CHAPTER 1: Summary of Proceedings

John Mason and Mahshid Lotfi, ACC/SCN, Geneva

Population growth has vital consequences for nutrition - ranging for instance from more mouths to feed from finite resources, to environmental degradation from intensive and inappropriate land use to meet nutritional needs. The food-people-resources balance, now and in the future, is a critical determinant of the quality of life. At the same time, programmes in family planning, health and nutrition are widely pursued to improve maternal and child health, with expected longer-term demographic effects.

The ACC/SCN decided to hold its annual symposium for 1991 on “Nutrition and Population”. Following views of the SCN’s Advisory Group on Nutrition, it was decided to focus on questions of direct relevance to programmes. This in turn came to concentrate on the triangle of breastfeeding, birth spacing, and infant nutrition and maternal health. The importance of macro-level issues of food-population-resources remain well-recognized, but such a crucial topic required more time and resources than were available. Considerations relating to programmes were felt to be more immediately applicable by the UN and donor agencies.

The Symposium on “Nutrition and Population” was hosted by UNFPA at their Headquarters in New York, in February 1991. The Symposium was chaired by Ms K. Trone, Head of the UNFPA Regional Office for Latin America. Three papers were presented. Dr Sandra Huffman, Center to Prevent Childhood Malnutrition, Bethesda, presented a paper on “Nutrition and Family Planning Linkages: What More Can Be Done?” Issues on “Breastfeeding, Fertility and Population Growth” were introduced by Professor Roger Short, Monash University, Melbourne. The effects of repeated cycles of reproduction were discussed in a paper on “Reproductive Stress and Women’s Nutrition”, by Professor Reynaldo Martorell, (at the time of Stanford University and now at Cornell, USA) and Dr Kathleen Merchant (Cornell). Dr Prema Ramachandran submitted a paper entitled “Nutrition and its Influence on the Mother-Child Dyad” but unfortunately could not attend the Symposium. Discussants for the papers included Dr Charlotte Gardiner, Director of Maternal and Child Health (Ghana), Professor Barry Popkin, Carolina

Population Center (USA), Dr Soledad Diaz, Institute of Reproductive Medicine (Chile), Dr Miriam Labbok, Georgetown University (USA), Dr Beverly Winikoff, Population Council (USA), and Dr Barry Edmonston, Urban Institute (USA), later. The Symposium papers, discussions and related literature form the basis for this article.

Breastfeeding, Birth Spacing and Nutrition

Breastfeeding exclusively for four to six months from birth is of well-known importance for infants’ nutrition. Breastfeeding delays the return of fertility in the mother, thus contributing to longer birth intervals. Birth spacing allows continuation of breastfeeding for the child’s benefit and has other advantages to mother and child. Better nutrition promotes infant and child survival, which in turn tends to increase birth intervals. And all these processes benefit the health and well-being of the mother. This is illustrated in Figure 1.

Fig. 1. Interactions of breastfeeding, birth spacing and nutrition.

The interactions are finely-tuned, developed as part of human evolution. They are worth understanding - some only recently worked out and still being researched - and are discussed in more detail below. A practical message emerged from the Symposium, at which the different disciplines present found (to their slight surprise) they were talking much the same language about the same conclusions from different starting points: support to breastfeeding should be part of population and nutrition and health programmes. Indeed these could be better integrated. As Dr Huffman pointed out “... instead of spending another 20 years justifying the link between family planning and nutrition activities, we may have more success if we start with an intervention that integrates both nutrition and population issues: breastfeeding promotion”.

Breastfeeding for Infant Health and Nutrition

Figure

The benefits of breastfeeding are constantly becoming better understood. Breastfeeding reduces exposure to pathogens in the environment, gives protection by immunization, provides anti-bacterial and antiviral substances, and supplies the correct mix and density of nutrients; it also has very little direct cost. Bottle feeding, which is the usual alternative in early life, tends to be contaminated, non-ideal in terms of nutrients, and not affordable to many families in poor societies.

