FAQ SHEET 3
Updated September 2001
What is the
Lactational Amenorrhea Method (LAM)?
The Lactational Amenorrhea Method (LAM) is a modern, temporary family planning
method that has been developed as a tool to help support both breastfeeding and
family planning use. It is based on the natural infertility resulting from
certain patterns of breastfeeding. “Lactational” means related to breastfeeding;
“Amenorrhea” means not having menstrual bleeding; and “Method” means a technique
LAM is defined by three criteria:
- 1. the woman’s menstrual periods have not resumed, AND
- 2. the baby is fully or nearly fully breastfed, AND
- 3. the baby is less than six months old.
When any one of these three criteria is no longer met, another family
planning method must be introduced in a timely manner to ensure healthy birth
|Optimal breastfeeding practices
include exclusive breastfeeding for the first six months and breastfeeding
with appropriate complementary feeding for two years or more. LAM is a
family planning method which supports improved breastfeeding, healthy
child spacing, child survival, and women’s health.
How effective is LAM?
LAM provides family planning protection comparable to other family planning methods.
What are the three LAM criteria?
- The woman’s menstrual periods have not resumed
Following childbirth, the resumption of menses is an important indicator of a
woman’s return to fertility. During breastfeeding a woman is less likely to
ovulate. However, once a woman starts to menstruate, ovulation has returned or
may be imminent. Bleeding during the first two months postpartum is lochial
discharge and is not considered menstrual bleeding. Menstruation is defined
for LAM use as two consecutive days of bleeding, or when a woman perceives
that she has had a bleed similar to her menstrual bleed, either of which
occurs at least two months postpartum.
- The baby is fully or nearly fully breastfed1
Full Breastfeeding is the term applied to both exclusive
breastfeeding (no other liquid or solid is given to infant) and almost
exclusive breastfeeding (vitamins, water, juice, or ritualistic feeds
given infrequently in addition to breastfeeds). Nearly Full Breastfeeding
means that the vast majority of feeds given to infants are breastfeeds.
While exclusive breastfeeding is not necessary for LAM to be effective,
the closer the pattern is to exclusive, the better for mother and baby. The
optimal pattern for the baby is to be nursed frequently and for as long as the
infant wants to remain on the breast, both day and night. At night, no
interval between feedings should be greater than six hours.
- The baby is less than six months old
At six months of age, the baby should begin receiving complementary foods
while continuing to breastfeed. Introduction of water, liquids, and foods can
reduce the amount of sucking at the breast, triggering the hormonal mechanism
that causes ovulation—and menses—to resume.
A mother may not want to switch to other family planning methods when she no
longer meets the LAM criteria and may choose to continue to rely on
lactational amenorrhea for pregnancy delay. In this case the woman should be
counseled to keep breastfeeding frequently and to breastfeed before giving the
infant other foods. She should be informed that her risk of pregnancy
What are the advantages and disadvantages of LAM?
- Very effective
- Provides up to 0.5 CYPs (Couple Years Protection)
- Has no side effects
- Does not require insertion of any device at the time of sexual intercourse
- May attract new family planning users
- Contributes to family planning prevalence directly and through increased acceptance rates
- Can be initiated immediately postpartum
- Is economical and requires no commodities or supplies
- Contributes to optimal breastfeeding practices and therefore enhances maternal and infant health and nutrition
- Acceptable to all religious groups
- Can only be used for a short period (up to six months postpartum)
- Requires breastfeeding frequently both day and night
LAM be initiated?
LAM can be initiated at any time during the first six months postpartum. The
best time to begin counseling a woman about LAM and other family planning
methods is during the antenatal period to allow her to make an informed choice
about which method she wishes to use following the birth of her baby. LAM can be
started immediately postpartum. The health care provider can help prepare the
woman to begin breastfeeding immediately after birth and, if the woman has
decided to use LAM, verify that she understands the three criteria for LAM use.
If a woman wants to initiate LAM use within the first two months postpartum, she
must verify that she has been fully or nearly fully breastfeeding her baby since
delivery. A woman may still be having postpartum bleeding (lochial discharge)
that may be similar to a monthly bleed. As long as she is fully or nearly fully
breastfeeding, the bleeding in the first two months does not disqualify her from
initiating LAM during this period.
If a woman wants to start using LAM when she is more than two months postpartum,
the health care provider must carefully verify that she has met the three
criteria for LAM use since delivery.
What is the difference between LAM, breastfeeding, and amenorrhea?
- LAM is a contraceptive method, based on the physiology of breastfeeding.
LAM is a method of contraception that a woman consciously chooses to use to
reduce her chance of becoming pregnant by adhering carefully to the three
- Breastfeeding is a feeding practice.
- Amenorrhea, or the absence of menstrual bleeding, reflects a reduced risk
of ovulation, but neither breastfeeding nor amenorrhea is a family planning method.
the optimal breastfeeding practices1
that contribute to breastfeeding and LAM success?
- Breastfeed as soon as possible after birth, and remain with the
newborn for at least several hours following delivery.
- Breastfeed frequently both day and night.
- Breastfeed exclusively for the first six months: no water, other
liquids, or solid foods.
- After the first six months when complementary foods are introduced,
breastfeed before giving complementary foods.
- Continue to breastfeed for up to two years and beyond.
- Continue breastfeeding even if mother or baby is ill.
- Avoid using bottles, pacifiers (dummies), or other artificial
- Mothers who are breastfeeding should eat and drink sufficient
quantities to satisfy their hunger and thirst.
