Catholic Health Care Advocates Papers
Lactational amenorrhea: A Catholic pediatrician’s perspective
Brian Donnely, MD
The most widely used method to space babies around the world is lactational amenorrhea. It is a method for which little training, expertise, or equipment is required and is therefore utilized unwittingly. Generally, all that is required is for the mother to exclusively breastfeed her baby.
There has been a great deal of research published recently about this subject. The consensus is that exclusive, or ecological, breastfeeding is very effective in spacing pregnancies. It works by delaying the resumption of ovulation in the mother. Aristotle observed "while women are suckling their children, menstruation does not occur according to nature, nor do they conceive." Today, we have a much deeper knowledge of the hormonal details of this process, but the basic observation remains the same. For the first six months post-partum, lactational amenorrhea is 98 to 100 % effective in preventing pregnancy.
References
Diaz S, Seron-Ferre M, Croxatto HB, Veldhuis J. Neuro-endocrine mechanisms of lactational infertility in women. Biol Res 1995; 28: 155-63.
Vekemans M. Postpartum contraception: the lactational amenorrhea method. Eur J Contrac Reprod Heath Care 1997; 2: 105-111.
Ramos R, Kennedy KI, Visness CM. Effectiveness of lactational amenorrhea in prevention of pregnancy in Manila, the Philippines: a non-comparative prospective trial. BMJ 1996; 313: 909-912.
France MM. A study of the lactational amenorrhea method of family planning in New Zealand women. NZ Med J 1996; 109: 189-91.
Thapa S, Short RV, Potts M. Breastfeeding, birth spacing and their effects on child survival.
Nature 1988; 335: 679-82.
Short RV, Lewis PR, et al. Contraceptive effects of extended lactational amenorrhea: Beyond the Bellagio consensus. Lancet 1991; 337: 715-17.
Perez A, Labbok MH, Queenan JT. Clinical study of the lactational amenorrhea method for family planning. Lancet 1992; 339: 968-70.
WHO. The World Health Organization multinational study of breastfeeding and lactational amenorrhea. I. Description of infant feeding patterns and of the return of menses; and, II. Factors associated with the length of amenorrhea. Fertil Steril 1998; 70: 448-471.
Breastfeeding, however, is more than just an effective birth spacer. It provides multiple health benefits for both mother and baby. Breastfeeding mothers will be protected from post-partum hemorrhage, and subsequent anemia, through the natural secretion of the hormone oxytocin. Breastfeeding mothers expend more calories in the production of breast milk, giving them an opportunity to achieve their pre-pregnancy weight more quickly. Mothers who breastfeed for longer than six months have a lower incidence of pre-menopausal breast cancer. There is also some evidence for a protective effect of breastfeeding against some ovarian and uterine cancers.
Reference
Dermer A. Breastfeeding and women’s health. J Women’s Health 1998; 7: 427-33.
For the baby, breast milk provides optimal, custom-made nutrition. It also provides significant protection against many infectious diseases. Breastfed babies tend to have higher IQs than their formula-fed counterparts. They also seem to have some protection against the development of obesity. Further, there are significant cost-savings for the family that chooses to breastfeed. Harder to document, but perhaps more important overall, are the subjective reports of the strength of the maternal - infant bond that breastfeeding solidifies and strengthens.
References
Hanson LA, Ashraf R, et al. Breast feeding is a natural contraceptive and prevents disease and death in infants, linking mortality and birth rates. Acta Paediatr 1994; 83: 3-6.
Villalpando S, Hamosh M. Early and late effects of breastfeeding: Does breastfeeding really matter? Biol Neonate 1998: 74; 177-91.
Ball TM, Wright AL. Health care costs of formula feeding in the first year of life. Pediatrics 1999;103; 870-6.
VonKries R, Koletzko B, et al. Breastfeeding and obesity: cross-sectional study. BMJ 1999; 319: 147-50.
Unfortunately for women who want to breastfeed, there is currently little cultural support for breastfeeding. Also physicians are not well trained in managing common problems that women encounter. These issues are interrelated. As the public’s demand for better breastfeeding management increases, so the supply of breastfeeding education of physicians will increase. Such a process is happening, albeit slowly, today.
There is also a substantial theologic basis to support and promote breastfeeding. Pope John Paul II, in his 1995 Address on Breastfeeding to the Pontifical Academy of Sciences, said: "All of this is obviously a matter of immediate concern to countless women and children, and something which clearly has general importance for every society, rich or poor. One hopes that your studies will serve to heighten public awareness of how much this natural activity benefits the child and helps to create the closeness and maternal bonding so necessary for healthy child development. So human and natural is this bond that the Psalms use the image of the infant at its mother’s breast as a picture of God’s care for man (cf. Ps 22:9). So vital is this interaction between mother and child that my predecessor Pope Pius XII urged Catholic mothers, if at all possible, to nourish their children themselves. (cf. Allocution to Mothers 26 October, 1941). From various perspectives therefore the theme is of interest to the Church, called as she is to concern herself with the sanctity of life and the family."
