CHAPTER 6: Breastfeeding, Family Planning and Child Health - Final Comments

Miriam Labbok, Georgetown University, Medical Center, Washington DC, USA.

The world’s resources are limited. Therefore, we must look for synergy and mutual complementarity in our work to support the health and nutritional status of women and children. The mutual complementarity of nutrition and family planning for safe motherhood may be defined within the parameters of the “seven stages of woman.” There are seven periods in a woman’s life (Table, next page) when intervention is appropriate, available, and tested:

i) Infancy: During infancy, breastfeeding provides excellent nutrition, immune system stimulus, and growth factors, as well as providing rapid involution of the postpartum uterus and a period of time for maternal calcium storage. Breastfeeding also helps protect infants against chronic diseases such as diabetes and certain cancers.

ii) Childhood: Girl children need good nutrition to achieve adequate stature so that, as they approach reproductive years, their ability to function in society as well as their ability to have safe deliveries will be enhanced.

iii) Adolescence: Young women must eat well to achieve full stature and must delay conception until long bone growth is completed. Again, the achievement of full stature and adequate energy stores are important both for the health of societal and procreative functions.

iv) Pregnancy: Nutritional intake is necessary that is adequate for maternal health, fetal growth, and storage for lactation.

v) Lactation: Breastfeeding supports maternal health. Maternal calories may be derived from relatively inexpensive foods and the mother will still produce excellent human milk for her infant.

vi) Recovery time: New studies show that the period of weaning is a time for renewing calcium stores. Clearly this time is created by appropriate child spacing. A breastfeeding woman may use the Lactational Amenorrhoea Method (LAM) as an introductory method, giving her time to select a complementary method needed to create a healthy 3-4 year birth interval.

vii) Post fertile time: The elders teach the social and cultural norms. Their interest in their daughters’ and daughter-in-laws’ health and well being dictate that they be informed and educated on these issues.

The mutual complementarity of breastfeeding and family planning extends well beyond the postpartum period, having an impact throughout life. Breastfeeding contributes to child spacing in populations by prolonging the average interval until the next pregnancy. However, it also contributes directly as LAM. LAM is an introductory family planning option. It is part of informed choice and allows a period of time to select and obtain a complementary method. It is a door opener for those who would or could not previously consider family planning. Furthermore, LAM increases optimal breastfeeding. Dr. Alfredo Perez’ work in Chile confirms that promotion of breastfeeding and LAM increases the percent of women exclusively breastfeeding, the percent of exclusive breastfeeders that are amenorrheic, and the frequency of breastfeeding among exclusive breastfeeders.

Conversely, family planning also contributes to the duration of breastfeeding worldwide, since pregnancy is the number one or two reason reported for cessation of breastfeeding. Therefore, family planning protects sustained breastfeeding and sustained weaning. Recent research by R. Martorell and K. Merchant calls for a period of non-pregnancy for six months after cessation of lactation to ensure complete maternal recovery. To achieve this six-month period of recovery necessitates family planning.

Programmatically, breastfeeding for family planning is sustainable; maintenance is not commodity dependent. Women believe in it, and it has been shown to be doable. In Ecuador, women attending CEMOPLAF clinics may and do choose LAM and use it successfully. Family planning and breastfeeding may well be combined in service programmes. This is more likely to happen if family planning programmes understand the linkage and contribution of breastfeeding to child spacing.

The obvious complementarity of population and nutritional programming also is often ignored. Worldwide, food supplies are often stretched to meet the needs of a rapidly increasing population, even accounting for the issue of mal-distribution. Within countries we often see the influence of population pressure on the carrying capacity of the land, with environmental disasters resulting.

In summary, we must conclude that there is a synergy between nutrition and population growth, that intervention is possible at seven stages in a woman’s life, and that breastfeeding, with its fertility impact, especially with LAM, serves as a cornerstone of the complementarity with its multiple positive health effects and with its role in linking the generations.

Seven Stages of Woman
	STAGE	INTERVENTION
*	Infancy	Breastfeeding and child spacing
*	Childhood	Adequate nutrition and support
*	Adolescence/Young adult	Nutrition and Family Planning
*	Pregnancy	Nutrition
*	Postpartum	Breastfeeding and LAM
*	Recovery	Weaning and complementary family planning
*	Post fertile years	Education on breastfeeding nutrition and family planning

Barry Edmonston, Population Studies Center, The Urban Institute, Washington DC, USA.

