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Everything you ever wanted to know about the Lactational Amenorrhea Method and the transition to other modern methods!

March 19-30, 2007
http://my.ibpinitiative.org/ppfp

This two-week forum focused on the lactational amenorrhea method of family planning and the transition to other modern family planning methods.

Discussion Statistics


Number of participants: 196
Number of participants' countries: 28
Number of contributions: 30 contributions
% of contributions from developing countries: 17%
Number of countries contributing: 8 countries

Contributing countries: USA, El Salvador, Egypt, Zambia, Guatemala, Afghanistan, Azerbaijan, Burkina Faso

Purpose and Objectives

Purpose:

This two-week forum focused on the lactational amenorrhea method of family planning and the transition to other modern family planning methods.                                                   

Objectives:

ORIGINAL DOCUMENT DOES NOT HAVE CONTENT FOR "OBJECTIVES"                                               

Day 1:  Experience with LAM 

Questions:

  1. What is your experience with LAM? Counseling? Managing programs?
  2. Do you have recommendations about timing of visits?
  3. Do you have recommendations about when to introduce information about other FP methods?                                                                        

Day 1 Summary:

Several participants noted that providers need to be appropriately trained and have a good understanding of LAM before counseling clients on the method. Specifically, providers need to be educated so that they accept LAM as efficacious and understand that LAM criteria can be used as an alternative to a pregnancy test. A guest expert, Marcos Arevalo, noted that current LAM materials and trainings try to give providers appropriate information so that they know that LAM users can be assumed to not be pregnant. In fact, pregnancy tests are not even mentioned in the materials and providers are encouraged to proactively help LAM users move on to their next method.

Day 2: Counseling clients about LAM

Question:

  1. It is my experience that family planning workers in developing settings are very willing and happy to have additional information for their clients. LAM offers a natural segue to supporting them in providing a healthy start on life for their children. How many of you reading this have include LAM actively in your service mix? What do the providers say about it? What do you think the issues are? 


Day 2 Summary:

A guest expert, Maryanne Stone-Jimenez, contributed a PowerPoint presentation from LINKAGES that promotes the importance of LAM as an integral part of ongoing reproductive health and maternal and child health programs. The presentation 1) defines LAM, the criteria for using LAM, and related terminology; 2) promotes the efficacy of LAM as a modern method of contraception; and 3) describes program implications for integrating LAM. The presentation can be found in the community library or by clicking on the link in the References and Resources section below.

Several participants discussed the best time to talk about family planning during pregnancy. One respondent working in El Salvador noted that the 28 week prenatal visit seems to be a good time to provide counseling and information on family planning methods, including LAM.  Marcos Arevalo stated that the earlier that discussion occurs in pregnancy, the better. 

Day 3: Frequently asked questions about LAM

Questions:

Miriam Labbok presents and responds to frequently asked questions about LAM:

  • How many times a day is it necessary to breastfeed? (Answer: Irrelevant)
  • Why 6 months? (Answer: Fairly irrelevant, but just to be sure that complementary feeding starts.)
  • What are the longest intervals? (Answer: 4 hours during the day, 6 hours once a night.)
  • Must I exclusively breastfeed? (Answer: No. In fact, LAM does not demand exclusive breastfeeding.)
  • What should I do if I want to get pregnant and I'm still breastfeeding? (Answer: The real answer to this question is long and complex. Short answers to this question are not very good.)
  • How do I transition from LAM to other methods? (Answer: Just start the other method if it’s right for you according to the WHO Medical Eligibility Criteria. There are first, second and third choice methods while breastfeeding.)
  • How do I transition from LAM to NFP? (Answer: It depends on the method)
                            

Day 3 Summary:

Participants posted comments about advocating for the efficacy of LAM as a modern family planning method to service providers. Several spoke about the importance of including pediatricians in the discussion so they are educated about exclusive breastfeeding.

