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close this bookMaternal Diet, Breast-Feeding Capacity, and Lactational Infertility (UNU/WHO, 1983, 107 pages)
close this folder5. Family planning and its relation to nutritional well-being and to maternal and child health
View the document(introductory text...)
View the documentFamily planning in perspective
View the documentMaternal care
View the documentLactation and breast-feeding
View the documentFamily-planning technologies and side-effects on lactation
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Family-planning technologies and side-effects on lactation

5.9. As already indicated, sociological changes have removed, at least partially, traditional barriers to population growth, and our current way of life is making artificial contraceptive methods more and more necessary. Unfortunately, these can have side-effects that may affect early life and the well-being of women and children. The high-dose oestrogen-combined pill has, for example, been shown to have an inhibitory effect of lactation and is no longer in general use. There is general agreement, however, that pills with under 50 µg of oestrogens do not affect lactation, if introduced after lactation is fully established (see section 4.11.). There is, however, a need for this to be confirmed in the lesser-developed countries, as there is some argument about the size of the women in relation to drug dosage.

The effect of the pill on micronutrient metabolism and physiological needs also needs to be clarified(19). Recently, the mini-pill (progestin only) has been advocated as the best contraceptive during breast-feeding, but it has also been claimed that this can limit breast-milk output and hence may result in earlier than desirable weaning. Saint and Hartmann (unpublished data) have found that milk production was not depressed in mothers who began to take the mini-pill. However, there is a general belief by mothers in Perth that the mini-pill decreases milk production. Because of the crucial importance of long-term lactation to health and well-being in the developing world, this is clearly a problem that needs to be studied in greater detail.

For over 12 years injectable contraceptives, mainly Depo-Provera (depomedroxyprogesterone acetate, DMPA), developing and some developed countries. It has proved safe and efficient and has been shown to have either no adverse effect or an enhancing effect on lactation. It is also secreted in the milk and this makes some concerned about its effect on the baby. But it is not an easily assimilable substance and no adverse effect on babies has been noted in studies thus far.

Because the FDA and the British Committee on the Safety of Drugs have refused to approve the use of DMPA as a contraceptive, there is intense controversy about its use in developing countries. The only way to silence the critics is to produce more evidence on the safety and efficacy of the drug in use.

Some studies have reported that progestin alone by mouth or by injection enhances lactation. Choudhury (20) reported that DMPA when administered to lactating women at a dose of 150 mg, every three months significantly raised prolactin levels over a control group. He also observed that, while suckling increased prolactin levels in both groups, the difference was greater in women receiving the injection, indicating that the drug enhanced the release of prolactin in response to the suckling stimulus.

Zanartu et al. (21 ) also reported similar findings in Chile. They showed that at 12 months, 42 per cent of women on oral progestins were still breast-feeding, while all subjects from the control groups had stopped. Parveen et al. (22) in Bangladesh were unable to confirm this finding and they reported that DMPA did not significantly increase lactation and actually caused a decline in milk. Further studies are still needed.

The side-effects of hormone-based contraceptives have led many to favour more mechanical approaches, such as the coil, but this too can lead to nutritional problems through excessive bleeding in some women. Furthermore, there is the question of what happens to the copper released in women who have loops inserted during lactational amenorrhoea. The seemingly safest method from a health point of view, the condom, has in practice in high failure rate, mainly due to human error.