Workshop on Breast-feeding and its Effect on Fertility in the Western Pacific Region, Manila, Philippines, 9-12 April 1991 : report

(WP)NUT/ICP /NUT/OOl-E Report series number: RS/91/GE/07(PHL)

ENGLISH ONLY

REPORT

/ WORKSHOP ON BREAST-FEEDING AND ITS EFFECI' /,/ON FERTILITY IN THE WESTERN PACIFIC REGION

I

Convened by the REGIONAL OFFICE FOR THE WESTERN PACIFIC OF THE WORLD HEALTH ORGANIZATION Manila, 9-12 April 1991

Not for sale Printed and distributed by the Regional Office for the Western Pacific of the World Health Organization Manila, Philippines August 1991

2 ti SEP U94

NOTE

The views expressed in this report are those of the participants, temporary advisers and the observers representing nongovernmental organizations who attended the Workshop on Breastfeeding and Its Effect on Fertility in the Western Pacific Region and do not necessarily reflect the policies of the World Health Organization.

This report has been prepared by the Regional Office for the Western Pacific of the World Health Organization for governments of Member States in the Region and for the participants in the Workshop on Breast-feeding and Its Effect on Fertility In the Western Pacific Region, which was held in Manila, Philippines, from 9 to 12 April 1991.

CONTENTS

SUMMARY ............................................................................................................................... . 1. INTRODUCTION ............................................................................................................ 1.1 1.2 1.3 1.4 2. Objectives ................................................................................................................... Participants and resource persons ......................................................................... Organization .............................................................................................................. Opening ceremony ....................................................................................................

1 2 2 2 2 3 4 4 4 8 12 12 12

PROCEEDINGS ............................................................................................................... 2.1 Summary of country reports ................................................................................... 2.1 Summary of research reports ................................................................................. 3.3 Summary of group discussions ...............................................................................

4.

CONCLUSIONS .............................................................................................................. 3.1 Conclusions ............................................................................................................... 3.2 Guidelines .................................................................................................................

ANNEXES: ANNEX 1 - UST OF PARTICIPANTS, CONSULTANT, TEMPORARY ADVISERS, OBSERVERS/REPRESENTATIVES AND SECRETARIAT .................................................................................... ANNEX 2 - AGENDA ............................................................................................... ANNEX 3 - SELECfED BACKGROUND PAPERS .........................................

15 21 23

ANNEX 4 - SUMMARY TABLE OF COUNTRY REPORTS ........................ 57 ANNEX 5 - UST OF SCIENTIFIC PAPERS ....................................................... ANNEX 6 - INNOCENTI DECLARAnON ........................................................ 65 67

Keywords Breasf-feeding / Fertility / Family planning / Western Pacific

SUMMARY

The relationship between breast-fe~ding and fertility has been the ~ub~ect of seven recent studies in the Western Pacific RegIon of the World Health OrgaDlzatlon. The Workshop on Breast-feeding and its Effect on Fertility in the Western Pacific Region was convened with a view to inform~g participants about the progres:: of suc~ research. Participants ca~e from te!, countnes an~ areas ofth~ Weste':fi.Pacific Region of WHO and comprised seDlor professIonals, academIcs and medIcal adnuOlstrators. They came together to review trends in the Region 0l! .the pr~ale!,ce patt~ms ~nd duration of. breast-feeding and its conseq~ent effect on fertility, to I~e~tify ways m whIch breast-feedmg promotion can be integrated mto a broader range of trammg and health programmes and to discuss the development of national guidelines to promote breast-feeding. Further emphasis was given to health system practices which encourage and enable mothers to breast-feed, the delivery of information on breast-feeding to both the public and frontline health workers, and on family planning. The participants identified the main difficulties affecting the prevalence and duration of breast-feeding in their country, and discussed possible solutions. Ongoing research was reported by investigators from Australia, China, Macau and Hong Kong, Philippines, Republic of Korea and Viet Nam. The results of the studies varied, at least in part due to non-differentiation between exclusive and partial breastfeeding and differences in sampling techniques and definition of terms. Longitudinal studies under way in the Region, in Australia and China, should provide more precise differences in feeding patterns as determined in their relation to the duration of amenorrhoea. Some of the factors involved were found to be urban/rural differences, age of mother, education of mother, ethnicity and socioeconomic level and family planning methods used during breast-feeding. The Workshop examined recent scientific information on the fertility control aspects of breast-feeding and came to the conclusion that, if a woman is breast-feeding exclusively on demand during night and day without any use of pacifiers, a 98% protection from another conception can be expected. The suppression of ovulation after six months diminishes progressively in such mothers, (but is still considerably higher compared to mothers who are bottle-feeding). The use of additional methods of family planning to delay another pregnancy is indicated after six months of exclusive breast-feeding, or if menstruation begins, or if breast-feeding ceases to be exclusive. Exclusive breast-feeding is thus an effective form of family planning and should be integrated into the overall strategy of family planning nationally. To that effect there is a need to improve hospital practices, the training of health workers through in-service training and curriculum change, and to disseminate breast-feeding information more widely to the general public. The Workshop also recommended that breast-feeding is an important national resource beside its biological benefits to the mother and the infant. All efforts for its continued promotion need to be undertaken. There is also a need to improve the training of health workers to include all new scientific information about the initiation, establishment and continuation of breast-feeding. It was also felt that policy-makers are often unaware of the importance of the existing problem of the decline of breast-feeding prevalence and that more coordination at ministry level is needed to increase breast-feeding rates.

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1. INTRODUCTION

The ~ela~ionship between b~east-fe~ding and fertility has been the subject of seven recent studles m the West~rn Pac~fic Region of the.~orld Health Organization. The Workshop ~n Bre~st-feedmg a.nd ItS ~rt:ect on Fertility in the Western Pacific Region was convened wlth a Vlew to exposmg.partlclpa~ts to t~e CUrrent progress of such research. The ~ecent UNICEF /~O Innocenti ~ecl~ratlOn, whlch emphasizes, among other things, the lffiportance of excluslve breast-feedmg m the first four to six months of a child's life to redu~e ~ertility of the mother, has been a further stimulus to reviewing the current position on thlS Issue. 1.1 Objectives The objectives of the workshop were as follows: (a) to review trends in the Western Pacific Region on the prevalence patterns and duration of breast-feeding and its effect on fertility; (b) to identify ways in which breast-feeding promotion can be integrated into a broader range of training and health programmes; and (c) through discussion of country-specific problems in breast-feeding, to enable participants to develop national guidelines to overcome the identified problems and to promote breast-feeding. 1.2 Participants and resource persons

The participants came from ten countries/areas of the Region and comprised senior professionals, academics and medical administrators. In addition, there were five temporary advisers who have been active in lactation and fertility-related research and hospital practices as well as one consultant. Representatives of UNICEF, UNFPA, observers from two nongovernmental organizations, and WHO staff members from Geneva and the Regional Office for the Western Pacific contributed to a lively exchange of scientific information and experiences. The full list of participants is given in Annex 1. 1.3 Oq~anization

The workshop activity consisted of presentations on research on breast-feeding and fertility, country reports, scientific papers, a field visit and discussions in small groups to identify problems and solutions for the individual countries of the Region. The agenda is attached as Annex 2. Days 1 and 2 were devoted to the presentations of country reports and scientific studies on the role of lactation in the control of fertility, including the quantification of such control. WHO Headquarters activities on breast-feeding, fertility and infant nutrition (Annex 3) were also presented. Days 2 and 3 were assigned to problem identification and their solution, followed by a scientific paper analysing problems in the management of lactation. Also included was a visit to the busy Dr Jose Fabella Memorial Hospital, which is also the home of the national course on lactation management, to observe the management of rooming-in and immediate lactation.

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Day 4, the final day, was devoted to reports from discussion groups and the finalization of conclusions and guidelines. 1.4 Qpenin& ceremony

Dr S.T. Han, Regional Director ofthe WHO Regional Office for the Western Pacific, welcoming participants to the workshop, said that it was an established fact that exclusive breast-feeding up to six months, if accompanied by amenorrhoea, could be used as a highly reliable contraceptive method which could help tremendously in spacing pregnancies, especially in countries where the coverage and acceptance of modem contraception were low. It had been calculated that, in certain very underdeveloped countries, the cessation of breast-feeding would almost double the present fertility rate, with disastrous consequences. Until recently, no distinction had been made between exclusive and mixed breastfeeding. However, research and experience had shown the importance of exclusive breastfeeding, initiated within one hour after birth and continued for four to six months. Unfortunately, the practice had been observed globally to be declining rapidly. Therefore breast-feeding promotion programmes were needed with special emphasis on exclusive breast-feeding to increase the present rates or at the very least maintain them. It had been shown that a successful breast-feeding promotion programme needed the support of the urban elite as trend-setters. Such programmes also needed the commitment of respected paediatricians and obstetricians, as well as the adoption of a National Code of Marketing of Breast-Milk Substitutes. Equally important were mass campaigns to inform the public; prolonged and paid maternity leave; breast-feeding facilities for working mothers; and supportive procedures in maternity services, such as rooming-in and immediate initiation of breast-feeding. Mothers needed proper care in order to breast-feed successfully, as well as strong support from the family and the community. It was also important to remember that after six months, or when amenorrhoea had ceased, some other means of contraception were needed. The only ones lactating mothers should avoid were combined oral or injectable hormonal contraceptives. Dr Han said that the benefits of birth spacing for maternal and infant health were well known. Exclusive breast-feeding for six months with no additions such as water also protected the infant against the sickness and deaths caused by malnutrition, diarrhoea and other infections. The beneficial effects of bonding between mother and child should also be borne in mind. By extending the period between births, exclusive breast-feeding could help decrease maternal mortality and morbidity. He then wished the participants a fruitful and successful workshop. The participant from Papua New Guinea, Mr Enoch Posanai, was then elected Chairman. Dr Linda Hui Yin-fun, Hong Kong, was elected Deputy Chairman. Dr Estelita 1. Papa (Philippines) and Dr Yuan Xiaohong (China) were elected Rapporteurs.

