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BACKGROUND Comprehensive prenatal education on infant feeding is recommended by many United States health organizations because of the need to maximize maternal preparedness for managing lactation physiology. Ready, Set, BABY (RSB) is a curriculum developed for counseling women about breastfeeding benefits and management including education on optimal maternity care practices. We hypothesized that RSB would be acceptable to mothers and that mothers' strength of breastfeeding intentions would increase, and their comfort with the idea of formula feeding would decrease after educational counseling using the materials. We also hypothesized that mothers' knowledge of optimal maternity care practices would increase after participation. METHODS Materials were sent to a total of seven sites in the United States and Puerto Rico. Local health care practitioners completed training before counseling mothers with the curriculum. A pre- and postintervention questionnaire was administered to participants. Statistical analysis of results included paired t tests, Wilcoxon signed-rank tests, and McNemar's tests. RESULTS Four hundred and sixteen expectant women participated. In the pre- and postintervention comparison, maternal participation in RSB significantly improved Infant Feeding Intentions Scale scores (P

The Academy of Breastfeeding Medicine is a worldwide organization of physicians dedicated to the promotion, protection, and support of breastfeeding and human lactation. Our mission is to unite into one association members of the various medical specialties with this common purpose.

Background: Insurance coverage for lactation management is proposed by the United States Affordable Care Act. International Board Certified Lactation Consultants (IBCLCs) are key providers of lactation services. In order to inform national discussion, this study examines the scope of insurance reimbursement of IBCLC services. Objectives: An email survey of US IBCLCs (N = 10 495) in March 2011 was used to explore frequencies of (1) submission—how often lactation consults were submitted to insurance providers for reimbursement and (2) recognition—the proportion of submitted charges recognized by insurance providers. Methods: Results (N = 2045) were analyzed to describe patterns of submission and recognition by IBCLC work setting, job classification, and reimbursement strategy. Results: Many survey respondents did not know their submission (41%) or recognition (57%) levels. Multiple strategies were used for reimbursement of IBCLC services with large variations in recognition between strategies. Overall, less than 15% reported high levels of submissions to insurance providers. Moreover, of submitted encounters, only 4% were consistently recognized by insurance providers. Inpatient hospital IBCLCs were least likely to have consults recognized (3%), and private community IBCLCs were most frequently recognized (32%). Compared with using IBCLC credentials for submitting an encounter, using another clinical license was the most successful strategy for achieving recognition of IBCLC consults (crude risk ratio, 1.44; 95% confidence interval, 1.04-2.01; P = .02). Conclusion: IBCLCs provide key care to a vulnerable population. However, we found that these services are not consistently reimbursed. IBCLCs poorly communicate their health care activities to insurance providers, but insurance providers also inconsistently recognize and reimburse IBCLC care.

Objectives (a) to apply an organisation-level, pre-implementation theory to identify and describe factors that may impact hospitals' readiness to achieve the Ten Steps and (b) to explore whether/how these factors vary across hospitals. Design a multisite, descriptive, qualitative study of eight hospitals that used semi-structured interviews of health-care professionals. Template analyses identified factors that related to organisation-level theory. Cross-site comparative analyses explored how factors varied across hospitals. Setting thirty-four health-care professionals from eight North Carolina hospitals serving low-wealth populations. The hospitals are participating in a quality improvement project to support the implementation of the Ten Steps. This study occurred during the pre-implementation phase. Findings several factors emerged relating to collective efficacy (i.e., the shared belief that the group, as a whole, is able to implement the Steps) and collective commitment (i.e., the shared belief that the group, as a whole, is committed to implementing the Steps) to implement the Ten Steps. Factors relating to both constructs included ‘staff age/experience,' ‘perceptions of forcing versus supporting mothers,' ‘perceptions of mothers' culture,' and ‘reliance on lactation consultants.' Factors relating to commitment included ‘night versus day shift,' ‘management support,' ‘change champions,' ‘observing mothers utilize breastfeeding support.' Factors relating to efficacy included ‘staffing,' ‘trainings,' and ‘visitors in room.' Commitment-factors were more salient than efficacy-factors among the three large hospitals. Efficacy-factors were more salient than commitment-factors among the smaller hospitals. Key conclusions and implications for practice interventions focused on implementing the Ten Step may benefit from improving collective efficacy and collective commitment. Potential approaches could include skills-based, hands-on training highlighting benefits for mothers, staff, and the hospital, and addressing context-specific misconceptions about the Steps.

Background Exclusive breastfeeding for 6 months and continued breastfeeding for at least 1 year is recommended by all major health organizations. Whereas 74.6 percent of mothers initiate breastfeeding at birth, exclusivity and duration remain significantly lower than national goals. Empirical evidence suggests that exposure to infant formula marketing contributes to supplementation and premature cessation. The objective of this study was to explore how women interpret infant formula advertising to aid in an understanding of this association. Methods Four focus groups were structured to include women with similar childbearing experience divided according to reproductive status: preconceptional, pregnant, exclusive breastfeeders, and formula feeders. Facilitators used a prepared protocol to guide discussion of infant formula advertisements. Authors conducted a thematic content analysis with special attention to women's statements about what they believed the advertisements said about how the products related to human milk (superior, inferior, similar) and how they reported reacting to these interpretations. Results Participants reported that the advertisements conveyed an expectation of failure with breastfeeding, and that formula is a solution to fussiness, spitting up, and other normal infant behaviors. Participants reported that the advertisements were confusing in terms of how formula-feeding is superior, inferior or the same as breastfeeding. This confusion was exacerbated by an awareness of distribution by health care practitioners and institutions, suggesting provider endorsement of infant formula. Conclusions Formula marketing appears to decrease mothers' confidence in their ability to breastfeed, especially when provided by health care practitioners and institutions. Therefore, to be supportive of breastfeeding, perinatal educators and practitioners could be more effective if they did not offer infant formula advertising to mothers. (BIRTH 40:2 June 2013)

The Ten Steps to Successful Breastfeeding outline maternity practices that protect, promote, and support breastfeeding and serve as the foundation for the Baby-Friendly Hospital Initiative. Research aim: This systematic review describes interventions related to Step 3 of the Ten Steps, which involves informing pregnant women about the benefits and management of breastfeeding. Our main objective was to determine whether prenatal clinic- or hospital-based breastfeeding education increases breastfeeding initiation, duration, or exclusivity.The electronic databases MEDLINE and CINAHL were searched for peer-reviewed manuscripts published in English between January 1, 2000, and May 5, 2016. Bibliographies of relevant systematic reviews were also screened to identify potential studies.Thirty-eight studies were included. The research studies were either randomized controlled trials or quasi-experimental studies conducted in developed or developing countries. Findings suggest that prenatal interventions, delivered alone or in combination with intrapartum and/or postpartum components, are effective at increasing breastfeeding initiation, duration, or exclusivity where they combine both education and interpersonal support and where women's partners or family are involved. However, varying study quality and lack of standardized assessment of participants' breastfeeding intentions limited the ability to recommend any single intervention as most effective.Future studies should test the strength of maternal breastfeeding intentions, assess the role of family members in influencing breastfeeding outcomes, compare the effectiveness of different health care providers, and include more explicit detail about the time and full cost of different interventions.