Breastfeeding and contraception are the two principal determinants of fertility in the developing world. Numerous researchers have shown that extended breastfeeding promotes prolonged postpartum amenorrhea and, as a result, longer birth intervals. In developing countries with low contraceptive use, breastfeeding is the primary factor affecting birth intervals and overall fertility. For this reason, there is great concern about decreases in the poorer countries that would both increase fertility as well as increase the likelihood of infant morbidity and mortality. In countries where contraceptive use is relatively high, breastfeeding durations are generally shorter.

Relationship of Breastfeeding and Contraceptive Use

To gain an understanding of the relative impact of breastfeeding and contraception on fertility, it is necessary to look at the relationships within the context of socioeconomic development and family planning programmes. Prior research on the effect of breastfeeding and contraception on fertility has usually been at the individual level. Individual level studies, however, have usually lacked information on a wide variation of social and economic conditions and family planning efforts. An alternative approach is to examine national level data, recognizing that national level data precludes examination of the distribution of individual responses.

I report in this presentation on national level data for 100 developing countries, using data on the median length of breastfeeding and contraceptive rates in 1982. Our data also includes measures of family planning programmes, socioeconomic development and related variables - for 1982 - and estimates of fertility and contraceptive prevalence rates in 1990. These data represent comprehensive, up-to-date estimates for the impact of breastfeeding and contraception on fertility in the developing world.

Regarding breastfeeding and socioeconomic development, the simple regression equation (Breastfeeding = 14.4 - 2.9 * Socioeconomic Development, r = .75) for 100 developing countries suggests a close relationship between improved socioeconomic conditions and decreased duration of breastfeeding. These data agree with numerous research papers on this topic.

Regarding contraceptive use and socioeconomic development, the simple regression equation (Contraceptive Prevalence + 23.4 + 9.7 * Socioeconomic Development, r = .73) indicates a strong relationship between increased socioeconomic development and contraceptive use.

Comparing the median duration of breastfeeding and contraceptive use, the inverse relationship (r = .64) suggests that these two factors may be complementary at the national level. However, the relationship evidently depends on the overall national fertility levels. In 37 moderately low fertility countries (TFR less than 5.0), the association between breastfeeding duration and contraceptive use is moderately strong (r = .49). In the 63 high fertility countries (TFR equal to or greater than 5.0), the association is somewhat stronger (r = .58).

Is the relationship between breastfeeding duration and contraceptive use complementary? In this case, I take the meaning of complementary to be that the processes are inherently inversely related, that contraceptive use increases as breastfeeding decreases. This is an important concern for family planning programmes because a complementary nature to the relationship between breastfeeding and contraception would imply that breastfeeding would decrease as family planning successfully increased contraceptive use. What impact, if any, does family planning programmes have on breastfeeding? As contraceptive use increases, how much decrease in breastfeeding generally occurs? And, taking breastfeeding and contraceptive conditions into account, how have fertility declines occurred in recent years?

Contraceptive Prevalence Rates, 1982

Examining the factors related to contraceptive prevalence, we find that family planning programme effort is positively and strongly related to increased contraceptive prevalence. Similarly, improved socioeconomic development is strongly associated with higher levels of contraceptive prevalence. Moreover, we find that breastfeeding duration is negatively related to contraceptive use, taking family planning programme effort and socioeconomic development into account. Thus, there is evidence that longer duration of breastfeeding, other factors being equal, is associated with lower levels of contraceptive use.

Median Breastfeeding Duration, 1982

Examining the factors related to national durations of breastfeeding, we find that family planning programme effort does not have a statistically significant effect on breastfeeding. Indeed, in our analysis, holding all other factors constant, it appears that countries with stronger family planning programmes have a net impact that decreases breastfeeding duration.

Socioeconomic conditions have a strong negative effect on breastfeeding duration. As socioeconomic development proceeds, the median duration of breastfeeding declines.

The net effect of contraceptive prevalence shows a statistically significant negative influence on the median duration of breastfeeding. All other factors being equal, increased contraceptive prevalence is associated with decreased breastfeeding. This suggests that there is a complementary relationship between contraceptive use and breastfeeding duration at the national level. Controlling for other factors, including family planning programme effort and socioeconomic development, suggests that breastfeeding and contraceptive use have a negative association. But how important are these two factors for overall fertility levels? If both contraceptive use and breastfeeding duration were equal partners in a complementary relationship, we would expect that each would have similar impacts on overall national fertility levels.

