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Family Planning in Perspective
Maternal Care
Lactation and Breast-Feeding
Family-planning Technologies and Side-effects on Lactation
References
Lactation and Birth Spacing
5.1. Lactational amenorrhoea is a well-recognized phenomenon and has frequently been presented as "nature's way of ensuring an adequate time interval between the birth of one baby an the next". Lactational amenorrhoea is a variable component, however, and its duration is influenced by a number of factors, notably dietary status and the specific hormonal responses of individual women, especially with respect to prolactin. It was largely because of the important endocrine links between diet, lactation and the return of fertility after child-birth that this multi-disciplinary workshop was organized.
The contraceptive effect of breast-feeding is frequently emphasized in public health teaching, but the fact that lactation is by no means 100 per cent effective as a method of birth-control is shown in table 14. In some countries - notably India, Zaire, and Ethiopia - a substantial number of women become pregnant while lactating and about 10 per cent become pregnant without menstruation. Quite clearly nutritionists and health workers who are involved in trying to improve the nutritional status of women during pregnancy and lactation need to be aware of potential side-effects on lactational infertility. It has indeed been argued that maternal dietary programmes need to be operated in close conjunction with those public health services providing family planning. In view of this, the working party felt it advisable to review current attitudes towards family planning, birth spacing, and child health in general.
TABLE 14. Percentage of Women Pregnant Who Were Still Breast-feeding and Who Said They Became Pregnant without Resumption of Menstruation
| Country | Group |
Breast-feeding |
Pregnant without menstruation |
| Hungary | all | 3.4 |
8.4 |
| Sweden | all | 0 |
11.1 |
| Ethiopia | rural | 30.4 |
4.2 |
| Nigeria | rural | 0 |
0.9 |
| Zaire | rural | 29.7 |
1.2 |
| Chile | rural | 4.2 |
7.3 |
| Guatemala | rural | 36.7 |
2.9 |
| Philippines | rural | 6.0 |
8.2 |
| India | rural | 70.0 |
11.3 |
Source: ref. 1.
Family Planning in Perspective
5.2. Family planning has been given many interpretations and meanings in different situations and over time. Within the context of this report, however, it is more rational to translate family planning as encompassing organized efforts to have child-bearing initiated at a culturally and biologically acceptable age, spacing the birth of individual children adequately, and stopping childbearing at an age commensurate with biological and social realities.
Family planning is not a new concept. Throughout history there have been taboos, customs, and practices that have evolved because of the need to ensure an adequate but not excessive or harmful rate of birth. The scientific rationale behind some of these taboos has not always been clear, but it is interesting that modern scientific investigations are beginning to provide an understanding as to why some customs have been so long maintained. Equally, it is apparent that these are times of rapid social change and in many situations newer life-styles, urbanization, women going out to work, and education, etc., have resulted in a loss of some valuable traditions. This has meant that in many societies child-bearing is taking place without the natural constraints that used to apply. As in so many facets of our life, we have been forced to apply modern technologies to ensure birth planning and the stabilization of population numbers.
It is widely held that the life-style and health status of mothers are closely related to the early viability and health of their offspring. Among the many factors that interact in this mother-child dyed, the following may be selected as being the most important: frank malnutrition, maternal age, nutritional state and status, birth interval and total family size.
Malnutrition
5.3. It is a general conclusion that malnutrition has to be extremely severe before it seriously affects actual fecundity, but it can influence the outcome of pregnancy, most notably by affecting placental growth, leading to babies with a low mean birth-weight. The seasonal effects on birth-weight found in the Gambia are shown in table 15(2). These data are similar to those obtained elsewhere; undernourished mothers tend to produce babies 300 9 smaller than well-nourished ones, and there is a greater proportion of children born less than 2.5 kg in weight. Low birth-weight babies are less likely to survive during the first year of life than normal birth-weight babies(3, 4, 5). Low birth-weight is closely associated with neonatal mortality rates (6).
TABLE 15. Seasonal Variations in Birth-weight in the Gambia
Dry season |
Wet seasona |
|
| 1976/77 | ||
| Birth-weight (kg)b | 3.02 ± 0.07 (39)c |
2.72 ± 0.08 (31)d |
| 1978/79 | ||
| Birth-weight (kg) | 2.94 ± 0.07 (33) |
2.78 ± 0.11 (21) |
| Gestational age (weeks) | 39.3 ± 0.25 (29) |
38.6 ± 0.57 (19) |
| Expected weight for age (%) | 89.0 ± 1.7 (29) |
84.7 ± 2.6 (18) |
Maternal Age
5.4. Maternal age is very important in pregnancy outcome and the early health of children (7). It is considered best for women to start having children in their early twenties and to stop at about 35 or soon thereafter (8, 9). Very young mothers have problems not only with their own health but with that of their children as well. The recent increase in teenage pregnancies in the industrialized countries has provided some opportunity to study the problem of child-bearing at too early an age (10), but more investigation is required, particularly in the developing countries. Here the mother may well still be growing towards her final mature stature, and the nutritional and metabolic stresses of pregnancy and lactation will be exceptionally severe. There are also more complications with the pregnancy itself and the baby, once it is born, also frequently faces grave difficulties. Irrespective of nutritional status, there is more likelihood of low-birth-weight children, of still-births and neo-natal deaths among the children of mothers who are younger than 20 years. The lower the age, the greater is the probability of difficulty. All studies of this problem have indicated that the optimum time for beginning child-bearing is 22 to 23 years.