The newborn infant’s needs and the mother’s ability to provide for them, not only to nourish but to protect¹, are closely linked. A continuity has evolved to bridge the gap between the safety of the womb and the shock of post-natal life, when the gut suddenly replaces the placenta as an interface with the world. The immature infant gut is adapted to the nutrition and protection of breast milk. Antibodies from colostrum and breast milk protect the gut and provide some immunity against other infections. Antibiotic activity in breast milk proteins is being shown to be selective against precisely certain of the harmful bacteria that cause infantile diarrhoea. The protein of breast milk is tailor-made to the infant’s needs, and is quite innocuous unlike many non-human proteins. The hazards of sudden exposure of the fragile gut to foreign materials is now being realized. The gut matures in the first few months - the recommendation for 4-6 months’ exclusive breastfeeding is no accident. “It is still true to say that the artificial feeding of our infants has been the largest uncontrolled clinical experiment in human history².”

Data collected during the 1970s by the World Fertility Survey show an overall historical decline in breastfeeding both in terms of its initiation and duration. In fact, a steady decrease had been observed by the early twentieth century. In Sweden, reduction in the rate of babies being exclusively breastfed at 2 months from 85% in 1944 to only 35% by 1970 was one example of this continued downward trend. Similar statistics are available for other developed and some urban areas of developing countries through the WHO Collaborative Study (Contemporary Patterns of Breastfeeding, WHO, 1981³). This changing pattern of infant feeding has been attributed to “the demands of modern life” and industrialization, as alternative means of feeding became available to public. According to Dr Short at the SCN Symposium “with the advent of Industrial Revolution, the artificial feeding of infants with paps and gruels became commonplace throughout Europe, and this was given an added boost by the growing availability of cow’s and goat’s milk and the development of feeding bottles with rubber teats”. But breastfeeding decline and increased use of artificial feeding did not immediately result in population increase. “The potential upsurge in fertility that this increase in artificial feeding might have created” in Dr Short’s view “was largely counteracted by the staggering increase in infant mortality resulting from these practices”. He notes that, for example, in London during the late 18th century almost 50% of children had died by the age of 2, and in Dublin during the same period artificial feeding resulted in the death of 99.6% of over 10,000 children admitted to the Foundling Hospital, mainly as a result of diarrhoea. In Dr Short’s opinion by improving formulation and hygienic aspects of artificial feeding, mortality in most developed countries decreased, but left a high potential for fertility in women who had abandoned breastfeeding.

But is breastfeeding decline an inevitable result of modernization? The WHO Collaborative Study while confirming earlier results on breastfeeding’s declining trend (particularly in cities and urban slums), found some notable exceptions. Thanks to efforts to encourage breastfeeding through health services, education and supportive measures to mothers, the number of Swedish mothers initiating breastfeeding actually increased in 1976 to 93%, and 50% were still breastfeeding at 4 months although with regular supplements. This and other examples from Australia, Eastern Europe, Scandinavia and the USA shows that the decline in breastfeeding is not an unavoidable result of industrialization if the necessary measures for its promotion and support are taken. In most cases, breastfeeding decline accompanied the society’s modernization, as noted by Berg and Brems⁴, “at a time when breastfeeding was not advocated in either medical or patient education”.

Breastfeeding and Birth Spacing

Figure

Breastfeeding directly contributes to increased birth intervals by tending to reduce the resumption of fertility in the mother. This is more pronounced with exclusive breastfeeding. It is related to “lactational amenorrhoea”, and has led to new recommendations for decisions by individuals on family planning. The SCN Symposium stressed that lactational amenorrhoea is particularly relevant to providing an opportunity in the first months after birth for counselling women on modern family planning methods, and that it is complementary to these not a substitute.

