Pre-service Education on FP and AYSRH

1. Pre-service Education on FP and AYSRH Session II, Topic 9 Natural Family Planning Methods

2. Lactational Amenorrhea Method (LAM)

3. What is the Lactational Amenorrhea Method (LAM)? LAM is a temporary family planning method based on the natural effect of breastfeeding on fertility. “Lactational” means related to breastfeeding. “Amenorrhea” means not having monthly bleeding.

4. LAM LAM: Key Points for Providers and Clients

5. LAM LAM: Key Points for Providers and Clients

6. LAM: Mechanism of Action • Baby’s suckling stimulates the nipple • Nipple stimulation triggers signals to mother’s brain • Signals disrupt hormone production • Disruption of hormones suppresses ovulation • No egg, no pregnancy

7. LAM Three LAM Criteria If breastfeeding now, can use LAM if:  Baby is less than 6 months old AND • The baby is fully or nearly fully breastfeeding and is fed often day and night AND • Menstrual periods have not come back But please ask woman if she: Has AIDS? Or infected with HIV, the AIDS virus, so that she can receive counseling and treatment

8. LAM How to Use LAM • Can start LAM as soon as baby is born • Breastfeed often day and night. Daytime feeding no more than 4 hours apart. Night-time feeding no more than 6 hours apart. • Start another method at the right time, BEFORE the LAM criteria no longer apply What to do after LAM: • Start giving baby other foods when he/she is 6 months old, but continue to breastfeed

9. Effectiveness of LAM More effective LAM Less effective In this progression of effectiveness, where would you place LAM? More effective Less effective

10. Effectiveness During Typical and Perfect Use Spermicides Female condom Standard Days Method Male condom Oral contraceptives DMPA LAM Rate during perfect use IUD (TCu-380A) Rate during typical use Female sterilization Implants 0 10 20 25 30 5 15 Percentage of women pregnant in first year of use, but note LAM only used for 6 months Source: CCP and WHO, 2007 (updated 20011).

11. LAM: Characteristics Advantages • Safe, natural and no side effects • Requires no supplies or procedures • Health benefits for mother and baby • Can be used immediately after childbirth • A temporary method • Facilitates modern contraceptive use by previous non-users • Is provided and controlled by the woman • Supports and builds on global infant-feeding recommendation to exclusively breastfeed for six months Limitations • No STI/HIV protection • Is only a temporary method • Not a good method for women who have to be away from their babies for long periods of time. Source: Hatcher, 2007; WHO, 2009; CCP and WHO, 2007 (updated 2008).

12. Importance of LAM Criteria (1) • The woman’s menstrual bleeding has not returned (“amenorrhea”) Menstrual bleeding signals return of fertility—the woman can become pregnant again. Remember: bleeding before two months postpartum is NOT considered menstruation.

13. Importance of LAM Criteria (2) 2. She fully or nearly fully breastfeeds her baby If baby receives food or liquids other than breast milk: • The baby becomes full and will not want the breast as often. • Infrequent suckling will cause the mother to produce less and her fertility to return • She can become pregnant again.

14. Importance of LAM Criteria (3) 3. The baby is less than six months old. Six months is a biologically appropriate cut-off point to start supplemental foods. Remember: continue to breastfeed beyond LAM and until baby is two years old.

15. Medical Eligibility Criteria LAM is safe for nearly all women. Source: WHO, 2010.

16. Key Counseling Topics for LAM Users • Screen for/educate about LAM criteria: • Three criteria and why each is important • Any conditions that exclude use of LAM • Discuss effectiveness of LAM • Select another modern method to which to transition from LAM • Encourage spacing of pregnancies by using another method of family planning for at least 2 years • Discuss optimal breastfeeding practices • Ensure that client knows to return if she has a problem

17. Transition to Another Method: An Essential Component of LAM • LAM is a “gateway” to other modern methods of contraception • LAM provides the couple time to decide on another modern method to use after LAM

18. When LAM counseling is initiated, the provider should discuss transition from LAM to another contraceptive method with the client: Another method should be started as soon as any one of three LAM criteria is not met. Transition method should be selected before this occurs. Transition to Another Method

19. Postpartum Contraceptive Options for Women Who are Breastfeeding Options include: • Implants: Can be inserted immediately following delivery • IUD: Can be inserted within 48 hours after giving birth or after 4 weeks • Progestin-only Pills: Anytime after delivery • DMPA: Delay 6 weeks after delivery • Condom: Anytime • Female Sterilization: Within the first week after delivery or after 6 weeks • Vasectomy: Anytime

20. Antenatal clinic Child health (well-baby) clinic Postpartum ward Postpartum clinic Family planning clinic Labor ward (during early labor or following birth) Community health visits Opportunities to Provide LAM Counseling

21. LAM in the Context of HIV WHO Guidelines for infant feeding in the context of HIV: • Mothers known to be HIV-infected (and whose infants are HIV uninfected or of unknown HIV status) should exclusively breastfeed their infants for the first 6 months of life, introducing appropriate complementary foods thereafter, and continue breastfeeding for the first 12 months of life. • Breastfeeding should then only stop once a nutritionally adequate and safe diet without breast milk can be provided. • When HIV-infected mothers decide to stop breastfeeding (at any time) they should do so gradually within one month. • Every woman should be supported in her infant-feeding decision and in her contraceptive choice.

22. LAM in the context of HIV, continued A mother with HIV who chooses to breastfeed or use LAM should: • Receive care and treatment for herself to minimize the risk of transmission to the infant and keep herself healthy. • Use condoms consistently • If she experiences cracked nipples or other breast problems, instruct her to feed from unaffected breast (and express and discard milk from affected breast) • Seek immediate care for baby with thrush or other lesions in mouth

23. LAM – Summary • Over 98% effective as long as all three criteria are met: • No menses • Breastfeeding only • Baby less than 6 months • “Gateway” to other modern methods of family planning • Provides important health benefits to the mother and child • Natural and no side effects