ICMR BULLETIN VOL. 24-No.-6 & 7-JUNE-JULY-1994.pdf

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Vol. 24, No. 6 & 7

June-July, 1994
CONTRACEPTION DURING LACTATION

Reproductive physiologists consider evolution of

Studies carried out in the sixties and seventies in

viviparity and lactation as the single most successful
attempt of nature in reducing reproductive wastage and

developed countries brought out unique advantages of

ensuring species survival. The growing foetus in utero

for (i) provision of appropriate nutrients in adequate

is assured of adequate nutrition and protection from

quantities to the infant; (ii) protection against infection;

external environmental hazards. After birth the nutri­
tional requirements of the infant are fully met during

(iii) promotion of growth, prevention of illness and

breast feeding. The fact that breast feeding is the best

death; and (iv) protection of the mother from early advent

early infancy. The presence of the mother affords some

of the next pregnancy, was documented by various

protection against adverse environmental factors during

infancy. Having assured belter survival of the species,

research scientists. There was a global movement to
promote breast feeding in areas where it had declined

nature also provided for concurrent fertility control to

and protect it in areas where it was the rule.

obviate over population and the attended hazards. Placental
steroids prevent ovulation during pregnancy. Suckling

As a part of studies on:he health benefits oflactation,

induced endocrine changes result in relative infertility

demographers, clinicians and endocrinologists explored

during lactation. Over millennia, breast feeding has been

the effect of lactation on fertility. These studies clearly

the major determinant of infant growth, health and

indicated that during the tirst few months of lactation

survival and the contraceptive effect of 1 actation has been
the principal regulator of human fertility.

when the women is solely breast feeding the child and

The first half of the present century witnessed a

is amenorrhoeic, breast feeding alone offers effective
protection against pregnancy. However, with the intro­
duction of supplements to the infant, and/or return of

profound decline in breast feeding in industrialised
countries, so that in the sixties most of the women in

menstruation the contraceptive effect of lactation wanes.

developed countries were not breast feeding their in­

fants; bottle feeding had become the convenient norm

Two often repeated and apparently contradictory
statements are made regarding the contraceptive effect

and the symbol of sophistication. Luckily the tradition

of breast feeding in developing countries. These are

of universal prolonged breast feeding in developing

(i) Breast feeding provides reliable contraception only

countries essentially remained unaltered during this

during the first few months and hence it is imperative

period.

that lactating women are given appropriate contraception

Division of Publication & Information, ICMR, New Delhi - 1 10 029

soon after introduction of supplements/return of men­

Lactation and Fertility

struation to prevent the too early advent of the next
pregnancy and all its adverse effects on maternal and

It has been recognised that lactation prolongs post­

child health; and (ii) in developing countries the con­

partum amenorrhoea and provides some degree of protection

traceptive effect of universal and prolonged breast feeding

against pregnancy1. There are, however, substantia)

prevents more pregnancies than all the temporary methods
of contraception provided by the governmental and

variations in the duration of lactational amenorrhoea and
interpregnancy interval between different commu-nities,

nongovernmental organisations.

in urban arid rural areas and in different income groups.
Variation in the suckling frequency and the time of

Both these statements are true; in fact they are not

introduction of supplements have jiow been shown to

contradictory but represent two sides of the same coin.

be the major factors responsible fbr these differences2.

Lactating mothers seeking reliable protection against
pregnancy cannot depend on the contraceptive effect of

The effect of lactation on fertility is mainly mediated

lactation beyond the initial few months. However, continued
lactation does postpone the advent of pregnancy by a

through the hormone prolactin. During the early weeks

period varying between 6-12 months. The cumulative
impact of this partial protection against pregnancy at

of lactation, plasma prolactin levels are high, and suckl ing
induces further elevation of these levels3. The presence
of high prolactin levels is associated with (i) altered

the community level is very high in countries like India
where lactation for 18-24 months is still the norm. In

pituitary responsiveness to GnRH, (ii) loss of pulsatile

India women using effective temporary contraceptive

ment and oestradiol production in spite of normal FSH

methods continuously, account for less than 10 per cent

levels, and (iv) enhancement of negative feedback and

of all eligible couple. It is therefore not surprising that

the abolition of a positive feedback mechanism between

in India even the partial contraceptive effect of lactation

oestrogens and FSH. It is still not known which of these

averts more pregnancies (because breast feeding is almost

changes in the hypothalamic-pituitary-ovarian axis is the
primary alteration induced by prolactin, that, in turn,

universal) than temporary methods of contraception

LH secretion, (iii) inhibition of ovarian follicular develop­

(because these are used by a very small proportion of

triggers other alterations. It is also possible that prolactin

women).

per se might induce many or all of these alterations in

During the last two decades there have been several

changes in the life style of women in India. There has
been increasing employment of women outside the home

the hypothalamic-pituitary-ovarian axis which result in
anovulation, amenorrhoea and infertility3.

and consequent reduction in udemand feeding**, earlier

In the early months of lactation when the infant is
exclusively breast-fed, suckling frequency and plasma

introduction of supplements to the infant, and some

prolactin levels are high; the mother has lactational

improvement in maternal nutritional status; these changes

amenorrhoea and is infertile. However, once the infant

singly or in combination may result in considerable

is older and supplements are introduced, suckling duration

reduction in duration of lactational infertility. With the

and frequency are reduced4; there is a fall in plasma

reduction in the duration of lactational infertility, there

prolactin levels (Table I)5; return of fertility and men­

is an ever increasing need for effective contraceptive

struation occur soon afterwards5-6.

