Contraceptive Update: Research Confirms LAM's Effectiveness
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.
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 Statement, WHO/UNICEF Consultation on HIV Transmission and Breastfeeding, Geneva, 1992.
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