Objectives. The Ten Steps to Successful Breastfeeding is a proven approach to support breastfeeding in maternity settings; however, scant literature exists on the relative impact and interpretation of each step on breastfeeding. We assessed the Ten Steps and their relationship with in-hospital breastfeeding rates at facilities serving low-wealth populations and explored the outcomes to identify step-specific actions. Methods. We present descriptive and nonparametric comparisons and qualitative findings to examine the relationship between the Ten Steps and breastfeeding rates from each hospital using baseline data collection. Results. Some steps (1-policy, 2-training, 4-skin-to-skin, 6-no supplements, and 9-no artificial nipples, followed by 3-prenatal counseling, 7-rooming-in) reflected differences in relative baseline breastfeeding rates between settings. Key informant interviews revealed misunderstanding of some steps. Conclusions. Self-appraisal may be less valid when not all elements of the criteria for evaluating Step implementation may be fully understood. Limited exposure and understanding may lead to self-appraisal errors, resulting in scores that are not reflective of actual practices. Nonetheless, the indication that breastfeeding rates may be better mirrored by a defined subset of steps may provide some constructive insight toward prioritizing implementation activities and simplifying assessment. These issues will be further explored in the next phase of this study.

The World Health Organization (WHO)/UNICEF Baby-Friendly Hospital Initiative (BFHI) was developed to support the implementation of the Ten Steps for Successful Breastfeeding. The purpose of this study is to assess trends in the numbers facilities ever-designated "baby-friendly," to consider uptake of the new WHO/UNICEF BFHI materials, and to consider implications for future breastfeeding support.The national contacts from the 2006-2007 UNICEF BFHI update were recontacted, as were WHO and UNICEF officers worldwide, to ascertain the number of hospitals ever-designated "baby-friendly," presence of a government breastfeeding oversight committee, use of the new BFHI materials and, if yes, use of the new maternity or human immunodeficiency virus (HIV) materials.Seventy countries reporting in 2010-2011 and the updates from an additional 61 reporting in 2006-2007 (n=131, or 66% of the 198 countries) confirm that there are at least 21,328 ever-designated facilities. This is 27.5% of maternities worldwide: 8.5% of those in industrialized countries and 31% in less developed settings. In 2010, government committees were reported by 18 countries, and 34 reported using the new BFHI materials: 14 reported using the maternity care and 11 reported using the HIV materials.Rates of increase in the number of ever-certified "baby-friendly" hospitals vary by region and show some chronological correlation with trends in breastfeeding rates. Although it is not possible to attribute this increase to the BFHI alone, there is ongoing interest in Ten Steps implementation and in BFHI. The continued growth may reflect the dedication of ministries of health and national BFHI groups, as well as increasing recognition that the Ten Steps are effective quality improvement practices that increase breastfeeding and synergize with community interventions and other program efforts. With renewed interest in maternal/neonatal health, revitalization of support for Ten Steps and their effective institutionalization in maternity practices should be considered. Future updates are planned to assess ongoing progress and impact, and ongoing updates from national committees are welcome.

Many women in industrialized countries return to work while their children are infants. This is often associated with decreased breastfeeding duration or exclusivity. In order to better understand the breastfeeding support activities in childcare settings, studies were undertaken in settings with very different levels of infant mortality, breastfeeding, and breastfeeding support: Adelaide, Australia, and Wake County, North Carolina. The researchers collaborated to explore, contrast, and compare their baseline data.Available data on breastfeeding rates and infant mortality rates were explored for the two settings. In addition, the two childcare datasets were explored for common questions, and descriptive and χ(2) analyses were carried out.Similarities were found between the response from childcare settings providers in Australia and the United States. Rates of having at least one breastfeeding infant (70.6% vs. 66.3%), a place to breastfeed (90.7% vs. 95%), and a refrigerator for storage (100% vs. 100%) were similar for Adelaide and Wake County, respectively. Qualitative data from Adelaide also mirrored Wake County data in that providers in neither setting were actively promoting breastfeeding. However, the Adelaide data reflected significantly higher rates of encouragement (95.3% vs. 21.7%), written policy (77.8% vs. 20.8%), resource/materials distribution (76.6% vs. 1% and 93.8% vs. 17%), and training (44.4% vs. 13.9%).Childcare practices may reflect the environment of support, or lack thereof, for breastfeeding in the society as a whole. The similarities and differences seen in these settings may reflect both official guidance as well as the breastfeeding environment. There is much work to be done in the United States to come up to the same level of support for breastfeeding in child care and in other programs as is seen in Australia.

The U.S. Department of Agriculture's Supplemental Nutrition Program for Women, Infants, and Children (WIC) nutrition services provides supplemental nutrition and counseling to more than 50% of families with young children in the United States. Given the program's significant reach, as well as large differences in rates of breastfeeding among whites, African Americans, and Hispanics, we explored the associations among breastfeeding initiation, the availability of WIC-based breastfeeding support, and the racial/ethnic composition of WIC clients in North Carolina.An electronic survey gathered data on ongoing breastfeeding support activities from local WIC directors in North Carolina. North Carolina Pregnancy and Nutrition Surveillance System data provided racial/ethnic composition and breastfeeding initiation rates. Linear and logistic regression models were used to examine county-level associations among (1) racial/ethnic composition of clients, (2) breastfeeding initiation, and (3) availability of the identified WIC breastfeeding support services.Responses were received from 50 of the state's 100 counties and were generally representative of the state. Breastfeeding initiation by site was negatively associated with percentage of African American clients and positively associated with percentage of white or Hispanic clients (p0.05). The availability and intensity of breastfeeding support services varied widely, with 50% offering clinic-based services, 46% offering home visits, 38% offering peer counseling, and 76% offering some other form of counseling. The WIC sites with larger Hispanic populations were more likely to be providing a broad base of services, including clinic-based services, peer counseling, and home visits (p0.05); those with higher African American populations were significantly less likely to offer clinic-based breastfeeding support services (p0.05) and trended toward fewer services in general.Results confirmed previous findings of racial/ethnic disparities in breastfeeding rates. We also found that differences in the availability of breastfeeding support services were associated with the racial/ethnic composition of the catchment area. This apparent inequity in the availability of breastfeeding support services at different WIC sites may merit further exploration and may inform implementation of aspects of the U.S. Surgeon General's Call to Action to Support Breastfeeding.

