The European Journal of Contraception and Rcproductive Health Care 2 (1997) 105-1 11

Postpartum contraception: the

lactational amenorrhea method
M. Vekemans
Universitt Libre de Bruxelles and Centre Hospitalier Universitaire Saint-Pierre,Bruxelles, Belgium
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ABSTRACT Breastfeeding still accounts for a significant proportion of all fertility reduction, the average
birth interval being longer among populations that breastfeed. However,per se it is not reliable
for individual fertility suppression. The lactational amenorrhea method (LAM) is a highly
efficient tool for the individual woman to utilize physiology to space births. Suckling induces
a reduction in gonadotropin releasing hormone, luteinizing hormone and follicle stimulating
hormone release, resulting in amenorrhea, through an intracerebral opioid pathway: p-
endorphins inhibit gonadotropin releasing hormone and dopamine secretions, which, in
turn stimulates prolactin secretion and milk production. Reduced suckling precipitates the
return of ovulation. During lactation, menses before 6 months are mostly anovulatory, and
fertility remains low. The lactational amenorrhea method is based on three simultaneous
conditions: (1) the baby is under 6 months; (2) the mother is still amenorrheic; and (3) she
practises exclusive or quasi-exclusive breastfeeding on demand, day and night. Experiments
For personal use only.

with LAM extended to 9-12 months are ongoingwe use a standardized algorithm to present
LAM. The lactational amenorrhea method is a way both to space births and to support
breastfeeding, which should be replaced by a contraceptive method in due course. A
‘Breastfeeding-LAh4-Family Planning’ team is very helpful in maternity wards for promoting
modern breastfeeding, LAM, and contraception, and for alleviating barriers and
misconceptions. The lactational amenorrhea method is at least 98% effective, comparing
favorably with other contraceptive methods. Acceptability and continuity are not very well
known; as with other ‘natural’methods the figures are probably low in a general population
but high for motivated couples.The lactational amenorrhea method avoids double protection,
and thus saves resources, is especially (but not exclusively) suitable for couples interested in
natural family planning and is accepted by religious authorities.The lactational amenorrhea
method gives time to decide upon a long-term method of contraception. Unwanted
pregnancies, although infrequent, conceived while using LAM result in very short, high-risk
birth intervals. Introduction of LAM in family planning programs demands training, attention
to be given to working mothers, positive attitudes of health personnel, close links between
postpartum and family planning teams, situation analysis, budgets, evaluations, follow-up
activities, modifications of record keeping systems and computing programs, and of national
family planning guidelines. In conclusion, LAM is an e6cient family planning method which
should be promoted. The lactational amenorrhea method should always include the shift to
another method when its criteria are no longer implemented.

KEY W0RDS Postpartuni contraception, Breastfeeding

Correspondence:Dr M.Vekemanc,Centre Hocpitalier Unlvercitaire Saint-Pierre, Gyn, Kue Haute 322, 1000 Bruxelles, Belgium

