Sent to BlogSpot after correction on 4/10/2016. Breastfeeding
as a method of Birth Control: Lactation Amenorrhoea Method
(A Type of N F P- Natural Family Planning Method.)
Introduction
This is the most common method of
contraception in the first six months after childbirth. Scientists have
recently designated this form of family planning as ‘Lactation Amenorrhoea Method’ or L.A.M. It is the use of
breastfeeding as a temporary family planning method. LAM provides natural
protection against pregnancy and encourages planning for initiation of
another method at the proper time.
Who will
get the Contraceptive Protection by breast feeding? Not all lactating
women are going to be protected against pregnancy. Only following group of
women are protected against pregnancy during breastfeeding period i.e. provided
a) Her baby
gets at least 85% of his or her feedings as breast milk, and she breastfeeds
her baby often, both day and night AND
b) Her menstrual periods have not returned since
childbirth , AND lastly,
c) Her baby is
less than six months old.
All these
three criteria should be fulfilled to achieve near 100% contraceptive effect of
breastfeeding. If a women keeps breastfeeding very often, her protection
from pregnancy may last even longer than stipulated six months and perhaps as
long as nine to twelve months or
beyond after last childbirth. This is
called extended use of LAM.
Knowingly or unknowingly, rural women enjoy the benefit of this method of extended
L.A.M. as LAM continue to offer contraception to some even beyond six
months. This is truer and often availed by Indian rural women. This is a type
of natural family planning and costs
nothing. Our nation therefore avoids several thousand unwanted births
annually by adopting extended LAM method. In this context
it may be pertinent to mention that a
mother should ideally breastfeed up to two years along with weaning at six
months followed by supplementary foods (partial breastfeeding).
Detailed criteria of LAM
As stated earlier to make
breastfeeding as a successful method of natural contraception the woman
concerned has to follow all the following criteria e.g.
1. She should
breastfeed at least six times during day
time and at least one preferably two
feeds at night without supplementing water or any other drink. This is what
is called exclusive breastfeeding. Author wonders how many urban women
will take the trouble to put her baby to breast two or three times in night.
LAM to be cent percent effective total feeding duration i.e. suckling time in
twenty four hours should be ideally above eighty minutes or more.
2. As soon as menstruation resumes after
childbirth she should commence some form of contraception because it is well
known that contraceptive efficacy of LAM is markedly reduced as menstruation
resumes after childbirth.
3. The
contraceptive efficacy fades markedly six month after childbirth in spite of
continued breastfeeding. Therefore, six
month age of infant is a landmark for initiation
of contraceptive even if menstruation do not resume.
Efficacy of LAM as contraceptive
LAM method of
contraception is about ninety eight
effective in preventing conception in first six months postpartum provided
the concerned woman remains amenorrhoeic (nonoccurrence of menstruation). How
reliable is breast feeding? The failure rate of LAM is up to two pregnancies
per 100 women in the first six months postpartum provided no supplementary food
is added to baby during this period. This means strict adherence to the policy
of exclusive
breastfeeding. Nevertheless, two percent failure rate is not uncommon
with other contraceptives too and no couple should raise their eyebrow on this
minimal failure rate.
Advantages of adopting LAM as
Contraceptive:
1. Effectively
prevents pregnancy for at least first six months and this the period of
coverage may be longer if a woman keeps breastfeeding often, day and night.
2. Encourages
the mother to adopt standard breastfeeding patterns thus indirectly improves
health of infant. The couple and relatives should remember that breast milk
provides the healthiest food for the baby.
3. No direct
cost for family planning.
4. No question
of contraceptive related side effects.
5. No need to
do anything at time of sexual intercourse. Coitaly independent like Copper
IUDs. Does not interrupt the pleasure of sex in the midway as is common in
withdrawal method or condoms.
6. Protects
the baby from life-threatening diarrhea and protects the baby from other infectious
diseases such as measles and pneumonia (respiratory tract infections) by transmitting the mother’s immunities to the
baby through breast milk. In Indian context breast milk provides a natural
and highly effective panacea against fatal diarrhea of neonates and infants.
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, 1-5th 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 4th
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.
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?
|
|
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?
|
|
||
|
3. Is your baby more than 6
months old?
|
|
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
Followings are uncorrected.
A.4
A Text Book on Breast Feeding and Child Spacing
( Vol – I )
AUTHOR
Prof. S.K. Pal
M.B.B.S., D.G.O.,
M.S. (Gynaecology), F.I.C.O.G., F.I.C.S. (U.S.A.), F.A.C.S. (U.S.A.)
