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ring-enhancing lesions over a matter of weeks, providing directevidence for the conjecture that older lesions can expandcentrifugally.The scanner is supported by the Multiple Sclerosis Society of Great Britain

and Northern Ireland and by the Medical Research Council. Gadolinium-DTPA was provided by Schenng AG for clinical trial and named patient use.

Multiple SclerosisNMR Research Group,

Institute of Neurology,London WC1N 3BG

A. G. KERMODEP. S. TOFTSD. G. MACMANUSB. E. KENDALLD. P. E. KINGSLEYI. F. MOSELEY

E. P. G. H. DU BOULAYW. I. MCDONALD

1. Harding AE, Radue EW, Whiteley AM Contrast-enhanced lesions on computerisedtomography in multiple sclerosis. J Neurol Neurosurg Psychiatry 1978; 41: 754-58

2. Vinuela FV, Fox AJ, Debrun GM, Feasby TE, Ebers GC. New perspectives incomputed tomography of multiple sclerosis AJR 1982, 139: 123-27.

3. Grossman RI, Gonzalez-Scarano F, Atlas SW, Galetta S, Silberberg DH. Multiplesclerosis. gadolinium enhancement in MR imaging. Radiology 1986; 161: 721-25

4 Miller DH, Rudge P, Johnson G, et al Serial gadolinium enhanced magneticresonance imaging in multiple sclerosis Brain 1988; 111: 927-39.

5. Kermode AG, Tofts PS, McDonald WI, MacManus DG Towards quantification ofgadolinium-DTPA leakage in multiple sclerosis. 7th annual meeting of Society ofMagnetic Resonance in Medicine (San Francisco, August, 1988); works in

progress, 21

6 Hawkins CP, Munro P, Kesselring J, et al Gadolinium-diethylenetriamine-pentaceticacid and gadolinium-protein markers used to study blood-brain barrier disturbancein vivo in experimental allergic encephalomyelitis 7th annual meeting of Society ofMagnetic Resonance in Medicine (San Francisco, August, 1988), works mprogress, 103.

7. Prineas JW, Connel F. The fine structure of chronically active multiple sclerosisplaques. Neurology NY 1978; 28 (suppl) 68-75

Consensus Statement

BREASTFEEDING AS A FAMILY PLANNINGMETHOD*

ALTHOUGH the benefits of breastfeeding for infant healthare universally recognised, many people are sceptical aboutthe use of breastfeeding as a family planning method. Aninternational group of scientists gathered in August, 1988, atthe Bellagio Study and Conference Centre, Italy, with thesupport of the Rockefeller Foundation, Family HealthInternational, and the WHO Special Programme of

Research, Development and Research Training in HumanReproduction. This group came to consensus about theconditions under which breastfeeding can be used as a safeand effective method of family planning. It recommendedthat lactational amenorrhoea should be regarded as anappropriate method of fertility regulation for many women,and that this strategy should be incorporated into familyplanning programmes and presented as one element ofinformed choice, particularly when other family planningmethods are not readily available or desired.Two alternative strategies were proposed to take

advantage of the period of lactational infertility:breastfeeding can be used either as a birth spacing method inits own right, especially when there are no alternatives

*Participants: Ann Ashworth, London School of Hygiene and TropicalMedicine; Samir Sanad Basta, UNICEF, New York; W. B. Rogers Beasley,Rockefeller Foundation, New York; James B. Brown, University of

Melbourne; Oona Campbell, London School of Hygiene and TropicalMedicine; Soledad Diaz, Universidad Catolica, Santiago; Anna Glasier,University of Edinburgh; Barbara Gross, Westmead Hospital, Westmead,NSW; Kathy Hinson, Family Health International, Research Triangle Park,NC; Peter Howie, Ninewells Hospital and Medical School, Dundee; SandraL. Huffman, Center to Prevent Childhood Malnutrition, Bethesda, MD;Boonsri Israngkura, Pramongkutklao Army Medical College, Bangkok;Kathy I. Kennedy, Family Health International; Miriam H. Labbok,IISNFP, Georgetown University Medical Center, Washington, DC; Alan S.McNeilly, MRC Reproductive Biology Unit, Edinburgh; Suzanne

Parenteau-Carreau, Serena Canada, Montreal; Barry M. Popkin, Universityof North Carolina, Chapel Hill, NC; D. Malcolm Potts, Family HealthInternational; Roberto Rivera, Family Health International; MamdouhShaaban, Assiut University, Assiut; James Shelton, Agency for InternationalDevelopment, Washington, DC; Roger V. Short, Monash University,Melbourne; Paul F. A. van Look, World Health Organisation, Geneva;Nancy Williamson, Family Health International; James Wood, PennsylvaniaState University.

