1. Lactational Amenorrhea Method (LAM) Characteristics of LAM
Session I:
Characteristics of LAM
Suggested script:
The Lactational Amenorrhea Method (LAM) is a highly effective, temporary family planning method for breastfeeding women. LAM provides natural protection against pregnancy for up to six months after birth while the woman continues breastfeeding. It encourages the timely transition to other modern methods of contraception. This presentation provides an overview of the underlying physiology of LAM, the evidence on its efficacy and contributions to MCH and FP as well as the advantages and limitations of this method. It also provides training on how to counsel, screen, and provide follow-up to clients to transition to another method once one of the three LAM criteria is no longer met.
Note to facilitator:
Note-taking pages for this presentation can be created and distributed to participants.

2. LAM Objectives Participants will:
Describe the three criteria for LAM in a manner that clients can understand.
Explain basic mechanism of action and effectiveness of LAM.
Identify appropriate timing to start other methods of contraception for breastfeeding mothers (for “transition” from LAM).
Identify advantages and limitations of LAM
Demonstrate how to counsel LAM-related topics (three criteria, transition from LAM to another method, optimal breastfeeding practices).
Suggested script:
The learning objectives for this module are based on input from various stakeholders <insert who provided input: participants, supervisors, health officials>.
The objectives of this module are as follows: By the end of this training session, participants will be able to: <click the mouse to advance through the objectives, reading each objective aloud >.

3. LAM: Key Points for Providers and Clients
A temporary contraceptive method based on breastfeeding.
“Lactational”—related to breastfeeding. “Amenorrhoea”—not having menstrual bleeding.
Using LAM means choosing to breastfeed in a way that prevents pregnancy. It works by stopping ovulation.
LAM means breastfeeding often, day and night, and giving baby little or no other food.
Fully or nearly fully breastfeeding (with little or no other food or drink) gives best protection from pregnancy and is best for the baby’s health.
Effective for 6 months after giving birth If periods have not returned.
Very effective when used correctly. (less than 1 pregnancy per 100 women using LAM in the first 6 months after childbirth).
But as commonly used it is less effective (2 pregnancies per 100 women ) in the first 6 months of use.
Adapted from WHO’s Decision-making tool for family planning clients and providers.
Review the key points about LAM.
LAM is:
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.
A “gateway” to other modern methods of contraception. (Ask participants to keep this in mind throughout this session. It will be discussed in much more detail later.)
Requires breastfeeding often, day and night. Almost all of the baby’s feedings should be breast milk.
LAM is not just “breastfeeding.” It is a family planning method based on the hormonal suppression of ovulation caused by breastfeeding.
LAM is one more method that is available to expand the local method mix and meet more contraceptive needs.
Ask participants: what conditions, or criteria, must be met to use LAM. Recognize any correct answers?

4. LAM: Key Points for Providers and Clients
Breast milk is the best food for babies
Healthiest way to feed most babies for first 6 months. Breast milk contains the exact nutrients the baby needs and helps protect the baby from infections. Breastfeeding benefits the mother’s health too.
Breastfeeding should be started within 1 hour after birth, and babies should be given no other food or drink until they are 6 months old.
Breast milk can be a major part of diet for 2 years or more.
No protection against STIs or HIV/AIDS.
For STI/HIV protection, also use condoms.
There is a chance that mothers living with HIV, if they are not taking antiretroviral therapy (ART), will transmit HIV to their infants through breastfeeding, but is still recommended in most cases.
Adapted from WHO’s Decision-making tool for family planning clients and providers.

5. LAM: Mechanism of Action
Baby’s suckling stimulates the nipple
Nipple stimulation triggers signals to mother’s brain
Signals disrupt hormone production
Disruption of hormones suppresses ovulation
No egg, no pregnancy
Explain that LAM prevents pregnancy by interfering with the release of hormones that allow ovulation. Suckling stimulates production of a hormone that tells the brain not to release the hormone necessary for ovulation. Regular and frequent nipple stimulation is necessary to ensure a continuous stimulation of the brain/hypothalamus.
Frequent and intense breastfeeding prevents ovulation through the following sequence of events: 
The baby’s sucking stimulates the nipple. The baby squeezes and rubs the nipple with his/her gums and palate; this causes a pressure or “mechanical stimulation” of the nipple.
This stimulation of the nipple sends a neural signal to the mother’s brain—specifically her pituitary, which produces and secretes hormones related to many bodily processes, including ovulation.
This signal to the mother’s brain disrupts the production of hormones that would normally stimulate the ovary.
In response to the suckling stimuli, there is an increased production of prolactin, which inhibits the secretion of GnRH (gonadotropin-releasing hormone) by the hypothalamus. Prolactin controls the rate of milk production but it is not considered to play a major role in suppressing ovarian function.
Disruptions in the release of GnRH, in turn, disrupt the pituitary’s production and release of hormones directly responsible for ovulation: follicle-stimulating hormone (FSH) and luteinizing hormone.
Thus, ovulation is prevented. Disruption in release of FSH impedes the normal maturation of the egg by the ovary; disruptions in the release of LH impede the release of a mature egg by the ovary.

