Background and Guidance
The Lactational Amenorrhea Method of contraception (LAM) was formalised over 20 years ago[i] and the Faculty of Sexual & Reproductive Healthcare (FSRH) guidance on postnatal sexual and reproductive health [ii] is clear:
“Women may be advised that if they are<6 months postpartum, amenorrhoeic and fully breastfeeding, the lactational amenorrhoea method (LAM) is over 98% effective in preventing pregnancy.
Women using LAM should be advised that the risk of pregnancy is increased if the frequency of breastfeeding decreases (stopping night feeds, supplementary feeding, use of pacifiers), when menstruation returns or when >6 months postpartum”
Yet a recent survey[iii] found “particular inconsistencies” in the advice given to breastfeeding women in the UK
“I received contradictory advice from the midwife and GP- the GP believed that breastfeeding was a safe form of contraception, whereas the midwife warned me that it wasn’t (but didn’t offer any alternatives.)”
There was also evidence that many practitioners fail to give advice to breastfeeding women about what action to take when the LAM criteria no longer apply.
LAM, breastfeeding rates and getting guidance into practice
LAM is more than a highly-effective, temporary and economical form of postpartum contraception. It can also help to improve breastfeeding rates[iv], and hence maternal and child health. For this reason, attempts were made to increase health professional knowledge of LAM in North London through the provision of brief training and the production of a local patient leaflet[v]. Unfortunately it seems that most health professionals are still reluctant to tell women about this method of postpartum contraception. As is often the case, guidance is not enough. Practitioners need to be convinced that the guidance is sound and that it will achieve positive patient outcomes.[vi]
Why are people wary of LAM?
HeaIth professionals gave us various reasons for their wariness of LAM which we discuss below. These responses were anecdotal, rather than systematically gathered, but we believe they are typical of the views held by many practitioners.
The public is also likely to be wary: 90 percent believe that the contraceptive effects of breastfeeding are a myth[vii]. LAM is not just a matter of breastfeeding, but the two are often conflated so public beliefs about effectiveness are probably similar to those of most health professionals.
1. “LAM is a natural method. Natural methods are notoriously unreliable”. Some natural methods of contraception are more reliable than others. The Standard Days Method (calendar-based) has a perfect use rate of 95%[viii]. Persona (a hormone measuring device) is around 94% effective[ix]. The sympto-thermal/fertility awareness based method requires specialist teaching but is 99.6% effective.8,[x]
LAM is probably the simplest natural method. It is easy to understand; over 98% effective10; does not require specialist teaching and has a strong evidence base.1,2,[xi]
2. “One of my patients/friends/relatives/colleagues got pregnant while breastfeeding.” Breastfeeding alone is not reliable contraception. Further questioning usually reveals that the LAM criteria were not being met.
3. “I don’t want women to use a method they’re not happy with.” LAM should not be presented as the only postpartum contraceptive option. As for all contraception, the choice should lie with the user. Women should be given clear, unbiased information to help them choose the best contraception for them at this time.
4. “It’s too hard to explain” – the algorithm in the faculty guidance helps (see below), but national information for patients is inadequate at present. The widely used NHS Choices website simply states “You can get pregnant as little as three weeks after the birth of a baby, even if you’re breastfeeding and your periods haven’t started.”[xii] A less prominent part of the website, and the fpa leaflet Contraception choices - after you’ve had your baby[xiii], includes basic information about LAM but only states it is “up to 98% effective”, not over 98% effective and does not include information about avoiding pacifiers. The RCOG-endorsed magazine for pregnant women states “fully breastfeeding does provide some protection but you should not rely on this as a secure form of contraception.” [xiiii]
6. “I don’t want a patient coming to see me for a termination because I’ve told her to use a less reliable method”. No contraceptive method completely eliminates the risk of pregnancy. Women who are very concerned can be prescribed an additional method. However, some women are uncomfortable with other methods and so are unlikely to use them, even if they do have a better effectiveness rate. LAM is a good temporary option for these women.
7. “If a woman waits to have her period before switching to another method it’s too late, the period means she’ll have ovulated and so been at risk of pregnancy.” A woman cannot rely on amenorrhoea alone. Ovulation can occur as early as day 28 for non-breastfeeding women, but initial cycles for breastfeeding women are associated with infertility as breastfeeding suppresses ovulation and shortens the luteal phase. Menstruation for this group occurs on average 28.4 (range15-48) weeks after delivery and the mean time to ovulation is 33.6 (range 14-51) weeks. [ii]
8. “Patients never listen. They just want pills.” Giving advice is not the easy option. Many clinicians will have encountered resistance from patients with a bad cold who want antibiotics rather than advice about rest, analgesia, and antibiotic resistance. It is easier to provide advice when it is backed up with clear written information [iv].
