Lactation and fertility

Breastfeeding suppresses ovarian activity resulting in amenorrhea and infertility. The frequency of breastfeeds and their duration appear to be important in maintaining amenorrhea--and night-time sucking appears to be particularly crucial. Supplementary feeding may affect fertility by altering suckling behaviour, but the evidence is confusing as to whether feeding supplements reduces the duration of amenorrhea and increases the risk of conception. Mothers who are better nourished tend to have a shorter period of amenorrhea than the malnourished, possibly because the infant has to suckle for a shorter period to obtain the nourishment needed. Lactation has an important effect on fertility at the population level. However, it cannot be considered a reliable contraceptive at an individual level.

Social factors predicting postpartum choice of Norplant among African-American and non-Hispanic white adolescents

PURPOSE

This study was designed to determine the factors associated with Norplant choice for postpartum teens.

METHODS

A total of 151 teenagers, ages 12-20 years, who delivered at the Medical Center of Delaware from July to December 1992, were offered insertion of Norplant within 48 h postpartum. A structured interview was conducted in the postpartum period after nondirective counseling sessions including a physical demonstration using anatomical models of various contraceptive methods. Student's t-tests, chi-square, and multivariate analyses were used.

RESULTS

Eighty-six teenagers were African-American (mean age = 17.3 +/- 1.9 years) and 65 non-Hispanic white (NHW) (mean age = 18.3 +/- 1.5 years). The NHW teenagers were older (p < 0.001); the African-American teenagers were more likely to have Medicaid (49% vs. 14%; p < 0.001) and to have one or more friends who use Norplant (62% vs. 34%; p < 0.001). In multivariate analyses, NHW teenagers were more likely to choose Norplant if they had discussed their choice with a parent or guardian [adjusted odds ratio (AOR) = 14.6, 95% confidence interval (CI), 2.12-100.57]; had Medicaid funding (AOR = 12.1; 95% (CI), 10.6-91.34); and had any friends who used Norplant (AOR = 6.3; 95% (CI), 1.38-28.40). However, for African-American teenagers, the strongest predictor for choice of Norplant was number of prior children delivered. After two deliveries, there was a better than four-fold likelihood (AOR = 4.8; 95% (CI), 1.47-15.94) that African-American teenagers would choose Norplant. For the African-American teenagers, parental discussion, Medicaid status, and friends' use of Norplant were not as important as family size, but far greater percentages of the African-American teenagers had access to Medicaid funding and peers who used Norplant.

CONCLUSIONS

NHW and African-American teenagers choose Norplant for different reasons. Lack of funding may have been a barrier to choosing Norplant. Discussions with parents and friends have a positive influence on choosing Norplant for NHW teenagers. African-American teenagers were more likely than NHW to have Medicaid coverage, and more frequently choose Norplant if the current birth was their third child.

Cervical cancer screening in a rural population of Zimbabwe

OBJECTIVE

To review cervical cancer screening since its introduction to a rural district hospital in Zimbabwe.

DESIGN

Retrospective, descriptive.

SETTING

Rural district hospital.

SUBJECTS

Data from 419 cervical smears performed on women who had cervical cancer screening as part of a routine post partum visit from 1994 to 1996 was available for analysis.

MAIN OUTCOME MEASURE

Rates of abnormal cervical smears.

RESULTS

The majority of the patients were of age 20 to 29 years (47.2%) and of low gravidity (Zero to three children) 62.6%). A total of 173 slides (41.3%) were normal. Of the abnormal smears, 158 (37%) had inflammation, and 65 cases (15.5%) demonstrated abnormal cytology of which 50 (12%) were low grade squamous epithelial lesions (atypia/CINI), and the remaining 15 (3.6%) high grade squamous intra-epithelial lesions (CIN II/III and carcinoma in situ).

CONCLUSION

There was a high frequency of abnormal smears at this rural district hospital. Furthermore, there were problems in sampling the population at highest risk, shortages of supplies, technical problems in sampling and interpretation, and difficulties in follow up of patients. These problems are discussed including the confounding effect of the Human Immunodeficiency Virus.

Regression analysis of the effect of full and partial lactation on post-partum amenorrhoea in lower middle class Indian females

This study presents a simple regression analysis of the impact of full and partial breast feeding on post-partum amenorrhoea (PPA) in lower middle class Indian women. The study has been done on a sample of hospital based data collected in 1992. The analysis shows a highly significant correlation. Further, the impact of lactation on PPA was notably less in case with partial breast feeding as compared to those with full breast feeding.