105
 Postpartum contraception
INTRODUCTION
Breastfeeding still accounts for a significant proportion
of all fertility reduction, the average birth interval being
longer among populations that breastfeed than among
populations that do not breastfeed'. However, for the
individual, breastfeeding per se is not reliable for fertility
suppression2.
The lactational amenorrhea method (LAM)' is a tool
for the individual woman to utilize breastfeeding
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physiology in order to help space her births.
PHYSIOLOGY
Infertility usually occurs for the first 50 days postpartum.
Thereafter, suckling suppresses follicular development
in 65% of lactating mothers, and, in most of the
remaining, follicular development is incomplete'. The
pattern differs between societies and between
individuals, nutrition of the mothers possibly being one
of the determinants (studies are still inconclusive).
Therefore, it has been difficult to develop universal
For personal use only.
guidelines to recommend the use of natural postpartum
infertility as a contraceptive method. LAM is a response
to the difficulty ofpredicting the duration of the natural
postpartum infertility period. It has proven to be highly
efficient, as will be shown below.
Suckling induces a reduction in the pulsatile release
of gonadotropin releasing hormone (GnRH) which
almost suppresses luteinizing hormone (LH) and follicle
stimulating hormone (FSH) secretions, which in turn
increases the duration of the lactational amenorrhea.
The mechanism seems to involve an intracerebral opioid
pathway (local release of P-endorphin, inhibiting
hypothalamic release of G n R H and suppressing
dopaniine secretion, thereby stimulating prolactin
secretion). Prolactin maintains milk production, and
thus encourages suckling, but has no major role in the
lactational infertility'.'. Reduced suckling precipitates
the return of ovulation.
T h e cumulative probability of ovulation during
lactational amenorrhea'-' varies. A few typical results
are presented in Table 1.
In breastfeeding mothers, the first postpartum
menstruation usually occurs before the first ovulation,
ifblood appears during the first 6 months postpartum'.
In a study in Manila', for women menstruating before
6 months postpartum, the lag between anovular first
106 The European Joumol
Kkemans
Table 1 Cumulative probability of ovulation during lactational
amenorrhea
At 6 months At 12 months
Ovulation 31 Y'o 67 Yo
Ovulation + adequate 14% 38 Yo
luteal phase
Menses 19-67% -
menses and subsequent ovu1;ition was 16 weeks (+ 4.4
weeks standard devi;ition). This figure shows that the
LAM criterion ';iiiieiiorrhe;i' is very conservative, which
explains the very good protection offered.
T h e return of ~iienstruationindicates ovarian
hormonal activity. T h e later this occurs, the more
ovulation OCCUI-sbefore the vaginal blood loss.
THE LACTATIONAL AMENORRHEA
METHOD
LAM is based 011 three conditions which have to be
respected siiiiu1t;iiieoiisly:
(1) The baby is iinder 0 months of age. Experiments
with LAM-9 (the bitby is under 9 months of age)
and 'extended LAM' (the baby is over 9 months
of age) are being conducted;
(2) The mother is still ;inienorrheic;
( 3 ) The mother prxtices exclusive or quasi-exclusive
breastfeeding (on dem;ind, day and night).
T h e use o f the questioiin;iire I I I Figure 1 is
recommended to ;issess the suitability of the lactational
amenorrhea method for nursing niothers'~"'.
During lactation, fecundity still remains impaired
after menstruation resunies. However, menstruation is
a more important indic;ition of the return of fertility,
as compared to the age of the b;iby, especially if
breastfeeding reni;iiiis quasi-exclusive (i.e. maternal milk
constitutes the m;ijor part of the infiint's food).
LAM is a way of both spacing births and supporting
breastfeeding, and this method is also ;I means by which
the user knows when ;I compleinentary method of
family planning iiiust be st;irted. Evidence exists that
exclusive breastfeeding for the first 6 months has a
of Co~i/r(ic~~pfion
ond Reproductive Health Care
 Postpartum contraception
I I
No i pregnancy is increased For
or allowing long periods without YES
breastfeeding, either day or night?
No i breastfeeding for the child's
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p y o u r baby more than 6 months old? I YES
/
There is only a 1-2% chance
of pregnancy a t this time'
When the answer to any of these three questions becomes YES
For personal use only.
"Spotting that occurs during the first 56 days is not regarded as menses, 'the mother may choose to use a complementary method of
contraception at any time
Figure 1 Questionnaire to assess suitability of mothers for the lactational amenorrhea method
positive impact on the nutrition of the infant, when
mothers are properly nourished and socially supported.
Their infants grow as well as, or better, than forniula-
fed infants2. Mothers should receive, or be spared
through decreased workload, the excess calories
needed to fully breastfeed. Feed the mothers and they
will breastfeed the babies. In addition, a subsequent
pregnancy does not obviate breastfeeding.
To succeed at breastfeeding, a number ofrules must
be followed:
(1) N o supplements (except vitamins, or to taste, or
exceptionally) ;
(2) Frequent sucklings (2 10/24 h; in total 100 min/
24 h);
(3) Each breast stimulated each time;
(4) Offer the breasts soon after delivery, best within
1 h and always within 12-24 h;
(5) Night sucklings;
(6) Ifa supplement is exceptionally given, let the infant
suckle first. Decreasing duration or number of
The EuropcianJournal of Contraception and Reproductive Health Care
Ekemans
The mother's chance of
continued protection, advise
the mother to begin using a
b
complementary family planning
method and to continue
health
i
sucklings increases the risk of ov ula t io t i before the
first menstruation.
Health workers should help to iinprove breastfeeding
practices.The appearance of the first tooth can be used
as a signal for Supplementing with other food, where,
and when the 6 months' time span is difficult to assess'.
LAM must be followed by another
contraceptive method or periodic abstinence
Breastfeeding should bc encour;iged in m;iternity wards,
and substitutes avoided as much ;IS possible. Hospitals
should refrain from offering the niothers milk powder,
presents and leaflets fi-om niilk powder tiianufacturers.
Cohabitation between mother and newborn must be
allowed and organized from the beginning.The creation
of a breastfeeding-LAM-family plmning team would
be very helpful in ninny hospitals kind maternity wards
in order to modernize their practices, i.e. promoting
breastfeeding, LAM and contraception. Suppression of
barriers and misconceptions surrounding breastfeeding
is a priority in many settings.
107
 Postpartum contraception Vekemans

