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Postpartum Family Planning: Sharing Experiences, Lessons Learned and Tools for Programming -- Meeting report, 12 May 2009, Washington, D.C.
Baltimore, Maryland, Jhpiego, ACCESS, Family Planning Initiative [ACCESS-FP], 2009.  p.On May 12, 2009, more than 76 experts and leaders in reproductive health (RH) and maternal, neonatal and child health (MNCH) from more than 22 global health organizations and programs convened in Washington, D.C., for the “Postpartum Family Planning: Sharing Experiences, Lessons Learned and Tools for Programming” meeting. The meeting had three objectives: 1. Present and discuss experiences and lessons learned in implementing PPFP in a variety of settings; 2. Share tools and other resources to support PPFP programming; and 3. Discuss progress, continuing priorities for research and advancing MNCH / FP integration. (Excerpts)
An evidence-based approach to postpartum use of depot medroxyprogesterone acetate in breastfeeding women.
Contraception. 2009 Jul; 80(1):4-6.This article reviews the evidence and safety of immediate depot medroxyprogesterone acetate (DMPA) use in lactating postpartum women. It presents the benefits for mothers and infants, the concerns, the safety issues, and states that existing data are not sufficient to limit DMPA use postpartum in women at high risk for unintended pregnancy.
The World Health Organization multinational study of breast-feeding and lactational amenorrhea. IV. Postpartum bleeding and lochia in breast-feeding women.
FERTILITY AND STERILITY.. 1999 Sep; 72(3):441-7.The main purpose of this study was to compare the duration of postpartum lochia among 7 groups of breast-feeding women, and in addition, to investigate whether age, parity, birth weight, or the amount of breast-feeding affects this duration. The participants included 4118 breast-feeding women aged 20-37 years living in China, Guatemala, Australia, India, Nigeria, Chile, or Sweden. The duration of lochia, frequency of an end-of-puerperium bleeding episode, and frequency of post-lochia bleeding episodes within 56 days of delivery were measured. This study revealed that the median duration of lochia was 27 days and varied significantly among the centers (range, 22-34 days). In about 11% of the women, lochia lasted >40 days. An end-of-puerperium bleeding episode around the 40th day postpartum was reported by 20.3% of the women. Bleeding within 56 days of delivery (separated from lochia by at least 14 days) occurred in 11.3% of the women and usually was followed by a confirmatory bleeding episode 21-70 days later. This study was able to quantify the average duration of postpartum lochia at 3-5 weeks, with significant variations by population. Lochia durations of >40 days were not unusual. A separate and distinct end-of-puerperium bleeding episode occurred in 1 out of every 4-5 women, although it is unclear how this phenomenon is clinically, socially, or culturally significant.
The World Health Organization multinational study of breast-feeding and lactational amenorrhea. III. Pregnancy during breast-feeding.
FERTILITY AND STERILITY.. 1999 Sep; 72(3):431-40.This prospective longitudinal study aimed to determine the risk of pregnancy during lactational amenorrhea relative to infant feeding status. The participants included 4118 breast-feeding mother-infant pairs, with maternal age of 20-37 years, recruited from 7 study centers located in China, Guatemala, Australia, India, Nigeria, Chile, and Sweden. Infant feeding practices, menstrual status, and the number of pregnancies were recorded. The results revealed that in the first 6 months after childbirth, cumulative pregnancy rate during amenorrhea, depending on how the end of amenorrhea was defined, ranged from 0.9% (95% confidential interval (CI) = 0-2%) to 1.2% (95% CI = 0-2.4%) during full breast-feeding, and from 0.7% (95% CI = 0.1-1.3%) to 0.8% (95% CI = 0.2-1.4%) up to the end of partial breast-feeding. At 12 months, the rates ranged from 6.6% (95% CI = 1.9-11.2%) to 7.4% (95% CI = 2.5-12.3%) during full breast-feeding, and from 3.7% (95% CI = 1.9-5.5%) to 5.2% (95% CI = 3.1-7.4%) up to the end of partial breast-feeding. Regardless of the degree of supplementation, the pregnancy rate increased with time from 6th to the 12th month postpartum. Overall, the rate of pregnancy during amenorrhea was unaffected by variations in the return of menses. This large, multicenter study found that the cumulative 6-month rate of pregnancy during lactational amenorrhea was between 0.8% (95% CI = 0-1.4%) and 1.2% (95% CI = 0-2.4%). This is equivalent to the protection provided by many nonpermanent contraceptive methods as they are actually used and upholds the 1988 Bellagio Consensus.