This report was contributed by Family Health International. The fullconference report is available from Kathy Kennedy, Family Health

International, PO Box 13950, RTP Branch, Durham, NC 27709, USA.

available or if a couple chooses not to use other familyplanning methods; or it can be used as a means to delay theintroduction of other family planning methods. Wherethere are difficulties with family planning availability,acceptability, or continuation (especially duringbreastfeeding), exploitation of the natural infertility of

breastfeeding followed by use of another family planningmethod (rather than the simultaneous employment of both)may serve to maximise the interbirth interval.The consensus was that the maximum birth spacing effect

of breastfeeding is achieved when a mother "fully" or nearlyfully breastfeeds and remains amenorrhoeic (bleedingbefore the 56th postpartum day being ignored). When thesetwo conditions are fulfilled, breastfeeding provides morethan 98 % protection from pregnancy in the first six months.At six months, or if menses return or if breastfeeding ceasesto be full or nearly full before the sixth month, the risk ofpregnancy increases. As soon as one of these events occurs,consideration must be given to adoption of other means offamily planning if a high degree of protection is desired orneeded.

Full or nearly full breastfeeding is associated with longerperiods of lactational amenorrhoea and infertility than

partial breastfeeding. Suckling frequency and the durationof the longest period of no suckling activity have sometimesbeen used as measures of the amount of breastfeeding.However, these variables may be hard to define and

implement as part of a set of general recommendations.Women who wish to or need to rely on the birth spacing

effect of breastfeeding should delay for as long as possiblethe introduction of other regular feedings to the infant’s diet,but without jeopardising infant growth and development.When additional foods need to be introduced (usuallybetween the fourth and sixth month postpartum), womenshould be encouraged to continue breastfeeding frequently(day and night) if they wish to maintain a milk supply.

It is hypothesised that, if additional foods are introducedinto the baby’s diet gradually over an extended period,continued breastfeeding may still exert a substantial

antifertility effect for a year or more. The key here is thatbreastfeeding is not reduced and other foods do not replacebreastfeeding. This seems to be the breastfeeding pattern inmany settings with long durations of lactationalamenorrhoea. Local operational definitions of "fullbreastfeeding" must be used and evaluated.

In general, lactational infertility decreases with time.After the sixth month postpartum, when breastfeeding willprobably cease to be full or nearly full, it is increasingly likelythat fertility will precede the first vaginal bleed. On the other

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hand, the period of lactational infertility is longer in

populations where the natural duration of lactation is verylong; and this may be dependent, at least in part, on thepattern of feeding and supplementation. Pregnancy ratesassociated with lactational amenorrhoea after the sixth

postpartum month, although low, have not been quantifiedprecisely by time postpartum or breastfeeding pattern.Demographic survey data suggest that the risk of pregnancyamong lactating amenorrhoeic women in developing

countries is not greater than 10% after six months, and inmany such settings lactational amenorrhoea may last up to ayear or more.

Guidelines specific to a particular country or populationfor use of breastfeeding as a postpartum family planningmethod can be developed from this consensus statement.The general guidelines can be adapted according to localinfant feeding practices and the average duration ofamenorrhoea.

Medicine and the Law

Suspended Doctors in the Health Service

THERE are, it seems, more than sixty doctors currentlysuspended, on full pay, from National Health Service practice.Investigations into professional conduct, competence, and othercomplaints (often at considerable public expense) can drag on foryears. There seems to be no way in which a doctor can have themerits of his suspension considered by the courts; if the processesthat led to the decision have been correctly followed he or she mustwait. I learned of one consultant in Scotland who tried to have his

suspension lifted, pending a decision on the merits, but the courtrefused to intervene on the grounds that since he was on full salaryhe was not disadvantaged.

Ironically, the system seems to favour the doctor later found to beunfit to practise or dishonest, for he will have been paid long afterthe point where, under the normal laws of contract, he might havebeen dismissed without compensation. In less clear-cut cases,however, both sides lose. The doctor is on full pay but he may sufferfrom the slur on his professional reputation, from adverse

comments and publicity, and from reduced skills as the years go by.And even if there is, in the end, no finding of incompetence orprofessional dishonesty meriting dismissal, reinstatement may notbe practicable and his prospects of finding an equivalent job may bemuch diminished, especially if he is approaching retirement age.

