Breast Feeding Promotion week

Let us discuss when to initiate contraception after childbirth and as expected this initiation relates to returns to ovulation after childbirth .Read and pass your comments please how you advise when you / your Asst discharge a case from hospital after delivery.

Breast feeding Promotion Weeks is every First Week of year across the Globe : 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,             (Mobile: +91-9333315050)

 

August first week:-:”The Global Breast feeding Promotion week” : August each year     This week  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 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 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 insititus 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, Sesonale).

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 cervical 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 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 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 guess 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 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 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)                  Progesterone  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 albeit 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 miscarriages  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.

 Vegaries 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).