Adolescent mothers also tend to be poor breast-feeders for various reasons. Their own pre-pregnancy nutritional status is often inadequate, the supervision of the pregnancy can be fraught with tension. After delivery, social requirements and pressures all militate against the proper establishment and maintenance of breast-feeding, with the customary far-reaching consequences for survival under the type of circumstances prevailing in the developing world. Frequently there are also pressures on the pregnant girl to have an abortion, and in practice this tends to be too late, often in the second trimester, and the complications that arise can be severe.
High maternal age, too, is of importance in this respect and, especially in the developing world, a woman having her first child in her early thirties is at special risk. Obstetric complications are greater and the risks of still-births, of immaturity and prematurity are also higher. Women who continue childbearing into their late thirties and forties are also at risk, as are their children. Congenital malformations increase with maternal age, and also with birth order, both having a separate, demonstrable effect.
Birth Intervals
5.5. Particularly in the developing world, pre-school child mortality is much higher among children in families with short birth intervals. Swenson(11), in a study in rural Bangladesh, reported that childhood mortality is significantly higher among children whose birth is followed by another pregnancy in less than 12 months compared with children whose birth is followed by another pregnancy in greater than 12 months.
Gordon and Wyon (12), in a study of 1,479 children in the Punjab, India, showed that infant mortality tended to increase with family size and short birth intervals. Over 50 years ago, in the United States, Woodbury(13) reported a decrease in both neonatal and infant mortality as birth interval increased from 12 to 48 months. Short birth intervals are also associated with a higher prevalence of malnutrition. Wray and Aguirre(14), in their study of preschool children in rural Colombia, showed that when inter-pregnancy interval was over 36 months there was an appreciable decline in malnutrition. They further showed that there was significantly less malnutrition, among children in families with four of fewer pre-school children compared with families with five or more. The birth intervals for a mother with four or five or more pre-school children must necessarily be very short.
It has been found in many studies that, when the interval between one birth and the delivery of the next child is at least 24 months after delivery, this proves to be the most satisfactory both for maternal and child health and wellbeing. In all studies in impoverished tropical countries where the birth interval is substantially less than two years, a higher incidence of protein-energy malnutrition has been reported. There is also a greater prevalence of diarrhoeal and other diseases.
Birth interval is also important in another respect. In many cultures the onset of pregnancy is the signal for a child to be weaned (see section 4.5). It is not impossible for fertility to return in under three months after the delivery of a child, and it is therefore theoretically possible for a woman to have two children in the same year. In the developing countries in general, or when mothers come from the lowest socio-economic stratum, any birth interval that does provide for long-term lactation and breast-feeding is very likely hazardous to that child's continued life; poverty and poor hygienic circumstances preclude the preparation and use of safe, nutritious commercial milk preparations or other weaning foods. In defining the minimum, safe birth interval it is always necessary to consider the prevailing circumstances of the mother and the society in which she lives, but all studies would suggest a minimum interval of two years.
Family Size
5.6. The total number of members in the family is also related to the incidence of adverse circumstances. Diarrhoeal and communicable disease have been shown to correlate positively with family size. Dingle et al. ( 15), in a longitudinal study of families, showed that the incidence of various common illnesses increased with family size. They observed that, not only does the number of episodes per family increase, but also the number of illnesses per person per year increases. The incidence of severe clinical malnutrition has also been shown to exhibit a marked increase after the seventh parity. In Ghana it has been shown that the food available to larger families, per head, was frequently lower than that available to smaller families, and this was reflected in growth rate (R. Orraca-Tetteh, personal communication).
The surveys made in Kivu and Rwanda (16, 17), show the same phenomenon: food intake per capita decreases with the size of the family. This seems a general rule when we deal with a self-subsistence economy. Mortality in infancy and the second year of life has also been shown to be high in families with over five children. Data from the Khanna Study (12) showed that the effect of family size on childhood mortality was more dramatic in the second year during which the seventh or later-born children had a second-year mortality six times greater than that of second-born children. Growth, too, is inversely related to family size. These effects almost disappear, but not quite, when data from high socio-economic families are examined. Social and economic development, as well as the creation of accessible family welfare services, should contribute to diminishing most of the above ill-effects associated with large family size.