Total Fertility Rates, 1982

Examination of the factors determining national fertility levels shows that contraceptive use and breastfeeding duration do not have equal impacts. The proportion of women in the childbearing years who use modern contraception is the single most important variable affecting national fertility levels. Contraceptive use has a strong inverse relationship with fertility levels, taking other factors into account. The effect of breastfeeding duration on fertility levels, however, is weak and is not statistically significant. Breastfeeding does not have an important effect on fertility levels, when measured at the national level and when taking other factors into account.

Conclusions

1. Breastfeeding and contraceptive use appear to be complementary factors in national data, as they have been found to be in prior individual level studies. Both breastfeeding and contraception are affected by socioeconomic development. However, family planning programme effort is apparently related to contraceptive use, and not to breastfeeding duration.

2. The role of breastfeeding and contraception do not appear to have a complementary role in their affects on fertility at the national level. This suggests that there is not an “automatic” inverse relationship whereby contraceptive use increases as breastfeeding declines. Therefore, fertility would increase as breastfeeding declines unless family planning programmes encourage the greater use of contraception.

3. Both socioeconomic conditions and family planning programme efforts work most effectively together in promoting increased contraceptive use. These results indicate that countries experiencing socioeconomic development can promote more rapid fertility decline by coupling development with an effective, strong family planning programme.

These results from national-level data indicate that a strong family planning programme has very little effect on breastfeeding duration. The policy implication seems clear: if a government wants to encourage its citizens to reduce fertility, it should pursue policies of social and economic development (as most countries would do regardless of population goals) and it should implement an aggressive family planning programme. National-level data indicates that breastfeeding duration declines with socioeconomic development. Although breastfeeding reductions have important health consequences, these data do not suggest that breastfeeding declines have a strong positive impact on fertility.

Beverly Winikoff, The Population Council, New York, USA.

In these comments I will try to bring forward some ideas about where the “disagreements” between family planning and breastfeeding come from and what can be done to integrate these two issues on a programmatic level.

In the first place, there seems to be no doubt on any side or in anyone’s mind about the major, positive effects of breastfeeding on both infant health and on fertility reduction. Nonetheless, the effects of breastfeeding operate differently with respect to each of these outcomes. One difference is that the fertility-reducing impact of breastfeeding can be replaced by technology (at least in theory), while the health benefits cannot be totally replaced in any environment.

(Parenthetically, data presented earlier in the day by Sandra Huffman suggest that, even with respect to fertility, there may be some problems. As she pointed out, birth spacing is longer, on average, in low contraceptive prevalence countries than in high contraceptive prevalence countries!)

In any case, the fact that some benefits of breastfeeding are more technologically replaceable than others, on an individual level, may contribute to tensions between breastfeeding and family planning advocates: family planning advocates may conclude that breastfeeding is totally replaceable whereas those focused primarily on breastfeeding will view the health effects as non-replaceable even if the fertility effects are replaced.

Another aspect of this discussion relates to programme functioning. I want to elaborate here, a little bit, on why breastfeeding advocates may have complained about family planning programmes in the past.

I emphasize here the word programme because I believe that this is where the problem lies: not on an intellectual, theoretical level or on an individual level, but on a programme level. It seems to me that there are two main issues here, and they both revolve about programme implementation:

a) Family planning programmes have in many places urged contraception on women when it is not yet biologically necessary, perhaps against the preferences of mothers and perhaps limiting mothers’ options, and

b) Family planning programmes have often failed to take into account, not only the importance of lactation, but even underlying the existence of lactation among clients. In many programmes, two-thirds to three-quarters of the clients are lactating women! Yet, programmes often totally lack special attention to (or even mention of) the special needs of lactating women. This is true in respect to the educational materials available for clients; to the counselling that is given on a one-to-one basis; and to the methods available at clinics. This often means, in the end, that methods inappropriate for lactating mothers and/or detrimental to lactation itself may be offered.

I should add here that a major problem is the technology-driven nature of the choices available to lactating women. Virtually all “modern methods” are stated to be optimally applied during menstrual bleeding. Since lactating women often request contraception when they are still amenorrheic, they may not receive any of the “modern methods” available. This applies to oral contraceptives, IUDs, and implants! Thus, we have, by programme norms and technology, restricted or made difficult the provision of effective contraception to lactating women. Women who are not bleeding are often asked to return at a later - often much later and unknowable - date when they have resumed menses. The result is that many women are essentially offered a choice between a) continuing to breastfeed or b) contraception. I believe that we need to rethink the ways we use existing methods - and the norms for the use of those methods - especially for lactating women and also to develop new methods especially for lactating women that do not have similar restrictions for optimal use.