[Lactation-induced amenorrhea as birth control method] Lactatieamenorroe als geboorteregelingsmethode.
NEDERLANDS TIJDSCHRIFT VOOR GENEESKUNDE.. 1998 Jan 10; 142(2):60-2.In 1966 WHO published a document on improving access to quality care in family planning, which who pronounced to be a fundamental human right. According to this document, despite the assortment of reliable contraceptives worldwide 350 million people have unmet need for contraception because of lack of access or availability. Adequate reproductive health depends not only access to contraceptives, but also on adequate screening and treatment of anemia, sexually transmitted diseases, and cervical carcinoma. Among 8 groups of birth control methods studied, the lactational amenorrhea method (LAM) was dealt with in detail. The underlying mechanism lies in the stimulation that breastfeeding brings about and in breastfeeding's suppression of the release of gonadotropin- releasing hormone and of dopamine (the prolactin inhibiting factor). A 1974 investigation in Rwanda demonstrated that 50% of rural women who breast fed their children frequently got pregnant within 23 months of childbirth and that 50% of city women became pregnant 9 months postpartum. The Bellagio consensus has stated that LAM provides 98% protection against pregnancy in the first 6 months postpartum as long as breast feeding is the exclusive feeding method practiced. A 1992 analysis of 9 prospective studies reported that 6 months postpartum only 0.7% of the women using LAM became pregnant. LAM still plays a crucial role in Africa, where the average number of children per woman is 6. Without breastfeeding the estimated figure would be 10.
NEDERLANDS TIJDSCHRIFT VOOR GENEESKUNDE. 1998 Jan 10; 142(2):60-2.In 1996, a document was published by the World Health Organization (WHO) with a detailed analysis of various birth control methods and stressing the right to them. At least 350 million couples in the world do not have access to safe and reliable contraceptive methods meaning that they have an unmet need. The WHO strategy concerning the dissemination of contraception consists of recognition of the central position of women; the availability of contraceptive methods; and scientifically credible counseling. Reproductive health means not only access to contraceptives, but also the treatment of anemia and STDs, and the promotion of breast-feeding. Eight groups of contraceptive methods were analyzed and ranked on a scale to ascertain their suitability for women of differing ages, lifestyles, and socioeconomic status. The reliability of contraceptives also greatly depends on patient compliance. The lactational amenorrhea method (LAM) was recognized as a reliable method for the first time by WHO. The mechanism of action of breast feeding results in the suppression of gonadotropin-releasing hormone (GnRH) and of prolactin inhibiting factor (PIF) leading to the stimulation of prolactin. A 1974 Rwandan study confirmed that 50% of rural women who breast fed their children ad libitum, in comparison to urban women who fed them according to the Western model, became pregnant 23 months postpartum in contrast to 9 months postpartum for city women. The Bellagio consensus stated that LAM provides a 98% rate of protection against pregnancy in the first 6 months, if exclusive breast-feeding is practiced. In 1997, LAM played a crucial role in global family planning, as modern contraceptives are still not widely available. In Africa, the average number of children per woman would be 10 without LAM, not 6.
Experiences in policy development on breastfeeding and LAM: panel presentations. International policy.
In: Bellagio and beyond: breastfeeding and LAM in reproductive health. End of project conference of the Breastfeeding and MCH Division, Institute for Reproductive Health, a WHO Collaborating Center on Breastfeeding, May 13-16, 1997. Conference summary and papers, edited by Kristin A. Cooney, Sheerin R. Nahmias. [Washington, D.C., Georgetown University, Institute for Reproductive Health], 1997.  p.. (USAID Cooperative Agreement No. DPE-3061-A-00-1029-00)The Institute for Reproductive Health (IRH) has been involved in policy change and development at all levels. On the international level, there have been the following major initiatives during the 1990s: the Innocenti Policy Makers Meeting, the International Conference on Population and Development (ICPD), and the Women's Conference in Beijing. IRH has also worked with the International Federation for Family Life Promotion, an organization whose policies and norms have international implications. Actions undertaken by the IRH to influence the development of policy at the Beijing Conference and as it would be contained in the ICPD's program of action are described. IRH efforts proved successful, with the final ICPD document including 12 references to breastfeeding rather than the one reference to child survival originally. Eight references were made to breastfeeding in the final Beijing document.
