Lactational Amenorrhea Method (LAM) : A critical yet underutilized element of maternal and infant health

In this session… Learn the basic mechanism of action and effectiveness of LAM Understand the definition of LAM and criteria for use List advantages and limitations of LAM Identify opportunities for LAM counseling Operationalize LAM for “transition” to another modern method

What is LAM? A family planning method for post partum women who meet the following criteria: Menstruation has not returned Mother is only breastfeeding Baby is less than 6 months

Effectiveness of LAM LAM is 99.5% effective with correct use LAM is more than 98% effective with typical use Photo: J. Cachan

LAM Mechanism of Action Nipple stimulation Nerve impulses affect hormones 3. Increases milk production 4. Suppression of ovulation

Rationale for Integration of LAM into Programs Attracts new FP users Serves as introductory / “gateway” FP method Contributes to healthy spacing of pregnancies Contributes to health of mother and child Supports optimal breastfeeding practices

Benefits of LAM Provides protection against pregnancy for a maximum of 6 months Can be used immediately after childbirth Can be used by all women post partum Is under the control of the woman herself

Benefits of LAM Does not require supplies or procedures Is economical (free) Has no hormonal, or other, side effects Raises no religious objections

LAM attracts new FP Users Study Site % (N) Never Used FP Prior to LAM Egypt 71% (42) Indonesia 84% (51) Philippines 66% (31) Mexico 58% (29) There are some characteristics of LAM that are less desirable. For instance, LAM is only a temporary method. It can be used for 6 months at most. Also, LAM is not usually an appropriate method when a mother must be separated from her baby for long periods of time – for instance, when she works outside of the home. Also, an HIV-positive mother may have concerns about breastfeeding. Hight-Laukaran et al, Contraception 1997; 55: 337-346

Benefits of Exclusive Breastfeeding Prevent neonatal and infant illness (diarrhea, respiratory infection) Prevent neonatal and infant death (mortality) Stimulates oxytocin release causing uterine contraction to reduce postpartum blood loss

LAM supports optimal breastfeeding behaviors Allow newborn to breastfeed as soon as possible after birth Breastfeed frequently, whenever the infant is hungry, both day and night Breastfeed only for the first six months

LAM supports optimal breastfeeding behaviors 4. Continue breastfeeding even if the mother or the baby becomes ill 5. Avoid using bottles, pacifiers or other artificial nipples 6. The mother must have proper diet and intake of liquids to be able to breastfeed

Simplified Approach to LAM : Provider/Client Tools

India Tools: LAM Comic & IEC materials including posters, client cards and integration in JSY card

Operationalizing LAM messages - Easier to understand, remember, & follow Exclusive breastfeeding messages: Breast milk only, no other liquids or food breastfeed on demand, day and night When the number of messages is reduced and simplified, women find LAM easier to understand, remember and follow. Operationalizng/simplication of messages given to women on the LAM criterion/criteria

You only breastfeed your baby LAM Criteria You only breastfeed your baby Adding other foods to the baby’s diet makes the baby suckle the breast less The mother will not produce as much breast milk With less breastfeeding the mother is more likely to ovulate

LAM Criteria Your period has not returned When you begin menstrual bleeding you are fertile again You can get pregnant even if you continue to breastfeed

Your baby is less than 6 months old LAM Criteria Your baby is less than 6 months old When your baby turns 6 months you may be fertile again because of initiation of supplementary foods You can get pregnant even if you continue to breastfeed

How can transition to other modern methods be facilitated?