Premature introduction of progestin-only contraceptive methods during lactation

Experts on contraceptive technology concur that progestin-only methods can be used safely during lactation. However, very few studies exist of the effects on lactation of the introduction of progestin-only methods prior to the sixth postpartum week. Since progesterone withdrawal is the likely stimulus that initiates lactogenesis, it appears necessary for natural progesterone levels to decline to baseline before a progestin-only contraceptive is initiated. Therefore, the use of such contraceptive methods should be delayed for at least 3 days after the birth. Non-hormonal methods remain the first choice category of contraceptive methods for breastfeeding women, since there is no possibility that they will interfere with lactation. Progestin-only methods comprise a viable and often desirable next choice category, although the timing of their commencement must be determined with care in order to support lactation.

Effects of age at introduction of complementary foods to breast-fed infants on duration of lactational amenorrhea in Honduran women

Lactational amenorrhea (LA) is associated with postpartum infertility and is known to be related to breast-feeding frequency and duration, but the exact role of complementary feeding of the infant has not been clearly defined. Data on LA were collected during and after a 2-mo intervention trial in which low-income Honduran women who had breast-fed fully for 4 mo were randomly assigned to one of three groups: continued full breast-feeding until 6 mo (FBF, n = 50), introduction of complementary foods at 4 mo with ad libitum breast-feeding from 4 to 6 mo (SF, n = 47), or introduction of complementary foods at 4 mo with maintenance of baseline breast-feeding frequency from 4 to 6 mo (SF-M, n = 44). Women were followed up until the infant was 12 mo of age, or later if menses had not occurred by then. All but six of the women continued to breast-feed for > or = 12 mo. With the exclusion of those whose menses returned before 18 wk postpartum (which could not have been due to the intervention), the proportion of women who were amenorrheic at 6 mo was 64.5% in the SF group, 80.0% in the FBF group, and 85.7% in the SF-M group (chi-square test = 4.13, P = 0.02; one-tailed test with the latter two groups combined). The total duration of LA did not differ significantly among groups. The most significant determinant of LA was time spent breast-feeding (min/d), which was in turn negatively associated (P = 0.06) with the infant's energy intake from complementary foods in regression analyses. These results indicate that there is a significant effect of introducing foods at 4 mo on the likelihood of amenorrhea at 6 mo postpartum, but not thereafter, and that this effect is not seen in mothers who maintain breast-feeding frequency.

Voluntary female sterilisation via minilaparotomy: report from Burkina Faso

We present the first study of voluntary female sterilisation in Burkina Faso. The average woman undergoing tubal ligation was a 37 year old, married, house wife para 8 with five living children. The main reasons for TL were: achieved desired family size (45.9%) and medical reason (29.5%). The TL was usually performed (77.8%) in the postpartum, using the Pomeroy technique. With a follow up of three to fifteen months, no pregnancy has been reported and no request for reversal expressed. The authors make some suggestions to increase the prevalence of TL in Burkina Faso.

Randomised clinical trial to determine optimum initiation time of norgestrel-progestin only contraception in Eldoret Teaching Hospital, Kenya

In a randomised controlled trial to determine the optimum time of initiation of Ovrette, a progestin only oral contraceptive among postpartum women, who fully or nearly fully breast-fed their infants in the first six months, no difference was found between group 1 (initiating at six weeks postpartum) and group 2 (initiating the pill at return of menses or 6 months postpartum). There were no pregnancies in either group during the 18 month follow-up. There were no significant differences in the continuation rates between the two group.

Chlamydia trachomatis and febrile complications of postpartum tubal ligation

OBJECTIVE

Our goal was to determine whether chlamydia-infected women have a higher rate of febrile complications after postpartum tubal ligation.

STUDY DESIGN

Cross-sectional analysis of 1447 women tested for chlamydial infection within 2 weeks of delivery and who underwent postpartum tubal ligation was performed. Subjects were identified with the Regenstrief Institute for Health Care database. Infected subjects were compared with uninfected subjects for incidence of fever not explained by nongynecologic sources.

RESULTS

Women infected with Chlamydia trachomatis at delivery were more likely to experience febrile postoperative complications after tubal ligation (p < 0.0001, relative risk 9.5, 95% confidence interval 4.5 to 20.1).

CONCLUSION

Women undergoing postpartum tuba ligation may benefit from prompt diagnosis and preoperative treatment of chlamydial infection.

The problem of post-partum fistulas in developing countries

Postpartum fistulas are frequent in the tropical environment. They are mostly found in very young women who live in remote areas. Without treatment women with fistulas will be condemned to the disconsolate life of social outcasts. Good operative treatment is crucial. The different operative methods are discussed. The operation through vaginal approach can be performed in any hospital. It does not need special surgical skill. More important than surgery is prevention of postpartum fistulas through a well-organised primary health care program which reaches out into the villages and which includes adequate prenatal controls and competent midwifery.