Having said all this, I believe, nonetheless, that breastfeeding promotion should not be seen in opposition to family planning. The two are not opposing but clearly complimentary. We have already seen how they are biologically complimentary. At the individual level, they are also complimentary. In terms of mothers’ own needs, desires, and goals, we can say at least the following things:

a) One thing mothers care about desperately is the survival and well-being of their children, and for this, breastfeeding is irreplaceable.

b) Another thing women want very much is not to have more children than they can care for properly, and for this, family planning programmes are needed.

I offer some conclusions about programme functioning from these thoughts:

i) It is clear that no matter how much we value breastfeeding, breastfeeding cannot substitute for family planning programmes.

ii) Family planning programmes must provide a full range of options for breastfeeding women, both as to timing and choice of method.

iii) It is, hence, urgent that family planning programmes (and those responsible for the policies of family planning programmes) recognize, understand, and support the importance and goals of breastfeeding promotion including, when necessary, revising practices and norms within programmes.

iv) Finally, family planning programmes need to remember the child, at least, in part, because the child is also the center of attention of the postpartum mother.

Some of the bad feeling between “family planning” and “breastfeeding” may be resolved by the realization that family planning is not a technology. It is a life strategy. Contraceptives are technologies. Family planning is what people do to plan births.

Breastfeeding can be an important component of family planning. But it cannot replace contraceptives. (Indeed, the fertility-reducing effects of breastfeeding extend beyond the period of amenorrhea but not reliably; therefore, as a strategy breastfeeding is not effective beyond amenorrhoea.) A holistic and realistic family planning programme needs to support women and families in the strategies they choose to plan births, including using breastfeeding as part of an overall plan.

At the same time as family planning programmes need to remember the importance of the baby, nutrition programmes need to remember the centrality of the mother to her children and husband, to production and income in the family, and particularly to her newborn.

Feeding the mother almost always makes more sense for mother’s and baby’s health (and programmatically) than supplementation directed at young infants. As Roger Short’s paper points out, the mechanisms that prevent ovulation in lactating work via neuroendocrine, and non-nutritional, pathways. After much research, we can now feel comfortable that feeding mothers will not have the negative effect of reducing lactation’s inhibition of ovulation.

No doubt, there have been strains between breastfeeding and family planning. (These are perhaps symbolic of potential, but rare, conflicts between maternal and infant well-being). Nonetheless, the need for both nutrition and family planning programmes is great. They need to, and can, support each other. For them to do so, policy-makers, professionals, and managers need to understand the importance of each others’ goals and incorporate positive and supportive elements in programmes.

Additional comments on service delivery

There are basically three categories of lactating women

i) Those immediately postpartum (often in service delivery institutions, e.g. hospitals),

ii) Interval postpartum women who have experienced the return of menstruation, and

iii) Interval postpartum women who are still amenorrheic.

Programmes need to think separately about these three categories of women, as they have different needs.

In particular, family planning, health and nutrition services have failed women in several ways:

i) There is a lack of counselling on how to manage breastfeeding successfully. There is lack of counselling on amenorrhea, what causes it, how to use it as part of a family planning strategy, and when to initiate other contraceptives for women who do not want contraception earlier than the return of menses.

ii) There is a lack of training for health workers to understand the importance of supporting breastfeeding and of providing proper advice to breastfeeding women. There is also a lack of information and education for these same workers regarding the effectiveness and feasibility of incorporating breastfeeding into a child-spacing plan.

iii) There is a lack of linkage of prenatal and delivery services. This makes difficult (if not unethical) the provision of immediate postpartum contraception when women have not been counselled and informed correctly during prenatal care.

iv) There are frequently no methods available specifically appropriate for lactating women. In particular, the progestin only pill is not available in many programmes that do supply oral contraceptives.

v) There are unrealistic norms for the provision of family planning technologies to amenorrheic breastfeeding women that involve the issue of initiation during menstrual bleeding mentioned above.

Service delivery issues for nutrition include expanding the possibility of supplementing the mother and specific referral to family planning for breastfeeding when menses have returned. Regrettably there are still nutrition programmes that supplement babies. Some distribute powdered milk or discounted formula products, in which case the nutrition programme itself is responsible for undermining breastfeeding.

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