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Miriam H. Labbok - One of the best experts on this subject based on the ideXlab platform.
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Postpartum sexuality and the Lactational Amenorrhea method for contraception
Clinical obstetrics and gynecology, 2015Co-Authors: Miriam H. LabbokAbstract:This chapter reviews the literature on postpartum coital behavior, anovulatory and ovulatory bleeding episodes, and the methodology and efficacy of Lactational Amenorrhea Method and progesterone-only oral contraceptives. Of interest is the finding that breastfeeding women may resume coital behavior earlier postpartum, but report increased discomfort over time. The high efficacy of the Lactational Amenorrhea Method is confirmed and data illustrating possible relaxation of some criteria are presented. The conflicting guidance of CDC and WHO concerning immediate postpartum use of progestin-only methods is presented. The dearth of recent studies calls for new research on these topics.
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Post-Marketing Study of the Lactational Amenorrhea Method (LAM): Impact of Putting LAM in Women’s Hands
Advances in Experimental Medicine and Biology, 2002Co-Authors: Miriam H. Labbok, Anne E. PetersonAbstract:The Lactational Amenorrhea Method for family planning, based on the physiology of Lactational infertility, has undergone extensive clinical study. Concern remains, among clinicians and demographers alike, that this is a behavior-based method and is therefore unreliable. This study was undertaken to observe method use under conditions that would more approximate use outside of a research setting.
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post marketing study of the Lactational Amenorrhea method lam impact of putting lam in women s hands
2002Co-Authors: Miriam H. Labbok, Anne E. PetersonAbstract:The Lactational Amenorrhea Method for family planning, based on the physiology of Lactational infertility, has undergone extensive clinical study. Concern remains, among clinicians and demographers alike, that this is a behavior-based method and is therefore unreliable. This study was undertaken to observe method use under conditions that would more approximate use outside of a research setting.
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The efficacy of the Lactational Amenorrhea method (LAM) among working women.
Contraception, 2000Co-Authors: Verónica Undurraga Valdés, Miriam H. Labbok, Edda Pugin, Alfredo PerezAbstract:The purpose of this study was to assess the efficacy of the Lactational Amenorrhea method (LAM) for family planning among mothers who are separated from their infants by work. The study population, 170 urban middle class women who planned to return to work before 120 days postpartum, were interviewed monthly for 6 months postpartum and contacted at 12 months. The study population received clinical support for expressing their milk and exclusively breast-milk feeding the infants and for the use of LAM for birth spacing. The cumulative life table pregnancy rate by 6-month was 5.2%, with 3 pregnancies, one at each of months 4, 5, and 6. LAM for working women, as described in this article, might be associated with a higher pregnancy risk than LAM use among non-working women. Therefore, women using LAM should be informed that separation from the infant might increase their risk of pregnancy.
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Multicenter study of the Lactational Amenorrhea Method (LAM): II. Acceptability, utility, and policy implications
Contraception, 1997Co-Authors: Virginia Hight-laukaran, Miriam H. Labbok, Anne E. Peterson, Veronica Fletcher, Helena Von Hertzen, P.f.a. Van LookAbstract:A multicenter study of the Lactational Amenorrhea Method (LAM) was carried out to determine acceptability, satisfaction, and utilization in 10 different populations, and to confirm the efficacy of the method. Efficacy data are presented in a companion paper. A protocol was designed at the Institute for Reproductive Health (IRH), Department of Obstetrics and Gynecology, Georgetown University Medical Center, and reviewed and modified in collaboration with the co-sponsors, the World Health Organization, the South-to-South Cooperation for Reproductive Health, and the principal investigators from each site. Data were gathered prospectively on LAM users at 11 sites. Data were entered and cleaned on-site, and further cleaned and analyzed at IRH, using country-level and pooled data to produce descriptive statistics. The overall satisfaction with LAM was 83.6%, and continuation with another method of family planning was shown to be 67.6% at 9 months postpartum, in most cases exceeding previous use of contraception prior to use of LAM. Knowledge and understanding of the method at discontinuation were high, ranging from 78.4 to 88.6% for the three criteria. LAM can be used with a high level of satisfaction and success by women in a variety of cultures, health care settings, socio-economic strata, and industrial and developing country settings. The results confirm that LAM is acceptable and ready for widespread use, and should be included in the range of services available in maternal and child health, family planning, and other primary health care settings.
