LINKAGES Project

LAM ADVOCACY PRESENTATION

June 2002

2

What is LAM?

The lactational amenorrhea method (LAM) is a modern, postpartum family planning method based on natural infertility resulting from certain

patterns of breastfeeding

Source: Cooney, Taking the First Steps, 1997

3

Consensus of the 1988 Bellagio Meeting

“Women who are not using family planning but who are fully or nearly fully breastfeeding and amenorrheic are likely to experience a risk of pregnancy of less than 2% in the first 6 months after delivery.”

Source: Gray et al, 1987 4

What is the Risk of Pregnancy in Non-Breastfeeding Women?

“By comparison, non-breastfeeding postpartum women typically have a 25-30% risk of pregnancy during the first 6 months after birth, following a short 2-6 week period of postpartum infertility.”

Source: Cooney, Taking the First Steps, 1997

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Conclusions from the 1995 Bellagio Meeting

Efficacy of LAM is well-established in prospective studies

Programs should regard LAM as an additional method that increases the menu of family planning choices

Programmatic and policy support for LAM is needed worldwide

Adapted from The Essentials of Contraceptive Technology, 1997

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Pregnancy Rates (%), by Family Planning Method

0

5

10

15

20

25

Nor

plan

tVa

sect

omy

DM

PA

/NE

T E

NFe

mal

e S

teril

izat

ion

IUD

Pro

gest

in-o

nly

Ocs

LAM

CO

Cs

SD

M

Con

dom

Dia

phra

gm w

/ spe

rmic

ide

Fert

ility

Fem

ale

Con

dom

Spe

rmic

ide

Perfect Use

Typical Use

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Non-Hormonal Family Planning Methods Complementary to Breastfeeding

Can be introduced the first 6 weeks postpartum and beyond:

Tubal ligation IUD LAM Condoms Natural family planning Diaphragm w/ spermicides

Source: The Essentials of Contraceptive Technology, 1997

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Method Typical Use Perfect Use Tubal Ligation 0.5 0.5

IUD (Tcu-380A) 0.8 0.6

LAM 2 0.5

Condoms 14 3

Natural FP 20 1-9

Diaphragm w/spermicide

20 6

Pregnancy Rates (%), by Non-Hormonal Family Planning Methods

9

Progestin-Only Family Planning Methods

Complementary to Breastfeeding

Can be introduced at 6 weeks postpartum and beyond:

Mini-pills

Injectables

Implants

The Essentials of Contraceptive Technology, 1997

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Method Typical Use Perfect Use

Implants 0.1 0.1

Injectables 0.3 0.3

Mini-pills 1 0.5

LAM 2 0.5

Pregnancy Rates (%), by Progestin-Only Family Planning Methods

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Estrogen-Based Family Planning Methods Complementary to

Breastfeeding

Can be introduced at 6 months postpartum and beyond:

Combined Oral Contraceptives

Combined Injectables

Various Sources; see bibliography 12

LAM Efficacy Studies at 6 Months Postpartum

(Rwanda measured LAM effectiveness at 9-months post-partum) 99.6% 99.5% 99.4% 99.0% 98.8% 98.5%

50%

60%

70%

80%

90%

100%

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What Criteria Must be Met for LAM to be Effective?

Menstruation has not returned, and…

Mother is fully or nearly fully

breastfeeding, and...

Baby is less than 6 months old

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Is Bleeding Menstrual or a Postpartum Discharge?

Among breastfeeding women:First 2 months postpartum Bleeding throughout the first 2 months postpartum is lochia, not menses

2-6 months postpartumMenses is: at least 2 consecutive days of

bleeding/spotting, or when a woman perceives that menses has

returned

Criterion 1

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What does “Fully Breastfeeding” Mean?

Exclusive: no water, other liquids or solids at

any time,-or-

Almost Exclusive: infrequent feeds of vitamins,

mineral water, juice, prelacteal or ritualistic foods

Criterion 2

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What does “Nearly Fully Breastfeeding” Mean?

The vast majority of the infant’s feeds comes from suckling at the breast

A bottle feeding should not replace a breast feeding

Breastfeeding intervals do not exceed 4 hours during the day or 6 hours during the night

Supplementation does not exceed 5-15% of all feedings

Criterion 2

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Is LAM still Effective after a Baby is 6 Months Old?

While some studies have shown LAM to be effective beyond 6 months, the current recommendation is to transition to another method of family planning when the baby reaches his 6 month birth date

Criterion 3

LINKAGES: Facts for Feeding, 1999

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LAM Improves Infant Health

Breastmilk:Provides a source of clean water

Enhances infant’s immune system (less diarrhea and acute respiratory infections)

Improves infant growth and development

Provides a source of essential fatty acids, vitamins, proteins, iron, minerals

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LAM Improves Maternal Health

Breastfeeding:Lessens iron depletion by suppressing

menses

Strengthens mother-baby bondConsists of suckling action which is

directly related to suppression of ovulation

Increases maternal control over fertility

Source: Ginneken, 1981. 20

What Effect does Breastfeeding alone have on Pregnancy Rates (%)?