Approximately half of all mothers of infants born in the United States receive services through the Special Supplemental Nutrition Program for Woman, Infants and Children (WIC). Although WIC promotes breastfeeding, data suggest that, despite advances in the last 2 decades, WIC participants are less likely to initiate breastfeeding, and much less likely to continue, than non-WIC participants, including the non-WIC participants who are eligible for WIC. WIC recently revised their food packages and enhanced the monetary value of the breastfeeding packages. While these changes are an important step in supporting WIC's efforts to promote breastfeeding, other major factors, such as participants' perceptions of the value of the packages and WIC's dependency on rebates from formula companies to fund a portion of the program, may dampen WIC's breastfeeding promotion and support efforts. There is great need for additional research on these issues.

Background: Most infant feeding studies present infant formula use as “standard” practice, supporting perceptions of formula feeding as normative and hindering translation of current research into counseling messages supportive of exclusive breastfeeding. To promote optimal counseling, and to challenge researchers to use exclusive breastfeeding as the standard, we have reviewed the scientific literature on exclusive breastfeeding and converted reported odds ratios to allow discussion of the “risks” of any formula use. Methods: Studies indexed in PubMed that investigated the association between exclusive breastfeeding and otitis media, asthma, types 1 and 2 diabetes, atopic dermatitis, and infant hospitalization secondary to lower respiratory tract diseases were reviewed. Findings were reconstructed with exclusive breastfeeding as the standard, and levels of significance calculated. Results: When exclusive breastfeeding is set as the normative standard, the re-calculated odds ratios communicate the risks of any formula use. For example, any formula use in the first 6 months is significantly associated with increased incidence of otitis media (OR: 1.78, 95% CI: 1.19, 2.70 and OR: 4.55, 95% CI: 1.64, 12.50 in the available studies; pooled OR for any formula in the first 3 mo: 2.00, 95% CI: 1.40, 2.78). Only shorter durations of exclusive breastfeeding are available to use as standards for calculating the effect of “any formula use” for type 1 diabetes, asthma, atopic dermatitis, and hospitalization secondary to lower respiratory tract infections. Conclusions: Exclusive breastfeeding is an optimal practice, compared with which other infant feeding practices carry risks. Further studies on the influence of presenting exclusive breastfeeding as the standard in research studies and counseling messages are recommended. (BIRTH 37:1 March 2010)

Objectives. We sought to assess whether breastfeeding-related hospital practices reported by mothers were associated with achievement of their intentions to exclusively breastfeed. Methods. We used data from Listening to Mothers II, a nationally representative survey of 1573 mothers who had given birth in a hospital to a singleton in 2005. Mothers were asked retrospectively about their breastfeeding intention, infant feeding at 1 week, and 7 hospital practices. Results. Primiparas reported a substantial difference between their intention to exclusively breastfeed (70%) and this practice at 1 week (50%). They also reported hospital practices that conflicted with the Baby-Friendly Ten Steps, including supplementation (49%) and pacifier use (45%). Primiparas who delivered in hospitals that practiced 6 or 7 of the steps were 6 times more likely to achieve their intention to exclusively breastfeed than were those in hospitals that practiced none or 1 of the steps. Mothers who reported supplemental feedings to their infant were less likely to achieve their intention to exclusively breastfeed: primiparas (adjusted odds ratio [AOR] = 4.4; 95% confidence interval [CI] = 2.1, 9.3); multiparas (AOR = 8.8; 95% CI = 4.4, 17.6). Conclusions. Hospitals should implement policies that support breastfeeding with particular attention to eliminating supplementation of healthy newborns.

Physicians commonly state the concern that, if they promote breastfeeding, they may “impose guilt upon those who do not breastfeed.” This article explores the genesis of this fear, who may benefit from this construct, and the terminology of guilt, shame, and loss. The article also explores the responsibility for both lactation failure and associated shame, considering the roles and responsibilities of physicians, the media, and society as a whole. An alternative construct for the guilt is offered, based on the consideration that the woman experiences lack of breastfeeding as a loss at some level, conscious or subconscious, and whether the choice to not breastfeed is her decision or imposed. Proposed approaches for acting to prevent and to treat shame and guilt are presented. J Hum Lact. 24(1):80-84.

This chapter reviews the literature on postpartum coital behavior, anovulatory and ovulatory bleeding episodes, and the methodology and efficacy of Lactational Amenorrhea Method and progesterone-only oral contraceptives. Of interest is the finding that breastfeeding women may resume coital behavior earlier postpartum, but report increased discomfort over time. The high efficacy of the Lactational Amenorrhea Method is confirmed and data illustrating possible relaxation of some criteria are presented. The conflicting guidance of CDC and WHO concerning immediate postpartum use of progestin-only methods is presented. The dearth of recent studies calls for new research on these topics.

After contraceptive use, breast-feeding duration is the major determinant of the birth interval length. Three methods of estimating births averted by breast-feeding, and the increase in contraceptive use needed to substitute for breast-feeding, are presented. Method 1 simply utilizes Bongaarts’ Ci, and the other two are based on mean birth intervals with and without breast-feeding. Estimates for each method are derived for six countries with DHS surveys from the mid-1990s: Burkina Faso, Uganda, India, Indonesia, Brazil and Peru. The estimated percentage of additional births that would occur if there were no breast-feeding ranged from 1–4% in Brazil to about 50% in Burkina Faso and Uganda, reflecting very low breast-feeding in Brazil and very high levels in the sub-Saharan African nations. Strengths and limitations of the three methods are considered.