use in lactating women to ward off the too early advent

of the next pregnancy. There are several contraceptive

Need for Contraception during Lactation

options available to lactating women. However, none
priate time for initiation of contraception and the choice

Ample data exist to indicate that conception during
lactational amenorrhoea is rare; less than 10 per cent

of appropriate method are critical for the well being

of women conceive during lactational amenorrhoea and

of both the lactating mother and her offspring . Lac-：

even this risk exists mainly in the month preceding

tation, nutrition and fertility interactions; the need for

resumption of menstruation5'7. With the return of men­

contraception during lactation; and the choice of appro­

struation the contraceptive effect of lactation wanes;

priate time and type of contraception in lactating women

lactation no longer offers effective protection against

under existing conditions in India are reviewed here.

pregnancy

of the contraceptives are perfect; the choice of appro­

68

fbr the

individual.

However,

even the

Table I. Prolactin levels (ng/ml) in relation to breast feeding practices

Duration of lactation (months)

Supplemented group

Nonsupplemented group

<3

3 -6

>6

Total

47.4 士 8.23

51.5 土 7.67

43.0 ± 5.73

46.1 ± 3.91

(6)

(5)

(11)

(22)

67.6 土 12.84

63.5 士 8.37

79.5 ± 18.63

67.7 ± 6.59

(9)

(19)

⑺

(35)

Values are mean ± SE

Mean values for no ns upplemented group were signiGcantly (p < 0.05) diflerenl from those for the supplemented group.
Figures in parentheses indicate the number of women studied.

Source: Ref. 5

relatively ineffective protection offered by continued
lactation after resumption of menstruation is of consid­

appropriate time in lactating women will prevent these
adverse consequences. Contraceptives chosen should,

erable demographic significance, especially in those
segments of the population in whom contraceptive use

however, not have any adverse effect either on lactation

or on the breast-fed infant.

is very low. Epidemiological studies in India have shown
that even in women who are not using any contracep­

tive, the mean
months5,8.

interpregnancy

interval

is

24-30

There is, however, another side to the same coin;
some epidemiological studies carried out at the National
Institute of Nutrition (NIN), Hyderabad have shown that
though conception during the first six months is rare,

Table II. Effect of pregnancy during lactation on maternal
weight in third trimester

Duration of
lactation(months)

Height
(cm)

Weight
(kg)

Not lactating

150.8 土 4.27
(1522)

49.5 ± 5.12
(1522)

<12

149.2 ± 6.13
(9)

41.9 ± 3.20
(8)

13-24

149.9 ± 4.49
(66)

47.1 士 6. 19*
(66)

>24

148.8 + 5.32
(3?)

46.9 ± 7.27**
(32)

no less than a third of all pregnancies occur in lactating

women9. If such a conception occurs, some woman stop
breast feeding; this has an adverse effect on the infant
who is suddenly weaned off the breast; others continue

breast feeding and incur the dual stress of pregnancy

and lactation. Data from these studies showed that among
764 women who conceived while lactating only 15.8
per cent did so in the first year of lactation, 33.6 per

cent conceived during the second year; 51.6 per cent
of women conceived during the third or subsequent year
of lactation9. Advent of the next pregnancy during
lactation has an adverse impact on maternal nutrition

(Table II)9. Birth weight of infants is lower if the
interpregnancy interval is short9. It has beeen reported

Values arc mean ± SD

"igures in parentheses indicate number of women studied

P * < 0.001; ♦* < 0.01

Source: Ref. 9

that foetal wastage, perinatal deaths10 and chil+ood

Over the last decade there has been an increasing

mortality rates11 are higher if interpregnancy interval

need for providing contraception to lactating women.

is less than two years. Initiation of contraception at the

Increasing numbers of women are seeking employment

69

ouiside the home. Work outside the home substantially

In the seventies when availability and utilisation of MCH

curtails suckling frequency and results in faster return

services were low, delivery and postpartum period

of fertility. Health education regarding weaning has led
to an increase in the proportion of women introducing

health care personnel and contraceptive care could be

supplements by four to six months and consequent earlier
return of fertility. Some available data from India and
elsewhere indicate that lactational amenorrhoea and
interpregnancy intervals are shorter in better nourished
women (Table III)5. Efforts to improve maternal nutri­
tion might therefore result in more rapid return of
fertility in lactating women. In view of all these, it is
imperative that all lactating women are provided with
contraceptives at the appropriate time so that the too

early advent of the next pregnancy does not nullify the
impact of intervention aimed at improving maternal and
infant nutritional status. A wide spectrum of contracep­

represented a time when women came into contact with
readily provided. Moreover it was felt that motivation
for accepting contraception might be high soon after

a delivery. These led to the evolution and implementation
of the All India Postpartum Programme. Initially the

Programme mainly provided tubal sterilisation, a pro­

cedure for which the postpartum period is eminently
suitable. However, the postpartum period may not be
the ideal time for initiation of many of the temporary
methods of contraception which are currently available
in the Family Welfare Programme.

