LINKAGES has identified key peer-reviewed journal articles on LAM research findings. Their citations and abstracts are listed below in chronologically descending order by the following categories:

• Efficacy and effectiveness (17 articles)
• Policy (5 articles)
• Program (3 articles)

For the citations only, click here. To request an article in its entirety, please contact the specific journal or as otherwise directed.

Peterson AE, Perez-Escamilla R, Labbok MH, Hight V, von Hertzen H, Van Look P. 2000. Multicenter study of the lactational amenorrhea method (LAM) III: Effectiveness, duration, and satisfaction with reduced client-provider contact. Contraception 62, no. 5: 221-30.

The objective of this effort was to assess the use and efficacy of the lactational amenorrhea method (LAM) with reduced numbers of client-provider contacts. A co-sponsored multi-center study of LAM was performed to test the efficacy and acceptability of the method under "post-marketing" conditions, with investigator-initiated contact occurring only twice: at the time of intake and then again at 7 months postpartum. These data are assumed to provide an assessment of LAM's use, efficacy, and performance that more closely reflects the prevailing conditions of these populations during normal use. Three hundred and sixty-two subjects were recruited through centers that had participated in the previous, more contact-intensive studies. Using a cooperatively developed protocol, data were gathered prospectively on at least 10 and up to 50 LAM acceptors at 9 sites and entered and cleaned on site. Data were further cleaned and analyzed at the Georgetown University Institute for Reproductive Health (IRH) and the Department of Nutrition at the University of Connecticut. From country-level and pooled data, descriptive statistics and life tables were produced. LAM efficacy in this sample is 100% because none of the participating sites recorded pregnancies. Satisfaction with the method was high, and the rate of continuation to another method after LAM was 66.7% at 7 months postpartum. Of the women who had never used family planning prior to LAM, 63.0% went on to use another method in a timely manner. LAM can be highly effective as an introductory postpartum family planning method when offered in a variety of cultures, health care settings, and industrial and developing country locales. Under conditions of limited client-provider contact, LAM remains effective and leads to acceptance of another method by about two-thirds of the acceptors. Women are able to use LAM effectively without extensive counseling or follow up and with a high level of user satisfaction.

Valdes V, Labbok MH, Pugin E, Perez A. 2000. The efficacy of the lactational amenorrhea method (LAM) among working women. Contraception 62, no. 5: 217-9.

The purpose of this study was to assess the efficacy of the lactational amenorrhea method (LAM) for family planning among mothers who are separated from their infants by work. The study population, 170 urban middle class women who planned to return to work before 120 days postpartum, were interviewed monthly for 6 months postpartum and contacted at 12 months. The study population received clinical support for expressing their milk, exclusively breastmilk feeding the infants, and using LAM for birth spacing. The cumulative life table pregnancy rate by month 6 was 5.2%, with 3 pregnancies, one at each of months 4, 5, and 6. LAM for working women, as described in this article, might be associated with a higher pregnancy risk than LAM use among non-working women. Therefore, women using LAM should be informed that separation from the infant might increase the risk of pregnancy.

Tommaselli GA, Guida M, Palomba S, Barbato M, Nappi C. 2000. Using complete breastfeeding and lactational amenorrhoea as birth spacing methods. Contraception 61, no. 4: 253-7.

The aim of this study was to evaluate the effectiveness of lactational amenorrhoea and to determine the relationship between extended breastfeeding and the return of fertility. Breastfeeding pattern, basal body temperature, cervical mucus, salivary ferning, vaginal blood discharge, frequency of sexual intercourse, and the presence of ovulation in the first cycle after the resumption of menses with ultrasonography were evaluated in 40 women. All subjects completed the study with only one case of incomplete breastfeeding. No pregnancies were observed. The mean number of feeding sessions and mean interval between sessions decreased significantly (p <0.01) during the first 6 months postpartum (7.5 +/- 1.3 after 60 days postpartum vs. 5.7 +/- 2.1 after 180 days, and 3.6 +/- 0.8 vs. 5.1 +/- 0.9, respectively). Eight women (20%) menstruated before weaning, but none had an adequate thermal shift, while 32 (80%) had their first vaginal bleeding after weaning with 12 (37.5%) registering an adequate thermal shift. Both basal body temperature and salivary ferning proved to be suggestive of ovarian activity, while mucus characteristics were not reliable in identifying fertile periods. The study showed that breastfeeding associated with lactational amenorrhoea proved to be a good method of postpartum fertility control. Because the importance of supplementation is still debated, a "complete" breastfeeding program is recommended.