Efficacy life table analysis. Two different curves have to be

considered: first, the ongoing users (how many still use
LAM is at least 98% effective".". In one studyI3 the
the method after x months?) and second, the complete
pregnancy rate was 1.7%. In a multicentric prospective
cohort (how many changed to other methods?).
study (centers in Mexico, Thailand, Egypt, Pakistan,
Pregnancy rates must be presented for the two groups,
the Philippines, Canada and A~stralia)'~ strict LAM-6
and for a control group. I t is not sufficient only to
(i.e. with quasi-exclusive breastfeeding of babies up to
present failure rates in women strictly adhering to the
6 months of age) resulted in a life table pregnancy rate
LAM criteria. A table can be set up reporting the
of 0.7%.With food supplementation, the rate remained
number of women contacted at the start and during
quite low (2.9%) although this figure can be considered
months 1-6, the number of women using LAM (with
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too high for going over to the promotion of 'unstrict'

number of pregnancies and number lost to follow-up),
LAM (i.e. when breastfeeding is supplemented).
the number of women who changed from LAM to
In a Slovenian study", LAM was found to be very
another contraceptive method (again with number of
efficient until 32 weeks postpartum, even with partial
pregnancies and number of lost for follow-up) and the
breastfeeding.
number of women who stopped using LAM without
In order to remain objective when studying the
having recourse to an alternative method (with number
efficacy of LAM, the low pregnancy rates obtained with
ofpregnancies and number of lost for follow-up).There
the method must be compared with figures obtained
is an urgent need for such investigations.
in a control population not trained in the method.The
probability of pregnancy in early postpartum may also
be low because intercourse is less frequent at that time. Double protection
A study in Chile has shown a very small difference in
For personal use only.

Using modern contraceptives during the first 6 months

pregnancy rates between the LAM group and the
in amenorrheic, lactating women is economically a
control group, 1% and 1.7% at 6 months, respectively.
waste, since the double protection (mean 26 weeks)
The main LAM promoters (i.e. The Institute for
offered is unnecessary'".The question is, is it necessary,
Reproductive Health, Georgetown University,
or indeed recommended, to start contraception soon
Washington DC, USA) found that pregnancy rates in
after delivery, where there is substantial lactational
LAM users and control cohorts do not differ statistically
amenorrhea? Rather, LAM should be offered as a
at 6 and 12 months postpartum.The gain is rather in
contraceptive method.
the field of family health (mother, infant, siblings,
husband) through, for the infant, optimal breastfeeding,
and of economic gain for the remainder of the family. Indications

