Sandra Huffman, Center to Prevent Childhood Malnutrition, Bethesda, USA.
We have learned much over the last 20 years about the rationale for integrating nutrition and family planning activities. Both data from the World Fertility Surveys and the Demographic and Health Surveys have illustrated clearly the benefits of increasing birth intervals to reduce infant and child mortality. Improvements in both maternal and child nutrition have also been shown to be related to increases birth spacing. Few programmes, however link nutrition and family planning activities. Is it a lack of rationale that has prevented more linkages? More likely, programmatic and policy constraints have continued to prevent linkages between the two.
Perhaps the greatest constraint to the linkage of activities has been the focus of the programme: whether it serves women or children. Family planning programmes focus primarily on women while nutrition programmes focus principally on the child. Rather than spend another 20 years justifying and stressing the need to link family planning and nutrition activities, we may have more success if we start with a intervention that integrates both nutrition and population issues: breastfeeding promotion. Breastfeeding naturally addresses both the mother and the child, and it results in benefits for population programmes by increasing birth intervals and for nutrition programmes by enhancing child growth and reducing infection.
We now have documentation of how programmes can successfully integrate breastfeeding promotion with family planning. By replicating such activities we may convince programme managers that linking additional nutrition and family planning activities will have benefits for both. This could then allow future linkages to be approached with more optimism, so that in another 20 years, more such examples will be common place.
Much has been said and written over the last 20 years about the possible linkages between nutrition and population programmes. Much of the debate in the 1970s centered around whether an integrated approach could be as successful as a vertical approach, with family planning given the primary emphasis. The early 1980s saw community based contraceptive distribution (CBD) programmes being a focus, and in some for example in Indonesia, they expanded to include growth monitoring because CBD workers were unsatisfied only offering family planning services. Subsequently, Child Survival activities gained predominance with targeted interventions primarily focused on diarrhoea treatment and immunizations. While family planning and nutrition were seen as part of the Child Survival strategy, family planning was able to keep its integrity because of continued high levels of funding, and strong commitment on the part of policy makers and programme managers. Nutrition however played little role in the Child Survival programme, although considered one component, little funding was provided.
We are now seeing a switch back to a more stated integrated approach with population funds feeding into large scale Ministry of Health programmes. Most developing countries are now stressing the need to develop a more integrated approach to the provision of health, nutrition and family planning. However, once at a clinic or community level, family planning services are still quite separate from nutrition and health activities, even though their impacts on mortality are mutually beneficial.
Nutrition and Health Impact of Fertility Reduction
We have learned much over the last 20 years about the rationale for integrating nutrition and population activities. Both data from the World Fertility Surveys and the Demographic and Health Surveys (DHS) have illustrated clearly the benefits for infant and child mortality of increasing birth intervals. As the duration of the preceding birth interval increases within an individual country, the mortality rates decreases (Haaga, 1990). We also have clear evidence for an association between increased birth intervals and child nutritional status (Figure 1). Analyses of DHS data for Northeast Brazil, Burundi and Sri Lanka show that short preceding birth intervals are significant predictors of stunting (low height for age) in preschool children after controlling other socio-economic variables including residence, parents education and survival of preceding child, and breastfeeding status (Somerfelt et al., 1989).
Figure 1. Height-for-age for Preschool Children: Percent Stunted by Preceding Birth Interval
Source: DHS, 1991Births occurring to older women and women of higher parity are also at increased risk to mortality (Haaga, 1990). The relationship of parity and birth interval duration on child mortality and child growth probably have similar causation. They may be related to a competition for food and child care in the household, or because such an infant may be more likely to be born at low birth weight due to depletion in the mothers nutritional reserves.
We also have more information of the health benefits for women of delayed child bearing, extended intervals between births and reductions in high parity births and births to older women (NAS, 1989). Grand multiparae have higher rates of anemia and malpresentation of births, and are at much higher risk of dying during childbirth than younger women of lower parity except for first births (Haaga, 1990, International Safe Motherhood Conference, 1987).