Immediate postplacental insertion of GYNE-T 380 and GYNE-T 380 postpartum intrauterine contraceptive devices: randomized study

OBJECTIVE

The purpose of the investigation was to compare the 1-year expulsion and efficacy rates of the GYNE-T 380 and the GYNE-T 380 Postpartum intrauterine contraceptive devices when inserted within 10 minutes after expulsion of the placenta in a term pregnancy. The two intrauterine contraceptive devices were identical, except that one was inserted by means of a temporary fundal suspension system and the other was placed directly into the uterine cavity.

STUDY DESIGN

The study was a multicenter, randomized trial of intrauterine contraceptive devices in which 300 subjects accepted the GYNE-T 380 IUD and 292 subjects the GYNE-T 380 Postpartum IUD in clinics with adequate follow-up.

RESULTS

At 1 year the gross cumulative expulsion rate was 13.2 per 100 cases (39 expulsions) with the GYNE-T 380 intrauterine contraceptive device and 16.2 per 100 cases (46 expulsions) with the GYNE-T 380 Postpartum device. There was no significant difference in the rate of expulsion between the two devices at any time during the year. There was one first-year intrauterine pregnancy, which occurred in a subject using the GYNE-T 380 device. The continuation rate for each device was above 80 per 100.

CONCLUSION

The results indicate that both the GYNE-T 380 Postpartum and the standard GYNE-T 380 intrauterine contraceptive devices are safe and effective when inserted immediately after delivery of the placenta.

Drug use among adolescent mothers: prepregnancy to 18 months postpartum

PURPOSE

Little is known about the substance use patterns of adolescent mothers, particularly in the postpartum period. This study provides descriptive, longitudinal data on the substance use behavior of a cohort of adolescent mothers.

METHODS

A total of 241 pregnant adolescents, under 18 years old and planning to carry the pregnancy to term, completed the initial interview. Respondents were interviewed again at 1, 6, 12, and 18 months postpartum. The data reported here are based on the 229 respondents who completed all five interviews.

RESULTS

Use of all substances decreased substantially during pregnancy, but increased steadily in the first 6 months postpartum. A similar pattern was observed for regular use of multiple substances. Regular use before and after the pregnancy, but not during it, was the most common pattern of substance use.

CONCLUSIONS

The prevalence of substance use among adolescent mothers is significant. To capitalize on the large decreases in use during pregnancy, drug prevention programs for adolescent mothers should target the first 6 months postpartum.

An evaluation of the Filshie clip for postpartum sterilization in Austria

Voluntary sterilization is a popular method of family size limitation. Among other techniques for surgical induction of female sterility, the application of various kinds of clips to the Fallopian tubes has been introduced. The Filshie clips consist of rubber-lined titanium and their use for interval sterilization has been repeatedly published. So far, there are only a few reports regarding the use of Filshie clips during the postpartum period, when tubes are edematous and more friable. Therefore, 300 women voluntarily requesting postpartum surgical sterilization for the purpose of family size limitation were enrolled into a prospective trial. Within 72 h of delivery, 282 women were sterilized under general anesthesia using a subumbilical minilaparotomy approach and Filshie clip application. Of these women, 251 were available for follow-up examination at 6 weeks, 240 at 6 months, 234 at 12 months, and 209 at 24 months after the sterilization procedure. Complication rates were low, and there were no pregnancies during the follow-up period. These results indicate that the application of Filshie clips is a safe and efficacious method of surgical female sterilization in the postpartum period.

The effect of levenogesterol (Norplant) contraception on coagulation as measured by antithrombin-III levels

PURPOSE

To determine the effect of contraception given immediately postpartum on coagulation as measured by antithrombin III.

STUDY DESIGN

In this prospective study, parturients (n = 85) self selected three means of postpartum contraception: levenorgesterol implants, oral contraceptives, or a barrier method.

RESULTS

Baseline coagulation was assessed by antithrombin-III levels in each of the 85 women within 48 hours of delivery (100.35 +/- 1.61%) and at one (109.1 +/- 1.89%) and six (105.51 +/- 1.71%) weeks postpartum. There was a rise in antithrombin-III after delivery but there were no significant differences between the groups.

CONCLUSION

The levenorgesterol implant system did not cause a decrease in antithrombin-III in normal parturients.

Effect of skim milk supplementation of the maternal diet on lactational amenorrhea, maternal prolactin, and lactational behavior

Effect of skim milk supplementation of the maternal diet on lactational amenorrhea was studied in 30 pairs of healthy lactating women matched for parity, body mass index, and previous experience of lactational amenorrhea. Supplementation of the maternal diet had no significant effect on the time of resumption of regular menstruation or ovulation, maternal prolactin concentrations, breast-feeding pattern, maternal body mass index, or infant weight. However, the supplemented group breast-fed nearly exclusively (supplemental feeds were introduced but did not exceed 20% of total feeds) for a significantly longer duration (P < 0.05) than did the control group. Previous experience of lactational amenorrhea was significantly positively correlated with the time of resumption of menstruation in the supplemented (P < 0.01) and control (P < 0.05) groups when frequency of breast-feeding, maternal body mass index, and supplementary feeds to the infant were controlled for. Thus, maternal nutritional supplementation does not appear to affect the contraceptive benefit of lactation when the frequency of breast-feeding is not compromised but apparently lengthens the duration of nearly full breast-feeding.