II

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2. PROCEEDINGS

2.1

SummaQ' of countQ' reports

The country reports of the participants and other available information were summarized and presented by Ms Ruth Charrondiere, a member of the Secretariat. Summary tables of these country reports appear in Annex 4. 2.2 SummaI)' of research reports

The Multicentre Study of the Duration of Lactational Amenorrhoea in relation to Breast-feeding Practice is currently in progress in seven countries: Australia, Chile, China, Guatemala, India, Nigeria and Sweden. The study began in May 1989. As of 28 February 1991, most centres had enrolled half the projected 550 subjects in the study. Australia In Australia, the study is being carried out in metropolitan Sydney at Westmead Hospital, and metropolitan Melbourne at Prince Henry's Institute of Medical Research with the collaboration of Professor Henry Burger. The major aims ofthe study are: (1) to describe the different durations of lactational amenorrhoea in different populations; (2) to establish whether there are real differences between women in different parts of the world; '(3) to determine which factors contribute to any differences observed; and (4) to establish guidelines for maternal and child health workers in relation to breast-feeding practices to optimize the benefit of breast-feeding in relation to child spacing. A total of 550 subjects will be enrolled in each centre and eligible subjects are admitted to the study between days 4 and 7 after delivery. Subjects continue in the study until the second normal menstrual bleed (normal as defmed by the subject as experienced in previous cycles). Eligibility criteria include maternal age 20-37 years, previous regular menstrual cycles 21-35 days; singleton infant delivered per vagina; with 1-3 children before the current infant; one infant previously breast-fed for at least four months and intention to breast-feed the current infant for at least six months. The mother should not be intending to use hormonal contraception, to be separated from the infant for more than eight hours or to breast-feed another infant or have her infant breast-fed by another mother. Subjects complete daily diary records of infant feeding patterns and a detailed diary chart of the time and duration of breast-feeds once every two weeks. Subjects are visited in their homes once every two weeks, at which time a follow-up interview is completed, diary records are summarized and infants are weighed and measured and mothers weighed; skinfold and arm circumference measurements are made as an estimate of the mother's nutritional status. Data relating to infant and maternal illnesses, family planning practice and coitus, vaginal bleeding episodes, work patterns, alcohol, smoking, maternal diet and maternal dietary supplements are recorded. At the end of February 1988, 269 subjects had been admitted to the study in the Australian centres and 92 had completed the study after two normal menstrual bleeds. A further 52 subjects have discontinued for other reasons. A preliminary analysis of some of the data for the 268 subjects has been completed although some of the data are for a smaller number of subjects. Many of these data are in relation to the previous infant. The previous infant was breast-fed for a mean duration of 12.7 (SD6.1) months and exclusively breast-fed for a mean 5.1 (1.5) months with some mothers introducing supplements before

- 5-

3 months and others between 10-12 months. Amenorrhoea returned on average at 9.8 (11.1) months after delivery, with 42.5% resuming menses before 6 months and 13.4% beyond 12 months. The median time to introduction of milk was 70 days, non-ca1oric liquids e.g water 131 days, caloric liquids, e.g. juice 175 days, and solid foods 147 days after delivery. The first bleed among the 92 mothers who have completed the study occurred on average 223 (SDllO) days after delivery, but this may reflect the proportion of women bleeding earlier and finishing the study. Of the 266 subjects in the study, a lifetable analysis indicated the median time to first bleed at 305 days after delivery with 25% resuming first bleed by 215 days. The feeding patterns by day (6 a.m. to 10 p.m.) and night (10 p.m. to 6 a.m.), including the number of feeds, average duration of a suckling episode, total 24 hours suckling duration, were illustrated for the farst year after delivery. Mothers breast-fed an average of 8.4 times per day in the ftrst week after delivery with little change over the ftcst 12 months. The duration of suckling was longer at night than during the day with the duration during the daytime feeds decreasing with the increasing age of the baby, with little change in the duration of nighttime feeds. Total 24 hours duration of suckling ranged from an average 107 minutes in the first week after delivery to 47 minutes at 12 months with marked individual variation. The growth of infants and changes in mothers' skinfold measurements were illustrated. The infants showed adequate continuing growth, by both weight and length, over the 12 months period, though the range of measurements varied between infants. There appears to be a significant correlation between the duration of lactational amenorrhoea experienced with a previous infant and that of the current infant. The timing of introduction of supplementary feeding was significantly associated with the time of resumption of ftrst bleed with the exception of non-caloric supplements. These preliminary data of the longitudinal study suggest that in this particular group of Australian breast-feeding women, breast-feeding prolonged the duration of lactational amenorrhoea for 9-10 months, conftrming previous studies in studies of a smaller number of Australian women.

The study is still ongoing and the Centre has not yet begun the ftnal data analysis. In the meantime the following fmdings have been made. Virtually all (99%) of the study population are rural middle class, 98% mothers have had one previous live birth and 2% per cent have had two. In all cases the last child was breast-fed. The mean duration of breast-feeding of the last child was 16.4 months, the mean duration of full breast-feeding being 7.8 months; the mean duration of lactational amenorrhoea while breast-feeding was 8.8 months. The mean interval between delivery and start of breast-feeding the index child is 41 hours. The mean numbers of feeds during daytime and night are 7 and 3.9 in the ftcst week, declining gradually to 5.5 and 2.7 times in the ftfth month respectively. The mean total duration of suckling per 24 hours is 62 minutes in the first month and 72 minutes in the fifth month. Almost all babies are breast-fed on demand.

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As a custom, sexual intercourse occurs six weeks after parturition. Contraceptive methods are usually introduced then, with either husband undergoing a vasectomy or the wife having an IUD inserted.

Up to the beginning of March, 330 mothers had been recruited in the Centre; of these 148 were discontinued from the study, having had two normal menstruations and 10 were discontinued because of pregnancy. The average length of lactational amenorrhoea for these mothers is 8.7 months. Only five babies were weaned. Each participating centre of this study will need 3 1/2 years to collect data, analyse the data and write up the results. It should then be possible to provide maternal and child health/family planning workers with a basis for the clinical management of fertility control among breast-feeding women. From a practical viewpoint, a set of simple guidelines could be established which would allow women to adjust their infant feeding practices to provide a longer or shorter inter-birth interval or to enable them to decide when the amount of time spent nursing was insufficient to protect against pregnancy and hence when other contraceptive measures should be taken. Macau and Hon" Kon" The prevalence of breast-feeding was found to be higher in Macau than in Hong Kong. At 2-3 months postpartum, 37% of Macau woman were breast-feeding compared with 4.5% at the age of 2-4 months in Hong Kong, and at 5-6 months the proportions were 26% and 3.1 % respectively. Amenorrhoea was present in 70% of breastfeeding women in Macau compared with 26.8% in Hong Kong at 2-3 months (2 months in Hong Kong). At 5-6 months post partum, 22% of breast-feeding mothers in Macau were amenorrhoeic as compared with 8.5% at 4 months in Hong Kong. A lower proportion of Macau women used contraception and no distinction was made in the study between subjects irrespective of the duration of breast-feeding and that of amenorrhoea. However, there is a stronger effect of breast-feeding on the duration of amenorrhoea in Macau compared with Hong Kong. No distinction was made between exclusive and partial breast-feeding in these studies and in Hong Kong this would appear to be of little relevance. Philippines Six hundred womer in an urban depressed population were studied using the WHO Simplified Methodology and it was found that 58% were both amenorrhoeic and breastfeeding. A very low proportion of infants (9.6%) were fully breast-feeding. This may be because many mothers introduced rice water early to the infant as has also been found in earlier studies. A total of 98% of the mothers were using family planning methods by 6 months with the highest proportion using natural family planning methods, rhythm, the Billings method and withdrawal. The relationship between breast-feeding and amenorrhoea was significant between 2 and 7 months post partum. Republic of Korea Using the WHO Simplified Methodology, 1634 urban and 1777 rural mothers were interviewed and a reference period of 24 months was applied. At one month, 84.9% of IBreast-feeding and fertility: a simplified methodology for community-based calculation of the proportion of mothers at risk of conception by breast-feeding status. Maternal and Child Health Unit, World Health Organization; Geneva. MCH/85.15. 1985.

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urban and 86.4% of rural women were still breast-feeding. At 3 months, 75.9% and 77.4%, respectively, and at 6 months 71.4% and 81.3% were breast-feeding. No differentiation of exclusive and partial breast-feeding was made. The rates of contraceptive use were 55.6% by urban and 28.9% by rural women at 3 months and 67.4% and 24.8%, respectively, at 6 months. The rates of amenorrhoeic women were at one month, 86.7% and 75.4% for urban and rural mothers, at 2 months, 83.6% and 73.8% and at 4 months 57.7% and 66.3%, respectively. VietNam The WHO Simplified Methodolo&y used in Viet Nam has shown a high incidence of breast-feeding in both urban Hanoi and rural Habac. Only 14.5% among 600 urban and rural infants were being exclusively breast-fed at the time of interview. This is probably due to the high proportion of mothers returning to work, with 34% of urban women doing so and 91 % of rural Habac mothers, who were predominantly farmers. The rural mothers also returned to work earlier than urban mothers. Although the duration of amenorrhoea is short, there was observed to be a low risk of pregnancy, (0.8%) during amenorrhoea. The Bellagio guidelines were confIrmed with only 0.5% of non-contracepting breast-feeding women conceiving during exclusive breast-feeding and amenorrhoea. Interim conclusion The results of the studies using the WHO Simplified Methodology illustrate the current practices in relation to breast-feeding and family planning although some studies are limited by the non-differentiation between exclusive and partial breast-feeding and amenorrhoea in relation to the breast-feeding and non-breast-feeding women. The Simplified Methodology provides a very rapid, low-cost method of determining current prevalence of types of breast-feeding, amenorrhoea and contraceptive use. The limitations include the sampling of the population and the definition of terms particularly in relation to breast-feeding and bleeding. Specific differences between population groups may be also observed but sample size will limit interpretation of the results. Longitudinal studies that are under way in the Region, e.g. in Australia and China, will provide more precise differences in feeding patterns as determined in their relation to the duration of amenorrhoea and may also provide some indications of other factors which explain differences between populations. Data from surveys in Asian countries highlight specific target groups within countries which may reward specific attention in breast-feeding promotion and fertility by becoming trend-setters in the country. They might be described as educated, urban women below 35 years of age. Some of the factors involved are as follows: Urban/rural differences. Significant differences between urban and rural (1) women occur in the prevalence of breast-feeding in Thailand, Philippines and Malaysia, with more rural mothers breast-feeding compared with urban mothers. A~e of mother. Younger mothers (under than 25 years) and those aged 25-34 (2) breast-feed for shorter durations compared with mothers 35 years and above, particularly in Malaysia, with a smaller trend occurring in Indonesia and not so obvious as one in the Philippines.

(3) Education. More women among the highly educated Asian mothers are less likely to breast-feed and also they breast-feed for shorter periods, a trend that is contrary to the one observed in more developed countries such as Australia, United States of America and United Kingdom.

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(4) Ethnicity and socio-economic level. Studies from Singapore suggest that there are differences between ethnic groups in the initiation as well as the duration of breast-feeding. Although breast-feeding prevalence and duration are low and have been declining in recent years, they are lowest among the higher socio-economic group and those of Chinese ethnicity and higher in the Indian and Malay population. There has been an increase in the percentage of mothers from the higher socioeconomic group who have been breast-feeding since 1970, with approximately 40% breast-feeding at one month in 1980 compared with 15% in 1970. (5) Family Plannin& prevalence durin& breast-feedin&. There is marked variability between countries in the prevalence of use of family planning methods (Annex 4). In most countries of Asia, the prevalence of family planning use is 10% or less in breastfeeding women. The double protection provided by lactational amenorrhoea and concurrent use of family planning has not been determined in these studies but should be addressed in the results of the current demographic health surveys. The impact of the reduced prevalence and duration of breast-feeding necessitating increased prevalence of use of family planning methods has been highlighted (see paper by Thapa, Short and Potts, 1987). The impact would be highest in countries with low prevalence of family planning use, e.g. Lao People's Democratic RepUblic. Summary The effect of breast-feeding on fertility is variable and is affected by various factors including the patterns of breast-feeding. There is ~ need to emphasize the "ten steps to successful breast-feeding" (WHO/UNICEF 1989) to increase the prevalence of breastfeeding. Guidelines are needed to determine those patterns of breast-feeding which provide optimum maintenance of lactation and maximize the effect of breast-feeding on fertility. These will be provided by longitudinal studies. The WHO Simplified Methodology provides a rapid method of estimating prevalence and duration of breast-feeding and amenorrhoea and further highlights target groups which should be the subject of specific attention in the context of advice and promotion. Selected scientific papers presented at the workshop are presented in Annex 3, including a summary of the work of the World Health Organization. A list of some of the scientific papers prepared for the workshop is attached in Annex 5. Copies of these papers are available from the Nutrition Unit, WHO Manila. 2.3 SummaQ' of &roup discussions

The participants identified the following major problems affecting breast-feeding in the Region and then proposed solutions. 2.3.1 Problems identified (1) National policy and legislation (a) Lack of a national code to control the promotion of infant formula. (b) Absence of monitoring of the promotional practices of milk companies. (c) Lack of clear political commitment to breast-feeding. 2WHO/UNICEF. Protecting, promoting and supporting breast-feeding: the special role of maternity services. World Health Organization: Geneva 1989.

