The family planning needs of breastfeeding women differ significantly from those of women who are not breastfeeding. Initially, lactation itself suppresses ovulation and delays a woman's return to fertility. Subsequently, women who are breastfeeding require advice about contraceptive methods that protect against pregnancy but also support breastfeeding.

Contraceptive methods must be weighed carefully in terms of their potential effects on breast milk production and infant health. Estrogen-containing methods, such as combined oral contraceptives, decrease milk volume and duration of lactation, and the breast milk of women who are using a hormonal contraceptive contains steroids that are absorbed by the infant.¹

During the first six weeks of life, when the most intense extrauterine neurological development occurs, hormonal contraceptive methods are contraindicated for breastfeeding women. However, there are other contraceptives that are appropriate during this period. Barrier methods and IUDs have no adverse effects on breast milk production or on infant growth and development. In addition, the lactational amenorrhea method (LAM) is a birthspacing option for women who are fully breastfeeding. After the sixth postpartum week, lactating women who wish to use hormonal methods should be advised to use progestin-only methods, which include the minipill, implants and injectables.²

This article examines the contraceptive advice given to, and contraceptive methods adopted by, breastfeeding women in Senegal, drawing on data from the Population Council's situation analysis of family planning service delivery points in that country. (Situation analysis, a rapid-assessment technique developed by the Council's Operations Research and Technical Assistance Project, systematically assesses the strengths and weaknesses of family planning programs and describes the functioning, availability and quality of family planning activities by collecting data from service delivery points.) Situation analysis data can be used to provide a "snapshot" of the advice and services given to breastfeeding women requesting contraception.

Methodology

The Senegal situation analysis was conducted in 1994 by the Population Council and the Senegalese Ministry of Health.³ All 180 service delivery points in the country that provided family planning services (public, para-public, International Planned Parenthood Federation affiliate and private) were included. The situation analysis consisted of an inventory of facilities and services at each site, an observation of service provision, an exit interview questionnaire for new family planning clients and an interview with providers and program managers.

All staff available at the time of the one-day site visit were interviewed. Two-thirds of the staff members who were interviewed and observed were midwives, and the remainder were community health agents and nurses' aides; no physicians or nurses were interviewed or observed. Information was gathered on providers' social and demographic characteristics, along with data on providers' knowledge of appropriate contraceptive methods for women who are breastfeeding. Additionally, data were collected from clinic managers on clinic policy regarding the provision of contraceptive services to lactating women.

At the exit interview, new family planning clients were asked to provide information on their social and demographic characteristics and were questioned about their breastfeeding status and contraceptive choices. They were also asked about the information they received from providers about contraception during lactation.

The exchange of information between providers and clients about both breastfeeding and contraception was assessed by direct observation of the provider-woman interaction and by the women's exit interviews. Women's responses in the exit interviews regarding contraceptive acceptance were used to verify observational data collected by the study team. Data on method choice were analyzed for all women and for breastfeeding women, then reanalyzed using the subset of women who were asked by the providers about their breastfeeding status or who breastfed in the provider's presence during the clinic visit. (Providers who did not ask about breastfeeding status directly may have assumed they knew a woman's status by asking, for example, the age of her youngest child and their knowledge of local breastfeeding practices. Since providers were not queried about their assumptions, only women definitely known to be breastfeeding were included in the subset analysis.)

Data were analyzed using SPSS, Release 6.1. Standard cross-tabulations and chi-square tests for significance were used.

Results

Background Information

The mean age of the 227 new family planning clients studied was 29 years, their median age was 28 and their average parity was 3.7 children. Approximately three-quarters of the women were married, and nearly one-quarter of them were in a polygamous union. Nearly all of the women were Muslim.

All women were visiting the clinic for the first time. Approximately 56% of these women said in their exit interviews that they were breastfeeding, and nearly all accepted a contraceptive method.

Provider Knowledge

When asked what advice to give a breastfeeding woman who wished to use a contraceptive, the vast majority of providers said that they would advise continuation of breastfeeding and use of a progestin-only method. Only 7% said that they would treat a breastfeeding woman no differently from other women.

Two-thirds of providers gave correct responses to questions about contraceptive advice for lactating women: avoid hormonal methods in the first six weeks, and, for the remainder of lactation, use only methods containing no estrogen. However, almost 40% of providers did not correctly identify breastfeeding as a contraindication to combined oral contraceptive use. In addition, almost 15% of providers believed that breastfeeding contraindicated progestin-only pill use, and a similar proportion felt that no other progestin-only hormonal methods should be used by breastfeeding women.

