The Lactational
Amenorrhea Method (LAM):
Another Choice for Mothers
Miriam H. Labbok, MD, MPH
Associate Professor, Georgetown University Medical Center;
Director, Breastfeeding and Maternal Child Health
Director, WHO Collaborating Center on Breastfeeding
from Breastfeeding Abstracts,
August 1993, Volume 13, Number 1, pp. 3-4.
At the six-week postpartum
checkup, the new mother is often told that she must begin contraceptive
use immediately to avoid a pregnancy too soon. But what method should
she choose? Research substantiates that women worldwide believe breastfeeding
is associated with fertility reduction, but the question remains: How
to use it effectively? The Lactational Amenorrhea Method (LAM) answers
that question.
LAM is a newly developed
interim family planning method that is based on utilization of lactational
infertility for protection from pregnancy. LAM provides optimal infant
nutrition, enhances immunity, prevents formula-related illness, and
physiologically promotes mother-child interaction while simultaneously
providing safe and effective temporary child spacing. It may be used
for up to six months postpartum during full or nearly full breastfeeding
and amenorrhea, and has been shown in clinical trial to be 99 percent
effective.
The Lactational Amenorrhea
Method was developed as a result of a meeting held at Georgetown University.1
It is designed to bring the health and fertility benefits of breastfeeding
to the attention of family-planning providers and demographers. A mother
is asked these three questions: Is your infant less than six months
old? Are you amenorrheic? Are you fully or nearly fully breastfeeding?
If she can answer yes to all three, she is counseled that her risk of
pregnancy is less than two percent and she does not need a complementary
family-planning method yet. She is also told that if any of these three
parameters changes, she should introduce a complementary form of family
planning to achieve this same low risk of pregnancy.
LAM is based primarily on
a previously published approach2 and on the results of the
Bellagio Consensus Meeting on Breastfeeding as a Family Planning Method
held in l988.3 It serves as a guide from which individual
programs can develop culturally appropriate presentations. Today, LAM
or MELA (Spanish) or MAMA (French) is in use in at least ten countries
and each program provides support for the mother's choice to breastfeed.
The available research has
made it virtually impossible for scientific analysts to deny the impact
of the LAM method. This method has undergone clinical trial in Santiago,
Chile.4, 5, 6 A case-control intervention study was established
whereby the control cohort was ascertained prior to the development
of an organized breastfeeding support program at the Pontificia Universidad
Católica de Chile. The intervention included prenatal education, immediate
postpartum breastfeeding, rooming-in, decreased in-hospital use of formula,
the establishment of a follow-up clinic, and the offer of LAM as an
introductory family planning method.
LAM proved highly efficacious,
with a pregnancy rate of less than 1/2 of 1 percent by six-month life
table. The intervention more than doubled the percent of women who achieved
six months of meeting LAM criteria. At six months postpartum, family
planning coverage had increased from 78 percent to 91 percent with the
inclusion of LAM in the "cafeteria" of methods available.
Pregnancy rates remained lower for the intervention group for over a
year, and the percent who were breastfeeding remained higher long after
the intervention was over. The duration of amenorrhea was also extended.
Where the control group performed similarly to other published studies
on the duration of amenorrhea during full breastfeeding among similar
women, 7 the intervention group had longer durations of amenorrhea,
even when comparing the full breastfeeders in each group. Clearly, optimizing
breastfeeding practices, even among full breastfeeders, extends the
duration of amenorrhea and the impact of breastfeeding on fertility,
even after LAM use has ceased.
Much work remains to fully
educate providers of health care on the use of the method, especially
those who doubt women's ability to monitor their own behavior. LAM may
be offered to women who prefer to postpone introducing a complementary
family planning method postpartum. In countries where family planning
is not widely accepted, LAM is useful for populations who have no experience
with family planning and may be hesitant to accept a so-called "modern"
approach. LAM may also promote more effective use of other methods of
family planning by breastfeeding women, since the method delays the
use of a complementary method until the mother's fertility returns.
LAM use results in improved breastfeeding support in the organizations
that provide it and improved breastfeeding practices among the women
who accept it. It also results in cost savings. When the costs of offering
LAM, including retraining and reorganization, are accounted for, there
remains a cost savings of 10 to 20 percent from the reduced need for
personnel, drugs, formula, and bottles.
Research indicates that the
LAM guidelines are very conservative and that each of the three parameters
has considerable flexibility.8 Six months is an arbitrary
time period; we know that continuing to breastfeed prior to each supplemental
feed can extend amenorrhea and infertility. Full breastfeeding is not
mandatory. Although a recently published manuscript seems to say that
any breastfeeding will do during the first six months,9
it is clear from our work and that of many others7, 8, 9, 10
that more intensive breastfeeding is associated with longer durations
of infertility. Even using menses as an indication of fertility return
has some flexibility: the first ovulation is often associated with inadequacies
in the luteal phase and other hormonal parameters. Based on worldwide
experiences with relying on lactational amenorrhea beyond six months,
we are now exploring what we call LAM II, a new more flexible method.
Some centers have already begun independently to experiment with "LAM
9," a nine-month variant, and women who have self-selected to extend
LAM are being studied in several settings.11, 12
The unique side effects of
LAM, improved infant and maternal health and satisfied family planning
workers, contribute in yet another way to the health of the community.
A mother's postpartum family
planning choices now include a reliable interim method based on the
behavior that is healthiest for her and her newborn.
ACKNOWLEDGEMENTS
Much of this paper is derived
from the referenced articles and collaboration with Drs. Pérez and Valdés
in Chile. Support for this publication was provided by the Institute
for Reproductive Health, Georgetown University, under Cooperative Agreement
with the Agency for International Development (A.I.D.) (DPE-3040-A-00-5064-01).
The views expressed by the authors do not necessarily reflect the views
or policies of A.I.D, or Georgetown University.
References
1. Labbok. M., P Koniz-Booher,
J. Shelton, K. Krasovec, and K. Cooney. Guidelines for breastfeeding
in family planning and child survival programs. Institute for Reproductive
Health, Georgetown University, 1990, rev. 1992.
2. Labbok, M. Breastfeeding
and contraception. New Eng J Med 1983; 308:51.
3. Kennedy, K., R. Rivera,
and A. McNeilly. Consensus statement on the use of breastfeeding as
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4. Valdes, V., A. Pérez,
M. Labbok, E. Pugin et al. The impact of a
hospital and clinic-based breastfeeding promotion program. J Trop
Pediatr In press.
5. Pérez, A. and V. Valdés.
Santiago Breastfeeding Promotion Program: preliminary results of an
intervention study. Am J Obstet Gynecol 1991; 165(suppl 2):2039-44.
6. Pérez, A., M. Labbok.
and J. Queenan. Clinical study of the lactational amenorrhea method
for family planning. Lancet 1992; 339:968-969.
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8. Wade, K., F. Sevilla,
and M. Labbok. LAM acceptability among family planning clients: process
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R. Apelo, S. Eslami et al. The risk of ovulation during lactation.
Lancet 1990; 335:25-29.
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12. Hoser, Fr. H: Personal
communication. December 1992.
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