Lactational Amenorrhea

• Breastfeeding delays the return of a woman's fertility in the first few months following childbirth. Women who breastfeed are less likely to ovulate in this period. 
• Lactational Amenorrhea Method (LAM) is a form of birth control that relies on the natural postpartum infertility that occurs when a woman is amenorrheic (not menstruating) and fully breastfeeding. 

1.0Definition of LAM

• The Lactational Amenorrhea Method (LAM) is a natural and healthy fertility awareness-based method (FABM) of family planning. The LAM is a special FABM that postpartum breastfeeding mothers can use. 
• Lactational- related to breastfeeding.
• Amenorrhea- no monthly bleeding 

2.0Mechanism of LAM

• LAM primarily works by preventing ovulation through frequent breastfeeding, which temporarily inhibits the release of the hormones that trigger ovulation. 
• This disruption affects the GnRH (gonadotropin-releasing hormone) rhythm, suppressing the hypothalamic–pituitary–ovarian axis. Consequently, there is a reduction in the production of LH (luteinizing hormone), leading to the prevention of ovulation.

3.0Criteria for LAM

The return of fertility postpartum can be predicted by 3 criteria, known as the criteria for LAM. The criteria are: 

1. Lactation- the baby is fully or nearly fully breastfed frequently, day and night; 

2. Amenorrhea- the woman's menstrual bleeding has not resumed, and 

3. The infant's age in months should be below six months.

1. Lactation 

• The pattern and intensity of breastfeeding affect the return to fertility.
• Women using LAM should fully or nearly fully breastfeed their infants frequently daily and on demand.
• A fully breastfed infant is exclusively breastfed (receives no other liquid or food, including water, in addition to breastmilk) or is almost exclusively breastfed.
• A nearly fully breastfed infant receives some liquid or food besides breast milk, but most of the feeds.

Ideal feeding patterns

• Start breastfeeding immediately (within the first hour) or as soon as possible after childbirth. 
• Exclusive breastfeeding is preferable. 
• Breastfeeding should ideally be "on demand," meaning whenever the baby signals a need to feed. In the first few weeks postpartum, this typically amounts to at least 10 to 12 feedings per day. As the baby grows, this frequency may decrease to 8 to 10 times a day, with at least one nighttime feeding during the initial months.
• Daytime feedings should be at most 4 hours apart, and nighttime feedings should be 6 hours apart. 
• Mothers should gently encourage their babies who do not want to breastfeed up to the required daily or night frequency to do so more often. 
• Supplementary foods or fluids, in addition to breastfeeding, should not interfere with breastfeeding frequency. Ideally, they should be given at most once or twice a week.

2. Amenorrhea

• Menstrual bleeding is regarded as any bleeding after 2 months postpartum. It excludes lochia in the first 2 months postpartum.
• The resumption of menstruation is marked by at least 2 days of consecutive bleeding or any bleeding occurring after 56 days postpartum and is perceived by the woman as a return of her menstrual bleeding.
• Ovulation has probably resumed once the woman starts to menstruate after childbirth.

3. Infant’s age

• The baby must be less than 6 months old for LAM to be effective. 
• This is because complementary feeding usually begins at 6 months. 
• The introduction of complementary feeds can reduce the frequency of breastfeeding, activating the hormonal mechanism that subsequently leads to the resumption of ovulation and menses.
• After 6 months, the chances of a woman having her ovulation before menses are higher, increasing the probability of pregnancy.

4.0Effectiveness of LAM

LAM is highly effective as long as the 3 criteria for LAM are met. 

• When LAM is used correctly, less than 1 pregnancy per 100 women occurs in the first 6 months after childbirth.
• With common usage, the average 6-month pregnancy rate for women using LAM is 2%, with two pregnancies per 100 women. 
• Among working women, the average 6-month pregnancy rate increases to 5% even if they express their breastmilk 4 hours daily. 
• The suckling of the infant may play a significant part in the contraceptive effect of LAM.
• The effectiveness of LAM among women who give supplementary feedings daily or express milk (by hand or pump) rather than breastfeeding needs to be better established and requires further research.

Indications for LAM:

• Need to avoid the use of other contraceptive devices or drugs during the postpartum period.
• Inability to afford other contraceptive methods 
• Desire for a temporary method of contraception in the postpartum period 
• Lack of ready access to other family planning methods 
• Lack of interest in other methods 
• Cultural or religious norms

When to start LAM:

LAM can be started at any time if: 

• It is within 6 months after childbirth. 
• The woman has been fully or nearly fully breastfeeding her baby since birth.
• The woman's monthly bleeding has not returned.

Transition from LAM to other modern contraceptive methods:

• The timely transition from LAM to other family planning methods is critical to effective programming for LAM. 
• Providers should ensure all women using LAM can reach their reproductive goals for spacing or limiting. 
• Women should understand each of the LAM criteria well. This facilitates the transition from LAM to other modern methods in six months.
• As long as the 3 LAM criteria are met, women can switch to a new method at any time without a pregnancy test, examination, or evaluation.
• Women must transition to other methods without delay when any of the 3 LAM criteria are no longer met or when they wish to switch to another appropriate contraceptive method of choice.
• Providers should counsel women to continue breastfeeding after switching to another method.

5.0Health Benefits of LAM 

Maternal:

• There is no documented negative effect on maternal health.
• Suckling stimulates uterine contractions in the immediate postpartum period.
• Reduces loss of iron since there is no menstrual bleeding.
• Enhances mother-baby relationship

Infant:

• Provides the complete nutritional needs of the infant in the first 6 months.
• Improves infant growth and development.
• Boosts the infant's immune system (fewer episodes of diarrhoea and acute respiratory infections).
• Source of Vitamin A, proteins, iron, minerals and essential fatty acids.

6.0Advantages and Disadvantages of LAM

Advantages of LAM:

• Natural family planning method 
• No side effects 
• Effectiveness rates of more than 98% are comparable with other user-directed methods of birth control (i.e., pills or barriers) 
• Acceptable and easy to learn 
• Simple to use and readily accessible 
• Breast Milk is cheaper than formula milk and does not run out 
• Provides family planning and infant feeding at no direct cost 
• The woman provides and controls the use of the method 
• It can be initiated in the immediate postpartum period, thus preventing pregnancy in the immediate and critical six months after birth.
• Supports and reinforces newborn and infant feeding recommendations for exclusive breastfeeding in the first six months of life 
• It can serve as an introductory method to other contraceptive methods 
• Provides a smooth transition to another modern contraceptive by giving women time for decision-making 
• Builds on established cultural and religious practices 
• Non-invasive as no gynecological examination is required 
• No effect on breastmilk production

Disadvantages of LAM:

• Cultural factors 
• Work-related constraints 
• Requires effective counseling and adequate knowledge about LAM criteria. Women need to be well educated about signs of returning fertility 
• Does not offer protection against sexually transmitted diseases (STIs) and HIV.