Breastfeeding, Fertility and the Life-Cycle

Miriam Labbok, MD, MPH, FABMSenior Advisor, Infant and Young Child Feeding and CareUNICEF NYHQ

Areas to be Discussed:1. What is a Life-cycle approach to Health? 2. How does Delaying the First Birth and

Increasing Birth Intervals contribute to Nutrition?

3. How does Breastfeeding contribute to Birth Spacing?

4. How does this effect us today, and what should be considered in terms of policy and programmes?

References: Labbok MH. Effects of Breastfeeding on the Mother. Ped Clin of

North America, 2001 Feb; 48(1)143-5 Optimal Birthspacing Saves Lives

http://www.rhcatalyst.org/site/DocServer/Catalyst_OBSI_Overview_Final.pdf?docID=341

Intergenerational Life-cycle Approach: Programme Entry Points

Adolescent and School Programmes:DELAY OF FIRST BIRTH

EPI, FP, All contacts:AT LEAST 3 YRS. SPACING

WITH EXCLUSIVE BREASTFEEDING, CONTINUED BREASTFEEDINGAND FREQUENT QUALITY CFs

Mother

Child

Birth

ANC: IRON/NUTRITION SAFE DELIVERY

FEEDING SPACING

Intergenerational Life-cycle Approach: Prolonging periods of the lifecycle to allow for improved

outcomes

Child’s Path

Maternal Path

Pregnancy

Complications/Abortion

Puberty

Birth

Paternal Path

Delay First UnionBreastfeedUse Contraception

Unable to prolong, extra intervention necessary

Breastfeeding is the Heartbeat of Intergenerational Health

Logo, Breastfeeding Division, IRH

Survival:Oral Rehydration

Growthand Development

Immunization

Women’s Health, Survival, and Reproductive Readiness

Nutrition

Birth Spacing and Fertility

Reduced Cancersand Chronic Diseases

Breastfeeding supports:

What is the importance of Maternal Nutrition?

Poor nutritional

status

Increased death from bleeding if already anemic

Increased risk of

SGA/LBW

Decreased stores for fetus and for breastfeeding

Reduced Growthand Productivity

Small statureat age of

Reproduction

2. How does Delaying the First Birth and Increasing Birth Intervals

contribute to Nutrition?

0.60

0.80

1.00

1.20

1.40

1.60

<17 18-23 24-29 30-35 36-41 42-47 48-53 54-59 60+

Duration of Preceding Birth Interval (months)

Ad

j. R

elat

ive

Od

ds

Rat

io

Small Size at Birth

Low Birth Weight

Length of the Birth Interval is Correlated with Small Size and Low Weight at Birth, controlled for many variables(Also, Mother’s Age and Nutritional Status, are associated with SGA/LBW)

It is good to be born three years after your sib!

Safest

0.4

0.6

0.8

1.0

1.2

1.4

1.6

<1718

-23

24-2

9

30-3

5

36-4

1

42-4

7

48-5

3

54-5

960

+

Length of Preceding Birth Interval (months)

Ad

j. R

elat

ive

Od

ds

Rat

io

Stunting

Underweight

Length of the Birth Interval is Correlated with Stunting and Underweight, controlled for many variables

It is good to be the youngest child for as long as possible!

Safest

0 20 40 60 80 100

Highest Risk of Under Five Mortality

Higest Risk of Infant Mortality

Highest Risk of Perinatal Mortality

Highest Risk of Maternal Mortality

Lowest Risk of Under 5 Mortality

Lowest Risk of Infant Mortality

Lowest Risk of Perinatal Mortality

Lowest Risk of Perinatal Mortality

Lowest risk of maternal Mortality

Highest Risk of Preterm Birth

Highest Risk of Pre-eclampsia

Highest Risk of Stillbirths

Data from analyses of Shea Rutstein, Agustín Conde-Agudelo, and Fuentes-Afflick and Hessol

Why the New Policy is “At least Three Years Birth Spacing” or “Three to Five Saves Lives”

monthsCurrentNorm

ProposedNorm

Where can we intervene for Maternal Nutrition?

Maintain her body

Develop Stores

Work

Breastfeeding

Fetal/placentalgrowth

FoodNutrients

DELAY!!

Golden Bow Initiative (UNICEF and WABA) Breastfeeding is the Gold Standard for

Resolution of Pregnancy and for Infant Feeding One Loop indicates the Child One Loop indicates the Mother The Knot: Father, Family, and Community,

without whose support, breastfeeding will not succeed.

One streamer for Continued Breastfeeding with Frequent and Quality Complementary Feeding

Second Streamer for the 3-5 Years of Birth Spacing

How does infant feeding contribute to Birth Spacing?

