Lactational Amenorrhea Method

Lactational Amenorrhea Method

Key Points for Providers and Clients

• A family planning method based on breastfeeding. Provides contraception for the mother and best feeding for the baby.

• Can be effective for up to 6 months after childbirth, as long as monthly bleeding has not returned and the woman is fully or nearly fully breastfeeding.

• Requires breastfeeding often, day and night. Almost all of the baby’s feedings should be breast milk.

• Provides an opportunity to offer a woman an ongoing method that she can continue to use after 6 months.

What Is the Lactational Amenorrhea Method?

• A temporary family planning method based on the natural effect of breastfeeding on fertility. (“Lactational” means related to breastfeeding. “Amenorrhea” means not having monthly bleeding.)

• The lactational amenorrhea method (LAM) requires 3 conditions. All 3 must be met:

1. The mother’s monthly bleeding has not returned
2. The baby is fully or nearly fully breastfed and is fed often, day and night
3. The baby is less than 6 months old

• “Fully breastfeeding” includes both exclusive breastfeeding (the infant receives no other liquid or food, not even water, in addition to breast milk) and almost-exclusive breastfeeding (the infant receives vitamins, water, juice, or other nutrients once in a while in addition to breast milk).

• “Nearly fully breastfeeding” means that the infant receives some liquid or food in addition to breast milk, but the majority of feedings (more than three-fourths of all feeds) are breast milk.

• Works primarily by preventing the release of eggs from the ovaries (ovulation). Frequent breastfeeding temporarily prevents the release of the natural hormones that cause ovulation.

How Effective?

Effectiveness depends on the user: Risk of pregnancy is greatest when a woman cannot fully or nearly fully breastfeed her infant.

• As commonly used, about 2 pregnancies per 100 women using LAM in the first 6 months after childbirth. This means that 98 of every 100 women relying on LAM will not become pregnant.

• When used correctly, less than I pregnancy per 100 women using LAM in the first 6 months after childbirth.

Return of fertility after LAM is stopped: Depends on how much the woman continues to breastfeed

Protection against sexually transmitted infections: None

Side Effects, Health Benefits, and Health Risks

Side Effects

None. Any problems are the same as for other breastfeeding women.

Known Health Benefits

Helps protect against:

• Risks of pregnancy

Encourages:

• The best breastfeeding patterns, with health benefits for both mother and baby

Known Health Risks

None

Correcting Misunderstandings

The lactational amenorrhea method:

• Is highly effective when a woman meets all 3 LAM criteria.

• Is just as effective among fat or thin women.

• Can be used by women with normal nutrition. No special foods are required.

• Can be used for a full 6 months without the need for supplementary foods. Mother’s milk alone can fully nourish a baby for the first 6 months of life. In fact, it is the ideal food for this time in a baby’s life.

• Can be used for 6 months without worry that the woman will run out of milk. Milk will continue to be produced through 6 months and longer in response to the baby’s suckling or the mother’s expression of her milk.

Lactational Amenorrhea MethodWho Can Use the Lactational Amenorrhea Method

Medical Eligibility Criteria for the Lactational Amenorrhea Method

All breastfeeding women can safely use LAM, but a woman in the following circumstances may want to consider other contraceptive methods:

• Has HIV infection including AIDS

• Is using certain medications during breastfeeding (including mood- altering drugs, reserpine, ergotamine, anti-metabolites, cyclosporine, high doses of corticosteroids, bromocriptine, radioactive drugs, lithium, and certain anticoagulants)

• The newborn has a condition that makes it difficult to breastfeed (including being small-for-date or premature and needing intensive neonatal care, unable to digest food normally, or having deformities of the mouth, jaw, or palate).

Why Some Women Say They Like the Lactational Amenorrhea Method

It is a natural family planning method
It supports optimal breastfeeding, providing health benefits for the baby and the mother
It has no direct cost for family planning or for feeding the baby.

The Lactational Amenorrhea Method for Women With HIV

• Women who are infected with HIV or who have AIDS can use LAM. Breastfeeding will not make their condition worse. There is a chance, however, that mothers with HIV will transmit HIV to their infants through breastfeeding. As breastfeeding is generally practiced, 10 to 20 of every 100 infants breastfed by mothers with HIV will become infected with HIV through breast milk in addition to those already infected during pregnancy and delivery. HIV transmission through breast milk is more likely among mothers with advanced disease or who are newly infected.

• Women taking antiretroviral (ARV) medications can use LAM. In fact, ARV therapy during the first weeks of breastfeeding may reduce the risk of HIV transmission through breast milk.

• Replacement feeding poses no risk of HIV transmission. If—and only if—replacement feeding is acceptable, feasible, affordable, sustainable, and safe, it is recommended for the first 6 months after childbirth. If available replacement feeding cannot meet these 5 criteria, exclusive breastfeeding for the first 6 months is the safest way to feed the baby, and it is compatible with LAM.

