Breast-feeding and fertility regulation: current knowledge and programme policy implications.

Articles in the Update series Les articles de la rubrique give a concise, authoritative. Le point fournissent un and up-to-date survey of the bilan concis et fiable de la present position in the se- situation actuelle dans le puale , , lected fields, and, over a domaine considere. Des ex-/ / / &~~~~~~~eriodof years, will cover / perts couvriront ainsi suc- / many different aspects oJf cessivement de nombreux the biomedical sciences aspects des sciences bio- / n{>},/Vll gf ( / and public health. Most oJf mddicales et de la sant / the articles will be writ- publique. La plupart de ces ten, by invitation, bY ac- articles auront donc ete knowledged experts on the rediges sur demande par les subject. specialistes les plus autorises. Bulletin ofthe WorldHealth Organization, 61(3): 371-382 (1983) © World Health Organization 1983 Breast-feeding and fertility regulation: current knowledge and programme policy implications* A WHO/NRC MEETING Lactational anovulation associated with amenorrhoea resulting from exclusive breast-feeding represents an important child-spacing mechanism in many Third World countries. This is because frequent stimulation of the nipple during breast- feeding produces neural inhibition of the hypothalamus, diminished secretion of pituitary gonadotropin, and inhibition of ovulation and menstruation. In places where contraceptive services are available, care should be taken to rationalize the use of contraceptive methods together with the lactation-induced inhibition of ovulation. If prolonged breast-feeding is likely, the early use of contraceptives may constitute unnecessary double protection; however, in cases where contraception is discontinued and lactation has been reduced or terminated, the mother may be placed at a higher-than-normal risk of becoming pregnant; attention must be given to the type ofcontraceptive method chosen, as well as to the timing of its introduction. Combined oral contraceptives reduce the volume of milk and may interfere with lactation. However, neither hormonal nor non-hormonal contraceptive preparations appear to interfere with initiation of milk production. A consistent policy on lactation and fertility regulation is lacking in many countries. Policies should be developed according to the national health needs and circumstances, including local patterns of breast-feeding and weaning, and the duration of lactational anovulation/amenorrhoea. National guidelines should include the promotion of breast-feeding for at least four months, continuation of breast-feeding after supplementaryfoods have been introduced, legislative and social supportfor breast-feeding, and preference for non-hormonal contraception during the first 4-6 months post-partum. During the past few years, there has been a rapid increase in knowledge about the relationship of breast-feeding and suckling practices to reproductive function, and about the social and health consequences of unregulated fertility and close birth-spacing on mothers, the family and the community. The steady decline in breast-feeding presents a significant hazard to infant health, particularly in the developing countries. The main- tenance of breast-feeding, on the other hand, is known to be conducive to increased birth- * This article is based on the summary report of thc WHO/NRC Joint Workshop and Programme Policy Meeting on Breast- feeding and Fertility Regulation, sponsored by the Special Programme of Research, Development and Research Training in Human Reproduction and the Division of Family Health of WHO and the US National Research Council, and held in Geneva in February 1982. Requests for reprints should be addressed to Division of Family Health, World Health Organization, 1211 Geneva 27, Switzerland. A French translation of this article will appear in a later issue of the Bulletin. X A full list of participants is given on pages 380-381. 4292 -371- 372 WHO/NRC MEETING spacing and although contraceptive techniques are a major factor in reducing fertility, their effect on the continuation of breast-feeding must also be taken into account. Lactation, nutrition, and fertility are clearly interrelated, and any modification of one may well have unforeseen and possibly deleterious effects on the others. CONTRACEPTIVE EFFECTS OF LACTATION In many developing countries, the contraceptive effect of breast-feeding, more than any other method of control, promotes the longer spacing of births.a Recent studies have shown that lactation exerts a strong contraceptive action because frequent stimulation of the nipple, during suckling, leads to neural inhibition of the hypothalamus. The conse- quent decrease in pituitary gonadotropin secretion, in turn, inhibits ovulation and promotes amenorrhoea.b The contraceptive action of breast-feeding is lessened by decreased