In the present setting, introduction of contraceptives!

tives is available today . The health care providers should

other than sterilisation can be delayed until just prior

be given all the necessary information on providing

contraceptive care to lactating women so that they in
turn counsel lactating women enabling them to make
the right choice to suit their needs.

to the anticipated return of menstruation because women
do know that they are unlikely to conceive during
lactational amenorrhoea and hence may not be willing
to accept contraceptives earlier. Further, the mother

Table III. Effect of body weight on duration of amenorrhoea

does repeatedly get in touch with the health care pro­
viders during the first nine months after delivery for
immunisation of the infant and these contacts could be

Body weight
(kg)

Duration of
lactation

Lactational
amenorrhoea

<40 (276)

21.3 ± 10.61

13.1 + 11.74

40-44 (356)

22.5 ± 10.32

12.0+

8.23

45-49 (297)

20.8 ± 10.76

10.7 ±

9.36

50-54 (209)

20.7 ± 10.58

9.3 ± 10.13

>55 (222)

20.7 ±

8.53

8.2 ± 7.82

utilised in motivating and counselling her, so that she

is ready to accept an appropriate contraceptive method
when menstruation returns.

There are marked differences in the return of
menstruation and fertility not only between different
countries and communities but also between different
segments of the population in the same community. At

the community level the expected time of return of
menstruation can be approximately predicted on the basis
of existing information on duration of lactation and
lactational amenorrhoea. In parous women, the past

Values are' mean + SD
Figured in parentheses arc the number of women studied
Source: Ref. 5

lactational history can be of some help in assessing the

time of return of menstruation in that individual. In any
lactational period, return of menstruation usually fol­
lows shortly after introduction of supplementary foods,

Appropriate Time for Contraception
The appropriate time for introduction of contracep­
tives in lactating women varies to a large extent de­

and/or reduction in suckling frequency or duration. In

countries with liberalized abortion laws and ready availability
of abortion services, lactating women can be requested
to seek contraception after resumption of menstruation

pending upon the breast feeding and weaning practices

and/ or introduction of supplements to breast-fed infant.

and also the availability and utilisation of contraceptive

The small number of pregnancies occurring during

facilities. A fully lactating woman is infertile during
the first few weeks after delivery and hence does not

termination of pregnancy (MTP) and concurrent con­

need additional contraceptive measures during this period.

traception.

70

lactational amenorrhoea could be tackled by medical

Following resumption of menstruation after lacta­
tional amenorrhoea irregular cycles are common in

lactating women, especialy in the first 12-18 months
oflactation. Many lactating women come to the gynaecologist
when their periods are overdue with a request that if

they are pregnant, MTP should be done. It has been
estimated that about a third of such women are not
pregnant. Under these circumstances it is essential that
if clinical examination does not clearly confirm preg­

nancy, a pregnancy test should be done. If the woman
is pregnant, MTP can be done and concurrently appro­
priate contraceptive use can be initiated. If the woman

is not pregnant, unnecessary invasive procedure for

MTP can be avoided and she can be given contraceptive
of her choice during this visit, without waiting for the
next period.

Appropriate Type of Contraception
The decision regarding the type of contraception to
be used will have to take into consideration the safety
and efficacy of the method, its effect on the lactating

is unnoticed, pregnancy may occur, Yet another problem
with postpartum IUD insertion is that even when the
IUD is in place, the thread may be drawn up; the clinician

will then have to resort to X ray or uterine sounding
to find out whether the IUD is in situ.

Perforation is a rare complication following IUD
insertion; incidence of perforation varies depending

upon several factors including design of thelUD, technique
of insertion, time of insertion and operator's experience.
Some studies from Singapore14 and India15 suggest that
insertion of IUD in the hyperinvoluted small mobile
uterus during lactational amenorrhoea might be asso­
ciated with a higher incidence of perforation of the
uterus; the perforated copper IUD provokes peritoneal
adhesions and has to be removed by laparotomy as early

as possible after the diagnosis. Taking all these factors
into consideration it might be preferable to insert the

copper T soon after return of menstruation in lactating
women; MTP and concurrent IUD insertion can be done
in the small number of women who become pregnant

during lactational amenorrhoea.

woman*s health, on lactation and on infant health.

Tubal sterilisation
Tubal sterilisation appears to be the contraceptive
method of choice in parous lactating women who have

completed their family. Tubal sterilization can be done
safely in the postpartum period or at any time during

lactation. If anaesthesia given for the procedure is
carefully chosen and the infant is not Separated from
the mother for long, the procedure per se has no adverse
effect on lactation or on infant grawth.

