Considerations for Clinician Counseling and Method Use

Postpartum contraception, like breastfeeding, should be discussed with women during their own obstetric prenatal and postpartum visits and the infant’s pediatric well-baby visits. A woman’s contraceptive choice depends on many factors such as previous experience with contraceptives, future childbearing plans, husband or partner’s attitude, level of user attention required for use, medical considerations, return of menses, and the woman’s lactation status. If a woman is not comfortable with a method, she may not use it effectively.

Advantages and Disadvantages of Available Options

Contraceptive counseling during breastfeeding extends beyond issues of efficacy, because the selected method must be appropriate for a woman’s breastfeeding expectations. Table J-14 provides useful information for counseling the breastfeeding mother. Considerations include the potential for hormonal methods to either disrupt milk synthesis or expose the infant to synthetic hormones. Because a falling progesterone level after birth is necessary for onset of milk production, initiation of hormonal contraception before lactation is established is of particular concern. Published evidence is insufficient to exclude these risks. At the same time, long-acting reversible hormonal methods have high contraceptive efficacy. Health care providers should discuss the limitations of the available data within the context of a mother’s desire to breastfeed, her risk of low milk production, and her risk of unplanned pregnancy, so that she can make an autonomous and informed decision.

Background

Data published in the 1970s showed that women who breastfed were less likely to ovulate early postpartum and that if breastfeeding were more intensive, they were less likely than partial or nonbreastfeeders to experience a normal ovulation prior to the first menstrual-like bleed. In 1988, at a Bellagio Conference, a group of expert scientists proposed three criteria as sufficient to predict fertility return. This three-criteria approach described in further detail below as the “Lactational Amenorrhea Method” was subsequently tested. Studies of the acceptability and contraceptive efficacy of active LAM use continue to confirm the original findings, demonstrating that LAM is acceptable, learnable, user-friendly, and as effective as many other alternatives. (II-2) (Quality of evidence [levels of evidence I, II-1, II-2, II-3, and III] is based on the U.S. Preventive Services Task Force Appendix A Task Force Ratings and is noted throughout this protocol in parentheses.)

Method: What is LAM?

LAM is presented as an algorithm ( Figure J-3 ) and includes three criteria for defining the period of lowest pregnancy risk. If one of these criteria is not met, women should immediately initiate another method. Clinically, the mother is asked these three questions:

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  “Are you amenorrheic?” meaning that you have not had a menstrual bleed or any bleed of > 2 days in duration (discounting any bleed in the first 2 months).

  
  
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  “Are you fully or nearly fully breastfeeding?” This includes not giving your baby any supplementary foods or fluids in addition to breastfeeding (greater than once or twice a week)?

  
  
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  “Is your infant less than 6 months of age?”

The lactational amenorrhea method (LAM).

If she answers “yes” to all three questions, she meets the requirements for LAM. If any of the above three questions is answered “no,” then her chance of pregnancy is increased, and she should be advised to initiate another form of contraception to prevent pregnancy. If the mother is interested in and qualifies for LAM, she should review these three questions regularly. Clinicians should ensure that she has chosen her next method of contraception and either has it on hand or knows how to obtain it if it is an implant or intrauterine device (IUD).

Definitions for LAM Use

To use LAM correctly, it is important that the patient understand each of the three criteria, which can be remembered using the letters “LAM” to indicate Lactation, Amenorrhea, and the number of Months:

• 1.
  

  Lactation. Full or nearly full breastfeeding includes exclusive, nearly exclusive, and some irregularly provided supplements, as long as they do not disrupt the frequency of feeds.

  
  
• 2.
  

  Amenorrhea. For the purposes of LAM use, menses return 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.

  
  
• 3.
  

  Months. The “6 months” criterion is added primarily because this is the time that complementary feeding should begin. If breastfeeding continues at the same frequency and complementary foods are offered after the breastfeed, efficacy apparently remains high as long as amenorrhea continues. In Rwanda, the method was used up to 9 months, by maintaining the breastfeeding frequency experienced during month 6. This was achieved by feeding before each complementary feeding. Another study in Pakistan found a continued high efficacy under these conditions for up to 12 months. (II-2)

Efficacy

A Cochrane Review (and assessed as up-to-date in 2008) concluded that fertility rates are low among fully breastfeeding, amenorrheic women. In controlled studies of LAM, pregnancy rates for 6 months ranged from 0.45% to 2.45%. In six uncontrolled studies of LAM users, pregnancy ranged from 0% to 7.5%. The World Health Organization (WHO) carried out a prospective trial on lactational amenorrhea and fertility return; although this was not a study of women selecting and using LAM, the findings confirmed the physiological potential for high efficacy as seen in the LAM trials. Subsequently, studies of method use have consistently found a 6-month pregnancy rate averaging 2% (I, II-2)

LAM Management Issues

Suggested behaviors contributing to method success and duration include:

• 1.
  

  Number of feedings. One controlled study found exclusively breastfeeding women using LAM are more likely to be amenorrheic at 6 months than exclusively breastfeeding controls (84% vs. 69.7%, respectively). Women using LAM had a higher feeding frequency and a shorter interfeeding interval than other exclusively breastfeeding women.

  
  
• 2.
  

  LAM can be used beyond the sixth month. The two studies mentioned above in Rwanda and Pakistan have indicated that the efficacy of LAM can be maintained during the 6- to 12-month period, provided the mother continues to breastfeed before giving complementary foods at less than 4-hour intervals during the day and 6-hour intervals at night while remaining amenorrheic. (II-2)

  
  
• 3.
  

  LAM effectiveness has not as yet been adequately tested to offer the method with confidence to women who are giving supplemental feedings daily or expressing milk by hand or pump instead of breastfeeding. (II-2) Women who are expressing milk more than a few times per week should be counseled to initiate an additional contraceptive method. (III)

Transition to Other Methods

LAM may also be used as an introductory method to inform the user when it is time to initiate use of another method. Of note is that fully breastfeeding women are very unlikely to conceive in the first 56 days postpartum so secondary methods can be delayed until at least 8 weeks postpartum. When LAM criteria no longer apply or whenever a breastfeeding woman wishes to use an alternate family planning method, she should have an alternative method readily available. Alternative methods are discussed in terms of advantages and disadvantages and special issues related to breastfeeding.