suckling frequency; this may be brought about by such practices as scheduled rather than on-demand feedings (in part, occasioned by separation of the baby from the mother during the day or night), reduction in night-feeds, introduction of bottle-feeding, and use of "4pacifiers"s.c Together with the spread of these practices, less attention has been given to the contra- ceptive effect of breast-feeding especially in areas where women breast-feed infrequently and provide their infants with bottle-fed supplements, and thus experience early resump- tion of menstruation and ovulation and are at high risk of pregnancy. Fortunately this has not thus far become typical of many developing countries, where traditional breast-feeding practices have continued and where lactational amenorrhoea for 1-2 years, or even longer, is still common.d Lactational anovulation associated with amenorrhoea is highly effective in preventing conception. Once ovulation occurs, it will in most cases be followed by menstruation. Conception, without prior menstruation, however, does occur in a small proportion of women. The risk of conception is least during the early postpartum months, but studies have shown that, even after 18 months, no more than 5-10% of women are likely to conceive prior to resumption of menstruation.e Assuming amenorrhoea lasts a year, on average, this 5-10% figure may be regarded as an annual failure rate; as such, it is no higher than the observed annual failure rate associated with oral contraceptives in many developing countries! It should be emphasized, however, that the time of return of ovulation cannot be accurately predicted and that once it has occurred, lactation no longer has the same contraceptive effect. Any change in breast-feeding practices in the developing world that reduces the present high incidence and long duration of breast-feeding and the high frequency of suckling is likely to increase fertility. The current situation in Kenya is an example: here the decline in both duration of breast-feeding and adherence to postpartum abstinence taboos over the past decades has brought about increased fertility while the adoption of other contracep- a ROSA, F. Breast-feeding in family planning. PAG Bulletin, 5 (3): 5-10 (1975). b SHORT, R. The biological basis ofthe contraceptive effect ofbreast-feeding. Paper presented at the WHO/NRC Workshop on Breast-feeding and Fertility Regulation, Geneva, February 1982. c PREMA, K. Effects of variations in breast-feeding practices and sociocultural factors on the return of fertility during lactation: a review. Paper presented at the WHO/NRC Workshop on Breast-feeding and Fertility Regulation, Geneva, February 1982. d HUFFMAN, S. L. Maternal and child nutritional status: its association with the risk ofpregnancy. Paper presented at the WHO/NRC Workshop on Breast-feeding and Fertility Regulation, Geneva, February 1982. e BUCHANAN, R. Breast-feeding: aid to infant health and fertility control. Population reports, Series J, No. 4, July 1975. f SIMPSON-HEBERT, M. & HUFFMAN, S. L. The contraceptive effect of breast-feeding. Studies in family planning, 12: 125-133 (1981). BREAST-FEEDING AND FERTILITY REGULATION 373 tive techniques has failed to keep pace.! As a result of this rise in fertility and coincident decline in mortality, Kenya today has one of the highest population growth rates in the world, i.e., the population will double in approximately 17 years. If increases in fertility are to be prevented, any decline in breast-feeding must be offset by a comparable increase in the use of contraceptives, especially in countries where breast- feeding is still an important factor. In Bangladesh, for example, if breast-feeding patterns were to change to those typical of industrialized countries, the already high fertility rates could be expected to rise by over 50%. To maintain fertility at current levels, a more than five-fold increase in contraceptive use -from 9% to about 52% (see Table 1)-would be required.! IMPACT OF CONTRACEPTIVE METHODS DURING BREAST-FEEDING Effect on lactation For populations wherein lactational amenorrhoea and anovulation are prolonged, early use of contraceptive methods frequently has the effect of providing "double coverage" and may not be justified in terms of efforts and resources involved. Furthermore, in situations where contraceptive discontinuation is common, lactating women may well start a hormonal contraceptive method and abandon it about the time their natural lactational infertility has waned, thus putting themselves at risk of pregnancy; this would not have happened had they commenced the contraceptive method later on in lactation. However, in societies where the duration of amenorrhoea is relatively short, early introduction of contraceptives will obviously reduce the risk of conception. Certain fertility regulating methods are known to influence the