A colleague also posed a question about body mass index and the implications for LAM. The guest experts agreed that they are unaware of any studies showing evidence that BMI affects the effectiveness of LAM. Another participant asked if the expression of breast milk, rather than fully or nearly fully breastfeeding, changes the effectiveness of LAM. A guest expert, Miriam Labbok, noted that one study of working women using LAM showed no statistical difference in efficacy if they expressed milk regularly while at work. However, while we know that expression of milk elevates prolactin, etc. in that one study of LAM use among women who return to work or school, the few pregnancies that did occur occurred during the period of milk expression. This study deserves to be repeated in a larger population to better understand the impact of separation, expression and stresses of work on fertility suppression.


Day 4

Day 4 Summary:

Annette Bongiovanni offered observations based on findings from the Jordan study, Promoting the Lacational Amenorrhea Method in Jordan Increases Modern Contraceptive Use in the Extended Postpartum Period. Details can be found by clicking on the Program Examples below. 


Day 5: Operationalizing messages about breastfeeding and LAM.

Questions:

  • The global recommendation from WHO promotes exclusive breastfeeding for six months. The breastfeeding criteria for LAM are fully or nearly fully breastfeeding. How do we operationalize these two messages?
                 

Day 5 Summary:

The issue of promoting exclusive breastfeeding (fully or nearly fully) as a way of simplifying LAM has been brought up during discussions on expanding the availability and use of LAM.

Advantages of having exclusive breastfeeding as a LAM criterion:

  • The message of “exclusive” breastfeeding is simpler, easier to understand than “fully or nearly fully.” It requires less explanation, is less likely to be misinterpreted, and/or less likely to be affected by the “slippery slope” phenomenon. Thus, LAM providers (particularly at the community level) may be more likely to explain it correctly, and LAM users might be more likely to follow instructions.
  • Making LAM simpler can make training of providers easier, facilitating expansion of services at the community level in low-resource settings.
  • Exclusive breastfeeding is better for the child, in terms of nutrition and for prevention of diarrhea.
  • It is in accordance with WHO’s and other recommendations on infant nutrition, on prevention of mother to child transmission of HIV (PMTCT).

Disadvantages:

  • Exclusive breastfeeding can be more difficult to maintain; it may discourage some women from using LAM, thus potentially erecting a barrier to access for some women.
  • LAM doesn’t really require exclusive breastfeeding, so we would be unnecessarily asking mothers to do something that is not that easy; or potentially making them not-eligible to use the method when in fact from a biological perspective they might meet all criteria.
Day 6: Revitalizing LAM as a family planning effort.

Questions:

  1. While LAM is essential to the method mix, what sort of context indicates that there is unmet need for this practice?
  2. What is the strategy for promoting LAM (ANC, PNC, other visits?)?
  3. How has LAM been successfully introduced in clinic settings (type of training, in-service, pre-service, etc.)?
  4. How do you assess training on LAM?
  5. How long does in-service training take on LAM for type of provider?
  6. What sort of IEC materials are available and could be used to support LAM?
  7. How can supervision of LAM be integrated into the supervisory structure/activities?
      

Day 6 Summary:

Many challenges exist in implementing LAM as part of postpartum/postnatal care, including the general lack of postpartum care in many countries, the fact that LAM seemed to be focused within the family planning services, rather than well integrated into breastfeeding and maternal/newborn health care.


Day 7

Questions:

NO CONTENTS IN THE ORIGINAL DOCUMENT
 

Day 7 Summary:

In many places, postpartum care providers lack the necessary skill and confidence to guide women in transitioning from LAM to modern methods of contraception. Maternal and newborn healthcare providers often fall outside of the target group for family planning training or for attention from family planning programs. However, as a method that demands only remembering full breastfeeding and amenorrhea, women from a wide variety of socio-economic strata, education, and religious groupings succeeded in using the method with high efficacy. LAM demands little supervision; however, when LAM no longer can be used, it is essential that women have access to a follow-on method.



Day 8. Using LAM with birth intervals of less than six months.