World Health Organization Task Force on Methods for the Natural Regulation of Fertility. 1999. The World Health Organization multinational study of breast-feeding and lactational amenorrhea IV. Postpartum bleeding and lochia in breast-feeding women. Fertil Steril 72, no. 3: 441-7.

OBJECTIVE: To describe and compare the duration of lochia in seven groups of women, to investigate the occurrence of a possible "end-of-puerperium" bleeding episode, and to determine the frequency of bleeding episodes before postpartum day 56, which applies to the practice of the lactational amenorrhea method of contraception. DESIGN: Prospective longitudinal study with fortnightly follow up, beginning within 7 days of delivery. SETTING: Five developing and two developed countries. PATIENT(S): Four thousand one hundred and eighteen breastfeeding women. INTERVENTION(S): Postpartum lochia and all days of bleeding per vaginam were recorded. MAIN OUTCOME MEASURE(S): Duration of lochia, frequency of an end-of-puerperium bleeding episode, and frequency of post-lochia bleeding episodes within 56 days of delivery. RESULT(S): The median duration of lochia was 27 days, varying significantly among the centers (range, 22-34 days). In 11% of the women, lochia lasted 40 days. An end-of-puerperium bleeding episode around the 40th day postpartum was reported by 20.3% of the women. Bleeding within 56 days of delivery (separated from lochia by at least 14 days) occurred in 11.3% of the women and usually was followed by a confirmatory bleeding episode 21-70 days later. CONCLUSION(S): The duration of lochia varied significantly among the study populations, and long durations were not unusual. The significance of the end-of-puerperium bleeding episode is unknown. Most users of the lactational amenorrhea method will not experience a postlochia bleeding episode before postpartum day 56.

World Health Organization Task Force on Methods for the Natural Regulation of Fertility. 1999. The World Health Organization multinational study of breastfeeding and lactational amenorrhea III. Pregnancy during breast-feeding. Fertil Steril 72, no. 3: 431-40.

OBJECTIVE: To determine the risk of pregnancy during lactational amenorrhea relative to infant feeding status. DESIGN: Prospective longitudinal study. SETTING: Five developing and two developed countries. PATIENT(S): Four thousand one hundred eighteen breast-feeding mother-infant pairs. INTERVENTION(S): Infant feeding practices, menstrual status, and pregnancy were measured. MAIN OUTCOME MEASURE(S): Life-table rates of pregnancy. RESULT(S): In the first 6 months after childbirth, cumulative pregnancy rates during amenorrhea, depending on how the end of amenorrhea was defined, ranged from 0.9% (95% confidence interval [CI] = 0%-2%) to 1.2% (95% CI = 0%-2.4%) during full breast-feeding, and from 0.7% (95% CI = 0.1%-1.3%) to 0.8% (95% CI = 0.2%-1.4%) up to the end of partial breast-feeding. At 12 months, the rates ranged from 6.6% (95% CI = 1.9%-11.2%) to 7.4% (95% CI = 2.5%-12.3%) during full breastfeeding, and from 3.7% (95% CI = 1.9%-5.5%) to 5.2% (95% CI = 3.1%-7.4%) up to the end of partial breast-feeding. CONCLUSION(S): These results support the Bellagio Consensus on the use of lactational amenorrhea for family planning, and confirm that the lactational amenorrhea method is a viable approach to postpartum contraception.

Prieto CR, Cardenas H, Croxatto HB. 1999. Variability of breast sucking, associated milk transfer and the duration of lactational amenorrhoea. J Reprod Fertil 115, no. 2: 193-200.

