Recommendations for Contraceptive Use
		Lactational Amenorrhea Method

Lactational Amenorrhea Method

The Lactational Amenorrhea Method (LAM) was codified at a meeting in Washington, DC in 1989, based on research, program work, and the findings of the Bellagio Consensus Meeting of 1988. It was recently reassessed at a 1995 meeting in Bellagio, and is now considered an appropriate method for programmatic use.

LAM has three criteria:

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 two months postpartum.

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.

Less than six months postpartum.

Adapted from: Labbok M, Cooney K, Coly S. Guidelines: breastfeeding, family planning, and the Lactational Amenorrhea Method-LAM. Washington, DC: Institute for Reproductive Health, 1994.

The effectiveness of LAM has been demonstrated in clinical trials and in programmatic use. As long as all three criteria are met, the method is about 98%-99% effective (perfect use). If any one of the criteria is unmet, the use of another method which is appropriate for use during breastfeeding should be recommended for continued high pregnancy protection.

The method allows deviation from the three criteria without a sudden increase in risk of unplanned pregnancy. Menses return is the least flexible. If a woman is no longer amenorrheic, she cannot use LAM.

If a woman has deviated only slightly from the fully or nearly fully breastfeeding criterion, she should be re-counseled about appropriate breastfeeding and may use LAM thereafter if she returns to nearly fully breastfeeding. Small amounts of other food or liquid which do not replace breastfeeds do not have a substantial effect on the woman's fertility. However, lowered frequencies of breastfeeding and regular supplementation to the infant's diet are associated with an increased risk of menses return and a higher probability that ovulation will precede that menses.

If an amenorrheic woman is separated from her infant and expresses milk, she may still use LAM. Milk expression by hand or pump may produce sufficient breast stimulation to prevent ovulatory activity. However, her risk of pregnancy is increased to 5 to 6%.

LAM can be taught during the prenatal, perinatal, or postnatal periods. Counseling on use of the method is very important. In order for LAM to provide effective protection against pregnancy, the method must be used consistently and correctly with another method started very soon after any of the LAM criteria no longer apply, particularly amenorrhea. It is recommended that the LAM user be provided with another method for self-initiation prior to menses return (See Question 1).

There are no medical contraindications to using LAM. However, there are a few conditions under which it is preferable not to breastfeed (e.g., if the mother is using a few specific drugs or has some infectious conditions, or if the infant has certain metabolic disorders). These conditions are discussed more fully in the World Health Organization (WHO) Medical Eligibility Criteria for Contraceptive Use.

The follow-up schedule for LAM should be similar to the follow-up schedule used for all temporary methods, with the understanding that before any one of the three criteria will no longer apply, the client should return for counseling and another method of family planning (FP).

Citations:

1. Kennedy KI, Rivera R, McNeilly AS. Consensus statement on the use of breastfeeding as a family planning method. Contraception 1989;39:477-96.
2. Kennedy KI, Labbok MH, Van Look. PFA: Consensus statement on the Lactational Amenorrhea Method for family planning. International Journal of Gynecology and Obstetrics 1996;54:55-7.
3. Labbok M, Cooney K, Coly S. Guidelines: breastfeeding, family planning, and the Lactational Amenorrhea Method-LAM. Washington, DC: Institute for Reproductive Health, 1994.
4. Perez A, Labbok ML, Queenan JT. Clinical study of the Lactational Amenorrhea Method for family planning. Lancet 1992;339:968-70.
5. Kazi A, Kennedy KI, Visness CM, Khan T. Effectiveness of the Lactational Amenorrhea Method in Pakistan. Fertility and Sterility 1995;64:717-23.
6. Labbok M, Perez A, Valdes V, Sevilla F, Wade K, Laukaran V, et al. The Lactational Amenorrhea Method: a new postpartum introductory family planning method. Advances in Contraception 1994;10:93-109.
7. Pugin E, Valdes V, Labbok M, Perez A, Aravena R. Does prenatal education contribute to the duration of full breastfeeding in a comprehensive breastfeeding promotion program? Journal of Human Lactation 1996;12:15-20.
8. Gray R, Campbell O, Eslami S, Zacur H, Labbok M, Apelo R. The return of ovarian function during lactation: results of studies from the United States and the Philippines. In Gray R (ed.) Biomedical and Demographic Determinants of Reproduction. Oxford: Clarendon Press, 1993.
9. Zinaman M, Hughes V, Queenan J, et al. Acute prolactin, oxytocin response and milk yield to infant suckling and artificial methods of expression in lactating women. Pediatrics 1992;89:437-40.
10. World Health Organization. Improving access to quality care in family planning: medical eligibility criteria for contraceptive use. Geneva: WHO, 1996.

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