quantity and compo- sition of breast milk and the duration of lactation. For example, combined oral contracep- tives that contain as little as 30 iLg of estrogen significantly reduce the volume of milk; h when used in the first few months of the postpartum period, they can decrease milk volume by as much as 40% within 3-6 weeks. The concentration of breast-milk constituents is unchanged by combined oral hormonal contraceptives initiated in the first six months. Some progestogen-only hormonal contraceptives, however, are associated with a small but significant decrease in total fat.' Although these changes in the quantity and composition of breast milk have had a small or nonmeasurable impact on the weight gain of infants in the populations studied, these findings may not be applicable in other situations. Neither hormonal nor nonhormonal contraceptive preparations have been shown to interfere with initiation of milk production; however, the duration of lactation is shortened in a dose-related manner by early implementation of combined oral contraceptives.? The use of injectable contraceptives has been associated with increased duration of lactation; the early use of progestogen-only pills and nonhormonal methods has little or no effect on the duration of lactation.! Nonhormonal contraceptive methods have no effect on either the quantity or compo- sition of breast milk, with the possible exception that some methods of anaesthesia used with sterilization may cause a temporary interruption in lactation. In societies where g LESTHAEGHE, R. Lactation and lactation-related variables, contraception andfertility: an overview ofdata problems and world trends. Paper presented at the WHO/NRC Workshop on Breast-feeding and Fertility Regulation, Geneva, February 1982. h KOETSAWANG, S. The effects of contraceptive methods on the quality and quantity of breast milk. Paper presented at the WHO/NRC Workshop on Breast-feeding and Fertility Regulation, Geneva, February 1982. ZANARTU, J. ET AL. Effects of hormonal and nonhormonal contraceptives on human lactation and re-establishment of fertility. Paper presented at the WHO/NRC Workshop on Breastfeeding and Fertility Regulation, Geneva, February 1982. LAUKARAN, V. H. Effects ofcontraceptives on the initiation and duration oflactation. Paper presented at the WHO/NRC Workshop on Breast-feeding and Fertility Regulation, Geneva, February 1982. 374 WHO/NRC MEETING Table 1. Use of contraceptives to prevent increased fertility levels due to decreased duration of lactational amenorrhoea and anovulation to 3 months' Projected use of Mean contraceptives Mean duration of Current to maintain Country duration of lactational use of current (year of World breast-feedingb amenorrhoeab contraceptives' birth ratesd Fertility Study) (months) (months) (%) (%) Bangladesh 30.5 21.7 9 52 (1976) Indonesia 25.4 18.1 26 57 (1976) Pakistan 21.4 14.7 5 39 (1975) Thailand 20.4 13.9 33 56 (1975) Kenya 16.8 10.8 7 32 (1977-78) Philippines 16.1 10.2 36 52 (1978) Peru 13.8 9.5 31 44 (1977-78) Mexico 11.6 6.9 30 41 (1976) Jamaica 7.5 4.5 40 44 (1975) a Adapted from: R. LESTHAEGHE, Lactation and lactation related variables, contraception and fertility: an overview of data problems and world trends. Paper presented at the WHO/NRC Workshop on Breast-feeding and Fertility Regulation, Geneva, February 1982. b Average duration of breast-feeding and amenorrhoea is calculated for mothers with surviving children. c Percentage of married women using any method of contraception (including both efficient and inefficient methods). d Percentage of married women who would need to use contraceptives in order to balance the increase in fertility resulting from a decrease in the average duration of lactational amenorrhoea and anovulation to 3 months. lactation is often terminated because of a subsequent pregnancy, contraception initiatedjust before the return of ovulation may actually extend the duration of breast-feeding.k Effect on infant health Among breast-feeding mothers using hormonal contraceptives, there is evidence that about 0.1% of the maternal dose of certain synthetic estrogens and of most synthetic progestogens reaches the infant daily.' For most combined oral contraceptives the infant is exposed to nanogram (10- 6 mg) amounts of estrogen and microgram (10- 3 mg) quantities of progestogens.m For the newer, high-potency implanted progestogens, the infant is exposed to picogram (10- 9 mg) quantities. These mean levels are very low relative to the quantity of natural sex steroids reaching the infant from either cows' milk or breast milk. Naturally-occurring steroids, however, are rapidly metabolized by the liver in infants in contrast to the longer half-life of synthetic steroids. Infants normally have a brief rise in the circulating concentrations of testosterone and estrogen in the first four months post- kThe Danfa Comprehensive