement feeding well before stipulated six months time (Source: National Family Planning Survey, III  2005-06, P-279). This is very unfortunate.

Early discontinuation of breastfeeding  amongst urban women:

In practice what happens is that those who are well off particularly urban couple often purchase ‘formula feeds because easy availability and affordability Time constraint is a great factor for such urban educated mothers. Some urban women are unnecessarily worried about the change in the shape of their breasts with continued breastfeeding after two to three months. Though this fear was has now been scientifically unfounded. Author has come across hundreds of such women who have stopped breastfeeding based on this erroneous idea in last thirty years of practice. No amount of counseling was effective to remove this false belief.

The incidence of partial breastfeeding practice before six month of age  is increasing in rural women too:

 What about rural women? What is their practice on this issue? It is tempting to believe that almost all rural women will continue to offer exclusive breastfeeding at least for first six months. But in practice it is not so. Many such rural women are now-a-days employed outside home. Many work in agricultural fields which may be located four to five kilo meter away from their home where she cannot carry her infant for safety purpose. Many are also employed in brick fields and road repair works. During their long absence the infant is often kept under the custody of in-laws or grandmothers. Additionally, in rural setting animal milk i.e. milk of cow, buffalo, goat is often freely available sometime even at no cost. Such milk is often allowed prematurely. Easy availability of animal milk poses a temptation to young rural mothers to embark on partial breastfeeding early. This practice needs urgent rectification and warrants attention of friends, relatives, caregivers of lactating woman and last but not the least community leaders. Most Indian mothers are now too busy outside their home settings so that they are unable to adhere to exclusive breastfeeding. This not only compromises her infant’s health but she becomes easy prey to unwanted pregnancy. .

b)      Wrong feeding practices in India: Not only total months for which a child is breastfed is important but ‘child feeding practice’ amongst Indian women has to be changed. This practice or methodology of breastfeeding is far from scientific. Detail techniques i.e. how to put the child in breast (see in Vol. I of this book) is seldom discussed by doctors, nurses or paramedics.

Besides wrong techniques of holding the baby and early communicant of supplementation in India there are other two obvious wrong breastfeeding practices. These are ‘delay in initiation of breastfeeding after the child is born’ and addition of prelacteal feeds prior to first breastfeeding.’ How rampant are these two notorious practice in India? In India seventy five percent infants are not put to breast within stipulated one hour of birth. In addition as many as 57% newborns received ‘pre-lacteal feed’ i.e. feeds in the form of drinks other than breast milk as the first feed. Th this area Indian Media has of late taken a key role for whichh author pay sincere thanks. These are not recommended by any International agencies. These two wrong feeding practices are detrimental to successful lactation at a later date. . These wrong feeding practices as prevail in India may be the principal cause of wasting in 43.5% of children below three years, the report suggested.

National Family Health Survey-3 (study period 2005-06) also revealed that in West Bengal, a state in India only 23.7% of newborns are put to breast within one hour of birth! Exclusive breastfeeding practice (no extra fruit juice, water, honey) is maintained by 58.6% mothers only up to 5 months of age! Ideally all lactating women should have exclusive breastfeeding up to six months

Take home message:

‘Lactation Amenorhoea    Method’ of natural contraception is prevention of conception in first six months of childbirth During the past few years, there has been a rapid increase in scientific knowledge about the relationship of ‘breastfeeding and suckling practices’ to ‘reproductive function and natural infecundity’ during breastfeeding. Much have been known about social and adverse health consequences of unregulated fertility not only on mothers, but also on increasing population, the family and the community.  But to achieve contraceptive effect of breastfeeding adequate time should be spent on breastfeeding (nursing should be more than six times per day including at least one feed at night) and there should be no resumption of menstrual period following childbirth.  If a) breastfeeding is less than six times per day or b) less than 80 minutes per day or c) menstruation has resumed after childbirth or baby is already six months old then efficacy of this method of contraception considerably lessens.

Now-a-days unfortunately a busy house wife often comprises with duration and frequency of breastfeeding due to her occupation and or social commitments. Publicity regarding benefits of breastfeeding is inadequate. Unfortunately there is minimal response from community on this aspect. However, if unscientific breastfeeding practice cannot be rectified then little can be done to improve health of baby. But natural contraceptive benefit offered by healthy breastfeeding for first six months (L.A.M method of contraception) can be covered by alternative contraceptive. Hence there is a crying need for early initiation of contraceptive use which may be as early as three months or even two months postpartum!

 As civilization progresses the duration of breastfeeding is decreasing and the concept of ‘lactation amenorrhoea method of fertility control’ is fading. This is unfortunate. Globalization is engulfing our golden old cultures in every sphere of life. A day may come in twenty second century when there will be no chapter on LAM in a book of postpartum contraception. Hope this won’t occur!

A Lactating woman can use following algorithm for ready reference:

Can a Woman Use LAM?

 Doctor/Counselor should ask the mother, or advise her to ask herself, these 3 questions:

1.      Have your menstrual periods returned after childbirth?	If YES	The mother’s chance of pregnancy is increased. For continued protection, advise her to begin using a complementary family planning method and simultaneously to continue breastfeeding for the child’s health.
2.      Are you regularly giving the baby much other food besides breast milk or allowing long periods without breastfeeding, either day or nighttime?	If YES
3.      Is your baby more than 6 months old?	If YES

If the answer to ALL of these question is NO                       But, when the answer to any ONE of

                                                                                                These questions becomes YES

 

She can us LAM. Only breastfeeding will prevent fresh pregnancy. There is no need to commence any other contraceptive. But there is only a 1% to 2% chance of pregnancy at this time.( Source: W H O).

Web Sites:

a.      Association of Breastfeeding Mothers (http://abm.me.uk/website/index.htm);

b.      Breastfeeding Network (www.breastfedingnetwork.org.uk/);

c.       Best Beginnings (www.bestbeginnings.info/) – Video clips of breastfeeding positioning and attachment

d.      Dipex (www.dipex.org/breastfeeding) – Video clips of women talking about their breastfeeding experiences and web links to other information resources.

e.      Breastfeeding your baby (www.eatwell.gov.uk/agesandstages/baby/breastfeed/) – Advice on what to eat when breast feeding.

f.        UNICEF (www. Childinfo.org/eddb/brfeed/index.htm) – Breastfeeding and complementary feeding Country.

g.      UNICEF UK baby friendly initiative (www.babyfriendly.org.uk/) – Supports health services to provide high quality care. Information about training and the latest research updates.

h.      Drugs in Lactation Advisory Service – www.ukmicentral.nhs.uk/drugpreg/guide.htm

Breastfeeding Network Drug line (a registered charity) –

i.        rk.org.uk