Questions:

  • On the topic of increased risk of dying for women with birth intervals of less than six months: This high risk period for mothers coincides with the LAM period; if LAM fails, the risk of death is 2.5 higher. Should we be counseling women to breastfeed exclusively AND use a backup contraceptive method?
                            

Day 8 Summary A:

Miriam Labbok and Marcos Arevalo respond to the question above. Miriam states that this question reflects a common misunderstanding about LAM. The question implies that LAM is less efficacious than other methods. In fact, LAM has the same high efficacy as the pill, for example, and a higher efficacy than barrier methods. Until we begin counseling all women to use two methods for contraception (yes, we do counsel condoms for AIDS prevention), there is no reason to do this for a method that is more efficacious than most other methods.  Marcos states that the added contraceptive protection of adding a second method would probably be very, very marginal (keeping in mind that the starting point is 98%). Emphasizing good compliance with LAM, and emphasizing the prompt transition to another method post LAM would achieve more in terms of contraceptive protection.

Day 8 Summary B:

Miriam Labbok responded positively to a participant who asked if a women who started breastfeeding later than recommended, say 24 hours after delivery, can fully rely on LAM for 6 months if she continues with exclusive breastfeeding and has no menses. Participants from Burkina Faso and Ethiopia discussed the use of LAM in their countries.


Day 9

Day 9 Summary A:

A participant asked if anyone had other practical experiences or knows of other models of integration, specifically linking LAM to immunization services or other non-family planning services.


                            

Day 9 Summary B:

One participant discussed the need for support for community education programs for LAM. Another participant – the M&E Advisor for the ESD (Extending Service
Delivery) Project in Washington D.C – discussed a new service/research project in Nepal to educate the community and encourage urban poor postpartum women about healthy timing and spacing of pregnancy (HTSP), LAM and transition to other modern family planning methods. The project will follow postpartum women for several years to track their use of LAM and transition to other methods, and for those who become pregnant, their inter-pregnancy intervals and birth outcomes.


Day 10

Questions:

NO CONTENTS IN THE ORIGINAL DOCUMENT
                            

Day 10 Summary:

One participant brought up the issue of bringing fathers/partners into the conversation when talking about family planning and Miriam Labbok provided a wrap-up summary of LAM. Her summary follows:

LAM is efficacious, reliable and easy for women from a very wide variety of backgrounds to understand and use successfully. It is a win-win: it supports both breastfeeding and birthspacing, and encourages both timely complementary feeding and timely introduction of a complementary family planning method.

Sometimes, it is harder for us, as program persons, to feel comfortable with trusting a client to self-monitor a behavior-based method. But for the user, your respect for her will help build her trust in you. As a result, we see very high levels of adoption of other methods among LAM users, once LAM no longer works for them.


Program Examples

Ethiopia. Experience of Community-based Reproductive Health Agents (CBRHAs) in offering LAM to community members in Ethiopia:

  • LAM is time-limited. There is now a fear among women who had previously experienced protection against pregnancy by breastfeeding for 2 – 3 years. They say that LAM is time limited because they are not protected beyond 6 months. Men in the community think of LAM as limiting (6 months) because their experience has been 2 – 3 years protection against pregnancy by breastfeeding. One mother said: “women have always known that breastfeeding and no monthly bleeding prevents pregnancy. Now women at 6 months use another method.”
  • More healthy babies seen in the community. Discarding colostrum and prelacteal feeds are now avoided and women see that the dark stool is expelled with colostrum. A decrease in prelacteal feeds – water and sugar water – is leading to a decrease in diarrhea and other illnesses. Babies no longer need herbal medication for colic. After LAM training, babies are put to the breast within one hour after birth, even before expulsion of the placenta. At 6 months, mothers continue to breastfeed, give complementary foods and transition to another method.
  • LAM is popular. LAM is the most-liked method, and is preferred by women who are ill. LAM is cost-free as supply of other methods may not be sustainable. Mothers like LAM because it has no side effects, and it is a gift from God.
  • Are women transitioning to other methods at 6 months?
  • After 6 months women are choosing other contraceptive options: Norplant and Depo provera are the common transition methods.
  • Women have more time to choose another contraceptive method during the 6 months they are practicing LAM.
  • Because there is a shortage of progesterone-only pills, women are using LAM until 6 months in order to begin combined oral contraceptives at that time.
  • Some women are transitioning to Norplant and Depo provera after 45 days.
  • A Community-based Reproductive Health Agents (CBRHAs) reported that 1 previous LAM user transitioned at 8 months when her menses resumed, and another previous LAM user is still using breastfeeding to prevent pregnancy.
  • LAM users are counseled about transition when their babies are approaching 6 months
               