Quantitative relationships between physical parameters of sucking, milk transfer and the duration of amenorrhoea were examined in normal mother-baby pairs under exclusive breastfeeding. Sucking pressures were recorded twice on the second and once on the fifth month after birth, during complete breastfeeding episodes, by means of a catheter attached to the nipple and connected to a pressure transducer, the signals of which were analyzed by computer. Babies were weighed before and after each sucking episode to estimate milk transfer. In the first nursing episode after noon, 2-month-old babies sucked from 140 to 800 times during 4-15 min from the first breast, obtaining from 20 to 100 g milk. The physical parameters of sucking and milk transfer exhibited high inter-individual but low intra-individual variabilities. There were significant differences in the physical parameters of sucking and milk transfer efficiency between first and second breast and between the second and fifth months after birth. Milk transfer efficiency was inversely correlated with time occupied by non-sucking pauses or = 1.5 s, and was directly correlated with mean intersuck intervals in the first breast and with duration of the sucking episode, number of sucks, mean pressure and area under the pressure curve in the second breast. There was no correlation between the physical parameters of sucking and duration of lactational amenorrhoea (n = 62). However, amenorrhea lasted 180 days among significantly more mothers whose babies spent a longer proportion of the nursing episode in non-sucking pauses or = 1.5 s. This finding indicates that sensory stimulation of the nipple produced during a nursing episode by stimuli other than sucking itself may have an important role in sustaining lactational amenorrhoea. The conclusion is that nursing episodes have a complex structure that allows the development of a breastfeeding phenotype in each mother-baby pair, exhibiting important inter-individual variability. The present analysis does not support the contention that this source of variability accounts for the variability in the duration of lactational amenorrhoea.

World Health Organization Task Force on Methods for the Natural Regulation of Fertility. 1998. The World Health Organization multinational study of breast-feeding and lactational amenorrhea II. Factors associated with the length of amenorrhea. Fertil Steril 70, no. 3: 461-71.

OBJECTIVE: To determine the relation between infant feeding practices (and other factors) and the duration of postpartum amenorrhea and to establish whether there are real differences in the duration of postpartum amenorrhea for similar breastfeeding practices in different populations. DESIGN: Prospective, nonexperimental, longitudinal follow-up study. SETTING: Five developing and two developed countries. PATIENT(S): Four thousand one hundred eighteen breast-feeding mothers and their infants. INTERVENTION(S): Breastfeeding women collected ongoing information about infant feeding and family planning practices, plus the return of menses. Fortnightly follow up occurred in the women's homes. MAIN OUTCOME MEASURE(S): A multivariate analysis explored the association between the risk of menses return and 16 infant feeding variables and 11 other characteristics. RESULT(S): Ten factors (in addition to center effects) were significantly related to the duration of amenorrhea. Seven of these were infant feeding characteristics and the remaining three were high parity, low body mass index, and a higher frequency of infant illness. CONCLUSION(S): The breastfeeding stimulus is strongly linked to the duration of postpartum amenorrhea. Cross-cultural effects also are extremely important and may have caused the variations in feeding, the variation in amenorrhea, or both.

World Health Organization Task Force on Methods for the Natural Regulation of Fertility. 1998. The World Health Organization multinational study of breastfeeding and lactational amenorrhea I. Description of infant feeding patterns and of the return of menses. Fertil Steril 70, no. 3: 448-60.

OBJECTIVE: To detect differences between populations in both infant feeding practices and the duration of lactational amenorrhea, if they exist. DESIGN: Prospective, nonexperimental, longitudinal follow-up study. SETTING: Five developing and two developed countries. PATIENT(S): Four thousand one hundred eighteen breast-feeding mothers and their infants. INTERVENTION(S): Breastfeeding women collected ongoing information about infant feeding and family planning practices, plus the return of menses. Fortnightly follow-up occurred in the women's homes. MAIN OUTCOME MEASURE(S): Breast-feeding frequency by day (and by night); 24-hour breast-feeding duration, percent of all infant feedings that were milk/milk-based (and solid/semisolid foods); time until the end of full breastfeeding; time until regular supplementation; and time until the end of lactational amenorrhea. RESULT(S): Differences between the centers in the duration of amenorrhea were substantial, ranging from a median of 4 months in New Delhi (India) to 9 months in Chengdu (China). Women in developed countries (but also women in Chengdu) were more likely to delay supplementation (for up to 5 months), whereas women in Santiago (Chile), Guatemala City (Guatemala), and Sagamu (Nigeria) started supplements much earlier, sometimes as early as 1 week after birth. CONCLUSION(S): Both breastfeeding behavior and the duration of lactational amenorrhea vary markedly across settings, indicating that breastfeeding promotion and family planning advice should be site- and culture-specific.

Hardy E, Santos LC, Osis MJ, Carvalho G, Cecatti JG, Faundes A. 1998. Contraceptive use and pregnancy before and after introducing lactational amenorrhea (LAM) in a postpartum program. Adv Contracept 1998 14, 1: 59-68.

