Periodic abstinence and calendar method use in Hungary, Peru, the Philippines, and Sri Lanka.

Focus group research was conducted in four countries to understand how couples who use calendar methods determine when they are at risk of pregnancy, what behavior they adopt during the fertile phase, and whether or not they are satisfied with their method. Calendar and periodic abstinence method users do not all know how to make correct calendar calculations of the fertile period, report being sexually active during the fertile period, and desire a more comprehensive approach to sexual behavior during the fertile period. Men's roles in the methods should be enhanced, and credible resources in the community should be enlisted to improve education, information, and communication.

Policy considerations for the introduction and promotion of the lactational amenorrhea method: advantages and disadvantages of LAM.

Some attributes of LAM are unquestionably positive, such as the fact that it is effective. Clinical trials of LAM have upheld the Bellagio Consensus that the chance of pregnancy is less than 2% in the first 6 months postpartum in amenorrheic women who are fully or nearly fully breastfeeding. Secondary data analyses in numerous settings have drawn the same conclusion. Whether as a strategy or a method, used correctly or even if used imperfectly, LAM is a reliable way to avoid pregnancy. To the extent that LAM represents an additional contraceptive option, this is also clearly positive since a broad array of contraceptive options maximizes the likelihood of finding a good fit between user and method, and increases contraceptive use. Other characteristics of LAM represent potentially positive impacts. If LAM is shown to be an effective conduit to other modern methods, the implications are profoundly positive. If LAM is cost effective, for households and/or for programs, this will also make the method extraordinarily attractive. Conversely, some aspects of LAM are negative, such as the fact that it affords no protection against STDs, it requires counseling from a well-informed provider, and intensive breastfeeding can make heavy demands on the woman's time. Many of the remaining attributes of LAM may not be important to a policy decision about LAM promotion. For example, whether LAM is actualized as a strategy or a method may not be important to a decision to promote LAM, although it has a huge impact on how services are delivered. Some factors may be profound on a local or individual level. For example, one simple factor, such as the absence of full/nearly full breastfeeding, can rule out the method as an option, while another, such as the fact that it provides the needed waiting period during vasectomy counseling, can make LAM the method of choice. Although LAM seems unlikely to have widespread popularity in societies like the United States, within such settings are breastfeeding women for whom other contraceptive choices are not satisfactory and to whom LAM is attractive. Although clinicians cannot be expected to directly provide LAM education in every setting, women should be informed about LAM as an effective contraceptive choice, and clinicians should be prepared to make referrals to competent sources. The future of LAM, especially in terms of formal, programmatic initiatives, may continue to be focussed in transitional and less developed settings. Comparative cost/benefit analyses for both the family planning program and the household will contribute meaningfully to decisions about whether to use LAM and whether to include LAM in national and local family planning policies and programs. The most important call to action is to implement operations research designed to determine what factors, if any, will maximize the uptake of a second modern contraceptive method after LAM protection expires among never-users of family planning, to compare this with other contraceptive strategies, and to evaluate the cost aspects. If the potential of LAM to be a conduit to other modern contraceptive methods is effectively realized, the method can be profoundly important in the development of communities and in family formation. Because LAM is effective in preventing pregnancies, and because it extends the range of contraceptive choices, considering LAM on the policy level is always appropriate. Despite the array of drawbacks to LAM, as with any other family planning method, the potential assets of LAM, especially the promise to introduce nonusers to contraception, are sufficiently important to warrant the introduction of LAM within an operations research framework to both capitalize on its intrinsic strengths and determine its programmatic robustness. In the 10 years since the concept of LAM was pronounced as the Bellagio Consensus, claims have been made both for and against its use. During this time, program and policy leaders have been giv

