Cynthia M. Visness

Effectiveness of the lactational amenorrhea method in Pakistan.

OBJECTIVE To determine the efficacy of the lactational amenorrhea method of family planning (amenorrhea during full or nearly full breastfeeding for 6 months postpartum). DESIGN Prospective noncomparative study. SETTING Normal breastfeeding women in Karachi and Multan, Pakistan, most delivered at home by a midwife. PATIENTS Three hundred ninety-nine newly delivered mothers who successfully had breastfed a previous child and chose the lactational amenorrhea method to prevent a subsequent pregnancy, 391 of whom were followed for a full year. INTERVENTIONS Mothers were taught, before or shortly after delivery, to use the method and were interviewed in their homes each month by a Lady Health Visitor. MAIN OUTCOME MEASURE Life-table pregnancy rates. Periods of postpartum or lactational abstinence were excluded in the calculation of the pregnancy rates. RESULTS During full or nearly full breastfeeding, while the women were amenorrheic and not otherwise contracepting, the rate of pregnancy was 0.6%. The pregnancy rate during lactational amenorrhea alone was 1.1% at 1 year postpartum. CONCLUSION The lactational amenorrhea method was found to be highly effective for 6 months. A high degree of contraceptive protection endures for a full year during lactational amenorrhea, but not after the return of menses during breastfeeding.

Effectiveness of lactational amenorrhoea in prevention of pregnancy in Manila, the Philippines: non-comparative prospective trial

Abstract Objective: To determine the contraceptive efficacy of the lactational amenorrhoea method. Design: Non-comparative prospective trial. Setting: Urban Manila, the Philippines. Subjects: 485 lower income, educated women with extensive experience of breast feeding. Intervention: Women were offered all available contraceptives for use after birth. Those who chose the lactational amenorrhoea method were taught the method, screened for the study, and followed for 12 months to determine the risk of pregnancy when the method was used. Main outcome measures: Life table pregnancy rates during correct and incorrect use of the method, censored monthly in the event of sexual abstinence or the use of another contraceptive method. Results: The lactational amenorrhoea method was 99% effective when used correctly (that is, during lactational amenorrhoea and full or nearly full breast feeding for up to six months). At 12 months the effectiveness during amenorrhoea dropped to 97%. Conclusions: The lactational amenorrhoea method provided as much protection from pregnancy as non-breast feeding women experience with non-medicated intrauterine devices and barrier methods. The contraceptive effect of lactation cannot be attributed to lactational or postpartum abstinence. Key messages Henceforth, data from clinical trials on contra-ceptives must be subject to the rigours of multiple censoring such as applied here. By excluding periods of abstinence from the calculation of risk of pregnancy, the contraceptive protection of the method cannot be attributed to postpartum or lac- tational abstinence During the first year post partum, the rate of pregnancy before the return of menses in lactating women was less than 3%

The duration and character of postpartum bleeding among breast-feeding women*

Objective To examine the postpartum bleeding experience of a cohort of breast-feeding women and to compare it with the conventional definition of lochia. Methods Four hundred seventy-seven experienced breast-feeding women in Manila, the Philippines, were followed prospectively from delivery and recorded vaginal bleeding in a menstrual diary. The median duration of lochia was calculated using survival analysis. In addition, all bleeding separate from lochia within the first 8 weeks postpartum was noted. Results The median duration of lochia was 27 days and did not vary by age, parity, sex or weight of the infant, breast-feeding frequency, or level of supplementation. More than one-fourth of the women experienced a bleeding episode separated from the original lochial flow by at least 4 bleeding-free days and beginning no later than postpartum day 56. Ten breast-feeding women may have had their first menstrual bleed before day 56. Conclusions Lochia lasted substantially longer than the conventional assumption of 2 weeks. It was common for postpartum bleeding to stop and again or to be characterized by intermittent spotting or bleeding. Return of menses is rare among fully breast-feeding. Return of menses is rare among fully breast-feeding women in the first 8 weeks postpartum.

Breastfeeding and the symptothermal method.

This prospective study was conducted among experienced users of periodic abstinence methods in Sydney, Montreal, and Birmingham (England) in order to describe the relationship between a laboratory measurement of ovulation and the natural symptoms of fertility during breastfeeding. Daily urinary estrogen and pregnanediol glucuronide assays were used to estimate the date of ovulation and to determine potentially fertile days. A standard set of Symptothermal Method (STM) rules was applied to daily STM records to assess the correspondence of the natural symptoms of fertility to the underlying hormonal profile. The STM symptoms and rules accurately identified 77-94 percent of the womens potentially fertile days, but abstinence was also recommended on about half of the days when the women were not fertile. An integrated set of common rules for STM use during breastfeeding is highly sensitive but not specific in its ability to screen for ovulation.

A comparison of two U.S. surveys of infant feeding.