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(d) Variation in promotional practices from area to area in the Region. (e) Breast-milk not looked upon as an economic resources for the nation. (f) Lack of coordination within ministries and no delineation of responsibility for leading breast-feeding promotion. (2) Training of health workers (a) Lack of teaching material and other resources. (b) Deficiencies in the curricula. (c) Teaching of breast-feeding within the framework of preventive medicine, which has low priority. (d) Need to establish model maternity units for teaching the management of lactation. (e) Lactation failure and short duration of breast-feeding not seen as a "medical" problem. (3) Public awareness about the importance of breast-feeding (a) Inappropriate and inconsistent information about breast-feeding. (b) Inadequate access to information for the general public. (c) Need for individual counselling and face-to-face teaching to create motivation and knowledge in relation to prolonged exclusive breast-feeding. (d) Lack of educational material. (4) Delivery of services (a) Hospital practices are out-dated, especially those regarding rooming in, immediate breast-feeding initiation and proper positioning. (b) Lack of follow-up and communication regarding the maintenance of lactation. (c) Lack of intersectoral collaboration and cooperation with nongovernmental organizations, mothers' groups, and other community organizations. (5) Community support groups (a) Insecurity of new mothers. (b) Inadequate national network of mother's groups, nongovernmental organizations, etc., especially outside the major centres.

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(6)

Working mothers (a) Maternity leave inadequate.

(b) Lack of creches at working places, including absence of nursing breaks and inadequate transport. (7) Social acceptability of breast-feeding in public places (a) Breast-feeding at the table not allowed in restaurants. Some airline companies however recommend breast-feeding in the toilets.

(b) (8)

Professional bodies (a) Conventions and scientific publications receive support from milk companies (b) Professional leaders accept support for presenting papers at scientific meetings and for attendance at meetings. (c) Lack of awareness of the negative influence of the marketing practices of infant formula companies adversely affecting the advice given to mothers on feeding modes.

(9)

Problems related to urbanization causing low prevalence of breast-feeding (a) Need for mothers to go out to work. (b) Breakdown of the extended family system and social support (c) High pressure commercial promotion of inappropriate infant feeding practices in urban areas.

2.3.2 Solutions proposed (1) Need for political commitment and financial support from the government.

(2) Establishment of a national task force at interministeriallevel for the promotion of breast-feeding: (a) Active collaboration between the task force, professionals, nongovernmental organizations and breast-feeding support groups (b) Development of national codes for marketing of infant formula, and establishment of mechanisms for monitoring infringements for government and private practitioners and hospitals. (c) Legislation to help working mothers to breast-feed for prolonged periods (i) maternity leave (ii) nursing breaks (iii) other social benefits ( iv) specific services e.g. creches, work-place nurseries.

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(3)

Changes in medical and nursing curricula: (a) Incorporation of new scientific information into the current curricula

(b) Provision of texts and audio-visual aids. (4) Changes in out-dated hospital practices, to promote lactation, including in-service training for health workers: (a) Development of health infrastructure and outreach services for the maintenance of1actation

(b) Development of in-service training programmes (c) Promotion of model maternity units and hospitals. (5) Creating public awareness of breast-feeding: (a) National "breast-feeding days· (b) Government support to encourage mothers' support groups, other women's groups and nongovernmental organizations to create a national forum for discussion about lactation and breast-feeding (c) Ministry of Health to prepare educational and promotional materials to replace those distributed by milk companies (d) Ministry of Education to include human lactation as part of the school curriculum. (6) Ministry of Labour to supervise legislation to facilitate breast-feeding by working mothers: (a) Maternity leave

(b) Removal of administrative blocks to promotional prospects of mothers (c) Nursing breaks (d) Creches at workplaces (e) Empower trade unions to press for such facilities for breast-feeding mothers. (7) International organizations (WHO, UNICEF, UNFPA, UNESCO, ILO) to provide technical support. (8) Workshops to be held at regular intervals for exchange of ideas and experience between Member States.

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3. CONCLUSIONS

3.1

Conclusions

3.1.1 Breast-feeding should be promoted for its nutritional, immunological and other benefits, including protection against diarrhoea, for the infant, and for the health and welfare benefits for the mother. 3.1.2 Exclusive on-demand breast-feeding during the night as well as during the day helps to protect against another pregnancy if still amenorrhoeic through suppression of ovulation during the first six months of lactational amenorrhoea, and this protection can be as high as 98 percent. 3.1.3 Since the suppression of ovulation is dependent upon maximal suckling stimulation of the nipple, "exclusive breast-feeding" means avoidance of any supplementation like water, fruit juices and so on, including the use of pacifiers. 3.1.4 Use of other methods of family planning to delay another pregnancy is indicated after six months of exclusive breast-feeding or if menstruation begins or if breast-feeding ceases to be exclusive. This should be communicated to mothers. 3.1.5 All mothers should be given an informed choice about using lactational amenorrhoea as a natural method of family planning. In the first six months of exlusive breast-feeding lactational amenorrhoea compares well with other methods of family planning. 3.1.6 Promotion for breast-feeding commences in the antenatal period, and even before for the mental and emotional preparation of any prospective mother. 3.1.7 After birth, the successful establishment of lactation is the next milestone to be achieved. Putting the baby to the breast within half an hour of birth is essential to the successful establishment of lactation and helps in mother-infant bonding. It also helps in getting the "let-down" reflex going in the mother as well as the rooting, suckling and swallowing reflexes in the baby. 3.1.8 Rooming-in for 24 hours and on-demand feeding during the day and night are key factors in the successful establishment and maintenance of lactation. 3.1.9 There is no need for prelactal feeding or any complementary or supplementary feeding in the first 4-6 months of life. 3. 1.10 Family and mothers' support groups including nongovernmental organizations are essential for the continuation of lactation after the immediate neonatal period. 3.2 Guidelines

3.2.1 It should be stressed in the training of all health workers that a true definition of the process of reproduction comprises conception, birth and lactation. Lactational amenorrhoea through exclusive breast-feeding needs to be made widely known to all health workers, and to be integrated with other maternal and child health activities, including family planning.

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3.2.2 Breast-feeding should be exclusive up to 4-6 months to ensure m~al benefits. By defmition, it should be without any supplementation such as water, frwt JUICeS, etc. Also the use of pacifiers is not recommended. 3.2.3 In all health facilities, breast-feeding must be encouraged and reinforced. To that effect in-service training programmes in the promotion and management of human lactation should be established. 3.2.4 Outmoded medical practices in maternity units and hospitals should be replaced by modem ones for the early initiation and successful establishment of lactation, which are outlined in the WHO IUNICEF 10 steps of successful breast-feeding. Examples are early initiation of lactation, avoidance of pre-Iaetal feeds, and 24-hour rooming-in. 3.2.5 The curricula in training institutions for all grades of health workers need to be revised to incorporate the new scientific advances in human lactation.

3.2.6 When advising on complementary feeding for an exclusively breast-fed infant, the risk of another pregnancy must be borne in mind, and counselling about the use of another method of family planning is indicated. The methods of family planning to be recommended will depend upon the informed choice of the couple. 3.2.1 The principle of lactational amenorrhoea should be integrated into the overall national strategy of family planning by the relevant national authority.

3.2.8 Because of the benefits of breast-feeding to the nation, legislation (including the adoption of the Code of Marketing of Breast-milk Substitutes) and other programmes are essential for its promotion and protection. 3.2.9 As women are increasingly entering the labour force, there is a need for legislation for helping with breast-feeding, e.g. maternity leave, nursing breaks, creches and so on.

3.2.10 Regular monitoring of the prevalence and duration of breast-feeding and lactational amenorrhoea should be continued.

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ANNEX 1

UST OF PARTICIPANTS, CONSULTANT, TEMPORARY ADVISERS, OBSERVERS/REPRESENTATIVES AND SECRETARIAT

1. PARTICIPANTS

AUSTRALIA

Dr Cathy Mead Medical Services Advisor Communicable Diseases and International Health Section Department of Community Services Canberra Dr Zheng De-yuan Pediatric Department Second University Hospital of West China University of Medical Sciences 610041 ChenKSJu Dr Yuan Xiaohong Deputy Director Child Health Division MCH Department Ministry of Public Health 100725 Beiiinl:

CHINA

HONG KONG

Dr Linda Hui Yin-fun Acting Senior Medical and Health Officer Department of Health Family Health Services 2/F, Centre Point 181-185 Gloucester Road Wanchai Ms Kee-Hey Choung Researcher Korea Institute for Health and Social Affairs San 42-14, Bulgwang-Dong, Eunpyung-Ku Seoul

REPUBUC OF KOREA

- 16-

Annex 1

lAO PEOPLE'S DEMOCRATIC REPUBLIC

Dr Anan Sacdpraseuth Maternal and Child Health Institute P.O. Box 2174 Vientiane Ms Somsiah Parman Nutrition Officer Ministry of Health Block E, 4th Floor, Offices Complex Jalan Dunguo, 50490 Kuala Lumpur Mr Enoch Posanai Acting Assistant Secretary Family Health Services Department of Health P.O. Box 3991 Boroko (N.C.D.) Dr Estelita J. Papa Chief, CDD/BF Division MCHService Department of Health San Lazaro Compound Sta. Cruz, Manila Dr Yap Gim Hong Medical Officer Ministry of Health College of Medicine Building 16 College Road Sin&apore Ms Kim Nguyen Thi Vice-Director Group of Maternal and Child Nutrition National Institute of Nutrition 48 Tang Bat Ho Street HmQi Dr To Thi Thanh Huong Head Department of Newborn Olof Palmer Children Hospital lW!gj

MAlAYSIA

PAPUA NEW GUINEA

PHILIPPINES

SINGAPORE

VIETNAM

- 17-

Annex I

2. CONSULTANT

Professor GJ. Ebrahim Professor of Tropical Child Health Institute of Child Health University of London 30 Guilford Street London WCIN IEH United Kingdom

3. TEMPORARY ADVISERS

Dr Ricardo Gonzales Chief of Hospital III Dr Jose Fabella Memorial Hospital Manila Philippines Dr Barbara Gross Senior Scientific Officer Endocrine Unit Department of Medicine Westmead Hospital Westmead. NSW 2145 Australia Professor Araceli Maglaya College of Nursing University of the Philippines Manila Philippines Dr Nian Cui Researcher Institute of Family Planning Research 15 Shi Duan Ren Min Nan Rd. 610041 ChenKdu. Sichuan Province China Professor Nguyen Kim Tong Director Institute for Protection of the Mother and Newborn 43 Trang Thi Street Hanoi, Viet Nam

- 18-

Annex 1

4. OBSERVERS/REPRESENTATIVES

INTERNATIONAL ORGANIZATION OF CONSUMERS UNIONS (IOCU)

Ms Ellen Sokol Legal Consultant IOCU Regional Office for Asia and Pacific P.O. Box 1045 10830 Penan&- Malaysia Dr Juan Perez Balikatan at Ugnayang Naglalayong Sumagip sa Sanggol (BUNSO) (National Coalition for the Promotion of Breastfeeding and Child Care) 6B K-6th Street Kamias Road OUezon City. Philippines Ms Judith Standley UNFPA/UNICEF MCH Adviser UNICEF Office for China 12 Sanlitun Lu Beijin& 610041 Chen,du. Sichuan Province China Ms Bituin Gonzales Programme Officer for Health and Nutrition UNICEF Office in Manila NEDA sa Makati Building Amorsolo Street, Legaspi Village Makatj, Metro Manila Philippines Dr Khin Let Ya Health Consultant UNICEF Office in Vientiane Quartier Wat Nak Route Tha Deua Vientiane Lao People's Democratic Republic

INTERNATIONAL BABY FOOD ACfION NETWORK (mFAN)

UNICEF

-19 -

Annex 1

5. SECRETARIAT

Dr I. Darnton-Hill (Operational Officer) Regional Adviser in Nutrition World Health Organization Regional Office for the Western Pacific Manila Dr G. Deodato (Co-operational Officer) Regional Adviser in Maternal and Child Health including Family Planning World Health Organization Regional Office for the Western Pacific Manila Ms R. Charrondiere Associate Professional Officer Nutrition World Health Organization Regional Office for the Western Pacific Manila Dr P. Volmanen Associate Professional Officer in Nutrition World Health Organization Regional Office for the Western Pacific Manila Dr S. Suomela Associate Professional Officer Diarrhoeal Diseases Control World Health Organization Regional Office for the Western Pacific Manila Dr S.F. Katoanga Acting Technical Officer Maternal and Child Health World Health Organization Suva Ms R. Saadeh Nutrition Unit World Health Organization Geneva

- 21-

ANNEX 2

AGENDA

1.