Intrauterine contraceptive devices (IUDs)

Barrier methods of contraception
The physical barriermethods of contraception are
increasingly being advocated because they are "user

controlled” methods and have no systemic adverse
effects on maternal health, lactation or the breast-fed

infant. The fact that all barrier methods have a higher
failure rate than oral contraceptives (OCs) or IUDs has
to be kept in mind while prescribing these methods,
especially in rural areas where even today both avail­

ability and access to safe abortion services are limited.
Condoms are the most widely used barrier method

in India. It may be used in combination with spermicidal
IUD is a safe, inexpensive, effective contraceptive

with reasonably high continuation rates and hence is

the most widely used contraceptive method for birth
spacing in India. Available information suggests that
IUDs have no adverse effect on duration of lactation,

and on the quality and quantity of milk produced and

so have no adverse effects on infant growth12. IUD may

thus be the method of choice in lactating women re­
quiring a temporary method of contraception. Time of
insertion of IUD should, however, be chosen with care.

cream to improve ease of use and efficacy. In Tecent
years the fact that this combination of condom and

spermicide offers protection both against pregnancy and
HIV infection has led to advocacy for its wider use.
Correct and consistent use of condom and spermicidal
cream is essential for ensuring protection. Health edu­

cation on these aspects to ensure client*s understand­

ing and

compliance

should

precede

provision

of

these methods; efforts should also be made to reinforce

these important messages during each follow up visit.

IUD insertion in the immediate postpartum period is
associated with a high expulsion rate13. Several IUDs

Studies in experimental animals have shown that

have been specially designed for postpartum use, but

nonoxynol 9, a widely used spermicidal agent, is absorbed
from the vagina and its presence has been demonstrated

expulsion rate continues to remain high. If expulsion

71

in maternal serum, milk and the serum of the suckling

administer oestrogens to lactating DMPA users espe­

rat16.There are no data on the effect, if any, of this agent

cially as the bleeding is usually self limiting.

on breast-fed infant. It might, therefore, be preferable
not tcyise this spermicide in lactating women especially

Low dose progestational agents

in the early months of lactation until data on the possible
effects on breast-fed infants become available.

Low dosage progestogens do not have any adverse
effect on duration of lactation, quantity or quality of
breast milk and infant growth1719. Very little of the

Diaphragm and cervical cap are two women con­
trolled barrier contraceptive methods; they are usually
used along with spermicidal creams. Fitting the dia­

phragm and cervical cap requires considerable time of

both the client and the health care provider. Women
may dislike the genital manipulation involved in fitting
and removing the device. These devices need be washed,
dried and kept safely for reuse and some women may

steroids is excreted in breast milk and so far, no adverse
side effects have been reported in breast-fed infants

whose mothers were using low dosage progestogens.
It would, therefore, appear that low dosage progesto­
gens, oral, injectable or implant, could be used as the
preferred mode of contraception in women who opt for

hormonal contraception during the early months of

find this a problem. Cervical cap and diaphragm can

lactation. Low dose progestogens, irrespective of the

be used in lactating women only after involution of the

type of delivery system used, are associated with menstrual

uterus is completed.

disturbances in substantial proportion of the users. The
bleeding is seldom excessive and these contraceptives

Injectable contraceptives
Injectable contraceptives like dq)o-medroxy proges­
terone acetate (DMPA) have been widely used in lac­

tating women in some developing countries like Thai­
land. DMPA has no adverse effect on duration of
lactation, quantity or quality of breast milk, or growth

of the breast-fed infant. DMPA is transferred through

breast milk to breast-fed infants.Long-term longitudinal

studies on infants exposed to DMPA in breast milk have
not revealed any adverse long-term consequences of such

exposure. Information on use of nor ethisterone enanthate
(NET-EN) in lactating women is not as extensive as
DMPA; however, findings are essentially similar17.

do not have any adverse effect on maternal health.
However, unpredictable bleeding and spotting seen in
users of low dose progestogens may not be culturaly

acceptable in some situations. It is essential that women
who opt for low dose progestogens are counselled, so
that only those who are able and willing to accept

irregularities in menstruation choose this form of contra­
ception.

Low dose combination pills
Clinical and metabolic side effects of use of combina­
tion pills in lactating women are similar to those seen
in nonlactating women. However, use of combination
pill early in lactation causes a reduction both in the

Unpredictable pattern of bleeding and disruption of

duration of lactation and in the quantity of breast milk

the menstrual cycle is the major side effect associated

secreted. Data from a recent WHO study suggest that

with the injectables-DMPA and NET-EN. Both these

when use of combination pill is initiated at six weeks

cause a rapid return of menstruation when given to

postpartum, there is a rapid decline in milk volume by

lactating women who are amenorrhoeic. However, by

as much as 40 per cent at the end of 24 weeks, but

the second or third injection, most of the women become

the composition of milk remains essentially unaltered20.

amenorrhoeic again. In women who are normally men­

The infants did not show any growth retardation, most

struating at the time of initiation of the injectable,

probably because these infants had received adequate

amenorrhoea and unpredictable spotting occur during

supplements; however, if growth monitoring and timely

the first few months and later amenorrhoea of varying

introduction of supplements is not ensured, growth

duration is the rule18. Rarely DMPA/NET-EN users

faltering due to reduction in breast milk may occur.

experience excessive bleeding. Oestrogen administra­

tion is considered as the first line of management of

Studies conducted in India have shown that combination
pill use initiated after six months has no adverse effect

such bleeding episodes in some countries. Administra­

on duration of lactation548 or on infant growth21.

tion of oestrogen during lactation, that too in high doses,
might have an adverse effect on lactation and the breast­

Surveys have shown that in spite of information

fed infant. In view of this, it is preferable not to

being available on the adverse effect of |ow dose

72

combination pill use early in lactation, combination type

maternal nutrition, it is to be expected that there will

of oral contraceptives are still being prescribed to

be substantial reduction in duration of lactational amen­
orrhoea and lactation mediated infertility. This will
result in an increasing need for safe and effective

lactating women, in the developed as well as in

de­

veloping countries22. A specific instruction that com­
bination pills should not be used earlier than six month

po5t-partum, in lactating women has been included in
the Guidelines for OC Use in the National Family
Planning Programme in India, so that the potential

adverse effect of combination pill use early in lactation
is avoided.
There is substantial evidence that both oestrogens
and progestogens in oral pills are excreted in breast milk.

