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BELLAGIO,Italy -- Recent research confirms that a form of
breastfeeding to achieve contraception, called the lactational amenorrhea method or LAM,
is more than 98 percent effective during the six months following delivery. Based on years
of data from thousands of women in more than a dozen countries, the research also suggests
that LAM may be dependable for longer -- perhaps up to a year after giving birth.
For years, scientists have recommended using lactational amenorrhea as a method of
fertility regulation.1 However, until the new research was
analyzed, the scientific basis for using breastfeeding for reliable contraception had not
been firmly established.
To use LAM correctly, a woman must remain amenorrheic (no
menstrual bleeding) since delivery, fully or nearly fully breastfeed, and be within six
months of delivery. When any of these three criteria changes, the woman should begin
immediately to use another family planning method if she wishes to prevent pregnancy.
The research indicates that lengthening the six-month criterion to nine or even 12
months after delivery might be possible under certain conditions, although more research
is necessary before changing this criterion.
During breastfeeding, ovulation (the release of an egg) is inhibited by a series of
physiological responses to nipple stimulation. More frequent or intense suckling sends
nerve impulses to the mother's hypothalamus in her brain, which in turn inhibits ovarian
activity. When breastfeeding diminishes, the chance of ovulation rises.
The research was coordinated in separate studies by FHI, the World Health Organization
(WHO) and Georgetown University's Institute for Reproductive Health (IRH). A panel of
experts in December 1995 analyzed the results of the studies and issued a consensus
statement, which said, "The efficacy of LAM has now been well established in
prospective studies, and programs should regard LAM as an additional method that increases
the family planning choices for postpartum women."2
"If the three rules for LAM are followed, the probability of becoming pregnant is
extremely small," says Dr. Roberto Rivera, FHI corporate director for international
medical affairs, one of the experts at the meeting.
Research results
In a long-term study, WHO analyzed the duration of lactational amenorrhea in relation
to breastfeeding practices chosen by women. Conducted in Australia, Chile, Guatemala,
India, Nigeria, China and Sweden, the study found an efficacy rate of more than 99 percent
in a retrospective analysis of women whose practices fulfilled the three LAM criteria. IRH
coordinated a prospective study among women using LAM in Egypt, Germany, Indonesia, Italy,
Mexico, Nigeria, the Philippines, Sweden, the United Kingdom and the United States. It
found an efficacy rate of more than 98 percent. Neither study is published yet.
Two prospective clinical trials coordinated by FHI also found LAM highly reliable. In a
study in Pakistan among 391 mothers who had just delivered a child, researchers found the
rate of pregnancy was 0.6 percent when the LAM criteria were met, fewer than one pregnancy
per 100 women.3 Periods of sexual abstinence or use of other
contraceptives were excluded from the calculation, addressing one of the methodological
concerns that had been raised about earlier lactational amenorrhea studies. Another FHI
study, conducted in the Philippines, reached similar conclusions.4
These clinical trials confirmed the findings of an earlier prospective study of LAM in
Chile, coordinated by IRH, which had found an efficacy rate of 99.5 percent, fewer than
one pregnancy per 100 women in six months.5
At the 1995 meeting, held in Bellagio, Italy, the experts agreed that the end of
amenorrhea is the most critical of the three LAM criteria since the resumption of menses
signals a return of ovarian activity and, hence, the risk of pregnancy. "The return
of menses does not always mean that ovulation has occurred or is about to occur, but it
does mean that the ovaries are no longer inactive," explains Dr. Kathy Kennedy, who
coordinated the expert meeting for FHI.
In the WHO study, even among breastfeeding women who were not fully or nearly fully
breastfeeding, pregnancy rates were low during lactational amenorrhea, less than 1 percent
during the first six months. While there appeared to be considerable evidence to suggest
that at least some supplementation can be tolerated in the use of LAM, the experts felt
that emphasis should still be given to the link between a dependable breastfeeding routine
and protection against unplanned pregnancy. "Before the choice is made to relax the
requirement of full or nearly full breastfeeding, the provider and the user should be
aware that it is the breastfeeding stimulus that causes amenorrhea and the associated
protection from pregnancy," the consensus statement said.