A major step forward was recently taken when an international group of experts met in Bellagio, Italy, in August 1988 to review the evidence for the contribution of breastfeeding to family planning. The conclusion: “Breastfeeding provides more than 98% protection from another pregnancy in the first six months post partum, if the mother is fully or nearly fully breastfeeding and has not experienced vaginal bleeding after the 56th day post partum”. Recent research by Dr Short and associates on a well nourished group of Australian women breastfeeding their babies examined the probability of becoming pregnant over a 24 month period after the birth. This showed that if modern contraception was adopted only after lactational amenorrhoea ceased, the cumulative probability of becoming pregnant over the 24 month period would have been only 13%⁵.

Lactation delays the resumption of fertility by physiological (neuroendocrine) mechanisms. Briefly, suckling at the breast affects hormone secretion that maintains the production of milk (prolactin) and, probably through other pathways, depresses the hormone levels necessary for fertility (inhibiting ovulation and producing amenorrhoea). The frequency of suckling is important, increasing milk synthesis and secretion and decreasing chances of fertility. An inhibitory peptide is secreted by the mammary alveoli to stop further milk synthesis if the alveoli are not emptied regularly. This, as Dr Short puts it, makes the breast a “supply meets demand organ”, and explains why exclusive, and not so much partial, breastfeeding has the potential to reduce fertility and increase birth intervals and child spacing. The six month period after birth is crucial both for mother and infant, and illustrates the closeness of the mother’s and infant’s needs.

The WHO Collaborative Study from 1976-78 indicated a consistent and close relationship between the duration of breastfeeding and the duration of post-partum amenorrhoea. About 85% of the total variability in the return of fertility could be attributed to reported differences in breastfeeding duration. The same conclusions were reached in many other studies, e.g. Bongaarts⁶, who demonstrated that the duration of breastfeeding explains most of the variation in the duration of post-partum amenorrhoea. Another factor claimed to influence the length of lactational amenorrhoea has been the nutritional status of the mother, with shorter amenorrhoea period in better nourished women. Dr Short, however, reported that in their studies and those of some others, women in developed countries, on an optimal plane of nutrition, still achieve prolonged periods of lactational amenorrhoea.

Such observations have been used to look at questions like the overall influence of breastfeeding practices on population growth, via its contraceptive effect; and the extent to which breastfeeding offsets contraceptive needs. It has been claimed that lactational amenorrhoea is the single most important variable among the proximate determinants of natural fertility⁷. A World Bank analysis⁸ has pointed to the significant effect of breastfeeding in reducing the total possible number of births to a great majority of the couples in developing countries who do not use modern contraceptives. Projections by Family Health International show that a 25% reduction in breastfeeding duration in five African countries would increase total fertility rates by 12%, and that halving the duration of breastfeeding could mean a 26% rise. Corresponding figures for 12 Asian countries are 11% and 23%⁹.

A major step towards reducing the excessive fertility that is currently fuelling the population explosion, concluded Dr Short, would be to persuade both developing and developed countries to do their utmost to support and encourage prolonged breastfeeding. Breastfeeding, thus, in addition to its nutritional and health values needs to be promoted and supported as a child-spacing strategy. Longer birth intervals will reduce total numbers of children per women as well as benefiting both mothers and their children in the other ways described here.

Birth Spacing Benefits Child Nutrition

Figure

A delay of two years or more before its mother becomes pregnant again is important for the baby’s welfare and indeed survival. One of the earliest observations of malnutrition was of kwashiorkor as the disease of the displaced child - displaced by a new pregnancy. Short birth intervals have often since then been related to malnutrition. They are also related to infant and child mortality - although this operates in both directions, as discussed in the next section. Nonetheless, anything that prevents too-short birth intervals will benefit the youngest child - including family planning programmes directly, and as an additional indirect result of breastfeeding. As Dr Huffman pointed out in her paper, birth intervals of less than two years have frequently been associated with low birth weight, high infant mortality, growth retardation, high morbidity and inferior nutritional status.

The advantage to the child of adequate birth interval goes beyond maintenance of breastfeeding. The burdens of time and stress on the mother tell on her ability to nurture the family, and these are worsened by too-close pregnancies. Her health itself may suffer, as discussed later - a serious blow particularly to poor families with many children.

