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Indian Journal of Community Medicine

Lactation Amenorrhea and its Determinants in Women in an Urban Resettlement Colony

Author(s): Pragti Chhabra, O.P. Aggarwal

Vol. 25, No. 3 (2000-07 - 2000-09)

Deptt. of Preventive and Social Medicine, University College of Medical Sciences, Delhi-110095.

Abstract:

Research questions: 1. What is the duration of lactation amenorrhoea in an urban area? 2. What are its determinants?

Objectives: To determine the median duration of lactation amenorrhoea and its determinants amongst women in an urban area.

Study design: Cross-sectional study.

Setting: An urban resettlement colony of East Delhi.

Study variables: Lactation amenorrhoea in relation to breast-feeding and other mother and child variables.

Statistical analysis: Chi-square test and multiple logistic regression analysis.

Results: The median duration of lactational amenorrhoea was observed to be 8.25 months. The amenorrhoeic status was significantly related to breast feeding and exclusive breast feeding (p<0.05). The prevalence of amenorrhoea declined with post partum interval, while it was not related to the parity or weight of the mother or duration of breast feeding per day. Contraceptive use was significantly higher in women who were menstruating compared to women with amenorrhoea.

Conclusions: Contraceptive campaigns may be delayed up to 6 months post-partum resulting in a longer period of overall protection, first from amenorrhoea and then by contraceptive use.

Keywords : Breast feeding, Lactation amenorrhoea, Urban resettlement colony.

Introduction:

The benefits of breast feeding for infant health are universally recognised, however, many people are sceptical about the use of breast-feeding as a family planning method. An international group of scientists at Bellagio in 1988 recommended that lactational amenorrhoea should be regarded as an appropriate method of fertility regulation for many women and this strategy should be incorporated into family planning programmes. This method is especially important when there are difficulties with family planning methods in terms of availability, acceptability or continuation. It can be used to delay the introduction of other family planning methods1,2.

The quality of breast feeding i.e. its timing, frequency, suckling patterns affect the duration of lactation amenorrhoea. Thus data on the breast feeding patterns and duration of lactation in a population is required to know when other family planning methods need to be introduced into the community3.

Previous research has demonstrated the pitfalls inherent in trying to measure the duration of amenorrhoea and breast-feeding. Recall bias may occur resulting in heaping phenomenon at every six months4. To overcome this, the current status analysis was used in the present study. In this method the status of a variable in each individual is ascertained in order to find the pattern in the population under study. This method creates a synthetic cohort as a result of the assumption that subjects of "early" cohorts will behave like that of "late" cohorts when the time between the former and later has elapsed5.

Material and Methods:

Women who had delivered normal full term infants 0 to 12 months back formed the study subjects. These women were chosen from a health centre attending the immunisation clinic from January 1997 to September 1997. The current status method requires at least 50 births in each month age group during the reference period, which was taken as 12 months for the present study5. Thus 650 mothers were included in the study. The period was taken in completed months. The subjects were administered a pre designed questionnaire to collect information regarding age, education, occupation, income, feeding pattern and their menstrual status. The feeding pattern included whether the child was exclusively breast-fed, breast fed, top fed, or on semisolids. The frequency of breast-feeds per day and duration of each feed was also enquired into. The duration of breast feeding and lactation amenorrhoea in the previous birth was also recorded.

Lactational amenorrhoea was defined as the interval between parturition and the first appearance of menses. Breast feeding referred to receiving breast milk while exclusive breast feeding was defined as the infant receiving only breast milk (including expressed breast milk or from wet nurse and allowed the infant to receive small amounts of water, vitamins, minerals, medicines and ORS but did not allow the child to receive non human milk and food based liquids).

The data was arranged to show the proportion of women still amenorrhoeic expressed according to the period elapsed since the delivery of the child. This gave us the prevalence of amenorrhoea for each month post partum. Survival curves were constructed after smoothening the data by determining 3 months moving averages. The median duration of lactation amenorrhoea was determined directly from the curve. The relation between various socio-economic variables, breast feeding patterns and lactation amenorrhoea was determined using chi square test and multiple logistic regression analysis.

Results:

Table I: Current status of amenorrhoea, breast-feeding and exclusive breast feeding in women.

