USAID PRH FP- MNCHN Integration MeetingFamily Planning and Nutrition Session

Lactational Amenorrhea Method (LAM), Exclusive Breastfeeding and the Transition

To Other Family Planning Methods

Presenters:Justine Kavle, PhD, MPH, Georgetown University, IRH

Barbara Deller, CNM, MPH, MCHIP/Jhpiego

March 30, 2011

Why does integration of services providing infant Why does integration of services providing infant feeding, LAM, and family planning (FP) make sense?feeding, LAM, and family planning (FP) make sense?

Maternal child health/nutrition is a programmatic entry point for reinforcing messages on LAM and FP during routine contact points

LAM reinforces exclusive breastfeeding for 6 months during prenatal and postnatal care

Transition from LAM to another FP method could be conjoined with a message on initiation of complementary feeding at 6 months postpartum

Referral to FP & health timing and spacing messages can be given during prenatal and postnatal care

LAM: Efficacy established in clinical research studies

Trial Multi-center

Ecuador Chile Philippines Pakistan

N 519 330 422 485 391

# of Pregnancies

5 1 1 2 1

Efficacy 98.5 99.9 99.6 99.0 99.4

Labbok et al, 1997, Perez et al 1992, FHI 1994a, FHI 1994 b, Wade, Sevilla and Labbok, 1994

3 LAM criteria tested in clinical research studies

Simplification and operational definitions for LAM criteria - LAM Working Group

1 Menses has not returned

Any menstrual-like bleeding or 2 days of spotting after 2 months postpartum.

Menses has not returned

Any bleeding including spotting after 2 months postpartum

2 Fully to nearly fully breastfeeding

- Breastfeed day and night - Occasional tastes of other foods or liquids

Breastfeed only

-Breastfeed day and night.-Do not give your baby any food or liquid (including water)

3 Baby is less than 6 mo. of age Baby is less than 6 mo. of age

LAM supports exclusive breastfeeding:Dual benefits for mother and baby

1. Prevents neonatal and infant illness (diarrhea, respiratory infection)

2. Prevents neonatal and infant mortality3. Supports growth and development4. Stimulates oxytocin release causing uterine

contraction to reduce postpartum blood loss5. LAM promotion increased percentage of women

that exclusively breastfeed - 58% intervention vs 47% in control group (p <0.01)

in Healthy Fertility Study

Leon-Cava et al, 2002 Horta et al, 2007, McKaig, C., Baqui A, et al., MCHIP, 2010

Low levels of LAM use at 3.0 to 5.9 months postpartum 2003-2007

DHS analysis, ACCESS-FP

0.0 20.0 40.0 60.0 80.0 100.0

Bangladesh 2007

Congo, DRC 2007

India 2005-2006

Kenya 2003

Malawi 2004

Pakistan 2006-…

Uganda 2006

Ethiopia 2005

Tanzania 2004-…

Rwanda 2005

Ghana 2003

Mali 2006

Nigeria 2003

Guinea 2005

Haiti 2005-2006

Madagascar…

Zambia 2007

Winfrey and Borda, 2010

Full Breastfeeding At 3.0 To 5.9 Months Postpartum2003-2007

DHS analysis, ACCESS-FP

0 20 40 60 80 100

Kenya 2003

Haiti 2005-2006

Tanzania 2004-2005

Bangladesh 2007

Congo, Democratic Republic of 2007

Pakistan 2006-2007

Zambia 2007

Uganda 2006

Ethiopia 2005

Malawi 2004

Nigeria 2003

India 2005-2006

Ghana 2003

Madagascar 2003-2004

Guinea 2005

Rwanda 2005

Mali 2006

Percent of women 3.0 to 5.9 months postpartum who are full breastfeeding.

Winfrey and Borda, 2010

Challenges for integration of LAM with optimal breastfeeding practices

●Demographic Health Survey (DHS) analysis, ACCESS-FP● High levels full breastfeeding, yet low LAM use● Poor breastfeeding practices require reinforcement for LAM use

●Confusion that breastfeeding = LAM● Women believe breastfeeding protects them from pregnancy● Local term for LAM = breastfeeding for family planning

●LAM is an underutilized method despite effectiveness● Providers’ knowledge and training are low● Women and health workers believe LAM is not effective● Few programs offer LAM

Winfrey and Borda, 2010, Tilley et al. 2009

LAM users were more likely to use contraceptives at 12 months postpartum, Jordan

Bongiovanni et. al 2005, Hardy et al, 1998, Hight-Laukaran et al, 1997BFFP = Breastfeeding for family planning

*Multicenter: ~ 68% use FP at 9 and 12 months*Brazil: After LAM introduction, at 12 months, lower

% women not using FP (pre-post) p<0.0001.

