Does Breastfeeding Reduce the Need for Family Planning in Kenya? Misperceptions and Consequences

In honor of World Breastfeeding Week, the Global Nutrition Report is pleased to post an article by Elizabeth Kimani at the African Population and Health  Research Center in Kenya. This article highlights the misconceptions of lactational amenorrhea method during breastfeeding through a qualitative analysis of interviews, focus groups and community dialogues. While the global nutrition report will present data on breastfeeding and coverage of continuum of care interventions, nuanced qualitative assessments such as Elizabeth’s research dig deeper into barriers, concerns and belief systems that can impact the practice and appropriate coverage of breastfeeding and other interventions such as family planning. 

Breast milk remains the most important food for new born babies. It contains various nutrients and protective components for the baby’s optimal growth. Breastfeeding therefore offers numerous benefits to the baby: it reduces infections and mortality in children; improves mental and motor development and protects against obesity, metabolic diseases, and premature deaths later in life. Breastfeeding has also been known to give various benefits to the mother as it results in faster recovery after delivery, reduced blood loss following delivery, reduced maternal stress, faster loss of excess weight, protection against conception and reduced risk of breast and ovarian cancer. 1-3 It is no wonder that, for optimal growth, development and survival of children, the World Health Organization (WHO) recommends exclusive breastfeeding in the first six months of life and sustained breastfeeding with complementary feeding for up to two years old or beyond.4

Despite the well-known benefits of breastfeeding, misinformation and misperceptions regarding these benefits remain which may be detrimental to both the health of the baby and the mother. One benefit of breastfeeding that seems to be widely misunderstood is that of Lactational amenorrhoea as a family planning (FP) method. Lactational amenorrhoea method (LAM), which has long been accepted as a viable method of family planning5 refers to temporary post-natal infertility when a woman is breastfeeding. A consensus conference held in Bellagio in 1988 proposed guidelines under which LAM can be acceptable as a family planning method. For LAM to be acceptable, a mother has to fully or nearly fully breastfeed and must remain amenorrheic (not menstruating), during the first six months after birth. When these two conditions are fulfilled, breastfeeding provides over 98 per cent protection from pregnancy in the first six months after birth. 6

The gospel of LAM has been widely spread in communities all over Kenya, but it seems that the conditions under which LAM is effective as an FP method are not adequately explained or understood. LAM has seemingly been strongly embraced because it is a natural method with no side effects that people often associate with other family planning methods e.g. “FP lowers sexual urge”, “FP reduces breast milk production,” easy access and no cost. What is really surprising, according to recent research by the African Population and Health Research Center (APHRC) in collaboration with the Unit of Human Nutrition and Dietetics, Ministry of Health, are the misperceptions regarding this method and the consequences of these misperceptions with regards to breastfeeding and health of the child.

Through a public engagement study funded by the Wellcome Trust, APHRC together with the Unit of Human Nutrition and Dietetics, Ministry of Health conducted qualitative studies across six counties, representing six geographical regions in Kenya, including Nairobi, Kwale, Vihiga, Kiambu, Machakos and Kajiado. These studies involved in-depth interviews (IDIs), key informant interviews (KIIs), focus group discussions (FGDs) and community dialogues (CDs) with mothers, fathers, health care workers, community health workers (CHWs), community leaders and traditional birth attendants (TBAs) and other community representatives regarding their knowledge, attitudes and practices on breastfeeding and other infant feeding practices. Narratives from these studies clearly portray the misperceptions regarding use of LAM. As illustrated below, there is belief that any breastfeeding (whether exclusive or not, and whether in the first six months or not) is protective against conception.

"Some say, like another woman told me she breastfeeds because she is not using any family planning method, so she has breastfed for three years now… You cannot conceive if you are breastfeeding!” (FGD, (FGD, Young Mothers, Nairobi slums)

While some women may be lucky to delay conception for the desired duration, many women conceive while breastfeeding and end up disappointed by unplanned pregnancy.