Prof. and Head, Department of Gynaecology, Obstetrics &
Family Planning
Residence: GD-207, Salt Lake, Kolkata – 700 106, Phone: +91-33-23376954 (Mobile: +91-9333315050)
Information about the Book: This book describes the details of healthy breastfeeding practices which are
recommended by Internationally Recognized Academic Bodies. Unfortunately many
women are unaware about the details of normal breastfeeding practice. As such
quite often the baby is put to breast 24-48 hours after their birth. Colostrums
(Yellow Milk) the first milk which is secreted soon after birth is often denied
to new born which is a very bad practice. Because this colostrum contain many protective
factors which prevent diarrhoea and bronchitis of infants. It is a
common observation that before putting to breast for the first time after birth
some other liquid food is offered e.g. water, honey or sugar water (pre-lacteal
feed). These interfere with subsequent milk production in the mother’s breast.
Many a mother do not know what is meant by Exclusive Breastfeeding for first
six month after childbirth. The position of the mother and the position of the
infant during the breastfeeding process are seldom discussed in the prenatal or
postnatal visits; as a result often a part of nipple only is introduced in the
mouth of infant. Ideally entire nipple, areola and a part of breast should be
put to the mouth of the infant so that he / she can suck the breast adequately with
full force and can draw his / her food in a natural way. This is often a common
cause of inadequate milk production in the breast. This treatise also discusses
the importance of breast milk in maintenance of health of infant. It also
highlights how to breastfeed a sick child and how a working mother can help her
baby to get own breast milk in spite of her busy office work. This is an
important book for all women who are going to give birth soon or who are
already breastfeeding their child. A Chapter on human breast milk banking has
been included.
Initiation of Birth Control Measures after Childbirth and Choice of
Contraceptives during breastfeeding period
(Postpartum
return of ‘menstruation’, ‘ovulation’ and ‘fertility’ – possibility of
unintended pregnancy in lactation period – list of available contraceptives
which may be safely used during postpartum period)
I.
Defining the
Problem: When fertility returns in lactation period? The answer not exactly known:
The exact time of the fertility returns in postpartum period
eludes the awareness of many women. The proper timing of initiation their
understanding and appreciation. Scientists too are equally in dilemma so far as
timing of initiation of contraceptives after childbirth is therefore not within
the orbit of their understanding and appreciation. Scientist too are equally in
dilemma so far as timing of initiation of contraceptives after childbirth is concerned.
This is simply because there is no set chronology of events like ‘return of menstruation’, ‘resumption of sexual activity’ and ‘restoration of ovulation’. All these
variations are primarily due to changes noticed in breast feeding practice and
thus the possibility of further pregnancy. Return of ‘fertility’, though
primarily depend upon frequency and duration of breastfeeding but there is
gross individual and racial variation. It is all these variations which have
prompted the author to write a special chapter on this issue i.e. timing of
initiation of contraceptives in lactation period.
In spite of innumerable member of cross Country
population breast studies the speculation on return of ovulation and thus
possibility of face pregnancy in postpartum period still remains a matter of
speculation :
We know
that pregnancy to occur there must be availability of egg released from ovary a
process termed as ‘ovulation’. Sperms also must be available in female genital
tract by the process of sexual intercourse. The act of intercourse however can
be easily assessed by the couple themselves but the process o ovulation and
thus presence or absence of ovum can’t be assessed neither by the wife nor by
the husband. Because the process of ovulation do not cause any noticeable
symptom or distress so that no woman can say with certainity when she has
ovulated and thus in need of contraception unlike ‘menstruation’, ‘breast
feeding’ and ‘sexual act’ unfortunately the process of ovulation remain
asymptomatic.
Due to lack of this scientific
knowledge some women are unnecessarily initiating contraceptive too early.
There is still another group who are eager to use contraceptive but they do so
quite let in lactation period. This chapter critically analyze the different
factors that influence the return of ‘fertility’ in postpartum period. This
chapter also highlights the time of initiation of contraceptives at an
appropriate time and taste of contraceptives which can be safely used in
lactation period. The magnitude and impact of ‘unintended pregnancy in
lactational period have also been discussed briefly.
II.
Where we were?
What the couple used to do earlier in initiation of contraceptive?
At the
present time of writing a conclutions couple has three choices about timing the
initiation of contraceptive lactation period. Firstly, the couple consider
initiation of contraceptive whenever they resume sexual activity after
childbirth. Logically it is a good practice but, quite often the sexual
activity resume after childbirth time when many women are naturally infecund
due to lack of resumption of ovulation. Thus if initiation of sex is considered
as the index of commencing contraceptive there will be always a chance of
initiation contraceptives too early which is possibly a burden to the couple.
As stated earlier, unlike menstruation and ‘sexual act’ the act of ovulation can
not be perceived by the woman. Thus a woman remains unaware about resumption of
ovulation in postpartum period.