Objectives. We determined the effectiveness of primary care–based, and pre- and postnatal interventions to increase breastfeeding. Methods. We conducted 2 trials at obstetrics and gynecology practices in the Bronx, New York, from 2008 to 2011. The Provider Approaches to Improved Rates of Infant Nutrition & Growth Study (PAIRINGS) had 2 arms: usual care versus pre- and postnatal visits with a lactation consultant (LC) and electronically prompted guidance from prenatal care providers (EP). The Best Infant Nutrition for Good Outcomes (BINGO) study had 4 arms: usual care, LC alone, EP alone, or LC+EP. Results. In BINGO at 3 months, high intensity was greater for the LC+EP (odds ratio [OR] = 2.72; 95% confidence interval [CI] = 1.08, 6.84) and LC (OR = 3.22; 95% CI = 1.14, 9.09) groups versus usual care, but not for the EP group alone. In PAIRINGS at 3 months, intervention rates exceeded usual care (OR = 2.86; 95% CI = 1.21, 6.76); the number needed to treat to prevent 1 dyad from nonexclusive breastfeeding at 3 months was 10.3 (95% CI = 5.6, 50.7). Conclusions. LCs integrated into routine care alone and combined with EP guidance from prenatal care providers increased breastfeeding intensity at 3 months postpartum.

OBJECTIVES: This study quantified the influence of employment, specifically a mother's employment away from her infant, on the use of breast milk substitutes in developing countries. METHODS: Data from the Demographic and Health Surveys were used to calculate the population attributable risk percentage for use of breast milk substitutes among women employed away from their babies in 15 countries for which suitable data were available. RESULTS: The estimated proportion of breast milk substitute use attributable to employment away from the baby ranged from 0.74% to 20.9% in the various countries. CONCLUSIONS: Employment is not the main determinant of breast milk substitute use. Efforts to improve breast-feeding can be safely targeted at the majority of women who are not employed away from their babies while nevertheless giving appropriate attention to the minority of new mothers who are employed away from their babies.

Data from many Demographic and Health Surveys I and II in developing countries were analyzed to determine the overlap between lactational amenorrhea and contraceptive use (nonhormonal methods) during the first 6 months postpartum. In Asia and the Near East region the level of double coverage during the first 3 months postpartum was 80% in Indonesia and Sri Lanka 60% in Thailand 50% in Egypt and 40% in Tunisia. In Africa the level of double coverage during the first 3 months postpartum was 80% or above for all countries studied except Sudan which did not have such data for 3 months postpartum. Double coverage remained high at 6 months postpartum (55% to

This study assessed reported changes in clinical breastfeeding support practices following a three-day (approximately 24 hour) course. The course, presented at the Catholic University in Santiago, Chile, included the physiology of lactation and lactational infertility, related policy, clinical skills, the Lactational Amenorrhea Method (LAM), and program-related findings. A questionnaire was sent to all participants and an additional systematic sample was telephoned to assure a statistically valid sample. Sixty-nine percent of respondents reported changes in clinical practices resulting from attendance at the course. The results support the concept, now being advanced by the Baby-Friendly Hospital Initiative, that an 18-24 hour course can change clinical practices.

This year we are supporting and participating in activities in celebration of the 20th World Breastfeeding Week. This annual event is celebrated during the first week in August to commemorate the signing of the Innocenti Declaration, adopted at the World Health Organization/UNICEF Policymakers’ Meeting, ‘‘Breastfeeding in the 1990s: A Global Initiative,’’ held at the Spedale degli Innocenti, Florence, Italy, July 30–August 1, 1990. Thirty countries signed on, with the goal of reaching four operational targets by 1995: (1) appoint a national breastfeeding coordinator of appropriate authority and establish a multisectoral national breastfeeding committee composed of representatives from relevant government departments, nongovernmental organizations (NGOs), and health professional associations; (2) ensure that every facility providing maternity services fully practices all 10 of the Ten Steps to Successful Breastfeeding set out in the joint WHO/UNICEF statement ‘‘Protecting, Promoting and Supporting Breastfeeding: The Special Role of Maternity Services’’; (3) take action to give effect to the principles and aim of all Articles of the International Code of Marketing of Breastmilk Substitutes and subsequent relevant World Health Assembly resolutions in their entirety; and (4) enact imaginative legislation protecting the breastfeeding rights of working women and established means for its enforcement. The Innocenti Declaration also called upon international NGOs to draw up action strategies for protecting, promoting, and supporting breastfeeding, support national situation analyses and development of goals, and en courage and support national authorities in planning, implementing, monitoring, and evaluating their breastfeeding policies. Mr. James Grant, then Director of UNICEF, called upon the NGO community to organize in this regard, and the World Alliance for Breastfeeding Action (WABA) was born. One of WABA’s first ground-breaking acts was to establish an annual World Breastfeeding Week: a time for action, a time for advocacy, a time for advancing support for breastfeeding. Each year, a different theme is chosen. This ongoing support, the increasing implementation of all four operational targets, the steady flow of evidence showing the vital importance of breastfeeding, and the fact that breastfeeding rates were shown to be responsive to programs of action, all contributed to a call for The Global Strategy for Infant and Young Child Feeding, which was endorsed by WBW 2012 image courtesy of WABA

More than 60% of newborn infants in the US are now breast-fed a far higher percentage than the 22% of newborns breast-fed in the country in 1971. The authors conducted a study to identify the social and biomedical variables which influence the selection of infant feeding methods in the US and to provide guidelines for the choice of control variables in designing and interpreting studies which examine the influence of breast-feeding upon infant and child health. Data were drawn from the Child Health Supplement of the 1981 Health Interview Survey conducted by the National Center for Health Statistics. The survey is based upon nationally representative samples of the US population living in households. Relationships between demographic socioeconomic and health variables were studied for the sample of 2951 children under age 5 years as well as for Black and White women separately. The survey data offer evidence of the importance of social and health variables as selection factors for breast-feeding in the US. Ethnicity socioeconomic status and health of the mother and child as determined by indications of a difficult pregnancy and delivery and length of hospital stay were all associated with the initiation and duration of breast-feeding. Substantial interactions were also noted between ethnicity and health determinants of breast-feeding.