Kamani H. Tennekoon - One of the best experts on this subject based on the ideXlab platform.
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Serum leptin and Lactational Amenorrhea in well-nourished and undernourished lactating women
Fertility and sterility, 2005Co-Authors: Kamani H. Tennekoon, Sudharshani Wasalathanthri, Siththaniparainpillai Jeevathayaparan, Eric H. KarunanayakeAbstract:Objective To ascertain the possible role of leptin in the resumption of postpartum menstruation in lactating women with differing nutritional statuses. Design Analysis of data and blood samples collected during a previous prospective study. Setting Healthy volunteers in an academic research environment. Patient(s) Undernourished (body mass index [BMI]≤19 kg/m 2 ) and well-nourished (BMI≥26 kg/m 2 ) lactating women who resumed regular menstruation before 24 weeks and at or after 24 weeks postpartum. Intervention(s) Venous blood samples at four-weekly intervals and other clinical data collected until resumption of regular menstruation. Main outcome measure(s) Serum leptin concentrations. Result(s) Leptin concentrations were significantly higher in the well-nourished than in the undernourished women, irrespective of the time of resumption of menstruation. Time of resumption of menstruation did not significantly affect leptin levels within well-nourished and undernourished groups. Leptin significantly correlated with BMI (r = 0.78). The BMI (r = −0.53), but not leptin, was significantly and negatively correlated with the duration of Lactational Amenorrhea. Conclusion(s) Leptin is unlikely to be a major determinant of early resumption of regular menstruation in well-nourished women.
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Lactational Amenorrhea anovulation and some of their determinants a comparison of well nourished and undernourished women
Fertility and Sterility, 2001Co-Authors: Sudharshani Wasalathanthri, Kamani H. TennekoonAbstract:Abstract Objective: To study the effect of maternal nutritional status and some other possible determinants on Lactational Amenorrhea/anovulation. Design: Prospective matched-pairs study. Setting: Postpartum wards and community and academic settings. Patient(s): Thirty matched pairs of otherwise healthy, well-nourished (body mass index ≥ 26.00 kg/m 2 ) and undernourished (body mass index ≤ 19.00 kg/m 2 ) postpartum women were selected. Intervention(s): Infant feeding pattern was recorded weekly, and infant weights, maternal body mass index, and maternal PRL levels were estimated every 4 weeks until resumption of menstruation. Ovulatory activity was determined using urinary estrone and pregnanediol glucuronide concentrations. Main Outcome Measure(s): Time of resumption of menstruation, regular and ovulatory. Result(s): Well-nourished women resumed regular menstruation significantly earlier than undernourished women but resumed ovulatory menstruation at almost the same time. Undernourished women had fewer anovulatory cycles preceding first postpartum ovulation and a higher prevalence of formula feeding. Effect of body mass index on Lactational Amenorrhea became nonsignificant when nonintroduction of formula feeds, maternal age, and socioeconomic status were controlled for. Conclusion(s): Improved maternal nutritional status has no significant effect on fertility: ovulation is not advanced despite early resumption of regular menstruation.
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Lactational Amenorrhea/anovulation and some of their determinants: a comparison of well-nourished and undernourished women
Fertility and sterility, 2001Co-Authors: Sudharshani Wasalathanthri, Kamani H. TennekoonAbstract:Abstract Objective: To study the effect of maternal nutritional status and some other possible determinants on Lactational Amenorrhea/anovulation. Design: Prospective matched-pairs study. Setting: Postpartum wards and community and academic settings. Patient(s): Thirty matched pairs of otherwise healthy, well-nourished (body mass index ≥ 26.00 kg/m 2 ) and undernourished (body mass index ≤ 19.00 kg/m 2 ) postpartum women were selected. Intervention(s): Infant feeding pattern was recorded weekly, and infant weights, maternal body mass index, and maternal PRL levels were estimated every 4 weeks until resumption of menstruation. Ovulatory activity was determined using urinary estrone and pregnanediol glucuronide concentrations. Main Outcome Measure(s): Time of resumption of menstruation, regular and ovulatory. Result(s): Well-nourished women resumed regular menstruation significantly earlier than undernourished women but resumed ovulatory menstruation at almost the same time. Undernourished women had fewer anovulatory cycles preceding first postpartum ovulation and a higher prevalence of formula feeding. Effect of body mass index on Lactational Amenorrhea became nonsignificant when nonintroduction of formula feeds, maternal age, and socioeconomic status were controlled for. Conclusion(s): Improved maternal nutritional status has no significant effect on fertility: ovulation is not advanced despite early resumption of regular menstruation.