There is a second
group of women who start using contraceptives only when they discontinued
breastfeeding : But this phylosopy is wrong and unscientific because
many woman do omlete after six month of childbirth insitite of continued
breastfeeding. There is a third group of couple who would like to commence
contraceptive whenever menstruation resumes in postpartum period. This
philosophy apparently sounds well but a doption of this method of initiating
contraceptive is also unscientific such policy may giverise to unintended
pregnancies because in many breastfeeding women ovulation precedes visible
event of menstruation. Thus scientifically speaking restoration of menstruation
also cannot be used as an index of initiation of contraception.
III.
What woman
expects from Science ?
Most couple would like to start
contraceptive when ovulatin resumes and dislike using contraceptive
unnecessarily before resortion of ovulation. There is a real taste of science
in this belief. Thus return of ovulation as an indexx of starting contraception
though scientifically correct but the process of ovulation can’t be gauged at
the present state of knowledge.
No cheap method for detection of
resumption ovulation is available. It would have been easier on the part of
couple and scientists too if there have been a easy ready made low cost but
predictable monitoring method of assessing maturation and release of eggs.
Unfortunately whatever home monitoring tests for ovulation exist that are too
costly for planning contraceptive use. Till date the use of these tests are
limited to infertility treatment only.
What PREVALENCE AND ILL EFFECTS
OF ‘ POVERTY ‘ AND
THEREFORE ‘HUNGER BURDEN ‘
& ‘MALNUTRITION’ OF OUR
RURAL PEOPLE
IV.
On which factors
the present day woman should depend on initation of Contraceptive?
Thus till
date couple as well as scientists are arbitrarily guided by three indices.
These are a) nature and freqauently of breastfeeding b) the event of return of
menstruation. And c) resumption of sexual activity. Return of ovulation though
the most decisive index of commencing contraceptive cannot be used by couple as
index of initiation of contraception population at the present state of
knowledge.
Additionally in office seeting i.e. when a couple come to clinic for advice
in postpartum period the contraceptive specialists usually require on nature of
breastfeeding practice and return of menstruation as the two indices for
planning on contraceptive use in postpartum period and the HCP thus tries to
correlate the possibility of return of ovulation with these to events. This is
just a gress of prob ability of becoming pregnancy.Couple too have relied either
on return of menstruation or initiation of sexual activity as indices of
initiation of contraceptive and of they at all rely on nature of breastfeeding
they consider wearing as the index.
Contraceptives which are licensed abroad but not
available in India (Newer birth control options):
1) Extra-pleasure
condms, Oscillating condms, Glow-in-dark condms, Extra strenth-Cond ms, Extra thin-Condms , Baggy Design Condms
etc etc.
2) Synthetic
Male Condoms
3) Newer Oral
Contraceptives, (Minesse, Sesonale).
4) Monthly Injectables
(for women e.g. Lunella)
5) Newer
quarterly shots (Sub cut route)
6) Contraceptive
Impalnts (Implanon)
7) Transdermal
patch (Ortho Evra patch), application weekly.
8) Vaginal
rings (NUVARING)
9) Frameless
IUD & other newer IUD’s
10) Newer
contraceptive sponge e.g. (conceptral & Protectaid sponge)
11) Electronic
Fertility Monitor (persona)
12) Reddy
Female Condom
13) New
certical barriers (Fem Cap/Lea’s shield)
This
description does not cover all new contraceptive that have been released
abroad.
V.
Summary of the present problem : Where we are now?
Principally there are four factors which
control return of ovulation and the restoration of fertility and each of the
factors mentioned below deserve detailed discussion. The factors are a>
Frequency and duration of ‘breastfeeding’, b> Restoration of ovulation,
c> Resumption of ‘menstruation’ after childbirth and above all, d>
initiation of ‘sexual intercourse’. Let us now analyse the role of each of
these four factors and each of these four factors incluence return of fecludity
independently it is worth remembaring that though breastfeeding, take a lead
role but the process of restoration of ovulation resumption of mensturation are
usually but not always interrelated. We shall see in the following pages that
always choice by benefit for and resumption of menstruation. The process of
‘ovulation’ and ‘resumption of menstruation’ are not always controlled by
breastfeeding. Giving identical time in breasefeeding two woman will outlet in
different times. Thus it is this natural ovulation which cause much concerned
to couple to fix up a time for initiation of contraceptives.
a)
Frequency and duration of breast
feeding per 24 hours
b) Resumption of menstruation
c) Initiation of sexual activity
d)
Return of ovulation (arbitary)
All these four factors have been discussed
at length in the following pages. The relevance of al these four factors have
been explained in details thus enabling couple to initiate contraceptive at a
reasonably appropriate time. Admuttedly, till date there is as yet no set
guideline about commencement of contraceptive in postpartum period due to
inaccuracies fallancies of all these four indices to foretell about the
probability of pregnancy.
