USAID PRH FP- MNCHN Integration Meeting
Family Planning and Nutrition Session
Lactational Amenorrhea Method (LAM),
Exclusive Breastfeeding and the Transition
To Other Family Planning Methods
Presenters:
Justine Kavle, PhD, MPH, Georgetown University, IRH
Barbara Deller, CNM, MPH, MCHIP/Jhpiego
March 30, 2011
Why does integration of services providing infant
feeding, LAM, and family planning (FP) make sense?
Maternal child health/nutrition is a programmatic entry point for
reinforcing messages on LAM and FP during routine contact points
 LAM reinforces exclusive breastfeeding for 6 months during prenatal and
postnatal care
 Transition from LAM to another FP method could be conjoined with a
message on initiation of complementary feeding at 6 months postpartum
 Referral to FP & health timing and spacing messages
can be given during prenatal and postnatal care
LAM: Efficacy established in clinical research
studies
Trial
Ecuador
Chile
Philippines
Pakistan
330
422
485
391
# of
5
Pregnancies
1
1
2
1
Efficacy
99.9
99.6
99.0
99.4
N
Multicenter
519
98.5
Labbok et al, 1997, Perez et al 1992, FHI 1994a, FHI 1994 b, Wade, Sevilla and Labbok, 1994
1
2
3
3 LAM criteria tested in clinical
research studies
Simplification and operational
definitions for LAM criteria LAM Working Group
Menses has not returned
Menses has not returned
Any menstrual-like bleeding or 2
days of spotting after 2 months
postpartum.
Any bleeding including spotting
after 2 months postpartum
Fully to nearly fully
breastfeeding
Breastfeed only
- Breastfeed day and night
- Occasional tastes of other
foods or liquids
- Breastfeed day and night.
- Do not give your baby any
food or liquid (including
water)
Baby is less than 6 mo. of age
Baby is less than 6 mo. of age
LAM supports exclusive breastfeeding:
Dual benefits for mother and baby
1. Prevents neonatal and infant illness (diarrhea,
respiratory infection)
2. Prevents neonatal and infant mortality
3. Supports growth and development
4. Stimulates oxytocin release causing uterine
contraction to reduce postpartum blood loss
5. LAM promotion increased percentage of women
that exclusively breastfeed
- 58% intervention vs 47% in control group (p <0.01)
in Healthy Fertility Study
Leon-Cava et al, 2002 Horta et al, 2007, McKaig, C., Baqui A, et al., MCHIP, 2010
Low levels of LAM use at 3.0 to 5.9 months postpartum
2003-2007
DHS analysis, ACCESS-FP
Zambia 2007
Madagascar…
Haiti 2005-2006
Guinea 2005
Nigeria 2003
Mali 2006
Ghana 2003
Rwanda 2005
Tanzania 2004-…
Ethiopia 2005
Uganda 2006
Pakistan 2006-…
Malawi 2004
Kenya 2003
India 2005-2006
Congo, DRC 2007
Bangladesh 2007
0.0
20.0
40.0
60.0
80.0
100.0
Winfrey and Borda, 2010
Full Breastfeeding At 3.0 To 5.9 Months Postpartum
2003-2007
DHS analysis, ACCESS-FP
Mali 2006
Rwanda 2005
Guinea 2005
Madagascar 2003-2004
Ghana 2003
India 2005-2006
Nigeria 2003
Malawi 2004
Ethiopia 2005
Uganda 2006
Zambia 2007
Pakistan 2006-2007
Congo, Democratic Republic of 2007
Bangladesh 2007
Tanzania 2004-2005
Haiti 2005-2006
Kenya 2003
0
20
40
60
80
100
Percent of women 3.0 to 5.9 months postpartum who are full
breastfeeding.
Winfrey and Borda, 2010
Challenges for integration of
LAM with optimal breastfeeding practices
●Demographic Health Survey (DHS) analysis, ACCESS-FP
● High levels full breastfeeding, yet low LAM use
● Poor breastfeeding practices require reinforcement for LAM use
●Confusion that breastfeeding = LAM
● Women believe breastfeeding protects them from pregnancy
● Local term for LAM = breastfeeding for family planning
●LAM is an underutilized method despite effectiveness
● Providers’ knowledge and training are low
● Women and health workers believe LAM is not effective
● Few programs offer LAM
Winfrey and Borda, 2010, Tilley et al. 2009
LAM users were more likely to use contraceptives
at 12 months postpartum, Jordan
*Multicenter: ~ 68% use FP at 9 and 12 months
*Brazil: After LAM introduction, at 12 months, lower
% women not using FP (pre-post) p<0.0001.