Opening ceremony A review of current understanding of breast-feeding and fertility

2. 3. 4. 5. 6. 7. 8 9. 10. 11. 12. 13. 14. 15.

WHO data bank on breast-feeding and fertility and overview of WHO activities Presentation of research results Trends, patterns and legislation concerning breast-feeding and fertility in the Western Pacific Region using country reports Quantifying the effect of breast-feeding on fertility Rooming-in and hospital policy guidelines Group discussion on identifying countries' breast-feeding and fertility problems and solutions already found; Presentation and discussion about a country's breast-feeding problems and promotion programmes Proposed plan of action for a selected country Common breast-feeding management problems and their solutions Group discussion on finding solutions for identified problems Preparation of plans of action by participants for own country Conclusions and guidelines Closing ceremony

- 23 -

ANNEX 3

SELECTED BACKGROUND PAPERS

- 24 -

Annex 3

A REVIEW OF CURRENT UNDERSTANDING OF BREAST-FEEDING AND FERTILITY by Professor G.J. Ebrahim Professor of Tropical Child Health Institute of Child Health University of London 30 Guilford Street London WC1N lEH United Kingdom

- 25 Annex 3

The ContraceptIve Effect of Breastfeeding - an update. In the 19705 there were a number of reports from studies in

:::mall (:c)lnmunities about the effects of breastfeedlng in l,.z

prolonging where

the

birth interval.

Initlally such reports came from Africa

the practice of sexual abstinence whilst the woman is breastteeding is common. In the late 1970s and early 'Bas a number of country

wide studies were carried out which helped to establish the role of breastieeding that in in the control of fertllity. In 1975 Rosa 3

reported births

developing countries breastteeding prevents

more

than all the other methods of contraception put together. Sin~e these early studies attempts have been made ~he

to

quantify

contraceptive effects of breastfeeding, and its contribution to control 4-

the

of fertility in general. The 1984

World

Development number as 4.65 6.84 in

Report stated that breastfeeding reduces the total possible of births per per woman. The reduction ranges from as doman in Bangladesh, 5.25 in Indone~ia

high and

births Senega 1 . An

analysis

of the World Fertility Survey data

6"

showed cent of

that for 12

breastfeeding five countries

reduces fertility by an average of 34 per in Africa: by 30 per cenl CBllt

in

the

case

countries

in Asia, and by 16 per

in the case of 12

countries

in Latin America, The possible effects of decline in rates by 25 per cent and 50 per cent from the current calculated as follows:

breastfeeding le~els

may be

- 26 -

Annex 3

Africa Total rates c~nt

fertIlity

rate wIll

Increase

from

current P'::1'

ot

6.3 to 7.1 and B.O respectIvely

(an Increase (If 12.7

and 27 per cent respectivelyl ContraceptIve use WIll hav~

to

Increase

from

the to

CUtTent: rnaIntain

7

per' c:o:<nt

te, 17

p.::y

c.::nt 6nd and

fertIlity constant (an lncrease of 143 per cent

286

per' cent respectively). Asia Current total fertility rate will increase from 5.4 5.~ ~nd

to

6,6 respectively I an Increase of 9.3 per cent and 22,2 per

cent respectively) ContracePtive use WIll have to increase trow. current 26 per cent to 32 per cent and 40 per cent respectively (an increase

of 23 per cent and 54 per cent respectively) , Latln America Current total fertillty late of 5,4 will lncrease to per

5,9 and 6,6 respectlve!y

(an increaso:< of 9.3 per cent and 22.2

cent respectively). Contraceptive use wi! 1 have to Increase trom current 26 per' cent to 32 per cent and 40 per cent r'espectlvely ( an of 23 per cent and 54 per cent respectIvely) Increase

- 27 -

Annex 3 The contribution of breas~feeding

to the control of

fertility

wlll vary from country to country according to the prevalence rates. and the pattern of breastfeeding. and the local cultural like post-partum par'tum abst i nence abstinence. is the In most of sub-saharan convn.:>n pract ice. There practices post been

Africa it has

estlmated that removal of 0l'eastfeedin9 al1·j post par-turn will cause

abstinence is no of

a

72

per

cent rise in

fer~ility

if

there as

convnensurate births to 11.4.

increase

in contraception. Expressed

number

per woman the average fertility rate of 6.6 could In Bangladesh. on the other' hand. it the mean

increase

lactational months triple present

amenorrhoea to from 12.7

were to decline trom the current level of 21.7 than the

months. contraceptive use will have to more current 9 per cent to 31 per cent to hold

the

fertIlity rate ot 6.3 constant. Epidemiological birth data must be viewed wIth caution. because factors

interval is lnfluenced by a varIety of

behavlollral

such as abstinence or use of contraceptives Including it 1S

termination.

also well known that between 2 and 10 per cent women conceiv,e

dUrIng lactational amenorrhoea. One confounding factor has been the effect that ver'y of maternal nutrition on fecundity. Recent work has shown a

except in situations like famine maternal nutrition

plays

· . , I none s t neg I 191ble role.

UIi

y to assess th e ro 1e

0

f

maternal

nutrition breastfeeding women in Bangladesh were divided into three groups by thei~

body weight as follows:

- 28 -

Annex 3 <38.5 kg; between 38.5 and >42.4 kg. The mean duration of lactational amenorrhoea was not and and 42.4 kg

sjgnjflcantly different between the three groups at 17.9. 17.5 16.3 months.

Several 5:rlVen

such studies have led to the understanding that in control of fertility is like: largely determined

a by

community

fertility Inhibiting factors (i). (ii) lat~

marriage or marital disruption. birth 01·

.d~liberate

control

through

abstention.

contraception (1ii).

termination.

breastfeeding. during

In a study designed to predict the return of ovulation lact~tioll ~mongst

mothers with different patterns of breastfeeding in Mani la recOl-dedtheir for of

60 breastfeedlng women in Baltimore and 41

reeding pattern daily. Ovarian actIvity was monItored by assay hormone B~ltlmore m~tabolites

In

daily

urine

samples.

In

the

case

women the average episodes of breastfeeding duration of feeding at each episode longer.

were The

fewer mean for

but

the

interval for ovulation was 27 weeks for Baltimore and 38 weeks I-1anila women. The risk of ovulation was reduced by a and

higher less had

frequency

of breastfeeds

longer duration of each feed.

supplementary feeding. low

In the first 6 month amenorrhoeic women partial

risk of OVlllation «10 per cent) with

breastfeeding.

- 29 -

Annex 3

Exclusive either woman

br~astfeeding

reduced the risk to 1 -5

per

cent If

with the she

frequent

short feeds or Infrequent longer

feeds.

started menstruation before 6 months post partum. or if

continued breastfeeding beyond 6 months the risk of ovulation roseY Since i nterva I. we hreastfeedlng acts through Increasing the birth

In a further analysis of the effect of

breastfeeding parts as

may divide birth interval into its three constituent

follows: - post partum amenorrhoea - the menstrual Interval a fixed period of 40 weeks of gestation. The mothers ~verdge

duration of post partum amenorrhoea is 2 months in br~astfeed.

who

do not

In those

who

practice

on-demand in

breastteedlng. post partum amenorrhoea averages about 11 months

younger women and slightly longer In older women. Thus. post partum amenorrhoea duration increas~s

by between 60 and 75 per cent of the

average of

of breast feeding. But there is a limit. The does not increase much if breastfeeding

.duration is

amenorrhoea

prolonged·

beyond 24 months. Nor does it decrease very steeply if the duration of breast feeding is less than 7 months. of It means that the duration crucial. It the

breastfeeding in the range 6 to 24 months is most

also happens to be the duration which is maximally affected by present decline in Next we breastfeeding. how the different strategies for

examine

familY

- 30 Annex 3

plannIng

work.

two main patterns can be ldentlfled with regard as follows:

to

t.i1e model'n contraceptive practices.

(il.

prolongation of the interval to next conceptIon.

Most modern contraceptive p:actices are directed at prolonging the interval between births. The barrier method. device. the withdl'awal method. the pill. have the the

intra-uterlne purpose of

and so on

increasing this interval. Termination of gestation. legalising abortlon a number of the syringe-suction method.

(ii).

Since the increasing trend for new

approaches have been evolved e.g.

and the new PIll RU 1n Hhat ways sLlPPI-ession of ovulation through bl-eastfeeding

can be integrated into the overall strategy of family planning? In qUdntiry order the to answer this question we nrust extent Studies of in suppression ScottIsh (If

first

attempt

to

ovulation who were

through practicing woman for to «

breastfeeding.

women

exclllSlve breastfeeding until supplementation showed that no ovulated nlOl-e if she was breastfeeding six or more times a day and

than 60 mi nutes a day. When women were grouped

accordi ng or early

whether they ovulated late () 40 weeks atter delivery)

30

weeks atter delivery) longer

it could be seen that the lactation 53

late weeks):

ovulators suckled

breastfed

(Iflean durat:ion of

- 31 -

Annex 3

oftener.

kept

up

night

time

feeding

longer

and

introduced were

supplementary introduced. had had

feeds to the baby gradually. When within 16 weeks of supplementation

supplements ovarian

follicles per Danish cent and

begun to develop in 80 per cent of the women and 56 ovulated. i

Silnilar observatlons have been made in

American women. From these and similar studies It can be now stated that in the first 6 months of lactation if a woman is exclusively with of

breastfeeding on-demand and both during the night and the day at least 6 episodes of feeding and a minimum total duration

suckling from

for 60 minutes in 24 hours then a 98 per cent can be expected. unless

protection has

another pregnancy

menstruation

resumed. Reviewing data from 13 prospective

stUdies

in

Australia.