A.
Nature of breastfeeding and return of postpatum fecundity :
So far as duration of postpartum
insusceptibility to pregnancy is concerned not only the total months for which
the infant is breastfed is mportant but frequency and total duration of
breast-feeding per twenty four hours are also important. Presumably, many
educated couple are aware that frequent breastfeeding practice prevents
conception by inhibiting release of eggs from ovaries but only few of them are
aware that adoption of this method of natural contraception has been recently
renamed as ‘Lactational Amenorrhoea Method (LAM)’ PARA. In LAM there are three
factors to be considered. Unfortunately for lack of proper publicity few Indian
couple have an clear idea on thest three essential criteria to make LAM method
of natural contraception successful. These three criteria are a) exclusive breastfeeding including on or
two feeds at night b) Persistence of postpartum
ammenorrhoea (nonoccurence of menstruaton) and this contraceptive efficacy
of LAM last only for first-six months
after childbirth. Contraceptive effieacy fades after six months inspite of
continued breastfeeding.
The importance of breastfeeding in
preventing contraception can be easily ganzed by following observation.
Sevently-five percent of non-lactating Indian women conceive within six to nine
months of delivery if effective contraception is not practised as against only
7-10 percent of those who breastfeed as per international norms.
B.
Partial breastfeeding and early return of fertility :
How vulnerable are women who breastfeed
infrequently or for only short duration, ‘Menstruation’, ‘Ovulation’ and
therefore ‘fertility’ return sooner than expected in such women and unintended
pregnancy can occur quite early say within three or four months after
childbirth inspite of continued partial
breastfeeding.
Owing to lack of this particular scientific
information many women fall prey to unintended pregnancy in lactation period.
They are under the false impression that they are immune to pregnancy because
of so called breastfeeding. In fact, partical breastfeeding confers little
protection against pregnancy as suckling of breasts in infrequent and hence
ovulation is not inhibited appropiately. The incidence of ‘escape ovulation’
during partial breastfeeding though not universal but is a distinct
possibility.
C.
What is then partial breastfeeding?
By partial breastfeeding we mean infreqent
and short-lived breastfeding that needs to be supported and supplemented by
edible extra-milk or non-milk products before six months of age. This practice
of providing extra-feeding is the total negation of science. If partial
breastfeeding practice is adopted then twenty percent of such women will
menstruate as early as two months after childbirth! I wonder, how many
partially breastfeeding Indian mothers are aware of this fact before they
embark on unprotected intercourse.
In fact, they simply do not know that they
are susceptible to pregnancy even as early as two months after childbirth! I am
also convinced that majority of such Indian women do not use any contraceptive
whats over as this early postpartum phase. It
is thus importantto fully breastfeed for first six months to avail and enjoy
contraceptive efficacy of breastfeeding. Some scientist however claim that
‘Lactation’ and ‘Ovulation’ are antagonistic but it has
now been proved that this principle does not hold good after six months
postpartum. What happens is that during lactation prolactin hormone in maternal
blood (milk secreting hormone) is high and this hormone suppresses the action
of gonadotrophins (hormone responsible for release of eggs from ovaries). To
simplify, ovaries of breastfeeding women are to some extent refractory to the
actions of gonadotrophin hormones responsible for release of eggs. So elease of
eggs from ovaries remain suspended at least for first six months provided no
supplementary feed is allowed and menstruation has not resumed. This is
exactily what has been called earlier, Lactational Amenorrhoea Method of
contraception (LAM).
D.
Return of Ovulation in postpartum period :
Postpartum Return of ovulation release of eggs varies from woman to
woman and as stated earlier, the timing of first ovulation in postpartum period
primarly depend on frequency of breastfeeding and duration of breastfeeding. In
nonlactating mothers ‘ovulation’ can rare occationally resume as early as
twently one day after childbirth. Many nonlactating women do ovulate by sixty
days postpartum.
By contrast who breastfeed as per international norm in them
resumption of ovulation frequently preceed the onset of menstruation. So the general belief of commencing
contraceptive after resumption of menstrual period does not hold good.
Unfortunately, many Indian women still believe that unless menstruation returns
till then she is protected from pregnancy. This false sense of security is a
common cause of unintended pregnancy in postpartum period.
E.
Return of
menstruation and return of fertility :
S. long we have discussed about role of breastfeeding in
preventing pregnancy. We now focus on the spatial relation of return of
menstruation in postpartum period and possibility of fresh pregnancy.
Postpartum amenorrhoea i.e. nonoccurrence of menstruation is
the interval between the birth of a child and resumption of menstruation. It is
the period following childbirth during which a woman becomes temporarily and
involuntarily infecund.