Rural Health and Family Planning Project, Ghana. Final report, Accra, University of Ghana Medical School and UCLA School of Public Health, September 1979. ' FOTHERBY, K. Transfer of contraceptive steroids in milk. Paper presented a the WHO/NRC Workshop on Breast-feeding and Fertility Regulation, Geneva, February 1982. m JOHANSSON, E. D. B. & ODLIND, V. Effects possibly related to breast-milk passage of exogenous hormones or their metabolites as additionally affected by maternal and infant nutrition. Paper presented at the WHO/NRC Workshop on Breast- feeding and Fertility Regulation, Geneva, February 1982. BREAST-FEEDING AND FERTILITY REGULATION 375 partum, which leads to the possibility that one or more organs or systems may be especially susceptible to the effects of exogenous sex steroids during this period." Intrauterine contraceptive devices (IUDs), sterilization, and physical barrier methods (condoms, diaphragms, and cervical caps) have not been shown to affect the health of breast-fed infants adversely. Effect on maternal health Contraception by sterilization or barrier methods has no adverse effects on the health of breast-feeding women. Although the spermicidal agent nonoxinol-9 is absorbed from the vagina, no adverse effects have yet been associated with the use of spermicidal creams or suppositories.' The potential benefits and risks of hormonal contraceptives and IUDs must be assessed in relation to physiological and metabolic changes that normally occur in the postpartum period and during lactation. The difficulties posed by IUDs relate to the postpartum physiological state of the uterus and antecedent anaemia. There is little evidence that lactation, per se, aggravates the situation, since the risk of expulsion or perforation is normally higher during the postpartum period. The greater blood loss associated with the Lippes loop may, in situations where anaemia is common, warrant consideration of alter- native IUDs, a matter that may be less important for lactating women, given that lactation prolongs postpartum amenorrhoea and thereby may reduce the blood loss associated with IUDs. Once lactation ceases, however, an alternative to the Lippes loop might be called for. The effects of progestogen-only, oral and injectable contraceptives on lactating women appear to be no different from those on nonlactating women. However, women with lactational amenorrhoea may experience less bleeding associated with progestogen-only contraceptives than do menstruating women.' In a small number of women, serious menorrhagia, particularly in association with depot-medroxyprogesterone acetate (DMPA), requires therapy; estrogens are effective in this regard but may affect lactation adversely.' Combined oral contraceptives appear to affect lactating and nonlactating women similarly. There is a slight increased risk of congestive heart failure in lactating women who have a pre-existing cardiovascular disease condition, such as chronic rheumatic heart disease, but it is no greater than that associated with pregnancy in comparable women.' Oral contraceptive use during lactation has been associated in some cases with biochemical (but only infrequently clinical) evidence of riboflavin and pyridoxine deficiency among women who were not previously deficient.' Those already showing biochemical evidence of deficiency showed no further deterioration. However, pyridoxine deficiency in a lactating woman is reflected in her breast milk. EFFECT OF LACTATION ON MATERNAL AND INFANT HEALTH The case for breast-feeding in the promotion of infant health is reflected in the resolutions adopted by the World Health Assembly.P Breast-feeding is a critical factor in nHARLAP, S. Are there long-term health and behavioural consequences of exposure to hormonal contraceptives in breast milk? Paper presented at the WHO/NRC Workshop on Breast-feeding and Fertility Regulation, Geneva, February 1982. ° BELSEY, M. Contraception during the postpartum period and while lactating: effects on the woman's health. Paper presented at the WHO/NRC Workshop on Breast-feeding and Fertility Regulation, Geneva, Februrary 1982. " Resolution WHA27.43 (Infant nutrition and breast-feeding). Resolution WHA31.47 (The role of the health sector in the development of national and international food and nutrition policies and plans with special reference to combatting malnu- trition). Resolution WHA33.32 (Infant and young childfeeding). Resolution WHA34.22 (International code of marketing of breast-milk substitutes). 