  • Problems encountered by CBRHAs in offering LAM follow:
  • LAM is the best contraception in comparison to others, but difficult because of the separation of mother and baby due to mother’s workload (farming, food preparation, child care, market and social affairs).
  • Community says: “Is LAM new? We are already doing it.”
  • A lactating mother needs to eat more food than a pregnant woman – mothers are counseled in eating more available and affordable foods.
  • CBRHAs know now about mixed feeding (giving water or butter) and they counsel women to exclusively breastfeed. Yet women still want to give water to their babies.
  • Women know that breastfeeding protects against pregnancy, but CBRAs need to stress 6 months protection only.
  • Women say they do not have sufficient milk.             

Jordan. The Jordanian Ministry of Health’s (MOH) promotion of LAM led to appropriate and effective use of LAM. LAM users in Jordan and other LINKAGES' focus countries, learned about LAM primarily through antenatal and child health services in the context of breastfeeding promotion, but were reported in the monitoring statistics of family planning programs where they were referred to once they reported using LAM. Such contacts can provide women with methods to use once menses have resumed thereby helping to support transition.

Many MOH and NGO programmers are dissuaded to promote LAM because they assume it is a missed opportunity for getting women started on non-temporary methods. However, recent literature (see Ross and Winfrey) notes that even the best contraceptors take a hiatus from modern methods during the postpartum period. The Jordan study shows that LAM can actually add to the pool of new contraceptors. In addition, women who previously used a modern method and then used LAM returned again to modern methods after LAM was no longer effective.

Potential Activities in Jordan:
Advocacy of family planning and MCH programmers interventions could be focused at increasing awareness of family planning programmers so they realize that LAM does not lead to missed opportunities for long term method use. Also, Maternal and child health (MCH) programmers could be educated to appreciate their important role in promoting family planning even though they have little to no experience in family planning promotion. Simply augmenting current breastfeeding counseling sessions to include LAM messages will have great potential for converting a woman who uses breastfeeding as a family planning method into LAM users.

Training of MCH workers in LAM along with training in breastfeeding would lead to increased family planning use once women transition. Adding LAM messages on to routine counseling on breastfeeding during antenatal visits can help increase overall rates of modern method contraceptive use. In addition, LAM promotion appears to bring about the added benefit of improved breastfeeding practices among users. MCH programs can improve child health by promoting LAM and thus get double benefits from their efforts (increased modern method use and improved breastfeeding practices). MCH programs promoting LAM need to focus attention on the six month criterion and emphasize the importance of transitioning to another modern method at the appropriate time when LAM criteria are no longer met.

Post-forum survey results

N of surveys completed - 18

% who have passed content to others - 21%

% who have or will use in their work - 7%

% very satisfied with forum content - 68%

References and resources

Click here to see community library/list of references

Organizing groups

ACCESS-FP

Contributing experts/facilitators 

Ms. Maryanne Stone-Jimenez, Academy for Educational Development (AED)

Dr. Miriam Labbok, University of North Carolina/Chapel Hill

Dr. Marcos Arevalo, Georgetown University

Steering committee

ACCESS-FP

Moderators

Cat McKaig, ACCESS-FP, Jhpiego

Angela Nash-Mercado, ACCESS-FP, Jhpiego