General Principles
Table. Principles for Consideration in Contraception During Lactation
| When helping a breastfeeding mother choose a method of family planning, consider her: |
In regards to: |
| 1. Breastfeeding patterns, status, and plans |
Issues concerning lactational amenorrhea method (LAM) and hormonal methods |
| 2. Child's age |
Issues concerning LAM, hormonal methods, intrauterine device (IUD) insertion, and barrier sizing |
| 3. Age |
Issues concerning hormonal methods |
| 4. Previous contraceptive experience |
Social and use issues, as well as sensitivities |
| 5. Husband's (partner's) opinions on various methods |
Social and use issues |
| 6. Childbearing plans |
Spacing versus limiting methods |
| 7. Health status |
Spacing versus limiting methods and hormonal methods |
| 8. Accessibility of family planning methods, health care personnel, and socio-economic status |
Local access, availability issues, and affordability issues |
Lactational Amenorrhea Method (LAM) of Postpartum Contraception
Method: What is LAM?
The Lactational Amenorrhea Method (LAM) is presented as an algorithm (see Figure 1 in the original guideline document) and includes three criteria for defining the period of lowest pregnancy risk. Furthermore, it advises the immediate commencement of other methods if any one of the three criteria is not met. Clinically, the mother is asked:
- Have you had a menstrual bleed?
- Are you giving any supplementary foods or fluids in addition to breastfeeding?
- Is your infant older than six months of age?
If she answers negatively to all three criteria, she meets the requirements for LAM efficacy. She should be advised to initiate another form of contraception if any of the above three questions are answered affirmatively to achieve adequate efficacy for birth spacing or fertility limitation. If the mother is interested in and qualifies for LAM, she is advised to ask herself the same three questions in an ongoing manner. It is advisable to ensure that she has her next method on hand, and initiates its use whenever her answer to any of the three questions changes. She should be advised to contact her health care professional immediately if she has any questions as to whether or not the method still applies.
Definitions for LAM Use
To use LAM correctly, it is important that the patient understand each of the three criteria. Menses return, for the purposes of LAM use, is defined as any bleeding that occurs after 56 days postpartum that is perceived by the patient as a menses, or any two consecutive days of bleeding. Full or nearly full breastfeeding is shown in Figure 2 in the original guideline document, and includes exclusive, nearly exclusive, and some irregularly provided supplements, as long as they do not disrupt the frequency of feeds. This method of family planning is now used in more than 30 countries and has been included in the family planning and Maternal and Child Health policy in several countries. It has been widely accepted as a natural family planning method that demands no abstinence. It is used as an introductory method for the postpartum period, or for the woman who hesitates to use a commodity-based method. It has the added benefit of encouraging optimal breastfeeding behavior, providing synergistic support for primary health of the mother and the child.
Considerations for Physician Counseling and Method Use
Postpartum contraception, like breastfeeding, should be discussed with patients during prenatal visits. The contraceptive choice a woman makes, with or without her partner's input, depends on factors such as previous experience with contraceptives, future childbearing plans, husband or partner's attitude, and her lactation status. If a patient is not comfortable with a method, she may use it ineffectively or not at all, even if she does not wish to become pregnant.
There are several common reasons why a woman may choose LAM: she may prefer a period of time without taking medicine or using any devices, she may prefer more time for selection of a long-term or permanent method, or she may wish to try something based on her natural physiology.
Frequent nursing and milk expression alters the hypothalamic pulsatility of gonadotropin releasing hormone (GnRH) production, which in turn mediates follicle stimulating and luteinizing hormones, so that effective ovulation is less likely to occur. Several milk expression studies confirmed that the hormonal response is not identical to breastfeeding, so if the milk expression is a regular occurrence, some of the physiological responses may be modified. This is not directly mediated by prolactin. A patient, who has had a spontaneous or induced abortion prior to 20 weeks, usually will have spontaneous ovulation that results in the secretory portion of the menstrual cycle leading to menses. The patient will usually ovulate before any vaginal bleeding. If she delivers at term and is fully breastfeeding, however, vaginal bleeding (once the 6 weeks of lochia has stopped) nearly always occurs prior to first adequate ovulation during the first 6 months. Once regular feeding begins, there is an increase in fertile first cycles. Ovulation in the non-lactating woman may occur as early as 3 weeks postpartum.
LAM Management Issues
There are several suggested behaviors that would contribute to method success and duration.
- LAM is not meant for patients who are giving regular supplemental feedings.
- Women can use LAM while working if they pump their breasts and provide milk to the baby's caregiver during their absence. However, in one study using this approach, the efficacy was about 95%, slightly lower, but not significantly different than efficacy in women not separated from their infants. Further research is needed on this issue; however, if this is the only method a woman is willing to accept and is well informed of the possibility of decreased efficacy, LAM should remain an option for women who are regularly separated from their infants.
- One set of studies found that exclusively breastfeeding women using LAM are more likely to be amenorrheic at 6 months than exclusively breastfeeding controls (84% vs. 69.7%, respectively). Women who use LAM actively, have a higher feeding frequency, and, hence, shorter inter-feeding intervals, than other exclusive breastfeeders (see Figure 4 in the original guideline document). However, even with short inter-feeding intervals, some women experience earlier menses return. While we do not know whether these cycles are adequate for conception, no other sign of imminent fertility return are evident. Therefore, whether or not breastfeeding continues to be frequent, another method must be used for birth spacing when menses return.
- Three studies have indicated that the efficacy of LAM can be maintained during the 6 to 12 month period, provided the mother who originally followed this method, continues to breastfeed before giving complementary foods at less than 4 hours intervals during the day and 6 hours intervals at night while remaining amenorrheic.
Transition to Other Methods
When LAM no longer applies, or whenever a breastfeeding woman wishes to use an alternate family planning method, not all other methods have equal consequences for breastfeeding success. Therefore, alternative methods are presented ranked by increasing potential impact on breastfeeding success (see Table below). While not equally efficacious, the first choice methods are those that do not interfere with lactation. While studies show no major problems when progestin-only methods are introduced, the weight of anecdotal evidence, as well as the possible postpartum impact of progestins on prolactin, merits the second choice rating. Estrogen containing pills are known to reduce milk quantity. Optimal child spacing for maternal recovery, the support of lactation duration, and for child growth, development and survival may be influenced by particular demographics. A minimum of 18 months between births is recommended under all circumstances and at least three years or longer is recommended in developing countries.
| Table. Family Planning During Lactation: Minimizing Physiologic Impact on Breastfeeding |
- First Choice Methods
- LAM
- Natural Family Planning
- Barriers
- Intrauterine Device (IUD)
- Second Choice Methods
- Third Choice Methods
- Estrogen containing contraceptives
|
Issues In Counseling Selection of Contraceptives During Breastfeeding
Advantages and Disadvantages
The issues to be considered in counseling a pregnant or postpartum woman concerning contraceptive choice for use during breastfeeding extend beyond issues of efficacy. She will also wish to ensure that the selected method is appropriate for breastfeeding expectations (as listed in "General Principles," above) in addition to the considerations for the non-lactating woman. The Table 3 in the original guideline document, titled "Use of Contraceptive Methods During Lactation: Advantages, Disadvantages and Impact on Lactation," provides useful information for counseling the lactating mother and is not generally considered in contraception handbooks.