1 Guidelines: Breastfeeding, Family
Planning, and the Lactational Amenorrhea Method (LAM). Institute for
Reproductive Health, Georgetown University, 1994 (available in Arabic, English,
French, Russian and Spanish).
return visits are needed by LAM users?
When counseling a new LAM acceptor, the health care provider should discuss her
follow-up needs and determine with the client how frequently she needs to be
seen and what setting is most accessible for her. At the very least, a client
needs to return for a visit if she perceives any breastfeeding difficulties or
as soon as any one of the LAM criteria changes. An additional followup visit at
five to six months postpartum is essential to determine the client’s plans for
switching to another contraceptive method and for introducing complementary
foods when her baby is six months old. Whenever possible, the health care
provider should schedule the visit when the client brings her baby for
assessment or immunization, in this way saving the mother time by reducing the
total number of visits to the clinic.
If the client is unable to schedule a visit or if she lives far away and will
have difficulty returning, the provider should give her a supply of condoms,
spermicides, and/or progestin-only pills. In this way she can maintain
contraceptive protection if LAM is discontinued before she is able to return to
contraceptive methods can be used after LAM?
When any one of the three criteria for LAM use is no longer met or when a woman
decides to stop using LAM, she needs to begin using another contraceptive method
for as long as she wants to prevent another pregnancy. Women who are
breastfeeding and who switch to another method should be advised on
contraceptive options. Combined oral contraceptive pills (COC) and combined
injectables are not recommended before six months postpartum because they
contain estrogen, which may decrease the quantity of breastmilk. After six
months postpartum, a woman who is breastfeeding can use any method of her choice
as long as she is properly screened and meets the eligibility criteria.
Can a woman
who is separated from her baby use LAM?
The amount of time that a woman is separated from her baby is a key factor in
establishing the LAM criterion of full or nearly full breastfeeding, day and
night, with no long intervals between feedings. A woman who is separated from
her baby regularly for more than four to six hours cannot expect a high level of
contraceptive protection from LAM, even if she expresses milk during the
separation. Expressing breastmilk may not be as effective as suckling at the
breast in suppressing ovulation, and for this reason a woman who expresses her
milk may not be able to rely on LAM. In a study on LAM in working women, the
pregnancy rate increased to five percent. Some women can make arrangements to
have their babies brought to them to nurse and/or are able to go to their baby
at regular intervals. Women who are able to keep their babies with them at the
work site, market, or in the fields and are able to breastfeed their children
frequently can rely on LAM.
flexible is the method?
LAM is a flexible method. In some countries, programs may modify the criteria
slightly to reflect cultural norms or national policies without decreasing the
method’s efficacy. Many women have occasionally had longer intervals between
feedings, their baby has slept through a night, or they have fed the baby
regularly with small amounts of complementary foods, and still have had the same
high level of effectiveness.
In some settings, programs modify or simplify the method to meet local
conditions. For example, they may require exclusive breastfeeding as an
eligibility criterion and not accept nearly full breastfeeding. It is important
for the health care or family planning provider to understand the criteria and
the parameters of flexibility of LAM when modifying any aspect of the method.
guidance can health workers give mothers about the use of LAM in areas of high
human immunodeficiency virus (HIV) prevalence?
Women who are HIV+ and who choose to breastfeed can use LAM if they meet the
three eligibility criteria. HIV+ women need to be carefully counseled regarding
their reproductive intentions and the contraceptive methods available to them.
These women and women at risk for HIV infection should be advised to use condoms
in addition to whatever contraceptive method is used. It is important
that HIV+ women be counseled about the benefits and risks of breastfeeding and
other infant feeding options. In fact, some studies indicate that exclusive
breastfeeding may help reduce the risk of passage of HIV to the infant when the
mother is infected. The infant feeding decision is the mother’s to make.
Some general counseling guidelines are:
- Where confidential testing for HIV is not available or used and a mother’s
HIV status is not known, promote exclusive breastfeeding for the first six
months as safer than breastmilk substitutes as these may not be regularly
available, affordable, or safely used. If status is unknown, exclusive
breastfeeding is especially important. Promote use of condoms and teach women
how to avoid exposure to HIV and other sexually transmitted infections. Under
these conditions, if the mother chooses to breastfeed, LAM can be used.
- If a mother knows she is HIV+ and breastmilk substitutes are not
available, not affordable, or cannot be safely used, promote exclusive
breastfeeding (never mixed breastfeeding) for the first six months as safer
than breastmilk substitutes. Promote use of condoms and teach her how to
prevent transmission of HIV to her partner and how to protect herself from
repeated exposure to HIV and other sexually transmitted infections. Under
these conditions, LAM can be used.
- If a mother is HIV negative, promote exclusive breastfeeding for the first
six months as the safest option for infant feeding. Promote use of condoms and
teach her how to avoid exposure to HIV.2
Under these conditions, LAM can be used.
|Encourage your local family planning and health care
providers to include LAM in their programming for its double impact,
supporting both optimal infant feeding and optimal child spacing of three
years or more. Many training curricula, job aids, and other modules are
available to help you include LAM in your program.
For additional information or questions, please contact the LINKAGES
2 FAQ Sheet 1, “Frequently Asked
Questions on: Breastfeeding and HIV/AIDS,” LINKAGES, October 1998.
FAQ Sheet is a publication of LINKAGES: Breastfeeding, LAM, Complementary
Feeding, and Maternal Nutrition Program. LINKAGES is supported by G/PHN/HN, the
United States Agency for International Development (USAID) under the terms of
Grant No. HRN-A-00-97-00007-00 and is managed by the Academy for Educational
Development. The opinions expressed herein are those of the authors and do not
necessarily reflect the views of USAID.