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Effect of skim milk supplementation of the maternal diet on Lactational Amenorrhea, maternal prolactin, and Lactational behavior
The American journal of clinical nutrition, 1996Co-Authors: Kamani H. Tennekoon, Eric H. Karunanayake, Harsha R. SeneviratneAbstract:Effect of skim milk supplementation of the maternal diet on Lactational Amenorrhea was studied in 30 pairs of healthy lactating women matched for parity, body mass index, and previous experience of Lactational Amenorrhea. Supplementation of the maternal diet had no significant effect on the time of resumption of regular menstruation or ovulation, maternal prolactin concentrations, breast-feeding pattern, maternal body mass index, or infant weight. However, the supplemented group breast-fed nearly exclusively (supplemental feeds were introduced but did not exceed 20% of total feeds) for a significantly longer duration (P < 0.05) than did the control group. Previous experience of Lactational Amenorrhea was significantly positively correlated with the time of resumption of menstruation in the supplemented (P < 0.01) and control (P < 0.05) groups when frequency of breast-feeding, maternal body mass index, and supplementary feeds to the infant were controlled for. Thus, maternal nutritional supplementation does not appear to affect the contraceptive benefit of lactation when the frequency of breast-feeding is not compromised but apparently lengthens the duration of nearly full breast-feeding.
Anne E. Peterson - One of the best experts on this subject based on the ideXlab platform.
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Post-Marketing Study of the Lactational Amenorrhea Method (LAM): Impact of Putting LAM in Women’s Hands
Advances in Experimental Medicine and Biology, 2002Co-Authors: Miriam H. Labbok, Anne E. PetersonAbstract:The Lactational Amenorrhea Method for family planning, based on the physiology of Lactational infertility, has undergone extensive clinical study. Concern remains, among clinicians and demographers alike, that this is a behavior-based method and is therefore unreliable. This study was undertaken to observe method use under conditions that would more approximate use outside of a research setting.
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post marketing study of the Lactational Amenorrhea method lam impact of putting lam in women s hands
2002Co-Authors: Miriam H. Labbok, Anne E. PetersonAbstract:The Lactational Amenorrhea Method for family planning, based on the physiology of Lactational infertility, has undergone extensive clinical study. Concern remains, among clinicians and demographers alike, that this is a behavior-based method and is therefore unreliable. This study was undertaken to observe method use under conditions that would more approximate use outside of a research setting.
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Multicenter study of the Lactational Amenorrhea method (LAM) III: effectiveness, duration, and satisfaction with reduced client–provider contact
Contraception, 2000Co-Authors: Anne E. Peterson, Helena Von Hertzen, R. Peŕez-escamilla, M.h. Labboka, V. Hight, P.f.a. Van LookAbstract:Abstract The objective of this effort was to assess the use and efficacy of the Lactational Amenorrhea Method (LAM) with reduced numbers of client–provider contacts. A co-sponsored multicenter study of LAM was performed to test the efficacy and acceptability of the method under “post-marketing” conditions, with investigator-initiated contact occurring only twice: at the time of intake and then again at month 7 of postpartum. These data are assumed to provide an assessment of LAM’s use, efficacy, and performance that more closely reflects the prevailing conditions of these populations during normal use. Three hundred and sixty-two subjects were recruited through centers that had participated in the previous, more contact-intensive studies. Using a cooperatively developed protocol, data were gathered prospectively on at least 10 and up to 50 LAM acceptors at nine sites, and entered and cleaned on site. Data were further cleaned and analyzed at the Georgetown University Institute for Reproductive Health (IRH) and the Department of Nutrition at the University of Connecticut. Using country-level and pooled data, descriptive statistics and life tables were produced. LAM efficacy in this sample is 100% because there were no pregnancies at any of the participating sites. Satisfaction with the method was high, and the rate of continuation on to another method after LAM was 66.7% at 7 months postpartum. Of the women who had never used family planning prior to LAM, 63.0% went on to use another method of family planning in a timely manner. LAM can be highly effective as an introductory postpartum family planning method when offered in a variety of cultures, health care settings, and industrial and developing country locales. Under conditions of limited client–provider contact, LAM remains effective and leads to acceptance of another method by about two-thirds of the acceptors. Women are able to use LAM effectively without extensive counseling or follow-up, with a high level of user satisfaction.