This study compares the 1988 National Maternal and Infant Health Survey (NMIHS) and the 1989 Ross Laboratories Mothers Survey with respect to sample characteristics and proportions of women who breastfed. Weighted proportions of women included in the two surveys were compared according to various characteristics to see how well they represented U.S. childbearing women. A z-statistic was produced to test for significant differences in the proportions who breastfed. In 1988-89, 52.2% of American women breastfed according to the Ross survey and 53.4% according to the NMIHS. Despite differences in sample size, sampling technique and the application of sample weights, the difference between the surveys was only 1 percentage point, and most levels of most variables examined were comparable. The Ross survey is a valuable source of data because it is ongoing, and it is generally corroborated by the NMIHS. The NMIHS is probably more representative of the U.S. population of childbearing women, and is a reliable source of data for setting U.S. objectives concerning infant feeding, and for the study of other issues vis-a-vis breastfeeding.

Users' understanding of the lactational amenorrhea method and the occurrence of pregnancy.

It is unknown whether a users understanding of the Lactational Amenorrhea Method (LAM) is related to its successful use. A study of 876 LAM users in Pakistan and the Philippines collected information about womens understanding of LAM. The present analysis aims to determine: (1) the proportion of LAM users who understand the method, (2) whether any known factors can distinguish those who understand LAM from those who do not, and (3) whether an understanding of LAM is related to subsequent pregnancy. Over 75% of LAM users could consistently recite the LAM guidelines correctly for a full year postpartum. However, 38% of users failed to display, at least once, an understanding of LAM during the first year postpartum mainly by failing to abstain, to use another method or to explain their nonuse of another method when their LAM protection expired. LAM understanding generally could not be predicted by sociodemographic factors. The occurrence of pregnancy during the first year postpartum was not related to LAM understanding, regardless of how LAM understanding was defined, nor could it be predicted by any other measured characteristic of the users.

Fertility of fully breast-feeding women in the early postpartum period

Objective To examine bleeding between 6 and 8 weeks postpartum in fully breast-feeding women and its association with fertility as assessed by hormone analysis. Methods Seventy-two fully breast-feeding women were followed prospectively from 42 days postpartum. Vaginal bleeding was recorded daily. Women who experienced bleeding were compared with women who did not with respect to time ovulation and time of first menses. Results Nearly half of the women experienced some vaginal bleeding or spotting between 6 and 8 weeks post-partum. These women eventually menstruated and ovulated earlier than the women who did not bleed, but the differences were not significant. The study had 34% and 45% power to detect a 20% difference in the proportion menstruating and ovulating, respectively, at 6 months postpartum, and 10% and 16% power to detect the same differences at 1 year. Seven women experienced ovarian follicular development before day 56, but neither bleeding nor follicular development was associated with ovulation in any woman in the first 8 weeks post partum. Conclusions It is unlikely that vaginal bleeding in fully breast-feeding women in the first 8 weeks postpartum represents a return to fertility.

Extending lactational amenorrhoea in Manila: a successful breast-feeding education programme.

An experimental breast-feeding education programme conducted at the Philippine General Hospital in Manila demonstrated that women could be motivated to improve their breast-feeding practices and lengthen their period of lactational amenorrhoea in comparison to a control group. Mothers who participated in the programme breast-fed their babies more frequently, delayed the introduction of regular supplements, used fewer bottles and pacifiers and maintained night feeding longer than mothers who were not exposed to the positive breast-feeding messages. The programme was successful in lengthening the period of amenorrhoea among women with elementary, high school, or technical school education, but not among college-educated women. Different educational approaches may be necessary for women of different education levels.

Progestin-only pill use and pill switching during breastfeeding.

The opinions of 20 international experts in reproductive endocrinology and family planning service delivery were solicited concerning contraceptive pill use during breastfeeding and, in particular, to determine whether the experts felt that breastfeeding women who use progestin-only pills (POPs) should be advised to switch to combined estrogen-progestin pills (COCs) during lactation. The experts agreed that POPs can be used safely and effectively throughout the period of lactation and there is no need to switch to another contraceptive method or another type of pill. If, however, a woman wishes to switch to COCs while she is still breastfeeding, it is acceptable for her to do so after six months postpartum.

Duración y características del sangrado postparto entre las mujeres que alimentan sus bebés al seno

Objetivo :Examinar la experiencia del sangrado postparto de una cohorte de mujeres que amamantan a sus bebes y compararla con la definicion convencional de loquios.Metodos: Se siguieron en forma prospectiva desde el parto a 477 mujeres con experiencia que amamantaban a sus bebes, en Manila, Filipinas, y se registro el sangrado vaginal en un diario menstrual. La duracion promedio de los loquios se calculo usando un analisis por tabla de sobrevida. Ademas se anoto todo sangrado separado de los loquios dentro de las primeras 8 semanas postparto.Resultados: La duracion promedio de los loquios fue 27 dias y no vario con la edad, paridad, sexo o peso del bebe, la frecuencia de la alimentacion al seno o el nivel de suplementacion. Mas de un cuarto de las mujeres experimentaron un episodio de sangrado separado de los loquios originales por al menos 4 dias libres de sangrado y que empezo a mas tardar en el dia 56 postparto. Diez mujeres que amamantaban pudieron tener su primer sangrado menstrual antes del dia 56.Conclusiones: Los loquios duraron substancialmente mas tiempo que la presuncion convencional de 2 semanas. Fue comun que el sangrado postparto se detenga y se inicie de nuevo o que se caracterice por manchado o sangrado intermitente. El retorno de las menstruaciones es raro entre las mujeres que brindan alimentacion-al seno exclusiva en las primeras 8 semanas postparto.