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Breast-Feeding and Child-Spacing: Importance of Information Collection for Public Health Policy R Breast-feeding and child-spacing: importance of information collection for public health policy R. Saadehl & D. Benbouzid2 The presence oflactational amenorrhoea cannot be fully relied upon to protect the individual mother against becoming pregnant. Nevertheless, the use of breast-feeding as a birth-spacing mechanism has important implications for global health policy. This article identifies the information that should be collected and examined as a basis for developing guidelines on how to reduce the dual protection afforded by postpartum lactational amenorrhoea and other family planning methods, and discusses when such methods should be introduced. Introduction on breast-feeding and its effect on fertility regulation.8 Many women have little or no access to modern This article first describes the methods used to assess contraceptive techniques and consequently they make lactational infertility and how the information obtain- little use of family planning methods of fertility ed is incorporated into the data bank. Relevant regulation. Thus, in cultures where frequent and information gathered from published sources and prolonged breast-feeding is common, postpartum from studies commissioned by WHO since 1983 is amenorrhoea and suppressed ovulation are frequent- then summarized. Finally, practical health policy ly the principal mechanisms that ensure adequately implications that are associated with lactation-asso spaced pregnancies. Indeed, in many developing ciated infertility are briefly discussed. countries, more births are still averted this way than by any other single family planning method. Birth interval, fertility, and lactational Although for the individual mother, lactational amenorrhoea amenorrhoea does not provide completely reliable protection against pregnancy, the effectiveness of Numerous studies indicate that breast-feeding length- breast-feeding as a birth-spacing mechanism has ens the interval between pregnancies and thus decreases natural fertility (Fig. 1) (1). In turn, longer important global health policy implications. An in- infant creased understanding of the reasons for the consider- intervals between births significantly enhance able differences in the duration of lactational amenor- survival and reduce maternal morbidity and mor- rhoea between communities and individuals, and of tality, especially in developing countries (2-3). the factors that control lactational infertility, should In populations where the prevalence of family facilitate development of guidelines for use by health planning methods is low, birth intervals are largely planners and health-care administrators in maximiz- determined by the frequency and duration of breast- feeding. Where breast-feeding is both frequent and ing the contraceptive effect ofbreast-feeding. Practical prolonged, birth intervals are increased by an guidance about when mothers should adopt artificial estimated 15-32%. Studies in rural areas of India contraceptive methods and how to prevent the adverse (Punjab) and China (Province of Taiwan) indicate effects of some hormonal contraceptives on lactation who are particularly important. that birth or pregnancy intervals for women To contribute to improved understanding of the breast-fed for an average of 1-2 years, and who used effectiveness of lactation as a contraceptive method no other form of contraception, were 5-10 months and its relation to the WHO Breast- longer than those who miscarried or whose infants child-spacing, died shortly after birth (4-5). feeding Data Bank collects and analyses information Studies among Inuits in Alaska (6) and Indians in Punjab show that rates of conception for women who did not use family planning methods, but who ' Consultant, Nutrition unit, World Health Organization, CH-1211 continued to breast-feed, remained low for nearly one Geneva 27, Switzerland. Requests for reprints should be sent to this author. 2 Medical Officer, Nutrition unit, World Health Organization, Geneva Switzerland. ' The WHO Breast-feeding Data Bank is managed by the Nutrition unit, World Health Organization, 1211 Geneva 27, Switzerland. Reprint No. 5117 Relevant information and inquiries should be sent to this address. Bulletin of the World Health Organization, U (5) 625-631 (1990) (3 World Health Organization 1990 625 R. Saadeh & D. Benbouzid Fig. 1. Illustration of the relationship between the dura- datory sexual abstinence during, or even beyond, the tion of lactational amenorrhoea and birth Interval. normal period of lactation in some traditional 40- societies (e.g., among the Yoruba in Nigeria) can also play an important role. Although this practice is 30' gradually being eroded, it remains important enough 25- to warrant careful consideration in any study of the 0 relation between breast-feeding practices and fertility. 