PIP: This paper explores the advantages and disadvantages of the lactational amenorrhea method (LAM) and their implications for policy and use. Clinical trials of LAM have upheld the Bellagio Consensus that the chance of pregnancy is less than 2% in the first 6 months postpartum in amenorrheic women who are fully or nearly fully breast-feeding. Secondary data analyses in numerous settings have resulted in the same conclusion. LAM, if used correctly or even if used imperfectly, should be a reliable strategy or a method to avoid pregnancy. To the extent that LAM represents an additional contraceptive option, this is also positive because a broad array of contraceptive options maximizes the likelihood of finding a good fit between user and method and increases contraceptive use. Other characteristics of LAM represent potentially positive impacts. If LAM is shown to be an effective conduit to other modern methods, the implications are profoundly positive. If LAM is cost-effective for households and/or programs, this will also make the method extraordinarily attractive. Conversely, some aspects of LAM are negative, such as the fact that it offers no protection against sexually transmitted diseases, it requires counseling from a well-informed provider, and intensive breast-feeding can make heavy demands on the woman's time. Because LAM is effective in preventing pregnancies, and because it extends the range of contraceptive choices, considering LAM at the policy level is always appropriate.

Users' understanding of the lactational amenorrhea method and the occurrence of pregnancy.

It is unknown whether a user's understanding of the Lactational Amenorrhea Method (LAM) is related to its successful use. A study of 876 LAM users in Pakistan and the Philippines collected information about women's understanding of LAM. The present analysis aims to determine: (1) the proportion of LAM users who understand the method, (2) whether any known factors can distinguish those who understand LAM from those who do not, and (3) whether an understanding of LAM is related to subsequent pregnancy. Over 75% of LAM users could consistently recite the LAM guidelines correctly for a full year postpartum. However, 38% of users failed to display, at least once, an understanding of LAM during the first year postpartum mainly by failing to abstain, to use another method or to explain their nonuse of another method when their LAM protection expired. LAM understanding generally could not be predicted by sociodemographic factors. The occurrence of pregnancy during the first year postpartum was not related to LAM understanding, regardless of how LAM understanding was defined, nor could it be predicted by any other measured characteristic of the users.

PIP: This study aims to determine 1) the proportion of lactational amenorrhea method (LAM) users who understand the method; 2) whether any known factors can distinguish those who understand LAM from those who do not; and 3) whether an understanding of LAM is related to subsequent pregnancy. Data were collected from 876 LAM users in Pakistan and the Philippines. It was found that 75% of LAM users could consistently recite the LAM guidelines correctly for a full year postpartum. However, 38% of users failed to display, at least once, an understanding of LAM during the first year postpartum mainly by failing to abstain, to use another method or to explain their nonuse of another method when their LAM protection expired. Also, the sociodemographic factors could not predict the level of understanding of LAM users. Therefore, the occurrence of pregnancy during the first year postpartum was not related to LAM understanding, regardless of how LAM understanding was defined, nor could it be predicted by any other measured characteristics of the users.

Premature introduction of progestin-only contraceptive methods during lactation.

Experts on contraceptive technology concur that progestin-only methods can be used safely during lactation. However, very few studies exist of the effects on lactation of the introduction of progestin-only methods prior to the sixth postpartum week. Since progesterone withdrawal is the likely stimulus that initiates lactogenesis, it appears necessary for natural progesterone levels to decline to baseline before a progestin-only contraceptive is initiated. Therefore, the use of such contraceptive methods should be delayed for at least 3 days after the birth. Non-hormonal methods remain the first choice category of contraceptive methods for breastfeeding women, since there is no possibility that they will interfere with lactation. Progestin-only methods comprise a viable and often desirable next choice category, although the timing of their commencement must be determined with care in order to support lactation.

PIP: All major international family planning organizations have endorsed the use of progestin-only contraceptive methods once lactation has been established. Prospective, multicenter studies of infants of acceptors of progestin-only pills, injections, and implants have found no deleterious effects of the drug on infant growth and development; however, women enrolled in these trials did not initiate method use until at least the sixth postpartum week. Of concern is a recent trend toward administration of progestin subdermal implants and injectables to women prior to their discharge from the hospital (i.e., 0-72 hours after delivery). Since progesterone withdrawal is the likely stimulus that initiates lactogenesis, natural progesterone levels need a chance to decline to baseline before progestin contraceptive use is initiated. Moreover, the immature neonatal liver may have difficulties metabolizing exogenous steroids, the binding capacity of plasma is low, and the immature kidney may be inefficient in steroid excretion. Use of progestin-only contraceptive methods should be delayed for at least 3 days (optimally, until 6 weeks) after birth so lactation can become established. Nonhormonal methods remain the first choice for breast-feeding women, given the lack of potential to interfere with lactation, while progestin-only agents are a viable second choice.