This article presents trends and differentials in exclusive breastfeeding patterns that occurred in developing settings during the 1990s and considers these trends in relation to the breastfeeding-support activities in that decade. Between 1990 and 2000, the data suggest that exclusive breast-feeding levels in the developing world increased 15% overall among infants younger than 4 months (from 46% to 53%) and among infants older than 6 months (from 34% to 39%). The increase in urban areas is of special note. Urban areas are presumed to be most susceptible to the ambient health system and social and commercial pressures against breastfeeding; the support activities of the 1990s (eg, the Baby-friendly Hospital Initiative and the International Code of Marketing of Breastmilk Substitutes) were developed to address these pressures. Given this, implementation of the Global Strategy for Infant and Young Child Feeding, which supports these proven interventions, should be effective in further increasing optimal breast-feeding practices.

Research on breast feeding has been hindered by inconsistent non-comparable definitions of breast feeding behavior. An April 1988 Interagency Group for Action on Breastfeeding meeting developed a set of definitions that could be used as standardized terminology for the collection and description of cross-sectional data on breast feeding behavior. Emphasis was placed on the development of definitions based on the physiological effects of breast feeding. The schema delineates full (exclusive almost exclusive) partial (high medium low) and token (minimal) breast feeding. In this classification system full or nearly full breast feeding is defined as exclusive or almost exclusive full breastfeeding and high partial feeding. Georgetown Universitys Institute for Reproductive Health has urged scientific journals to adopt this schema as a guideline for authors and researchers.

A multicenter study of the Lactational Amenorrhea Method (LAM) was carried out to test the acceptability and efficacy of the method. Additionally, the data are used to test new constructs for improvement of method criteria. A protocol was designed at the Institute for Reproductive Health (IRH), Department of Obstetrics and Gynecology, Georgetown University Medical Center, a World Health Organization (WHO) Collaborating Center, and was reviewed and modified in collaboration with the co-sponsors, the World Health Organization and the South to South Cooperation for Reproductive Health, and the principal investigators from each site. Data were gathered prospectively on LAM acceptors at 11 sites. Data were entered and cleaned on-site and further cleaned and analyzed at IRH, using country-level and pooled data to produce descriptive statistics and life tables. The 98+% efficacy of LAM is confirmed in a wide variety of settings. In addition, the results yield insight on the possibility of continued use beyond 6 months. LAM is found to be highly effective as an introductory postpartum method when offered in a variety of cultures, health care settings, socio-economic strata, and industrial and developing country locales. In addition, LAM acceptance complements breastfeeding behaviors without ongoing breastfeeding support services. The parameters studied yield high efficacy and method continuation. Therefore, the basic tenets of the 1995 Bellagio consensus on LAM is reconfirmed and it is recommended that LAM be reconfirmed and it is recommended that LAM be incorporated into hospital, maternity, family planning, maternal and child health, and other primary health care settings.

A multicenter study of the Lactational Amenorrhea Method (LAM) was carried out to determine acceptability, satisfaction, and utilization in 10 different populations, and to confirm the efficacy of the method. Efficacy data are presented in a companion paper. A protocol was designed at the Institute for Reproductive Health (IRH), Department of Obstetrics and Gynecology, Georgetown University Medical Center, and reviewed and modified in collaboration with the co-sponsors, the World Health Organization, the South-to-South Cooperation for Reproductive Health, and the principal investigators from each site. Data were gathered prospectively on LAM users at 11 sites. Data were entered and cleaned on-site, and further cleaned and analyzed at IRH, using country-level and pooled data to produce descriptive statistics. The overall satisfaction with LAM was 83.6%, and continuation with another method of family planning was shown to be 67.6% at 9 months postpartum, in most cases exceeding previous use of contraception prior to use of LAM. Knowledge and understanding of the method at discontinuation were high, ranging from 78.4 to 88.6% for the three criteria. LAM can be used with a high level of satisfaction and success by women in a variety of cultures, health care settings, socio-economic strata, and industrial and developing country settings. The results confirm that LAM is acceptable and ready for widespread use, and should be included in the range of services available in maternal and child health, family planning, and other primary health care settings.

In December 1995 a conference on the lactational amenorrhea method (LAM) for family planning was held in Bellagio Italy to review the findings of studies expressly designed to test the consensus of the 1988 meeting on LAM also held in Bellagio and findings of other relevant research. At the 1988 meeting on LAM participants came to a conclusion now referred to as the Bellagio consensus: women who are not using family planning but are fully or nearly fully breast feeding and amenorrheic face a risk of pregnancy less than 2% during the first six months postpartum. 1995 conference participants found that the findings clearly confirmed the Bellagio consensus. The criteria to meet LAM guidelines are amenorrhea full or nearly full breast feeding and the first six months postpartum. The 1995 participants concluded that it is impossible to eliminate the amenorrhea criterion. It may be possible to relax the criterion of full or nearly full breast feeding and to extend LAM beyond six months postpartum. They defined the end of amenorrhea to be two consecutive days of bleeding/spotting or of the womans perception that her menses have returned. The LAM guidelines advise women who no longer meet any of these criteria or no longer wish to use LAM that they should immediately begin using another family planning method to avoid pregnancy. Family planning programs and policies should support LAM so it can be available worldwide. Programmatic research needs are studies on the LAM performance under a wide range of field conditions impact of LAM on family planning use LAM use in mothers who are separated from their babies for a prolonged period each day and in mothers of premature babies integration of LAM into family planning and other health services and the level and nature of support needed for effective LAM use. Biomedical research needs are studies on the factors that determine whether a woman ovulates before or after her return to menses the levels and patterns of infant feeding needed to maintain low pregnancy rates and the relative importance of the various factors that contribute to lactational infertility.

A control/intervention study carried out in Santiago, Chile assessed the impact of five interventions on breastfeeding patterns and duration, and demonstrated a significant increase in full breastfeeding at six months (32 percent to 67 percent). Fifty-nine of 422 post-intervention women were included in a sixth intervention: prena tal group educational sessions emphasizing the skills necessary to initiate and maintain breastfeeding past the neonatal period. A significantly higher percentage of this subset of women were fully breastfeeding at six months compared to those who received only the five basic interventions (80 percent and 65 percent, respectively). The effect was greater among primiparous women. We conclude that prenatal group education with hands-on skills reinforcement is a significant and additive component of breastfeeding support, especially among those who have no previous breastfeeding experience. JHL 12:15-19, 1996.