In 1975, Dr Royce Darnell was appointed assistant to the directorof the Public Health Laboratory Service in Derby, and thatNovember he became acting director and honorary consultantmicrobiologist to the Trent Regional Health Authority (RHA). (Hequalified in 1962, having started work as a laboratory technician,winning a medical school place at Sheffield on A-levels achieved atnight school.) In April, 1977, responsibility for the laboratory wastransferred to an area health authority (AHA) and he was appointedas an NHS consultant. In 1978 differences arose between the

principal medical laboratory scientific officer and Darnell over thebudget for microbiology and staff appointments. This dispute overwho was in charge of the laboratory intensified, involving thechairman of the division of pathology, and the regional and areaadministration. In December, 1980, the AHA complained formallyto the region alleging non-compliance by Darnell with laboratorystaff appointment procedures. On June 14, 1982, Trent RHAdecided to begin disciplinary proceedings, in accordance withcircular HM(61)112, and on June 25 Darnell was suspended.The hearing took place a year later. In December, 1983, the

inquiry panel found Damell at fault-in his relations with thedivision of pathology, over the budget and staff appointments, overmanagement of the microbiology department, and on two specificcomplaints in relation to safety procedures and practising after theRHA had suspended him-and recommended dismissal. In May,1984, Trent RHA dismissed him, with effect from Aug 19.Darnell then appealed to the Secretary of State. A professional

committee met in May, 1985, and reported in July; their report wasmade available in February, 1986. The committee criticised theRHA’s handling of the case-notably the decision to hold aninquiry without seeking Damell’s comments, the authority’sinaction in the early stages of the dispute, the lack of a warning to thedoctor about the possibility of dismissal, and the long period of

suspension before decisions were taken. Further, they questionedthe justification of the suspension itself, on the grounds that Darnellwas a competent microbiologist who had never put patients at risk.The doctor’s actions might well have been influenced by a nationalcontroversy over the management of laboratories, and Trent RHAhad not properly taken that aspect into account. The committeedecided that a severe reprimand and the offer of a job elsewherewould have sufficed.

In October, 1985, the Secretary of State directed Trent RHA tooffer Darnell a consultant post without managerial responsibilities.If he did not accept the offer the decision to terminate his

employment should stand. Darnell was not included in negotiationsover this compromise, and no such post was offered, on the groundsthat restoration would cause personnel and operational difficulties.Subsequently, the Secretary of State decided that he was not boundby the committee’s advice and in February, 1986, he concluded thatthe doctor should be dismissed.

In July, 1986, Darnell applied to the Divisional Court, whichdeclared the decision to be invalid, on grounds of fairness andnatural justice, in that the Secretary of State had been influenced bycontacts with Trent RHA after October, 1985, the substance ofwhich had not been communicated to Darnell for his comments.The matter was referred back to the Secretary of State.

In August, 1986, the Secretary of State proposed to invite Darnelland the RHA to make written representations and attend a meeting.He did not intend to reconvene the professional committee or set upanother one since the committee’s advice that he already had had notbeen criticised by the court. In October, 1986, Trent RHAsuggested that each side should have the opportunity to commenton the written representations of the other, and on Dec 31, 1986, theSecretary of State told both parties that he proposed to follow thatprocedure. Written representations were made. However, Damellthen indicated that he would not attend a meeting. There thenfollowed further submissions by Darnell and some correspondence.On March 18, 1988, the Secretary of State confirmed the RHA’sdecision to terminate his employment.

Darnell’s attempt to quash this decision, by way of an applicationfor judicial review in the High Court in November, 1988, has failed,and the outlook for him is bleak. As he states in his affidavit: "I am58 years of age and despite trying to keep abreast of the currentchanges in microbiology by reading, attending seminars and doingsome locum work, I will still find it extremely difficult, if notimpossible to find further employment". He noted that Trent RHAhad been criticised and that the authority’s chairman "has recentlygone on record as saying that such delays are unconscionable ..."Darnell asked the Court to grant an injunction to prevent hisdismissal and to tell the Secretary of State to order the Trent RHAto reinstate him in his previous position or in another post or tocompensate him. The application failed because there were nogrounds on which a further judicial review of the decision-makingprocess could lie.

Apparently, six years is not an unusual period in which hearingsand appeals of this sort can drag on. However, a consultative paper,now being circulated, seeks to impose strict time limits, and therebylessen the financial implications of a suspension, for both doctor andthe health authority.

DIANA BRAHAMS,Barrister-at-law