In the USA, the extent of combined pill use among

Acceptability
A study in Ecuador found that 31% of the women to
whom LAM was presented accepted participation. Of
them, 90% correctly understood the method after two
visits and 75% expressed satisfaction.
Continuity
At 12 months postpartum, menstruation had returned
in 87.5% of all the women in a multicentric studyI4.
The authors noted high discontinuation rates, so they
recommend use of LAM only to the time before
beginning other contraceptive methods. In prospective
studies, continuation rates are to be calculated using
lactators has declined since the early 1 9 7 0 ~ 'The
~.
introduction of LAM, followed by another method of
contraception, ;ippears to be ; i n excellent proposal
nowadays.
Arguments in favor of the use of the
lactational amenorrhea method
Some women may perceive contraception and
breastfeeding as incompatible". LAM is very well
adapted to such individuals, m d gives time to discuss
the necessary move to natural faillily planning or use
ofa modern method of contr;iception after LAM ceases
to offer protection.
LAM is certainly suit;ible for couples who want to

108 The EuropeanJournal (IfContraception and Reproductive Health care

 Postpartum contraception
practice natural family planning since body signs of
ovulation are difficult to detect during lactational
amenorrhea. However, LAM should not be restricted
for use to natural family planning amateurs, as some
authors feel]’,but rather be proposed as an intermediary
method of contraception before changing to a modern
one.
LAM gives time to the couples to choose their long-
term method of contraception, and is accepted by all
religious authorities. It saves money for the families
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and is in harmony with the prevailing belief that
lactation delays fertility and is thus easily understood
and accepted. LAM decreases the unnecessary use of
contraceptives. It also regulates the introduction of
supplements and improves babies’ health.
Sustained breastfeeding saves family resources which
helps to provide proper nutrition for other family
members. Money saved helps to feed and clothe the
other children.This is important in very poor families
and in developing countries. Formula milk is extremely
expensive for poor family budgets.
For personal use only.
LAM establishes links between the maternity and
the family planning programs.
Arguments against the use of the lactational
amenorrhea method
Unwanted pregnancies conceived while using LAM,
although infrequent, result in very short, and thus high-
risk, birth intervals.This has to be kept in mind whilst
counselling couples: if the risk taken is considered
unacceptable, a modern method of contraception can
be recommended and started. Some authors use this as
an argument against LAM promotion”. This seems
unwise. ‘They do not seem to balance the risks and
benefits properly, and assume that not having recourse
to LAM results in the use of modern contraceptives,
which is certainly far from being automatic. Only when
a long-lasting method, not involving the user, can be
started (e.g.6-monthly injections, implants, intrauterine
device, sterilization) is LAM not the first choice, on an
individual scale. O n a public health scale, double
protection prevents savings.
Malnutrition should not be an obstacle for the use
of LAM. Intervention projects should focus on the
nutrition of the mother.
Early introduction of supplements is not a contra-
indication for LAM. O n the contrary, practices can be
The European Journal of Contraception and Reproductive Health
Vekemans
improved through the program. Similarly, late
introduction of supplements is not an obstacle. LAM
teaches the right nionient for introduction of
supplements.
The introduction of LAM in a faniily planning
program necessitates the training of staff in order to
ensure that all staff understand the special family
planning needs of lactating women and that all staff are
able to support breastfeeding (including the physical
and psychological aspects).
Constraints
The often-used message that additional food has to be
introduced to an infant a t 4 months of age is not
compatible with LAM-6. UNICEF, other agencies and
non-governmental organizations active in co-operation
could change their message,and advise giving additional
food from 4 to 6 months of age.
Working mothers imagine dificulties with LAM.
Co-operation by employers can alleviate the problems
(e.g. time allowed for breastfeeding, going home at
noon, expressed milk given during the day by a helper).
However, LAM does not necessarily need to extend to
the full 6 months. In addition, cultural norms and
attitudes towards breastfeeding change. It is worthwhile
to try to promote LAM everywhere.
Another difficulty is that nowadays LAM training is
not given in medical and paramedical schools.
Some of the constraints can be summarized as
follows, using four categories.
Providers arid liealth workers
Easily give artificial milk (formula). Often don’t
encourage breastfeeding;
Don’t think LAM is effective;
Have to be trained;
Are overwhelmed with work;
Think LAM does not add any good to the prevalent
situation;
Have to add LAM to childbirth education classes;