Twelve themes arose during the conference which, when presented to the group in a summary session, were greeted by general consensus and approval. These themes fall into four categories: women and health care; women and other life choices; women and men; and women and political action. Additional concerns that were not included in the 1-day conference are outlined, including a discussion of: (1) respect for the reproductive roles of women, the three 'I's', and other reproductive health issues; (2) a 7-stage approach to women's nutrition; (3) the supervisory role of the health care provider versus a role as a creator of self-efficacy; (4) the cost of breastfeeding; and (5) the impact on the environment. Conclusions and next actions also are presented for consideration.

Breastfeeding is a major contributor to child spacing and reproductive health, and, as such, is a vital women's issue. Further, if breastfeeding levels were to decline, the increase in family planning services that would be required to replace the lost fertility impact would be prohibitive, both in terms of cost and difficulty. This concern places breastfeeding centrally as a family planning policy issue as well. This paper discusses how breastfeeding contributes to child spacing and reduced fertility; the appropriate and timely introduction of complementary family planning methods during breastfeeding; issues and controversies in the support of breastfeeding as a family planning issue in the context of women's concerns, including the concept of exclusive breastfeeding for 6 months, the encouragement and support to maintain breastfeeding after 6 months, and the use of the Lactational Amenorrhea Method (LAM) and other family planning methods in the early postpartum period; and the role of family planning programs in supporting women's informed reproductive health choices.

It is well accepted that breastfeeding contributes significantly to child survival and child nutrition. Healthful child spacing is associated with improved birth outcomes and maternal recovery. On a population basis, breastfeeding may contribute more to birth spacing than all family planning use combined in many countries. However, while breastfeeding does provide a period of infertility, until recently, there was no reliable way for an individual woman to capitalize on this lactational infertility for her own efficacious child spacing. The Lactational Amenorrhea Method (LAM) is a new introductory family planning method that simultaneously promotes child spacing and breastfeeding, with its optimal nutrition and disease preventive benefits for the infant. LAM, as it is called, is based on the utilization of lactational infertility for protection from pregnancy and indicates the time for the introduction of a complementary family planning method. LAM is recommended for up to six months postpartum for women who are fully or nearly fully breastfeeding and amenorrheic, and relies on the maintenance of appropriate breastfeeding practices to prolong lactational infertility, with the concomitant delay in menses return. A recent clinical trial confirmed the theoretical 98% or higher effectiveness of the method and field trials are demonstrating its acceptability. Nonetheless, some demographers and family planning organizations continue to debate its value. The development, efficacy, and sequelae of the method are presented using data from several studies by the authors.

A prospective case-control study compared data on 422 urban middle-class mother-child pairs who were part of the breast feeding promotion program (BFPP) with data on 313 controls of like socioeconomic status. All mothers delivered at the Clinical Hospital of the Catholic University of Chile in Santiago. BFPP interventions included training of the health team (physicians midwives nurses and nutritionists) in breast feeding prenatal clinic activities (individual and group counseling on breast feeding educational materials) hospital activities (early contact with newborn rooming-in individual counseling) and follow-up care at a newly-created outpatient lactation clinic. The maternity ward gave formula to 18% of newborns. Cases were significantly more likely to practice exclusive breast feeding at 6 months than were controls (66.8% vs. 31.6%; p < .0001). They were also more likely to still have lactational amenorrhea at 6 months than controls (56.2% vs. 22%). BFPP mothers had 30 minutes more breast feeds per day than did controls which likely contributed to their prolonged lactational amenorrhea. The postpartum separation period for the BFPP group was shorter than that for controls (2.8 hours vs. 6.7 hours; p < .0001). BFPP reduced infant supplementation from 53 to 19%. Both early postpartum breast feeding and reduced supplementation decreased expenses on formula and bottles. Rooming-in alone reduced personnel costs by 34% (i.e. US$0.50-1.20 savings/day). The researchers thought that the training and motivation of health care providers and the quality of mother-child care at the outpatient clinic were the most important activities of BFPP.

The effect of breastfeeding on fertility is well known; however, its use as a method of family planning was, until recently, untested. In 1988, the Bellagio Consensus Conference proposed guidelines that became the basis for a method of family planning called the lactational amenorrhoea method (LAM). The principle of LAM is that a woman who continues to fully or nearly fully breastfeed her infant and who remains amenorrhoeic during the first 6 months postpartum is protected from pregnancy during that time. We have assessed this method in the context of a breastfeeding support intervention study of 422 middle-class women in urban Santiago, Chile. The cumulative 6-month life-table pregnancy rate was 0.45% among women who relied on LAM as their only family planning method (1 woman pregnant in month 6). The findings indicate that LAM, with its high acceptance and efficacy, is a viable method of family planning and can safely serve as an introductory method for breastfeeding women.

Studies of method effectiveness must be carefully assessed for comparability of findings. Several parameters are identified that are important in the assurance of comparable results. This article discusses these issues with the use of data from previously published studies and emphasizes the management implications of use-effectiveness data.The focus of the article on natural family planning (NFP) efficacy studies is on issues in data analysis and the use of efficacy data in management decisions. Data problems are identified as variable study designs, different times of entry, accuracy of self selection and self reporting, and consistency of method use and followup. Examples with actual data of these problems are given for Chile, Bangladesh, Kenya, and Korea. The methods used to measure effectiveness are not comparable. Clinical trials are prospective measures of efficacy, while population surveys are sometime as used for in-use efficacy. use efficacy may be calculated in 2 ways: the Pearl Index (the failure rate expressed as the number of pregnancies divided by the number of months of exposure and multiplied by 1200) and the cumulative life table method. Numerator problems occur due to reporting bias and loss of followup. Denominator problems suffer from self selection into the method, bias of recall, different times of entry into the study, and unreported concurrent use of other methods. Another variable is the median age of participants and the number of months of method use completed at the time date gathering began. The comparative example is given of data from Bangladesh, Kenya and Korea where entry into the study was late and related to the lowest unplanned pregnancy rate. The center with the youngest population also showed the lowest unplanned pregnancy rate. The timing is also related to whether the respondent is breastfeeding just after delivery or interbirth, where unplanned pregnancies are greater. It is pointed out that another method such as effectiveness assessment might be used. It measures the % of clients achieving adequate spacing or their stated goal. The advantages are in its being a personalized indicator, easier to assess, and provides excellent time series data. It is not useful in comparing methods or programs. Examples of usefulness of efficacy data are given; i.e., multiple decrement life tables can tell management about continuers versus discontinuers. The reason for the unplanned pregnancy may tell whether there was a misunderstanding. In the Chilean data set, most of the pregnancies occurred during lactation after the return of menses. When lactation is controlled for, the rates between spacers and limiters disappears. A common error is knowledgeable users do not follow the rules of the ovulation method and there is cultural resistance to revealing the number of sexual partners.

