LACTATIONAL AMENORRHEA METHOD (LAM) NATURAL BIRTH CONTROL WHILE BREASTFEEDING Presented by: Heather Eckstein, LLLL

Fertility Cycle Basics  A woman's fertility cycle (menstrual cycle) includes both fertile and non-fertile days.  There are typically 5-7 fertile days each month. During these fertile days, a woman can become pregnant.  There are signs of fertility that signal ovulation, the release of an egg.

Fertility Cycle Basics  Once ovulation has occurred, the egg only lives for hours.  After 24 hours, an unfertilized egg will be absorbed in the fallopian tube.  Sperm can live for up to 5 days in fertile cervical fluid. (Kass-Annese, Danzer 2003; Weschler 2006)

NFP, FAM, and LAM Tracking Changes in Fertility

What is NFP? Natural Family Planning (NFP) is a method of non- hormonal birth control based on the natural changes in fertility that take place in a woman every month. By tracking certain fertility signs, a woman is able to determine which days during her cycle are most fertile and least fertile so that intercourse may be timed accordingly.

What is FAM? Fertility Awareness Method (FAM) is a method of natural birth control that also uses a woman's natural changes in fertility to track fertile and non- fertile days during her cycle. This method involves observing signs of fertility and using a contraceptive method during the fertile cycle days instead of abstinence.

What are fertile signs? During a woman's monthly cycle, there are obvious changes in cervical fluid and resting (basal) body temperature. These changes signal ovulation and allow fertile and non-fertile days to be charted and recorded. Learning to observe signs of fertility involves taking your temperature each morning before rising and noting changes in the type of cervical fluid present throughout your cycle. An NFP or FAM instructor can teach you more about using these signs as a method of natural birth control.

Cervical Fluid Changes  Wet  Stretchy  Slippery  Egg white consistency  Sticky  Pasty  Crumbly Fertile FluidNon-Fertile Fluid

 Fertile cervical fluid is usually described as wet, stretchy, slippery fluid, often compared to the consistency of egg white. Non-fertile fluid can be sticky, pasty, or crumbly.  Some women experience creamy cervical fluid (like lotion) as they near ovulation, just before the wet, slippery, stretchy fluid appears.

What is LAM? LAM is the Lactational Amenorrhea Method, a natural method of birth control that can be used when a mother is breastfeeding. Lactational amenorrhea means no menstruation (amenorrhea) because of breastfeeding (lactation). Exclusively breastfeeding women usually do not begin to ovulate right away after giving birth. This is sometimes referred to as "natural child spacing" and there are many misconceptions surrounding pregnancy when breastfeeding.

Many women mistakenly believe that they cannot become pregnant when they are breastfeeding or that they will not ovulate when breastfeeding. Although ovulation usually occurs before menstruation during a typical fertility cycle, most women experience an anovulatory cycle (no ovulation occurs) before their fertility returns after giving birth. (Eslami 1990)

This means that women usually have some warning before ovulation resumes in the postpartum period. The longer a woman experiences lactational amenorrhea, the greater the chances of ovulating prior to her first period.

The timing of this return to fertility can vary from woman to woman. The earliest return of ovulation using LAM is about 10 weeks after birth and the average return of ovulation is about 14.5 months after birth. (Kass-Annese, Danzer 2003)

LAM is a scientific method of birth control that involves exclusive breastfeeding (sometimes called "ecological breastfeeding") during the first 6 months after giving birth. When LAM is used correctly, pregnancy can be avoided. There are benefits to using LAM and there are strict criteria that must be kept in mind.

Benefits of LAM  Free  Convenient  Non-hormonal  Safe  Effective  Breastfeeding is the best nutrition for baby

Efficacy  Chances of pregnancy 1% when used perfectly  Chances of pregnancy 2% with typical use (Institute for Reproductive Health 1994; Kennedy 2010; Labbok 2007)

Failure (pregnancy) rates are higher when women are not counseled on the criteria for LAM and when women are not meeting the following criteria… (Türk 2010) (ACNM 2012)

LAM Criteria  Breastfeeding must occur at least once every 4 hours during the day  Breastfeeding must occur at least once every 6 hours at night  Woman must not have begun menstruating  Baby must be 6 months of age or younger  No supplements should be given to the baby, no artificial nipples (Institute for Reproductive Health 1994)