Female sterilization in Ramathibodi Hospital: 1987-1993

A 7 year (1987-1993) restropective review of female sterilization in the Department of Obstetrics and Gynecology, Ramathibodi Hospital was reported. This paper is part of a continuing study of female sterilization in Ramathibodi Hospital. A total of 9,968 cases of female sterilization was done from January 1987 to December 1993. Post partum acceptors accounted for 63 per cent of total female sterilization, the overall postpartum female sterilization rate was 117.4 per 1,000 deliveries. 37 per cent was interval sterilization. The peak of interval sterilization was in March. 69.8 per cent of interval sterilization was performed by minilaparotomy technique, the remainder were by laparoscopy.

Prelacteal feeding: influencing factors and relation to establishment of lactation

This study was carried out with a view to finding out factors influencing prelacteal feeding and its relation to establishment of lactation in rural Bangladesh. 420 mothers in early post-partum period were interviewed at home. Prelacteal feeding was given to 77% of the babies, and honey was given to 72% of them. The common methods of prelacteal feeding were by finger (41%) and spoon (40%). Twelve socio-demographic and health care variables were studied for their probable influence on prelacteal feeding. Nine of them accounted for 22% of the variability in giving prelacteal feeding. Reasons of giving prelacteal feeding and the time of first breast feeding influenced the practice significantly (P < 0.05). Type and duration of prelacteal feeding had significant negative influence on "coming in" of milk (P < 0.05). Prelacteal feeding accounted for 44% of variations in coming in of milk. Prelacteal feeding and coming in of milk formed a vicious cycle: the former delayed initiation of lactation and on the other hand delay in coming in of milk encouraged prelacteal feeding. These observation emphasized the need for coordinated efforts for promotion of proper infant feeding practices in our rural community.

Impairment of a pregnant woman's acquired ability to limit Plasmodium falciparum by infection with human immunodeficiency virus type-1

In Africa, the human immunodeficiency virus (HIV) is the most serious emerging infection and Plasmodium falciparum malaria is one of the most prevalent infectious diseases. Both infections have serious consequences in pregnant women, their fetuses, and infants. We examined the association between HIV and P. falciparum in pregnant women enrolled in a malaria chemoprophylaxis study in rural Malawi. Pregnant women (n = 2,946) were enrolled at their first antenatal clinic visit (mean 5.6 months of pregnancy), placed on one of three chloroquine regimens, and followed through delivery. Plasmodium falciparum parasitemia was measured at enrollment, monthly thereafter, at delivery, and 2-6 months postpartum; placental and newborn (umbilical cord blood) infection was measured for hospital-delivered infants. Serum collected during pregnancy was tested for antibodies to HIV by enzyme-linked immunoassay with Western blot confirmation. Parasitemia was detected in 46% of 2,946 women at enrollment and 19.1% at delivery; HIV seroprevalence was 5.5%. The prevalence and geometric mean density (GMPD) of parasitemia at enrollment and at delivery were higher in HIV-seropositive(+) than in HIV-seronegative(-) women (at enrollment: 57% prevalence and a GMPD of 1,558 parasites/mm3 versus 44% and 670/mm3, respectively; P < 0.0001; and at delivery: 35% and 1,589/mm3 versus 18% and 373/mm3; P < 0.0005). Placental infection rates were higher in HIV(+) compared with HIV(-) women, (38% versus 23%; P < 0.0005). This association was strongest in multigravidas. Compared with infants born to HIV(-) women, newborns born to HIV(+) women had higher rates of umbilical cord blood parasitemia. Both HIV(+) and HIV(-) women had similar rates of parasitemia 2-6 months postpartum. The HIV infection diminishes a pregnant woman's capacity to control P. falciparum parasitemia and placental and newborn infection, the major determinants of the impact of P. falciparum on fetal growth and infant survival.

Immediate postpartum insertion of the norplant contraceptive device

OBJECTIVE

To determine the safety and efficacy of Norplant (Wyeth-Ayerst Laboratories, Philadelphia, PA) insertion immediately postpartum.

DESIGN

Prospective study of 14 women receiving Norplant immediately postpartum compared with controls (n = 6) having a bilateral tubal ligation. Subjects were followed for 3 months postpartum, and data were analyzed by analysis of variance and chi2.