376 WHO/NRC MEETING infant nutrition and growth, health and survival; this is especially so in low socioeconomic groups in developing countries. Among other things, it provides protection against gastro- intestinal and other infections not only in developing countries, but also in highly industrialized settings as well. Available evidence indicates that the energy and protein levels in breast milk are little affected by maternal nutritional status; the volume of milk may be reduced, but it is generally adequate to maintain infant growth during the first few months.' Most studies show that substantial differences in maternal nutritional status account for a difference of only a few months or less in the duration of lactational amenorrhoea and are thus of little demographic importance in terms of natural birth-spacing. Maternal undernutrition during pregnancy, however, affects birthweight, and low-birthweight babies face a greater risk of morbidity and early death. Milk synthesis and secretion nevertheless involve a considerable nutritional demand on the mother. Women whose dietary intake is inadequate during pregnancy often have limited physiological reserves with which to support these additional nutritional demands. However, the available data suggest that although some deterioration in maternal nutritional status may occur if diets during pregnancy and lactation are inadequate, adaptive mechanisms appear to increase the efficiency of food utilization and prevent marked deterioration in maternal nutritional status as assessed by anthropometric indices.r Malnourished women often succeed in producing viable, albeit smaller, babies and in breast-feeding them successfully. PROGRAMME POLICY IMPLICATIONS In many countries, there are no consistent policies on lactation and fertility regulation. Given the scientific evidence presented at the workshop, it is clear that maternal and child health and family planning policies should be more closely integrated. Thus the inter- relationship of lactation and fertility regulation, as well as the unique role of breast-feeding and lactational amenorrhoea and anovulation in child health, birth-spacing, and fertility regulation should be taken into account. As a way of incorporating the most recently available scientific information into programme policies appropriate to a given set of health systems and sociocultural conditions, the following common principles are generally applicable: (a) Infant and young child health, nutrition and fertility regulation are factors influ- encing the achievement of any significant improvement in maternal health. (b) Education of health workers and dissemination of general information to other sectors of society can play a supporting role in infant and young child feeding, and the importance of breast-feeding and lactational amenorrhoea should be an integral compo- nent of any programme designed to enhance the health and wellbeing of mothers and children. (c) Social and health support systems that favour and encourage frequent suckling, including on-demand and night-time feedings, contribute to the prolongation of lactational amenorrhoea and its effectiveness as a means of birth-spacing, and should therefore be promoted. q NUTRITION COMMITTEE OF THE CANADIAN PEDIATRIC SOCIETY AND COMMITTEE ON NUTRITION OF THE AMERICAN ACADEMY OF PEDIATRICS. Breast-feeding. Pediatrics, 62 (4): 591-601 (1978). rWHITEHEAD, R. G. Maternal diet, breast-feeding capacity, and lactational infertility. Report of a UNU/WHO/IPPF/ UNICEF Workshop, Cambridge, England, March 1981. Tokyo, United Nations University, 1983. BREAST-FEEDING AND FERTILITY REGULATION (d) Health service routines and social practices which unnecessarily interfere with the promotion and maintenance of breast-feeding should be identified and modified, dis- couraged or discontinued. (e) Lactational amenorrhoea is a highly effective contraceptive. However, when the risk of conception during amenorrhoea is considered too high, other contraceptive techniques should be initiated as close as possible to the expected termination of lactational amenor- rhoea. Unfortunately, the duration of amenorrhoea varies among different social groups, and so no time can be specified that will apply to all population groups. The appropriate time for introducing other contraceptive techniques must, therefore, be set by family planning and health officials on the basis of what they know of breast-feeding and lactational amenorrhoea patterns in the specific situation at hand. The policy could be, for example, that contraception should be initiated at the time when a quarter to one-half of lactating women resume menses (the 25 percentile or the median) or at the resumption of menses, whichever time comes first. (f) Nonhormonal contraceptives are preferable during lactation; they reduce the likeli- hood of a new conception and may thus prolong lactation. IUDs should be used in the immediate postpartum period only where follow-up facilities are available to ensure that the IUD is in its proper position and for reinserting those that are not. (g) Combined hormonal contraceptives should be discouraged in the early months of lactation, because they diminish the yield of milk. When a woman prefers to use hormonal contraceptives