Lactational Amenorrhea Methods

The Lactational Amenorrhea Method (LAM) is a modern, temporary family planning method that has been developed as a tool to help support both breastfeeding and family planning use. It is based on the natural infertility resulting from certain pat- terns of breastfeeding. “Lactational” means related to breastfeeding; “Amenorrhea” means not having menstrual bleeding; and “Method” means a tech- nique for contraception.

LAM is defined by three criteria:

1. the woman’s menstrual periods have not re- sumed, AND
2. the baby is fully or nearly fully breastfed, AND
3. the baby is less than six months old.

When any one of these three criteria is no longer met, another family planning method must be intro- duced in a timely manner to ensure healthy birth spacing.

Optimal breastfeeding practices include exclu- sive breastfeeding for the first six months and breastfeeding with appropriate complementary feeding for two years or more. LAM is a family planning method which supports improved breastfeeding, healthy child spacing, child sur- vival, and women’s health.

How effective is LAM?

LAM provides family planning protection compa- rable to other family planning methods.

Adapted from: the Essentials of Contraceptive Technology, Johns Hopkins Population Information Program, 1997.

1. The woman’s menstrual periods have not resumed

Following childbirth, the resump- tion of menses is an important in- dicator of a woman’s return to fertility. During breastfeeding a woman is less likely to ovulate.

However, once a woman starts to menstruate, ovulation has re- turned or may be imminent.

Bleeding during the first two months postpartum is lochial dis- charge and is not considered men- strual bleeding. Menstruation is defined for LAM use as two con- secutive days of bleeding, or when a woman perceives that she has had a bleed similar to her men- strual bleed, either of which oc- curs at least two months postpartum.

2. The baby is fully or nearly fully breastfed

Full Breastfeeding is the term ap- plied to both exclusive breastfeeding (no other liquid or solid is given to infant) and almost exclusive breastfeeding (vitamins, water, juice, or ritualistic feeds given infre- quently in addition to breast- feeds). Nearly Full Breastfeeding means that the vast majority of feeds given to infants are breastfeeds.

While exclusive breastfeeding is not necessary for LAM to be effec- tive, the closer the pattern is to exclusive, the better for mother and baby. The optimal pattern for the baby is to be nursed fre- quently and for as long as the in- fant wants to remain on the breast, both day and night. At night, no interval between feedings should be greater than six hours.

3. The baby is less than six months old

At six months of age, the baby should begin receiving comple- mentary foods while continuing to breastfeed. Introduction of water, liquids, and foods can reduce the amount of sucking at the breast,

triggering the hormonal mecha- nism that causes ovulation—and menses—to resume.

A mother may not want to switch to other family planning methods when she no longer meets the LAM criteria and may choose to continue to rely on lactational amenorrhea for pregnancy delay. In this case the woman should be counseled to keep breastfeeding frequently and to breastfeed be- fore giving the infant other foods. She should be informed that her risk of pregnancy increases.

What are the advantages and disadvantages of LAM?

LAM can be initiated at any time during the first six months post- partum. The best time to begin counseling a woman about LAM and other family planning meth- ods is during the antenatal period to allow her to make an informed choice about which method she wishes to use following the birth of her baby. LAM can be started immediately postpartum. The health care provider can help pre- pare the woman to begin breastfeeding immediately after birth and, if the woman has de- cided to use LAM, verify that she understands the three criteria for LAM use.

If a woman wants to initiate LAM use within the first two months postpartum, she must verify that she has been fully or nearly fully breastfeeding her baby since de- livery. A woman may still be hav- ing postpartum bleeding (lochial discharge) that may be similar to a monthly bleed. As long as she is fully or nearly fully breastfeeding, the bleeding in the first two months does not disqualify her from initiating LAM during this period.

If a woman wants to start using LAM when she is more than two months postpartum, the health care provider must carefully verify that she has met the three criteria for LAM use since delivery.

• LAM is a contraceptive method, based on the physiology of breastfeeding. LAM is a method of contraception that a woman consciously chooses to use to reduce her chance of becoming pregnant by ad- hering carefully to the three criteria
• Breastfeeding is a feeding practice.
• Amenorrhea, or the absence of menstrual bleeding, reflects a reduced risk of ovulation, but neither breastfeeding nor amenorrhea is a family planning method.

1. Breastfeed as soon as possible after birth, and remain with the newborn for at least several hours following delivery.
2. Breastfeed frequently both day and night.
3. Breastfeed exclusively for the first six months: no water, other liquids, or solid foods.
4. After the first six months when complementary foods are introduced, breastfeed before giving complementary foods.
5. Continue to breastfeed for up to two years and beyond.
6. Continue breastfeeding even if mother or baby is ill.
7. Avoid using bottles, pacifiers (dummies), or other artificial nipples.
8. Mothers who are breastfeeding should eat and drink sufficient quantities to satisfy their hunger and thirst.