This stresses another way in which too-short birth intervals are disadvantageous - through family economics: more mouths to feed with the same resources, or probably less as the mother contributes in cash or kind into the family income. Part of the motivation for short birth intervals, ironically, may itself have an economic perspective, in ensuring for old age, encouraging rapid births to reach large desired family size. In a sense this contributes to a vicious circle, as more births will be wanted when mortality is high: reductions in child mortality are needed to motivate birth spacing.

Short birth intervals thus are to no one’s advantage: the future infant, the current infant, or the mother herself. “Adequate child spacing can mean the difference between complete recuperation of the mother and depletion of her physical resources. It can also mean the difference between adequate care of the preceding child, including its continued breastfeeding, and early abrupt weaning from the breast due to a new pregnancy and hence the deprivation of maternal attention”¹⁰.

The health impact of family planning will clearly be greater if it has a specific effect on birth intervals. But a considerable number of the births prevented by family planning programmes are due to sterilization. “While family planning programmes have been more successful in reducing higher parity births, and terminating births through sterilization, they are not generally associated with increasing birth intervals” says Huffman. “Worldwide, over one third of effective modern contraceptive use is through sterilization. This, while preventing any further birth, is usually not associated with adequate birth intervals for the preceding pregnancies.”

Child Survival Affects Birth Spacing

Figure

A feedback is shown in Figure 1 from infant/child nutrition, through child survival, to birth spacing. This is important in the long-run, as part of the motivation for smaller family size, hence eventually reduced population growth rates. The link of nutrition to survival or mortality is clear. The effect of child mortality on birth spacing can act in several ways. As implied earlier, the death of a breastfed infant will tend to lead biologically to resumption of fertility. But conscious decisions may be made to replace the child as soon as possible - perhaps before the mother has recovered from the previous pregnancy. This decision can be based on the family’s desire to achieve a certain family size. Indeed the decision to have rapidly-succeeding pregnancies for this reason may be taken without experiencing a child-death in the family, if it is perceived that this risk is high, to insure against possible future deaths and reach the desired family size before the reproductive cycle of the family is complete. This, in turn, may well depend on the overall community perception of risk, influencing the family’s decisions.

Here too, we are dealing with a cycle that can benefit from deliberate intervention to break. In this case, for example, promoting infant and child nutrition and survival can gradually establish more motivation for longer birth intervals, hence acceptance of family planning.

Mothers’ Health and Nutrition

Figure

The consequences of frequent child bearing have been considered more often for the child than for the mother herself. Drs Martorell and Merchant gave evidence in their paper that spacing reproductive events is necessary for maternal recovery. Repeated reproductive cycles have been referred to as “maternal depletion syndrome”, but they proposed avoiding this term and regarding effects of reproductive stress on women’s health and nutritional status as a continuum. “The question is not whether or not maternal nutrition is affected by reproductive stress, but under what circumstances are effects noted and to what degree and in what aspects.”

A substantial proportion of women in developing countries are lactating and pregnant at the same time. This situation - perhaps not widely appreciated - is clearly likely to increase the stress on women’s health and nutrition. It is referred to as “overlap” by Martorell and Merchant, defined as two or more weeks of breastfeeding during pregnancy. The phenomenon has been reported to be common among women in a number of poor areas: 30% in Guatemala and Senegal, 40% in Indonesia, and as high as 70% in India (stressed by Dr Ramachandran¹¹ (in a paper prepared for the meeting). Although lactation is generally associated with post partum amenorrhoea, partly because of prolonged breastfeeding in many developing countries, perhaps as many as one third of all pregnancies occur in lactating women. This observation clearly has important implications for both family planning and breastfeeding practices, but here we focus on the impact of this phenomenon on women’s health and nutrition.

