1. Lactational Amenorrhea Method (LAM)
Session III:
Counseling on LAM

2. Return of Fertility and Risk of Pregnancy
In women 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.
Refer to Session Guide for short case studies;
Ask participants: Why is early initiation of LAM or another contraceptive critical if the couple does not want to become pregnant again right away?
Because fertility can return soon after birth.
If not breastfeeding, ovulation will occur on average at 45 days; and it may occur as early as 21 days postpartum.
The breastfeeding woman who is not practicing LAM is likely to ovulate before return of menses.
Between 5% and 10% of women conceive within the first year postpartum. 2

3. Counseling about LAM: Key Counseling Topics for LAM Users
Screen for/educate about LAM criteria:
Three criteria and why each is important
Any conditions that exclude use of LAM
Discuss effectiveness of LAM
Select another modern method to which to transition from LAM
Encourage spacing of pregnancies by using another method of family planning for at least 2 years
Discuss optimal breastfeeding practices
Ensure that client knows to return if she has a problem
Using Handout # 4, discuss each of these items with women who choose LAM:
LAM criteria, including:
Reasons each criteria is important
Conditions that exclude use of LAM
Effectiveness of LAM
Selection of a another modern method of contraception to transition to from LAM.
Healthy timing and spacing of pregnancies, that is, waiting at least two years after a previous pregnancy to become pregnant again.
Optimal breastfeeding practices.
Where the woman should go if she has a problem.

4. Transition to Another Method: An Essential Component of LAM
LAM can be a bridge to other modern methods of contraception
LAM provides the couple time to decide on another modern method to use after LAM
Explain that:
By the time any one of the three LAM criteria is no longer met, the woman/couple should be using another modern method of family planning if they do not want to become pregnant.
Therefore, counseling to support effective transition to another modern method must begin before the woman starts using LAM, such as when LAM counseling is initiated.
The woman who is using LAM needs to know that she may become pregnant even when she is breastfeeding:
If she has had any vaginal bleeding after two months postpartum,
If she is no longer breastfeeding fully or nearly fully, or
If the baby is six months of age or older.
A woman can ovulate, and therefore become pregnant, even before her menses return. The woman who meets all three LAM criteria, however, can transition to another family planning method with confidence that she is not pregnant
A woman transitioning from LAM should be encouraged to continue breastfeeding her baby even after she begins using another method of contraception, as appropriate. Continued breastfeeding should be kept in mind when choosing the next method.

5. Transition to Another Method
When LAM counseling is initiated, the provider should discuss transition from LAM to another contraceptive method with the client:
Another method should be started as soon as any one of three LAM criteria is not met.
Transition method should be selected before this occurs.
Providers can help ensure that another modern method of contraception follows the cessation of LAM, by:
Mentioning the importance of transition from the very first contact with the mother (and in all subsequent contacts).
Advising the woman to select the method to which she will transition BEFORE any one of the three criteria is no longer met.
Providing the woman with advance contraceptive supplies (if the program can afford it).
Review: early initiation of LAM or any other contraceptive is critical if the couple does not want to become pregnant again right away. Again:
If not breastfeeding, ovulation will occur on average at 45 days; and it may occur as early as 21 days postpartum, and
A breastfeeding woman not practicing LAM is likely to ovulate before return of menses.
Between 5% and 10% of women conceive within the first year postpartum.
Postpartum contraception reduces the numbers of women becoming pregnant, and therefore the 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 two years after their sibling was born.
The message is to wait two years to become pregnant, not to wait two years to give birth to another baby.
As described earlier, LAM can provide a “gateway” to other modern methods of contraception. What do we mean by “gateway”? For one thing, LAM provides the couple time to think about, discuss and decide on another modern method that they can use when LAM criteria are no longer met, or if they choose to discontinue use of LAM.

6. Source MCHIP via K4 Health 2015 https://www. k4health

7. Source MCHIP via K4 Health 2015 https://www. k4health

8. Opportunities to Provide LAM Counseling
Antenatal clinic
Child health (well-baby) clinic
Postpartum ward
Postpartum clinic
Family planning clinic
Labor ward (during early labor or following birth)
Community health visits
All pregnant or postpartum women should be informed about LAM and offered the opportunity to use it as a highly effective, temporary method of contraception.
Opportunities to inform women about LAM and counsel them on its use include antenatal clinics; immediate postpartum wards; well-baby, nutrition and immunization visits; postpartum clinics; family planning clinics; labor wards (during early labor or after birth); and community health visits.
The immediate postpartum visit is especially important to the successful implementation of LAM. This may occur at home or in a clinic, hospital or other health care setting.
Likewise, a later postpartum visit at the time of transition (i.e., when a woman no longer meets all three LAM criteria or wants to begin using another method) is essential to facilitate the successful transition to another modern method of contraception.