in the early months of lactation, progestogen-only contraceptives -oral or injectable should be made available. (h) Promotion of improved maternal health and nutrition is an essential component of any breast-feeding and fertility-regulation policy. Improvement of the maternal diet during pregnancy decreases the risk of low-birthweight infants, perinatal mortality, and infant morbidity. Even where maternal nutrition is less than optimal, women can provide adequate nourishment to sustain infant growth in the first months of life. However, because lactation also poses nutritional demands on the mother, it is important to improve the maternal nutritional status during pregnancy and lactation. (i) In order to prolong maternal amenorrhoea and provide adequate nutrition for the infant, both mothers and health workers should be given information on when and how to introduce additional, locally available foods so as to meet the infant's nutritional needs without diminishing the frequency and intensity of suckling. The appropriate approach to infant nutrition and health, maternal wellbeing, and fertility regulation will depend upon a variety of social and health care factors. For example, in highly industrialized societies, where women tend to work away from home and are subject to rigid time schedules, frequent on-demand breast-feeding may be imprac- tical beyond the period allowed by postpartum maternity leave. In these societies, any adverse health implications of shorter durations of breast-feeding are often minimized by ready access to health care, including family planning services. In less industrialized societies, where women still tend to work at or close to home and where there is opportunity for frequent contact between mother and infant, breast-feeding merits active support. Emphasis should be given to the importance of breast-feeding not only as a source of nutrition and a protection against infection, but also as an effective contraceptive under appropriate conditions. Developing countries all too often have but limited health and family planning services; large rural populations lack services adequate to ensure the continuity of care essential for effective family planning and follow-up. Fortunately, child-bearing women in these circumstances frequently have a relatively long postpartum lactational amenorrhoea which provides natural contraceptive protection until shortly before the return of menses. 377 WHO/NRC MEETING In the determination of how best to combine the promotion of breast-feeding, appro- priate addition of other foods, and family planning, a number of issues dealing with health and the social and health care system must be taken into account. Various combinations of strategies will be called for, depending on the nature of the community, its health profile, and the extent to which it is served by a health care system that will provide maternal and child health care and family planning support. The important information to be considered includes: the customary pattern of breast-feeding in the community, the duration and frequency of breast-feeding, the age at which supplementary foods are usually introduced, prevailing birth-spacing intervals, and the mean duration of lactational amenorrhoea. Patterns of breast-feeding and of lactational amenorrhoea commonly vary from one socio- economic group to another. Lifestyle, female work and employment patterns, and health care system support are among the factors that influence both the behavioural component (breast-feeding) and the resultant physiological responses (lactational amenorrhoea). More than any other factor, the duration of lactational amenorrhoea determines what type of family-planning strategy should be employed and what contraceptive methods are to be recommended. Whenever decisions cannot be based on individual histories, and when the variation in patterns of breast-feeding and lactational amenorrhoea is relatively slight, it is possible to follow a general strategy to arrive at the optimal time for starting a contraceptive method. Such a strategy is applicable to amenorrhoeic women only, since all menstruating women who desire contraception should be offered protection. Fig. 1 illustrates the different times at which two different populations (A and B) would require contraceptive protection. Population A, with a relatively short period of amenor- rhoea, should have contraception introduced at about time Al. But to recommend the 100 C0 ~~~~~~POPULATION A \POPULATION BE 50 3.1 50~~~~~~~~~~~~~ Age of infant Fig. 1. The duration of lactational amenorrhoea, shown here in two populations (A and B), as a factor deter- mining the appropriate time for the introduction of another contraceptive method (see text). 