Regarding the six-month criterion, several studies found that among women who breastfed
longer than six months, even when giving the infant supplements, the rate of pregnancy
during lactational amenorrhea remained low. "While the rates were higher than at six
months, they may be low enough to allow the extended use of LAM up to nine months and, in
certain situations, possibly even to 12 months," reported Dr. Paul Van Look, who
coordinated the WHO study. The pregnancy rates were about 3 percent at nine months and 4.5
percent at 12 months -- more reliable in typical use than some contraceptives, such as
barrier methods. The experts concluded, however, that additional research is needed to
establish the conditions under which such extended use of LAM should be recommended. The
likelihood of LAM being effective beyond six months increases when women breastfeed
intensively during the first six months and when they breastfeed immediately prior to each
feeding of a supplement.6
The scientists identified other research questions that still need to be answered. For
example, the performance of LAM under a wide variety of field conditions should be
studied, including the level of support from family planning providers that would be
needed for effective LAM use.
Impact in the field
Besides confirming LAM's scientific validity, the consensus statement by the 24 experts
from universities and research organizations in nine countries recommended that "the
lactational amenorrhea method should receive the programmatic and policy support necessary
to become available worldwide."
Worldwide, more than 90 percent of mothers with infants breastfeed and may be counseled
on LAM use, providing a natural way to prevent pregnancy immediately after birth. But the
intensity and duration of breastfeeding are declining due to urban lifestyles and other
changes in the postindustrial years. "Bottle-feeding has been seen as a sign of
modernizing, as a sign of progress in many developing countries, even in rural
areas," said Dr. Olukayode Dada of the Centre for Research in Reproductive Health in
Sagamu, Nigeria, one of the scientists at the meeting.
Family planning programs generally have not been promoting breastfeeding. To address
this, Georgetown University's IRH has developed guidelines for using LAM in five languages
and has supported service programs in nearly 40 countries. The guidelines explain LAM,
answer typical questions about it, summarize contraceptive choices after LAM and provide
other information. "We have now tested LAM in many settings under a variety of
conditions, including among poorly nourished women, working women and women following a
wide range of breastfeeding practices," explains Dr. Miriam Labbok, director of the
IRH breastfeeding program. These efforts have been successful and led to requests for
program expansions, she says.
"In addition, where the timely introduction of a complementary method is
emphasized, LAM leads to increased acceptance of other methods after the LAM criteria no
longer apply," she says. The timely use of an appropriate complementary method should
be considered a major component of LAM, says Dr. Labbok.
A study in Ecuador, part of the IRH fieldwork, showed that LAM could be introduced
successfully as a contraceptive method for postpartum women. In four clinics operated by
Centro Médico de Orientación y Planificación Familiar (CEMOPLAF), a nationwide family
planning and maternal and child health service delivery organization, about one-third of
all postpartum clients accepted LAM (133 women) during a five-month period. There were no
pregnancies among those using LAM correctly, and a 2 percent pregnancy rate among all
acceptors.7 An expanded study of efficacy among acceptors from
20 clinics found a pregnancy rate of about 2 percent. CEMOPLAF has now added LAM as a
contraceptive option to all of its 20 clinics and is training its 500 community-based
distributors to offer LAM.
Introduction of LAM through government family planning programs has also begun. In the
Philippines, for example, the National Family Planning Program has adopted LAM as a
postpartum contraceptive method. The Philippines has a nationwide network of 800 hospitals
that participate in the Mother-Baby Friendly Hospital Initiative, a worldwide effort by
WHO and UNICEF to encourage immediate postpartum breastfeeding and mother-child bonding.
"There is no full-scale campaign to promote LAM in the hospitals yet," said
Dr. Rebecca Ramos, of the Women's Health and Safe Motherhood program in the Philippines
Department of Health, a participant in the Bellagio meeting and the principal investigator
of the LAM clinical trial conducted in Manila. "Providers need to be trained to
counsel women on the advantages of breastfeeding and the importance of using another
method if one of the LAM criteria changes."