Survival Fertility Delay Método de Lactancia y Amenorrea

(MELA / LAM)

Timing of subsequent pregnancy by month postpartum and by

breastfeeding status

0

10

20

30

40

50

60

70

80

90

0 3 6 9 12 15 18 21 24 27 30 33 36 Months since last birth

% p

reg

nan

t

Non-lactating,non-contracepting -IndiaNon-lactating,non-contracepting -AlaskaLactating, non-contracepting -India

Lactating, non-contracepting -Alaska

Median duration of breastfeeding

and lactational amenorrhea in selected countries

0

5

10

15

20

25

30

35

Bangladesh Sri Lanka Senegal Peru

Breastfeeding AmenorrheaDHS, 1980s

LAM / MELAHave menses returned?

Have you begun regular supplementary

feeding?

Is the baby more than 6 months old?

It is time to begin use of a new

method to ensure the optimal 3-5 years spacing

needed for best maternal and child

health and nutrition

outcomes

YES

YES

YES

NO

NO

NO

YOU MEET CRITERIA TO RELY ON LAM / MELA

Begin frequent high quality

complementary feedings

Results of Studies on LAM Efficacy

by 6 (or 9) Month Life Table

99.6 98.8 99 99.4 100 98.5 100 99.5 96.5

80

85

90

95

100

Chile

1

Ecua

dor

Phili

ppin

es

Pakis

tan

New

Zeala

nd

Multi

cent

er

Post

-Ma

rket

ing

9-Mo

nth

Wor

king

%

Return of Menses among Exclusively Breastfeeding Women: Approximate Cumulative Percent by Six-Month Life Table

0

5

10

15

20

25

30

35

40

1 2 3 4 5 6

Control Group

LAM Group

Average Number of Feeds per Day by Month Postpartum

6.5

7

7.5

8

8.5

9

1 2 3 4 5 6 months

LAM group

Control group

*

* * *

*p<0.05

Why does LAM have improved efficacy over lactational amenorrhea?

Slightly, but significantly, shorter intervals Slightly, but significantly, more feeding

episodes per day Greater attention to night feeds Dedication to breastfeeding patterns for

fertility impact

Conclusion: Women who choose LAM will practice closer to optimal breastfeeding behaviors

Healthy Spacing for Maternal Nutrition and Child Survival

Birth 6 Months 30 mo. 36 mo. 45 mo.Next Birth

Excl.BF

BF with Comp. No BFNo Preg

Pregnant

Derived from INCAP studies

Time

0

2

4

6

8

Indonesia Pakistan Brazil Peru Burkina Faso Nigeria

If there were no Breastfeeding - additional births (000,000)

Current Births (000,000)

Additional Births If There Were No Breastfeeding...

Becker et al, 1999

Globally, if breastfeeding disappeared, the birth rate Globally, if breastfeeding disappeared, the birth rate would increase immediately and significantlywould increase immediately and significantly

3. How does this effect us today, and what should be considered in

terms of policy and programmes?

Risk of Pre-Menopausal Breast Cancer Among Women Who Breastfed

00.2

0.40.60.8

11.21.4

1.61.8

?Breastfeeding and Reduced Osteoporosis?

YES: Melton et al, Influence of breastfeeding and other reproductive factors on bone mass later in life. Osteoporos Int 1993 Mar;3(2):76-83

YES: Kreiger N, Kelsey JL, Holford TR, O'Connor T. An epidemiologic study of hip fracture in postmenopausal women. Am J Epidemiol 1982 Jul;116(1):141-8

NONE: Ramalho AC, Lazaretti-Castro M, Hauache O, Vieira JG, Takata E, Cafalli F, Tavares F Sao Paulo Med J 2001 Mar;119(2):48-53 Osteoporotic fractures of proximal femur: clinical and epidemiological features in a population of the city of Sao Paulo.

NONE: Clark P, de la Pena F, Gomez Garcia F, Orozco JA, Tugwell P. Risk factors for osteoporotic hip fractures in Mexicans. Arch Med Res 1998 Autumn;29(3):253-7

HIV Breastfeeding and Maternal Mortality Nduati R, Richardson BA, John G, Mbori-Ngacha D,

Mwatha A, Ndinya-Achola J,Bwayo J, Onyango FE, Kreiss J. Effect of breastfeeding on mortality among HIV-1 infected women: a randomised trial Lancet. 2001

Versus

Coutsoudis A, Coovadia H, Pillay K, Kuhn L. Are HIV-infected women who breastfeed at increased risk of mortality? AIDS 2001 Mar 30;15(5):653-5

WHO Statement, 2003, no reason to change policy that states that pregnancy is not an additional risk

For today’s woman: Delayed first birth and birth spacing allow mothers’ bodies

to mature and achieve better nutritional status. Better maternal nutritional status at conception is

associated with less SGA/LBW and reduced MMR Better maternal nutrient status supports best breastfeeding

practices The longer the baby is the youngest, the longer it will be

breastfed, the more time the mother will have for active feeding, the longer this child will remain the center of family care and benefit in terms of survival, growth and development.

The best birth interval for both maternal and child outcomes is three to five years

Considering all “best choices” results in “best outcomes”

Recognize that our bodies evolved for survival, and if problems arise, they merit consideration from an evolutionary and intergenerational life-cycle perspective.

Thank you!!!

Muchas Gracias!!!

Merci!!!

Cпасибо!!!

Danke!!!