Consensus Statement: Lactational Amenorrhea Method for Family Planning

Experts from around the world, representing the fields of biomedical research, social research, family planning policy and clinical practice, medical education, women's health, and communications, gathered in Bellagio, Italy, 11-14 December 1995, to discuss the Lactational Amenorrhea Method of Family Planning. The sponsors of the conference were the World Health Organization, Family Health International, and the Georgetown University Institute for Reproductive Health. The conference was supported by the Rockefeller Foundation.

While it has long been known that breastfeeding can 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 who are fully or nearly fully breastfeeding and amenorrheic, are likely to experience a risk of pregnancy of less than 2 percent in the first six months after delivery. (Consensus Statement: Breastfeeding as a Family Planning Method, The Lancet, 19 November 1988). This conclusion came to be known as the "Bellagio Consensus."

Subsequent to the 1988 Consensus meeting, several studies designed expressly to test this Consensus were conducted. 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.

The studies conducted to assess the Bellagio Consensus have shown that women who are fully or nearly fully breastfeeding are at a very low risk of becoming pregnant in the first six postpartum months as long as they remain amenorrheic. Indeed, the observed life table pregnancy rates were less than 2 percent. In addition, in the studies that included the promotion of appropriate breastfeeding practices, the percentages of women still amenorrheic and still fully breastfeeding at six months postpartum were higher than in control groups not receiving such support.

In 1989, the use of the Bellagio Consensus as a family planning method for individual women was defined and called the Lactational Amenorrhea Method (LAM), and guidelines for its use were developed. These guidelines include three criteria, all of which must be met to ensure adequate protection from an unplanned pregnancy: 1) amenorrhea, 2) full or nearly full breastfeeding, and 3) first six months postpartum. The guidelines for LAM include the advice that women who no longer meet these three criteria, or no longer wish to use LAM, should immediately initiate the use of another family planning method if they wish to avoid pregnancy. Programs should ensure that any LAM user is able to begin the new method in a manner that ensures continuity of protection from an unplanned pregnancy.

The efficacy of LAM has now been well established in prospective studies, and programs should regard LAM as an additional method that increases the family planning choices for postpartum women. The Lactational Amenorrhea Method should receive the programmatic and policy support necessary to become available worldwide.

In addition to the unanimous agreement that the Bellagio Consensus has been confirmed, the group also reached the following conclusions concerning the three criteria of LAM:

1. It is not possible to eliminate the amenorrhea criterion.
The end of amenorrhea is the clearest marker indicating increased risk of pregnancy. The participants agreed that in the use of LAM a reasonable definition of the end of amenorrhea is the occurrence, after day 56 postpartum, of two consecutive days of bleeding/spotting or of the woman's perception that her menses have returned, whichever of the two comes first.

2. It may be possible to relax the requirement of full or nearly full breastfeeding.
Full or nearly full breastfeeding is recommended in the first six months postpartum to maintain lactational amenorrhea as well as for the health of the child. In many of the studies reviewed, even in those studies in which many women do not remain fully or nearly fully breastfeeding, pregnancy rates during lactational amenorrhea are very low in the first six months. Before the choice is made to relax the requirement of full or nearly full breastfeeding, the provider and the user should be aware that it is the breastfeeding stimulus that causes amenorrhea and the associated protection from pregnancy. Hence, adding supplements to the infant's diet or decreasing the breastfeeding stimulus may hasten the return of menses and shorten the use of LAM. Whether the risk of pregnancy increases under those circumstances needs further research.

3. It may be possible to extend LAM beyond six months postpartum.
Infants older than six months need supplemental feeding. Supplementation with other foods typically decreases breastfeeding. However, in many, but not all, of the studies reviewed, among women who continue to breastfeed beyond six months despite supplementation, the rate of pregnancy during lactational amenorrhea, albeit higher than at six months, remains low, possibly allowing the extended use of LAM. Additional research is needed to establish the conditions under which such extended use would be possible.

Participants agreed that research is needed in both the programmatic and biomedical areas in addition to the above suggested research on the LAM criteria.

Programmatic research needs include, among others, studies of:

• the performance of LAM under a wide variety of field conditions
• the impact of LAM on the use of family planning, especially among women who would not otherwise choose to use family planning
• the use of LAM in special populations such as mothers who are separated from their infants for a prolonged period each day and mothers of premature babies
• the integration of LAM into family planning and other relevant health care services, such as those dealing with maternal/child health and reproductive health
• the level and nature of support needed for effective LAM use, such as ways to simplify counseling without losing efficacy.

Biomedical research needs include, among others, studies of:

• the factors that determine whether a woman ovulates before or after menses return
• the levels and patterns of infant feeding necessary to maintain the low pregnancy rates seen with current LAM guidelines
• the relative importance of the various factors that contribute to lactational infertility.

Participants:

Ms. Kristin Cooney, Institute for Reproductive Health, Georgetown University, Washington, DC, USA
Dr. Olukayode Dada,Centre for Research in Reproductive Health, Sagamu, Nigeria
Dr. Soledad Díaz, Instituto Chileno de Medicina Reproductiva, Santiago, Chile
Mr. William Finger, Family Health International (FHI), Durham, NC, USA
Dr. Anna Glasier, Family Planning and Well Women Services, Edinburgh, UK
Dr. Barbara Gross, Royal Hospital for Women, Paddington, Australia
Dr. Helena von Hertzen, Special Programme of Research Development and Research Training in Human Reproduction, World Health Organization (WHO), Geneva, Switzerland
Dr. Virginia Hight-Laukaran, IRH Washington, DC, USA
Ms. Kathy Kennedy, FHI, Denver, CO, USA
Dr. Miriam Labbok, IRH, Washington, DC, USA
Dr. Alan McNeilly, Centre for Reproductive Biology, Edinburgh, UK
Dr. Chloe O'Gara, US Agency for International Development (USAID), Washington, DC, USA
Dr. Alfredo Perez, Pontificia Universidad Catolica de Chile, Santiago, Chile
Dr. Rebecca Ramos,Women's Health and Safe Motherhood, Manila, Philippines
Dr. Roberto Rivera, FHI, Durham, NC, USA
Dr. Pramilla Senanayake, International Planned Parenthood Federation, London, UK
Dr. Mamdouh Shaaban, Assiut University, Assiut, Egypt
Professor Roger Short, Monash University, Victoria, Australia
Mr. Jeffrey Spieler, USAID, Washington, DC, USA
Dr. Jean-Christophe Thalabard, Unité de Pharmacologie Clinique, Lyon, France
Dr. James Trussell, Princeton University, Princeton, NJ, USA
Dr. Verónica Valdés, Pontificia Universidad Catolica de Chile, Santiago, Chile
Paul Van Look, Special Programme of Research Development and Research Training in Human Reproduction, WHO, Geneva, Switzerland
Beverly Winikoff, The Population Council, New York, NY

The statement presented above is the consensus of those participating in the conference and does not necessarily reflect the views of the World Health Organization, Family Health International, Georgetown University Institute for Reproductive Health, or the Rockefeller Foundation.