Series L, Number 14
Issues in World Health

CONTENTS

Home (Key Points)

Breastfeeding Gains and Goals
Table 1. Breastfeeding Practices Improving
Web Table 1. Early Initiation of Breastfeeding Over Time
Web Table 2. Exclusive Breastfeeding Over Time
Web Table 3. Breastfeeding at Two Years
Table 2. Breastfeeding Common but Not Usually Optimal
Web Figure 1. Most Infants Breastfed Initially
Web Figure 2. Levels of Breastfeeding Vary Widely

Comprehensive Strategies Needed

Spotlight: Madagascar’s Comprehensive Approach Improves Breastfeeding

Breastfeeding Increases Women’s Contraceptive Options
Table 3. When Breastfeeding Mothers Can Begin a Family Planning Method After Childbirth Compared with Mothers Not Breastfeeding

Centerspread: Breastfeeding Is Best
Figure 1. Better Breastfeeding Reduces Diarrhea

Women with HIV Face Crucial Breastfeeding Decisions
Figure 2. Estimated Risk of HIV Infection in Infants and Young Children

Bibliography

Credits

• Counseling Aid: When Can a Woman Use LAM?
• Counseling Aid: HIV and Infant Feeding Counseling Flow Chart

• Box: Taking Ten Steps to Successful Breastfeeding
• Table: When Breastfeeding Mothers Can Begin a Family Planning Method

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Breastfeeding Increases Women's Contraceptive Options

• Who Can Use LAM?
• Understanding the LAM Criteria
• Can Employed Women Use LAM?
• Making a Transition from LAM
• Other Contraceptive Methods for Breastfeeding Women

LAM has three criteria, all of which must be met if breastfeeding is to provide effective temporary protection from another pregnancy:

1. The mother's menstrual periods have not returned, AND
2. The baby is fully or nearly fully breastfed, and frequently, day and night,AND
3. The baby is less than six months old. (For a discussion, see "Understanding the LAM Criteria".)

When a woman meets all three of these criteria, her risk of pregnancy is less than 2% (112-114, 128, 176, 186, 241, 273). That is, among 100 women using LAM for six months, 1 or 2 would be expected to become pregnant.

After LAM no longer applies, or whenever a nursing mother wishes, she may change to another method of contraception to continue avoiding pregnancy. Various family planning methods provide effective protection from pregnancy and do not affect breastmilk production. A nursing mother can choose from several hormonal and nonhormonal methods, depending on how much time has passed since childbirth.

Who Can Use LAM?

Almost all nursing women can safely and effectively rely on LAM, including adolescents and women over age 40 (265). Health conditions that prevent some women from using other contraceptive methods do not prevent them from using LAM.

The majority of medications are safe while breastfeeding. Women taking a certain few medications should not breastfeed, however, and thus cannot practice LAM. A small amount of whatever a mother ingests is passed to the baby while breastfeeding (170). Medications that breastfeeding mothers should avoid because they would be risky for the baby are mood-altering drugs, certain anticoagulants, high doses of corticosteroids, and a few others (for a complete list see the Breastfeeding and Maternal Medication Recommendations for Drugs in the Eleventh WHO Model List of Essential Drugs) (268).

Maternal care providers and family planning providers can inform and counsel women about breastfeeding, LAM, family planning, and birth spacing. Maternal care providers can counsel women during antenatal visits, immediately postpartum, and during follow-up care in the first weeks and months after childbirth-such as during immunization and growth monitoring visits. Family planning providers can counsel women who intend to become pregnant when the women visit clinics for such services as IUD or contraceptive implant removal, as well as when mothers seek family planning while breastfeeding. Both family planning providers and maternal care providers can advise women on the triple value of optimal breastfeeding- for their child's health, for their own health, and for temporary contraception.

Providers can use a simple checklist to determine whether a woman meets the three criteria necessary to use LAM (see box 'When Can a Woman use LAM?'). Providers can help women understand how best to practice LAM, starting as soon as possible after giving birth, and breastfeeding properly. Providers also can help women plan for a transition from LAM to another contraceptive method when they no longer meet the LAM criteria, or if they no longer want to rely on LAM for contraception.

In addition to offering advice about preventing pregnancy, health care providers can and should counsel women about how to protect themselves from HIV/AIDS and other sexually transmitted infections (STIs). Of all contraceptive methods, only condoms, used consistently and correctly, help protect against HIV/AIDS and other STIs.