Such results add further emphasis to previously reported data (Winikoff and Brown, 1980; Winikoff and Sullivan, 1983; Huffman, 1984, Zeitlin et al., 1982; Mosley and Chen, 1984). Numerous conferences and reports by international agencies have emphasized the importance of family planning for the health of women and children or the importance of nutrition programmes to promote increased child spacing (Better Health for Women and Children through Family Planning, 1987; International Safe Motherhood Conference, 1987; Measham and Rochat, 1988, Berg, 1973; Berg and Brems, 1990).
Most studies illustrate that the health impacts of family planning will be greatest by extending birth intervals. For example, Trussell and Pebley, (1984) showed that infant mortality would decrease by 10% and child mortality by 21% if all births were spaced at least two years apart. This can be compared to a 5% fall in each if childbearing were limited to maternal ages of 20-34, and a 4% decrease if fourth and higher births were eliminated. To be more effective, family planning programmes need to emphasize extending birth intervals. This will have additional benefits for child and maternal nutrition and health.
However while family planning programmes have been more successful in reducing higher parity births, they are not generally associated with increasing birth intervals. In fact, based on analyses of 39 WFS countries comparing low (0-10% of married women of reproductive age), medium (10%-40%) and high (40-60%) rates of contraceptive prevalence, the percent of births that have a birth interval less than 2 years, increases from 25% for countries with low contraceptive prevalence to 30% and 36% for higher contraceptive use countries, respectively (Bongaarts, 1987, Haaga, 1989).
Family planning has had its greatest success in terminating births, with 20% of couples in developing countries using sterilization (Mauldin and Segal, 1986). Worldwide, over one-third of effective modern contraceptive use is through sterilization. Sterilization terminates child bearing and thus does not lead to increased birth intervals with the important health benefits associated with enhanced birth intervals.
Family planning programmes have been inhibited in their ability to extend birth intervals. Nutrition programmes have generally been hesitant to promote family planning use often because of political or cultural sensitivities. This is certainly not due to a lack of rationale that has prevented more linkages between nutrition and population programmes. It would be helpful if we could address both concerns simultaneously by promoting an intervention that extends birth intervals in both programmes that is not subject to the constraints that have affected both nutrition and family planning programmes in the past.
Family planning programmes focus primarily on women (with men served only to a small degree). Nutrition programmes focus principally on the child. While women are those that need to carry out any proposed nutrition or health intervention, and are those who usually bring the child to receive services (whether they be curative care, growth monitoring, Vitamin A distribution, etc), the focus of attention is either on the mother or on the child. Even in the US, where family planning services provided by the government are often offered within the same clinics as those offering nutrition services for women and children, they are often offered on different days. It is more common that they are offered by different clinics. A current advocacy position in the US is the attempt to provide one stop shopping so that we can improve the linkages between nutrition and family planning here as well.
Rather than spend another 20 years justifying and stressing the need to link family planning and nutrition activities, we may have more success if we start with an intervention that integrates both nutrition and population issues: breastfeeding promotion. Breastfeeding naturally addresses both the mother and the child, and it results in benefits for population programmes by delaying the return of fertility and for nutrition programmes by enhancing child growth and reducing infection.
Breastfeeding Promotion in Nutrition and Health Programmes
The importance of breastfeeding promotion for child nutrition has been well acknowledged, but new research over the last several years has enabled the quantification of the substantial health benefits of exclusive breastfeeding during the first 6 months of life on the prevention of diarrhoeal morbidity and mortality. In urban slums in Brazil, the risk of mortality from diarrhoea was 25 times higher in infants 0-2 months of age who were not breastfed compared to those who were exclusively breastfed (Victora et al., 1987). Each additional feed of milk or non-milk liquids such as tea or juice was associated with a higher risk of dying from diarrhoea. This study also showed a decreased risk of mortality from acute respiratory illnesses (ARI) and other illnesses for infants who were breastfed compared to non-breastfed infants. This risk of dying from ARI was nearly 4 times as high for non-breastfed infants compared to those who were fully breastfed.