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Maternal Nutritional Status Is Inversely Associated with Lactational Amenorrhea in Sub-Saharan Africa: Results from Demographic and Health Surveys II and III
The Journal of nutrition, 1998Co-Authors: Yu-kuei Peng, Anne E. Peterson, Virginia Hight-laukaran, Rafael Pérez-escamillaAbstract:Breast-feeding is positively associated with the duration of postpartum Amenorrhea; thus it is a major determinant of fertility in countries where effective contraceptive methods are not widely available. The objective of these analyses was to examine the association between maternal nutritional status and Lactational Amenorrhea (LA) among breast-feeding women. Women who were not pregnant, who were breast-feeding, who were not using hormonal contraceptives and who had a child
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maternal nutritional status is inversely associated with Lactational Amenorrhea in sub saharan africa results from demographic and health surveys ii and iii
Journal of Nutrition, 1998Co-Authors: Yu-kuei Peng, Anne E. Peterson, Virginia Hightlaukaran, Rafael PerezescamillaAbstract:Breast-feeding is positively associated with the duration of postpartum Amenorrhea; thus it is a major determinant of fertility in countries where effective contraceptive methods are not widely available. The objective of these analyses was to examine the association between maternal nutritional status and Lactational Amenorrhea (LA) among breast-feeding women. Women who were not pregnant, who were breast-feeding, who were not using hormonal contraceptives and who had a child pooled analysis showed that women with BMI < 18.5 kg/m2 (odds ratio; 95% confidence interval: 1.6; 1.2-2.3) were more likely to remain amenorrheic at the time of the survey than their "better-nourished" counterparts. The 9-24 mo pooled analysis showed that the differential probability of being amenorrheic between undernourished and "better-nourished" women increased with time postpartum, where the adjusted difference in the median duration of Amenorrhea associated with maternal nutritional status among breast-feeding women was 1.4 mo. These results suggest that maternal nutritional status plays an independent role in the return of ovulation after delivery.
Alfredo Perez - One of the best experts on this subject based on the ideXlab platform.
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The efficacy of the Lactational Amenorrhea method (LAM) among working women.
Contraception, 2000Co-Authors: Verónica Undurraga Valdés, Miriam H. Labbok, Edda Pugin, Alfredo PerezAbstract:The purpose of this study was to assess the efficacy of the Lactational Amenorrhea method (LAM) for family planning among mothers who are separated from their infants by work. The study population, 170 urban middle class women who planned to return to work before 120 days postpartum, were interviewed monthly for 6 months postpartum and contacted at 12 months. The study population received clinical support for expressing their milk and exclusively breast-milk feeding the infants and for the use of LAM for birth spacing. The cumulative life table pregnancy rate by 6-month was 5.2%, with 3 pregnancies, one at each of months 4, 5, and 6. LAM for working women, as described in this article, might be associated with a higher pregnancy risk than LAM use among non-working women. Therefore, women using LAM should be informed that separation from the infant might increase their risk of pregnancy.
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The Lactational Amenorrhea Method (LAM): a postpartum introductory family planning method with policy and program implications.
Advances in contraception : the official journal of the Society for the Advancement of Contraception, 1994Co-Authors: Miriam H. Labbok, K A Cooney, Alfredo Perez, Francisco Sevilla, Verónica Valdés, V. H. Laukaran, S. Coly, Christian J. Sanders, John T. QueenanAbstract:It is well accepted that breasteeding contributes significantly to child survival and child nutrition. Healthful child spacing is associated with improved birth outcomes and maternal recovery. On a population basis, breastfeeding may contribute more to birth spacing than all family planning use combined in many countries. However, while breastfeeding does provide a period of infertility, until recently, there was no reliable way for an individual woman to capitalize on this Lactational infertility for her own efficatious child spacing. The Lactational Amenorrhea Method (LAM) is a new introductory family planning method that simultaneously promotes child spacing and breastfeeding, with its optimal nutrition and disease preventive benefits for the infant. LAM, as it is called, is based on the utilization of Lactational infertility for protection from pregnancy and indicates the time for the introduction of a complementary family planning method. LAM is recommended for up to six months postpartum for women who are fully or nearly fully breastfeeding and amenorrheic, and relies on the maintenance of appropriate brastfeeding practices to prolong Lactational infertility, with the concomitant delay in menses return. A recent clinical trial confirmed the theoretical 98% or higher effectiveness of the method and field trials are demonstrating its aceptability. Nonetheless, some demographers and family planning organizations continue to debate its value. The development, efficacy, and sequelae of the method are presented using data from several studies by the authors.