There has also been much speculation about the influence of family size on intellectual attainment(181. Studies in France, the United States, and the United Kingdom, using different measurements of intelligence, have all indicated that there is an inverse relationship with family size, but the exact nature of the association depends on social class. Thus, it is more apparent in the children of farm-workers, manual labourers, and unskilled office-workers than in the children of the professional classes. It has been concluded that family size is only one factor affecting intellectual attainment, and it is only when other external and social circumstances are also suboptimal that family size exerts a truly strong influence.
5.7. It would be wrong to think of child development only in terms of its interaction with malnutrution, infection, and social status. The amount of time a mother can spend with her baby is also of paramount importance. Such attention is inevitably concentrated on the youngest baby and therefore the weaned child who is not quite old enough to help himself is likely to be ignored much more than is desirable: he does not get sufficient maternal stimulation to optimize his neurological development. In extreme circumstances he may also not get his fair share of the family food. Studies of this phenomenon have shown the problem to be at its worst when a mother has more than one child under five years at the time a new pregnancy commences.
5.8. This was one of the central themes of the workshop and is thus discussed in detail in section 6. Maximal lactation and breast-feeding up to two years used to be a major mechanism by which two- to three-year birth spacing was achieved in many developing countries. Various taboos and religious beliefs that forbade intercourse while a mother was lactating supported this process, as did indirectly, polygamy and the separation of husband and wife into different sleeping huts. Breast-feeding does afford protection against conception, but its effectiveness cannot be specifically guaranteed in the individual woman. On a statistical basis there is no doubt about this phenomenon, and many studies have shown a marked difference in the return of menstruation between mothers who bottle-feed, partially breast feed, and completely breast-feed their babies. As with most of the factors considered, however, the effect is influenced by socio-economic class, and it has been postulated that part of the long-term protective effect of longterm lactation in the Third World can be attributed to the poor dietary and health status of the mother. This, too, is discussed in section 6.
Family-planning Technologies and Side-effects on Lactation
5.9. As already indicated, sociological changes have removed, at least partially, traditional barriers to population growth, and our current way of life is making artificial contraceptive methods more and more necessary. Unfortunately, these can have side-effects that may affect early life and the well-being of women and children. The high-dose oestrogen-combined pill has, for example, been shown to have an inhibitory effect of lactation and is no longer in general use. There is general agreement, however, that pills with under 50 µg of oestrogens do not affect lactation, if introduced after lactation is fully established (see section 4.11.). There is, however, a need for this to be confirmed in the lesser-developed countries, as there is some argument about the size of the women in relation to drug dosage.
The effect of the pill on micronutrient metabolism and physiological needs also needs to be clarified(19). Recently, the mini-pill (progestin only) has been advocated as the best contraceptive during breast-feeding, but it has also been claimed that this can limit breast-milk output and hence may result in earlier than desirable weaning. Saint and Hartmann (unpublished data) have found that milk production was not depressed in mothers who began to take the mini-pill. However, there is a general belief by mothers in Perth that the mini-pill decreases milk production. Because of the crucial importance of long-term lactation to health and well-being in the developing world, this is clearly a problem that needs to be studied in greater detail.
For over 12 years injectable contraceptives, mainly Depo-Provera (depomedroxyprogesterone acetate, DMPA), developing and some developed countries. It has proved safe and efficient and has been shown to have either no adverse effect or an enhancing effect on lactation. It is also secreted in the milk and this makes some concerned about its effect on the baby. But it is not an easily assimilable substance and no adverse effect on babies has been noted in studies thus far.
Because the FDA and the British Committee on the Safety of Drugs have refused to approve the use of DMPA as a contraceptive, there is intense controversy about its use in developing countries. The only way to silence the critics is to produce more evidence on the safety and efficacy of the drug in use.
Some studies have reported that progestin alone by mouth or by injection enhances lactation. Choudhury (20) reported that DMPA when administered to lactating women at a dose of 150 mg, every three months significantly raised prolactin levels over a control group. He also observed that, while suckling increased prolactin levels in both groups, the difference was greater in women receiving the injection, indicating that the drug enhanced the release of prolactin in response to the suckling stimulus.
Zanartu et al. (21 ) also reported similar findings in Chile. They showed that at 12 months, 42 per cent of women on oral progestins were still breast-feeding, while all subjects from the control groups had stopped. Parveen et al. (22) in Bangladesh were unable to confirm this finding and they reported that DMPA did not significantly increase lactation and actually caused a decline in milk. Further studies are still needed.
The side-effects of hormone-based contraceptives have led many to favour more mechanical approaches, such as the coil, but this too can lead to nutritional problems through excessive bleeding in some women. Furthermore, there is the question of what happens to the copper released in women who have loops inserted during lactational amenorrhoea. The seemingly safest method from a health point of view, the condom, has in practice in high failure rate, mainly due to human error.