There is good evidence that lactational amenorrhea (LAM) is an effective method of fertility regulation during the first 6 months postpartum, provided no other food is given to the baby and the mother remains amenorrheic. However, although breastfeeding is strongly promoted in many maternity hospitals that also run postpartum family planning programs, LAM is rarely included among the contraceptive options offered. This paper presents the results of an operational study that compared the prevalence of contraceptive use and the cumulative pregnancy rate at 12 months postpartum among 350 women observed before and 348 women studied after introducing LAM as an alternative contraceptive option offered to women following delivery at the Instituto Materno Infantil de Pernambuco (IMIP) in Recife, Brazil. The percentage of women not using any contraceptive method was significantly lower (p<0.0001) after the intervention (7.4%) than before (17.7%). This difference remained statistically significant after controlling for age, number of living children, marital status and years of schooling. The proportion pregnant one year postpartum was also significantly lower (p<0.0001) after the introduction of LAM (7.4%) than before (14.3%), but the difference was no longer significant after controlling for the same variables. The study concludes that LAM is a useful addition to family planning postpartum programs.

Hight-Laukaran V, Labbok MH, Peterson AE, Fletcher V, von Hertzen H, Van Look PF. 1997. Multicenter study of the lactational amenorrhea method (LAM): II. Acceptability, utility, and policy implications. Contraception 55, no. 6: 337-46.

A multicenter study of the lactational amenorrhea method (LAM) was carried out to determine acceptability, satisfaction, and utilization in 10 different populations, and to confirm the efficacy of the method. Efficacy data are presented in a companion paper. A protocol was designed at the Institute for Reproductive Health (IRH), Department of Obstetrics and Gynecology, Georgetown University Medical Center, and reviewed and modified in collaboration with the co-sponsors, the World Health Organization, the South-to-South Cooperation for Reproductive Health, and the principal investigators from each site. Data were gathered prospectively on LAM users at 11 sites. Data were entered and cleaned on site and further cleaned and analyzed at IRH, using country-level and pooled data to produce descriptive statistics. The overall satisfaction with LAM was 83.6%, and continuation with another method of family planning was shown to be 67.6% at 9 months postpartum, in most cases exceeding previous use of contraception prior to use of LAM. Knowledge and understanding of the method at discontinuation were high, ranging from 78.4% to 88.6% for the three criteria. LAM can be used with a high level of satisfaction and success by women in a variety of cultures, health care settings, socio-economic strata, and industrial and developing country settings. The results confirm that LAM is acceptable and ready for widespread use, and should be included in the range of services available in maternal and child health, family planning, and other primary health care settings.

Labbok MH, Hight-Laukaran V, Peterson AE, Fletcher V, von Hertzen H, Van Look PF. 1997. Multicenter study of the lactational amenorrhea method (LAM): I. Efficacy, duration, and implications for clinical application. Contraception 55, no. 6: 327-36.

A multicenter study of the lactational amenorrhea method (LAM) was carried out to test the acceptability and efficacy of the method. The data are also used to test new constructs for improving method criteria. A protocol was designed at the Institute for Reproductive Health (IRH), Department of Obstetrics and Gynecology, Georgetown University Medical Center, a World Health Organization (WHO) Collaborating Center, and reviewed and modified in collaboration with the co-sponsors, the World Health Organization and the South to South Cooperation for Reproductive Health, and the principal investigators from each site. Data were gathered prospectively on LAM acceptors at 11 sites. Data were entered and cleaned on site and further cleaned and analyzed at IRH, using country-level and pooled data to produce descriptive statistics and life tables. The 98+% efficacy of LAM is confirmed in a wide variety of settings. Moreover, the results yield insight on the possibility of continued use beyond 6 months. LAM is found to be highly effective as an introductory postpartum method when offered in a variety of cultures, health care settings, socio-economic strata, and industrial and developing country locales. In addition, LAM acceptance complements breastfeeding behaviors without ongoing breastfeeding support services. The parameters studied yield high efficacy and method continuation. The results confirm the basic tenets of the 1995 Bellagio consensus on LAM. It is recommended that LAM be reconfirmed and incorporated into hospital, maternity, family planning, maternal and child health, and other primary health care settings.