Enlargement of the breast, which subsides after discontinu­
ation of OC use or cessation of lactation has been
reported21 in breast-fed infants of women using combi­
nation OCs. No other adverse effects of steroid ingestion
through breast milk has so far been reported. Recent
studies have shown that the ingested steroids may induce
drug metabolising enzymes in the infant's liver23; the

contraceptives for lactating women in all segments of
the population in the next few years in India.

Data reviewed here suggest that there is, at the

moment, no ideal contraceptive free from side effects

and complications, which is suitable for use in all

lactating women, at all periods of lactation. Neither is
any such method likely to emerge in the foreseable
future. We do, however, have a variety of methods from

which the most appropriate method for any couple can
be chosen. The resources of the nation and that of the
individual, the socio-cultural milieu, health status of the

population, health care delivery system, and the needs
of the individual are factors which are to be taken into
consideration for choosing the appropriate contraceptive
method and providing it to women at the appropriate

implications, if any, of this finding on efficacy of drugs

time. A balanced presentation of the risks and benefits

administered subsequently to these infants, are at the

of all the available methods of contraception, and coun­

moment not clear. Considering all these aspects, the use
of combination pills should preferably be considered

the right method. Adequate follow up care will go a

selling is essential to ensure that lactating women choose

only in lactating women who are unable to use other

long way in providing not only safe and effective

methods of contraception.

contraceptive c^re, but also improvement in maternal

Studies undertaken in the NIN, Hyderabad, indicate
that use of hormonal contraceptives, irrespective of the

and child health.

References:

type, dosage or route of administration and mechanism
of action results in rapid return of menstruation in

1.

Kennedy, K.I., Rivera, R., and McNeilly, A.S. Consensus
statement on use of breast feeding as family planning method.
Contraception 39: 477, 1989.

2.

Contemporary Patterns ofBreast Feeding. Report of the WHO
Collaborative Study on Breast Feeding. World Health Organi­
sation, Geneva, 1981.

3.

McNeilly, A.S., Howie, P.W. and Houslan, M.J. Relationship
of feeding patterns, prolactin and resumption of ovulation
postpartum. In: Research Frontiers in Fertility Regulation.
Eds. G.I. Zutchni,M.J. Lebbok, and J J. Sciarra. Harper and
Row, New York, 1980, p.102.

4.

Shatrugna, V., Raghuramuhi, N. and Prema, K. Serum pro­
lactin levels in undernourished Indian lactating women. Br J
Nutr 48: 193, 1982.

5.

Ramachandran, P. Lactation-nulrition and fertility interaction,
In: Vfomen and Nutrition in India. Eds. C. Gopalan and S. Kaur.
Nutrition Foundation of India, New Delhi, 1989, p. 194.

6.

Prcma, K. and Ravindranalh, M. Effect of breast feeding
supplements on return of fertility. Stud Fam Plann 13: 293,
1982.

lactating women who are amenorrhoeic18. In some countries
like Bangladesh24 and India, women do not take con­
traceptive tablets regularly. Studies from Bangladesh

have shown that use of combination pills early during
lactation with poor patient compliance might shorten the

interpregnancy interval24. Thus, too early initiation of
combination pills might not have any beneficial effect

as far as fertility regulation is concerned in countries
where lactational amenorrhoea lasts for longer than one

year, irregularity in pill taking is common, and con­

tinuation rate of oral contraceptive use is low.

Conclusion
Lactation mediated infertility is the major natural

fertility regulating method especially in the poorer seg­
ments of the population in rural India. However, with

increasing employment of women outside the home in
HOntraditional occupations, earlier introduction of supple­

ments to the breast-fed infants and improvement in

73

7：

Prema, K., Naidu, A.N. and Neelakumari, S. Lactation and
fertility. Am J Clin Nutr 32: 1298, 1939.

17.

Hormonal contraception : New long acting methods. Popula­
tion Report, Series K 3: 58, 1987.

8.

Annual Report, National Institute of Nutrition, Hyderabad.
1980； p.91.

18.

9.

Ramachandran, P. Nutrition in pregnancy. In: \\bmen and
Nutrition in, India. Eds. C.Gopalan and S.Kaur. Nutrition
Foundation of India, New Delhi, 1989, p. 153.

Prcma, K. Duration of lactation and return of menstruation
in lactating women using hormonal contraception and IUDs.
Contracept Deliv Syst 3: 39, 1982.

19.

Bienneal Ropoit 1990-91. Special Programme of Research,
Development and Research Training in Human Reproduction,
WHO Geneva: 1992, p.U7.

20.