9. Health Benefits Breastfeeding
Mother
Stimulates uterine contractions in early postpartum period
Promotes involution (return of uterus to pre-pregnancy state)
Leads to less anemia because of less iron depletion (due to amenorrhea)
Strengthens mother–baby bonding
Baby
Adapts to needs of growing infant
Promotes optimal brain development
Provides passive immunity and protects from infections
Provides some protection against allergies
There are a number of benefits to breastfeeding, which is one of the three LAM criteria.
In early postpartum, breastfeeding stimulates uterine contractions.
It promotes involution (return of the uterus to its pre-pregnancy state).
Also, there is less anemia because there is less iron depletion due to absence of menses.
In addition, breastfeeding strengthens mother-baby bonding.
There are also many health benefits to the baby.
Breast milk adapts to needs of growing infant. As the infant grows and sucks more, more breast milk is produced.
Breast milk promotes optimal brain development and it provides passive immunity and protects from infections. Certain antibodies in breast milk provide immunity to many infections.
Researchers have also found that breast milk provides some protection against allergies. Bottle-fed babies are at higher risk for allergies.
Also, breastfeeding decreases risk of Sudden Infant Death Syndrome (SIDS). Note: This may be deleted if no one in this setting is familiar with SIDS.

10. Limitations of LAM
Offers only temporary contraceptive protection (up to six months)
Is not usually appropriate if mother will be separated from baby for periods of time
HIV-positive mothers may worry about HIV transmission through breastfeeding
LAM does have some limitations. For instance:
LAM is only a temporary method. It can be used for six 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 – such as if she works outside of the home.
Also, an HIV-positive mother may have concerns about transmission of HIV to her infant through breastfeeding.

11. Correcting Rumors and Misunderstandings
There are many misconceptions about LAM that need to be addressed, including:
LAM is not effective
Women who work away from home cannot use LAM
Women with HIV cannot use LAM
Concerns that if used for 6 months the woman will run our of milk
Fat/thin women cannot use LAM
Special foods are needed by women
Babies need more than just breastmilk in their first six months
Explain that rumors are unconfirmed stories that are transferred from one person to another by word of mouth. In general, rumors arise when:
An issue or information is important to people, but it has not been clearly explained.
There is nobody available who can clarify or correct the incorrect information.
The original source is perceived to be credible.
Clients have not been given enough options for contraceptive methods.
People are motivated to spread them for political reasons.
A misconception or misunderstanding is a mistaken interpretation of ideas or information. If a misconception is imbued with elaborate details and becomes a fanciful story, then it acquires the characteristics of a rumor.
Ask participants: What are some common misconceptions about LAM? <participants brainstorm; write the answers on a flip chart>
Discuss methods for counteracting rumors and misinformation
When a client mentions with a rumor, always listen politely. Don't laugh.
Define what a rumor or misconception is.
Find out where the rumor came from and talk with the people who started it or repeated it. Check whether there is some basis for the rumor.
Explain the facts.
Use strong scientific facts about FP methods to counteract misinformation.
Always tell the truth. Never try to hide side effects or problems that might occur with various methods.
Clarify information with the use of demonstrations and visual aids.
Give examples of people who are satisfied users of the method (only if they are willing to have their names used). This kind of personal testimonial is most convincing.
Reassure the client by examining her and telling her your findings.
Counsel the client about all available FP methods.
Refer back to the flipchart and ask participants how they could counteract each rumor or misconception.

12. Optimal Breastfeeding Practices
Allow newborn to breastfeed as soon as possible after birth, and to remain with the mother after birth
Breastfeed as often as the baby wants, for as long as s/he wants, day and night
Continue breastfeeding even if mother or infant becomes ill
Do not give the baby any foods or other liquids for the first six months
Do not use bottles, pacifiers or other artificial nipples
It is important for the mother to practice optimal breastfeeding practices for the health of the baby and effectiveness of LAM:
The baby needs to breastfeed as soon as possible, preferably within the first hour of birth in order for the mother to feed the baby colostrum (substance rich in nutrients produced immediately postpartum).
The baby should breastfeed “on demand” as often as a frequently and for as long as it wants.
Even if the mother or the baby becomes ill, the mother should continue breastfeeding.
And the baby should not be given ANYTHING but breast milk for the first six months – whether or not the woman is using LAM. Breast milk is the perfect and complete food for the baby.
The family should not use any bottles or pacifiers [use local term(s)] because these discourage the baby from breastfeeding as frequently.
February 2010 – Draft Combined Oral Contraceptives – Family Planning Training Resource Package 12