In: Bellagio and beyond: breastfeeding and LAM in reproductive health. End of project conference of the Breastfeeding and MCH Division, Institute for Reproductive Health, a WHO Collaborating Center on Breastfeeding, May 13-16, 1997. Conference summary and papers, edited by Kristin A. Cooney, Sheerin R. Nahmias. [Washington, D.C., Georgetown University, Institute for Reproductive Health], 1997.  p.. (USAID Cooperative Agreement No. DPE-3061-A-00-1029-00)The International Planned Parenthood Federation (IPPF) is a worldwide federation of indigenous autonomous family planning associations which develops policies and guidelines to guide the work of the federation and its affiliates. IPPF has for many years adopted and advocated a health rationale for family planning which states that child spacing is important for infant and child health and survival, as well as for maternal health. Breastfeeding has a major role in child spacing. Since the 1980s, the IPPF has been part of the safe motherhood initiative which emphasizes the importance of women's education and care before, during, and after pregnancy. That initiative clearly involves education and care during breastfeeding. The IPPF focuses its policies and activities regarding the contraceptive effect of lactational amenorrhea method (LAM) in the context of the other benefits of breastfeeding. The IPPF International Medical Advisory Panel's policy statement describes breastfeeding as an important part of the human reproductive process which must be seen from the perspectives of the child, the woman, and the family. That means that breastfeeding should be promoted because of the known benefits it provides in infant nutrition and health, as well as for the benefits it promotes to the mother and its role in fertility regulation.
The Interagency Group for Action on Breastfeeding: donor to donor cooperation for policy enhancement.
In: Breastfeeding policy: the role of U.S.-based international organizations. Report of a panel presentation at the NCIH Annual Meeting, June, 1989, edited by John T. Queenan, Miriam H. Labbok, and Katherine Krasovec. Washington, D.C., Georgetown University, Institute for International Studies in Natural Family Planning, 1990 May. 22-5. (Institute Issues Report No. 5)Indicative of increased interest in breast feeding promotion on the part of the international donor community, United Nations Children's Fund (UNICEF) and the World Health Organization (WHO) co-sponsored the first meeting of the Interagency Group for Action on Breast Feeding. This 1987 gathering was followed by an interagency needs assessment, establishment by WHO of an international data bank, and identification of successful breast feeding promotion programs. The long-term goal, however, is to influence high-level policy makers to support the goal of empowering all women to exclusively breast feed for 4-6 months and continue supplemented breast feeding well into the second year of life. One of the most effective ways to promote support of breast feeding is to convince governments that this practice decreases the incidence of diarrheal and respiratory disease and increases child spacing, thereby reducing infant mortality. A review of the efforts of selected countries to reverse declining trends of breast feeding initiation and duration is underway, and health care worker training programs are being developed. Two WHO-UNICEF publications--a Joint Statement on the role of health services and "Ten Steps to Successful Breast Feeding"--are facilitating implementation of breast feeding promotion activities.
BULLETIN OF THE WORLD HEALTH ORGANIZATION. 1990; 68(5):625-31.Lactational amenorrhea in many developing countries is still the most successful form of contraception, especially when modern forms of contraception are not available. In cultures where frequent or prolonged breast feeding is common, postpartum amenorrhea and suppressed ovulation are frequent and serve to space births. It is this spacing of births that leads to decreased infant and maternal morbidity and mortality. It must be remembered that lactational amenorrhea is not a completely reliable form of contraception. In fact the figures indicate that in cultures were family planning use is low, birth intervals are largely determined by the duration and intensity of breastfeeding. Studies indicate that an increase of 15% 32% in birth intervals can result from prolonged lactation. It would be to the advantage of health care planners and providers to examined more closely the causes and properties of lactational amenorrhea. Field directed education can provide women with the information necessary to help them control their child spacing. The WHO Breast-feeding Data Bank collects and analyzes information on breast-feeding and its effects on fertility regulation. Methods used to assess lactational infertility and how the information is used by the data bank are described in this article. There is a summary of relevant information gathered from published sources and post 1983 studies of the WHO. The practical implications to health policy that are associated with lactation-associated infertility are also mentioned.