Post partum
period
in months
Prevalence
of amenorrhoea
Prevalence
of breast
feeding*
Prevalence
of exclusive
breast feeding*
0 50 (100) 49 (98) 37 (74)
1 31 (62) 50 (100) 32 (64)
2 29 (58) 49 (98) 32 (64)
3 27 (54) 46 (92) 25 (50)
4 29 (58) 46 (92) 23 (46)
5 31 (62) 45 (90) 17 (34)
6 23 (46) 48 (96) 2 (4)
7 16 (32) 45 (90) 7 (14)
8 21 (42) 48 (96) 2 (4)
9 19 (38) 42 (84) 4 (8)
10 13 (26) 47 (94) 3 (6)
11 18 (36) 44 (88) 2 (4)
12 16 (32) 48 (96) 5 (10)

Figures in parentheses indicate percentages; *p<0.05; **p<0.001

Table I shows the current status of amenorrhoea and contraceptive use for the 650 women. The prevalence of amenorrhoea was 100% immediately post partum while after 1 month 62% were amenorrhoeic. It rapidly declined to 32% at 12 months post partum. The median duration of lactational amenorrhoea in the study subjects was 8.25 months by the survival curve. As the post partum period progressed there was a rise in the contraceptive use. In the first month only 14% were using contraceptives while at 6 months 38% and at 12 months 42% were using contraceptives.

Amenorrhoea in the mothers was significantly related to their breast feeding status. Women who were breast feeding were more likely to be amenorrhoeic (p<0.01). The significance was higher when exclusive breast feeding was considered (p<0.001). consequently, mothers who were giving top feeds and semisolids were less likely to be amenorrhoeic, as depicted in Table I.

Table II: Lactational amenorrhoea in relation to certain variables.

Variable Number of women amenorrhoeic Number of women menstruating
Birth order of the child* 1(n=188) 91 (48.4) 97 (51.6)
2(n=231) 124 (53.7) 107 (46.3)
3(n=172) 105 (61.0) 67 (39.0)
>4(n=59) 33 (55.9) 26 (44.1)
Weight of mother* <35(n=62) 27 (43.5) 35 (56.5)
36-40(n=170) 90 (52.9) 80 (47.1)
41-45(n=212) 116 (54.7) 96 (45.3)
46-50(n=124) 77 (62.1) 47 (37.9)
>51(n=82) 42 (51.2) 40 (48.8)
Duration of breast feeding per day (minutes)* <50(n=185) 94 (50.8) 91 (49.2)
51-100(n=292) 174 (59.6) 118 (40.4)
101-150(n=95) 56 (58.9) 39 (41.1)
>150(n=35) 21 (60.0) 14 (40.0)

*not significant, p>0.05; Figures in parentheses indicate percentages

The duration of breast-feeding per day was calculated in minutes by determining the number of times the child was breast fed per day and the duration of each feed. Post partum amenorrhoea was not related to the duration of breast-feeding per day (p>0.05). No association between the weight and parity of the mother and amenorrhoea was observed (p>0.05).

Table III: Relation of contraceptive use and menstrual status of the women.

  Contraceptive use Total
Present Absent
Amenorrhoea present 98 (27.9) 253 (72.1) 351
Amenorrhoea not present 121 (40.5) 178 (59.5) 299
Total 219 (33.7) 431 (66.3) 650

Figures in parentheses indicate percentages; p<0.01

Contraceptive use was significantly higher in women who were menstruating than in those who were amenorrhoeic. The difference was statistically significant (p<0.01).

Table IV: Multiple regression analysis of variables for lactational amenorrhoea.

Predictor variable Coefficient SE Odds ratio
Exclusive breast feeding 0.070 0.2139 1.75(1.31-1.96)
Post partum duration 0.1322 0.0263 0.89(0.85-0.94)

Figures in parentheses indicate 95% confidence interval

These variables were then subjected to multivariate analysis using multiple logistic regression. Post partum duration, exclusive breast feeding, duration of breast-feeding per day, parity and weight of mother were the independent variables while amenorrhoea was the dependent variable. It was observed that exclusive breast-feeding emerged as the only factor influencing post partum amenorrhoea positively while as the post partum duration of the woman increased there was a decrease in the duration of post partum amenorrhoea.

Discussion:

The median duration of amenorrhoea was 8.25 months amongst the study subjects by the current status survival curve method. Previous studies have shown a wide variation in the duration of post partum amenorrhoea in the developed and developing countries. Studies from Bangladesh have reported prolonged lactational amenorrhoea with duration ranging from 12 to 17 months6-8. A retrospective study from Philippines observed an average of 8.5 months while from our country a figure of 9 to 11 months has been reported9-11. A median duration of as low as 3 months has been reported from some developed countries12.

Post partum amenorrhoea was significantly related to breast feeding and exclusive breast feeding status. Several studies indicate that breast-feeding lengthens post partum amenorrhoea3,8,11. Prema et al observed the mean duration of post partum amenorrhoea to be 4.6 months in the non-lactating women and 11.1 months amongst the lactating women11. In a retrospective study in Philippines amenorrhoea averaged 8.5 months in breast-feeding and 3.5 months in non-breast feeding women9. Also exclusive breast-feeding is associated with longer periods of amenorrhoea and infertility than is supplemented breast feeding13.

