. 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. Coitally 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-Armor 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:
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.
Breastfeeding Network Drug line (a
registered charity) –
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 accessed
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 certainty 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 conclusions
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 in fecund 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 cannot 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 philosophy is wrong and
unscientific because many woman do omelet after six month of childbirth insatiate
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 adoption of this method of initiating
contraceptive is also unscientific such policy may give rise 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 ovulating resumes and dislike
using contraceptive unnecessarily before resorption of ovulation. There is a
real taste of science in this belief. Thus return of ovulation as an index 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 readymade
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 imitation of Contraceptive?
Thus till date couple as well as
scientists are arbitrarily guided by three indices. These are a) nature and frequently
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 seating 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 two events. This is just a grass of probe 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
condoms, Oscillating condoms, Glow-in-dark condoms, Extra strenth-Cond ms, Extra thin-Condoms , Baggy Design Condoms
etc.
2)
Synthetic
Male Condoms
3)
Newer
Oral Contraceptives, (Minesse, Seasonable).
4)
Monthly
Injectables (for women e.g. Lunella)
5)
Newer
quarterly shots (Sub cut route)
6)
Contraceptive
Implants (Implanon)
7)
Transdermal
patch (Ortho Vera patch), application weekly.
8)
Vaginal
rings (NUVARING)
9)
Frameless
IUD & other newer IUD’s
10)
Newer
contraceptive sponge e.g. (conceptual & Protectaid sponge)
11)
Electronic
Fertility Monitor (persona)
12)
Reddy
Female Condom
13)
New
cortical 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 precede 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 in fecund.
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 individualizing of initiation of contraceptive and possibly to some extent
unscientific.
The degree of
lactation induced inhibition of ovulation is difficult to assess from history
and only a grass 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 initiation
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 chosen 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 sub dermal 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 interrupts (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)
Sub dermal 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 initiation 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)
Progestin
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 difference 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 ale bait
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 spontaneous 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 massages. 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 India 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 ill effects of abortions in India. But what
is the global situation? Unless we realize the magnitude of unsafe abortions we
will not be able to assess 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 can 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 to 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.
Regales 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 can 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 implants (implanon Emergency contraceptives may be used in
special situations).
|
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Prof.
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GD-207,
Kolkata – 700 106, India, Mob: +91-33-9333315050
Also
available at M/S Soshibhusan Mitra
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Road, Kolkata – 700 009, India
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