Maternal employment and breast-feeding: findings from the 1988 National Maternal and Infant Health Survey.

OBJECTIVES: This analysis uses nationally representative data from the 1988 National Maternal and Infant Health Survey to explore the factors, including employment, associated with breast-feeding initiation and duration. METHODS: Multiple logistic regression was used to model the determinants of breast-feeding initiation among 9087 US women. Multiple linear regression was used to model the duration of breast-feeding among women who breast-fed. RESULTS: Fifty-three percent of mothers initiated breast-feeding in 1988, and the decision to breast-feed was not associated with maternal employment. However, among breast-feeders, returning to work within a year of delivery was associated with a shorter duration of breast-feeding when other factors were controlled. Among employed mothers, the duration of maternity leave was positively associated with the duration of breast-feeding. CONCLUSIONS: The low rates of breast-feeding initiation in the United States are not attributable to maternal participation in the labor force. However, returning to work is associated with earlier weaning among women who breast-feed.

A comparison of two U.S. surveys of infant feeding.

This study compares the 1988 National Maternal and Infant Health Survey (NMIHS) and the 1989 Ross Laboratories Mothers Survey with respect to sample characteristics and proportions of women who breastfed. Weighted proportions of women included in the two surveys were compared according to various characteristics to see how well they represented U.S. childbearing women. A z-statistic was produced to test for significant differences in the proportions who breastfed. In 1988-89, 52.2% of American women breastfed according to the Ross survey and 53.4% according to the NMIHS. Despite differences in sample size, sampling technique and the application of sample weights, the difference between the surveys was only 1 percentage point, and most levels of most variables examined were comparable. The Ross survey is a valuable source of data because it is ongoing, and it is generally corroborated by the NMIHS. The NMIHS is probably more representative of the U.S. population of childbearing women, and is a reliable source of data for setting U.S. objectives concerning infant feeding, and for the study of other issues vis-à-vis breastfeeding.

The duration and character of postpartum bleeding among breast-feeding women.

OBJECTIVE: To examine the postpartum bleeding experience of a cohort of breast-feeding women and to compare it with the conventional definition of lochia. METHODS: Four hundred seventy-seven experienced breast-feeding women in Manila, the Philippines, were followed prospectively from delivery and recorded vaginal bleeding in a menstrual diary. The median duration of lochia was calculated using survival analysis. In addition, all bleeding separate from lochia within the first 8 weeks postpartum was noted. RESULTS: The median duration of lochia was 27 days and did not vary by age, parity, sex or weight of the infant, breast-feeding frequency, or level of supplementation. More than one-fourth of the women experienced a bleeding episode separated from the original lochial flow by at least 4 bleeding-free days and beginning no later than postpartum day 56. Ten breast-feeding women may have had their first menstrual bleed before day 56. CONCLUSIONS: Lochia lasted substantially longer than the conventional assumption of 2 weeks. It was common for postpartum bleeding to stop and start again or to be characterized by intermittent spotting or bleeding. Return of menses is rare among fully breast-feeding women in the first 8 weeks postpartum.

Fertility of fully breast-feeding women in the early postpartum period.

OBJECTIVE: To examine bleeding between 6 and 8 weeks postpartum in fully breast-feeding women and its association with fertility as assessed by hormone analysis. METHODS: Seventy-two fully breast-feeding women were followed prospectively from 42 days postpartum. Vaginal bleeding was recorded daily. Women who experienced bleeding were compared with women who did not with respect to time of ovulation and time of first menses. RESULTS: Nearly half of the women experienced some vaginal bleeding or spotting between 6 and 8 weeks postpartum. These women eventually menstruated and ovulated earlier than the women who did not bleed, but the differences were not significant. The study had 34% and 45% power to detect a 20% difference in the proportion menstruating and ovulating, respectively, at 6 months postpartum, and 10% and 16% power to detect the same differences at 1 year. Seven women experienced ovarian follicular development before day 56, but neither bleeding nor follicular development was associated with ovulation in any woman in the first 8 weeks postpartum. CONCLUSIONS: It is unlikely that vaginal bleeding in fully breast-feeding women in the first 8 weeks postpartum represents a return to fertility.