Additionally, recent studies in urban Peru and in urban and rural Philippines have shown benefits for diarrhoeal morbidity of exclusive breastfeeding and of any breastfeeding. In Peru, infants who received only herbal teas and other non-nutritive waters, had twice the risk of having diarrhoea than those who only received breastmilk (Brown et al., 1989). Popkin et al., (1990) report an increased relative risk for diarrhoea during the first 2 months of life of 17 for non-breastfed infants in urban areas compared to those exclusively breastfed, and a relative risk for infants receiving breastmilk and non-nutritive liquids 3 times that of exclusively breastfed infants. They also noted that the risk was even higher in urban areas, despite higher access to health care. In these same studies, breastfeeding has been shown to be effective in preventing acute respiratory tract infections.
Diarrhoea and ARI account for the majority of deaths among infants, and thus its health impact can not be over emphasized (Huffman and Steel, 1989).
We also know that malnourished mothers are able to produce sufficient amounts of breastmilk during the first few months of life to maintain adequate growth in their infants (Huffman and Combest, 1988). What about the impact on the mothers themselves? Some have suggested that womens health may suffer and that researchers should examine the real conditions under which women live before recommending for or against breastfeeding in a particular circumstance (Sadik, 1990). But what are the alternatives? If women under poor conditions do not breastfeed, infant mortality rates will increase, and for the individual women, the drain on her health of repeated short pregnancies associated with infant death may be worse than that of longer birth intervals and extended breastfeeding (Huffman, 1990). The risk of her own death under the high rates of maternal mortality seen in poor settings if much greater than the risk of sustained breastfeeding. Rather than pose the issue of whether women should be encouraged to breastfeed, it would be better for both maternal and child health to ask how we can improve maternal nutritional status.
As shown by Merchant and Martorell (1988), an increased interval helps the mother recover her nutritional reserves. The best way for her to do so, aside from the fertility reducing effect that breastfeeding provides, is to extend the interval between births by family planning. The most common reasons for termination of breastfeeding are a subsequent pregnancy or a subsequent child death (Thapa, 1989; Labbok, 1990; Huffman et al., 1980). Once menses returns, contraceptive use is needed to prevent another pregnancy. Thus nutrition programmes need to consider linking with family planning activities to help protect breastfeeding by providing contraception to the breastfeeding mother who is no longer amenorrheic. Data from the DHS survey shown in Figure 2 illustrate that from 4% to 24% of women 6 months postpartum are neither amenorrheic nor using contraception.
Figure 2. Breastfeeding/Not Amenorrheic and Not Using Contraceptives at Six Months Postpartum
Source: DHS, 1991As Merchant (1990) has shown, another common occurrence is the overlap of pregnancy and breastfeeding, with associated high energy demands for the mother. The use of appropriate family planning would be an important step to help restore the mothers nutrient reserves.
We therefore know clearly now that the promotion of exclusive breastfeeding is an important nutrition and health intervention for infants. Where can promotion of breastfeeding be supported? Health professionals in numerous fields need to have basic knowledge, not only on breastfeedings benefits, but how to manage it so that women can successfully breastfeed. Obstetricians and midwives who deliver infants provide an important link between birth, immediate breastfeeding, and during postpartum visits, when family planning also needs to be a part of the visit.
Where are there examples of nutrition programmes that support family planning activities? Integrated primary health care activities offer both, but even vertical programmes have also been shown to combine breastfeeding support and family planning information. In two breastfeeding promotion projects in Honduras and Guatemala, referrals are provided by breastfeeding counselors to family planning. In addition, exclusive breastfeeding is being taught as a family planning method, with the signs of return of fertility taught to breastfeeding women. Referrals to family planning services are offered so that women who choose to use breastfeeding as a family planning method, will know where to obtain additional protection.
A recent study conducted in San Pedro Sula in Honduras, showed that combining the promotion of breastfeeding with the promotion of family planning can lead to increases in both (Canahuati, 1989). The project included the creation of combined breastfeeding and family planning clinics, along with training of health professionals and changes in hospital practices. Along with pre-natal, postnatal and postpartum counseling, mothers received a discharge pack with pamphlets reinforcing messages of breastfeeding and family planning, and a sample of family planning methods, including 10 condoms and foam or tablets. Results of the project showed that exclusive breastfeeding at 3 months increased from 14% to 23% and use of modern methods of contraception increased from 54% to 68% at 6 months postpartum (Canahuati, 1990). The duration of postpartum amenorrhea also increased substantially.