Washington, D.C., World Bank, 1989. 55 p. (World Bank Technical Paper No. 102)After a brief explanation of the impact of breastfeeding on fertility worldwide, inaccurate assumptions about the decline of breastfeeding are explored to point out the need for renewed promotion of breastfeeding by World Bank projects. Breastfeeding, by inhibiting fertility through lactational anovulation, is one of the most important determinants of fertility, especially for 83% of couples in developing countries who do not use modern contraception. Many believe that breastfeeding does not need promoting in areas where it is the norm, yet this belief does not take into account the need for supporting breastfeeding women, teaching them to breastfeed exclusively and frequently for the 1st 4 months. The belief that declines in breastfeeding are inevitable is belied by recent evidence in developed countries. The reliability of breastfeeding as a contraceptive for individual women varies: poor, undernourished women who breastfeed extensively may be protected up to 21.7 months (Bangladesh). Advantages of breastfeeding include significant savings of money, foreign exchange, scarce contraceptive supplies, medical treatment of diarrhea and malnutrition in infants, and possibly mothers' time. In contrast, other caregivers can prepare milk substitutes, but breastfeeding can be encouraged in the work setting, or milk expressed for later use. A review of 68 World Bank Projects revealed that 37% of all Population, Health and Nutrition projects, enumerated in an appendix, contained explicit actions to promote breastfeeding. 10 recommendations for promoting breastfeeding end the report.
IPPF MEDICAL BULLETIN. 1990 Apr; 24(2):2-4.Breast milk provides infants with their nutritional requirement plus antibodies to combat certain infections. Prolonged breast feeding and concurrent postpartum amenorrhea contribute to natural infertility, but considerable variability occurs among different populations. Further, certain variables exist that contribute greatly to the length of amenorrhea and infertility. They include nutritional status of the mother; length of breast feeding; giving supplements to the infant; frequency and duration of suckling; and geographic, social, and cultural factors. Many studies indicate that the longer a woman breast feeds, the longer she will experience amenorrhea. Anovulation is contingent on the frequency and distribution of nursing episodes day and night and the time of the infant feeds at the breast. Feeding an infant supplementary milk or food also reduces the inhibitory affect of breast feeding on ovarian activity and fertility, especially when supplements are introduced early. Educating mothers about the value of child spacing, breast feeding, maternal nutrition, and contraception should be done during pregnancy and the postpartum period, the times when mothers most often visit health clinics. Mothers should also be informed that it is not possible to anticipate how long they will be infertile while breast feeding, so contraceptive use should be encouraged. If possible, nursing mothers should avoid using hormonal contraceptives because they can interrupt lactation or pose a risk to the infant. IUDs are highly efficacious. If a woman is in a hospital to deliver, postpartum sterilization is another option. Barrier methods are effective, if used regularly, especially during this time of reduced fertility. Since the reoccurrence of menses is unpredictable and the efficacy is not know, nursing mothers should not rely on periodic abstinence.