Canoda. Brltain. PhillPpines. Mexico. Egypt. Thailand and Chile tpe Bellagio consensus stated that the maximum effect on suppression of OVUlation is achieved in the first 6 months post partum 'f

when

a

mother is fully breastfeeding and remains What is the level of protection if

amenorrho~lc.

menstrual

bleeding

has.

commenced before 6 months post partum in women who are

exclusive!y

One protectlon

study

in

Chilean

women

confirmed

the

98

per

cent

1n the first six months post partum women who are amenorrhoeic.

among and 75

exclusively per cent of with

breastfeeding protection menstruation

if menstrual bleeding has started. After resumption the risk of pregnancy increased progressively

- 32 -

Annex 3 time but was far less compared to the risk in non-nursing controls~' What about long term protection? Recent work in Australian women II

who

were

exclusively of

breastfeeding showed a mean duratlon of 9.5 +_ 4.9 months. months. Ii Q

lactational amenorrhoea

and a mean dUl-ation of anovulatIon of 10.6 +_5.0 lactational menstruation

woman had unprotected intercourse durIng when

amenorrhoea resumed.

and adopted contraceptlve measures

then the chances of pregnancy were as tollows: months

1.7% would have become pregnant during the first six

ot amenorrhoea - 7% after 12 months - 13% after 24 months In the case of lactatIng women who had unprotected intercourse

50% became pregnant by 12 months. 85% became pregnant by 18 months. ThIS study now gives us a quantifiable effect of lactation on

fertility. There is excellent protection in the first 6 months post partum, and qood protection for upto 12 months. Once menstruation

has returned other forms of contraCeptIOn are needed. These observations can be worded as a general guide line viz. At 6 months OR

If menses return OR

If breastteeding ceases to be exclusive then other measures of

- 33 -

Annex 3

family planning are lndicated. How do these rates compare wlth the 6 - month other methods fail~re

rates of month

of contraception? The generally agreed

6

failure rates of the other methods are: r-Ie thod Natural Famlly Planning :3permi c ide::; Diaphragm Condoms IUD Oral Contraceptives How can the lactational amenorrhoea Six month Failure Rates

9.4% 8.9%

7.2% 4.8%

2.4% 2.3% method (LAM) be

Incorporated into the overall strategy of familY planning? It has been a mistake In the past to dismiss LAM as of

unreliable. A rational approach wIll be to have a clear measure its strengths and weaknesses and to integrate it into the

overall

strategy of family planning. There are two situations where LAM· is particularly useful VlZ.

(i) When no alternatives are availoble OR

If the couple choose not to use other methods. (i i )

To

delay

the

introduction

of

other

contnlcept i ve

methods.

- 34 -

Annex 3 A way ot Integratlnq LAM into the overall strateqy ot integration of LAM into the national strategy of MCH be accomplished in four easy to learn steps at every child clinic lalso called under fives' T",rgetlng. woman is who more is breastieeding and at risk of another welfare include .. a 0("1

MCH·~

FP. can

FP

welfare

clinic)

in the following manner:

(J).

The pregr,ancy

likelY te, be enc(Iuntered in the That 15

child

(under-fives') .::iaiogue nutrItIon. lii) about

clInic. family

where consultation must addition to

planning in

cO l l l1selling

llTUnunisatl0n.

and curative care. for the clinic for

CalculatIon and

of the average birth interval deciding on the probable

POPUlc.tlon.

vulnerable

month

C')I"lCeptl,)11 in that cOnlrflunity. The ~he

Road to HealH. Chart IS a useful deVIce birth interval in a clinic

for

calculating The. birth ~n

aver~ge

population.

intervals chal·t. step IS

in

100 to 200 women are recorded by monthg

a The

blank next

From this the mean birth intet"val is Identified. to identity the birth interval for the early

5%

births. the

Counting

'9 months backwards froll\ the month at early 5% bIrths

earliest vulnerable month tor conception can be determined for that population. (iii). Corrunencement ot dialogue WIth the mother. The weight vulnerable month must be clearly marked on the chart. ,Dialogue can corrunence long before this child:s .

vulnerable

- 35 -

Annex 3 month is reached. .' incluolng a coun td own t t'ne approaching month

0

when conception is most likely. This helps to remove an attitude of fatalism concernlng conception amongst the mothers and clInic staff. iiv), Motnres' education. In the health education message mothers and health workers can be taught to look out for three milestones to approaching

vulnerabIlIty by : (1) onset of menstruation (ii). Initiation of supplementation. (iii) The child'S monthly birthday. In

the absence or menses and supplementation 93 per mothers are usually anovular ror

cent

of post this an~

breastieedIng partum. p~1'i0d

3

months Arter wane

and

88

to 89 per cent for upto six

months.

the protection effect of breastieeding begins to

other methods or contraception are needed. The quantification of the contraceptive effect available of, for

breastfeeding increasing LAM post

helps us to list LAM amongst methods of

the birth interval. Like all methods

contraception six months

has its strengths and failure rates.

In the first

partum the failure rates are comparable to other of contraception. On the other hand the

established benefits of

measures

breastfeeding are immense. The Integration of LAM 1nto the strategy of MCH - FP is yet another strong ground for

overall national

policy measures to halt the decline in breastfeeding.

- 36 -

Annex 3

REFERENCES 1.

r_ron I. n TJ. Lanc~ t

Influenc~

of

lactation upon ovulation

1968;

i I: 422-4 Fertility

Parkes AS. Thomson AM. Poas M. Herber~son MA rEds). regliiatlon during human lacLation.

J.Biosoc. SCI. 1977: suppl nO.4 3.

Rosa FW. The role of breastfeedIng in family pl~nning. PAG BulletIn 1975:5:5-10

4.

The World Bank. World Development Report 1984. Oxford.Oxford UnIversIty Press 1985.

5.

Thapa 3. Snort RV. Po~ts M. Breast feedIng. their effect on ChIld survlval. Nature 1988:

bir~h

SpacIng

and

335 :679-682. of

6.

Bongarts evidence.

J. ['oes ITIcdnu~ritlon afrect tecundity? A summary

SClence 1980;208:564-569. 7. (~ray

RH.Campbell

OM.

Apeto

R. Eslami SS

et

al.

Risk

of

~vulation dU)-lng Lance~

lac~ation.

1990;335:25-29. RV.Breast Feeding. Scien~lfic

8.

Shor~

Amer'ican 1984;250:23-29. McNeIllY

9.

Kathy

I.

Kennedy on

MA.

RIvera

R.

AS. famlly

Consensus planning

statement method.

the use of breastreeding as a

Contraception.

1989:39:477-496.

- 37 -

Annex 3

10.

Diaz S. Rodriguez G. Peralta 0 et al. LactatIonal and the recovery of of ovul~tlan

amenorrhoea in fully.

and

fertility

nurSIng Chilean women. Contr~ception.

1988;38:53-67.

11.

Sh<:.rt RV. Lewis RR. Reni ree [vL8. Shaw G. Contracept j ve of extenaed iac~atlonal

et i ects Bellagio

amenorrnoea:

beyond

the

consensus. Lancet 1991: 337:715-7.

- 38 -

Annex 3

QUANTIFYING THE EFFECT OF BREAST-FEEDING ON FERTILITY by Dr Barbara Gross B.Pharm., M.Sc., Ph.D. Endocrine Unit, Department of Medicine Westmead Hospital, Westmead, Australia

Exclusive or almost exclusive breast-feeding for six months delays the return of menses and ovulation. Furthermore, provided an infant has adequate growth, no supplementary feeding is needed for 6 months after delivery. We should be aware that very few countries have adequate growth curves for exclusively breast-fed infants and that most growth curves have been derived from measurements of infants with no distinction as to the type of infant feeding. Furthermore when supplements are introduced, provided a mother is lactating well, supplements should be given gradually as tastes to educate the infant rather than to replace the breast-feed. Bellagio Consensus Statement Studies on return of fertility in breast-feeding women have indicated that there is a less than 2% of pregnancy before the first vaginal bleed in the first six months provided a mother is exclusively, or almost exclusively breast-feeding. We can ignore any bleed up to the first 56 days postpartum as this is generally considered part of the lochial or post-delivery discharge. This finding has been defined as the Bellagio Consensus Statement (Lancet, November 1988) and in practice can be applied as a natural method of birth spacing - the Lactational Amenorrhoea Method or LAM. Beyond six months studies suggest that only 30% of women ovulate and have a normal luteal phase before the first bleed. Using an accepted rate of fecundity of 25% - this suggests that there is an approximate risk of pregnancy of 7-8% during prolonged lactational amenorrhoea - irrespective of whether the infant is exclusively or partially breast-fed. This figure compares well with the 7-10% risk of pregnancy cited in demographic studies and recently reported from an Australian longitudinal study (Short et.al., Lancet March 23, 1991). The 2% risk for mothers of exclusively breast-fed infants up to six months postpartum may further be reduced if we consider that episodes of spotting or light bleeding of 4 days or more, which may not be considered as "bleeding" may herald the infrequent early ovulation.

- 39 -

Annex 3 Factors Affecting Duration of Lactational Amenorrhoea Several factors must be considered which could affect the duration of lactational infertility of exclusively breast-fed infants. These include practices associated with the delivery of the infant and establishment of lactation, those associated with the maintenance of lactation and environmental and genetic factors. It is for these reasons that we may have individual variations in the duration of lactational amenorrhoea particularly up to six months postpartum. Suckling patterns influence hormonal factors which control the process of ovulation and fertility. These suckling patterns include the frequency and duration of suckling episodes during day and night, the interval between feeds and the intensity of suckling. Other variables may influence these suckling patterns or the hormonal control directly or indirectly. Some of these are related to the infant e.g. prematurity, sex of the infant (since it is known in some populations that there is a difference, objective or subjective, in the duration of breast-feeding boys versus girls), suckling of other objects, fingers, toes, etc. Other characteristics are related to the mother e.g. weight, nutrition, beliefs and attitudes. Important variables such as the timing and rate of introduction of supplementary feeding will affect the suckling patterns directly and influence the duration of lactational amenorrhoea. The importance of other factors such as climate, altitude and environment may also be important but remain to be determined. These and other factors have been identified by members of the WHO Task Force of Natural Regulation of Fertility, Family Health International and the International Institute for Studies in Natural Family Planning. These factors have been included in the Annex to the Report on the Bellagio Consensus Statement (Kennedy et.al., Contraception May 1989) included in the papers for the workshop. Suckling Patterns There is marked individual variability in the patterns of suckling patterns at the time of resumption of menses. The relative importance of individual factors, of the suckling patterns in determining the onset of menses is one of the major objectives of the ongoing WHO Multicentre Study of the Duration of Amenorrhoea in Relation of Breast-feeding Practices (reported yesterday). In a previous longitudinal Australian study of 34 breast-feeding mothers we found that at the resumption of menses, the average frequency of feeding was 5.7 feeds per day. However the range was from 1 to 11 feeds per day. In other words, one mother resumed menses when she was giving eleven feeds per day while another did not resume until the baby was having one feed per day. Similarly, the average longest interval between breast-feeds was nine hours with a range from 4 to 24 hours. The total 24 hour suckling time on average was 54 minutes with a range from 4 to 120 minutes at the time of onset of menses. Mothers were giving between one and four solid supplements and one to three liquid supplements. For the majority of women in our Australian study, menses did not resume until after supplementary

- 40 -

Annex 3 feeding was begun. In this group of women, supplements introduced as "tastes" for educational purposes and the frequency is increased gradually so that by nine months usually having three supplementary solid meals and some liquids as well as breast-milk. are usually amount and the infants are additional

If the supplementary feeding is rapid and is used to replace breast-feeds then menstruation is likely to resume earlier. In our Australian study women who resumed menses before 39 weeks after delivery introduced supplementary feeding more rapidly and there was a significantly longer interval between feeds at night compared to mothers whose menses returned beyond 40 weeks. These infants also suckled for a shorter time at the breast. But it is also apparent that some infants who have reduced feeds at night suckle for longer durations during the day, so there is an overall similar total suckling stimulus over the 24 hours. When both suckling stimulus throughout the 24 hours is reduced and the interval at night is longer between feeds then mothers are likely to resume menses earlier. These findings are similar to these reported for breast-feeding mothers in Edinburgh. Comparison of Sucklin& Frequency between Populations A comparison of studies of breast-feeding mothers in three countries - Australia, Scotland and Chile illustrate the differences between these specific groups of mothers. Menses resume earlier in breast-feeding mothers in Santiago (Chile) compared with EdinburAh (Scotland) who resume menses earlier than the Canberra (Australia) mothers. This occurs in spite of higher frequencies of breast-feeding in Chile of 8-12 times a day compared with Australian mothers breastfeeding 4-6 times a day. When the breast-feeding frequency was compared in these three studies it was observed that breast-feeding more than six times a day reduced the risk of resuming menstruation by only 45% in Chile compared with nearly 80% in Australia and Scotland. Furthermore, when the age of the baby was considered only Australian mothers continued to have an 80% reduction in risk with greater than six feeds per day. It is possible these differences are due to other factors such as study design and the WHO longitudinal study should clarify this. A Kother's Previous Experience This comparison again illustrates that infants have individual feeding patterns and this may vary between infants of one mother. On the other hand, we have shown that the duration of amenorrhoea a mother experiences while breast-feeding one child may be a very good predictor for her next experience - provided the breast-feeding patterns are similar.