Data from two prospective studies of the ovulation method were used to assess pregnancy rates and users' fertility-related behaviors among breastfeeding women. The rate of unplanned pregnancy was less than 1% during the first 6 months of lactational amenorrhea. However, the unplanned pregnancy rate was elevated among breastfeeders during the months after menses return compared with the pregnancy rate during nonlactating cycles. Rates were also elevated at the time when infant feeding supplementation was started. This increase in unplanned pregnancies was not directly attributable to nonadherence to the ovulation method rules; there was some indication that adherence to the rules actually may be increased during those months. Therefore, special emphasis on both the need for improved breastfeeding support to delay menses return and the increased potential for method failure among new users during this period of time should be incorporated into ovulation method training and support programs.Data from two prospective studies of the ovulation method in Nyahururu, Kenya, and Santiago, Chile, were analyzed to assess the occurrence of pregnancy and related behaviors among breastfeeding women. The rate of unplanned pregnancy was less than 1% during the first six months of lactational amenorrhea, but was elevated among breastfeeding women during the months after menses return compared with the pregnancy rate during nonlactating cycles. Rates were also elevated at the time when infant feeding supplementation was started. The authors note that the increase in unplanned pregnancies cannot be directly attributed to nonadherence to the ovulation method rules. In fact, there was some indication that adherence to the rules may even be increased during those months. The authors also encourage special emphasis in ovulation method training and support programs upon both the need for improved breastfeeding support to delay menses return and the increased potential for method failure among new users.

60 breastfeeding mothers in Baltimore and 41 in Manila recorded their infant feeding patterns daily, and gave additional information at weekly interviews. Ovarian activity was monitored by assays for hormone metabolites in daily urine samples. On average, women in Baltimore breastfed less often but for longer at each feed than women in Manila, and the mean times until ovulation were 27 and 38 weeks post partum. 41% of first ovulations had luteal phase defects. Anovular first menses were common (45.1%) during the first 6 months post partum but the rate fell greatly thereafter. The risk of ovulation was reduced by a higher frequency of breastfeeds, longer duration of each feed, and less supplementary feeding. During the first 6 months post partum, amenorrhoeic women had low risks of ovulation (below 10%) with partial breastfeeding, and exclusive breastfeeding reduced the risk to 1-5% with either frequent short feeds or infrequent longer feeds. However, if the woman started menstruating before 6 months post partum, or if she continued breastfeeding beyond 6 months, the risk of ovulation rose, and contraception would be needed.The factors predicting the return of ovulation during lactation were investigated in 60 breast feeding mothers from Baltimore, Maryland, and 41 mothers from Manila, the Philippines. The women in Manila breast fed more frequently (11.0 mean daily feeds) than those in Baltimore (5.8 feeds) throughout the first postpartum year. However, during the first 6 months, the average length of an individual breast feed was longer among US women. Although both groups gave few supplementary feeds during the first 20 weeks after delivery, more non-bottle feeds were given thereafter in Manila. Use of bottle feeds was similar in both groups. Women who first ovulated before 6 months gave significantly fewer mean daily breast feeds during this period (8.5) than those who first ovulated after this point (10.7). Women who first ovulated before 6 months also had a lower percentage breast feeds of total feeds (84.2%) than women who first ovulated later (88.2%). The mean duration of amenorrhea was 25.3 weeks in Baltimore and 31.7 weeks in Manila; the average times before first ovulation were 27.0 weeks and 38.0 weeks, respectively. Multivariate analyses showed that the length of suckling per feed, the daily number of breast feeds, and the proportion of breast feeds were all significantly and independently associated with a low risk of ovulation. Up to 6 months postpartum, exclusive breast feeding reduced the risk of ovulation by 98-99% during amenorrhea and by 94-97% after anovular menstruation. Only amenorrheic women practicing exclusive breast feeding during the first 6 postpartum months can achieve a pregnancy rate below 2%. These findings suggest that contraceptive use is indicated among women who resume menstruating before 6 postpartum months or continue breast feeding beyond 6 months.

This review of periodic abstinence for family planning emphasizes terminology and distinctions between the prevalent methods, and issues that will enable the health practitioner to be informed about this family planning choice. Periodic abstinence developed in the 1930s when Ogino and Knaus independently discovered the timing of ovulation, and consequently the calendar-based rhythm method became sanctioned by the church. Philippine surveys find a 40/100 woman-year pregnancy rate with rhythm. The cervical mucus method is also known as the ovulation, Billings or mucus method. Coitus is permitted by the 4th night after the peak day. Symptoms may be obscured by vaginal or seminal fluids, infections, allergies, or drugs. The symptothermal method employs mucus symptoms and basal body temperature. Coitus is allowed on the 3rd night after the temperature rise. It has the lowest failure rate, ranging from 11.2-19.8. Some family planning groups also use other symptoms such as midcycle spotting or pain, cervical position, dilation or texture, moods or libido. Various teaching groups have published charts that facilitate charting symptoms, such as temperature graphs with wide scales to make it easier to read the temperature rise. Measuring efficacy rates is difficult, and different definitions are used for several types of failures. The most important factor in success with natural family planning is the motivation of the couple. The most common cause of failure is conscious departure from the rules. Some current issues regarding abstinence are possible risks of birth defects from aged gametes, the difficulty of predicting ovulation in women with irregular cycles, the effects of vaginal infection and illness on the mucus signs, the potential for sex selection through the use of timing of intercourse and development of tests and devices to predict ovulation.