Non-Contracepting Women

0

10

20

30

40

50

60

70

80

90

0 3 6 12 18 24 30 36

Months since last birth

% p

reg

na

nt

Non-BF - IndiaNon-BF - AlaskaBF - IndiaBF - Alaska

Source: Conde-Agudelo & Belizan, British Medical Journal, 2000

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What Difference can 6 Months of Birth Spacing Make on

Maternal Health Outcomes? (based on a reference inter-pregnancy interval of 18-23 months)

Mothers who have inter-pregnancy intervals of

0-5 months have:

30% more anemia 70% more third trimester bleeding 70% more premature rupture of membranes 30% more puerperal endometritis

and are 2.5 times more likely to die

Source: Conde-Agudelo & Belizan, forthcoming 2001

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What Difference can 6 Months of Birth Spacing Make on Infant Health Outcomes?

(based on a reference inter-pregnancy interval of 18-23 months)

All figures are for live births; figures for fetal and neonatal deaths also include fetal deaths in the denominator.

Infant Outcome 0-5 mo. 18-23 mo.

Low birth weight 15.3% 6.9%

Pre-term 18.9% 8.2%

Very pre-term 5.2% 1.4%

Small for gestationalage

15.4% 12.5%

Fetal death 4.2% 1.5%

Neonatal death 3.1% 0.7%

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LAM Benefits for Mothers

98%+ contraceptive effectivenessNo commodities or associated costsNo gynecological examNo side effectsNo preparation or negotiation needed for

sexual intercourseNo cultural or religious conflictAllows time for decision/adoption of

another FP method during postpartum

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LAM Challenges for Mothers

Postpartum period only

Short-term method

No protection from STDs or HIV

Reduced efficacy if mother and infant are separated for extended periods

Source: Perez A, International Journal of Fertility, 1981

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Ovulation Before

First Postpartum Menses

41%

75%

91%

0%

20%

40%

60%

80%

100%

Full Partial None

Breastfeeding Status

(clinical trial measurements: endometrial biopsy,

basal body temp, vaginal cytology, cervical mucous; n =200)

Source: Hardy E, et al., Advances in Contraception, 1998

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LAM Leads to Higher Contraceptive Prevalence at 12 Months Postpartum

7.4 7.4

14.3

17.7

0

5

10

15

20

No Contraception Pregnant

% in each status at 12 mo. postpartum

LAM Intervention Control

(clinical trial hospital-based in Brazil p<0.0001; n =348)

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Pregnancy Rates of LAM Acceptors at 12 Months

Women who do not transition to another family planning method after 6 months

Study Site 12 month pregnancyrates amongbreastfeedingamenorrheic women

Bangladesh 0%Pakistan 1.1%Philippines 3%Multicenter Study(11 sites in9 countries)

8.8%

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Previous Non-Users of Family Planning Methods Using LAM

Study Site % LAM acceptorsnew to any familyplanning method

Pakistan 94%Indonesia 84%Philippines 80%Rwanda 77%Ecuador 73%Egypt 71%

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Transition from LAM toAnother Family Planning Method

Multicenter Study Continuation with another FP method was 66.7%

at 7 months postpartum Transition among previous non-users was 63%

Ecuador Service provider knowledge of LAM resulted in

earlier IUD insertions among breastfeeding women

Rwanda 85% of women completing 9 months of LAM

successfully switched to another FP method

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Integrating LAM into Existing Programs

Integrating LAM into a family planning or maternal & child health program is similar to promoting any other contraceptive method

Education and advocacy at policy, services, community levels may be necessary to distinguish LAM from Natural Family Planning and to clarify that LAM and breastfeeding are not interchangeable terms

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When and Where can LAM Interventions Take Place?

LAM counseling can be integrated during:

Antenatal visits, included with breastfeeding counseling

Intrapartum service delivery, packaged with Baby and Mother Friendly Initiatives

The postpartum period

Primary health care, well baby or sick child visits

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Program Implications

Wherever women breastfeed, LAM is an appropriate FP method

LAM uptake improves when included in a broad integrated program rather than in a vertical program context

Community involvement is important

Training alone is not sufficient

Provider bias influences counseling

Importance of supervision, monitoring & evaluation

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Key LAM Messages

Typically used, LAM is more than 98% effective

LAM, readily accessible, is uncomplicated to use

Women making informed choices about modern family

planning methods should have LAM available to them

Evidence suggests that LAM attracts women who have never used modern family planning methods

Evidence also suggests that LAM users transition to become new users of modern family planning methods