Admittedly the duration and frequency of breastfeeding
primarily govern the length of postpartum amenorrhoea but there are other
hitherto unknown factors as well. As breastfeeding practice varies in different
parts of India so also the duration of postpartum amenorrhoea (nonoccurrence of
menstruation). However the usual trend of amenorrhoea amongst India women is
discussed below.
Postpartum initiation of sexual intercourse :
As this chapter is dedicated to fix up the time of initiation
contraceptives in postpartum period it will be pertinent to highlight some
aspects of human sexual behavior in postpartum period.
Postpartum coital behavior varies greatly in different parts
of globe. Initiation of sexual activity depends on factors like socio cultural
taboo, health of the partners, nature of delivery (natural or caesarean)
whether the women stays at her father’s residence and obviously the educational
status of the couple. By and large most couple start enjoying sex by three
months after childbirth. A woman need not consider contraceptives if she is not
exposed to the risk of pregnancy either because she is amenorrhoeic (true for
first six months of after childbirth) or because she is abstaining from sexual
intercourse.
A recent European study revealed that after a normal birth
ninety-four percent abstain from sex in first month and as postpartum duration
proceeds the rate of abstinence falls. As many as twenty percent of European
women abstain from sexual intercourse eight month after birth and only as
twelve percent retain from sex even twelve months after a birth! By contrast, a
U.S. study, conducted in 1998 revealed that two thirds of new mothers report
having resuming sexual activity by fourth month. Unfortunately, in the same
study was also observed that fifteen percent of lactating women with last
childbirth beyond six month report being
sexually active but not using any contraceptive method and thus are at risk
of unintended pregnancy. Due to lack of contraceptive knowledge they are simply
unaware about the possibility of unintended pregnancy.
What about India? The proportion of mothers abstaining from
sexual intercourse in the first month
after a birth is nearly the same as the proportion amenorrhoeic (94 percent and
96 percent, respectively), but the proportion abstaining falls far more quickly
with the passage of time since birth than does the proportion who are
amenorrhoeic. Only one-quarter of mothers are still abstaining from sexual
intercourse four months after a birth, and by six months, 85 percent of India
women have resumed sexual relations (source : NFHS – 3).
What exactly than the time of postpartum initiation of
Contraceptive :
Care should be exercised in individualizing such timeframe
one should remember that sperm retain fertilizing capacity in the female
genital tract five days after intercourse. Thus, it would had been appropriate
if women could have assessed first postpartum ovulation process 3-5 days prior
to the occurrence of ovulation. So that appropriate contraceptive method may be
initiated prior to first ovulation. Unfortunately till date there is no such
subjective symptom or Laboratory test exist which can detect ovulation 5 days
prior to ovulation. Thus individulaizan of initiation of contraceptive and
possibly to some extent unscientific.
The degree of lactation induced inhibition of ovulation is
difficult to assess fromhistory and only a gress is possible. For instance, if
frequent and prolonged breastfeeding is going on then early use of
contraceptives may constitute and unnecessary
double protection i.e. L.A.M. along with some other contraceptive what
should be then, the take home message?
The international guideline is that a) for fully breastfed
women (not giving any artificial milk, fruit juice honey etc.). Who has not yet
started menstruation contraception should be commenced after six months of
delivery. There is only two percent chance of conception during the last two
months i.e. fifth and six month of postpartum period. One can use some
contraceptive in those two months if one intends to avoid the said 2% risk
though that is not the usual recommended protocol. B) Nonlactating women on the
other hand and who partially breastfed they should definitely start
contraceptive by two and four months after childbirth respectively unless the
start menstruating earlier. C) After an abortion (spontaneous a induced) one
should start using contraception after two weeks and not later. Before this
timeframe for all practical purpose pregnancy is very unlikely though not
impossible.
One may ask why not to initiate contraceptive from the very
first sexual act in postpartum period? There is no harm if one opts using a
contraceptive from the very first coital act after childbirth. But one has to
consider that no contraceptive is 100% effective. If one accepts this
philosophy of occasional ‘contraceptive accidents’, which is not uncommon, then
above mentioned guideline is possibly more acceptable to couple rather than
very early inihiation of contraceptive.
Contraceptive Options after childbirth :
We have discussed about the timing of introduction of
contraceptives in detail but attention must also be given to the type of
contraceptive methods that are safe in this special period. Whatever
contraceptive is choosen one has to remember that baby is breastfeeding and
many drugs including systemic contraceptive are excreted in breast milk. Thus
early initiation of systemic contraceptive (Tablet/Injection) should be better
avoided unless they have proven safety profile for infant. The usual choices
for first six months are male barrier methods (condom), progesterone-only-pill,
intrauterine contraceptive devices three monthly progesterone injections and
subdermal implants (not available in India) on emergency situation one can
resort to morning after pills e.g. postcoital pills.