WORLD HEALTH. 1987 Nov; 10-2.Breastfeeding is at times referred to as "nature's contraceptive." Intensive breastfeeding naturally stops the discharge of eggs from the ovaries, which commonly is experienced as a delay in the return of menses after the birth of a baby. An obvious limitation is that for breastfeeding to produce a contraceptive effect, a successful pregnancy and suckling are essential, and it is not possible to predict when the contraceptive protection might cease. Consequently, in terms of fertility regulation, breastfeeding is regarded as a birth spacing rather than as a contraceptive method per se. The sooner a woman starts to menstruate after a birth, the shorter the birth interval is likely to be, assuming the woman is sexually active, there are no miscarriages, and no contraceptives are used. In women who do not breastfeed, the menses usually returns within 2-3 months after delivery. For those who breastfeed intensively for 1 or 2 years, the menses generally return within 6-10 months or 15-18 months, respectively. The ideal way of prolonging the birth interval seems to be by combining prolonged breastfeeding with the commencement of contraceptive use at the appropriate time, provided this time were known. Without breastfeeding and contraceptive use, the birth interval averages 16 months, but with prolonged and intensive breastfeeding it potentially could be extended by another 18 months, giving an average interval of 34 months. This suggests that the fertility of women who do not breastfeed could be halved by breastfeeding alone. The tendency for fertility to increase during the early stages of modernization is observed in countries where the trend away from a traditional of prolonged breastfeeding is not accompanied by increased use of modern contraceptive methods. It is known widely that breastfeeding helps to postpone the next pregnancy, practices and beliefs vary by region and ethnic group. For a long time, the World Health Organization Special Program of Research, Development and Research Training in Human Reproduction has been involved in the study of natural methods of fertility regulation, and it is important that WHO continues to study breastfeeding in different ethnic and social group if it intends to give sound advice on this issue to family planning programs.
Studies in Family Planning. 1986 May-Jun; 17(3):153-60.Data from a prospective child health study conducted in Gaza by the WHO was used to examine the relationship between infant feeding and subsequent fertility. The study group consisted of 769 women living in 2 refugee camps in Gaza who gave birth in a 2-month period in 1978, and their index children, followed up for 23 months with monthly visits. Women who became pregnant within the 23 months were followed up until the end of their pregnancy. Women who practiced contraception after the birth of the index child were excluded. Life table analyses demonstrate a strong relationship between breastfeeding and 2 components of birth intervals, the postpartum anovulatory period and the waiting time from the end of the anovulatory period to conception. Duration of breastfeeding in this population averaged 12 months. Once menses have resumed, main factors related to waiting time to conception are age, husbands education, and measures of breastfeeding intensity and duration. Women who are breastfeeding when menstruation resumes and continue to do so are less likely to conceive than other women.
In: State of the world 1985. A Worldwatch Institute report on progress toward a sustainable society [by] Lester R. Brown, Edward C. Wolf, Linda Starke, William U. Chandler, Christopher Flavin, Sandra Postel, Cynthia Pollack. New York, New York, W.W. Norton, 1985. 200-21.The demographic contrasts of the 1980s are placing considerable stress on the international economic system and on national political structures. Runaway population growth is indirectly fueling the debt crisis by increasing the need for imported food and other basic commodities. Low fertility countries are food aid donors, and the higher fertility countries are the recipients. In most countries with high fertility, food production per person is either stagnant or declining. Population policy is becoming a priority of national governments and international development agencies. This discussion reviews what has happened since the UN's first World Population Conference in 1974 in Bucharest, fertility trends and projections, social influences on fertility, advances in contraceptive technology, and 2 major family planning gaps -- the gap between the demand for family planning services and their availability and the gap between the societal need to slow population growth quickly and the private interests of couples in doing so. The official purpose of the 1984 UN International Conference on Population convened in Mexico City, in which 149 countries participated, was to review the world population plan of action adopted at Bucharest. In Bucharest there had been a wide political schism between the representatives of industrial countries, who pushed for an increase in 3rd world family planning efforts, and those from developing countries, whose leaders argued that social and economic progress was the key to slowing population growth. In Mexico City this division had virtually disappeared. Many things had happened since Bucharest to foster the attitude change. The costly consequences of continuing rapid population growth that had seemed so theoretical in the 1974 debate were becoming increasingly real for many. World population in 1984 totaled 4.76 billion, an increase of some 81 million in 1 year. The population projections for the industrial countries and East Asia seem reasonable enough in terms of what local resource and life support systems can sustain, but those for much of the rest of the world do not. Most demographers are still projecting that world population will continue growing until it reaches some 10 billion, but that most of the 5.3 billion additional people will be concentrated in a few regions, principally the Indian subcontinent, the Middle East, Africa, and Latin America. What demographers are projecting does not mesh with what ecologists or agronomists are reporting. In too many countries ecological deterioration is translating into economic decline which in turn leads to social disintegration. The social indicator that correlates most closely with declining fertility across the whole range of development is the education of women. Worldwide, sterilization protects more couples from unwanted pregnancy than any other practice. Oral contraceptives rank second. The rapid growth now confronting the world community argues for effective family planning programs.