378 BREAST-FEEDING AND FERTILITY REGULATION introduction of contraceptives at time Al for population B would be wasteful of resources, since virtually none of the women would as yet be at risk of pregnancy. Also if dis- continuation of contraceptives is common in population B, many women could terminate their use at a time when they might be at risk of pregnancy. To initiate contraception at time BI would provide unnecessary coverage for some women in population B, but would cover virtually all those likely to become pregnant during lactational amenorrhoea. To initiate contraception at time B2 is a compromise: some women would be at risk of becoming pregnant but there is less unnecessary use of contraceptives overall. In an individual case, health and family-planning workers should ascertain, during the prenatal period, whether the mother intends to breast-feed and, if so, for how long. Health workers should then arrange for a postnatal follow-up at about the time supplemental foods are introduced, bearing in mind that the duration of lactational amenorrhoea will be affected by this introduction of supplemental foods, the pattern of day- and night-feeding, and the termination of breast-feeding. The selection of a contraceptive method prior to weaning, as indicated above, should be governed by the following: - the extent to which it does not interfere with breast-feeding; - its reliability and acceptability; - the extent to which the mother can be expected to return for regular consultation; - the availability of family planning services. If the mother has breast-fed previously, it is wise for the health worker to inquire about her history of lactation and lactational amenorrhoea, in order to determine an appropriate time for initiation of an additional contraceptive method. SUMMARY GUIDELINES FOR PROGRAMME POLICY 1. Breast-feeding and family planning should be mutally reinforcing components of any health policy, which should itself be tailored to local needs. 2. In the promotion of breast-feeding, information on its effect in increasing birth intervals by inducing lactational amenorrhoea, the nutritional benefit to the infant, and its protection against infection should be included. 3. Information on the contribution of lactational amenorrhoea to birth-spacing should be disseminated to the public and all health sector personnel and be incorporated into the curricula for training of health workers. Emphasis should be given to the following measures which promote lactational amenorrhoea: - breast-feeding exclusively for four months, with frequent suckling on demand, both by day and night; - continuation of breast-feeding after supplemental foods have been introduced at 4-6 months. 4. The most appropriate time for introducing other family planning methods should be established, for each situation, on the basis of breast-feeding patterns and trends, and the duration of lactational amenorrhoea. 5. In order to realize optimal benefits from breast-feeding in relation to family planning, it is essential that social and health programme policies should be strengthened by the following actions: - Protect and promote breast-feeding through maternity legislation and social support systems, the provision of education and information, as well as implementation of other legislative and social actions. 379 380 WHO/NRC MEETING - Provide fertility regulating methods and services appropriate for lactating women; encourage the use of nonhormonal contraceptives for 4-6 months postpartum; for breast- feeding women who desire hormonal contraceptive protection, provide progestogen-only hormonal contraceptives during the period of lactational amenorrhoea, and a warning on the effect of combined oral contraceptives on the quantity of breast milk. - Encourage, by providing information on fertility-regulating techniques and services, the timely initiation of family planning shortly before the return of menses. 6. Health workers and the community require information on the interrelations between maternal nutrition, breast-feeding, and fertility, including the following: - Optimal benefits of breast-feeding with respect to infant nutrition, protection from infection, and birth-spacing may be realized without significant deterioration in the nutritional status of the mother. - Changes in breast-feeding practices are among the more important factors that affect the duration of lactational amenorrhoea and consequent birth intervals, in contrast to variations in maternal nutrition, which have only a marginal impact on birth-spacing. - Optimal health of the mother, and hence of the family, can best be assured by pro- viding locally available foods that are good sources of energy and other nutrients during pregnancy and lactation, preventing and alleviating nutritional deficiencies such as anaemias, and identifying and using local social and physical support systems that can reduce maternal work loads and thus reduce maternal morbidity. - Infant survival and longer intervals between births are promoted by providing the infant with supplemental food from locally available sources in a manner and at a time that favours continued and frequent breast-feeding. 