Emphasizing timely transition Offer postpartum women choice of all appropriate FP methods during first PP visit During this and subsequent visits, discuss what she will use after LAM Encourage women to keep breastfeeding after LAM LAM provides time to decide on another FP method Another method should be started as soon as any one of the three LAM criteria is not met A woman should be counseled on FP when LAM counseling is initiated Reinforce transition at each counseling contact

Transition to Another Method: An Essential Component of LAM LAM is a “gateway” to other modern methods of contraception LAM provides the couple time to decide on another modern method to use after LAM As described earlier, LAM can provide a “gateway,” to other modern methods of contraception. For one thing, LAM provides the couple time to decide on another modern method of contraception that they might use when LAM criteria are no longer met or they choose to discontinue use of LAM. How do you ensure that LAM facilitates transition? How do you make sure that another modern method of contraception follows the cessation of LAM? Because another method should be started as soon as any one of the 3 criteria is not met, the woman should be counseled to decide on the method to which she should transition when LAM counseling is initiated How can providers facilitate the transition Providers mentioning the importance of transition from the very first contact with the mother and in all subsequent contacts. For programs that can afford it, consider providing the LAM user with advance contraceptive supplies How can programs facilitate transition: Training not only FP personnel in LAM and post-partum contraception but also MCH and MNH personnel; prepare materials, stock FP commodities in clinics where mothers take their babies for check-ups, etc.

Transition to Another Method: An Essential Component of LAM How do you ensure that LAM facilitates transition? Another method should be started as soon as any one of the three LAM criteria is not met The woman should be counseled to decide on the method to which she should transition when LAM counseling is initiated As described earlier, LAM can provide a “gateway,” to other modern methods of contraception. For one thing, LAM provides the couple time to decide on another modern method of contraception that they might use when LAM criteria are no longer met or they choose to discontinue use of LAM. How do you ensure that LAM facilitates transition? How do you make sure that another modern method of contraception follows the cessation of LAM? Because another method should be started as soon as any one of the 3 criteria is not met, the woman should be counseled to decide on the method to which she should transition when LAM counseling is initiated How can providers facilitate the transition Providers mentioning the importance of transition from the very first contact with the mother and in all subsequent contacts. For programs that can afford it, consider providing the LAM user with advance contraceptive supplies How can programs facilitate transition: Training not only FP personnel in LAM and post-partum contraception but also MCH and MNH personnel; prepare materials, stock FP commodities in clinics where mothers take their babies for check-ups, etc.

Why is Timely Transition So Essential? Fertility May Return Soon after Delivery If not breastfeeding, ovulation will occur at 45 days postpartum on average; may occur as early as 21 days Breastfeeding women not practicing LAM are likely to ovulate before return of menses Between 5% and 10% of women conceive within the first year postpartum We have mentioned this before, but it is so important, we want to emphasize this again. We have talked about timely transition to another modern method of contraception. Why is early initiation of LAM or any other contraceptive so important if the couple does not want to become pregnant right away? If not breastfeeding, ovulation will occur on average at 45 days; and it may occur as early as 21 days postpartum And the breastfeeding woman who is not practicing LAM is likely to ovulate before return of menses, In a study conducted in Peru and Indonesia, 10% of women in Peru and 8% of women in Indonesia became pregnant before resuming menses (81-82% of these women were breastfeeding). Between 5-10% of women conceive within the first year postpartum