SETTING

Academic Health Sciences Center.

PATIENTS

Female subjects 18 to 35 years old who had an uncomplicated term pregnancy, normal spontaneous vaginal delivery, and did not breast-feed.

INTERVENTION

A brief interview, physical exam, and blood and urine samples were evaluated during a 12-week postpartum period.

MAIN OUTCOME MEASURES

Major complaints, serum chemistry panels, hematologic and coagulative measures, serum E2, P, levonorgestrel, PRL, LH, FSH, and urinary estrone-3 conjugates and pregnanediol-3-glucuronide concentrations.

RESULTS

Serum levonorgestrel peaked at approximately 2,000 pg/mL (6,400 pmol/L) during the 1st week after Norplant insertion, declining to approximately 250 pg/mL (800 pmol/L) by the 8th week. Significant differences between Norplant and control groups included bleeding irregularities, headaches, alopecia, and abdominal discomfort. Serum electrolytes, metabolic markers, and blood components were within normal limits. Serum E2, P, and urinary steriod biomarkers indicated that steroid secretion was suppressed severely in the Norplant group compared with controls who exhibited normal postpartum ovarian activity.

CONCLUSION

Norplant inserted immediately postpartum appears to be a safe and effective method of contraception. However, the long-term hypoestrogenic state and contraceptive efficacy beyond the 3-month postpartum period as observed in this study are concerns that need further clinical evaluation.

A comparative study of two techniques used in immediate postplacental insertion (IPPI) of the Copper T-380A IUD in Shanghai, People's Republic of China

Chinese women in Shanghai who delivered vaginally and who chose to use an IUD for contraception received a Copper T-380A IUD inserted vaginally within 10 minutes after delivery of the placenta (i.e., immediate postplacental insertion, IPPI). Among them, 97.7% were primipara. The women were randomly divided into two groups: IUD inserted by hand and IUD via ring forceps. The follow-up rate of six months was 95.2%. Using Tietze's life table method and log rank test, the expulsion and other discontinuation rates were compared at three and six months postinsertion between these two different insertion techniques. Expulsions were the main reason for discontinuation. The six-month gross cumulative expulsion rates were 13.3 and 12.7 per 100 women in the hand-insertion group and ring forceps-insertion group, respectively. Discontinuation rates for medical removals (bleeding/pain) were 2.1 and 1.0 in these two groups, respectively. Neither of the differences was statistically significant (p > 0.05). No uterine perforation, infection or pregnancy occurred. The results suggest that these two different insertion techniques do not significantly affect discontinuation rates in vaginal IPPI using the TCu 380A, and the TCu 380A appears to be suitable for postpartum insertion in Chinese women. Other relevant issues, such as breastfeeding and IUD placement in uterine cavity, are also analyzed and discussed in this report.

A study of the lactational amenorrhoea method of family planning in New Zealand women

AIM

To evaluate the acceptance and efficacy of the lactational amenorrhoea method of family planning in breastfeeding clients attending clinics of the NZ Association of Natural Family Planning.

METHODS

Mothers who were fully breastfeeding their babies, were amenorrhoeic and were early postpartum were offered for the purpose of family planning either lactational amenorrhoea method or the usual fertility awareness charting method. The clients who chose lactational amenorrhoea method were contacted at monthly intervals to check if they continued to meet the lactational amenorrhoea method criteria of fully breastfeeding and amenorrhoea. The fertility awareness group followed the normal practice of clinic visits for instruction until they became autonomous users. The status of both groups were assessed at 6 months postpartum when lactational amenorrhoea method users were advised to adopt another family planning method.

RESULTS

Of 149 breastfeeding clients, 110 met the lactational amenorrhoea method criteria. Seventy chose lactational amenorrhoea method, the majority (56.7%) because of its simplicity. Thirty (48.6%) of initial lactational amenorrhoea method users were able to use the method for the full 6 months postpartum period. None of the women conceived while using lactational amenorrhoea method.

CONCLUSION

For mothers who choose to fully breastfeed and who maintain a state of amenorrhoea lactational amenorrhoea method is an effective means of avoiding pregnancy during the first 6 months postpartum.

Tubal ligation candidates who did not get their operation

OBJECTIVE

To identify bottlenecks in the delivery of comprehensive family planning to women in contact with the Health Services and to find ways to reduce unmet demand for contraception.

DESIGN

Exploratory descriptive study.

SETTING

Large Bulawayo Government Hospital and the high density areas in the same city.

SUBJECTS

Case notes of 284 women who indicated together with their partners that they had completed families and who had their tubal ligation forms duly signed but who never had their operation. Follow up of a sample of patients.

INTERVENTIONS

Non intervention study.