13. Optimal Breastfeeding Practices, continued
Offer the second breast after the infant releases the first
Eat and drink more than usual
Continue to breastfeed for the first two years, providing complementary foods beginning at six months of age.
Remember: breastfeeding mothers often need family or social support.
It is important for the mother to practice optimal breastfeeding practices for the health of the baby and effectiveness of LAM:
When the baby finishes sucking on one breast, offer the other breast.
Breastfeeding uses fluid and calories, so the mother should eat and drink more than usual.
And even though the baby will begin to get other food after six months, the mother should continue to breastfeed (as complementary to the other food) for two years. This supplemental breast milk provides special nutrients and antibodies that the baby continues to need.
Note: Breastfeeding consumes a lot time and energy, so you may need to talk with other family members to remind them to provide help to the mother during this time.
February 2010 – Draft Combined Oral Contraceptives – Family Planning Training Resource Package 13

14. LAM and HIV
Every woman should be supported in her infant-feeding decision and in her contraceptive choice.
Breastfeeding will not make HIV worse.
Early and exclusive breastfeeding is the best way to promote the child’s survival, including for women with HIV.
Giving ART to an HIV-infected mother or an HIV-exposed infant significantly reduces the risk of HIV transmission through breastfeeding
Mothers living with HIV and their infants should receive appropriate ART and exclusively breastfeed their infants for the first 6 months of life, then introduce appropriate complementary foods and continue breastfeeding for at least 12 months and up to 24 months or more while being fully supported to keep taking ART.
Note to Facilitator: Review the WHO Guidelines for HIV and infant breastfeeding and compare with the corresponding country national guidelines, as often times there are differences. Note that all of the practices mentioned on the slide are good breastfeeding practices and could apply to women who are not infected with HIV
Mention that mothers have a right to obtain preventive treatment for their infant to minimize the chance of HIV transmission to the infant.
Explain to participants that HIV-positive women may use LAM. All women should be encouraged to breastfeed.
Replacement feeding should not be encouraged, it is rarely:
(A) acceptable (i.e., in some cultures bottle feeding is not accepted);
(F) feasible (i.e., is not appropriate because the woman does not have the resources to prepare and give replacement feeding);
(A) affordable (i.e., some families cannot afford to pay the high price of formula/replacement feeding);
(S) sustainable (i.e., some people who can afford and prepare formula now may not be able to a month from now); and
(S) safe (i.e., contaminated water or unclean feeding equipment may be the only thing available in some settings)
should be encouraged to fully or nearly fully breastfeed their infants for six months. You may have heard this referred to as “AFASS” in PMTCT programs.
After six months, breastfeeding should continue in addition to supplementary feeds until AFASS criteria are met. The HIV-positive infant should also continue to breastfeed until AFASS criteria are met.

15. LAM and HIV, Continued
Breastfeeding should then only stop once a nutritionally adequate and safe diet without breast milk can be provided.
When HIV-infected mothers decide to stop breastfeeding (at any time) they should do so gradually within one month.

16. LAM and HIV, Continued
A mother with HIV who chooses to breastfeed or use LAM should:
Receive care and treatment for herself to minimize the risk of transmission to the infant and keep herself healthy.
Use condoms consistently
If she experiences cracked nipples or other breast problems, instruct her to feed from unaffected breast (and express and discard milk from affected breast)
Seek immediate care for baby with thrush or other lesions in mouth
*Note:the last two bullets are pretty much true for ALL mothers, although they are particularly relevant for HIV+ mothers. The woman who is HIV-positive should be on ARV therapy if clinically eligible. ARVs taken by the mother greatly reduce the likelihood of transmission of the virus through breast milk.
The woman who is HIV positive should continue to use condoms consistently as LAM does not protect against sexually transmitted infections.
HIV is more likely to be transmitted to the baby if the nipples are cracked or bleeding.
HIV is more likely to be transmitted through lesions in the baby’s mouth than through a healthy oral mucosa.
Breast problems in the mother or problems in the mouth of the baby may encourage transmission of the virus from mother to baby.

17. LAM – Summary
Over 98% effective as long as all three criteria are met:
No menses
Breastfeeding only
Baby less than 6 months
Can be a bridge to other modern methods of family planning
Provides important health benefits to the mother and child
Natural and no side effects
Picture: IRH, Nicaragua
Conduct roleplays and case studies using Facilitator’s Guide and Handouts #5 and #6.
Summarize the session:
LAM has characteristics that make them a desirable family planning method for many clients.
Over 98% effective as long as all three criteria are met.
“Gateway” to other modern methods of family planning.
Provides important health benefits to the mother and child.
Natural and no side effects.
Appropriate counseling plays an important role, with special attention to helping with partner negotiation and consistent and correct use.