WHO Teisk Force on Oral Contracelpives. Effect of hormonal
contraceptives on breast milk composition and infant growth.
Stud Fam Plann 19: 361, 1988.

Annual Report,National Institute of Nutrition, Hyderabad.
1983, p. 141.

10.

11.

Sattar, Z.A. Birth spacing and childhood mortality. IPPFMed
Bull 17: 4, 1983.

12.

Belsey, M.A. and WHO Task Force on Oral Contraceptives.
Contraception during postpartum period and during lactation.
Ini J Oynaecol Obstet 25(suppl): 13 y 1987.

13.

Tietze, C. and Lewit, S. Evaluation of intrauterine devices:
(Nintli Progress Report of Cooperative Statistical Program).
Stud Fam Plann 1: 1, 1970

14.

Wolfer, D. Postpartum Contraception in Singapore. Excerpta
Medica Foundation, Amsterdam. 1970, p.134.

15.

Prema, K., Malhotra, U., Choudhury, S.D. and Saxena, N.C.
Uterine perforations with copperT IUD. Contracept Deliv Syst
. 2: 327, 1981.

16.

Chapvil, M. Studies on nonoxynol 9 — Intravaginal absorption,
distribution, metabolism and excretion in rats and rabbits.
Contraception 22: 325, 1980.

Ramachandran, P. Steroidal -contraception and lactation. In:
Proc. XI Nforld Congress on Fertility and Sterility. Ed. R.F.
-Harruon. MTP Press, Lancaster, 1984, p. 337.

21.

*22. Strauss, L.T., Speckhard, M., Rochat, R.W. and Senanayakc,
P. Oral contraception during lactation. A global survey of
physicians practice. Int J Gynaecol Obstet 19: 169, 1981.
23. Annual Report. Institute. for Research in Reproduction,
Bombay, 1993, p. 51.
24. Bhatia, S., Becker, S. and Kim, Y.J. Effect of o ral contracqjtion
acceptance on fertility in the postpartum period. Int J Gynaecol
Obstet 25 (suppl): 1, 1987.

This write-up is contributed by Dr. P. Ramachandran, Deputy
Director-General (Sr. Grade), ICMR Hqrs, New Delhi.

ABSTRACTS
Some Research Projects Completed Recently
Risk factors for hepatitis B infection in patients with

number of cancer patients with no history of HBV

cancer.

infection, matched for sex and duration of disease.

The study was carried out on 330 cancer patients

(200 in cross sectional study and 130 in the case control

stud》to identify the risk factors for hepatitis B virus
(HBV) infection, the burden of illness due to HBV and
the most cost effective method for prevention of HBV

infection among cancer patients. Oi the 200 patients in

the cross sectional study, 43 were positive for hepatitis B

surface antigen (HBsAg) and 46 were positive for
antibody. Maximum number of HBV marker positives
were

among

patients

with

malignancy

of

the

haemopoetic system, carcinoma breast and carcinoma
cervix. Significant factors for the transmission of HBV

among the patients were found to be antitumour
chemotherapy, blood transfusion and surgery.

Significant risk factors for HBV infection were found to
be

antitumour

chemotherapy,

blood

transfusion,

surgery and injections with reusable needle. Thus the
study showed that apart from the immunosuppressed
state, other risk factors also play an important role m
the transmission of HBV among cancer patients.

It is thus suggested that as the burden of illness is
high among cancer patients, vaccination of high risk
groups (ie) those
chemotherapy, those

preparing for antitumour
receiving blood transfusions,

patients

surgery,

undergoing

receiving multiple

and

those

patients

injections, will reduce the high

incidence of hepatitis B. Other precautions like use of

safe disposable syringes, screening of blood for HBV

65 cancer

markers before transfusion and proper sterilisation of

patients with acute hepatitis B along with an equal

instruments will further r^luce the high incidence. Early

The

74

case control study comprised

vaccination seems to be the only measure to prevent

HBV infection and its consequences among cancer
patients.

Sheela Rani
M. Narendranathan
Department of Gastroenterology
Medical College
Thiruvananthapuram.

Prevalence of hepatitis C in blood donors and persons
with chronic liver disease.
The prevalence of hepatitis C Virus (HCV) was
assessed in 100 consecutive voluntary blood donors, 100
patients with chronic liver disease and 12 patients with

hepatocellular carcinoma.

Six per cent of blood donors had anti-HCV.
Fourteen blood donors had alanine amino transferase
(ALT) levels more than 45 1U/1; of these 5 were antiHCV positive, indicating a correlation between high
ALT and anti-HCV positivity. Three of the blood
donors were HBsAg positive; one of whom was also
anti-HCV positive. Prevalence of anti-HCV in patients
with chronic liver disease was 17 per cent. Ninteen
patients were positive for HBsAg; of these 3 were antiHCV positive as well. A total of 35 patients gave history
of previous blood transfusions; among them 7 were
anti-HCV positive. Of the 47 cirrhotic patients with
history of significant alcohol consumption, 8 were
positive for anti-HCV. There were 4 cases of Wilson's
disease; none of whom had anti-HCV antibodies. One
patient of haemochromatosis with previous history of
blood transfusion was positive for anti-HCV. Three of
18 patients with chronic liver disease with no known

reduce the risk of post-transfusion HCV infection.