Cervical Fluid Patterns during LAM Some of the cervical mucus patterns that may be observed when a woman is breastfeeding:  Dry days throughout duration of breastfeeding.  Days of crumbly, pasty, sticky mucus between dry days.  Occasionally some women may experience wet mucus (usually creamy) between dry days or days of crumbly, pasty, sticky mucus.  Changes in breastfeeding routine may result in changes in mucus pattern. This means that fertility can return at any time.  Days of bleeding are possible and any bleeding should be treated as a return of fertility. (Singh 1993; Bellagio 1995) (Kass-Annese, Danzer 2003)

Will LAM work for you? 1. Have your menses returned? (Defined as 2 consecutive days of bleeding after 8 weeks postpartum or a vaginal bleed that you would consider your period.) 2. Are you supplementing regularly or allowing long periods without breastfeeding either day or night? 3. Is your baby more than 6 months old? If you can answer "no" to all three questions, you have less than a 2% chance of pregnancy. You should ask yourself these questions regularly and if any question is answered "yes", you should begin using another method of contraception. (Mohrbacher 2010)

LAM in Special Situations

Pumping Moms  Pumping moms might have a higher risk of pregnancy when using LAM.  Women using LAM while separated from their baby might increase their risk of pregnancy, even when they are pumping milk and their baby is receiving breastmilk exclusively.  One study showed a 5.2% pregnancy rate in working mothers using LAM. (Valdes 2000)

Change in breastfeeding frequency  A change in breastfeeding frequency can result in a change in fertility.  A sudden decrease in breastfeeding frequency may cause a sudden return of fertility.

Appearance of fertile signs without menstruation  If a breastfeeding mother experiences fertile cervical fluid (wet, stretchy, slippery), she should consider it a return of fertility.

Additional Resources

References American College of Nurse-Midwives (2012). Breastfeeding and Birth Control. Journal of Midwifery & Women’s Health, 57: 209–210. Bellagio, Italy. Press Release, December 14, Family planning method endorsed. Family Health International; World Health Organization; Georgetown University. Institute for Reproductive Health. Eslami SS, Gray RH, Apelo R., Ramos R. The reliability of menses to indicate the return of ovulation in breastfeeding women in Manila, The Philippines. Stud Fam Plann Sep-Oct;21(5): Institute for Reproductive Health. Guidelines: breastfeeding, family planning, and the Lactational Amenorrhea Method-LAM. Washington, DC: Georgetown University, Kass-Annese, B., & Danzer, H. (2003). Natural birth control made simple (7th ed). Alameda, CA: Hunter House Publishers. Kennedy, K.I. (2010). Fertility, sexuality, and contraception during lactation. In J. Riordan & K. Wambach (Eds.), Breastfeeding and human lactation (4th ed., pp ). Boston, MA: Jones and Bartlett. King, J. (2007). Contraception and Lactation. Journal of Midwifery & Women's Health, 52:614–620.

References (cont’d) Labbok, M. H. (2007). Breastfeeding, birth spacing, and family planning. In T. W. Hale & P. F. Hartmann (Eds.), Hale & Hartmann's textbook of human lactation (pp ). Amarillo, TX: Hale Publishing. Mohrbacher, N. (2010). Breastfeeding answers made simple: A guide for helping mothers. Amarillo, TX: Hale Publishing, L.P. Mohrbacher, N. and Stock, J. (2003). BREASTFEEDING ANSWER BOOK, third revised edition. Schaumburg, Illinois: LLLI, 2003; Singh, K. et al. Effects of breastfeeding after resumption of menstruation on waiting time to next conception. Human Bio 1993; 65(1): Türk R, Terzio ğ lu F, Ero ğ lu K. (2010). The use of lactational amenorrhea as a method of family planning in eastern Turkey and influential factors. Journal of Midwifery & Women's Health Jan- Feb;55(1):e1-7. Valdés V., Labbok MH, Pugin E., and Perez A. The efficacy of the lactational amenorrhea method (LAM) among working women. Contraception, 01 Nov 2000; 62(5): Weschler, T. (2006). Taking charge of your fertility: The definitive guide to natural birth control, pregnancy achievement, and reproductive health (Rev. ed.). New York, NY: Collins.