When counseling a new LAM ac- ceptor, the health care provider should discuss her follow-up needs and determine with the cli- ent how frequently she needs to be seen and what setting is most accessible for her. At the very least, a client needs to return for a visit if she perceives any breastfeeding difficulties or as soon as any one of the LAM crite- ria changes. An additional follow- up visit at five to six months postpartum is essential to deter- mine the client’s plans for switch- ing to another contraceptive method and for introducing complementary foods when her baby is six months old. Whenever possible, the health care provider should schedule the visit when the client brings her baby for as- sessment or immunization, in this way saving the mother time by re- ducing the total number of visits to the clinic.

If the client is unable to schedule a visit or if she lives far away and will have difficulty returning, the provider should give her a supply of condoms, spermicides, and/or progestin-only pills. In this way she can maintain contraceptive protection if LAM is discontinued before she is able to return to the clinic.

When any one of the three crite- ria for LAM use is no longer met or when a woman decides to stop using LAM, she needs to begin using another contraceptive method for as long as she wants to prevent another pregnancy. Women who are breastfeeding and who switch to another method should be advised on contraceptive options. Combined oral contraceptive pills (COC) and combined injectables are not recommended before six months postpartum because they contain estrogen, which may decrease the quantity of breastmilk. After six months postpartum, a woman who is breastfeeding can use any method of her choice as long as she is properly screened and meets the eligibility criteria.

The amount of time that a woman is separated from her baby is a key factor in establishing the LAM cri- terion of full or nearly full breastfeeding, day and night, with no long intervals between feedings. A woman who is sepa- rated from her baby regularly for more than four to six hours can not expect a high level of contra- ceptive protection from LAM, even if she expresses milk during the separation. Expressing breastmilk may not be as effective as suckling at the breast in sup- pressing ovulation, and for this reason a woman who expresses her milk may not be able to rely on LAM. In a study on LAM in working women, the pregnancy rate increased to five percent.

Some women can make arrange- ments to have their babies brought to them to nurse and/or are able to go to their baby at regular intervals. Women who are able to keep their babies with them at the work site, market, or in the fields and are able to breastfeed their children fre- quently can rely on LAM.

LAM is a flexible method. In some countries, programs may modify the criteria slightly to reflect cultural norms or national policies without decreasing the method’s efficacy. Many women have occasionally had longer intervals between feedings, their baby has slept through a night, or they have fed the baby regularly with small amounts of comple- mentary foods, and still have had the same high level of effectiveness.

In some settings, programs modify or simplify the method to meet local conditions. For example, they may require exclusive breastfeeding as an eligibility criterion and not accept nearly full breastfeeding. It is important for the health care or family planning provider to understand the criteria and the parameters of flexibility of LAM when modifying any aspect of the method.

Ask the mother, or advise her to ask herself, these three questions:

Women who are HIV+ and who choose to breastfeed can use LAM if they meet the three eligibility criteria. HIV+ women need to be carefully counseled regarding their reproductive intentions and the contraceptive methods available to them. These women and women at risk for HIV infection should be advised to use condoms in addition to whatever contraceptive method is used. It is important that HIV+ women be counseled about the benefits and risks of breastfeeding and other infant feeding options. In fact, some studies indicate that exclusive breastfeeding may help reduce the risk of passage of HIV to the infant when the mother is in- fected. The infant feeding decision is the mother’s to make.

Some general counseling guide-lines are:

• Where confidential testing for HIV is not available or used and a mother’s HIV status is not known, promote exclusive breastfeeding for the first six months as safer than breastmilk substitutes as these may not be regularly available, affordable, or safely used. If status is unknown, exclusive breastfeeding is especially im- portant. Promote use of condoms and teach women how to avoid exposure to HIV ​​and other sexually transmitted infections. Under these conditions, if the mother chooses to breastfeed, LAM can be used.

• If a mother knows she is HIV+ and breastmilk substitutes are not available, not affordable, or cannot be safely used, pro- mote exclusive breastfeeding (never mixed breastfeeding) for the first six months as safer than breastmilk substitutes. Promote use of condoms and teach her how to prevent transmission of HIV to her partner and how to protect herself from repeated expo- sure to HIV and other sexu- ally transmitted infections. Under these conditions, LAM can be used.

If a mother is HIV negative, promote exclusive breastfeeding for the first six months as the safest option for infant feeding. Promote use of condoms and teach her how to avoid exposure to HIV. Under these conditions, LAM can be used.

Encourage your local family planning and health care providers to include LAM in their programming for its double impact, supporting both optimal infant feeding and optimal child spacing of three years or more. Many training curricula, job aids, and other modules are available to help you include LAM in your program.