- 41 -

Annex 3 Seasonal/Environmental Factors The differences in duration of amenorrhoea observed in various populations may be due to environmental factors. In Australia we have noted that a significant number of mothers resume menstruation during summer compared to other seasons independent of whether they have weaned the infant. This also coincides with the Christmas holiday time and may reflect reduced frequency of feeding or her stress factors associated with this particular time of the year. In some countries the season influences the mother's work pattern particularly in rural areas. In Bangladesh breast-feeding frequency is reduced when mothers return to the fields during harvest and menses resume. Definitions In studies of resumption of menses, whether they be longitudinal, simplified methodology, cross-sectional or retrospective the definition of terms and standardization is extremely important. The recent framework of definitions to be used in describing breast-feeding has already been mentioned by Professor Ebrahim and Ms R. Saadeh from WHO. Exclusive breast-feeding means - no other liquid (including water) or solid or semi-solid foods. One particular example of errors in definition was apparent to me in my studies in the Philippines. Here full or exclusive breast-feeding is interpreted to mean "no formula or other milk" but allows/includes other liquids or solids. Similarly, mensestb1eeding. Many of the studies reported at this meeting have a frequency of mothers resuming menses by one month after delivery. In the Bellagio Consensus meeting we considered that all bleeding occurring before day 56 postpartum was lochial fluid or post delivery discharge. It is unlikely that mothers who report bleeding this early continue to bleed at regular cyclical intervals. Beyond this time even an episode of four or more days of spotting or light bleeding may herald the return of cyclicity and might be considered the first episode of "bleeding" for the definition of the end of the period of lactational amenorrhoea. This 'early bleeding' remains the subject of future research. SUmmary of WHO Studies and Other Studies of Breast-feeding and Return of Menstruation World Fertility and other surveys have shown that in Asia the duration of breast-feeding varies widely from duration of less than 10 months in Malaysia to 15 months in the Philippines and over 25 months in Indonesia. However, this duration varies widely within countries and there are particular populations where the duration is very low and so we would expect that the duration of amenorrhoea is also low. The WHO studies reported at this meeting illustrate some of the differences observed within a particular country and between countries.

- 42 -

Annex 3 WHO Longitudinal Study The longitudinal multicentre study of two urban Australian populations (a selected population rather than random and therefore possibly not representative of the Australian population) showed that for the previous child the women breast-fed on average 12 months exclusively for five months and resumed menstruation at an average of ten months with approximately 18% resuming menses by three months. The current infant is exclusively breast-fed for over 150 days with most mothers delaying the introduction of caloric and solid supplements beyond four months. The mean time to first bleed was 223 days for 92 mothers but this may reflect earlier bleeding. The longitudinal study defines more specifically the types and timing of supplements and the breast-feeding patterns in relation to time of resumption of menses but data analysis to date is only preliminary and complete for only 92 of 268 subjects admitted to the study. The median time to first bleed was 305 days with 25% resuming at a medium of 215 days postpartum as calculated by life table analysis. WHO Simplified Methodology

The study in Korea did not differentiate between exclusive and partially breast-feeding women. As shown in Figure I, there was little difference between the percentage of women breast-feeding in rural and urban populations at one (86.4 and 84.9%) and three months (77.4 and 75.9%) while at 6 months slightly more rural women (81.3%) were breastfeeding compared to urban women (71.4%). Slightly higher proportions of urban women were amenorrhoeic compared with rural women at one (86.7 and 75.4%) and two months (83.6 and 73.8%) while a higher percentage of rural women (66.3%) were amenorrhoeic at four months compared with urban women (66.3%). No distinction was made between mothers breast-feeding and non-breast-feeding so it is expected that a higher percentage of breast-feeding mothers would be amenorrhoeic at each time period. Contraceptive use was much higher for urban women compared with rural women at three (55.6 and 28.9%) and six months (67.4 and 28.4%). These figures indicate that most women would have either been amenorrhoeic and/or contracepting by six months postpartum. Hong Kong In Hong Kong the duration of breast-feeding (for 3230 women) is low - average 7.4 weeks with 45% breast-feeding less than 2 weeks. 4.5% breast-fed for 2-4 months and 3.1% for more than 4 months. The high percentage reported as menstruating before one month (either breastfeeding or not breast-feeding), approximately 40%, illustrate the need for definition of first bleeding. Breast-feeding women were amenorrhoeic longer than non-breast-feeding women but the duration was very small with only 8.5% of breast-feeding mothers amenorrhoeic at 4 months (see Figure 3). After 4 months 95% of women are using

- 43 -

Annex 3 contraception so that breast-feeding is not considered as important for birth spacing. The reasons given for not breast-feeding illustrate in this population the importance for advice re the nutritional benefits of breast-feeding.

In a nearby population, Macau, although the results were not reported at this meeting, the WHO Simplified Methodology shows a much higher prevalence of breast-feeding in a study of 573 women over a 12-month reference period (see Figure 2). The comparison between the two populations of the duration of amenorrhoea Hong Kong and Macau is clearly illustrated in Figure 3. At one month 55% of Macau women were breast-feeding. Between two to three months 37% were breast-feeding in Macau compared with 4.5% between two to four months in Hong Kong. At. 5-6 months the ~roportion was 26% and 3.1% respectively, 70% of breastfeeding women compared with 26.8% in Hong Kong were amenorrhoeic between 2-3 months (2 months in Hong Kong) and 22% at 5-6 months in Macau compared to 8.5% at 4 months in Hong Kong. A lower proportion of Macau women used contraception and no distinction was made by the duration breast-feeding and amenorrhoea duration. However, it can clearly be seen that there is a stronger effect of breast-feeding on the duration of amenorrhoea in Macau compared with Hong Kong. No distinction was made between exclusive and partial breast-feeding in these studies and in Hong Kong this would appear to be of little relevance. Viet Nam The WHO Simplified Methodology used in Viet Nam has shown a high incidence of breast-feeding in both urban Hanoi and rural Habac. Only 14.6% of 600 urban and rural infants were being exclusively breast-fed at the time of interview. This is probably due to the high proportion of mothers returning to work with 34% of urban Hanoi and 91% of rural Habac mothers who are predominantly farmers returning to work. The rural mothers also returned to work earlier than urban mothers. Although the duration of amenorrhoea is short, there was only a low risk of pregnancy (0.8%) during amenorrhoea. The Be11agio guidelines were confirmed with 0.5% of non-contracepting breast-feeding women conceiving during exclusive breast-feeding and amenorrhoea. Philippines A WHO study using the Simplified methodology of 600 women in an urban depressed popUlation found that 58% were both amenorrhoeic and breast-feeding. A very low proportion of infants - 9.6% were fully breast-feeding. This may be because many mothers introduce rice water early to the infant as we found in earlier studies. 91% of the mothers were using family planning methods by 6 months with the highest proportion using natural family planning methods - rhythm and the

- 44 -

Annex 3 Billings method - and withdrawal. The relationship between breast-feeding and amenorrhoea was significant between two and seven months, post delivery. The results of these WHO Simplified Methodology studies illustrate the current practices in relation to breast-feeding and contraception although some studies are limited by the non-differentiation between exclusive and partial breast-feeding and amenorrhoea in relation to the breast-feeding and non-breast-feeding women. The Simplified Methodology provides a very rapid, low-cost method of determining current prevalence of types of breast-feeding, amenorrhoea and contraceptive use. The limitations include the sampling of the population and the definition of terms particularly in relation to breast-feeding and bleeding. Specific differences between population groups may be also observed but sample size will limit interpretaiton of results. The longitudinal studies provide more precise difference in feeding patterns to be determined in relation to the duration of amenorrhoea and may also provide some indications of other factors which explain differences between populations. Data from World Fertility Surveys of Asian countries highlight specific target groups within countries which may need specific attention in breast-feeding promotion and fertility (Ferry, 1981). Urban/Rural Differences Significant differences between urban and rural women occur in the prevalence of breast-feeding in Thailand, Philippines and Malaysia with more rural mothers breast-feeding compared to urban mothers. Age of Mother Younger mothers (less than 25 years) and those 25-34 breast-feed for shorter durations compared to mothers 35 years and older particularly in Malaysia and also with a smaller trend occuring in Indonesia but not as obvious in the Philippines. Education More highly educated mothers are less likely to breast-feed and breast-feed for shorter times, a trend that is opposite to that observed in developed countries such as Australia, United States of America and United Kingdom. Ethnicity and Socio-economic Level Studies from Singapore suggest that there are differences between ethnic groups in the initiation of breast-feeding and the duration. Although breast-feeding prevalence and duration is low and has been declining in recent years it is lowest amongst the higher socio-economic group and those of Chinese ethnicity and higher in the Indian and Malay population. There has been an increase in the percentage of higher socio-economic mothers breast-feeding since 1970 with approximately 40% breast-feeding at one month in 1980 compared with 15% in 1970.

- 45 -

Annex 3 Fagily Planoin& Prevalence During Breast-feedin& There is marked variability between countries in the prevalence of use of methods of family planning. In most countries of Asia, the prevalence of family planning use is lOX or less in breast-feeding women. The double protection provided by lactational amenorrhoea and concurrent use of family planning has not been determined in these studies but should be addressed in the results of the current Demographic Health Surveys. The impact of the effect of reduced prevalence and duration of breast-feeding necessitating increased prevalence of use of family planning methods has been highlighted (see paper by Thapa, Short and Potts, 1987). The impact would be highest in countries with low prevalence of family planning use e.g. Indonesia. St!mmary

The effect of breast-feeding on fertility is variable and is affected by various factors including the patterns of breast-feeding. There is a need to emphasize the steps for successful initiation of breast-feeding to increase the prevalence of breast-feeding. Guidelines are needed to determine the patterns of breast-feeding which provide optimum maintenance of lactation and maximize the effect of breastfeeding on fertility. These will be provided by longitudinal studies. The WHO Simplified Methodology provides a rapid method of estimating prevalence and duration of breast-feeding and amenorrhoea and further highlights target groups for specific attention for advice and promotion.