Understanding the LAM Criteria

Many women incorrectly believe that any breastfeeding protects them from becoming pregnant (27, 95). In fact, only breastfeeding according to the three LAM criteria provides reliable contraception. Health care providers can help breastfeeding women avoid unintended pregnancies by counseling them about the three LAM criteria, their importance, and the reasons for them:

1. The mother's menstrual periods have not returned. Following childbirth and while breastfeeding, a woman is less likely to ovulate and menstruate. The return of a woman's menses is an important indicator that her postpartum infertility is at an end. It indicates that ovulation has resumed or may soon resume. During the first eight weeks after childbirth, women may experience light bleeding or spotting, but this is not menstrual bleeding. Light bleeding during this time would not prevent a woman from practicing LAM. But if a woman perceives that her menses have returned, or if she has two consecutive days of bleeding, then she can no longer safely rely on LAM for contraception.

2. The baby is fully or nearly fully breastfed, and frequently, day and night. The effectiveness of LAM depends on a pattern of breastfeeding that is full or nearly full breastfeeding and is frequent. Full breastfeeding in this context refers both to exclusive breastfeeding (when the infant receives no other liquid or solid) and to almost-exclusive breastfeeding (when the infant receives vitamins, water, juice, or other nutrients infrequently in addition to breastmilk). Nearly full breastfeeding means that the majority of feedings (more than three-fourths) are breastfeeds.

Women should aim for exclusive breastfeeding and avoid giving their babies regular supplementation. Infants who are fully or nearly fully breastfed suckle the most. Frequent suckling is crucial because the effectiveness of LAM depends on a baby's suckling. As long as additional foods do not decrease the frequency and amount of breastfeeding- and thus suckling-by much, small amounts of supplementation do not lessen the effectiveness of LAM.

Active suckling brings about the biological actions necessary to suppress ovulation. A baby's suckling stimulates the nipple, which gives a signal to the mother's hypothalamus- the region of the brain that secretes hormones. The hypothalamus then releases the hormone prolactin, which stimulates milk production. Prolactin also blocks the release of the gonadotropin-releasing hormone (GnRH), which is one of the hormones that promotes ovulation (146, 220). When the baby's suckling falls below a certain frequency and intensity, GnRH and other hormones that promote ovulation are no longer blocked, and menstrual cycles-and thus fertility-soon resume (147).

Frequent breastfeeding helps mothers obtain the full contraceptive benefits of LAM as well as being key to optimal breastfeeding. An ideal pattern varies with the age of the child-between 10 to 12 feedings a day in the first few weeks after childbirth and thereafter between 8 to 10 times a day or on demand (whenever the baby wants to be fed), including at least once at night in the first months. Breastfeeding sessions during the day should be no longer than four hours apart and at night no longer than six hours apart. Some babies may not want to breastfeed 8 to 10 times a day and may want to sleep through the night. These babies may need gentle encouragement to breastfeed more frequently.

3. The baby is less than six months old. A woman can begin LAM anytime during the first six months after childbirth, as long as she has been fully or nearly fully breastfeeding her baby since birth and her menstrual periods have not returned. This is especially important if she wants to start LAM more than two months after childbirth. After six months of age, when a child starts to get other food, suckling diminishes, and ovulation eventually resumes.

An estimated 10% to 40% of women using LAM resume menstruating before six months postpartum (241). The probability that a woman's menses will return before six months depends on many factors. For instance, menses are likely to return later in women with many children and women who are underweight (272). For some women, LAM can continue to be effective beyond six months if the mother's menses have not returned, and if she can continue to breastfeed frequently and can breastfeed before giving the infant other foods at each meal (47, 207).

Can Employed Women Use LAM?

Women who are able to keep their infants with them at the work site or nearby and are able to breastfeed frequently can rely on LAM as long as they meet the three criteria for LAM. Women who are separated from their infants by work or for other reasons can use LAM if the separation is less than four to five hours at a time.

Pregnancy rates may be higher for women who are separated from their infants, however. The one study that assessed use of LAM among working women estimated a risk of pregnancy of 5% during the first six months postpartum (238). In this study each woman was asked to express her breastmilk while away from her infant-at least as often as the feeding pattern at home and never less than every four hours. Expressing breastmilk may not signal the mother's hypothalamus to stimulate milk production as well as suckling does.

An employed woman may want to use LAM but worry that her job will prevent it. Health care providers can encourage the woman to breastfeed more often when she is with her baby. This may ensure enough suckling to maintain the contraceptive effectiveness of LAM (238). Providers also can advise the woman that full and frequent breastfeeding provides immediate health benefits for the infant whether or not she can practice LAM.

