Steroid Contraception and Its Effects on Lactation Are a Public Health Dilemma: A Review

I SWEAR by Apollo the physician ... I will prescribe regimen for the good of my patients according to my ability and my judgment and never do harm to anyone.. "-HippocratesFamily planning is taking its place as one of the leading priorities of many of the world's peoples.Steroid contraceptives are becoming a corner- stone in successful family planning programs.Yet, in some areas of the world, steroid contraceptives may become a double-edged sword."Breast feeding is one of the most effective ways of overcoming factors related to lack of resources, such as infection and poor nutrition.Since these factors are of such importance, a significant increase in the practice of breast feeding would surely lead to a reduction in infant mortality" (1).Conversely, a decrease in the practice of breast feeding would lead to an in- crease in infant mortality.Kwashiorkor means "first-second" according to some sources or "the disease the child gets when the next baby is born" (2).In other words, protein malnutrition comes about only after the mother stops breast feeding her infant.A frequent reason for the discontinuation of breast feeding is the next pregnancy.According to Semm (3), in only about 50 percent of lactating women is pregnancy delayed until after the cessation of breast feeding.Kwashiorkor is a major cause of infant morbidity in many developing countries.Therefore, in these countries, the length of time that a mother suc- cessfully breast feeds her infant has a profound influence on the future of that child.It might well be argued that increasing the time between pregnancies would increase the mean lactating time for the receiving infant.In many areas this increase would be advantageous to the infant's health.To obtain more time would require the use of a contraceptive.If, however, this contraceptive measure had as one side effect a decrease in the mean period of lactation or a detrimental effect on the nutritive value of breast milk, then it would lose much of its positive value.In this regard, steroid contraceptives have come under heavy attack. Results of StudiesMany studies of animals have been done to determine the effect of steroid contraception on lactation.These studies as predictors of human response must, however, be suspect, as Joshi and Rao (4) showed wide variation in response to the same drug in three animal species.They gave 5.0 mg norethynodrel plus 75,ug mestranol (see box) to the mouse, the rat, and the rabbit in a high and a low dosage form.The lower dose was