Annex 3

- 46 -

PERCENTAGES OF WOMEN BREAST-FEEDING, AMENORRHOEIC, OR CONTRACEPTING IN KOREA, MACAU AND HONG KONG AS DETERMINED USING WHO SIMPLIFIED METHODOLOGY WHO SIMPLIfiED nrnroOOl06Y tO~A

_ CIJITI.\aPI RIll

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- 47 -

Annex 3

WHO DATA BANK ON BREAST-FEEDING AND FERTILITY AND OVERVIEW OF WHO ACTIVITIES by

Ms Randa Saadeh Technical Officer. Nutrition Unit World Health Organization Geneva. Switzerland

- 48 Annex 3

WORKSHOP ON BREAST - FEEDING AND ITS EFFECT OR FERTILITY IN THE VEST PACIFIC REGION BREAST-fEEDING ACTIVITIES 1.

AI HO

Breast-feedin, Data Bauka A. B. Breast-feeding prevalence and duration Breast-feeding / Fertility / Child-spacing

2.

Publication of Proceedings of a Technical Meeting (Breast-feeding in the 1990s) Geneva 25-28 June '90 Contents: A. Executive Summary and Recommendations B. Technical Papers I. II. Trends in Breast-feeding and Supplemental Practices Health Care Systems and Practices as they relate to Breast-feeding

III. Education and Training in Lactation Hanagement IV. V. VI. Integration of Breast-feeding with related Maternal and Child Health Interventions Direct to Hother Support: The Role of Mothers' Support Groups Yomen, York, and Breast-feeding

VII. Information. Education. and Communication VIII.Review and Evaluation of Country Case Studies giving effect to the "International Code of Marketing of Breast-milk Substitutes. WHO Geneva 1981 3. Reviewing and Evaluating COuntry Experiences ,iving Effect to the Code of Breast-milk Substitutes: Overall objectives Specific objectives Actual process CREF Compile a report Convene a meeting - Sept / Oct 1991 Hague

- 49 Annex 3

4.

Working Group of Infant feeding Objectives - Units envolved

5.

Traininl A. B. C. Training in lactation counselling Training in lactation management skills at Lactation Training Centres Training of senior health professional

6. 7.

Breast-feeding Indicator. Other PublicatiON Physiological Basis - Infant Feeding Joint WHO / UNICEF Statement: Protecting, Promoting and Supporting Breast-feeding

8. 9.

Reyieyinl eurricylu. and Medical Text. Other Releyant Actlyltle. Breast-feeding / Fertility studies Growth curve for exclusive breast-feeding infants

10.

Support to NQQ.

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- 53 -

Annex 3

LACTATION MANAGEMENT EDUCATION TRAINING (LMET) by

Dr Ricardo Gonzales Director Jose Fabella Memorial Hospital Sta. Cruz Manila Philippines

- 54 Annex 3

LACTATION MANAGEMENT EDUCATION TRAINING (LMET) IDEHTJFYJNG DA1,~;:

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coon:1 ina t ion H.;:;snit.al

Chilel ~IHalth ~;f~rvic.(? in ",Ii t.h ,Jose F abe 11 ,l I'lemor i a 1

r· .-.1. t.t~ :

February 4-8.

1991

Jo=e Fabella 11eiloGI-jf.ll HO=Dita.l Lope de Vf~qa. SL.•.. Cr·u2. 1·I,anil ..,

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- 55 Annex 3 d(.~ f i c. i I..;.'\t'·f" V b~?CI in!:; ~'I.i I:. h 'h~:.: i n ~.tJf.:~tllJ~':' tc.. 'j rtf.:' ] us .ton t) -f t h6~ in th,=:, btlSic: cur·t--icula of ~-;choc,llc;: ( ) ' f med.ic:.itie. QUt"'f5in(J {"~I-jd m.i(.f("I.trl:-.'r-\.' ;~_f',d is perp(-?t.uc·1tpt.1 :':"V ]dck uf jr"i-"'~'€,;\,·\;ir.e t?duc:.. . tj,on npl)DI"tunit.'.e·:;;, r:ltlth deficit~l1ci.(i-~~; rnu!:.l: IlP ,:~"wt-~,cl;ed i'f i.)r(',.,~'>tfHr.~d,i,IH' pt·umr...t:ion c·ffl)f't·; i.H"2' l.':. be =',.cc.e!;sf",l .:~nd <:'·H.·.~;; t~t.indble. Thus thE~ L(3C I:.-:"t. ion f1·~na.()einEH)t F:dl ..E:=- t~ i~Jn rt-;J:,in inu i,U·lF.T) ",,:,s d.?"d,unf'o'ci le.. pt'()yjde U,p lll'''sef'vi.t:'(;,' ""duc6',t:ion on

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- 56 Annex 3

on ,'eturn '~\'id

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- 57 -

ANNEX 4

SUMMARY TABLE OF COUNTRY REPORTS by

Ms Ute Ruth Charrondiere Associate Professional Officer in Nutrition World Health Organization Regional Office for the Western Pacific Manila. Philippines

Annex 4

- sa BREAST-FEEDING AND FERTILITY RELATED INFORMATION. MARCH 1991

Total fertility rate (lrcnds)(a)

Contraceptivl: coverage of ·currcntly users· (tr.cnds)( d) ,

Contraceptivcs used (in % of current users)(d)

IMR(a) (trcnds)

BF pre\'alence at three monlhs (trcnds)(e)*

Associations found belwccn . BF and amenorrhoca

" Low risk AUS 1988: 1.8 (dc:er.) 1988: 1.3 (deer.) rapidly) NA. Pill increase IUD decrease 1972: Pills (27-36) 1982: Female steril. (28) . PiUs (27) 1974: Pills (24). IUD (23) 1985: Female . steril. (45) 1973: Pills (36) Condom (28) 1982: Condom (33) Female steril. (30) 1988: 8.7 (deer.) 1987: 7.6 (deer.) 1983: 56% (iner.) 1988: 4.5% (2-4m) (incr .)

Yes Not investigated

HOK

1982: 72% (meL)

KOR

1983: 1.6 (deer .. rapidly)

1988: 77% (incr.)

1988: 12.5 (deer. rapidly)

1982: u: '55% r: 92%' (incr.)

Not invest;· gated

SeN

1988: 2.0 (slightly iner.)

1982: 74%' (iner.)

1987: 6.9 (decr.)

1985: Exclusivc: 20% (high SES incr.) (low SES deer.)

N.A.

Medium risk CHN 1987: 2.6 (slightly iner.) 1984: 4.7 (3.7(b) 1985: 74% (incr.) 1982·85: IUD (41·50) 1987: 39.8 (deer.) 1983-86: u: 43% ·r: 70% (decr.) 1986: 65%(b) Malays longest (incr.) Yes

MAA

1984: 51% ,(incr.) . least used by Malays(b)

1974: Pills (49) 1984: PiUs (23)

1987: 10.2·21.1 (deer.)

NA.

.. ··.h risk LAO 1981-1985: 5.8 (6.8(b) ( ~onst.) 1986: 5.2 (deer.) 2 hospilals involved(b) N.A. 1988: 104.9 (deer.) 1984: 99% (eonst) N.A.

PNG

NA.

NA.

1987: 12 (decr.)

1986: 99% 1983: exclusive 68% (const)

BF36 01; Amenorr'hoea .. ' 13.610 Between

PHL

1987: 4.0 (decr.)

1983: .45% (iner.)

1983: Rhythm (19-24) Wilhdrawal (21-26)

1989: 51.5 (decr.)

1983: u: 65% r: 87% (deer.) 1988: 98% (const.)

2-7 oonths

VTN

1975,.80: 5.8 (NA.)

1989: IUD. Pills 1989: 48% Hanoi: 70%(c)

1986: 36.6 (deer. raPidly)

N.A.

(a)from CHIPS. (d)Contraceplive use. . '(b)from country report. (e)BF data bank and others. (c)frolll other sources. "No information available ror exclusive breast-feeding except Singapore and Papua New Guinea.

= increase decr. = decrease const. = constant SES = socioeconomic status lOCI.

u = urban r = rural BF = brcastfccding steril. ; slerilization .

- S9 -

Annex 4

SPECIFIC

INFO~HATION

ON BREAST-FEEDING, MARCH 1991 Hinistry responsible for BF

Complementary feeding Low risk

Maternity leave

Creches

AUS

No problem

6 weeks for gov't workers, paid

Rare, planned to increase Rare

Dept. of ComDiunity Services and Health, Nutrition Section (l) __ ,I>!!Pt. ,of Health, - (2)

HOI(

N.A.

10 weeks paid

Family Health Service Hospital Service Dept.

!COR

N.A. N.A.

2 lDonths paid

existing·

N.A.

SIN

1-2 months - paid for 1st and 2nd child

N.A.

Medium risk CHti Too early _ (1 month) 90 days paid'

Strongly encouraged

MAA

Too early (one week)

42 days for gov't workers 'paid; 60 dilYs for private sector, paid.

Sometimes

ijinistry of Public Health, HGH, Child Health Division (2) small industry (milk companies) . (3) hospital administration Ministry of Health, Family Health Division, Nutrition Services (only. at regional level) (~)

High-ris~

LAO

Too early (1 month 1D0stly) Inadequate Too early

3 months, paid 84 'days,

Frequent

Ministry of Health, Department of Curative Aff~irs and MCH Institute. Dept. -nf Health. Nutrition Services Dept. of-Health liCH, CDD/BF

PNG

N.A. By law if

paid

pm.

60 days, . govt workers 42 days, private sector, .paid -- 180' <fays -{or. gOY I t- workers, paid

over 50 female _ workers

VTN

Early, fr-om 3 months

N.A.

N.A.

- 60 -

Annex 4 SPECIFIC INF'ORHATION ON FERTILITY

. Family planning infor.mation dissemination via: Special consultation

Prenatal

Postnatal

Media·

NGO

Low risk AUS

existing

FPA, others

HOK

KOR

SIN

Nedium risk·

CHN

MAA

High risk LAO Existing Existing LWU - World

Concern

PNG

PHL

VTI/

- 61 -

Annex 4

SPECIFIC INFORNA'fION ON FERTILITY

Attit;udes FP cU'rricula

Public

Doctors

. Government

·in

FP

Religion

in-service training

Low risk AUS

. positive

active in distributing especially natural FP

N.A •

of doctors

HOK KOR SIN

strongly for FP since 1987 promote 3 and more children pe·r family

tledium risk

CHN ~\AA

promote one child family

High risk LAO Positive Positive Positive - Medical school Nurse college . Not yet

PNG

PlfL

planning

FP programme VTN

FP

= Family

Planning

- 62 Annex 4 SPECIFIC INFOR~IATION Oil BRE.\ST-FEEOING, ~IARCH 1991 BF information dissel.ination via:

IIHO Code

Prenatal

Postnatal

·Hedia

NGOs

Low risk AUS

- AllDost whole, - voluntary' - Nonitoring developing Vetting cornmittee - Guidelin~s - Does not cover feed ing bottles - Legislation for lab<!ling - No ,sampling in hospitals - No advertiSing - Education/ information - &lucation/ information - Samples prohibited - No advertisement Almost whol", voluntary - Prepi'red with milk companies

~lCH

cen tres

IlGO's

Increasing through lactation consultotion

Videos, lDass media, booklets

ALe"', N~IAA

HOK

During workshops and classes

Done

Mass media, ' telephone, individual radio, videos

N.A.

KDR

N.A.

N.A.