Ramos R, Kennedy KI, Visness CM. 1996. Effectiveness of lactational amenorrhoea in prevention of pregnancy in Manila, the Philippines: Non-comparative prospective trail. BMJ 313, no. 7062: 909-12. Full-text available free online at http://bmj.com/cgi/content/full/313/7062/909?view=full&pmid=8876092

OBJECTIVE: To determine the contraceptive efficacy of the lactational amenorrhoea method (LAM). DESIGN: Non-comparative prospective trial. SETTING: Urban Manila, the Philippines. SUBJECTS: 485 lower income, educated women with extensive experience of breast feeding. INTERVENTION: Women were offered all available contraceptives for use after birth. Those who chose LAM were taught the method, screened for the study, and followed for 12 months to determine the risk of pregnancy when the method was used. MAIN OUTCOME MEASURES: Life table pregnancy rates during correct and incorrect use of the method, censored monthly in the event of sexual abstinence or the use of another contraceptive method. RESULTS: LAM was 99% effective when used correctly (that is, during lactational amenorrhoea and full or nearly full breast feeding for up to six months). At 12 months the effectiveness during amenorrhoea dropped to 97%. CONCLUSIONS: The lactational amenorrhoea method provided as much protection from pregnancy as non-breastfeeding women experience with non-medicated intrauterine devices and barrier methods. The contraceptive effect of lactation cannot be attributed to lactational or postpartum abstinence.

Cooney KA, Nyirabukeye T, Labbok MH, Hoser PH, Ballard E. 1996. An assessment of the nine-month lactational amenorrhea method (MAMA-9) in Rwanda. Stud Fam Plann 27, no. 3: 102-71.

This report presents a secondary data analysis based on prospectively collected records gathered during a field assessment carried out in Rwanda in August 1993. The assessment used service statistics and follow-up interviews to evaluate the efficacy of a modified lactational amenorrhea method (LAM) as a 9-month introductory postpartum natural family planning method. The program, carried out by Action Familiale Rwandaise (AFR), reflects high efficacy of the method in a compliant sample that sought this method followed by another form of family planning. These results are promising and provide guidance for the extended use of LAM past 6 months. Programmatic findings suggest that studies be conducted of the contribution of extended LAM to improved weaning practices, the high efficacy of continued reliance on substantial lactation and amenorrhea beyond 9 months, and male involvement in LAM and breastfeeding.

Kazi A, Kennedy KI, Visness CM, Khan T. 1995. Effectiveness of the lactational amenorrhea method in Pakistan. Fertil Steril 64, no. 4: 717-23.

OBJECTIVE: To determine the efficacy of the lactational amenorrhea method of family planning (amenorrhea during full or nearly full breastfeeding for 6 months postpartum). DESIGN: Prospective non-comparative study. SETTING: Normal breastfeeding women in Karachi and Multan, Pakistan, most delivered at home by a midwife. PATIENTS: Three hundred ninety-nine newly delivered mothers who successfully had breastfed previous children and chose the lactational amenorrhea method to prevent a subsequent pregnancy, 391 of whom were followed for a full year. INTERVENTIONS: Mothers were taught before or shortly after delivery to use the method and were interviewed in their homes each month by a lady health visitor. MAIN OUTCOME MEASURE: Life-table pregnancy rates. Periods of postpartum or lactational abstinence were excluded in the calculation of the pregnancy rates. RESULTS: During full or nearly full breastfeeding, while the women were amenorrheic and not otherwise contracepting, the rate of pregnancy was 0.6%. The pregnancy rate during lactational amenorrhea alone was 1.1% at 1 year postpartum. CONCLUSION: The lactational amenorrhea method was found to be highly effective for 6 months. A high degree of contraceptive protection endures for a full year during lactational amenorrhea, but not after the return of menses during breastfeeding.

Weis P. 1993. The contraceptive potential of breastfeeding in Bangladesh. Stud Fam Plann 24, no. 2: 100-8.

A consensus statement issued by the World Health Organization and the United Nations Children's Fund at the Bellagio conference in 1988 recommended that women begin practicing contraception 6 months after childbirth or when their menstrual cycle resumes, whichever occurs first. The question to be resolved is whether this approach, known as the Bellagio mixed-t strategy, should be adjusted to local patterns of lactational amenorrhea. Data from interviews with 4,580 Bangladeshi women with a currently open birth interval were analyzed with respect to the women's current status of breastfeeding, amenorrhea, contraception, and pregnancy. Pregnancies among breastfeeding, amenorrheic women occurred only beyond 12 months postpartum, while some menstruating women were observed to be pregnant from 3 months postpartum onward. The results of this study provide evidence that the Bellagio recommendation can be best applied with country-specific adjustments. Bangladesh, for example, could safely adopt a strategy with a 12-month cutoff point.