Approximately one-quarter of the providers had received training in family planning counseling, and almost two-thirds stated that they had been trained in clinical family planning. However, nearly three-quarters of those interviewed described their training as inadequate to provide general family planning services.

Program Policy

Nearly 85% of clinic managers stated that "instruction on breastfeeding" was one of the services provided by their program. However, there was no information available on the content of the instruction, the frequency with which it was actually offered or whether it was offered to all women or only upon request.

Almost 80% of clinic managers asserted that there were written procedural guidelines specifying that providers ask women about their breastfeeding status. Nevertheless, observation of provider-client interactions found that 21% of new clients seeking contraceptive services were not asked at the time of their visit whether they were breastfeeding.

Contraceptive Method Accepted

More than one-third of breastfeeding women said in their exit interviews that they had accepted combined oral contraceptives, and only about one-eighth of breastfeeding women planned to begin using progestin-only pills (Table 1), indicating that breastfeeding women, and perhaps the providers, were insufficiently educated about the importance of not using estrogen-containing contraceptives during lactation. A significantly lower proportion of breastfeeding women than nonbreastfeeding women accepted combined oral contraceptives (36% vs. 44%), and a substantially higher proportion of breastfeeding women accepted progestin-only pills (12% vs. 1%). But breastfeeding women were much less likely than nonbreastfeeding women to have accepted IUDs (16% vs. 21%). Still, IUD use was less than half that of reliance on combined oral contraceptives, regardless of the women's breastfeeding status.

Although women whom providers knew to be breastfeeding were marginally less likely to use combined oral contraceptives than were women known not to be breastfeeding (p=.06) and were more likely to have accepted progestin-only pills, the ratios differed little from women whose status was not determined (Table 2). LAM was not offered to any of the women.

High acceptance of estrogen-containing methods could not be attributed to a poor supply of alternate contraceptives. More than 95% of service delivery points offered progestin-only pills, over three-quarters had more than 80 packs of progestin-only pills in stock at the time of the study visit and fewer than 4% of all service delivery points reported being out of stock of progestin-only pills in the six months preceding the study. Over 75% of service delivery points offered at least one type of IUD; only 14% of clinics had fewer than 10 Copper T380A IUDs in stock. (Similar data for the other types of IUDs stocked were not collected.)

Discussion

A sizable proportion of women seeking family planning services in Senegal were breastfeeding. However, insufficient efforts were made by family planning facilities to meet the needs of these women.

First, providers did not always ask women their breastfeeding status before assisting them to make contraceptive choices. Second, providers did not adequately tailor contraceptive advice to women's current breastfeeding status, because of a lack of knowledge, a failure of communication or a divergence between knowledge and practice. Third, the providers had not been trained in the provision of LAM for the early postpartum period. Therefore, breastfeeding had not been built into the discussion of contraceptive method options, which would have ensured attention to women's breastfeeding status.

These results are better than findings from other situation analysis studies. In Ghana, a mere 19% of women visiting service delivery points were asked their breastfeeding status,⁴ and in Tanzania, just 50% of women were asked.⁵ Only in Zimbabwean family planning clinics did the proportion of women asked their breastfeeding status (83%) surpass the level seen in Senegal. However, providers in Zimbabwean community-based distribution programs, which provided both combined and progestin-only pills, only asked women about breastfeeding 35% of the time,⁶ and the content of the advice provided to breastfeeding women was often deficient.

In order to meet the needs of breastfeeding women, providers must have accurate information about the appropriate use of all contraceptive methods during lactation. While providers in Senegal had some knowledge of appropriate contraceptive advice for breastfeeding women, it was far from adequate. Many providers did not know that combined oral contraceptives are contraindicated for breastfeeding women. Those providers who were aware that some hormonal methods are not recommended for breastfeeding women often assumed that progestin-only methods fell under a blanket prohibition. More information is needed on providers' knowledge of breastfeeding and contraception so that specific improvements can be made in training curricula.

The existence of program protocols requiring providers to give specialized services to breastfeeding women did not ensure that breastfeeding women received appropriate care. Apparently, there were other reasons for the lack of appropriate services to breastfeeding women. Research to explicate the barriers to appropriate care, which may include lack of time during consultations, lack of training in or provision of LAM, or program emphasis on promoting a particular method, is a priority. Additionally, more information is needed on provider attitudes and on why providers do not always translate their knowledge about breastfeeding and contraception into practice.