The frequency of coitus during breastfeeding.

BACKGROUND: New mothers and clinicians would benefit from an understanding of typical sexual behavior during breastfeeding. Unfortunately, little information is available about both the typical length of time to resumption of coitus and the frequency of sexual relations during breastfeeding. This paper describes the commencement and frequency of coitus among breastfeeding women in a variety of settings. METHODS: The analysis draws on data from two separate research studies. The first was undertaken in three sites (Birmingham, United Kingdom; Montreal, Canada; Sydney, Australia), the purpose of which was to correlate natural observations of fertility with the underlying hormonal profile among breastfeeding women using the symptom-thermal method of natural family planning. The second was a clinical trial of the lactational amenorrhea method of family planning conducted in Manila, the Philippines. RESULTS: Coital frequency reported by these populations of breastfeeding women appears to be lower than that reported in other studies for married women in general. As other research demonstrated, we found coital frequency and postpartum resumption of coitus to be associated with age, but not with the number of children in the household. CONCLUSIONS: A better understanding of the level of sexual activity among breastfeeding women could inform and improve programs that offer postpartum support and counseling about family planning.

Effectiveness of lactational amenorrhoea in prevention of pregnancy in Manila, the Philippines: non-comparative prospective trail.

OBJECTIVE: To determine the contraceptive efficacy of the lactational amenorrhoea method. DESIGN: Non-comparative prospective trial. SETTING: Urban Manila, the Philippines. SUBJECTS: 485 lower income, educated women with extensive experience of breast feeding. INTERVENTION: Women were offered all available contraceptives for use after birth. Those who chose the lactational amenorrhoea method were taught the method, screened for the study, and followed for 12 months to determine the risk of pregnancy when the method was used. MAIN OUTCOME MEASURES: Life table pregnancy rates during correct and incorrect use of the method, censored monthly in the event of sexual abstinence or the use of another contraceptive method. RESULTS: The lactational amenorrhoea method was 99% effective when used correctly (that is, during lactational amenorrhoea and full or nearly full breast feeding for up to six months). At 12 months the effectiveness during amenorrhoea dropped to 97%. CONCLUSIONS: The lactational amenorrhoea method provided as much protection from pregnancy as non-breast feeding women experience with non-medicated intrauterine devices and barrier methods. The contraceptive effect of lactation cannot be attributed to lactational or postpartum abstinence.

Post-partum contraception.

The choice of a post-partum contraceptive method depends on many factors, including the need for a temporary versus a permanent method, the infant feeding choice and the extent to which informed consent is made prior to delivery. For maximum protection, the non-breast-feeding woman should be protected from the fourth week post-partum, even if that means using a temporary method, such as condoms or spermicides, until her method of choice is procured. Combined oestrogen/progestin methods should be avoided by all women for 2-3 weeks to avoid elevating the risk of thromboembolism. Preparations containing oestrogen should be avoided altogether during lactation because they have been associated with a reduction in milk production. POPs, implants and injectables are appropriate regardless of infant feeding choice. They can be administered immediately post-partum in bottle-feeding women, but should ideally be postponed for 6 weeks in breast-feeding women. It is best to insert IUDs within 10 minutes of delivery of the placenta, in order to minimize the risk of IUD expulsion. Insertion immediately after expulsion of the placenta requires special training, and expulsion rates are reduced with the insertion experience of the practitioner. Breast-feeding is not associated with an increase in IUD expulsion or uterine perforation, and it is associated with fewer removals for bleeding or pain. Tubal sterilization is safe, convenient and cost-effective when performed immediately after delivery, but it requires extensive counselling and fully informed consent prior to the onset of labour to avoid potential regret over post-partum tubal ligation. If the procedure is performed immediately, any effect on the establishment of lactation may be minimized. LAM is a method that can only be used by breast-feeding women. It may prove to be a useful way to time the commencement of a second, less temporary contraceptive method. Natural family planning methods require a period of abstinence for the establishment and identification of the new symptoms of fertility. When LAM is used during this interval, the need for abstinence may be reduced significantly for breast-feeding women. Breast-feeding provides health benefits for the woman and her infant, as well as the best possible nutrition for the baby. The International Planned Parenthood Federation (1990) (among others) recommends that, 'As far as is practicable, all women should be advised and encouraged to breastfeed fully'. The infant feeding decision affects the choice of a contraceptive method, and this is an important reason for the woman's physician to be interested in her infant feeding choice.