• One strategy for making breastfeeding safer is expressing breast milk and heat-treating it. For women relying on LAM, expressing milk may be slightly less effective at preventing pregnancy than breastfeeding.

• Urge women with HIV to use condoms along with LAM. Used consistently and correctly, condoms help prevent transmission of HIV and other STIs.

Providing the Lactational Amenorrhea Method

When to Start
Woman’s situation When to start
 Within 6 months after childbirth   Start breastfeeding immediately (within one hour) or as soon as possible after the baby is born. In the first few days after childbirth, the yellowish fluid produced by the mother’s breasts (colostrum) contains substances very important to the baby’s health.Any time if she has been fully or nearly breastfeeding her baby since birth and her monthly bleeding has not returned.

When Can a Woman Use LAM?

A breastfeeding woman can use LAM to space her next birth and as a transition to another contraceptive method. She may start LAM at any time if she meets all 3 criteria required for using the method.

Explaining How to Use

Breastfeed often

• An ideal pattern is feeding on demand (that is, whenever the baby wants to be fed) and at least 10 to 12 times a day in the first few weeks after childbirth and thereafter 8 to 10 times a day, including at least once at night in the first months.

• Daytime feedings should be no more than 4 hours apart, and night-time feedings no more than 6 hours apart.

• Some babies may not want to breastfeed 8 to 10 times a day and may want to sleep through the night. These babies may need gentle encouragement to breastfeed more often.

Start other foods at 6 months

• She should start giving other foods in addition to breast milk when the baby is 6 months old. At this age, breast milk can no longer fully nourish a growing baby.

Plan follow-up visit

• Plan for the next visit while the LAM criteria still apply, so that she can choose another method and continue to be protected from pregnancy.

• If possible, give her condoms or progestin-only pills now. She can start to use them if the baby is no longer fully or nearly fully breastfeeding, if her monthly bleeding returns, or if the baby reaches 6 months of age before she can come back for another method. Plan for a follow-on method. Give her any supplies now.

Supporting the User

“Come Back Any Time”: Reasons to Return

Assure every client that she is welcome to come back any time—for example, if she has problems, questions, or wants another method; she has a major change in health status; or she thinks she might be pregnant. Also, if:

• She no longer meets one or more of the 3 LAM criteria and so cannot keep relying on LAM.

Helping Continuing Users

Helping Clients Switch to a Continuing Method

1. A woman can switch to another method any time she wants while using LAM. If she still meets all 3 LAM criteria, it is reasonably certain she is not pregnant. She can start a new method with no need for a pregnancy test, examinations, or evaluation.

2. To continue preventing pregnancy, a woman must switch to another method as soon as any one of the 3 LAM criteria no longer applies.

3. Help the woman choose a new method before she needs it. If she will continue to breastfeed, she can choose from several hormonal or nonhormonal methods, depending on how much time has passed since childbirth.

Managing Any Problems

Problems With Use

• Problems with breastfeeding or LAM affect women’s satisfaction and use of the method. If the client reports any problems, listen to her concerns, give her advice, and, if appropriate, treat.

• Offer to help the client choose another method—now, if she wishes, or if problems cannot be overcome.

Questions and Answers About the Lactational Amenorrhea Method

1. Can LAM be an effective method of family planning?

Yes. LAM is very effective if the woman’s monthly bleeding has not returned, she is fully or nearly fully breastfeeding, and her baby is less than 6 months old.

2. When should a mother start giving her baby other foods besides breast milk?

Ideally, when the baby is 6 months old. Along with other foods, breast milk should be a major part of the child’s diet through the child’s second year or longer.

3. Can women use LAM if they work away from home?

Yes. Women who are able to keep their infants with them at work or nearby and are able to breastfeed frequently can rely on LAM as long as they meet all 3 criteria for LAM. Women who are separated from their infants can use LAM if breastfeeds are less than 4 hours apart. Women can also express their breast milk at least every 4 hours, but pregnancy rates may be slightly higher for women who are separated from their infants. The one study that assessed use of LAM among working women estimated a pregnancy rate of 5 per 100 women during the first 6 months after childbirth, compared with about 2 per 100 women as LAM is commonly used.

4. What if a woman learns that she has HIV while she is using LAM? Can she continue breastfeeding and using LAM?

If a woman is newly infected with HIV, the risk of transmission through breastfeeding is much higher than if she was infected earlier, because there is more HIV in her body. The breastfeeding recommendation is the same as for other HIV-infected women, however. If replacement feeding is acceptable, feasible, affordable, sustainable, and safe, she should be counseled that, with such replacement feeding, her baby will have no risk of HIV infection through breastfeeding. If replacement feeding cannot meet these 5 criteria, she should breastfeed exclusively during the first 6 months. Thus, she can continue relying on LAM. If she chooses to stop breastfeeding, she should stop completely over a period of about 2 days to 3 weeks. After 6 months, breast milk alone is no longer enough nutritionally for the baby, and she should switch from LAM to another contraceptive method.