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, 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, 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, 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, Pregnancy Rates (%), by Family Planning Method

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

11 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 bibliography12 LAM Efficacy Studies at 6 Months Postpartum (Rwanda measured LAM effectiveness at 9-months post-partum)

13 What Criteria Must be Met for LAM to be Effective? Ê Menstruation has not returned, and… Ë Mother is fully or nearly fully breastfeeding, and... Ì Baby is less than 6 months old

14 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 postpartum Menses is:  at least 2 consecutive days of bleeding/spotting, or  when a woman perceives that menses has returned Criterion 1

15 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

16 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

17 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, 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

19 LAM Improves Maternal Health Breastfeeding:  Lessens iron depletion by suppressing menses  Strengthens mother-baby bond  Consists of suckling action which is directly related to suppression of ovulation  Increases maternal control over fertility

Source: Ginneken, What Effect does Breastfeeding alone have on Pregnancy Rates (%)?

Source: Conde-Agudelo & Belizan, British Medical Journal, What Difference can 6 Months of Birth Spacing Make on Maternal Health Outcomes? (based on a reference inter-pregnancy interval of 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 What Difference can 6 Months of Birth Spacing Make on Infant Health Outcomes? (based on a reference inter-pregnancy interval of months) All figures are for live births; figures for fetal and neonatal deaths also include fetal deaths in the denominator.

23 LAM Benefits for Mothers  98%+ contraceptive effectiveness  No commodities or associated costs  No gynecological exam  No side effects  No preparation or negotiation needed for sexual intercourse  No cultural or religious conflict  Allows time for decision/adoption of another FP method during postpartum

24 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, Ovulation Before First Postpartum Menses (clinical trial measurements: endometrial biopsy, basal body temp, vaginal cytology, cervical mucous; n =200)

Source: Hardy E, et al., Advances in Contraception, LAM Leads to Higher Contraceptive Prevalence at 12 Months Postpartum (clinical trial hospital-based in Brazil p<0.0001; n =348)

27 Pregnancy Rates of LAM Acceptors at 12 Months Women who do not transition to another family planning method after 6 months

28 Previous Non-Users of Family Planning Methods Using LAM

29 Transition from LAM to Another 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

30 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

31 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

32 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

33 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