Rema, V.
M. Narendranathan
Department of Gastroenterology
Medical College,
Thiruvananthapuram.

Study of normal range of motion at the neck.
The study was carried out to estimate the normal
range of various movements of the neck in individuals
of various age groups using an objectively reliable,
simple instrument—the cervical goniometer, which is
based on the principle of gravity and pendulum. Four
basic movements at the neck were evaluated on 250
normal healthy subjects (125 male and 125 female) in
the age group of 20 to 70 years.

The mean normal values for the individual
movements of flexion, extension, lateral-flexion to right
and left and rotation to right and left were 53.3, 70.9,
46.6,48.6, 81.9 and 82.3 degrees respectively. The mean
normal values for the range of motion from-flexion to

extension, total lateral-flexion and total rotation were
124.5, 95.6 and 164.3 degrees respectively.

A significant decrease in each movement was
observed with increase in age in both sexes. Although
females showed slightly better mobility, differences in
he mean values amongst the males and females was not
significant.
In 25 patients of ankylosing spondylitis in the age

group of 20-30 years, restriction of all the movements in
general and lateral-flexion in particular was observed.

cause, were anti-HCV positive.

Cervical goniometry thus appears to be useful for
(i) estimating the normative values of the neck
movements (ii) assisting in the detection of ankylosing
spondylitis at an early age; (iii) systematically planning

One of the 12 patients with hepatocellular
carcinoma was anti-HCV positive; neither of the 2
HBsAg positive patients of hepatocellular carcinoma

and evaluating outcome of therapeutic procedures; and
(iv) evaluating the degree of disability.
J.B. Joshi

had anti-HCV antibodies.

Sitaram Bhartia Institute

The
combined

results

with

suggest
donor

that

screening

anti-HCV

testing

will substantially

of Science & Research
New Delhi.

75

ICMR NEWS
symposium on New Epidemics in Occupational Health

Dr. S.P. Tripathy, who took over as the Dircctor-

at Helsinki (May 16-19, 1994).

Gencral, ICMR, on Septembers, 1991 retired on May 7.
1994 (on superannuation) after distinguished service of

Dr. N.Raghuramulu, Dy. Director, (Sr. Grade),
National Institute of Nutrition, Hyderabad,

over three decades in the ICM R.

participated in the ninth workshop on Vitamin D at

Dr. (Mrs) G.V. Satyavati, a well known
pharmacologist (with specialization in Medicinal

Plants/ Indigenous Drugs/ Ancient Systems of
Medicine) and a reputed biomedical editor, took overas
the new Director-General of ICM R on May 7, 1994. She
is the first woman to head a scientific/or research agency
in India

***
The

following

***
meetings

of

various

technical

groups/committees of the Council were held at New
Delhi:

Expert Group on Tobacco

Orlando (May 28-June 2. 1994).
Dr. B.N. Saxena, Senior Dy. Director-General,
ICMR, participated in the Steering Committee meeting

of the WHO Task Force on Research on the
Introduction and Transfer of Technologies for Fertility
Regulation at Geneva (June 6-9, 1994)
Dr. S.K. Kar, Director, Rajendra Memorial
Research Institute for Medical Sciences. Patna,
participated in the meeting on Protective Immunity in
Lymphatic Filariasis at Glasgow (June 30-July k 1994).

Dr.

May 17, 1994

related Health Hazards.

Saxena

participated

in

the

International

Symposium on Ethics in Medicine and Reproductive
Biology and in the meeting of the International

Task Force on Food
Contamination/ Adulteration

June 13-14, 1994

Task Force on Male
Contraception.

June 22-23, !994

respectively).

Project Review Group of the

June 28-29, 1994

Dr. G.V. Satyavati, Director-General, ICMR, co­
chaired the meeting of the Joint Working Group of the
Vaccine Action Programme at Washingaton D.C. (July

Division of Human Resource
Development Research

Federation of Gynaecology and Obstetrics (FIGO)
Ethics Committee at Paris (June 6-8, and 9-10, 1994

1994).

Participation of ICMR Scientists in Scientific Events:
Dr. S.K. Kashyap, Director, National Institute of
Occupational Health, Ahmedabad, participated in a

Dr. T. Adak, Asstt. Director, Malaria Research
Centre, Delhi, participated in a workshop on New
Animal Model, organized under the auspices of the
Indo-US Vaccine Action Programmeat Baltimore (July
11, 1994).

ICMR AIDED SYMPOSIA/SEMINARS/WORKSHOPS/COURSES/CONFERENCES
Symposium/Seminar/Workshop/
Course/Conference

Date & Place

Contact Address

Workshop on Quality Controlled Determination
of Antimicrobial Susceptibility.

June 6-11, 1994;
(at New Delhi)

Prof. Ramesh Kumar, Chairman, Organising Comm­
ittee of the Workshop, Department of Microbiology,
All India Institute of Medical Sciences, New Delhi.

National Seminar on Recent Trends in Bio­
logical Sciences.

July 18-20, 1994;
(at Raipur)

Prof. M.L. Naik, Convenor of Seminar, Department
of Biosciences, School of Life Sciences. Pt. Ravi Shankar
Shukla University,Raipur.

National Workshop on Laboratory Diag­
nosis of Fungal Infections.