Perez A. 1981. Natural family planning: Postpartum period. Int J Fertil 26, no. 3: 219-21.

The length of the postpartum anovulatory period was studied in 200 mothers by means of endometrial biopsy, basal body temperature, vaginal cytology, and cervical mucus. The occurrence of the first ovulation and the first bleeding after childbirth are analyzed in relation to the type of nursing. The characteristics of 408 postpartum menstrual cycles are studied using the same methodology. The shortest anovulatory period for non-nursing mothers was 36 days; for partial nursing mothers, 40 days; and for full nursing mothers, 70 days. The first postpartum bleeding appeared to be preceded by ovulation in 41% of the full nursing mothers, 75% of partial nursing mothers, and 91% of non-nursing mothers. Postpartum cycles were significantly longer and showed a luteal phase significantly shorter than control cycles, especially when the mother was fully nursing.

Van Ginneken JK. 1974. Prolonged breastfeeding as a birth spacing method. Stud Fam Plann 5, no. 6:201-6.

Most mothers in developing countries start nursing their babies after birth and continue for 1-2 years. One reasons that nursing is common and prolonged in developing countries is the widespread belief that it effectively postpones the next conception. This paper summarizes findings in recent investigations on the fertility reducing effect of breastfeeding. These studies fall into two groups: those that determine the effect of lactation on pregnancy and birth intervals and those that focus on the impact of lactation on the resumption of ovulation and menstruation.

Kennedy KI, Kotelchuck M. 1998. Policy considerations for the introduction and promotion of the lactational amenorrhea method: Advantages and disadvantages of LAM. J Hum Lact 14, no. 3: 191-203.

Some attributes of LAM are unquestionably positive, such as its effectiveness. Clinical trials of LAM have upheld the Bellagio consensus that the chance of pregnancy is less than 2% in the first 6 months postpartum in amenorrheic women who are fully or nearly fully breastfeeding. Secondary data analyses in numerous settings have drawn the same conclusion. Whether as a strategy or a method, used correctly or even if used imperfectly, LAM is a reliable way to avoid pregnancy. To the extent that LAM represents an additional contraceptive option, this is also clearly positive because a broad array of contraceptive options maximizes the likelihood of finding a good fit between user and method and increases contraceptive use. Other characteristics of LAM represent potentially positive impacts. If LAM is shown to be an effective conduit to other modern methods, the implications are profoundly positive. If LAM is cost effective for households and/or programs, the method will be extraordinarily attractive. Conversely, LAM's negative aspects include the fact that it affords no protection against STDs and requires counseling from a well-informed provider, and that intensive breastfeeding can make heavy demands on women's time. Many of the remaining attributes of LAM may not be important to a policy decision about LAM promotion. For example, whether LAM is actualized as a strategy or a method may not be important to a decision to promote LAM, although it has a huge impact on how services are delivered. Some factors may be profound on a local or individual level. For example, one simple factor, such as the absence of full or nearly full breastfeeding, can rule out the method as an option, while another, such as the fact that it provides the needed waiting period during vasectomy counseling, can make LAM the method of choice. Although widespread popularity of LAM seems unlikely in societies such as the United States, such settings contain breastfeeding women for whom other contraceptive choices are unsatisfactory and LAM is attractive. Although clinicians cannot be expected to provide LAM education directly in every setting, women should be informed about LAM as an effective contraceptive choice, and clinicians should be prepared to make referrals to competent sources. The future of LAM, especially in terms of formal, programmatic initiatives, may continue to focus on transitional and less developed settings. Comparative cost/benefit analyses for both the family planning program and the household will contribute meaningfully to decisions about using LAM and including it in national and local family planning policies and programs. The most important call to action is to implement operations research to determine what factors, if any, will maximize the uptake of a second modern contraceptive method after LAM protection expires among never-users of family planning, to compare this with other contraceptive strategies, and to evaluate the cost aspects. If LAM's potential to be a conduit to other modern contraceptive methods is effectively realized, the method can be profoundly important in the development of communities and in family formation. Because LAM effectively prevents pregnancies and extends the range of contraceptive choices, it is always appropriate to consider it on the policy level. Despite the array of drawbacks, as with any other family planning method, LAM's potential assets, especially the promise to introduce non-users to contraception, are sufficiently important to warrant introducting the method in an operations research framework to both capitalize on its intrinsic strengths and determine its programmatic robustness. In the 10 years since the concept of LAM was pronounced as the Bellagio consensus, claims have been made both for and against its use.

