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