MAIN OUTCOME MEASURES

Are reproductive rights taken seriously? Is there service related unmet demand for family planning.

RESULTS

Even those who had all their paperwork in order for a durante or post partum sterilization did not have any guarantee that this service would be given. The main reason was found to be lack of well motivated health staff.

CONCLUSION

Much can be improved in contraceptive service delivery. Reproductive rights are not respected.

Who gives advice about postpartum contraception?

Women were interviewed to determine what advice they received about postpartum contraception and what they thought of it. Only 4% of women discussed postpartum contraception antenatally. Up to 84% discussed the issue with a midwife on the postnatal ward but discussion was often felt to be brief, limited and frequently held as the mother was leaving the hospital. Obstetricians appeared to have little interest in the subject and only 50% of mothers left the hospital with supplies of a contraceptive. Almost all women discussed contraception with their general practitioner at the postnatal check but a significant number felt that the choice of method was limited to condoms or pills. The postnatal check is traditionally held at six weeks--two to three weeks after the recommended time for starting contraceptive precautions. Women with short inter-pregnancy intervals were younger, less likely to be married and more likely to default from postnatal follow-up. Pregnant women should be offered the opportunity during the antenatal period to discuss postpartum contraception with someone who has a special interest in the subject. The postnatal ward is not an appropriate setting for discussion about future contraception.

Post-partum contraception

The choice of a post-partum contraceptive method depends on many factors, including the need for a temporary versus a permanent method, the infant feeding choice and the extent to which informed consent is made prior to delivery. For maximum protection, the non-breast-feeding woman should be protected from the fourth week post-partum, even if that means using a temporary method, such as condoms or spermicides, until her method of choice is procured. Combined oestrogen/progestin methods should be avoided by all women for 2-3 weeks to avoid elevating the risk of thromboembolism. Preparations containing oestrogen should be avoided altogether during lactation because they have been associated with a reduction in milk production. POPs, implants and injectables are appropriate regardless of infant feeding choice. They can be administered immediately post-partum in bottle-feeding women, but should ideally be postponed for 6 weeks in breast-feeding women. It is best to insert IUDs within 10 minutes of delivery of the placenta, in order to minimize the risk of IUD expulsion. Insertion immediately after expulsion of the placenta requires special training, and expulsion rates are reduced with the insertion experience of the practitioner. Breast-feeding is not associated with an increase in IUD expulsion or uterine perforation, and it is associated with fewer removals for bleeding or pain. Tubal sterilization is safe, convenient and cost-effective when performed immediately after delivery, but it requires extensive counselling and fully informed consent prior to the onset of labour to avoid potential regret over post-partum tubal ligation. If the procedure is performed immediately, any effect on the establishment of lactation may be minimized. LAM is a method that can only be used by breast-feeding women. It may prove to be a useful way to time the commencement of a second, less temporary contraceptive method. Natural family planning methods require a period of abstinence for the establishment and identification of the new symptoms of fertility. When LAM is used during this interval, the need for abstinence may be reduced significantly for breast-feeding women. Breast-feeding provides health benefits for the woman and her infant, as well as the best possible nutrition for the baby. The International Planned Parenthood Federation (1990) (among others) recommends that, 'As far as is practicable, all women should be advised and encouraged to breastfeed fully'. The infant feeding decision affects the choice of a contraceptive method, and this is an important reason for the woman's physician to be interested in her infant feeding choice.

Lactation, nutrition, and postpartum amenorrhea in lowland Papua New Guinea

Prolonged on-demand breast feeding is known to delay the resumption of postpartum ovarian cyclicity. At present, however, little is known about the factors that influence the effectiveness of breast feeding as a natural contraceptive. Here, I examine the effects of maternal nutritional status on the duration of postpartum amenorrhea in two socioeconomic groups of Au forager-horticulturalists of lowland Papua New Guinea. Although women in both groups continue to breast-feed their offspring for approximately three and one-half years, well-nourished wage-earning Au women experience their first postpartum menses just over one year earlier (median = 12.5 months) than their more poorly nourished traditional counterparts (median = 26.6 months). Probit analyses are used to demonstrate that, even after controlling for time since delivery, maternal age, parity, and supplementation of infants' diets, the duration of postpartum amenorrhea is significantly (p < 0.05) negatively associated with indexes of maternal fat mass. No association between indexes of maternal lean body mass and the duration of postpartum amenorrhea were found. The results of this study suggest that components of maternal nutritional status, in particular, adiposity, play an important role in influencing fecundity in human populations.