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The Lactational Amenorrhea Method (LAM): a postpartum introductory family planning method with policy and program implications.
Advances in contraception : the official journal of the Society for the Advancement of Contraception, 1994Co-Authors: Miriam H. Labbok, K A Cooney, Alfredo Perez, Francisco Sevilla, Verónica Valdés, V. H. Laukaran, S. Coly, Christian J. Sanders, John T. QueenanAbstract:It is well accepted that breastfeeding contributes significantly to child survival and child nutrition. Healthful child spacing is associated with improved birth outcomes and maternal recovery. On a population basis, breastfeeding may contribute more to birth spacing than all family planning use combined in many countries. However, while breastfeeding does provide a period of infertility, until recently, there was no reliable way for an individual woman to capitalize on this Lactational infertility for her own efficacious child spacing. The Lactational Amenorrhea Method (LAM) is a new introductory family planning method that simultaneously promotes child spacing and breastfeeding, with its optimal nutrition and disease preventive benefits for the infant. LAM, as it is called, is based on the utilization of Lactational infertility for protection from pregnancy and indicates the time for the introduction of a complementary family planning method. LAM is recommended for up to six months postpartum for women who are fully or nearly fully breastfeeding and amenorrheic, and relies on the maintenance of appropriate breastfeeding practices to prolong Lactational infertility, with the concomitant delay in menses return. A recent clinical trial confirmed the theoretical 98% or higher effectiveness of the method and field trials are demonstrating its acceptability. Nonetheless, some demographers and family planning organizations continue to debate its value. The development, efficacy, and sequelae of the method are presented using data from several studies by the authors.
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Santiago Breastfeeding Promotion Program: Preliminary results of an intervention study
American Journal of Obstetrics and Gynecology, 1991Co-Authors: Alfredo Perez, Verónica ValdésAbstract:A prospective intervention study was undertaken in Santiago, Chile, to assess the impact of a breastfeeding promotion program and the acceptance and use of the Lactational Amenorrhea method for natural child spacing. The intervention study significantly increased the duration of exclusive breastfeeding and Amenorrhea. In addition, the use of the Lactational Amenorrhea method proved highly efficacious, with an unplanned pregnancy rate of less than 0.5% by 6-month cumulative life table. Total family planning coverage at 6 months was increased in the intervention group.
Soledad Diaz - One of the best experts on this subject based on the ideXlab platform.
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Prolactin bioactivity and the duration of Lactational Amenorrhea.
The Journal of clinical endocrinology and metabolism, 1994Co-Authors: Carmen Campino, Soledad Diaz, S Ampuero, María Serón-ferréAbstract:In our population, only half of fully nursing women remain amenorrheic 6 months postpartum. The other half recover their menstrual cycles between 90-180 days postpartum in spite of a high suckling frequency and elevated immunoreactive PRL (IR-PRL) concentrations. To further investigate the association of PRL with the recovery of ovarian function, we compared PRL bioactivity (BIO-PRL) 3-4 months postpartum in fully nursing amenorrheic women who subsequently experienced long (> 180 days; n = 5) or short (< 180 days; n = 5) Lactational Amenorrhea. In the present study, BIO-PRL in plasma was measured by the Nb2 lymphoma cell assay in samples taken before and 30 min after a suckling episode at 0800, 1600 and 2400 h. Women in the long Amenorrhea group had higher overall mean BIO-PRL (mean +/- SE, 129.9 +/- 12.1 micrograms/L) than nursing women in the short Amenorrhea group (66.6 +/- 5.2 micrograms/L; P < 0.05). Mean basal values were similar, but the women in the long Amenorrhea group had more BIO-PRL in respon...