The effects of reproductive stress on mothers and infants were shown by Drs Martorell and Merchant using the data from an INCAP longitudinal study. They focussed on women actively exposed to different degrees of reproductive stress by carefully studying the period of overlap. Overlap was found to occur in 50% of a sample of 504 pregnant women. Two extreme situations were compared: the “least stressed” women (those with a recuperative interval of more than six months) and the “most stressed” ones (those experiencing an overlap duration of more than three months). Despite higher consumption of food supplements available freely to all women, the “most stressed” group had lower fat reserves (more pronounced earlier in pregnancy), and gave birth to lighter infants when compared to the “least stressed” mothers. While the emphasis of the paper was on mothers themselves, their results showed that reproductive stress also adversely affects the infant. It is interesting to note the results of the National Institute of Nutrition, India, in which pregnant and lactating women were under even greater stress: while women were similarly facing overlap of different degrees, they were not supplemented and their food consumption, as usual in poor areas, was similar to non-pregnant subjects (NIN, 1984/85 Annual Report). In reporting the results of these studies Ramachandran concluded that irrespective of the duration of lactation and period of gestation, women who continued lactating during their pregnancy had lower body weights than their non-lactating pregnant counterparts. Here too, the differences were more marked in the small group of those working women becoming pregnant in the first 6 months of lactation. Their babies had also lower birth weights.

These results pointed to the fact that overlap should be prevented and birth intervals need to be adequate. Using the fertility-inhibiting effect of exclusive breastfeeding, later followed by other family planning methods, another pregnancy can be planned at a more appropriate time and with reasonable spacing.

Integrating Nutrition and Family Planning Activities

The mutual benefits of breastfeeding and family planning programmes mean that they will be more successful if they are integrated. Both nutritional support and birth spacing have impacts on mortality reduction and nutritional status improvements. Breastfeeding is now recognized as a child survival strategy. Keeping a child alive is associated with preventing another birth, since the death of an infant is usually followed by another pregnancy. Some reasons for integration are shown in the box below.

Exclusive breastfeeding can be used to protect against conception in the early months after birth when lactation has induced amenorrhoea. Its contraceptive effect will however wane over time and therefore should not be regarded as a substitute to other family planning methods, but as a complement to them. Even with the gradual appearance of other contraceptive devices in the world market, exclusive breastfeeding has remained the only protection many women in developing countries have (whether due to non-accessibility or non-acceptability) against another untimely pregnancy. In 1975 it was stated that more births were averted in the third world countries by breastfeeding than by any modern method of contraception (Rosa¹²). But the fact is that many such women are not protected against pregnancy even when breastfeeding can no longer prevent fertility. These will benefit most from integrated programmes where family planning and breastfeeding promotion are offered together. Family planning programmes can increase their coverage and thus effectiveness by including many women who do not want to use contraceptives until menses have resumed, if they encourage these women to exclusively breastfeed.

Even if contraceptive supply and demand are not constrained - as in reality they often are - significant declines in breastfeeding may place greater pressure on family planning services than can, presently, be coped with. In this regard, breastfeeding can help to use scarce family planning resources more efficiently. But to achieve this effect, family planning programmes should take into account the local breastfeeding patterns and beliefs in order to promote and support breastfeeding, to achieve its maximum fertility-inhibiting effect. When the fertility regulating role of lactation is waning over time, or when more security is demanded, breastfeeding can be combined with other contraceptive methods that do not interfere with lactation. This needs to be accompanied by proper advice and encouragement. Nutrition programmes should similarly combine breastfeeding promotion with family planning messages, appropriate counselling and referrals. In other words, services devoted to maternal and child health should be in close coordination with family planning services.

Some examples given by Dr Huffman indicate that integration works well in practice. “In two breastfeeding promotion projects in Honduras and Guatemala, referrals are provided by breastfeeding counselors to family planning. In addition, exclusive breastfeeding is taught as a family planning method, with the signs of return of fertility taught to breastfeeding women... A recent study conducted in Honduras showed that combining the promotion of breastfeeding with the promotion of family planning can lead to increase in both... The project included the creation of combined breastfeeding and family planning clinics, along with training of health professionals and changes in hospital practices. Along with prenatal, postnatal and post-partum counselling, mothers received a discharge pack with pamphlets reinforcing messages of breastfeeding and family planning... Results of the project showed that exclusive breastfeeding at 3 months increased from 14% to 23% and use of modern methods of contraception increased from 54% to 68% at 6 months post-partum” with substantial increase in duration of amenorrhoea.