At the expert meeting, participants emphasized that they were not promoting LAM above
other methods but were validating its scientific effectiveness. "LAM is a part of an
informed choice," said Dr. Soledad Díaz of Chile. "The message we need to give
providers is that LAM represents an additional choice among contraceptive methods suitable
to nursing women."
Dr. Roger Short of the Royal Women's Hospital in Victoria, Australia added, "We
are not promoting breastfeeding just because of LAM. We also promote breastfeeding for a
host of reasons that are lifesaving for the baby." Among other benefits,
breastfeeding enhances child survival through proper birth spacing,8
helps promote the proper development of a newborn's gastrointestinal9
and immune systems,10 and, by providing extra immunity,
lowers the risk of diseases such as meningitis and infections of the respiratory system.11 Benefits to the mother are also well-established, including
more rapid postpartum recovery and a reduction in breast cancer risk.
Breastfeeding protects babies from diarrhea, the major cause of infant death in
developing countries, and provides excellent nutrition without potential infection from
unclean water.12 Even though HIV, the virus that causes AIDS,
can be transmitted by breastfeeding, WHO and UNICEF have said that where other infectious
diseases and malnutrition are primary causes of infant deaths, "breastfeeding should
remain the standard advice to pregnant women, including those who are known to be
HIV-infected, because their baby's risk of becoming infected through breastmilk is likely
to be lower than its risk of dying of other causes if deprived of breastfeeding."13
For many reasons, family planning programs should offer LAM as a reliable temporary
contraceptive option. "If family planning programs and policy-makers begin offering
LAM as a regular part of their family planning options, the health of women and infants
will improve," says Dr. Van Look, who chaired the expert meeting.
-- William R. Finger
Editor's Note: William R. Finger, Network senior science writer/editor,
attended the Dec.11-14, 1995 LAM conference in Bellagio, Italy, which was sponsored by
FHI, IRH and WHO, and received financial support from the Rockefeller Foundation.
References
- Kennedy KI, Rivera R, McNeilly A. Consensus statement on
the use of breastfeeding as a family planning method. Contraception 1989;39(5):
477-96.
- Kennedy KI, Labbok MH, VanLook PFA. Consensus statement:
Lactational amenorrhea method for family planning. Int J Gynecol Obstet
1996:54(1):55-57.
- Kazi A, Kennedy K, Visness CM, et al. Effectiveness of
the lactational amenorrhea method in Pakistan. Fertil Steril 1995;64(4): 717-23.
- Ramos F, Kennedy KI, Visness CM. Effectiveness of the
lactational amenorrhea method in preventing pregnancy in Manila, the Philippines.
Unpublished paper.
- Pérez A, Labbok MH, Queenan J. Clinical study of the
lactational amenorrhea method for family planning. Lancet 1992;339: 968-70.
- Cooney K, Nyirabukeye T, Labbok M, et al. An assessment
of the nine-month lactational amenorrhea method (LAM-9) in Rwanda. Stud Fam Plann
1996;27(3):162-71.
- Wade KB, Sevilla F, Labbok MH. Integrating the
lactational amenorrhea method into a family planning program in Ecuador. Stud Fam Plann
1994;25(3): 162-75.
- Thapa S, Short RV, Potts M. Breastfeeding, birth spacing
and their effects on child survival. Nature 1988;335(6192): 679-82.
- Sheard NF, Walker WA. The role of breast milk in the
development of the gastrointestinal tract. Nutrition Review 1988;46:1-8.
- Saarinen UM, Kajosaari M. Breastfeeding as prophylaxis
against atopic disease: prospective follow-up study until 17 years old. Lancet
1995;346: 1065-69.
- Newman J. How breast milk protects newborns. Sci Am 1995;273(6):76-79.
- Feacham RG, Koblinski MA. Interventions for the control
of diarrheal disease among young children; promotion of breastfeeding. Bull WHO
1984;62: 271-91.
- Consensus Sta tement, WHO/UNICEF Consultation on HIV
Transmission and Breastfeeding, Geneva, 1992.
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