520- The duration of lactational amenorrhoea, which vo varies from 2 months to 20 months, has the greatest 15 i impact on differences in birth intervals, and is an- o v - other method of assessing lactational infertility (8-9). Jordan Mexico Zaire Philippines India Based on the results of a number of studies that have attempted to establish a relation between lactation Birth interval f Amenorrhoea and postpartum amenorrhoea (see Table 1), the median duration of amenorrhoea following child- year postpartum. Of the Indian women who breast- birth appears to be about 7-10 weeks in the absence fed for 7 months or longer, 98% had not conceived of lactation. In contrast, the average duration of by the end of the sixth month; however, the cumu- amenorrhoea among lactating women can be up to 2 lative rate of conception increased to 13% after one years (Table 1 and Fig. 2). The extent to which year and continued to rise rapidly thereafter, even fertility is reduced during the months prior to, and though the women in question were still breast-feed- immediately following, resumption of menstruation ing at the time of conception (7). can thus be determined and analysed by collecting Breast-feeding alone is not always responsible data, by month postpartum, on the proportion of for increasing birth intervals. For example, man- mothers who are menstruating. Table 1: Median duration of breast-feeding and postpartum amenorrhoea In selected countries Median duration (in months) of: Country Period Sample size Breast-feeding Postpartum amenorrhoea Mexico 1985-86 1131 5.0 3.0 Colombia 1988 702 8.0 3.0 Jordan 1978 769 13.0 3.0 Zaire 1987-88 1102 9.0 4.0 Fiji 1981-84 2660 9.0 5.0 Thailand 1984 - 18.0 6.0 Yemen 1981-84 2216 11.0 7.0 Syrian Arab Republic 1981-84 4025 11.0 7.0 Turkey 1975 515 13.0 7.0 Tunisia 1981-84 3021 14.0 7.0 Botswana 1984 3064 19.5 7.3 Philippines 1981-84 6667 13.0 8.0 Sri Lanka 1986-87 1350 23.0 8.0 Mauritania 1981-84 2447 16.0 9.0 Egypt 1981-84 5667 16.0 9.0 Kenya 1981-84 5679 17.0 10.0 Cote d'lvoire 1981-84 3804 18.0 10.0 Lesotho 1981-84 2348 19.0 10.0 Indonesia 1982 1254 24.0 10.0 Sudan 1981-84 2242 16.0 11.0 China (Province of Taiwan) 1972 1516 18.0 11.0 India 1982 428 20.0 11.0 Haiti 1981-84 1489 15.0 12.0 Pakistan 1986 1098 17.0 12.0 Ghana 1981-84 3335 18.0 12.0 Cameroon 1981-84 4650 18.0 12.0 Benin 1981-84 2803 19.0 12.0 Republic of Korea 1973 746 25.2 13.6 Bangladesh 1981-84 3836 27.0 15.0 Nepal 1976 5954 25.0 18.0 626 WHO Bulletin OMS. Vol. 68 1990. Breast-feeding and child-spacing Fig. 2. illustration of the relationship between the dura- more closely associated with longer periods of lac- tVon of breast-feeding and that of postartum amenor- tational amenorrhoea and infertility than is partial or rhoea. supplemented breast-feeding. -a 30 It is very important to make a distinction be- Rep. of Korea hdonsala tween full and partial breast-feeding. Women who * 0 40 i 24 0 are partially breast-feeding are at higher risk of .! i conceiving than women who are fully breast-feeding. X 18 * Egypt* 0 1 The consensus statement on the use of breast-feeding Jordan I 0 as a family planning method made by participants at J 12 * Phillppirnz Colombia * - the Bellagio Consensus Conference on Lactational =6 Infertility in 1988 affirmed that the maximum birth- Mxico spacing effect of breast-feeding is achieved when a u mother "fully" or "nearly fully" breast-feeds and 0 6 12 remains amenorrhoeic (12). When these two condi- Duraton of postpartum amenofrhoea (months) tions are fulfilled, breast-feeding provides more than 98% protection from becoming pregnant in the first 6 The return of menstruation and fertility occur months postpartum. The data in Table 1 need to be much more rapidly among women in industrialized analysed in this light. Thus since in Jordan, for countries than among those from poor segments of example, the median duration of postpartum amen- populations in developing countries (Table 2) (10, 11). orrhoea is only 3 months, but the median duration of This may be due to differences in breast-feeding breast-feeding is 13 months, the vast majority of these practices, since full or exclusive breast-feeding is women must be introducing feeding supplements to Table 2: Percentage of mothers who had begun menstruating, by age of the child, and whether or not i was breast-fed" Percentage of mothers, with child aged:b 3-4 months 7-8 months 11-12 months Country Groupc BF NBF BF NBF BF NBF Ethiopia A 56 94 - 100 - C 32 - 31 90 38 83 R 8 - 9 - 16 Nigeria A 52 - 58 82 - B 32 - 54 91 50 90 C 7 - 29 - 25 - R 7 - 28 - 39 - Zaire A 26 - 46 - 64 - C 25 - 32 - 44 - R 4 - 20 - 39 - Chile A 23 85 - 98 - 98 C 53 100 64 96 69 97 R 26 80 71 100 56 97 Guatemala A 40 96 - 99 - 98 C 35 94 43 100 50 94 R 11 - 17 - 50 100 India A 56 84 74 97 86 100 B 33 80 62 100 85 97 C 17 - 25 - 33 - R 1 - 12 - 20 - Philippines A 21 98 - 100 - 100 C 28 94 44 91 69 88 R 23 87 41 94 69 95 Hungary All 52 93 63 98 79 99 Sweden All 17 93 42 97 - - ' Source: Contemporary patterns of breast-feeding: report on the WHO Collaborative Study on Breast-feeding.
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