Making a Transition from LAM

Family planning providers can help women make a transition from LAM to another family planning method. Providers can help women make informed choices about other contraception while they still rely on LAM or whenever they want to change from LAM to another method.

Women who use LAM to delay their next pregnancy generally want another form of contraception after LAM in order to continue their protection from pregnancy. For example, in a 2004 study in Amman, Jordan, 41% of previous LAM users had made a transition to using an IUD, oral contraceptives, or condoms by 12 months postpartum. In contrast, 23% of women who breastfed but were not practicing LAM had adopted one of these methods (27).

Other Contraceptive Methods for Breastfeeding Women

A breastfeeding woman has other contraceptive options besides LAM. These include both nonhormonal and hormonal methods. Her options depend on how much time has passed since childbirth (see Table 3).

Table 3. When Breastfeeding Mothers Can Begin a Family Planning Method After Childbirth, Compared with Mothers Not Breastfeeding
Family Planning Method	Breastfeeding	Not Breastfeeding
Lactational amenorrhea method (LAM)	Immediately	Not applicable
Vasectomy Condoms Spermicides	Immediately	Immediately
Copper IUD	Within 48 hours; otherwise delay 6 weeks	Within 48 hours; otherwise delay 4 weeks
LNG-IUD	Within 7 days; otherwise delay 6 weeks	Within 7 days; otherwise delay 6 weeks
Female Sterilization	Delay 4 weeks	Delay 4 weeks
Fertility awareness-based methods*	Delay until menses return	Delay 4 weeks
Diaphragm	Delay 6 weeks	Delay 6 weeks
Progestin-only oral contraceptives Progestin-only injectables Progestin-only vaginal rings Implants	Delay 6 weeks	Immediately
Combined oral contraceptives Combined injectables Contraceptive patch Combined vaginal rings	Delay 6 months	Delay 3 weeks
*The Standard Days Method of fertility awareness-based family planning should be delayed until a woman's regular menstrual cycle resumes and she has had three postpartum menses. The traditional calendar rhythm method should be delayed until a woman's regular menstrual cycles resume and she has had six postpartum menses to gauge the length of her cycle. Source: WHO 2004 (265)

Nonhormonal methods do not affect breastfeeding or breastmilk. Nonhormonal methods for breastfeeding women or their partners include condoms, spermicides, the diaphragm, copper IUDs, and some fertility awareness-based methods, as well as the permanent methods, female and male sterilization. Women can begin these methods almost immediately after childbirth, with the exception of the diaphragm and fertility awareness-based methods.

Experts recommend delaying use of the diaphragm until at least six weeks, when the woman's uterus has returned to normal size and the diaphragm can be fitted (265). Couples can learn to use fertility awareness-based methods, but, to practice them effectively, they should delay use until six weeks after childbirth or until menstruation resumes depending on the method. This delay is necessary because fertility-based methods either track the signs of fertility or monitor days in the cycle. The signs of fertility may be misleading if a woman is not having menstrual cycles (265).

Also, if the copper IUD is not inserted immediately after childbirth, insertion should be delayed until four weeks postpartum (265). IUD insertion within 48 hours after delivery is safe and convenient. There is a greater chance, however, that the IUD will be expelled as contractions return the uterus to normal size (226). Similarly, if tubal ligation is not performed within one week after childbirth, it should be delayed for six weeks, until the uterus has contracted (265). Tubal ligation is commonly performed soon after childbirth; IUD insertion immediately postpartum is less common. Both postpartum procedures require training in special techniques (44, 226).

Hormonal methods that contain only a progestin are appropriate as early as six weeks after childbirth. By that time breastfeeding is well established (265). Progestin-only contraceptives include certain oral contraceptives, injectables, vaginal rings, implants, and the LNG-IUD. Before six weeks small amounts of the hormone would be passed to the newborns, who cannot metabolize steroids at that age (18, 25, 61). When the hormones are taken at six weeks or later, the small amounts in breastmilk do not appear to harm an infant's growth or affect the quantity and quality of breastmilk (227).

Six months after childbirth, a breastfeeding woman also can safely use combined hormonal methods, which contain an estrogen as well as a progestin. These include combined oral contraceptives, combined injectables, the contraceptive patch, and combined vaginal rings. By six months, the effect that these methods might have on the quantity and quality of breastmilk, if any, is small (194). Use of these methods between six weeks and six months is usually not recommended unless other, more appropriate methods are not available or not acceptable (265).