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The Lactational Amenorrhea Method (LAM): Another Choice for Mothers

Miriam H. Labbok, MD, MPH Associate Professor, Georgetown University Medical Center; Director, Breastfeeding and Maternal Child Health Director, WHO Collaborating Center on Breastfeeding
from Breastfeeding Abstracts, August 1993, Volume 13, Number 1, pp. 3-4.

At the six-week postpartum checkup, the new mother is often told that she must begin contraceptive use immediately to avoid a pregnancy too soon. But what method should she choose? Research substantiates that women worldwide believe breastfeeding is associated with fertility reduction, but the question remains: How to use it effectively? The Lactational Amenorrhea Method (LAM) answers that question.

LAM is a newly developed interim family planning method that is based on utilization of lactational infertility for protection from pregnancy. LAM provides optimal infant nutrition, enhances immunity, prevents formula-related illness, and physiologically promotes mother-child interaction while simultaneously providing safe and effective temporary child spacing. It may be used for up to six months postpartum during full or nearly full breastfeeding and amenorrhea, and has been shown in clinical trial to be 99 percent effective.

The Lactational Amenorrhea Method was developed as a result of a meeting held at Georgetown University.1 It is designed to bring the health and fertility benefits of breastfeeding to the attention of family-planning providers and demographers. A mother is asked these three questions: Is your infant less than six months old? Are you amenorrheic? Are you fully or nearly fully breastfeeding? If she can answer yes to all three, she is counseled that her risk of pregnancy is less than two percent and she does not need a complementary family-planning method yet. She is also told that if any of these three parameters changes, she should introduce a complementary form of family planning to achieve this same low risk of pregnancy.

LAM is based primarily on a previously published approach2 and on the results of the Bellagio Consensus Meeting on Breastfeeding as a Family Planning Method held in l988.3 It serves as a guide from which individual programs can develop culturally appropriate presentations. Today, LAM or MELA (Spanish) or MAMA (French) is in use in at least ten countries and each program provides support for the mother's choice to breastfeed.

The available research has made it virtually impossible for scientific analysts to deny the impact of the LAM method. This method has undergone clinical trial in Santiago, Chile.4, 5, 6 A case-control intervention study was established whereby the control cohort was ascertained prior to the development of an organized breastfeeding support program at the Pontificia Universidad Católica de Chile. The intervention included prenatal education, immediate postpartum breastfeeding, rooming-in, decreased in-hospital use of formula, the establishment of a follow-up clinic, and the offer of LAM as an introductory family planning method.

LAM proved highly efficacious, with a pregnancy rate of less than 1/2 of 1 percent by six-month life table. The intervention more than doubled the percent of women who achieved six months of meeting LAM criteria. At six months postpartum, family planning coverage had increased from 78 percent to 91 percent with the inclusion of LAM in the "cafeteria" of methods available. Pregnancy rates remained lower for the intervention group for over a year, and the percent who were breastfeeding remained higher long after the intervention was over. The duration of amenorrhea was also extended. Where the control group performed similarly to other published studies on the duration of amenorrhea during full breastfeeding among similar women, 7 the intervention group had longer durations of amenorrhea, even when comparing the full breastfeeders in each group. Clearly, optimizing breastfeeding practices, even among full breastfeeders, extends the duration of amenorrhea and the impact of breastfeeding on fertility, even after LAM use has ceased.

Much work remains to fully educate providers of health care on the use of the method, especially those who doubt women's ability to monitor their own behavior. LAM may be offered to women who prefer to postpone introducing a complementary family planning method postpartum. In countries where family planning is not widely accepted, LAM is useful for populations who have no experience with family planning and may be hesitant to accept a so-called "modern" approach. LAM may also promote more effective use of other methods of family planning by breastfeeding women, since the method delays the use of a complementary method until the mother's fertility returns. LAM use results in improved breastfeeding support in the organizations that provide it and improved breastfeeding practices among the women who accept it. It also results in cost savings. When the costs of offering LAM, including retraining and reorganization, are accounted for, there remains a cost savings of 10 to 20 percent from the reduced need for personnel, drugs, formula, and bottles.

Research indicates that the LAM guidelines are very conservative and that each of the three parameters has considerable flexibility.8 Six months is an arbitrary time period; we know that continuing to breastfeed prior to each supplemental feed can extend amenorrhea and infertility. Full breastfeeding is not mandatory. Although a recently published manuscript seems to say that any breastfeeding will do during the first six months,9 it is clear from our work and that of many others7, 8, 9, 10 that more intensive breastfeeding is associated with longer durations of infertility. Even using menses as an indication of fertility return has some flexibility: the first ovulation is often associated with inadequacies in the luteal phase and other hormonal parameters. Based on worldwide experiences with relying on lactational amenorrhea beyond six months, we are now exploring what we call LAM II, a new more flexible method. Some centers have already begun independently to experiment with "LAM 9," a nine-month variant, and women who have self-selected to extend LAM are being studied in several settings.11, 12

The unique side effects of LAM, improved infant and maternal health and satisfied family planning workers, contribute in yet another way to the health of the community.

A mother's postpartum family planning choices now include a reliable interim method based on the behavior that is healthiest for her and her newborn.

ACKNOWLEDGEMENTS

Much of this paper is derived from the referenced articles and collaboration with Drs. Pérez and Valdés in Chile. Support for this publication was provided by the Institute for Reproductive Health, Georgetown University, under Cooperative Agreement with the Agency for International Development (A.I.D.) (DPE-3040-A-00-5064-01). The views expressed by the authors do not necessarily reflect the views or policies of A.I.D, or Georgetown University.

References

    1. Labbok. M., P Koniz-Booher, J. Shelton, K. Krasovec, and K. Cooney. Guidelines for breastfeeding in family planning and child survival programs. Institute for Reproductive Health, Georgetown University, 1990, rev. 1992.

    2. Labbok, M. Breastfeeding and contraception. New Eng J Med 1983; 308:51.

    3. Kennedy, K., R. Rivera, and A. McNeilly. Consensus statement on the use of breastfeeding as a family planning method. Contraception1989; 39:477-96.

    4. Valdes, V., A. Pérez, M. Labbok, E. Pugin et al. The impact of a hospital and clinic-based breastfeeding promotion program. J Trop Pediatr In press.

    5. Pérez, A. and V. Valdés. Santiago Breastfeeding Promotion Program: preliminary results of an intervention study. Am J Obstet Gynecol 1991; 165(suppl 2):2039-44.

    6. Pérez, A., M. Labbok. and J. Queenan. Clinical study of the lactational amenorrhea method for family planning. Lancet 1992; 339:968-969.

    7. Diaz, S., G. Rodriguez, O. Peralta, P. Miranda et al. Lactational amenorrhea and the recovery of ovulation and fertility in fully nursing Chilean women. Contraception 1988; 38:53-67.

    8. Wade, K., F. Sevilla, and M. Labbok. LAM acceptability among family planning clients: process analysis and interim results of a pilot study. In press, 1992.

    9. Gray, R., O. Campbell, R. Apelo, S. Eslami et al. The risk of ovulation during lactation. Lancet 1990; 335:25-29.

    10. Kennedy, K. and C. Visness. Contraceptive efficacy of lactational amenorrhoea. Lancet l992; 339: 227-229.

    11. Howie, P. and A. McNeilly. Effect of breastfeeding patterns on human birth intervals. J Reprod Fertil 1982; 65:545-57.

    12. Hoser, Fr. H: Personal communication. December 1992.

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