7. Development of simple methods to enable women to identify the resumption of ovarian function is important in order to maximize the fertility-regulating impact of breast- feeding. LIST OF PARTICIPANTS A. Akin, Institute of Community Medicine, Hacettepe University, Ankara, Turkey R. Apelo, National Family Planning Office, Ministry of Health, Manila, Philippines D. Ashley, Ministry of Health, Kingston, Jamaica *J. Bale, Food and Nutrition Board, National Academy of Sciences, Washington, DC, USA S. Bhatia,International Centre for Diarrhoeal Disease Research-Bangladesh, Depart- ment of Population Dynamics, Johns Hopkins University, Baltimore, MD, USA *J. Bongaarts, The Population Council, New York, NY, USA P. Cholnoky, Szombathely, Hungary H. Cruz-Ruiz, Ministry of Health, Lima, Peru. R. Rivera-Damm, Institute of Scientific Research, University of Juarez, Durango, Mexico H. L. Delgado, Division of Human Development, Institute of Nutrition of Central America and Panama (INCAP), Guatemala City, Guatemala. * Member of the Committee on International Nutrition Programmes, National Research Council (NRC) Subcommittee on Nutrition and Fertility. The Subcommittee also includes Gretchen Berggren (Harvard School of Public Health, Boston, MA) and Carl Taylor (The Johns Hopkins University, Baltimore, MD). BREAST-FEEDING AND FERTILITY REGULATION 381 K. Fotherby, Department of Steroid Biochemistry, Royal Postgraduate Medical School, Hammersmith Hospital, London, England M. T. Hamamey, Basic Health Services Department, Ministry of Health, Cairo, Egypt S. Harlap, Department of Medical Ecology, Hebrew University of Jerusalem, Jerusalem, Israel *S. Huffman, School of Hygiene and Public Health, Johns Hopkins University, Balti- more, MD, USA (Co-Secretary) V. J. Hull, Department of Demography, The Research School of Social Sciences, The Australian National University, Canberra, Australia S. Jafery, Jinnah Postgraduate Medical Centre, Karachi, Pakistan E. D. B. Johansson, University Hospital, Department of Obstetrics and Gynaecology, Uppsala, Sweden *J. B. Josimovich, Department of Obstetrics and Gynaecology, College of Medicine and Dentistry of New Jersey, New Jersey Medical School, Newark, NJ, USA S. Koetsawang, Family Planning Research Unit, Department of Obstetrics and Gynaecology, Siriraj Hospital, Bangkok, Thailand V. Height Laukaran, The Population Council, New York, NY, USA R. Leke, Central Hospital, Yaounde, United Republic of Cameroon R. Lesthaeghe, Inter-University Programme on Demography, Brussels, Belgium *J. Menken, Office of Population Research, Princeton University, Princeton, NJ, USA B. Muntasser, United Nations Fund for Population Activities, Geneva, Switzerland K. Prema, National Institute of Nutrition, Hyderabad, AP, India J. Rooks, United States Agency for International Development, Washington, DC, USA B. Saxena, Indian Council of Medical Research, New Delhi, India P. Senanayake, International Planned Parenthood Federation, London, England R. Short, MRC Reproductive Biology Unit, Medical Research Council, Edinburgh, Scotland A. R. Soerano, Family Planning Services, Ministry of Health, Jakarta, Indonesia K. Sundstroem, The National Board of Health and Welfare, Stockholm, Sweden M. Q. Talukder, Institute of Postgraduate Medical Research, Dhaka, Bangladesh 0. Thanangkul, Research Institute for Health Sciences, Chiang Mai University, Chiang Mai, Thailand J. Vince, Port Moresby General Hospital, Port Moresby, Papua New Guinea H. L. Vis, Paediatric Clinic, University Hospital of St Pierre, Free University of Brussels, Brussels, Belgium R. Whitehead, Dunn Nutritional Laboratory, Cambridge, England B. Winikoff, The Population Council, New York, NY, USA S. Zacharias, Department of Obstetrics and Gynaecology, Faculty of Medicine, Uni- versity of Chile, Santiago, Chile Zhang De-wei, Shanghai Institute of Planned Parenthood Research, Shanghai, China WHO Secretariat M. A. Belsey, Special Programme of Research, Development and Research Training in Human Reproduction (Co-Secretary)a M. Carballo, Maternal and Child Health, Division of Family Health (Co-Secretary) A. Kessler, Special Programme of Research, Development and Research Training in Human Reproduction A. Petros-Barvazian, Division of Family Health B. Underwood, Consultant, Nutrition Unit, Division of Family Health a Currently Maternal and Child Health, Division of Family Health. 382 WHO/NRC MEETING ACKNOWLEDGEMENTS Funding support for the workshop and meeting was provided by theWHO Special Programme of Research and Development and Research Training in Human Reproduction, by the Division of Family Health from resources provided by the United Nations Fund for Population Activities (INT/79/P46), and by the US National Research Council.