This theme is developed in much greater depth in the book "Mother and Infant: The moral theology of embodied self-giving in motherhood in light of the exemplar couplet Mary and Jesus Christ" by Rev. William D. Virtue. Here the mother is seen as the infant’s private tutor of love. As the mother gives of herself, both in time, effort and substance, the infant is able to grow and develop optimally, in physical as well as moral health. Indeed, one can liken breast milk to God’s grace, freely and abundantly given to those who both desire and require it.
It is worth noting, however, that much of the current research on lactational amenorrhea is being carried out with a specific agenda in mind. The guidelines for the use of lactational amenorrhea could promote the adoption of other methods of "family planning" once the six months of reliable protection has ended. "It is therefore conceivable that using lactational amenorrhea may increase subsequent use of contraception," is the way Paul Fa Van Look puts it (Lactational amenorrhea method for family planning. BMJ 1996; 313: 893.). Other researchers have explicitly expressed their desire to introduce families to the use of other, less natural, contraceptive methods during the period when they are naturally infertile. Caveat succor! References
Salway S, Nurani S. Uptake of contraception during postpartum amenorrhea: understandings and preferences of poor, urban women in Bangladesh. Soc Sci Med 1998; 47: 899-909.
Kennedy KI, Kotelchuck M. Policy considerations for the introduction and promotion of the lactational amenorrhea method: Advantages and disadvantages of LAM. J Hum Lact 1998;14: 191 - 203.
Bender DB, Dusch E, McCann MF. From efficacy to effectiveness: selecting indicators for a community-based lactational amenorrhea method programme. J Biosoc Sci 1998; 30 : 193-225.
Heinig MJ. The Bellagio consensus: ten years later. J Hum Lact 1998; 14: 185-6.
Use of the "Lactational Amenorrhea Method" should logically lead to the consideration, and increased utilization, of the physiologic methods of spacing pregnancies. Natural family planning methods have also been getting some good press lately, as their results are being heralded in scientific journals. This attention, however, does not constitute universal endorsement. The natural family planning methods require such virtues as fidelity, chastity, and diligence, all of which are required to build a culture of life. These virtues are seen as impediments to those who have no interest in such culture building. Therefore, other contraceptive methods will continue to be promoted, despite their much higher potential for morbidity and mortality.
References
Hilgers TW, Daly KD, Prebil AM, Hilgers SK. Cumulative pregnancy rates in patients with apparently normal fertility and fertility-focused intercourse. J Reproductive Med 1992; 37: 864-6.
Kambic RT, Notare T. Roman Catholic Church sponsored natural family planning services in the United States. Adv in Contracept 1994; 10: 85-92.
Djerassi C. Fertility awareness: jet age rhythm method? Science 1990; 248:1061.
Kambic R. Natural family planning use-effectiveness and continuation. Am J Obstet Gynecol 1991; 165: 2046-8.
Gray RH, Kambic RT, et al. Evaluation of natural family planning programmes in Liberia and Zambia. JBiosoc Sci 1993; 25: 249-258.
Davis MS. Natural family planning. NAACOG's Clin Iss 1992; 3(2): 280290.
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A growing number of women are unhappy with their options when it comes to spacing pregnancies, and would be open to learning about the fertility-focused approaches. It is incumbent upon us to improve their knowledge. It also lies with us to improve the general state of medical awareness of the efficacy of current natural family planning methods. So far, NFP has been one of medicine’s best kept secrets. We need to better heed Dr. William Osler’s admonition: "One of the first duties of the physician is to educate the masses not to take medicine." References
Stanford JB, Lemaire JC, Thurman PB. Women's interest in natural family planning. JFam Pract 1998; 46: 65-71. Rosenfeld JA, Zahorik PM, Saint W, Murphy G. Women's satisfaction with birth control. J Fam Pract 1993; 36: 169-173. Stanford JB, Lemaire JC, Fox A. Interest in natural family planning among female family practice patients. Fam Pract Res J 1994; 14: 237-249.
In this country, breastfeeding is an under-utilized natural resource. Bottle-feeding is perceived as the cultural norm. In such an environment, lactational amenorrhea becomes an almost overlooked aspect of a woman’s health. We cannot afford to forsake this crucial physiologic shield. It is the once and future key to protecting the health of women and children. It is an important aspect of more fully recognizing what Pope John Paul II referred to as the "genius of women" (Letter to Women, 29 June 1995). Dr. Herbert Ratner was a long time proponent of breastfeeding. He understood better than anyone its superiority to bottle-feeding, both from a scientific as well as a cultural perspective. It is fitting to close with his comments: "The road our society must take to recover the virtue of fidelity as intended by nature starts with the nursing couplet, with the example of fidelity that the mother - the prime tutor of love, the cement of society - conveys to the infant. No one claims motherhood to be an easy task; it becomes a task of joy, however, as the mother matures with the child. Motherhood changes a woman’s life forever, and, although it may interfere with or postpone other personal plans and dreams, it brings with it a very special kind of lifelong happiness. An old Yiddish saying provides us with the route to this happiness if we but adhere to the simple wisdom encapsulated in its aphoristic message: ‘Small children disturb your sleep. Big children disturb your life.’ " from The Nursing Couplet V. Fidelity. Child & Family 19: 242-4, 1980.
Respectfully submitted, September 29, 1999 Brian W. Donnelly, M. D.208 Thompson Drive Pittsburgh, PA 15229