Breastfeeding Promotion in Family Planning Programmes
Why should family planning programmes promote breastfeeding? We know that exclusive breastfeeding is highly effective during the first 6 months of life, when the lactational amenorrhea method is used. Since many women do not want to use contraception until menses has resumed, promotion of the breastfeeding practices that will optimize the fertility reduction effect of breastfeeding should be an important family planning objective. Keeping the current child alive of course is another important goal for family planning workers, because a child death is likely to be soon followed by another birth. We also have historical examples of increases in fertility associated with the decline in breastfeeding (Dyson, 1988). Theoretical calculations have also shown the large increase in contraceptive use that would be need with decreases in breastfeeding (WHO/NRC, 1983; Thapa et al., 1989).
We also know that the promotion of breastfeeding is not associated with decreases in modern use of contraception. For example, in Honduras the promotion of breastfeeding through the PROALMA project in the 1990s resulted in increases in breastfeeding, with concurrent decreases in total fertility in conjunction with increases in contraceptive use (Bailey et al., 1988).
The need for family planning programmes to include breastfeeding as an option is illustrated by data from both the WFS and the DHS which show a large proportion of women at six months postpartum who neither are amenorrheic nor using contraception. For example in Mexico where family planning usage is relatively high (51% of married women of reproductive age at 6 months postpartum), the DHS found that 16% were not breastfeeding nor using contraception (Figure 3). There is therefore a role for exclusive breastfeeding and its contraceptive effect for women currently protected by neither. Data from the other DHS countries illustrate a range from 2% to 18% of such women (Figure 4).
Figure 3. Breastfeeding and Contraception At Six Months Postpartum - Mexico, 1987
Source: DHS, 1991
Figure 4. Not Breastfeeding and Not Using Contraceptives at Six Months Postpartum
Source: DHS. 1991The amenorrhea associated with breastfeeding also has an important role in protecting women not using contraception. In Mexico, of the 48% of women 6 months postpartum not using contraception, half were amenorrheic (DHS, 1991). In Senegal, a country with low rates of contraceptive use, at 6 months postpartum, 82% were not using contraception, but nearly 90% of those were amenorrheic.
Postpartum family planning activities provide an important focus for breastfeeding education. Health workers in family planning programmes need to be sensitive to the impact that contraceptives can have on breastfeeding. Many programmes refuse to provide family planning, especially birth control pills, until a woman stops breastfeeding (Labbok, 1989). This often is associated with earlier termination of breastfeeding (Potter et al., 1987). While estrogen containing pills should preferably not be prescribed for breastfeeding women, especially in the first 6 months postpartum, if no other suitable contraceptives are available, their use should not be restricted to breastfeeding women.
The promotion of breastfeeding within such programmes will help in this impact, using a method that has additional benefits with little costs and few logistics. Where oral contraceptives or barrier methods are the common methods used, discontinuation and poor use effectiveness can limit the success of programmes.
Promoting exclusive breastfeeding with its high effectiveness, can lead to more successful family planning programmes (Jennings, 1990). In the last several years, much new information has emerged on the benefits of exclusive breastfeeding and associated lactational amenorrhea. A recent conference in Bellagio reviewed several clinical studies that assessed the impact of lactational amenorrhea on conception. The results showed that 2% of women became pregnant while amenorrheic during the first 6 months postpartum when they were fully breastfeeding (Family Health International, 1988). Based on these results, the Lactational Amenorrhea Method (LAM) is being promoted to be an additional method for use in family planning programmes (Labbok, 1990). This method is being tested in pilot projects in Mexico, Chile, Ecuador, and Honduras (Labbok, 1990). In Chile, preliminary data show a use effectiveness pregnancy rate of less than 2%. This can be compared to a use effectiveness rate of 3%-20% for oral contraceptives (Potter and Williams-Deane, 1990).
