CONTENTS
October 1996 |
Lactational Amenorrhea
Method The lactational amenorrhea method (LAM) is a family planning method based on the physiology of breastfeeding. If a breastfeeding woman meets the three LAM criteria, her risk of pregnancy in the first 6 months after childbirth is about 2%, or 1 in 50. The three LAM criteria are: 1. Amenorrhea, defined as the absence of the menses. Menses return is defined as the first two sequential days of bleeding or spotting which may occur after 2 months postpartum. 2. Fully or nearly fully breastfeeding, includes exclusive breastfeeding, almost exclusive breastfeeding, and nearly fully breastfeeding, day and night, on demand by the infant. Efficacy and duration of LAM are enhanced with more intense breastfeeding patterns, especially during the earlier weeks and months. 3. Less than 6 months postpartum.
Q.1. When should LAM users begin another method?According to WHO, progestin-only methods (e.g., POPs, Depo-Provera, Norplant implants) should not be initiated before 6 weeks postpartum, and estrogen-containing methods (e.g., COCs, CICs) should not be started by breastfeeding women before 6 months postpartum. Rationale: While the LAM criteria are met, LAM is a very effective contraceptive method (214). Nonhormonal methods have no effect on lactation or the infant. Progestin-only methods have no known effect but are WHO Category 3 (risks usually outweigh advantages) in the first 6 weeks postpartum due to theoretical concerns about steroid transmission in breast milk. Estrogenic methods generally should not be used by breastfeeding women prior to 6 months postpartum due to their effects on lactation (WHO Category 3) (302). Recommendation: It is appropriate for a LAM user to have a contraceptive method on hand that she can initiate herself. A woman should have the opportunity to make an informed choice to begin any other method that is appropriate for her while she is still protected by LAM. She can then initiate that method when the LAM criteria no longer hold or she chooses to end reliance on LAM. Rationale: The method a LAM user has on hand (for use after she is no longer relying on LAM) may be a woman's chosen follow-up method, or it may be for use as a temporary complementary method until she has a chance to visit her family planning provider to procure the method she desires. A service provider can be reasonably sure that a LAM user is not pregnant if the LAM criteria are met. The provider can then provide the chosen method (as per the protocol for that method) before the end of LAM (214). Having a contraceptive method on hand that the user can initiate herself when LAM expires (or when the woman no longer wishes to rely on LAM) is thought to have the potential of reducing the chance of a gap in protection. Recommendation: Women using LAM are still at risk of STDs, including HIV/AIDS, and may need to use condoms or other barrier methods for STD protection. Rationale: LAM does not offer protection from STDs or HIV. Clients at risk for these diseases should be encouraged to use barrier methods and counseled about behaviors that can decrease risk.
Q.2. Can LAM use be extended beyond 6 months?Rationale: Prenatal breastfeeding education and information on LAM can increase the duration of breastfeeding, lactational amenorrhea, and LAM protection (45, 223). Recommendation: The extended versions of LAM (e.g., LAM-9, MAMA-9, LAM-12) are based on amenorrhea and maintenance of a high-frequency pattern of breastfeeding, with full or nearly full breastfeeding, and with breastfeeding before each supplemental feed. Lactational amenorrhea beyond 6 months postpartum conveys a good deal of protection from pregnancy, although it provides less protection than in the first 6 months. As with standard LAM, use of another method should be encouraged when menses return. If she is amenorrheic, before the woman ceases to fully or nearly fully breastfeed, she should return for counseling (either to continue relying on extended LAM, or for another contraceptive method if she wishes). (See Question 1.) Rationale: The probability of becoming pregnant during lactational amenorrhea is low during the first 6 months postpartum. While the risk of pregnancy during lactational amenorrhea is higher after 6 months postpartum, among women with intensive breastfeeding practices the failure rate for lactational amenorrhea up to 1 year postpartum is comparable to the perfect-use failure rates for other reversible methods. However, more research is needed on the efficacy of the extended Lactational Amenorrhea Method (45, 138, 147, 225). |