6. Three LAM Criteria If breastfeeding now, can use LAM if:
 Baby is less than 6 months old
AND
The baby is fully or nearly fully
breastfeeding and is fed often day and night
Menstrual periods have not come
back
Adapted from WHO’s Decision-making tool for family planning clients and providers.
The three LAM criteria are:
The woman’s menstrual bleeding has not returned; AND
The baby is fully or nearly fully breastfeeding and is fed often day and night; AND
The baby is less than six months old.
LAM will not be effective if any one of the three criteria is not met. LAM is not just “breastfeeding.” While any breastfeeding may decrease fertility, LAM cannot be used as an effective method of contraception unless the other two criteria are also met.

7. How to Use LAM Can start LAM as soon as baby is born
Start giving baby other foods when he/she is 6 months old, but continue to breastfeed
Can start LAM as soon as baby is born
Breastfeed often day and night. Daytime feeding no more than 4 hours apart. Night-time feeding no more than 6 hours apart.
Start another method at the right time, BEFORE the LAM criteria no longer apply
What to do after LAM:
Adapted from WHO’s Decision-making tool for family planning clients and providers.
Begin LAM as soon as baby is born
Breastfeed often day and night. Daytime feeding no more than 4 hours apart. Night-time feeding no more than 6 hours apart.
Start another method at the right time, BEFORE the LAM criteria no longer apply.
Start giving baby other foods when he/she is 6 months old, but continue to breastfeed

8. Effectiveness of LAM
In this progression of effectiveness, where would you place LAM?
Less effective
More effective
Male Sterilization
Female Sterilization
IUDs
Progestin-Only Injectables
Combined Oral Contraceptives
Male Condoms
Standard Days Method
Female Condoms
Spermicides
Less effective
More effective
LAM
Ask participants: Where would you put LAMon this list? <After participants respond, click the mouse to reveal the answer>.
The list on this slide categorizes contraceptive methods from most effective to least effective as commonly used. In this list, spermicides are the least effective method and the most effective methods are sterilization and IUDs.

9. Effectiveness Spermicides Female condom Standard Days Method
Oral contraceptives
Suggested script:
LAM is very effective when used correctly. This chart compares the pregnancy rates for LAM with the rates for other contraceptive methods. The red rectangles show pregnancy rates for correct and consistent use, reflecting how often a contraceptive fails when it is used both correctly and consistently. The blue rectangles show pregnancy rates for typical use, reflecting how often a contraceptive fails in real-life situations, when it may not always be used correctly and consistently.
In the case of LAM, there is little difference between pregnancy rates for correct and consistent use and typical use.
DMPA
LAM
Rate during perfect use
IUD (TCu-380A)
Female sterilization
Rate during typical use
Implants 5 10 15 20 25 30
Percentage of women pregnant in first year of use, but note LAM only used for 6 months
Source: CCP and WHO, 2018.
Family Planning Training Resource Package

10. LAM: Characteristics Advantages Safe, natural and no side effects
Requires no supplies or procedures
Health benefits for mother and baby
Can be used immediately after childbirth
A temporary method
Facilitates modern contraceptive use by previous non-users
Is provided and controlled by the woman
Supports and builds on global infant-feeding recommendation to exclusively breastfeed for six months
Limitations
No STI/HIV protection
Is only a temporary method
Not a good method for women who have to be away from their babies for long periods of time.
The purpose of this activity is to keep participants focused on how they translate technical information into concepts that their clients can understand.
Brainstorming instructions:
Ask trainees to brainstorm first a list of positive characteristics (advantages) and then negative characteristics (limitations) of LAM.
Write these suggested characteristics on a flip chart. Then show the slides of LAM characteristics and compare them to the list generated through brainstorming.
If you use the terms advantages and limitations, mention that the same characteristic of a FP method may be an advantage for one person and a limitation to another.
Discuss and correct any misconceptions and counter any myths that may arise about female condoms.
Remind participants that people with similar characteristics in similar situations may have very different reasons for making choices about contraceptive methods. When counseling clients it is important to help them consider how these method characteristics fit with their lifestyles and reproductive health goals and desires.
Source: Hatcher, 2011; WHO, 2015; CCP and WHO, 2018 10