While there have been some successes in integrating nutrition and family programmes during over the last 20 years, many of the suggestions made over the last two decades have not been implemented. The most successful linkage between family planning and nutrition over the last 10 years, has in fact been the DHS survey. The first phase of the DHS conducted nationally representative surveys of women between ages of 15-49 in 30 countries between 1984-1989 (Rutstein and Sommerfelt, 1989). Twenty of these surveys included child anthropometry. The second phase of DHS will be conducted between 1988-1993, and most will contain anthropometric measures. The added information that has been collected on morbidity, mortality and nutritional status is most encouraging. When data on both family planning and nutrition needs are available within the same survey, then they are most likely to be used to affect policies affecting population and nutrition.
One reason for the inclusion of nutritional issues in the DHS was the concern for need for more data on breastfeeding and amenorrhea. We can use this as a model to further integrate nutrition and family planning activities by promoting breastfeeding, with subsequent benefits for maternal and child health and fertility reduction.
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Charlotte Gardiner, Ministry of Health, Ghana
As Dr Huffman has demonstrated so ably in her paper, family planning and nutrition programmes are synergistic resulting in improved health and survival of both mother and child. Improved maternal and child health by definition (since mothers and children constitute 60% or more of the population of developing countries) is an integral component of population and development planning. Characteristic of populations of the Third World, as we all know, is a young age composition, early age at first marriage and first birth, high fertility and birth rates, low educational attainment (especially amongst women) and low income levels (again especially amongst women). Each of these characteristics has been shown to be associated with impaired maternal and child health.
Governments in most Third World countries have, in the face of all this documentation, increasingly related over the past ten years or so, to what has been called the human face of development. They have responded with increased emphasis on agriculture and improved nutrition, maternal child health and family planning programmes, and increased emphasis on educational programmes both formal and non-formal.
The status of women is being influenced for the better by a number of factors: national and international. At the national level, migratory patterns result in more and more female-headed households and farmers; economic realities stimulate the active promotion of the private sector and integration of the non-formal sector within the private sector. All of which is leading to increased recognition of the role of women in national development. International development policies, fuelled by the arguments of the womens movement in developed countries, reinforce this pressure building at national level. Women-in-development programmes recognize the need for fertility control, improved female health and nutrition as well as child health and child survival.
Ironically, it seems to me, it is the issue of breastfeeding in relation to women in development that presents a dilemma for maternal, child health and family programmes. Breastfeeding for the first year (and preferably the first two years of a childs life) has been recognized as a child survival intervention affordable to even the lowest income populations. However, breastfeeding takes mothers time - time that is needed to improve her status through income-generation activities and time that is needed to improve her role in national development. This conflict weakens significantly the links between breastfeeding and family planning programmes and is fuelling a need for increased dependence on contraceptive use to regulate fertility. This is the issue that has caused the most opposition to adoption and implementation of the Code on the Marketing of Breastmilk Substitutes.
However, in the area of delaying the number of adolescent pregnancies, the linkage between nutrition and family planning appears to be unassailable worldwide. The need for an individual to complete physical (not to mention psychological) growth is readily acceptable. So is the need for adequate maternal nutrition prior to conception and delivery. In fact, this appears to be the most widely accepted rationale for child spacing. Child spacing is also universally accepted as being an intervention appropriate for preventing childhood malnutrition.
Family planning programmes benefit from these nutrition linkages. Indeed, our experience in Ghana is that family planning as a vertical programme is not acceptable: our IPPF affiliate. Planned Parenthood
Association of Ghana (PPAG), in 1987 initiated an Integrated Nutrition, Intestinal Parasite and Family Planning project in a pilot area. Four years after its inception, the pilot project is recording contraceptive use rates of 20% and more compared to the national rate of 5% (achieved 20 years after the National Family Planning Programme).
With the increased awareness created by Women in Development Programmes, we are tending to lose sight of the fact that in many developing countries, it is not only the situation status of women and children that is low. Men are also affected, albeit to a lesser degree.
In many developing countries there is a growing demand for male involvement in family planning (a recognition of existing male dominance in decision making). Linking nutrition and family planning would appear to address this issue of male involvement in family planning given the fact of female-dominated methods of contraception.
In summary, nutrition and family planning linkages need to be viewed in relation to other population programmes before the true synergism of their relationship can be demonstrated.