Kennedy KI, Labbok MH, Van Look PF. 1996. Lactational amenorrhea method for family planning. Int J Gynaecol Obstet 54, no. 1: 55-7. Full-text versions in English, French, and Spanish are available.

While breastfeeding has long been known to delay the return of fertility, until recently the conditions under which women could reliably take advantage of this phenomenon were not clear. In 1988 scientists meeting in Bellagio, Italy, proposed how postpartum women could use lactational amenorrhea as a family planning method. From research reviewed at that meeting, they concluded that women who are not using family planning but are fully or nearly fully breastfeeding and amenorrheic are likely to experience a risk of pregnancy of less than 2% in the first 6 months after delivery. (Consensus Statement: Breastfeeding as a Family Planning Method, Lancet, 19 November 1988). This conclusion came to be known as the Bellagio consensus. After the 1988 consensus meeting, several studies were designed expressly to test this consensus. To review the results of these studies as well as other relevant research, the experts gathered at Bellagio in 1995. They concluded that the Bellagio consensus clearly has been confirmed. Statement was also published in the Journal of Nurse-Midwifery. 1996 Sept/Oct; 41(5):405-6 and is available on Family Health International's Web site http://www.fhi/org/en/gen/lamstat.html.

Labbok MH, Perez A, Valdes V, Sevilla F, Wade K, Laukaran VH, Cooney KA, Coly S, Sanders C, Queenan JT. 1994. The lactational amenorrhea method (LAM): A postpartum introductory family planning method with policy and program implications. Adv Contracept 10, no. 2: 93-109.

Breastfeeding's significant contribution to child survival and child nutrition is well accepted. Healthful child spacing is associated with improved birth outcomes and maternal recovery. On a population basis, breastfeeding may contribute more to birth spacing than all family planning use combined in many countries. However, while breastfeeding does provide a period of infertility, until recently, there was no reliable way for an individual woman to capitalize on this lactational infertility for her own efficacious child spacing. The lactational amenorrhea method (LAM) is a new introductory family planning method that simultaneously promotes child spacing and breastfeeding, with its optimal nutrition and disease preventive benefits for the infant. LAM is based on the use of lactational infertility for protection from pregnancy and indicates the time for the introduction of a complementary family planning method. LAM is recommended for up to 6 months postpartum for women who are fully or nearly fully breastfeeding and amenorrheic and relies on the maintenance of appropriate breastfeeding practices to prolong lactational infertility, with the concomitant delay in menses return. A recent clinical trial confirmed the theoretical 98% or higher effectiveness of the method, and field trials are demonstrating its acceptability. Nonetheless, some demographers and family planning organizations continue to debate its value. The development, efficacy, and sequelae of the method are presented using data from several studies by the authors.

Laukaran VH, Rutstein SO, Labbok MH, Ballard E. 1994. Contraceptive use during lactational amenorrhea: Estimates of double coverage among postpartum women using DHS I and II data. Working paper, Institute for Reproductive Health, Georgetown University: Washington, DC. Full-text version in English is available.

Efforts to improve the coverage and quality of postpartum family planning have focused on the need to consider both the fertility impact of breastfeeding and the possible side effects of contraception for lactation. One aspect of the breastfeeding fertility relationship that has been of interest to both demographers and family planning managers is the utilization of contraceptives by women during lactational amenorrhea. This overlap between contraception and lactational amenorrhea has been called double coverage. In population groups with considerable double coverage, and particularly where the median duration of contraceptive use is short, the impact of contraceptive use on birth interval may be reduced. This paper estimates the prevalence of double coverage using the available Demographic and Health Survey data. Two methods are used to estimate this double coverage: a simple prevalence estimate based on the percentage of all contraceptive users who are in lactational amenorrhea, and the percentage of all person-months of contraceptive use that overlap with lactational amenorrhea. With either method, the prevalence of lactational amenorrhea was found to be very high, particularly in most countries of Africa and the Near East, where the median duration of lactational amenorrhea is extended. In Latin America and the Caribbean, the prevalence of double coverage and the duration of lactational amenorrhea is much shorter because of poorer breastfeeding patterns. The significance of this "double coverage" depends to some extent on the duration of use for contraceptives. The mean duration of use for oral contraceptives was estimated from DHS data and its relationship to the percentage overlap of contraceptive use and lactational amenorrhea is briefly explored.

