Lactational Amenorrhea Method (LAM) Who Can and Cannot Use LAM Session II: Who Can and Cannot Use LAM

LAM Eligibility Criteria The woman’s menstrual bleeding has not returned; AND She fully or nearly fully breastfeeds her baby; AND The baby is less than six months old. Use slide 2 to review eligibility criteria. The woman’s menstrual bleeding has not returned; AND She fully or nearly fully breastfeeds her baby; AND The baby is less than six months old.

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. 1. The woman’s menstrual bleeding has not returned (“amenorrhea”). Bleeding within two months postpartum is not considered menstruation. It is considered lochial discharge and would not disqualify a woman from using LAM. However, any bleeding after two months postpartum should be considered the return of menses and thus the client should start using another modern method immediately. If any bleeding (after two months) is considered menstrual bleeding: it can increase the effectiveness of LAM because this reduces or eliminates the probability that a true but scanty menstruation will be ignored. Some women experience a bleeding episode before ovulation returns (pre-ovulatory bleeding). This is a sign that the endometrium was hormonally stimulated by the ovary without ovulation occurring. However, the woman has no way of knowing whether or not ovulation took place, so such a bleeding episode must be considered a sign of the return of fertility. Remember: bleeding before two months postpartum is NOT considered menstruation.

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. She fully/or nearly fully breastfeeds her baby. Fully breastfeeding or exclusive breastfeeding means the infant receives no other liquid or food in addition to breast milk. It means no milk substitutes, pap, herbal tea—all are considered food/liquids. Nearly fully breastfeeding means that the infant receives some liquid or food in addition to breast milk, but the majority of feedings (more than three fourths of all feeds) are breast milk. Breastfeeding should be “on demand” (not scheduled). (Babies who are fully or exclusively breastfed tend to breastfeed more frequently than every four hours.) The baby should go no longer than four hours during the day and six hours during the night between feeds. Mechanical or hand pumping does NOT appropriately stimulate the nipples. Breastfeeding should begin as soon as possible after birth (preferably within the first hour); it can even begin before the placenta is expelled. Breastfeeding includes feeding of colostrum. Colostrum is important to the newborn for immunity and to help “clean” its intestines. It is important that the woman continues to fully or nearly fully breastfeed so that she doesn’t ovulate and her menses does not return.

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. The baby is less than six months old. Up until six months of age, breast milk is the best and only nutrition needed by the baby. This is supported by evidence and recommended by WHO. When the baby turns six months old, s/he should begin receiving supplemental foods, so suckling will decrease and the mother’s fertility will return. Remember: continue to breastfeed beyond LAM and until baby is two years old.

Medical Eligibility Criteria What are medical eligibility criteria? Define the categories. Review the job aid. Demonstrate how to use the WHO MEC Wheel. Explain that implants are safe for the overwhelming majority of women. Use slides 7-8 to provide an overview of the medical eligibility criteria for implants. This activity has two purposes: To give participants an opportunity to share what they know about the eligibility criteria used in their national FP guidelines or the WHO medical eligibility criteria (WHO MEC) so that the facilitator can determine whether the participants understand the criteria and how they are used or whether they need additional background information before proceeding. To introduce job aids that help participants understand eligibility criteria (and that they may also use at their worksites), such as the WHO Medical Eligibility Criteria Wheel for Contraceptive Use, or the Quick Reference Chart for the WHO Medical Eligibility Criteria for Contraceptive Use.

With clinical judgment WHO’s Medical Eligibility Criteria with Clinical Judgment Category Description With clinical judgment 1 No restriction for use Use the method under any circumstances 2 Benefits generally outweigh risks Generally use the method 3 Risks usually outweigh benefits Use of method not usually recommended, unless other methods are not available/acceptable 4 Unacceptable health risk Method not to be used Category 1: For women with these conditions or characteristics, the method presents no risk and can be used without restrictions. Category 2: For women with these conditions or characteristics, the benefits of using the method generally outweigh the theoretical or proven risks. Women with Category 2 conditions generally can use the method, but careful follow-up may be required. For women with category 2 conditions, the advantages of using this method outweigh the theoretical or proven risks. Category 3: For women with these conditions or characteristics, the theoretical or proven risks of using the method usually outweigh the benefits. Women with Category 3 conditions generally should not use the method. However, if no better options for contraception are available or acceptable, the provider may judge that the method is appropriate, depending on the severity of the condition. In such cases, ongoing access to clinical services and careful follow-up will be required. Category 4: For women with these conditions or characteristics, the method presents an unacceptable health risk and should not be used. Source: WHO, 2015.

When clinical judgment is limited WHO’s Medical Eligibility Criteria in Settings Where Clinical Judgment is Limited Category When clinical judgment is limited 1 Use the method 2 3 Do not use the method 4 According to WHO, in settings where clinical judgment is limited, category 2 conditions should be treated in the same manner as category 1 conditions. This means that women with category 1 and category 2 conditions should be able to obtain and use the method. Source: WHO, 2015.

LAM is safe for all women. Category 1 Who Can Start LAM LAM is safe for all women. WHO Category Conditions Category 1 All conditions listed in MEC fall into category 1 for LAM For LAM, all the conditions that are presented in the MEC are considered category 1. Therefore, LAM as a contraceptive method is a safe choice for most women and can be used without restrictions by women with the LAM category 1 conditions. In certain situations, however, the provider would need to consider whether or not breastfeeding as a method of infant feeding is recommended with certain conditions or with the drugs used to treat certain conditions. Source: WHO, 2015.