“Breastfeeding is a form of FP and I can say it is effective from what I have personally experienced because I breastfed my children for two and a half years during which I could stay even two years without monthly periods. There are some who breastfeed and get pregnant and I do not understand this.”

(KII, TBA, Nairobi slums)

The consequence of the unplanned pregnancies is that they shorten the duration of breastfeeding. Mothers get pregnant within a short time following delivery and “the day that you realize you are pregnant you stop breastfeeding” (FGD, CHWs, Kajiado). While breastfeeding could continue for some months even when the mother gets pregnant to safeguard the health of the child, there are widespread myths across the country associated with breastfeeding while pregnant. Many people believe that breastfeeding while pregnant drastically affects the breastfeeding child: the child may become sick with diseases like diarrhoea or marasmus, may be deformed or may actually die. Many mothers have to therefore stop breastfeeding immediately when they discover they are pregnant, a fact illustrated in the following excerpts:

“When my wife got pregnant, I shared the news with my mother who told me that the baby should not be breastfed anymore nor should the mother continue sleeping with the baby anymore. They should not share the same blanket because that warmth will affect the baby”

(FGD, Man, Vihiga)

“They don’t breastfeed while pregnant. They say that the child in the womb will become stupid. Some say that the one breastfeeding will have diarrhoea or even become sick… we were told to tell them to continue breastfeeding even if they are pregnant but they do not accept”

(FGD, CHWs, Kiambu)

“They believe that the milk is spoilt and it will harm the baby and in case they breastfeed the baby then it becomes sick they say it is because of the pregnancy so the milk has become watery and that is why the baby has diarrhea.”

(KII with Health Professional, Kwale)

“It is said that if you breastfeed the child (while pregnant), the child  will get marasmus…I hear that when pregnant, the milk is hot so when the child feeds they get diarrhea… also when one breastfeeds when pregnant the child stops developing they say that the milk is harmful to the baby… I think it is not good because the breastfeeding baby is finishing the food for the one in the womb… For us we think that when a baby is in the womb, they are using the body’s food so this other one should not be allowed to also eat that food”

(Community Dialogue, Machakos)

The misperceptions regarding LAM may be a major contributing factor to the high levels of unmet need for family planning (25 per cent) among currently married women and also the high prevalence of unintended pregnancies (43 per cent) among women of reproductive age (15-49 years old) reported in Kenya. 7 Consequently, unintended pregnancies, coupled with the myths surrounding breastfeeding while pregnant may contribute to the high levels of malnutrition among children in Kenya with stunting levels of 35 per cent among children aged less than five years. 7 There is an immediate need to address the misperceptions surrounding LAM and the myths surrounding breastfeeding to achieve optimal breastfeeding practices, growth and the development of children in Kenya.

References

1.            Lanigan J, Singhal A. Early nutrition and long-term health: a practical approach. Proc Nutr Soc 2009: 1-8.

2.            Victora CG, Adair L, Fall C, et al. Maternal and child undernutrition: consequences for adult health and human capital. Lancet 2008; 371(9609): 340-57.

3.            Grantham-McGregor S, Cheung YB, Cueto S, Glewwe P, Richter L, Strupp B. Developmental potential in the first 5 years for children in developing countries. Lancet 2007; 369(9555): 60-70.

4.            WHO. Global strategy for infant and young child feeding. Geneva: WHO 2003.

5.            Perez A, Labbok MH, Queenan JT. Clinical study of the lactational amenorrhoea method for family planning. Lancet 1992; 339(8799): 968-70.

6.            Kennedy KI, Rivera R, McNeilly AS. Consensus statement on the use of breastfeeding as a family planning method. Contraception 1989; 39(5): 477-96.

7.            Kenya National Bureau of Statistics (KNBS), ICF Macro. Kenya Demographic and Health Survey 2008-09: Calverton, Maryland: KNBS and ICF Macro; 2009.