Modern intra-uterine devices

Modern intrauterine devices (IUDs) provide effective, safe and long-term contraception and could be recommended to most women. The mechanism of action of an IUD is still not fully understood, but most recent research suggests that copper-IUDs as well as hormone-releasing intrauterine systems (IUSs) prevent conception. In women in mutually monogamous relationships the risk of PID is low and related to the insertion procedure. IUD/IUS use should be discouraged if there is a suspicion of increased risk of sexually transmitted disease. The risk of ectopic pregnancy is extremely low if modern, highly effective IUDs/IUSs are used. Copper-IUDs increase menstrual blood loss by around 50%, whereas hormone-releasing IUSs substantially reduce menstrual blood loss. Careful patient selection and counselling are the most important tools in order to provide acceptable and safe IUD use.

Prolactin response to suckling and maintenance of postpartum amenorrhea among intensively breastfeeding Nepali women

The aim of the study was to determine the association between PRL responses to suckling and maintenance of postpartum amenorrhea among breastfeeding mothers. Three blood spot samples (5, 30, and 50 min following a timed nursing bout) were collected from 71 intensively breastfeeding Nepali women for PRL determination. Maternal age, BMI (weight/height2), menstrual status, caste, infant age, nursing bout length, and duration of supplementation were recorded at time of sample collection. Independent and paired t tests, linear regression analyses, and general linear models were used to evaluate differences between cycling (n = 36) and amenorrheic (n = 35) women and associations among variables. Logistic regression analyses were used to relate PRL measures to the odds of maintaining lactational amenorrhea. Amenorrheic breastfeeding mothers had higher (P < .001) PRL levels at all 3 collection times than cycling breastfeeding mothers, and PRL levels declined with time since birth (P < 0.05). The odds (OR) of having ceased lactational amenorrhea was significantly higher (OR = 5.0, 95% Cl = 1.3-19.9) among mothers with lower PRL levels (< or = 10 ng/mL) at 50 min post-sucking, and PRL at 50 min showed a significant dose response relationship with menstrual status. The association between 50 min PRL levels and lactational amenorrhea appears to be independent of time postpartum, maternal age, BMI, nursing bout length, and duration of supplementation. Among intensively nursing women, maintenance of elevated PRL levels across the interbout interval increases the odds of maintaining lactational amenorrhea.

Clinical outcomes of two early postpartum IUD insertion programs in Africa

Postpartum IUD insertion programs are new to Africa and few have been carefully evaluated. Also, data on the clinical outcomes of postpartum IUD insertions using the Copper T 380A IUD are sparse. Therefore, we conducted a study to evaluate introductory postpartum IUD programs using the Copper T 380A IUD in Kenya and Mali. Postpartum IUD acceptors in Kenya (n = 224) and Mali (n = 110) were interviewed at baseline and at 1, 3, amd 6 months after delivery. We compared expulsion, medical removal, and discontinuation rates by insertion characteristics in each country. Six-month cumulative expulsion rates were lower for immediate insertions (those within 10 minutes of placental delivery) than for late insertions (generally between 10 minutes and 72 hours after placental delivery) in both Kenya (0.01 vs 0.05) and Mali (0.15 vs 0.27). Medical removals occurred in 1% and 7% of Kenyan and Malian acceptors, respectively, while pelvic infections were rare in both countries (< or = 2%). Differences in 6-month cumulative discontinuation rates between immediate and late insertions were not significant in either Kenya (0.05 vs 0.07) or in Mali (0.24 vs 0.32). This study suggests that postpartum IUD insertions can be performed safely with acceptable expulsion rates in African settings. Previous studies of other IUDs showed that expulsion rates are lower for immediate insertions compared with late postpartum insertions. This study suggests that these findings can be extended to the Copper T 380A IUD.

Mother-to-child transmission of human immunodeficiency virus type 1

A great deal of progress has been made in our understanding of mother-to-child transmission of HIV-1. Standardization of case definitions and transmission rate calculation methodologies, and a broader array of diagnostic options for detection of infant HIV-1 infection, will enhance our ability to evaluate and compare cohorts worldwide. In the next decade, several intervention studies should be completed. Carefully designed intervention studies have the potential both to determine which interventions are effective as well as to add to our understanding of vertical transmission of HIV-1. Regional differences in vertical transmission rates reflect a variety of viral, host, and obstetric factors. Intervention strategies will probably need to be regionally designed, taking into consideration these factors. Further research on timing and correlates of vertical transmission is necessary to determine the extent to which specific clinical trials can be extrapolated to public health policy.