9. “It only applies to a tiny proportion of women”. In 2010, 81 percent of women began breastfeeding in the UK. Three months after delivery, 17 percent of women were exclusively breastfeeding and at five months just 5 percent.15 This not a large number of women, but good quality advice is essential at this time.[ii, iii]
10. “I don’t want my patients to think I’m judging them” Breastfeeding and parenting are sensitive subjects. Many parents use pacifiers or give formula milk as well as breast milk. It doesn’t make them “bad parents”, it just means they can’t rely on LAM.
11. “I’m not a breastfeeding expert, they might ask me tricky questions” Breastfeeding has to be going well for LAM to be effective. If the parent needs breastfeeding support, refer them to their local infant feeding team or the national breastfeeding helpline (Tel: 0300 100 0212).
We need better national information for patients about LAM. This will help health professionals to provide clear and consistent advice, in line with the FSRH guidance. However, information for patients will not make a difference unless family planning practitioners, and those that rely on them for advice, trust the evidence.
Further research may be helpful, but the evidence base for LAM is strong. It is an effective temporary postpartum contraceptive option, it can help to improve breastfeeding rates, and there are almost no costs involved. Breastfeeding women should be routinely informed about all suitable methods of contraception and especially LAM, the two per cent failure rate, and the need to have another contraceptive method ready for when any of the criteria change. Women should be receiving the same message whether they look at the NHS Choices website, or speak to their midwife, health visitor or family planning practitioner.
[i] Consensus Statement. . Breastfeeding as a family planning method. Lancet. 1988;ii:1204-5
[ii] Royal College of Obstetricians and Gynaecologists. Faculty of Sexual and Reproductive Healthcare Clinical Guidance. Postnatal sexual and reproductive health. London: RCOG. 2009.
FREE full text: http://www.fsrh.org/pdfs/CEUGuidancePostnatal09.pdf
[iii] bpas. Mumsnet/bpas survey shows gaps in contraception care for new mums – unclear advice to breastfeeding women raises risk of unplanned pregnancy [Press Release, accessed Jan 2012].
[iv] Peterson AE, Perez-Escamilla R, Labbok MH et al. Multicenter study of the lactational amenorrhea method (LAM) III: effectiveness,duration, and satisfaction with reduced client provider contact. Contraception 2000;62:221-30.
[v] Panzetta S. Lactational amenorrhoea method contraception: improving knowledge. Community Pract 2011;84:35-7..
[vi] NICE. How to change practice. Understand, identify and overcome barriers to change. 2007.
FREE full text: http://www.nice.org.uk/media/AF1/73/HowToGuideChangePractice.pdf
[vii] Populus. (2009) Sex and contraception survey.
FREE full text: http://www.populus.co.uk/Poll/Sex-and-Contraception-Survey-/
[viii] Trussell J. Contraceptive failure in the United States.Contraception. 201;83(5):397-404 [ix] Fpa. Your guide to natural family planning [leaflet, accessed Dec 2012]
FREE full text: http://www.fpa.org.uk/professionals/publicationsandresources/downloads
[x] Frank Herman P, Heil J, Gnoth C et al. The effectiveness of a fertility awareness based method to avoid pregnancy in relation to a couple’s sexual behaviour during the fertile time: a prospective longitudinal study. Human Reproduction: 2007;22(5);1310-1319.
FREE full text: http://humrep.oxfordjournals.org/content/22/5/1310.long
[xi] Van der Wijden C, Kleijnen J, Van den Berk T. Lactational amenorrhea for family planning. Cochrane Database Syst Rev 2003;4:CD001329
FREE full text: http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD001329/abstract
[xii] NHS Choices [Internet]. Health A-Z/Pregnancy and Baby/Sex and Contraception. [accessed Sept 2012]
Available from: http://www.nhs.uk/Conditions/pregnancy-and-baby/Pages/sex-contraception-after-birth.aspx
[xiii] fpa. Contraceptive choices after you’ve had your baby [leaflet, accessed Sept 2012]
FREE full text http://www.fpa.org.uk/helpandadvice/contraception/contraceptionafterbaby
[xiiii]CW Publishing Group (in association with the RCOG). You and Your Family. Summer/Autumn 2011.
SEE www.youandyourfamily.co.uk [distributed by health professionals]
[xv] NHS Information Centre for Health and Social Care. UK Infant Feeding Survey 2010.
Available from: http://www.ic.nhs.uk/pubs/infantfeeding10