PIP: The alterations in both fertility and coital behavior associated with childbirth necessitate special consideration of postpartum contraception. To maximize the likelihood of success, both infant feeding and family planning decisions should be made during the pregnancy. The choice of a postpartum contraceptive method and the timing of its initiation depend on whether the woman is breast feeding. For normal non-breast-feeding women, the first ovulation occurs, on average, at 45 days postpartum, indicating the need for an effective (even if temporary) contraceptive method by four weeks after delivery. Condoms, spermicides, male and female sterilization, IUDs, progestin-only pills, injections, and implants are all appropriate options for postpartum women who are not breast feeding, and this article reviews the considerations associated with each of these methods. For breast feeding women, contraceptive methods can be organized into a hierarchy of clinical appropriateness: 1) non-hormonal methods that do not interfere with lactation, 2) progestin-only hormonal methods, and 3) hormonal methods. Included in the preferred (non-hormonal) category are the lactational amenorrhea method, postpartum tubal sterilization, IUDs, and barrier/spermicide methods. Combined estrogen-progestin formulations should be avoided by all women for at least three weeks postpartum to avoid elevating the risk of thromboembolism.

Effectiveness of the lactational amenorrhea method in Pakistan.

OBJECTIVE: To determine the efficacy of the lactational amenorrhea method of family planning (amenorrhea during full or nearly full breastfeeding for 6 months postpartum). DESIGN: Prospective noncomparative study. SETTING: Normal breastfeeding women in Karachi and Multan, Pakistan, most delivered at home by a midwife. PATIENTS: Three hundred ninety-nine newly delivered mothers who successfully had breastfed a previous child and chose the lactational amenorrhea method to prevent a subsequent pregnancy, 391 of whom were followed for a full year. INTERVENTIONS: Mothers were taught, before or shortly after delivery, to use the method and were interviewed in their homes each month by a Lady Health Visitor. MAIN OUTCOME MEASURE: Life-table pregnancy rates. Periods of postpartum or lactational abstinence were excluded in the calculation of the pregnancy rates. RESULTS: During full or nearly full breastfeeding, while the women were amenorrheic and not otherwise contracepting, the rate of pregnancy was 0.6%. The pregnancy rate during lactational amenorrhea alone was 1.1% at 1 year postpartum. CONCLUSION: The lactational amenorrhea method was found to be highly effective for 6 months. A high degree of contraceptive protection endures for a full year during lactational amenorrhea, but not after the return of menses during breastfeeding.

PIP: 399 mother-infant pairs were admitted into the study, 99 in the rural areas around Multan and 300 in Karachi. 378 remained in the follow-up for the full year. The mean age of the volunteers was 27.2. 25% were from the rural areas, and 37.6% were able to read and write. The women reported an average of 4.4 pregnancies and had 3.9 living children. Only 6% ever had used a family planning method in the past, and this included withdrawal as well as modern contraceptive methods. 26.4% of the women returned to menses during the first 6 months postpartum, and 40.7% of the infants were given regular supplements by this time. Considering both factors together, 47.9% of women were still protected by the lactational amenorrhea method (LAM) by the end of the 6th month postpartum. By the end of the 8th month, virtually all infants were receiving regular supplements, although only 7.4% had been weaned by the end of follow-up at 1 year postpartum. By the end of 12 months there were 29 pregnancies, including two miscarriages. Of the two pregnancies that occurred during amenorrhea, one occurred after 5 months postpartum (single LAM failure) and the other occurred at 9 months postpartum, 3.5 months after regular supplementation began. The single LAM failure, which occurred during the 6th postpartum month, resulted in a life-table pregnancy rate of 0.58% (95% confidence interval [CI], 0.00-1.58%). The rate of pregnancy during the first 6 months postpartum during breastfeeding in the absence of the use of another contraceptive constituted the failure rate of the LAM during correct plus incorrect use. During use of the LAM so defined, 0.96% were pregnant by the end of 5 months postpartum (95% CI, 0.00-2.15%) and 1.65% were pregnant by 6 months (95% CI, 0.12-3.18%). Two pregnancies occurred by the end of a year, for a 12-month life-table pregnancy rate of 1.12% (95% CI, 0.00-2.59%).

