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Presenters: Justine Kavle , PhD, MPH, Georgetown University, IRH

Presenters: Justine Kavle , PhD, MPH, Georgetown University, IRH Barbara Deller, CNM, MPH , MCHIP/Jhpiego.

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Presenters: Justine Kavle , PhD, MPH, Georgetown University, IRH

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  1. Presenters: Justine Kavle, PhD, MPH, Georgetown University, IRH Barbara Deller, CNM, MPH, MCHIP/Jhpiego USAID PRH FP- MNCHN Integration MeetingFamily Planning and Nutrition SessionLactational Amenorrhea Method (LAM), Exclusive Breastfeeding and the Transition To Other Family Planning Methods March 30, 2011

  2. 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

  3. LAM: Efficacy established in clinical research studies Labbok et al, 1997, Perez et al 1992, FHI 1994a, FHI 1994 b, Wade, Sevilla and Labbok, 1994

  4. LAM supports exclusive breastfeeding:Dual benefits for mother and baby • Prevents neonatal and infant illness (diarrhea, respiratory infection) • Prevents neonatal and infant mortality • Supports growth and development • Stimulates oxytocin release causing uterine contraction to reduce postpartum blood loss • 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

  5. Low levels of LAM use at 3.0 to 5.9 months postpartum 2003-2007DHS analysis, ACCESS-FP Winfrey and Borda, 2010

  6. Full Breastfeeding At 3.0 To 5.9 Months Postpartum2003-2007DHS analysis, ACCESS-FP Winfrey and Borda, 2010

  7. 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

  8. 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

  9. Modern contraceptive use increased over postpartum (PP) period, when women received LAM and FP via integrated MNCH care, Bangladesh McKaig, C., Baqui A, et al., MCHIP, 2010

  10. Barriers to transitioning to another FP method, Bangladesh and GuineaACCESS-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

  11. LAM Integration in Programs LAM Ambassadors in Bangladesh Photo J. Mungia

  12. 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

  13. 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)

  14. 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

  15. 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

  16. 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

  17. Bangladesh (HFS): Contraceptive Use Projection at 12 Months Postpartum

  18. 1.00 0.75 Probability 0.50 0.25 0.00 1 2 3 4 5 6 Months since delivery Intervention Control Bangladesh (HFS): Duration of Exclusive Breastfeeding At three months, EBF 58% in Intervention 47% in 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).

  20. 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

  21. 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

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