Kennedy KI, Rivera R, McNeilly AS. 1989. Consensus statement on the use of bresastfeeding as a family planning method. Contraception 39, no. 5: 477-496.

An interdisciplinary international group of researchers in the area of lactational infertility gathered to reach consensus about the conditions under which breastfeeding can be used as a safe and effective method of family planning. The consensus was that the maximum birth spacing effect of breastfeeding is achieved when a mother "fully" or nearly fully breastfeeds and remains amenorrheic. When these two conditions are fulfilled, breastfeeding provides more than 98% protection from pregnancy in the first 6 months. Data are reviewed from 13 prospective studies in both developed and developing countries supporting the consensus. The rationale for the consensus is given in detail. Recommendations are made based on current knowledge of the anti-fertility effects of breastfeeding. Research should continue to measure a broad spectrum of variables so that these guidelines can be refined as new information becomes available.

Conde-Agudelo A, Belizan JM. 2000. Maternal morbidity and mortality associated with interpregnancy interval: cross sectional study. BMJ  321(7271):1255-9.

OBJECTIVE: To study the impact of interpregnancy interval on maternal morbidity and mortality. DESIGN: Retrospective cross sectional study with data from the Perinatal Information System database of the Latin American Centre for Perinatology and Human Development, Montevideo, Uruguay. SETTING: Latin America and the Caribbean, 1985-1997. PARTICIPANTS: 456,889 parous women delivering singleton infants. MAIN OUTCOME MEASURES: Crude and adjusted odds ratios of the effects of short and long interpregnancy intervals on maternal death, pre-eclampsia, eclampsia, gestational diabetes mellitus, third trimester bleeding, premature rupture of membranes, postpartum haemorrhage, puerperal endometritis, and anaemia. RESULTS: Short (<6 months) and long (59 months) interpregnancy intervals were observed for 2.8% and 19.5% of women, respectively. After adjustment for major confounding factors, compared with those conceiving at 18-23 months after a previous birth, women with interpregnancy intervals of 5 months or less had higher risks for maternal death (odds ratio 2.54; 95% confidence interval 1.22 to 5.38), third trimester bleeding (1.73; 1.42 to 2.24), premature rupture of membranes (1.72; 1.53 to 1.93), puerperal endometritis (1.33; 1.22 to 1.45), and anaemia (1.30; 1.18 to 1.43). Compared with women with interpregnancy intervals of 18 to 23 months, women with interpregnancy intervals longer than 59 months had significantly increased risks of pre-eclampsia (1.83; 1.72 to 1.94) and eclampsia (1.80; 1.38 to 2.32). CONCLUSIONS: Interpregnancy intervals less than 6 months and longer than 59 months are associated with an increased risk of adverse maternal outcomes.

Bender DE. Dusch E. McCann MF. 1998. From efficacy to effectiveness: Selecting indicators for a community-based lactational amenorrhoea method promotion programme. J Biosoc Sci 30, no. 2: 193-225.

This paper reviews the results of clinical trials and community studies of lactational amenorrhoea and its role as a contraceptive method. Indicators which are used in efficacy trials and effectiveness interventions are compared and sets of indicators of effectiveness appropriate to community-based lactational amenorrhea method (LAM) programs are recommended. A five-tiered ecological framework is used to facilitate selection of indicators ranging from individual to policy level outcomes. The indicator framework is intended as a tool for health practitioners in family planning and maternal and child health service delivery settings who are interested in designing programmatic interventions for the promotion of LAM, particularly among less well-educated women of lower socioeconomic communities.

Wade KB, Sevilla F, Labbok MH. 1994. Integrating the lactational amenorrhea method into a family planning program in Ecuador. Stud Fam Plann 25, no. 3: 162-75.

This paper reports the results of a 12-month implementation study documenting the process of integrating the lactational amenorrhea method (LAM) into a multiple-method family planning service-delivery organization, the Centro Medico de Orientacion y Planificacion Familiar (CEMOPLAF) in Ecuador. LAM was introduced as a family planning option in four CEMOPLAF clinics. During the program's first 5 months LAM was accepted by 133 breastfeeding women, representing about one-third of postpartum clients. Seventy-three percent of LAM acceptors were new to any family planning method. Follow-up interviews with a systematic sample of 67 LAM users revealed that the method was generally used correctly. Three pregnancies were reported, none by women who were following LAM as recommended. Service providers' knowledge of LAM resulted in earlier IUD insertions among breastfeeding women. Relationships with other maternal and child health organizations and programs were also established.

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