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prolactin bioactivity and the duration of Lactational Amenorrhea
The Journal of Clinical Endocrinology and Metabolism, 1994Co-Authors: Carmen Campino, Soledad Diaz, S Ampuero, Maria SeronferreAbstract:In our population, only half of fully nursing women remain amenorrheic 6 months postpartum. The other half recover their menstrual cycles between 90-180 days postpartum in spite of a high suckling frequency and elevated immunoreactive PRL (IR-PRL) concentrations. To further investigate the association of PRL with the recovery of ovarian function, we compared PRL bioactivity (BIO-PRL) 3-4 months postpartum in fully nursing amenorrheic women who subsequently experienced long (> 180 days; n = 5) or short (< 180 days; n = 5) Lactational Amenorrhea. In the present study, BIO-PRL in plasma was measured by the Nb2 lymphoma cell assay in samples taken before and 30 min after a suckling episode at 0800, 1600 and 2400 h. Women in the long Amenorrhea group had higher overall mean BIO-PRL (mean +/- SE, 129.9 +/- 12.1 micrograms/L) than nursing women in the short Amenorrhea group (66.6 +/- 5.2 micrograms/L; P < 0.05). Mean basal values were similar, but the women in the long Amenorrhea group had more BIO-PRL in response to suckling (160.1 +/- 4.0 vs. 71.9 +/- 6.7 micrograms/L; P < 0.05). Compared with their respective basal values, nursing women in the long Amenorrhea group demonstrated increased BIO-PRL in response to suckling, whereas the other group did not. The relationships between BIO-PRL and IR-PRL were similar in the two groups of nursing women before suckling. However, after suckling, the long Amenorrhea group had significantly higher BIO-PRL levels than IR-PRL levels (P < 0.05, by likelihood test) than the short Amenorrhea group. This suggests that suckling differentially changes in each group either the composition of PRL present or substances that may modify the bioactivity of PRL in plasma.
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Early difference in the endocrine profile of long and short Lactational Amenorrhea.
The Journal of clinical endocrinology and metabolism, 1991Co-Authors: Soledad Diaz, H. Cárdenas, A. Brandeis, P. Miranda, V. Schiappacasse, Ana Maria Salvatierra, C. Herreros, María Serón-ferré, H. B. CroxattoAbstract:The endocrine profiles associated with long and short Lactational Amenorrhea were assessed in a longitudinal study in which morning blood samples were drawn in 48 women from the first postpartum month until the recovery of ovulation and in a cross-sectional study in which the samples were drawn throughout 24 h at the end of the third postpartum month in 10 fully nursing and amenorrheic women. PRL, LH, FSH, estradiol (E2), progesterone, cortisol, and dehydroepiandrosterone sulfate were measured. In both studies we detected a smaller PRL increase in response to suckling (P < 0.001) and higher E2 levels (P < 0.001) in nursing women who ovulated within 6 months postpartum compared to those in women who did not. Such differences were observed early after delivery when all women were fully nursing and amenorrheic. These results suggest some probable sources of variability in the duration of Lactational Amenorrhea in our population. The greater PRL response to suckling associated with longer Amenorrhea may be du...
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Contraceptive efficacy of Lactational Amenorrhea in urban Chilean women
Contraception, 1991Co-Authors: Soledad Diaz, H. Cárdenas, P. Miranda, V. Schiappacasse, R. Aravena, M.e. Casado, H. B. CroxattoAbstract:Abstract The contraceptive efficacy of breastfeeding was assessed in 236 healthy urban women who were followed at monthly intervals during the first postpartum year. Proportional hazard models were used to evaluate the influence of time postpartum, menstrual status and breastfeeding pattern upon the risk of pregnancy. Time and menstrual status had a highly significant effect on this risk. Those women who remained in Amenorrhea had cumulative probabilities of pregnancy of 0.9% and 17% at 6 and 12 months postpartum, respectively. In those who recovered menstrual cycles, the risk rose to 36% and 55% at 6 and 12 months, respectively. Milk supplementation also increased significantly the risk when considered alone but not when time and/or menstrual status were included in the analysis. However, amenorrheic women who introduced bottle feeding, had a higher risk of pregnancy after 6 months postpartum than those who remained fully nursing. The analysis was unable to detect a significant influence of the nursing frequency. The results confirm that Lactational Amenorrhea is an effective contraceptive during the first six months postpartum. The first postpartum bleeding marks a great increase in the risk of pregnancy. Supplementation also increases the risk, particularly in amenorrheic women.