Who Chronicle. 1984; 38(3):109-15.The theme of the 1984 World Health Day--children's health, tomorrow's wealth--provides an occasion to convey to a worldwide audience the message that children are a priceless resource, and that any nation which neglects them does so at its peril. World Health Day 1984 spotlights the basic truth that the healthy minds and bodies of the world's children must be safeguard, not only as a key factor in attaining health for all by 2000, but also as a major part of each nation's health in the 21st century. An investment in child health is a direct entry point to improved social development, productivity, and quality of life. Care of child health starts before conception, through postponement of the 1st pregnancy until the mother herself has reached full physical maturity, and through spacing of births. It continues from conception on, through suitable care during pregnancy, childbirth, and childhood. In the developing countries the child must be protected by all available means, particularly from the killer diseases. What happens in the immediate family and community around the mother and child, and even far away in the world, can have a direct impact on the health and security of both of them. The mother and child need to be placed in an environment that will ensure their health by protecting the overall setting in which they live. This means providing clean water, disposing of waste, and helping to improve shelter. Nothing can diminish the importance of good food, enough food, and proper nutrition for children and their mothers. Beyond the immediate physical needs are the equally important needs for love and understanding which stimulate the healthy development of the child. The emergence of new health problems of mothers and children in developing and developed countries should be kept in mind. Better health services must be made available to all who need them. The World Health Organization (WHO) provided resource material on World Health Day issues for dissemination throughout the world. Extracts from 4 articles on this year's theme are reproduced. The articles report on the success of the Rural Health Center in Ballabhgarh (India) in reducing maternal and infant mortality, the value of breastfeeding as 1 of the simplest and safest ways of ensuring adequate spacing of births, Tunisia's integration of a program of immunization into the routine activities of the health care system, and the needs of the healthy child.
London, International Planned Parenthood Federation, 1984. 43 p. (IPPF Medical Publications)This booklet, for health care workers in developing countries, reviews the fertility-controlling effects of breastfeeding, its strengths and limitations as an element in family planning, and how to provide modern methods of contraception to lactating women. Breastfeeding currently provides about 30% more protection against pregnancy in developing countries than all of the organized family planning programs. The recent trend toward a falling off in the practice of breastfeeding poses a threat to infant welfare and a danger of increased fertility. Health workers are urged to reach pregnant women in the community with knowledge about the value of breastfeeding versus bottle feeding. Each country must set its own policies concerning contraception for lactating women. It is preferable for lactating women to use nonhormonal methods, but if selected, they should not be used too early. Lowest-dose preparations, especially progestogen-only pills, are preferable. Determination of when to start contraception during lactation should be based on breastfeeding patterns in the community, the age at which supplementary foods are introduced, usual birth spacing intervals, and the mean duration of lactation amenorrhea. If the usual time of resumption of menstruation in a given community is known, a rough guide to the optimal time for starting contraception is returning menstruation minus 2 months.
In: Jelliffe DB, Jelliffe EF, Sai FT, Senanayake P, eds. Lactation, fertility and the working woman. London, International Planned Parenthood Federation, 1979. 7-9.The principal objective of the International Planned Parenthood Federation (IPPF) -- an international federation of 95 voluntary national family planning associations with operations in 110 countries -- is to enable people to practice responsible parenthood as a matter of human right, family welfare, and the well-being of the community. A second IPPF objective is to increase understanding on the part of people and governments of the demographic problems existing in their communities and the world. In the area of lactation the IPPF has had several activities in the past few years. 1 activity was a Biological Sciences Workshop on Lactation and Contraception in November 1976. A 2nd activity is a study on breastfeeding being conducted in collaboration with the World Health Organization (WHO). The Central Medical Committee of the IPPF passed a resolution early in 1976 which states that lactation is a good thing in itself, that breastfeeding is the best way of feeding an infant in the early months, if not the early years of its life, and that breastfeeding is a good contraceptive in its own right. A definite advantage of breastfeeding is that there is more avoidance of pregnancy and more protection of women from unwanted pregnancy by breastfeeding than by all combined scientific technology in family planning based programs. Some of the problems of breastfeeding and outside work relate to sheer expense, both in a positive and negative sense. There is also the question of inconvenience of breastfeeding. 1 approach to the disadvantages has been prolonged maternity leave with pay. Another approach is causing the child to invert its feeding rhythm.