Have to discard all obstacles: a team’s work;
Have to teach mothers how to breastfeed;
Have to teach the advantages of breastfeeding:
ideal growth and development of children;
decreases infectious diseases;
decreases breast and ovarian cancer risks;
Care 109
 Postpartum contraception
increases birth intervals (developing countries);
saves money;
Have to teach mothers about timing of supplement
introduction;
Have to encourage 2 years (after 6 months partial)
lactation.
Sociocultural aspects
Marketing of human milk substitutes is free;
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Artificial lactation is considered ‘normal’;
Women’s work needs adaptation;
Breastfeeding in public has to be right;
Pacifiers are not indicated.
Mothers and healthcare providers
Incorrect breastfeeding practices may occur;
Artificial lactation is attractive.
Teaching
For personal use only.
Need for new modules;
Use of the new LAM knowledge;
Follow-up of newly trained service providers has to be
organized.
Promotion of LAM in developing and
developed countries
More and more authors admit that LAM is a valuable
tool which may be used to space families and control
fertility in developing countries’*, as lactation has
contraceptive properties. However, prolonged lactation
has to be protected by efficient contraception because
(1) a new pregnancy often means abrupt weaning of
the last child, accompanied by bad health risks and (2)
the contraceptive effect of lactation statistically decreases
with time.
In developing countries, breastfeeding is a universal
practice: often more than 95% ofmothers start lactation.
Throughout the world, 95% of newborns are breastfed.
In Rwanda, for instance, 82% of the mothers still
exclusively breastfeed their babies for 6 months, and
22% for 12 months (although this is not recommended:
supplements should be started at 6 months of age). In
rural Tunisia, a study showed figures for lactation of
91% at 6 months postpartum and 67% at 12 months
110
Vekemans
postpartum. In such countries, which are representative
of many developing countries, LAM c:in be welcome.
LAM i nip rove s 1 act a t i o n , in c re ;i s e s t h e m e an
amenorrhea duration and, in a cohort, the number of
women continuing with lactation. As a consequence,
LAM saves lives.
LAM seems less likely to be accepted in developed
countries, because of a series of objections. In most
developed countries, postparturn women are advised
to initiate artificid contraception soon, or at the latest,
6 weeks after delivery.
O n the other hand, almost all medical authorities
currently admit that i t is n e c e w r y to promote
breastfeeding for health reasons. LAM and breastfeeding
are complenientnry x i d support each other. LAM can
be safely and efficiently encouraged ;is both a family
planning m e t h o d and a s a m e t h o d supporting
breastfeeding. LAM constitutes a strong link between
the postpartum clinic and the Eimily planning clinic,
in so far as those two activities are not integrated.
Reproductive healthcare clinics ideally offer both
services, as do maternity wards.
In 1994, LAM trials were conducted in a t least 12
countries. I n t h e author’s o p i n i o n , nowadays
reproductive health prograins should integrate LAM.
Programmatic aspects for introduction of LAM include
the following short and incomplete list to show the
complexity of starting with a new activity:
Needs evaluation;
Current situation evaluation including attitudes of
the population, healthcare providers and decision-
makers;
Identificatioii of resource-persolis;
Training;
Set objectives;
Describe the action plan;
Calculate budgets;
Implement, evaluate, follow-up, learn lessons,
etc. . .
One complete case of LAM use gives 0.25 couple-
years protection.
T h e costs relsited to the implenientation of the
method could include training costs, counselling time,
follow-up activities, modifications of record keeping
The European Journal (rfCorrtrz?ceptiorrarid Reproductive Health Care
 Postpartum contraception
systems and o f computing programs, National
Committee meetings and changes in national family
planning guidelines.
C0N CLU SI 0N S
Breastfeeding, in contrast to the lactational amenorrhea
method (LAM), is not a family planning method. In
developed and developing countries, women ideally
should exclusively breastfeed their infants for the first 6
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months postpartum and, providing they have not
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and children. Occasional paper no. 6, 1993, Institute
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for Reproductive Health, Georgetown University,
Washington D C , USA
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The European Journal of Contraception and Reproductive Health Care
Vekemans
experienced menstruation, they do not need to use
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Az..socintiotr of Anierica,
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Health Eainitiwr Rev 1993; 3: 101-6
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15. Rojnik B, Kostiielj K, Andolsek-Jeras L. Initiation of
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111