Bellagio Consensus on L.A.M. of Contraception: not on probability of ovulation and selection of drug dosage in ovulation induction?

 

Bellagio Consensus on L.A.M. of Contraception:

      In 1988 a group of reproductive scientists from all over the world met in Bellagio, Italy. They proposed that postpartum women could use lactation amenorrhoea method as a means of family planning. It is these experts who first unambiguously disclosed that women who are fully or nearly fully breastfeeding and amenorrhoeic are likely to experience a risk pregnancy at the rate of less than two percent in the first six months after childbirth. This consensus later came to be known as ‘Bellagio Consensus’. This method of natural contraception, very rightly was soon widely accepted in many countries. The principle of Bellagio consensus as a standard method of natural family planning was reaffirmed by another meeting at Bellagio in 1989 and this consensus was renamed as ‘Lactation Amenorrhoea Method (LAM)’ of contraception.

      Incidentally, it may be recalled that International consensus conference on Medical abortion i.e. nonsurgical method of abortion was also held at Bellagio city, Italy, 1-5^th November 2004 under the auspices of World Health Organization, Rockefeller Foundation and a NGO (IPAS). Thus Bellagio city is dedicated to reproductive rights and reproductive freedom of woman!

      After Bellagio consensus an International guidelines on ‘Breastfeeding and LAM’ were framed in 1989 and these guidelines were widely circulated in different countries. These guidelines included all three previous standard criteria, all of which must be fulfilled to ensure adequate protection from an unplanned pregnancy i.e. a) amenorrhoea, b) full or nearly full breastfeeding, c) first six months postpartum. The newly issued guidelines however included one additional warning for lactating women. The warning is that if any women who no longer meet all these three criteria, or no longer wish to use LAM, should immediately initiate use of additional family planning method if she intends to avoid pregnancy. It means partial breastfeeding does not offer cent percent protection from pregnancy. The guideline however had another clear message. That is it is the suckling stimulus that results both amenorrhoea and associated protection from pregnancy due to an anovulation (nonrelease  of eggs). Hence, adding supplements to the infant’s diet or decreasing the duration of breastfeeding below sixty minutes per twenty four hours and therefore  decreasing total suckling period may hasten the return of ovulation and shorten the efficacy of LAM.

What opinion Bellagio consensus encompasses on extended use of LAM ?

As an Indian we would be interested to know the effect of extended breastfeeding on contraception i.e. if breastfeeding is continued beyond six months. Many women in rural India breastfeed up to four or five years. What opinion the said experts expressed on breastfeeding-induced natural contraception in such cases? Are they as immune to pregnancy as is enjoyed in first six months? Certainly not. Let us now see what experts say on this issue which is so relevant in Indian context.

Experts opine that it may be possible to extend LAM beyond six months and there is nothing wrong in this age old practice. But so far as contraceptive effect is concerned their argument was that infants older than six months definitely need some supplemental feeding to maintain their health and development. Naturally, supplementation with other foods decreases breastfeeding frequency considerably. This by reducing suckling duration can result in release of eggs from ovaries. The experts also warned that in such cases ovulation and mistimed pregnancy can follow even if she remains amenorrhoeic. As such, women who continue to breastfeed beyond six months despite supplementation, (that is the usual scenario in rural India) the rate of pregnancy during ‘lactation amenorrhoea’ will be higher than that of first six months postpartum. Pregnancy rate however, remains low, than those women who do not breastfed at all. This is called ‘extended use of LAM’.

      Many studies on LAM were conducted since Bellagio consensus. Experts again gathered at Bellagio on 4^th Dec, 1995 and they collectively reviewed all the study reports which were available from different countries. The committee concluded that the Bellagio consensus of 1989 was worthy and appropriate including ‘extended use of LAM.’ Sporadic studies conducted thereafter (1996-2008) to assess the validity of Bellagio consensus have reaffirmed that women who are fully or nearly fully breastfeeding are at very low risk of becoming pregnant in the first six months postpartum or as long as they remain amenorrhoeic.

How can we motivate Indian mothers to accept scientific breastfeeding practices?

There is urgent need to educate all pregnant women (would -be -mothers) about standard breastfeeding practices. Family members and community leaders should also be communicated about benefits of exclusive breastfeeding and other healthy breastfeeding practices. Doctors and health care providers too need updating of their counseling skills on breastfeeding by attending workshops and seminars on this issue. Their noble duty is to part all these scientific knowledge i.e. ‘Dos’ and ‘NOT to dos’ to would be mothers during prenatal visits and also during discharge from hospital or nursing home after childbirth.

a)         Who is responsible for wrong breastfeeding practices? Readers will be shocked to know the results of one Indian survey. This recent study disclosed that of the mothers who decided for early formula feeding 46% were motivated by the suggestions received from family members and neighbors and in 43% such women the decision to start a formula feed was influenced by the doctors and health workers! What an unfortunate scenario! In rest 11% women who started formula feed too early were influenced by different media and advertisements.

b)        We can do better: Tips to promote breastfeeding: Breastfeeding and family planning are mutually reinforcing components of any health policy. Many of us understand that early discontinuation of breastfeeding presents considerable health hazards to infant. But we seldom understand that acceptance of standard breastfeeding practice not only benefits the concerned infant but also increase the birth interval by inducing lactation amenorrhoea. Lactation anovulation associated with amenorrhoea resulting from exclusive breastfeeding represents an important child-spacing mechanism in many third world countries. This is because frequent stimulation of the nipple during breastfeeding produce prolactin hormone which in turn reduces some hormones called pituitary ( a gland located in  brain )(pituitary gonadotrophins). It is this prolactin hormone which causes inhibition of menstruation of egg release. For more details of mechanism of an ovulation interested readers may consult vol-II ‘Breastfeeding and Child spacing’ written by the author.