Among the World Bank projects in population, health and nutrition, according to Berg and Brems¹³ “at least four projects have explicitly recognized the value of breastfeeding for birth spacing and four have made specific provision for data collection regarding breastfeeding prevalence, duration or practices”. All these have promoted breastfeeding in some way. Yet it appears that there is considerable scope for enhancing both the number and extent of such activities.

One successful linkage between family planning and nutrition over the last 10 years, in Dr Huffman’s view, has been the Demographic Health Survey (DHS). Information on morbidity, mortality and nutritional status are added in recent reports of DHS. Among the reasons for inclusion of nutritional issues in the DHS, Dr Huffman explains, has been the need for more data on breastfeeding and amenorrhoea. She notes that when data on both family planning and nutrition needs are available within the same survey, then they are most likely to be used to affect population and nutrition policies.

Challenges Ahead

Reflecting on the important relations between breastfeeding, family planning and nutrition, the Symposium agreed a statement - subsequently endorsed by the ACC - as shown in the introduction. This emphasized the practical steps now needed - the challenges ahead.

How can programmes promoting breastfeeding and those encouraging the use of family planning be more complementary? Although an integrated approach has been stressed, breastfeeding has only infrequently been promoted in population projects. Because of political, religious or cultural sensitivities, nutrition programmes have often been hesitant to promote family planning use. Dr Huffman was of the view of the view that in reality while most developing countries are now stressing the need to develop a more integrated approach “once at a clinic or community level, family planning services are still quite separate from nutrition and health activities, even though their impacts are mutually beneficial”, and that few programmes link nutrition and family planning activities. It is no longer a lack of rationale, but programmatic and policy constraints that have continued to prevent more linkages between the two.

One important obstacle preventing more linkages is that the two programmes address different targets - “family planning programmes focus primarily on women while nutrition programmes focus principally on the child”. Breastfeeding promotion naturally addresses both the mother and the child, and results in benefits for population and nutrition programmes. The conclusions of the Symposium emphasized four priorities for improving integration. An underlying issue is one of policy: the need for organizing different programmes to be mutually supportive notably in promoting breastfeeding. This would then lead to detailed aspects of implementation, such as providing a similar message from different field workers, ensuring appropriate referrals during and after pregnancy, and so on. Importantly leading on from this, the training of health and family planning workers should take account of new efforts for integration. Getting more specific to breastfeeding (in the third point at the end of the statement) the very real constraints to breastfeeding experiences in many countries need to be more widely recognized, and tackled. Within this, sensitivity is needed to the competing demands on women’s time, including her need for income-earning work outside the home, which impinge on her choice of infant rearing practices, particularly breastfeeding. Finally, all this requires resources, not only for implementation, but also for research and gathering relevant information.

The Symposium thus emphasized the importance of training both health and family planning workers, before they can educate and encourage mothers to take full advantage of breastfeeding potentials. Training and retraining of the medical and health professionals in numerous fields is necessary to support breastfeeding, and to take into account the special needs of lactating women when offering them other contraceptives. In Indonesia, the National Family Planning Coordinating Board has launched a programme to train counselors and family planning field workers to educate women about the nutritional and contraceptive benefits of breastfeeding. Education is key in promoting the use of breastfeeding for contraception. Research in this area in the Philippines has shown that through appropriate education programmes women can be encouraged to increase the duration and intensity of their breastfeeding behaviour. The participants in the SCN Symposium felt that it is only through training and education that women can make an informed choice, free from the negative influences of the mass media, advertisements and attitudes which may inadvertently raise barriers to breastfeeding. Policy makers, programme managers and health authorities should equally be informed to set priority to relevant policies and practices and to channel necessary resources. A supportive environment should be created in which breastfeeding can be continued and reinforced in harmony with other responsibilities in and out of household.