August 1-7, 1994:
(at Madurai)

Dr. V.V. Pankajalakshmi, Organising Secretary of
the Workshop, Institute of Microbiology, Maduari
Medical College. Maduari.

76

Symposium/Seminar/Workshop/

Contact Address

Date & Place

Course/Conference

Continuing Medical Education in Psychiatry.

September 10-11, 1994;

Dr.P.S.V.N. Shanna, Organising Secretary,4th Annual

(at Manipal)

Conference

of

of

Department

Indian

Psychiatry

Society,

Psychiatry,

Kasturba

Medical

the

College, Manipal.

M ICON-lntemationr 94.

November 9-12. 1994;

Dr. R. Shankaran, Chairperson of the Organising

(at Mysore)

Committee, MICON-latemationar94, Defence Food
Research Laboratory, Siddhartha Nagar, Mysore.

Lalji

Ill International Conference on DNA Finger­

December 13-16, 1994;

Dr.

printing.

(at Hyderabad)

Conference,

Singh,

Organising

Centre for

Secretary

Cellular and

of

the

Molecular

Biology, Hyderabad

COUNCIUS TRAINING PROGRAMMES FOR 1994-95
Virology

Training Course on Air Pollution Monitoring and
Risk Assessment (October 19-25, 1994).

At the National Institute of Virology, Pune:
...

Diploma in
Mayl995).

Medical

Virology (June

1994-

...

Training Course in Pesticide Residue Analysis
(December 5-9, 1994).

Reproductive Biology

Medical Entomology

At the Institute for Research in Reproduction, Bombay:

At the Vector Control Research Centre, Pondicherry:

...

Workshop on Gynaecologic Cytology and immuno­
cytochemistry (September 26-October 1, 1994).

Endocrinology

...

M.Sc in Medical Entomology (from August 1994:
for 2 years).

...

Short-term Course on Malaria, Filariasis and
Urban Vector Control for in-service candidates
(June 1994).

At the National Institute of Nutrition, Hyderabad:

Annual Training Course on Endocrinological
Techniques and their Applications (August 1September 16, 1994).

...

Nutrition

Laboratory Animal Technology

At the Laboratory Animal Information Service Centre,
National Institute of Nutrition, Hyderabad:
...

Training Course for Laboratory Animal Techni­
cians (June 15-July 31, 1994).

...

Training Course for Laboratory Animal Super­

At the National Institute of Nutrition, Hyderabad:
M.Sc.in Applied Nutrition (June 1,1994-February

visors (September 12- December 10, 1994).

28, 1995).

...

Annual Training Course in Nutrition (December 1,

1994-February 28, 1995).

Haematology

At the Institute of Immunohaematology, Bombay:

Occupational Health

...

Blood Bank Methodology for Technicians (August

At the National Institute of Occupational Health,
Ahmedabad:
...

Orientation Course on Occupational Health for

Industrial

1994).

Medical

Officers (September

19-24,

Training Course in Blood Group Serology and

9-September 8, 1994).

...

Training Course in Blood Group Serology and

Blood Bank Methodology for Medical Officers
(August 9-October 7, 1994).

77

INDIAN COUNCIL OF MEDICAL RESEARCH

Grant-in-aid for organising Seminars/Symposia/Workshops
Council provides partial financial assistance for organising Seminars/ Symposia/ Workshops.
Applications for grant of financial assistance (complete in all respects in the prescribed proforma), will
be considered only if furnished atleast four months before the date of commencement of the
Seminar/Symposium/ Workshop, etc.

Training Course on Modern Techniques for the Chemical Synthesis, Purification
and Characterization of Peptides
Institute for Research in Reproduction, Bombay.
Applications are invited from mid-career scientists/technologists (preferably below 40 years)
working in regular positions in Universities/ National Laboratories/ Research Institutions/in-house
R&D Centres for admission to a DBT-sponsored short-term training course on Modern Techniques for
the Chemical Synthesis, Purification and Characterization of Peptides, to be organized during
November 14-December 2, 1994. The course content will cover latest techniques in the synthesis of
peptides by the solid phase technology, their purification and characterization. There will be no
registration fee. TA/ DA will have to be borne by the sponsoring institution. Outstation candidates will
be provided accomodation at subsidized rates.
Applicants should give the following details:(i)

Educational qualifications, research experience, age.

(ii)

Present place and nature of work.

(iii)

Facilities for R&D available in the candidates9 laboratory.

(iv)

Present and future research interests of the candidate's laboratory.

(v)

How the candidate proposes to make use of the training in his/her research programmes.
Applications (duly sponsored) through proper channel, should reach Dr. K.S. Iyer, Course

Director, Institute for Research in Reproduction, Jehangir Merwanji Street, Parel, Bombay-400012
(Fax: 91-022-4139412) on or before August 31, 1994. Selected candidates will be informed by the third
week of September 1994.

Editorial Board
Chairperson

Members

Dr. G.V. Satyavati

Dr. Badri N. Saxena
Dr. C.R. Ramachandran

Director-General

Editor
Dr. N. Medappa*

Printed and Published by Shri J.N. Mathur fbr the Indian Council of Medical Research, New Delhi

at the ICMR Offset Press, New Delhi-110029
R.N, 21813/71

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