We are whose that all hormonal contraceptives and IVD are
very effective contraceptive but combined oral contraceptives reduce the milk
secreting hormone prolactin and thus volume of milk may be reduced
considerably. Therefore combined oral contraceptives which interfere with
lactation process is not recommended at least for first six months postpartum.
If hormonal contraceptives are used at all only progesterone containing methods
should be used which do not reduce milk flow. These are either minipill (P) and
three monthly injections (P).
Female barrier methods too may not be that effective due to
laxity of genital tract Vaginal topical contraceptives like (sponge, pessaries
and foam tablets (spermicides) are not very effective one. Couple often do not
rush into permanent sterilization (vasectomy for male or tubectomy for female)
in postpartum period unless family size is complete and a proper counseling is
done in antenatal period. Many a couple repent after undergoing permanent
sterilization. Where decision has been taken in a hurry and sometime they
course health care provides for not allowing sufficient time to think over the
issue of permanent sterilization (Tubectomy).
List of Contraceptives in postpartum period :
A. Natural Methods :
a)
Coitus interruptus (P)
b)
Lactational Amenorrhoea Method (P)
c)
Safe Period Method (P)
B.
Barrier
Methods :
a)
Male Condom (P)
b)
Female Condom (P)
c)
Spermicides (P)
C.
Hormonal
Contraception (Progesterone only) :
a)
Progesterone only pill (P)
b)
Quarterly Injection (P)
c)
Subdermal Implant (P)
D.
Intrauterine
Device :
a)
Copper containing IUD (P)
b)
Progesterone hormone containing IUS (P-4)
c)
Newer IUDs (P-4)
E.
Emergency
Contraceptives :
F.
Permanent
Method :
a)
Vasectomy (P)
b)
Tubectomy (P)
List of Contraceptives and timing of inihiation of
Contraceptives after childbirth or abortion.
|
Nature of Family Planning
Method
|
How early
one can adopt family
planning measure
|
||
|
Non Breastfeeding
|
Breastfeeding
|
After Abortion
|
|
|
1) Lactational amenorrhoea
|
Not applicable
|
Immediately
|
Not applicable following
first trimester abortion IUD may be applied immediately
|
|
2) Copper IUD
|
Within 48 hours, otherwise
delay 4 weeks (WHO Category-2)
|
||
|
3) Male Condom
|
No
|
Restriction
|
|
|
4) POP
|
Immediately
|
Delay 6 Weeks
|
One can use these methods
within seven days of abortion
|
|
5) Progestion only
injectables
|
Immediately
|
Delay 6 Weeks
|
|
|
6) Implants
|
Immediately
|
Delay 6 Weeks
|
|
|
7) Combined Inj. COC, weekly
contraceptive patch contraceptive vaginal rings
|
Commence 3 Weeks after
childbirth
|
May be used after six
months (but better to avoid so long baby is breast following (Category-2
risk)
|
COC may be commenced on
the following day of abortion
|
|
8) LNG IUS
|
Delay 4 Weeks
|
Delay 4 Weeks
|
|
|
9) Spermicides
|
Immediately
|
|
|
Following
second trimester abortion (gestational period 14-20 Weeks) one can be fitted
with copper bearing IUD or LNG IUS (Mirena IUD) but expulsion rate of the
device will be greater compared to first trimester abortion. These is no
diference in safety or expulsion rate after insertion of LNG IUS compared to
Cu-IUD.
Return of fertility after abortion :
Any
conscientious couple will like to know probable duration between abortion and
return of ovulation so that they can use contraceptive at appropriate time.
Following an abortion, (Spontaneous or induced) a woman generally menstruates
within four to six weeks. Contrary to term childbirth, the first period is often ovular in at least 75-85 percent of cases. As
a matter of fact ovulation has been documented as early as eighteen days after
spontaneous abortion. However, the mean time of commencement of ovulation post
abortion period is 22-33 days. Hence, the chance of inadvertent pregnancy is
much common after an abortion than after term childbirth. The golden rule, therefore, will be to initiate contraceptive two weeks
after abortion. It is a herculean task on the part of doctors to counsel
and communicate this message of timely initiation of contraception to 10
million mothers who undergo induced abortion annually in India as most of these
women are non users of contraceptives. Paramedical staff, NGO officials and
media can help to spread this message of reproductive health to such women Who
may fall into prey of another pregnancy after induced abortion.
Relevance of Contraceptives what will happen if a
couple do not use contraceptive?
