Counsel the couple with confidence. Lactation amenorrhoea Method: What we as obstetricians need to know enabling us to counsel the couple efficiently in clear language ?? Ans: LAM is surprisingly is the most common method of contraception in the first six months after childbirth. Believe me or not. Scientists have recently designated this form of family planning as ‘Lactation Amenorrhoea Method’ or L.A.M. It is the use of breastfeeding as a temporary family planning method. LAM provides natural protection against pregnancy and encourages starting another method at the proper time. Not all lactating women are protected against pregnancy and only following group of women are protected against pregnancy during breastfeeding period i.e.
a) Her baby gets at least 85% of his or her feedings as breast milk, and she breastfeeds her baby often, both day and night AND
b) Her menstrual periods have not returned since childbirth AND lastly,
c) Her baby is less than six months old.
All these three criteria should be fulfilled to achieve near 100% contraceptive effect of breastfeeding. If a women keeps breastfeeding very often, her protection from pregnancy may last even longer than stipulated six months and perhaps as long as nine to twelve months after last childbirth. This is called extended use of LAM. Knowingly or unknowingly this extended L.A.M. i.e. natural contraception beyond six months is often availed by Indian rural women. This is a form of natural family planning and costs nothing. Our nation thus avoids several thousand unwanted births annually by adopting extended LAM method. In this context it may be pertinent to mention that a mother should ideally breastfeed up to two years along with weaning at six months followed by supplementary foods (partial breastfeeding).
Detailed criteria of LAM
As stated earlier to make breastfeeding as a successful method of natural contraception the woman concerned has to follow all the following criteria e.g.
1. She should breastfeed at least six times during day time and at least one preferably two feeds at night without supplementing water or any other drink. This is what is called exclusive breastfeeding. Author wonders how many urban women will take the trouble to put her baby to breast two or three times in night. LAM to be cent percent effective total feeding duration i.e. suckling time in twenty four hours should be ideally above eighty minutes or more.
2. As soon as menstruation resumes after childbirth she should commence some form of contraception because it is well known that contraceptive efficacy of LAM is markedly reduced as menstruation resumes after childbirth.
3. The contraceptive efficacy fades but not markedly reduce six month after childbirth in spite of continued breastfeeding. Thus six month age of infant is a landmark for initiation of contraceptive even if menstruation do not resume.
Efficacy of LAM as contraceptive
LAM method of contraception is about ninety eight effective in preventing conception in first six months postpartum provided the concerned woman remains amenorrhoeic (nonoccurrence of menstruation). Failure rate of LAM is up to two pregnancies per 100 women in the first six months postpartum even if no supplementary food is added to baby during this period i.e. strict adherence to the policy of exclusive breastfeeding. Nevertheless, two percent failure rate is not uncommon with other contraceptives too and no couple should raise their eyebrow on this minimal failure rate.
Advantages of adopting LAM as Contraceptive:
1. Effectively prevents pregnancy for at least first six months and this the period of coverage may be longer if a woman keeps breastfeeding often, day and night.
2. Encourages the mother to adopt standard breastfeeding patterns thus indirectly improves health of infant. The couple and relatives should remember that breast milk provides the healthiest food for the baby.
3. No direct cost for family planning.
4. No question of contraceptive related side effects.
5. No need to do anything at time of sexual intercourse.
6. Protects the baby from life-threatening diarrhea and protects the baby from other infectious diseases such as measles and pneumonia (respiratory tract infections) by transmitting the mother’s immunities to the baby through breast milk. In Indian context breast milk provides a natural and highly effective panacea against fatal diarrhea of neonates and infants.
Disadvantages of LAM method of contraception:
1. Effectiveness after six months is uncertain.
2. The words ‘exclusive breastfeeding’ sounds simple but it requires considerable effort and dedication on the part the woman. Frequent breastfeeding, though ideal may be inconvenient or impractical for some women, especially working mothers.
3. Unlike condoms, there is no protection against sexually transmitted Infections (STIs) including HIV/AIDS. Thus if a woman is infected with HIV and if her partner does not use condom during sexual intercourse she may transmit the HIV through such unprotected sex. So ideally partners of all HIV positive women should use barrier methods of contraception during sexual intercourse though women can use female condom or newer cervical barrier devices which will be equally effective in prevention of STI. Breast milk also can transmit HIV virus to neonate though such chance again is little. Such transmission of virus through breast milk is also applicable for Hepatitis B virus which is also secreted in milk.
Limitation of breastfeeding as contraceptive:
Though, breastfeeding is an important and effective means of child spacing, still some uncertainty exists about the extent to which a woman can rely on lactation induced suppression of ovulation for contraception. This is because feeding practice varies from women to women. When compared to oral contraceptives or sterilization, breastfeeding may not be that effective form of contraception, since women may occasionally resume ovulation within six months of childbirth while still breastfeeding as per norms. It all depends on how frequently the baby is put to breast and above all the total duration of breastfeeding per twenty four hours. It is needless to mention that these two factors have great individual variations. What are more important, day to day variations may occur due to maternal or infant illness or for social or religions grounds. Thus if a woman fails to breastfeed as per norms for couple of days for above quoted valid reasons then ovulation can ensure prematurely. All these factors pose a problem in judging initiation of additional contraceptive in an individual woman. Therefore, there is a need of individualization in timing of initiation of contraceptives during breastfeeding period which is at times difficult.
As stated earlier during lactation amenorrhoea the probability of pregnancy for first six months is initially low i.e. 2%. But chance of pregnancy increases after six months even if the woman concerned remains amenorrhoic ,e nonoccurence of menstruation). All Breastfeeding women should remember that once she regains her menstrual pattern, contraceptive reliability induced by breastfeeding decreases rapidly and hence other means of contraception are always advisable. This applies particularly when the baby is being weaned and solid foods are gradually introduced. As stated, in rural India partial breastfeeding may continue for many months which offers some protection from pregnancy but not hundred percent.
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