Breastfeeding and the symptothermal method.

This prospective study was conducted among experienced users of periodic abstinence methods in Sydney, Montreal, and Birmingham (England) in order to describe the relationship between a laboratory measurement of ovulation and the natural symptoms of fertility during breastfeeding. Daily urinary estrogen and pregnanediol glucuronide assays were used to estimate the date of ovulation and to determine potentially fertile days. A standard set of Symptothermal Method (STM) rules was applied to daily STM records to assess the correspondence of the natural symptoms of fertility to the underlying hormonal profile. The STM symptoms and rules accurately identified 77-94 percent of the women's potentially fertile days, but abstinence was also recommended on about half of the days when the women were not fertile. An integrated set of common rules for STM use during breastfeeding is highly sensitive but not specific in its ability to screen for ovulation.

PIP: Periodic abstinence from sexual intercourse as a pregnancy prevention technique is sometimes the sole method used by women. The effectiveness of this technique is based on the woman's ability to fully understand her own menstrual cycle. Factors like breastfeeding and endocrine irregularities have been shown to interfere with a women's ability to determine periods of fertility. This article reports on a prospective study on the relationship between breastfeeding and hormonal levels, as a measurement of fertility, in women using periodic abstinence. The 73 women in this study were from England, Canada, and Australia. All women were breastfeeding. Daily symptothermal method (STM) records, which documented the cervical mucus conditions and basal body temperature, were kept. All women had experienced healthy pregnancies. Chi-square analysis and the analysis of variance (ANOVA) were the statistical methods employed. Significantly less abstinence is recommended by the STM rules during the anteovulation stage than during either of the later stages. Significantly less abstinence is also recommended during amenorrhea than after the first menstrual period. During the anteovulation stage, significantly fewer days were reported with fertile-type mucus than later stages. First ovulations were reported in 48 women (65%) during amenorrhea; of these, 25 (52%) were characterized as having adequate luteinization for conception. The STM method used in this study was considered to be sensitive but lacked specificity.

Effects of breastfeeding on women's health.

Research about the effects of breastfeeding on maternal health has concentrated primarily on breast cancer, bone loss, and maternal depletion. Breastfeeding may provide some protection against breast cancer. Adequate maternal nutrition, a prolonged period of weaning, and adequate child spacing are expected to alleviate any potential bone loss or maternal depletion caused by breastfeeding. Regardless of how one chooses to weight the relative benefits and risks of breastfeeding to the mother, it seems clear that the programmatic tasks are to see that breastfeeding women are adequately fed and enabled to space their pregnancies.

Breastfeeding education and infant health in the rural Philippines.

PIP: In the Philippines, all mothers in one rural community near Dumaguete on Negros Oriental who delivered infants within a specified period took part in a health education program, while mothers in a control community also near Dumaguete did not receive such education. Group classes and individual counseling about optimal infant feeding practices comprised the health education program. It focused on feeding colostrum, breast feeding frequently, and countering local breast feeding myths. During months 2-7, infants in the experimental community were much healthier than those in the control community. The difference between the communities was especially great during months 5-7 (p 0.05). For example, in month 7, only 9 % of infants in the control community were healthy compared to 42% of those in the experimental community. Respiratory illness was the most frequent illness for both groups (3-28% for cases and 11-43% for controls). During the months when mothers introduced semisolid foods as supplements (months 5-6) and even the following month, infants in the control community were significantly more likely to have diarrhea than those in the study community (7-12% vs. 0, p 0.1, and 18% vs. 0, p 0.01, respectively). In every month, some infants in the control group had diarrhea, while in 7 of the 12 months no infant in the experiment group had diarrhea. Mothers of study infants were less likely to seek treatment than those in the experimental group, the difference being significant during months 4-7. Although the proportion of healthy infants fell with infant's age and proportion receiving supplements increased with age in both groups, supplementation occurred earlier and illnesses occurred more often in the control group than the study group. Despite differences in illnesses between the two communities, infant weight was similar for both groups. Regular supplementation was not associated with illness, but measurement of illness may have been subject to reporting bias. These findings suggest that the education program on infant feeding had a positive effect on infant health.^ieng

Contraceptive efficacy of lactational amenorrhoea.

