How Does Breastfeeding Affect Postpartum Return to Fecundity?

Photo: Jhpiego

This blog was originally published by MCHIP. Written by Chelsea Cooper.  

This is a question that many women find themselves asking after childbirth. In fact, breastfeeding, return to fecundity, and postpartum family planning (PPFP) are all closely intertwined.  Exclusive breastfeeding delays a woman’s postpartum return to fecundity and is a critical aspect of the Lactational Amenhorrea Method of family planning (LAM), which requires that women exclusively breastfeed, have a baby less than six months, and have not had a return of menstruation. 

The theme for this year’s World Breastfeeding Week—“Breastfeeding: A Winning Goal – For Life!”—asserts the importance of increasing and sustaining the protection, promotion and support of breastfeeding.  Promotion of LAM and timely transition to another modern FP method can help to advance these goals during the Millennium Development Goal countdown and beyond.  

Evidence from the Healthy Fertility Study in Bangladesh has shown that LAM has a positive effect on the duration of exclusive breastfeeding: length of exclusive breastfeeding was 25% higher at six months among LAM users compared with non-LAM users.  And evidence from Jordan demonstrates that women who use LAM are twice as likely to use FP at one year postpartum (compared with women who are only breastfeeding). 

Observations have shown that almost all healthy newborns placed skin-to-skin immediately after birth are able to locate the nipple without assistance and spontaneously attach and suck. Moreover, studies have suggested early skin-to-skin contact and early initiation of breastfeeding is likely to enhance chances of continued breastfeeding at 1-3 months of age.  

Breastfeeding is practiced and valued by most mothers in developing countries. And the vast majority of women in the first year postpartum want to delay or avoid another pregnancy altogether. Why, then, do substantial gaps in exclusive breastfeeding and postpartum contraceptive use remain?

USAID’s flagship Maternal and Child Health Integrated Program (MCHIP) and the SPRING Project co-facilitate the Maternal, Infant, and Young Child Nutrition and Family Planning (MIYCN-FP) Working Group, which serves as a forum for sharing learning and resources on this topic.  The Working Group has reviewed existing scientific and programmatic literature and has noted a number of factors which influence the practice of optimal MIYCN and FP behaviors. These include:

  • Perceptions about the role of breastfeeding in preventing return to fecundity:  Findings from Egypt, Yemen and other countries reveal that women may think that they are protected from pregnancy for as long as they breastfeed (even beyond six months), or if they are only partially breastfeeding.  It is important to ensure that women understand that they are only effectively protected from pregnancy by breastfeeding for as long as all three LAM criteria are met, and that they should transition to another modern FP method before the criteria are no longer met in order to ensure continuous protection.
  • Knowledge and perceptions about breastfeeding: Program learning has revealed gaps in knowledge about optimal breastfeeding practices and the benefits of exclusive breastfeeding and continued breastfeeding.  In Kenya, for example, MCHIP found that it was important to specify that exclusive breastfeeding involves feeding the child only breastmilk with no other foods, water or other liquids, even during “hungry times” (when food is less plentiful).  Correct practice of exclusive breastfeeding affects the effectiveness of LAM if mothers are trying to use it as a FP method.
  • Knowledge and perceptions about postpartum return to fecundity: Program learning from numerous countries has revealed that women often wait until their menstruation returns to use a modern FP method, even if they say they are using LAM (Uganda, Guinea and Bangladesh LAM Barrier Analyses). In Bangladesh, through the Healthy Fertility Study, a narrative story (“" href="">Asma’s Story”) was incorporated within home visits and community mobilization meetings to reinforce the importance of starting a modern FP method before menses return. 
  • Knowledge/retention of LAM criteria and cues to transition among postpartum women: Most women who report using LAM do not meet the criteria for correct LAM practice (Fabic and Choi, 2013). New opportunities to reinforce the LAM criteria and cues to transition should be further explored, such as through LAM Champions or using an e-Health approach.
  • LAM knowledge, perceptions, and counseling practices among health providers: In some settings, health providers do not routinely counsel on LAM, often due to lack of knowledge or misconceptions about the method’s efficacy.  It is important to ensure that health workers are properly oriented (and supervised) on LAM counseling, and to provide them with job aids to help standardize counseling messages.
  • Monitoring and follow-up of LAM users: LAM use is often not tracked in FP registers, and health workers are not proactive in following up with LAM users to encourage a timely transition to another modern method before the woman is at risk. Tracking LAM within FP registers and conducting proactive follow up may help to improve timeliness of transition to another modern method.

A recent study in Egypt revealed that women who are given emergency contraception along with LAM counseling are significantly more likely to initiate regular contraception within or shortly after the first six months postpartum when compared with those in the LAM-only group (30.5% vs. 7.3%) (Shaaban et al, 2013).  

Remaining barriers to optimal breastfeeding, timely postpartum contraceptive uptake, and optimal practice of LAM and transition need to be addressed to improve PPFP and MIYCN outcomes.  New and innovative strategies for communicating about maternal and infant nutrition, LAM, and postpartum return to fecundity should be considered.  It is time to reflect on previous communication approaches and to “think outside the box”—beyond the traditional LAM messages—to focus on designing dynamic, strategic approaches that address barriers and motivate women and health providers.  

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