In: Raphael, D., ed. Breastfeeding and food policy in a hungry world. New York, Academic Press, 1979. p. 245-251The World Health Organization has undertaken an extensive survey of breastfeeding practises in an attempt to analyze prevalence, duration, motivation, attitude and demography of lactating mothers. A point prevalence study was implemented in 1975 in 10 locations. Mothers from 3 groups: urban elite, urban, and rural, were interviewed concerning background, medical history, pregnancy conditions, postnatal infant care, feeding schedules and diet, return of menstruation, and family planning behavior. 5 additional surveys were conducted among approximately 20,000 women. The first was a health, demographic, and socioeconomic survey. The second was an assessment of infant food marketing practises. The third survey was of health-related workers regarding their knowledge and training. The organization and delivery of health services and the social support systems for lactating mothers comprised the fourth and fifth surveys. Following these surveys WHO also conducted a cross-sectional study of the volume and composition of breast milk. The results of the studies will be input for an action program.
In: Raphael, D., ed. Breastfeeding and food policy in a hungry world. New York, Academic Press, 1979. p. 253-258UNICEF has promoted breastfeeding in developing countries through health service innovations such as nutrition rehabilitation centers and under 5s clinics. UNICEF has also helped establish departments of social pediatrics and sponsored special training programs for pediatricians in developing countries. It helped put 240 milk plants in operation in 40 countries. Skim milk powder has been distributed in the largest quantity in food-aid programs. Other milk substitutes include immature coconut milk, soy milk, whole milk powder, cheese, and butter oil. Some cases of severe malnutrition do not respond to milk unless the lactose is replaced with sucrose, some protein and fat. K-MIX-II has been distributed since 1970 and consists of skim milk powder, calcium caseinate, and sugar. Fat and water are added at the point of consumption.
In: Mishell DR Jr, ed. Advances in fertility research. Vol. 1. New York, Raven Press, 1982. 1-18.This discussion of natural family planning (NFP) focuses on the following: calculation of the calendar method; the basal body temperature method; the ovulation method; sympto-thermal methods; international studies on NFP; effectiveness of NFP; breastfeeding and birth spacing; psychological and psychosexual aspects of NFP; and research and development of new methods to determine the fertile period. The calendar method, the oldest technique for determining the fertile period, involves the identification of the fertile time from the records of the previous 6-12 menstrual cycles. The temperature or thermal method depends on the identification of the rise in the basal body temperature (BBT) from a relatively low level during the follicular phase to a relatively higher level during the luteal phase of the menstrual cycle. The basis of the ovulation method is that the cervical glands are highly sensitive indicators of the estrogen level in the blood and thus accurately reflect the follicular maturation in the ovary. In order to use the ovulation method, the woman must learn to recognize the sequence of changes in the quality and quantity of her mucus and the associated sensation at the vulva. The sympto-thermal methods incorporate several markers of ovarian function in order to define the infertile period with greater accuracy. From the perspective of fertility control, it should be recognized that traditional breastfeeding has a central regulating role in the spacing of births and is of considerable importance where methods of fertility control are either unacceptable or unavailable. Couples who follow the rules of NFP methods have a highly effective means of fertility regulation with method failure rates of 0.5-3.0 pregnancies in 1300 cycles. In general use, the methods are around 80% effective. The major advantage of NFP is that no hormones or chemicals are introduced into the woman's body. The couple oriented method promotes both self knowledge and self reliance. NFP calls for an education rather than a medical delivery system, and it aims to make the users both autonomous and potential educators of other users. The major problem with NFP is the modification of the sexual behavior involved and the extent of motivation necessary for successful use. Easy to use and inexpensive tests that identify the fertile period and ovulation would be useful for fertility control, and the World Health Organization task force is currently at work on the development of new technology in this field.