The duration of breast-feeding per day did not have any significant effect on the amenorrhoeic status of the mother. Some studies have shown that the quality of breast-feeding, its timing, frequency and suckling patterns are important variables that affect the duration of lactational amenorrhoea14,15. Jones observed that post partum amenorrhoea was prolonged in women with more minutes per episode, more episodes per day and night time feeds14. However, others have observed that when frequent breast feeding is maintained, the introduction of supplementary feeds particularly after feeding the breast, has little effect on the resumption of menstruation16,17. Probably, women in our area although had introduced non human milk and semisolids, they were still frequently breast feeding the child. Also majority of the infants were receiving night feeds.

Parity of the women did not show any relation with the duration of amenorrhoea. Age of the mother was not included, as most of the women were not sure of their age. Some studies have reported an increase in post partum amenorrhoea with increasing age and parity3,6,15. We failed to observe any significant relation between nutritional status and amenorrhoeic status of the woman. Available data from developing and developed countries indicate the lactational amenorrhoea is shorter among well nourished and socio-economically better off segments of the population11. In part, this may be attributable to confounding variables such as earlier introduction of supplements and schedule feeding among these women. Maternal nutritional status has not been found to affect significantly the duration of post partum infertility by others7.

Amenorrhoeic women had a lower contraceptive prevalence as compared to menstruating women. Weis observed the same in Bangladeshi women8. This relationship should be taken into account when planning family planning programmes. Thus, most of the women who breast-feed have amenorrhoea of about six months, therefore, lactational amenorrhoea method serves as family planning method in them. It is recommended that exclusive breast feeding for the first four to six months to be encouraged. This will benefit the child as well as provide effective contraception. Women in our area may begin using family planning methods six months after child birth or when menstrual cycle resumes, whichever is earlier.

References:

  1. Consensus statement. Breast feeding as a family planning method. Lancet 1988; 332: 1204-05.
  2. Kennedy Kathy I, Rivera R, McNeily Alan S: Consensus statement on the use of breast-feeding as a family planning method (Bellagio, Italy, August 1988). Contraception 1989, 39: 477-96.
  3. Saadeh R, Benbouzid D: Breast feeding and child spacing-importance of information collection for public health policy. Bull. WHO 1990; 68: 625-31.
  4. Jain AK, Bongaarts J: Breast feeding - Patterns, correlates and fertility effects. Studies in family planning 1981; 12: 79-98. from page 111
  5. Danko RA, Selwyn BJ, Zamora-Romero R, Chavez Ordonez XP. A simplified methodology for the community based assessment of breast-feeding and amenorrhoea in Mexico. Bull WHO 1990; 68: 223-30.
  6. Chen LC, Ahmed S, Geshe M, Mosley WH: A prospective study of birth interval dynamics in rural Bangladesh. Popul. Studies 1974; 28: 277-96.
  7. Huffman SL, Chowdhary AKMA, Chakraborty J, Simpson NK: Breast-feeding patterns in rural Bangladesh. Am J Clin Nutr 1980; 19: 128-32.
  8. Weis P: The contraceptive potential of breast feeding in Bangladesh. Studies in Family Planning 1993; 24: 100-08.
  9. Del Mundo F, Adiao AC: Lactation and child spacing as observed among 2,102 rural Filipino mothers. Philippines J Pediatr 1970; 19: 128-32.
  10. Srinivasan K, Pathak KB, Pandey A: Determinants of breast feeding and post partum amenorrhoea in Orissa. J Biosoc Sci 1989; 21: 365-71.
  11. Prema K, Naidu AN, Neela Kumari S: Lactation and fertility. Am J Clin Nutr 1979; 32: 1298-1303.
  12. Jones RE: Breast feeding and post partum amenorrhoea in Indonesia. J Biosoc Sci 1989; 21: 83-100.
  13. Prema K: The effect of breast feeding supplements on the return of fertility. Studies in Family Planning 1982; 13: 293-96.
  14. Jones RE: Breast feeding and post partum amenorrhoea in Indonesia. J Biosoc Sci 1989; 21: 83-100.
  15. Diaz S: Determinants of lactational amenorrhoea. Int J Gynecol Obstet 1989; Suppl 1: 83-9.
  16. Ravera M, Ravera C, Reggiori A, Cocozza, Cianta F, Riccioni G, Kleimay R: A study of breast feeding and the return of menses in Hoima District, Uganda. East Afr Med J 1995; 72: 147-9.
  17. Short RV, Lewis PR, Renfree MB, Shaw G: Contraceptive effects of extended lactational amenorrhoea: beyond the Bellagio consensus. Lancet 1991; 337: 715-7.
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