Bongiovanni et. al 2005, Hardy et al, 1998, Hight-Laukaran et al, 1997
BFFP = Breastfeeding for family planning
Modern contraceptive use increased over postpartum (PP)
period, when women received LAM and FP via integrated
MNCH care, Bangladesh
100
90
80
70
Intervention
60
50
40
10
25
24
30
20
Control
40
13
10
16
0
3 mo PP
6 mo PP
12 mo PP
McKaig, C., Baqui A, et al., MCHIP, 2010
Barriers to transitioning to another FP method,
Bangladesh and Guinea
ACCESS-FP, 2010
• Waiting for menses before taking up a FP method, based on
previous experiences with return to fertility*
• Misconceptions about timing and risk of pregnancy after delivery if
not using LAM or another FP method
• More likely to believe there is a risk of pregnancy 1 year or more
postpartum
• Concerns about side effects, lack of information, access to methods
• Perceived lack of social support (i.e. husbands, mother-in-laws)
R. Kouyate, 2010
* Also in: Bongiovanni 2005; Winikoff and Mensch 1991; Salway and Nurani 1998
LAM Integration in Programs
LAM Ambassadors in Bangladesh
Photo J. Mungia
Current Situation – Jharkhand, India and Mali
LAM, EBF, and FP messages integrated into programs
LAM and FP messages not well integrated (FP in Mali is encouraging)
LAM not conjoined with EBF
• Prenatal care messages received
• LAM: 14% while 67% in India, 68% in Mali received EBF message
• FP: 18%- India, 41% - Mali
• Postnatal care messages received
• LAM: 1% - India, 17% - Mali
• EBF: 48% - India, 61% - Mali
• FP: 12%- India, 40% - Mali
•India: Late initiation of breastfeeding, early introduction of foods, and low
exclusive breastfeeding rates present challenges for implementing LAM,
where LAM use is nonexistent (1%).
•Mali: infant feeding practices are more favorable, LAM use is low (4.5%).
Kavle, 2010, Georgetown IRH
Program Component: ADVOCACY
• At district, state, and national levels
• Program examples – Burkina Faso (IRH/Jhpiego), Mali (IRH),
India (IRH), Kenya (MCHIP), Afghanistan (MCHIP)
• (Re)positioning within the context of MNCH/nutrition
• Health benefits for mother and baby
• Entry point for family planning – LAM as a gateway
• Supports exclusive breastfeeding for longer time
• Program examples – Nigeria (MCHIP), Burkina Faso (IRH,
ACCESS-FP)
Program Component: MESSAGING
• Recognize local / cultural barriers
• Address misconceptions
• Distinguish between BF and LAM
• Risk of pregnancy
• Program examples: Barrier study countries (Guinea and
Bangladesh)
• Simplify and harmonize messages
• Facilitates integration
• Program examples: Burkina Faso
Program Component: INTEGRATED SERVICES
• Multiple contacts within other services –
• ANC + pre-discharge + PNC + well-child
• Program examples: India (WV), Burkina Faso
(IRH/Jhpiego), Kenya
• Timing – contact during ANC, early postpartum, and
later postpartum
Program Component: INTEGRATED SERVICE (cont)
COMMUNITY CONTACTS
• Home visits
• Program examples – India (WV), Nigeria, Bangladesh,
• Targeted male/female community meetings
• Program examples: Bangladesh (HFS), Guinea (STC),
Nigeria (MCHIP)
• LAM Ambassadors
• Program example: Bangladesh
Father in Mirzapur, India with his new baby. Photo: Chandrakant Ruparelia
Bangladesh (HFS): Contraceptive Use
Projection at 12 Months Postpartum
18
1.00
BANGLADESH (HFS): DURATION OF
EXCLUSIVE BREASTFEEDING
0.00
Probability
0.25
0.50
0.75
At three months,
EBF 58% in Intervention
47% in Control
1
2
3
Months since delivery
Intervention
4
5
6
Control
19
LAM in Programs, Georgetown IRH
An eye towards scale-up
• INDIA – Launched community radio programs with messages on
LAM and birth spacing, trains CHWs on LAM using comic book style
job aid for phased-in scale-up in Jharkhand
• 3 districts in 2008-2009
• 3 additional districts 2010 = 6 districts
• 6 additional districts 2011 = 12 districts
• GUATEMALA – IRH is part of the MOH-led technical team to ensure
co-madronas (traditional birth attendants) can effectively offer
LAM, condoms, pills and SDM
• 1 department pilot
• Scale up to national level
• MALI – Integrated LAM messages in breastfeeding support groups in 1
area (Koulikoro), with plans to scale-up to 6 more areas. Advocated for
LAM in national health info system and DHS (planned for 2012).
Future Directions / Research Gaps
• Research gaps/ more evidence needed
• Facilitating factors and barriers to transition to another FP method
• Optimal timing for delivering LAM, EBF and FP messages
• Introduction of LAM user card to improve recording of users in heath system
in Guatemala – Georgetown IRH, planned 2011
• Correct measurement of LAM in health systems and in national
surveys, LAM is often equated with BF (MIYCN/FP Working Group)
• Cost effectiveness of integrating FP/nutrition
• Providers, clients, and users perspectives on integration
Summary
• Scientific and programmatic evidence
• LAM efficacy is high
• Low levels of LAM use, even where full breastfeeding
• LAM users more likely to use FP postpartum (by 12 mo.)
• LAM use may increase exclusive breastfeeding rates and
contraceptive use postpartum when delivered with FP via
integrated MNCH services
• Programming essentials
• Advocacy
• Simplified, culturally appropriate messages
• Integration
• Scale Up