Between April 1981 to March 1984, 419 urban middle class postpartum women entered the Natural Family Planning (NFP) program of the Pontificia Universidad Catolica de Chile. This NFP program teaches the Ovulation Method (Billings). Only 1.9% of the women did not learn how to recognize the mucus pattern of fertility awareness. The sample of 378 women who were practicing the method to avoid a pregnancy completed 4,935 months of use of the OM. The cumulative life table unplanned pregnancy rate at the 12th postpartum month was 11.1 +/- 1.9 and the Pearl Rate was 12.1 per 100 woman-years. The Pearl Rate calculation of method-related failure was only 2.1 pregnancies per 100 woman-years. The breastfeeding group showed a significantly lower rate of unplanned pregnancies than the nonbreastfeeding group and there was no significant increase in unplanned pregnancy at the time of menstruation among previously amenorrheic women as compared to later intervals. The protection against unplanned pregnancy shown in this study should be viewed as the combination of two factors: breastfeeding and the Ovulation Method (OM) of NFP.

Assays of first morning urine samples for pregnanediol-3 alpha-glucuronide (PdG), estradiol-17 beta-glucuronide (E2G), and LH were used to monitor endocrine function in 16 regularly cycling women and 22 postpartum nonbreastfeeding women. Twice weekly blood samples were also obtained from the postpartum group. Ovulation was inferred by a significant rise in LH and PdG, and reversal of the E2G to PdG ratio. Luteal phase PdG excretion was measured by the peak of smoothed PdG levels and the area under the smoothed luteal phase PdG curve. The lower limits of normal established in 16 cycling women were a peak luteal phase PdG of 4 micrograms/ml and an area under the PdG curve of 20 micrograms/ml. In the postpartum women, 32% of first cycles were anovulatory, and among ovulatory cycles, 73% had abnormally low luteal phase PdG excretion or short luteal phases. In second and subsequent cycles, 15% were anovulatory and 26% had luteal phase abnormalities. There was a progressive increase in luteal PdG excretion from the first to third cycles. The mean delay before first ovulation was 45.2 days, and no woman ovulated before 25 days after delivery. The correlations between blood and urinary hormone levels were 0.78 for PdG, 0.65 for E2G, and 0.55 for LH. We conclude that assays of daily early morning urine samples provide reliable information on ovulation and luteal phase adequacy, and that there is gradual recovery of pituitary ovarian function after parturition.

Sociodemographic and reproductive health data were gathered on approximately 200 acceptors in each of three programs offering the Ovulation Method of Natural Family Planning. The programs were located in Bangladesh, Kenya, and Korea. In addition, a one year follow-up was attempted to assess continuation and efficacy. Descriptive data show a variety of religious, educational, income, family, and family planning backgrounds among acceptors. Life table analyses of reported unplanned pregnancy occurrence among spacers and limiters combined was 15% at 12 months in Bangladesh, 11% in Kenya and 13% in Korea. The pregnancy rate at 12 months for all pregnancies, planned and unplanned, was 27.0, 26.0, and 23.7, respectively. In Bangladesh 37 of the 48 unplanned pregnancies were user-related as were all of the 14 unplanned pregnancies in Kenya and 17 of the 20 in Korea. Method failure was the reported cause of pregnancy in only 2 of the 83 unplanned pregnancies. A major aspect of this study was the assessment of higher risk population subgroups; increasing age, education, previous pill use and previous family planning are significantly associated with fewer unplanned pregnancies while religion, attendance as a couple, family planning intention, size and source of referral do not have a demonstrated impact on pregnancy occurrence. The time of entry into the data set in relation to time of initial NFP acceptance may be an important variable in assessing OM effectiveness.

National Surveys of Family Growth data showed that as of 1982, most lactating women who were sexually active used a contraceptive method; barrier methods were most frequently used. Black women and women of higher parity and lower educational level were more likely to be sexually active and not using a method.

Data from the National Survey of Family Growth are analyzed to estimate the prevalence of contraceptive use during lactation. Approximately 20 per cent of lactating women were sexually active and did not use a method in months two through six, postpartum. Among method users, the largest proportion chose barrier methods but 14 per cent used oral contraceptives in the early postpartum period. Between 1973 and 1976 there was an increase in the percentage of women who utilized a contraceptive method during lactation and a decrease in the per cent using oral contraceptives.

SummaryLactating women are at reduced risk of conception, but the individual woman may not wish to accept even a reduced level of risk. The risk increases when infant feeding supplementation begins and an alternative form of contraception is then required for the lactating mother. The relationship between lactation and fertility, trends in prolonged lactation, factors affecting these trends, and contraceptive use during lactation are reviewed. Suggestions for advising individuals and formulating programme guidelines are discussed.

Five programs of instruction in the ovulation method (OM) in diverse geographic and cultural settings are described, and characteristics of approximately 200 consecutive OM acceptors in each program are examined. Major findings include: the religious background and family size of acceptors are variable, as is the level of previous contraceptive use. Acceptors are drawn from a wide range of socioeconomic and religious backgrounds; however, family planning intention was similarly distributed in all five countries. In sum, the ovulation method is accepted by persons from a variety of backgrounds within and between cultural setting.Researchers studied sociocultural characteristics of successive acceptors from 5 diverse geographic and cultural programs that teach the ovulation method (OM). The programs were in Bangladesh, India, Kenya, South Korea, and the United States. Acceptors who professed Catholicism as their religion ranged from 87% in Kenya to 34% in Bangladesh. The percentage of couples who sought OM instruction varied from a high of 85% in Kenya to a low of 39% in India. This finding suggests that the OM method need not be learned by each partner to be successful. A large variation of educational attainment existed among countries and between men and women: men were generally more educated than women, as are both men and women in the US and South Korea. Despite this level of high educational attainment among the US and South Korean acceptors, paid employment outside the home occurred less often in these 2 groups. Except in the US, 9 represented the median number of years married, and the average number of children fluctuated around 3. Average desired family size included 3.4 in Bangladesh, 3.2 in India, and 6.3 in Kenya, all below the present total fertility rates (TFRs) of 6.3, 4.8, and 8.0 respectively. South Koreans wanted 2.6 children on average and Americans desired 3.6, almost equal to and above TFRs of 2.7 and 1.8, respectively. "Health reasons" led as the predominant reason for choosing the OM method and "the family planning worker" was the primary referral source, both of which are inconsistent with the myth that acceptors are basically religiously motivated.

SummaryBreast-feeding is an integral part of the reproductive process. This paper reviews the consequences of breast-feeding and bottle-feeding for the child and the mother with emphasis on health parameters and child spacing. Controversies that have arisen in this field are considered. Methodological problems in study design and areas for further research are discussed.