Proximate determinants of fertility in eastern Uttar Pradesh

Our main objective here is to examine and discuss the effects of some sociocultural and economic factors on the proximate determinants of fertility in rural areas of eastern Uttar Pradesh (population more than 40 million persons). The region is known for its present demographic trends because the crude birth, death, and infant mortality rates are among the highest for India. The determinants considered are age at marriage of female, postpartum amenorrhea (PPA), fecundability and sterility, and menopause. The sociocultural and economic factors studied are caste, education, breast-feeding status, and social status of the currently married females in the reproductive age group. The study population is predominantly Hindu, among whom caste is a strong indicator of socioeconomic conditions. The average age of the female at return marriage (RM) is below 18 years in each religion or caste group but has been increasing over time. Median durations of breast feeding and PPA differ significantly among various socioeconomic and demographic subgroups. These are longest in scheduled castes and shortest in upper-caste Hindus. As the social status of the household increases, the median durations of breast feeding and PPA decrease. The estimates of fecundability consistently decrease with age, whereas those of sterility increase with age after 35 years. The smallest estimate of sterility is 4%, corresponding to the 25-30-year age group in each religion or caste group. Occurrence of menopause is rare before age 35, and it increases with the age of the female irrespective of religion or caste. However, the risk is minimum for females in upper castes and maximum for those in scheduled castes.

Correlates of breastfeeding frequency among nomadic pastoralists of Turkana, Kenya: a retrospective study

Recent research has shown that significant variation in breast-feeding behavior exists among natural fertility populations, all of whom have been characterized as practicing "on-demand" breastfeeding. A number of recent prospective studies have contributed to a better understanding of breastfeeding structure and of its consequences for population differences in fertility. Currently, there is a growing interest in quantifying the complex environmental and biocultural interactions which influence that structure; in other words, in establishing an ecology of breastfeeding. In this paper, a carefully structured retrospective study of breastfeeding behavior among nomadic Turkana is used to identify environmental, biobehavioral, and socioeconomic factors associated with variation in breastfeeding frequency among Turkana women. In agreement with the results of a prospective study conducted as part of the same research, the age (growth) and physical development of nurslings show significant correlations with breastfeeding frequency. Maternal physical status, the depth of the maternal social network, and, to a lesser degree, rainfall patterns are also significant. All of these factors appear to influence breastfeeding through their effects on maternal participation in herding activities and related absences from camp. Finally, the study also presents new strategies for collecting and utilizing retrospective data, which are notoriously unreliable and difficult to classify according to operational definitions recently developed for prospective studies. Results of the present study suggest methods by which the quality and reliability of recall data may be enhanced.

Maternal mortality in a maternity hospital in Turkey

BACKGROUND

To determine the leading causes of maternal mortality in a large maternity hospital and to define priorities regarding this subject throughout Turkey.

METHODS

Retrospective, institutional study among 100,531 live births between 1983 and 1992.

RESULTS

Seventeen maternal deaths took place in this institution. Thus, the overall maternal mortality ratio was 16.9 per 100,000. The leading causes of maternal mortality were hemorrhage in seven (41.2%) and pulmonary embolism in six (35.3%) patients. The majority of deaths were observed in the 25-29 and 30-34 age groups and in patients with parity more than two.

CONCLUSION

The relatively low figure of 16.9/100,000 for maternal mortality may be seen as a promising health index. However, obstetric hemorrhage is still the leading cause of this series. Pregnant women less than 20 years old and greater than 35 years old, and grand multiparous women as well as women with hypertension and heart disease are at high mortality risk. The observation of such cases demands further efforts for improved obstetric care in the hospital and throughout Turkey.

Hmong cultural practices and beliefs: the postpartum period

The purpose of this study was to explore the cultural practices and beliefs of the Hmong in the postpartum period. Using the qualitative research method of in-depth interviewing, data were collected through semistructured interviews. A convenience sample of 52 childbearing Hmong women was interviewed with the help of Hmong interpreters. The interviews were audiotaped and transcribed for analysis. Data analysis revealed cultural practices and beliefs categories related to diet, rest period, appropriate clothing, breast feeding, and sex practices in the postpartum period. Implications for nursing include both cultural sensitivity and an understanding of such traditional practices, before suggesting or implementing any health-promotion activities.

Premature weaning in east Bhutan: only if mother is pregnant again

The relationship between breast-feeding and subsequent pregnancy in East Bhutan is examined, against the background of local attitudes to family planning. Ninety-eight mothers who had given birth 30-36 months earlier were interviewed. Semisolid supplementary feeding was introduced at a median age of 3 months. Median total duration of breast-feeding was 28 months, and day and night breast-feeding on demand was continued throughout. Median duration of postpartum amenorrhoea was 12 months, and was associated with the timing of the introduction of supplementary foods. There was a significant association between the occurrence of a subsequent pregnancy and early termination of breast-feeding. The relationships between breast-feeding pattern and pregnancy interval are complex, and their relative influence changes with time. During the first year postpartum, infertility during lactational amenorrhoea is important. During the second year there is a strong negative effect on lactation from the next pregnancy. The only important reason for ceasing to breast-feed within 2 years seems to be a new pregnancy.