We were so long talking on initiation
of contraceptives in postpartum period. Let us view the problem in a reverse
way. What are the benefits of timely use of contraceptives? We know that the
very purpose of using contraceptive is to avoid unintended pregnancies and non
use can lead to mistimed pregnancy during lactation period. As conceivable most
women proceed for induced abortion if they unfortunately conceive during
breastfeeding period and in India many such abortion procedures are being
carried by nonmedical persons (backstreet abortions). Interested readers may now
enquire what is the global incidence of induced abortion? We are aware of the
fact that globally about 210 million pregnancies do occur annually. We also
know that not all pregnancies go to term. About fifteen Percent to twenty five
percent of all human pregnancies end in abortion before three months of
gestation. This unfortunate though alebait natural process is commonly called
miscarriage and no cause can usually be ascertained for this mishap. So far as
induced abortion is considered one will be surprised to know that globally
about 20 million pregnancies are voluntarily terminated each year! It is also
estimated that 68,000 young women embrace death annually out of backstreet
abortion. Conceivably many such unwanted i.e. mistimed pregnancies do happen in
lactational period and hence the relevance of commencing contraceptives in
postpartum period at most appropriate time. The whole idea is to avoid untimely
pregnancies and miseries of induced abortion.
Induced Abortion Rate in India –
‘Difference between ‘Recorded figures’ and ‘Estimated figures’. It is also
estimated that about 10-15 million sontanous miscarriage do occur with great
distress to the women concerned and grief to family members. In India there is
28 million pregnancies per year with
annual birth rate of 25 million and misages. But A large number of abortions
are intentionally carried out in India even today for nonuse of contraceptives.
There are many causes for nonuse of contraceptives. The abortion rate in India
is 40-7- abortions per 1000 women of reproductive age which comes to an
abortion ratio of 260-450 per 1000 live births! It is difficult to collect and
definite figure on total annual induced abortion in any country but the estimated
figure is only 1-2 million per year. There is about 12,000-20,000 maternal
deaths per year due to such clandestine abortions in India. As a matter of fact
33-50 % of Indian women undergo at least one induced abortion in their
lifetime! This is simply due to nonuse of contraceptives. Most of these
abortion are carried out when the youngest child is below two years of age i.e.
in lactation period.
The death
rate of such induced abortions if carried out in unsafe surroundings is about
50-200 per 1,00,000 such procedures which amounts to one maternal death in
Indai in every 50 minutes due to unsafe abortion! All these figure points to
relevance of contraceptives use in lactation period.
We have so long discussed about magnitude and illeffects of
abortions in India. But what is the global situation? Unless we realize the
magnitude of unsafe abortions we will not be able to asses the relevance or
importance of contraceptive use in appropriate time nether the Indian couple
will be able to realize why World Health Organization has declared contraceptives
as essential drugs.
Scrutiny of National Unintended Pregnancy Rate in
India Reveal that many Indian couple do not use contraceptives.
The ‘unintended pregnancy rate’
varies in different countries. It depends not only on format education but also
on contraceptive availability and contraceptive awareness of the couple of that
country. For instance in India twenty one percent of all pregnancies that
resulted in live births during the period 1997-98 and also in 2005-06 were
unplanned i.e. unwanted at the time the women became pregnant. Ten percent
women wanted later (mistimed pregnancy) and eleven percent women did not want
all (source: National Family Health Survey-3, p.108). These statistics however
refers to only those ‘untimely’ and ‘never wanted’ pregnancies which ended in
live births. These statistics however do not include large number of unwanted
pregnancies which ended in spontaneous or induced abortions or stillbirths
taken together at is estimated that 50-60 % of pregnancy are either mistimed or
unwanted! All these statistics point out that even today millions of such
unwanted or mistimed pregnancies continue to occur in our country. It is
needless to mention that majority of these mistimed pregnancies do occur during
breastfeeding period and admittedly these mishaps occur due to lack of back
knowledge of contraceptive amongst Indian couple.
Task of Indian Health care Providers (HCP):
We, the health Care Providers (HCP),
have to spread the message of usefulness of timely commencement of postpartum
contraception. Admittedly, this is a huge task because In India there is 168
million eligible couple (as on 31.3.99) and on an average 2.5 million couple
enter into reproductive group each year. There is always a burden of 27 million
pregnant mothers with 25 million annual
births. So if one intends to minimize wanted births and further population
rise the same, then has to counsel all would be Indian mothers about importance
of timely initiation of postpartum contraception. Admittedly, this message has
to be communicated to all 25 million of women annually who are going to be
mothers at or near term. For first time pregnancy of women such counseling
session will probably require fifteen minutes or more depending upon the
intelligence of the woman (men seldom join in counseling session at hospital).
Fortunately, for multi gravid a short reminder will hopefully suffice. This
will snatch much of the time of HCP and Counseling such huge number of women is
not an easy task indeed. This may be the reason why Govt. of India has very
recently appointed 4,00,000 female Accredited Social Health Activists (ASHA)
who will act as interface between the community and the public health system for
examples ANM and Doctors of community Health Centres (Source: National Rural
Health Mission for 2005-12).
