The Lactational Amenorrhea Method (LAM): A Postpartum Contraceptive Choice for Women Who Breastfeed

The Lactational Amenorrhea Method is an effective, temporary contraceptive method based on natural infertility resulting from certain patterns of breastfeeding. Studies suggest that LAM attracts previous non-users to the modern method mix. Providers should discuss with clients healthy timing and spacing of pregnancies and return to fertility as part of LAM counseling. Programs should assist mothers in transition from LAM to another method by providing or linking to family planning services.

The Lactational Amenorrhea Method (LAM) is a modern, temporary contraceptive method based on natural infertility resulting from certain patterns of breastfeeding.

All postpartum women who meet the following three criteria can use LAM:

1. Menstrual periods have not resumed; AND
2. The infant is fully¹ or nearly fully² breastfed frequently, day and night³; AND
3. The infant is under six months of age.

Because LAM is a short-term, temporary contraceptive method, an essential component of LAM services is introducing and providing ongoing supplies of another contraceptive method when any one of the three criteria is not met, or when the woman no longer wishes to rely on LAM for family planning. In fact, changing to another method can be discussed well before a woman discontinues LAM, in order to ensure there is no time she is at risk for unintended pregnancy.

Key Elements of LAM Services
Key programmatic elements of quality LAM services for postpartum women who breastfeed include:

  

ELEMENT	DISCUSSION POINTS
Counseling on the criteria for effective LAM use:	Explain the three criteria for LAM use, what each means for ensuring contraceptive protection, and that all three criteria must be met.
Offering encouragement and support to maintain exclusive breastfeeding for six months:	Explain the optimal breastfeeding behaviors that help maximize the contraceptive effect of LAM (textbox below). Inform clients of when to contact a provider for support or management of breastfeeding difficulties.
Educating about return to fertility:	Explain that the chances of becoming pregnant during the postpartum period change according to breastfeeding status, intensity of breastfeeding, and length of time postpartum. If any one of the three criteria for LAM use is not met, pregnancy can occur even when menses has not returned.
Discussing reproductive goals and fertility intentions for spacing or limiting:	Discuss the woman’s or couple’s desire for more children and for spacing or limiting births.
Healthy timing and spacing of pregnancies:	Encourage women/couples who want another child to wait at least two years before trying to get pregnant again for the sake of the infant’s and mother’s health.
Counseling about appropriate contraceptive methods:	Present the range of available contraceptive methods available for use by breastfeeding women. Explain which methods are appropriate, depending on the timing of their use and the woman’s need for protection from sexually transmitted infections and pregnancy. Provide contraceptive methods or referrals as needed.
Transition from LAM to another modern method:	Explain the conditions that indicate a need to use, or transition to, another contraceptive method.

 
Timing and frequency of counseling for LAM: LAM counseling during the antenatal period informs women about the method, yet studies find that two client visits during the postpartum period encourages LAM acceptance, correct LAM breastfeeding practices, and continued use⁴. The timing of these two visits is critical: the first during the immediate postpartum, the second at the time of transition to another method—either when a woman no longer meets all three LAM criteria or when she wants to transition to another family planning method. The first postnatal visit helps a provider determine whether a woman is breastfeeding correctly and according to the LAM criteria. During the second visit, the provider can facilitate the transition from LAM to another modern contraceptive method by helping the woman choose an appropriate method based on her fertility intentions. Providers can also discuss the importance of exclusive breastfeeding up to six months and of introducing supplemental feeding after six months while continuing to breastfeed for up to two years and beyond.

Addressing Perceived Limitations
A common rationale for not offering LAM is that women might otherwise initiate a longer-term modern method in the first few months postpartum if they are not using LAM.  In fact, studies suggest that LAM attracts previous non-users to the modern method mix. Another concern is that LAM is less effective if mother and child are separated for extended periods, such as while working. While LAM use among working mothers is slightly less effective than typical or ideal LAM use (a pregnancy rate of 5.2% versus 2% or less), it is still far less than the 25–30% pregnancy rate among women who are not breastfeeding and not using any form of contraception.

Rationale for Including LAM in Maternal and Child Health, Reproductive Health and Family Planning Programs

• LAM effectiveness has been proven repeatedly in prospective clinical trials over the past two decades; LAM effectiveness is 99.5% for ideal use and 98% for typical use.⁵
• To promote informed choice, the contraceptive method mix should include LAM. LAM is simple to use and readily accessible, but requires effective counseling.
• LAM has child survival benefits. It supports exclusive breastfeeding for the first six months, which provides nutrients and immunological protection to the infant, as well as prevents pregnancies during the critical first months postpartum.
• LAM reaches the sub-population of women who have not been using modern contraception. Evidence suggests that LAM users within this group transition to become new acceptors of other modern methods.
• In countries with high fertility and low contraceptive prevalence, including LAM in the method mix can serve as an “entry point” for stimulating the use of other modern methods.
• Infant immunization visits provide opportunities to inquire about LAM criteria and counsel on the need to transition to other methods.

References: 
¹ A woman is fully breastfeeding when she breastfeeds her infant:

—  exclusively—giving no water, other liquid, or solid to the infant; or
—  almost exclusively—giving vitamins, mineral water, juice or ritualistic feeds infrequently, in addition to breastfeeds.

² A woman is nearly fully breastfeeding when the vast majority of feedings given to her infant are breastfeeds.
³ In this context, frequently means whenever the infant is hungry, both day and night. 
⁴ Peterson, A. 2000. Multicenter study of the lactational amenorrhea method (LAM) III: Effectiveness, duration, and satisfaction with reduced
   client-provider contact. Contraception 62: 221–230.
⁵ World Health Organization Department of Reproductive Health and Research (WHO/RHR) and Johns Hopkins Bloomberg School of Public Health/Center for Communications Programs (CCP), INFO Project. Family Planning: A Global Handbook for Providers. Baltimore and Geneva: CCP and WHO, 2007.

For more information about LAM, see the ACCESS-FP Web site: www.accesstohealth.org
The ACCESS-FP Program is a five-year, USAID-sponsored global program with the goal of responding to the significant unmet needs for family planning among postpartum women. As an Associate Award through the ACCESS Program, ACCESS-FP is implemented by JHPIEGO in partnership with Save the Children, Constella/Futures, the Academy for Educational Development, the American College of Nurse-Midwives and IMA World Health.