What are the advantages of waiting two years after having a baby to become pregnant again? Benefits for the mother, baby & the family [For countries where “3 to 5 saves lives” has been promoted, facilitator may need to explain that waiting 2 years to become pregnant again results in births no closer than 57 months apart (2 years plus 9 months.)] Couples who wait at least two years after having a baby before becoming pregnant again: Are more likely to have a healthy outcome for their baby – Babies born more than 3 years after their sibling are generally healthier. Also, a baby is more likely to be healthy and have better nutritional status (breastfeeding) if its mother doesn’t have another baby for at least 3 years. The mother will be healthier – There are fewer complications for women who waited two years to become pregnant after their previous birth Reduces neonatal, infant and child mortality. – Few deaths among newborns, infants and children born more than 3 years after their sibling Improves nutritional status of children – Both babies benefit from breastfeeding more than infants born too close together Addresses unmet need for contraception among postpartum women – Most women do not want to become pregnant within two years of their previous birth Economic benefits to family – Fewer births reduce economic demand on families Postpartum contraception reduces the numbers of women becoming pregnant, and therefore at risk of dying from pregnancy-related complications. Pregnancy intervals of less than six months (15-month birth intervals) are associated with 150% increased risk of maternal death. These intervals are also associated with 70% elevated risk of third trimester bleeding, 70% increase of premature rupture of membranes, 30% increase of anemia, and 30% increased risk of postpartum endometritis in the next pregnancy. Fewer newborns, infants and children die if they have been conceived at least 2 years after their sibling was born (World Health Organization. 2006. Report of a Technical Consultation on Birth Spacing: 13-15 June 2005. Geneva) Source: Conde-Agudelo and Belizan 2000 More than 100 million women in less developed countries would prefer to avoid pregnancy, but are not using any form of FP. These women are considered to have an "unmet need" for FP. (Ross and Winfrey 2002) The message is to wait two years to become pregnant, not to wait two years to give birth to another baby 24

Opportunities to Provide LAM Counseling and Integration Antenatal clinic Child health (well-baby) clinic Postpartum ward Postpartum clinic Immunization centres Family planning clinic Labor ward (during early labor or after birth) Community health visits [Allow participants to answer question and describe opportunities for LAM counseling.] Summarize discussion by reading this slide. You may list various community sites that are appropriate to the local setting.

Why is it important to integrate LAM in all health programs that serve pregnant and postpartum women? Has significant health benefits for both mothers and children Provides women with effective protection from pregnancy for up 6 months – a high risk period Can facilitate a timely transition to other family planning methods

Rationale for supporting LAM in FP & MNCH services LAM attracts many women who are not FP users Can serve as introductory / “gateway” FP method Contributes to health benefits of healthy timing and spacing of pregnancies Can support exclusive breastfeeding Development. Women who use LAM have been shown to be twice as likely to be using family planning at one year postpartum than women who are only breastfeeding.

Jharkhand, India: Integration in MoH and ICDS programs in select districts MoHFW in FP programs: Environment supportive of PPFP Trg of all service providers including MOs, ANMs, LHVs and CHWs on LAM Printing of LAM client cards through Govt resources Partially included in reporting format Included in JSY (maternal health) card for pregnant mothers

Jharkhand, India: Integration in ICDS program Supportive environment for LAM as it encourages EBF which is a key intervention Training of all service providers including AWWs, cluster coordinators, CDPOs and DPOs Govt notification to all District Officers to support inclusion of LAM in the activities at Anganwadi Centres Counseling on LAM to be given to all pregnant and lactating mothers

Case Studies: Case 1 A mother comes to you four weeks after giving birth reporting that she has had 2 days of some bleeding. She is only breastfeeding her baby. Can this mother rely on LAM for contraception? - Yes she can rely on LAM for contraception Why? - Her spotting is part of the post partum bleeding and not return of menstruation - She meets the 3 criteria of LAM use What advice will you give to this mother? - She must continue to breastfeed her child at all times during day and night - To return to a health provider if any of the three conditions break

Case Studies: (contd) Case 2 Rita gives birth on Jan 7, 2010. Rita is following the 3 criteria's of LAM until she comes to you for advise. Her mother in law wants the baby to be given honey each evening. Will Rita be able to continue using LAM if she starts giving honey? - Rita will not be able to use LAM if she starts to give her baby any additional food or liquid before the baby turns 6 months old What advice will you give to Rita? Rita must continue to ONLY breastfeed her baby while she introduces supplementary food at 6 months only Also talk to her mother In law to help her make the right choice for the baby and Rita Rita must start using a FP method when LAM is no longer effective for her. Provide her options and advice.

Thank you! Georgetown University Institute for Reproductive Health www.irh.org Institute for Reproductive Health, India http://www.irh.in/