Miseries of unwanted child birth & abortion:
It may be mentioned that there is
approximately 1,00,000 maternal deaths in India and 22.8% mothers do not
receive any antenatal care. Trained Birth Attendant (TBA) is not available
during child birth in 53.4% cases and anaemia in pregnancy is ???? common (56%). Thus one ca easily
imagine the magnitude of the task placed before HCP of India.
Keeping all these sufferings of
Indian Women in mind let us now critically analyze how best we can help Indian
mothers in postpartum period, so that they do not fall prey to accidental
pregnancy in postpartum period.
The national impact of unwanted birth as evident in
HFHS-3 survey (2005-06):
The proportion of births that were
not wanted at all increases sharply by birth order of children, from just I
percent for first order births to 29 percent for births of order four and
above. The impact of unwanted fertility can be measured by comparing the total
wanted fertility rate with the total fertility rate (TFR). The total wanted
fertility rate represents the level of fertility that theoretically would
result if all unwanted births were prevented. The total wanted fertility rate
of 1.9 is lower by 0.8 children (i.e. by 30 percent) than the total fertility
rate of 2.7. This means that if unwanted births could be eliminated, the TFR
would drop to below the replacement level of fertility (1.9 children per
woman). The difference between the total fertility rate and the total wanted
fertility rate is larger for rural women (0.9 children) than for urban women
(0.5 children). Reduction of unwanted fertility amongst rural women
particularly those with no education was one of the key message of NFHS-3.
Because rural women and women with no education form a large proportion of the
population, the TFR would drop substantially if their unwanted fertility could
be eliminated.
Concluding Remarks :
The answer to the question as too
when one should start contraception after childbirth is not known her to
scientists though. It is a pertinent and perplexing question to all couple. Do
all women need to initiate contraceptive in postpartum period after a fixed
time frame? Unfortunately, the answer is in the negative Even in twenty first. Many
Indian couple are bewildved about the time of initiation of contraceptives in
postpartum period. Some start too early such as couples of well to do
families say few wells after childbirth. Again there are millions of women who
practice contraception quite late say after couple of months after childbirth.
Indian mothers do seldom have appropriate scientific knowledge on reproductive
health. Another issue also remains to be explained to couple i.e. about which
contraceptive will be safe during postpartum period because most mothers are
worried about contraceptive induced risk of infant rather than her won risk of
untimed pregnancy. Let us now place the facts before you.
Veganles of resumption
of menstruation and ovulation create a problem for the care givers to advice
about the initiation of contraceptives in postpartum period. Some couple and HCP
are too cautions and therefore prescribe contraceptives too early white others
advise to start contraceptive at a later date. Then hat is the golden rule
which should be adopted by postpartum women?
If one does not like to take any
chance of unwanted pregnancy i.e. desires cent percent protection from
pregnancy then fully breastfeeding women will have to use contraceptive as soon
as menstruation resumes or on the very first day of seventh month of postpartum
period whichever appear earlier. But for those who partially breastfeed they
should not wait for resumption of menstruation. Instead, they should use
contraceptive after two months of childbirth the latest.
We know that the inhibition of egg
release process primarily depend on duration of suckling. The longer the
lactation is continued, the more likely that the ovulation process (i.e.
monthly release of eggs) will remain suspended. This made of ovulatory
suppression effect disappears quickly once complementary feeding (extra drink
or food) is introduced i.e. partial breastfeeding.
Unfortunately in India the median
length of ‘exclusive breastfeeding’
is only two months and the median length of ‘predominant breastfeeding’ i.e.
breastfeeding plus supplementing plain water and/or non-milk liquids is five
months. As explained earlier, supplementation and bottle feeding has a direct
effect on the mother’s exposure to the risk of pregnancy because the period of
amenorrhoea may be shortened when breastfeeding is reduced or completely
replaced by bottle feeding. Early supplementation is thus a gross negligence on
the part of mother, family members and possibly caregivers counselors too.
Because incomplete factual counseling during prenatal visits may be the main
cause of such irrational and unscientific breastfeeding practice in India.
Regarding choice of contraceptives
one ca choose barrier methods like made condom, pop pill, three monthly
progesterone injections or IUD after six months after the birth of baby if baby
is still breastfeeding. In case of nonlactating mother in addition to those
methods for mother can opt. for combined oral contraceptives or sub dermal
implasnts (implanon Emergency contraceptives may be used in special
situations).
|
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Prof.
S.K. Pal
GD-207,
Kolkata – 700 106, India, Mob: +91-33-9333315050
Also
available at M/S Soshibhusan Mitra
& Sons,
55,
M.G. Road, Kolkata – 700 009, India
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