Pregnancy is rare among breastfeeding women with lactational amenorrhoea. The lactational amenorrhoea method (LAM) is the informed use of breastfeeding as a contraceptive method by a woman who is still amenorrhoeic, and who is not feeding her baby with supplements, for up to 6 months after delivery. Under these three conditions, LAM users are thought to have 98% protection from pregnancy. It can be difficult, however, to determine when supplementation of the baby's diet begins. We have analysed data from nine studies of the recovery of fertility in breastfeeding women to assess the effectiveness of lactational amenorrhoea alone, irrespective of whether supplements have been introduced, as a fertility regulation method post partum. Cumulative probabilities of ovulation during lactational amenorrhoea were 30.9 and 67.3 per 100 women at 6 and 12 months, respectively, compared with 27.2 at 6 months when all three criteria of the LAM were met. Cumulative pregnancy rates during lactational amenorrhoea were 2.9 and 5.9 per 100 women at 6 and 12 months, compared with 0.7 at 6 months for the LAM. The probability of pregnancy during lactational amenorrhoea calculated from these studies is similar to that of other modern contraceptive methods, and it seems reasonable for a woman to rely on lactational amenorrhoea without regard to whether she is fully or partly breastfeeding. So that amenorrhoea and fertility suppression can be maintained, counselling about good breastfeeding and weaning practices remains important.

PIP: Researchers analyzed data on 346 women from prospective studies conducted in 8 different countries which examined return of ovulation in breast feeding mothers to determine the contraceptive effectiveness of lactational amenorrhea. The countries included Mexico, Thailand, Egypt, Pakistan, Philippines, Canada, Australia, and England. As a result of the Bellagio conference on breast feeding, health researchers have promoted the lactational amenorrhea method (LAM) as a family planning method for 6 months postpartum. Lactational amenorrhea provided significant protection from pregnancy. The researchers learned that the effect of LAM during amenorrhea and before food supplementation was a life table pregnancy rate of 0.7/100 women at 6 months postpartum. Indeed when they considered food supplementation the rates for 6 months and 12 months postpartum stood at 2.9 and 5.9 respectively. These rates showed that LAM provided either greater than or equal protection against pregnancy during the 1st 12 months postpartum in the US than typical modern contraceptive method use. The researchers did observe, however, that LAM had high discontinuation rates. For example, by 12 months, menstruation had returned to 87.5% of all the women. The researchers recommended that health workers continue to promote breast feeding practices that encourage increased suckling since reduced suckling precipitates the return of ovulation. In fact, they hypothesized that improved breast feeding practices which increase the duration of lactational amenorrhea may actually result in greater protection. Since the findings revealed that LAM had low pregnancy rates and high discontinuation rates, LAM can be used to time when to begin other contraceptive methods.

The natural family planning--lactational amenorrhea method interface: observations from a prospective study of breastfeeding users of natural family planning.

Methods of natural family planning are sometimes difficult for women to use during lactation. When this is so, the lactational amenorrhea method may prove useful. Researchers agree that a fully breastfeeding woman who is amenorrheic is 98% protected from pregnancy for up to 6 months after delivery. The fertility status of 74 users of natural family planning during the time they would have been protected by the lactational amenorrhea method is examined. Underlying hormonal profiles show that there was little ovarian activity during this time. Eight ovulatory events occurred during the period of protection by the lactational amenorrhea method, of which four fulfilled minimum criteria for adequacy; there were no pregnancies during this period. However, some women did report experiencing fertile mucus symptoms during this time that were often unrelated to estrogen production. Using the lactational amenorrhea method rather than natural family planning allows them to avoid unnecessary abstinence.