Modern contraceptive use increased over postpartum (PP) period, when women received LAM and FP via integrated

MNCH care, Bangladesh

1324

40

1016

25

0

10

20

30

40

50

60

70

80

90

100

3 mo PP 6 mo PP 12 mo PP

Intervention

Control

McKaig, C., Baqui A, et al., MCHIP, 2010

Barriers to transitioning to another FP method, Bangladesh and Guinea

ACCESS-FP, 2010

• Waiting for menses before taking up a FP method, based on previous experiences with return to fertility*

• Misconceptions about timing and risk of pregnancy after delivery if not using LAM or another FP method

• More likely to believe there is a risk of pregnancy 1 year or more postpartum

• Concerns about side effects, lack of information, access to methods

• Perceived lack of social support (i.e. husbands, mother-in-laws)

R. Kouyate, 2010* Also in: Bongiovanni 2005; Winikoff and Mensch 1991; Salway and Nurani 1998

LAM Integration in Programs

LAM Ambassadors in BangladeshPhoto J. Mungia

Current Situation – Jharkhand, India and MaliLAM, EBF, and FP messages integrated into programs

LAM and FP messages not well integrated (FP in Mali is encouraging)LAM not conjoined with EBF

• Prenatal care messages received• LAM: 14% while 67% in India, 68% in Mali received EBF message• FP: 18%- India, 41% - Mali

• Postnatal care messages received• LAM: 1% - India, 17% - Mali• EBF: 48% - India, 61% - Mali• FP: 12%- India, 40% - Mali

•India: Late initiation of breastfeeding, early introduction of foods, and low exclusive breastfeeding rates present challenges for implementing LAM, where LAM use is nonexistent (1%).

•Mali: infant feeding practices are more favorable, LAM use is low (4.5%).

Kavle, 2010, Georgetown IRH

Program Component: ADVOCACY

• At district, state, and national levels• Program examples – Burkina Faso (IRH/Jhpiego), Mali (IRH),

India (IRH), Kenya (MCHIP), Afghanistan (MCHIP)

• (Re)positioning within the context of MNCH/nutrition • Health benefits for mother and baby

• Entry point for family planning – LAM as a gateway• Supports exclusive breastfeeding for longer time

• Program examples – Nigeria (MCHIP), Burkina Faso (IRH, ACCESS-FP)

Program Component: MESSAGING

• Recognize local / cultural barriers• Address misconceptions

• Distinguish between BF and LAM• Risk of pregnancy• Program examples: Barrier study countries (Guinea and

Bangladesh)

• Simplify and harmonize messages• Facilitates integration• Program examples: Burkina Faso

Program Component: INTEGRATED SERVICES

• Multiple contacts within other services –• ANC + pre-discharge + PNC + well-child• Program examples: India (WV), Burkina Faso

(IRH/Jhpiego), Kenya• Timing – contact during ANC, early postpartum, and

later postpartum

Program Component: INTEGRATED SERVICE (cont) COMMUNITY CONTACTS

• Home visits • Program examples – India (WV), Nigeria, Bangladesh,

• Targeted male/female community meetings• Program examples: Bangladesh (HFS), Guinea (STC),

Nigeria (MCHIP)• LAM Ambassadors

• Program example: Bangladesh

Father in Mirzapur, India with his new baby. Photo: Chandrakant Ruparelia

18

Bangladesh (HFS): Contraceptive Use Projection at 12 Months Postpartum

BANGLADESH (HFS): DURATION OF EXCLUSIVE BREASTFEEDING

19

0.0

00

.25

0.5

00

.75

1.0

0Pro

babili

ty

1 2 3 4 5 6Months since delivery

Intervention Control

At three months, EBF 58% in Intervention 47% in Control

LAM in Programs, Georgetown IRH An eye towards scale-up

• INDIA – Launched community radio programs with messages on LAM and birth spacing, trains CHWs on LAM using comic book style job aid for phased-in scale-up in Jharkhand

• 3 districts in 2008-2009• 3 additional districts 2010 = 6 districts• 6 additional districts 2011 = 12 districts

• GUATEMALA – IRH is part of the MOH-led technical team to ensure co-madronas (traditional birth attendants) can effectively offer LAM, condoms, pills and SDM

• 1 department pilot • Scale up to national level

• MALI – Integrated LAM messages in breastfeeding support groups in 1 area (Koulikoro), with plans to scale-up to 6 more areas. Advocated for LAM in national health info system and DHS (planned for 2012).

Future Directions / Research Gaps

• Research gaps/ more evidence needed

• Facilitating factors and barriers to transition to another FP method

• Optimal timing for delivering LAM, EBF and FP messages

• Introduction of LAM user card to improve recording of users in heath system in Guatemala – Georgetown IRH, planned 2011

• Correct measurement of LAM in health systems and in national surveys, LAM is often equated with BF (MIYCN/FP Working Group)

• Cost effectiveness of integrating FP/nutrition

• Providers, clients, and users perspectives on integration

Summary

• Scientific and programmatic evidence• LAM efficacy is high• Low levels of LAM use, even where full breastfeeding• LAM users more likely to use FP postpartum (by 12 mo.)• LAM use may increase exclusive breastfeeding rates and

contraceptive use postpartum when delivered with FP via integrated MNCH services

• Programming essentials• Advocacy• Simplified, culturally appropriate messages• Integration• Scale Up