Posters, lV, pa",!,Jhlets P.:!mphle ts',

Major ~n's as~iation,

SIN

through NCO and health services

Very rare

booklets posters,

cOllSUller groups !IF mothers' group

- Vetting COlDlilittee - Code of advertising HediulD risk , CHN - Draf t ing cod e - Education/ information - Almost whole ,into law, - Pr epared with .. ilk cOI.panies - Vetting committee High risk

videos slides teleph~ne

Mostly during closses with husbands

Mostly dur ing cl"sses in hGspit:11s Govt. clinics

TV, radios, broadc(lst ing, . ~ational

1I.A.

Sf

promotion day

Govt. clinics

~rn

service

booklets, leaflets, newspapers, radio, lV, magazines

IOCU, ISFAN (b) ~n' s

association association of breastf eed1.ng Jl¥)tilers

LAO PNG

- Preppring code - Prescription oeboLtle feeding materials (teats, bottles, special cups) - Whole into la" Monitoring Vetting committee - Considering Code - Education

!·CH dillies

tCH dinics

!.eaflets, posters Posters, booklets radiO, broadcast, individual

S::F (UK) Susu :1amas

N.A.

N.A.

, . -N.A. Posters,' b'ooklets slides; textbooks posters, TV, radios Radio, videos, TV, coonpetitions BUNSO

PHL

VT~

N.A ..

N.A.

N.A.

- 63 -

"nnex 4 SPECIFIC INFOR~lATION ON BREAST-FEEDING, ~IARCH 1991

Hospital Immediate breast-feeding Hospital guidelines

Rooming-in Low risk AUS

Mostly In gavt hospitals Encouraged.

N.A. N.A. N.A. N.A.

existing

HOK KOR

N.A. N.A.

SIN

N.A.

N.A.

Medium risk CHN

Extremely rare, partly, on pilot base In most govt. hospitals

Delayed for 1-3 days At hpme -deliveries early

None

MAA

N.A.

High-risk

LAO PNG

. N.A. N.A. Increasing· In rural health stations, frequent

Delayed for 1-3 days

N.A. N. A., Being drafted

N.A. Mostly delayed \

PHL VTN

Delayed for 1-3 day3 (35% after .72 hours)

N.A.

- 64 -

Annex '4

SPECIFIC

INFOR~~TION

ON BREAST-FEEDING, MARCH 1991

Doctors. ,_nurses BF,-in curricula Low risk AUS For paramed;i.cal, locally different In-service training Lactation manallemen t cour se Attitudesl knowledGe

N.A. throush health authorities; NGOs and milk companies. Books for midwives O.B..

N.A.

HOK

Public health nurses, -paediatricians schools N.A.

None

paediatricians N.A. through NGO N.A. N.A.

KOR

Doctors do - con~ider breastfp.~'iing as not i!llportant

N.A. N.A.

SIN Medium risk CHN

Since 1968 in some medical curricula Midwives, nurses, secondary schools community workers

Starting

Planned

Mixed

t1AA High risk LAO

nurses

N.A.

N. A. ,-

t-ledical school, nurse college but not a~out early breast-feeding initiation N.A. Some nurses and lOlid\livcs '

N.A.

N.A.

Mixed; breastfeeding not seen as a problem N.A. ~lixed

PNG PHL

M.A. N.A.

N.A.

1 national ex,sting 2 sub-national planned N.A.

VTN

N.A.

N.A.

N.A.

- 65 -

ANNEX 5

LIST OF SCIENTIFIC PAPERS

Berg A., Brems S. A case for promoting breastfeeding in projects to limit fertility. World Bank Technical Paper No. 102. Bongaarts J. Does malnutrition affect fecundity? evidence. Science 19; 208:564-569. A summary of

Breast-feeding prevalence and duration. The Western Pacific. World Health Organization, Nutrition Unit, Division of Family Health, Geneva (1990). Charrondiere U.R. Report on Infant and Young Child Nutrition with Special Emphasis on Breast-feeding in the Western Pacific Region (1991). Dfaz S., Rodriguez G., Peralta o. et al. Lactational amenorrhoea and the recovery of ovulation and fertility in fully nursing Chilean women. Contraception 1988; 38:53-67. Ebrahim G.J. Common breast-feeding management problems and their solutions. Workshop on breast-feeding and its effect on fertility in the Western Pacific Region (WPR/NUTjNUT/(l)/9l.5) Manila (1991). Editorial. Breastfeeding as a family planning method. Lancet 1988; Nov 19:1204-1205. Gray R.H., Campbell O.M., Apelo R. et al. Risk of ovulation during lactation. Lancet 1990; 335:25-29. Gross B.A. Eastman C.J. Weaning cancels contraceptive effect of breast-feeding. Medical Digest 1984; 29:16-17. Jones,R.E. The effect of initiation of child supplementation on resumption of post-partum menstruation. J.biosoc. Sci. (1990) 22:173-189. Kennedy K. Presentation B: changing patterns of breastfeeding. Reprinted from Dying for Love: New perspectives on human reproduction, (1988) 25-32. Kennedy K.I., Rivera R., McNeilly A.S. Consensus statement on the use of breast-feeding as a family planning method. Contraception 1989; 39:477-496.

- 66 -

Lactation management course outline based on the Wellstart San Diego Lactation Program, modified and adapted by Lactation Management Education Training, Jose Fabella Memorial Hospital, Manila, Philippines. Labbok M., Krasovec K. Toward Consistency in Breastfeeding Definitions. Studies in Family Planning (1990) 21,4:226-230. Lai P., So K. Abstract of study on breast-feeding, infant nutrition and birth spacing in Hong Kong. Workshop on breast-feeding and its effect on fertility in the Western Pacific Region (WPR/NUT/NUT/(1)/91.8) Manila (1991). Nguyen Thi Kim. Nutritional value of mothers' milk and children's development - the relation between mother food ration and milk quantity and quality. Ministry of Health, Hanoi (1986). Rosa F.W. Breast-feeding in family planning. V:5-10. PAG Bulletin

Saadeh R., Benbouzid D. Breast-feeding and child-spacing: importance of information collection for public health policy. Bulletin of the World Health Organization 1990; 68(5):625-631. Said S., Johansson E.D.B., Gemzell C. Return of ovulation during the postpartum period. Acta obstet Gyne Scand 1974; 53:63-67. Short R.V. Breast-feeding. Scientific American 1984; 250:23-30. Short R.V., Lewis P.R. Renfree M.B., Shaw G. Contraceptive effects of extended lactational amenorrhoea: beyond the Bellagio Consensus. 1991; 337:715-717. Supplement. Breastfeeding as a family planning method. Mothers and children 1989; 8(1). Tapa S., Short R.V., Potts M. Breast-feeding, birth spacing and their effects on child survival. Nature 1988; 335:679-682. Thonson A.M., Hytten F.E., Black A.E. Lactation and reproduction. Bull World Health Organization 1975;52:337-349. Updated information (1980-1989). The prevalence and duration of breast-feeding. Reprinted from WHO Wkly Epidem. Rec. (1989) Part I 42:321-324, (1989) Part II 43:331-335. Winikoff B., Baer E.C. The obstetrician's opportunity: translating "breast is best" from theory to practice. Am.J. Obstet. Gyneco1. 1980; 138:105.

- 67 -

ANNEX 6

INNOCENTI DECLARATION On the Protection, Promotion and Support of Breastfeeding

The Innocenti Declaration was produced and adopted by participants at the WHOjUNICEF policymakers' meeting on "Breast-feeding in the 1990s: A Global Initiative," co-sponsored by the United States Agency for International Development (A.I.D.) and Swedish International Development Authority (SIDA), held at the Spedale degli Innocenti, Florence, Italy, on 30 July - 1 August 1990. The Declaration reflects the content of the original background document for the meeting and the views expressed in group and plenary sessions. It represents the general consensus emerging at the meeting but not necessarily the individual views of each participant. Recognizing that Breastfeeding is a unique process that: • provides ideal nutrition for infants and contributes to their healthy growth and development; • reduces incidence and severity of infectious diseases, thereby lowering infant morbidity and mortality; • contributes to women's health by reducing the risk of breast and ovarian cancer, and by increasing the spacing between pregnancies; • provides social and economic benefits to the family and the nation;

• provides most women with a sense of satisfaction when successfully carried out; and that Recent research has found that: • these benefits increase with increased exclusiveness l of breastfeeding during the first six months of life, and thereafter with increased duration of breastfeeding with complementary foods, and • program interventions can result in positive changes in breastfeeding behaviour;

lExclusive breastfeeding means that no other drink or food is given to the infant; the infant should feed frequently and for unrestricted periods.

- 68 -

Annex 6 Ve therefore declare that As a global goal for optimal maternal and child health and nutrition, all women should be enabled to practice exclusive breastfeeding and all infants should be fed exclusively on breast milk from birth to 4-6 months of age. Thereafter, children should continue to be breastfed, while receiving appropriate and adequate complementary foods, for up to two years of age or beyond. This child-feeding ideal is to be achieved by creating an appropriate environment of awareness and support so that women can breastfeed in this manner. Attainment of the goal requires, in many countries, the reinforcement of a "breastfeeding culture" and its vigorous defence against incursions of a "bottle-feeding culture". This requires commitment and advocacy for social mobilization, utilizing to the full the prestige and authority of acknowledged leaders of society in all walks of life. Efforts should be made to increase women's confidence in their ability to breastfeed. Such empowerment involves the removal of constraints and influences that manipulate perceptions and behaviour towards breastfeeding, often by subtle and indirect means. This requires sensitivity, continued vigilance, and a responsive and comprehensive communications strategy involving all media and addressed to all levels of society. Furthermore, obstacles to breastfeeding within the health system, the workplace and the community must be eliminated. Measures should be taken to ensure that women are adequately nourished for their optimal health and that of their families. Furthermore, ensuring that all women also have access to family planning information and services allows them to sustain breastfeeding and avoid shortened birth intervals that may compromise their health and nutritional status, and that of their children. All governments should develop national breastfeeding policies and set appropriate national targets for the 1990s. They should establish a national system for monitoring the attainment of their targets, and they should develop indicators such as the prevalence of exclusively breastfed infants at discharge from maternity services and the prevalence of exclusively breastfed infants at four months of age. National authorities are further urged to integrate their breastfeeding policies into their overall health and development policies. In so doing they should reinforce all actions that protect, promote and support breastfeeding within complementary programmes such as prenatal and perinatal care, nutrition, family planning services and prevention and treatment of common maternal and childhood diseases. All health care staff should be trained in the skills necessary to implement these breastfeeding policies.

- 69 -

Annex 6 Operational Targets: All governments by the year 1995 should have:

• appointed a national breast feeding coordinator and established a multisectoral national breastfeeding committee composed of representatives from relevant government departments, non-governmental organizations and health professional associations; • ensured that every facility providing maternity services fully practices all ten of the Ten Steps to Successful Breastfeeding set out in the joint WHOjUNICEF2 statement ·Protecting, promoting and supporting breastfeeding: the special role of maternity services·; • taken action to give effect to the principles and aim of all Articles of the International Code of Marketing of Breast-milk Substitutes and subsequent relevant World Health Assembly resolutions in their entirety; and • enacted imaginative legislation protecting the breastfeeding rights of working women and established means for its enforcement. We also call upon international organizations to: • draw up action strategies for protecting, promoting and supporting breastfeeding, including global monitoring and evaluation of their strategies; • support national situation analyses and surveys and the development of national goals and targets for action; and • encourage and support national authorities in planning. implementing. monitoring and evaluating their breastfeeding policies.

2World Health Organization, Geneva, 1989.