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Overview and summary: The interface of breastfeeding, natural family planning, and the lactational amenorrhea method
SESSION III. THE INTERFACE OF BREASTFEEDING, NATURAL FAMILY PLANNING, AND THE LACTATIONAL AMENORRHEA METHOD Miriam H. Labbok, Chair Alfredo Perez, Co-Chair Peter Howie, Rapporteur
Overview and summary: The interface of breastfeeding, natural family planning, and the lactational amenorrhea method Miriam H. Labbok, MD, MPH: and Peter W. Howie, MDb MDb Washington, D.C., and Dundee, Scotland This session explores the use of natural family planning during breastfeeding and the operationalization of the research findings related to the breastfeeding-natural family planning interface into training programs. Worldwide, the vast majority of women breastfeed their infants; in many countries breastfeeding continues for several months. Studies show that women learning natural family planning during lactation, particularly pregnancy. Altered hormonal those whose menses have returned, returned , have an increased risk of unplanned pregnancy. levels may make interpretation of the signs of fertility return (mucus, and so forth) difficult during this time. time. The lactational amenorrhea method may be a useful adjunct to natural family planning training. (AM J OBSTET OBSTET GVNECOL 1991 ;165:2013-4.)
Key words: Natural family planning, breastfeeding, lactational amenorrhea method This session explores two issues. The first is the use of natural family planning (NFP), especially the ovulation method, during breastfeeding. Worldwide, nearly 100% of women will breastfeed their infants for some period of time. Therefore we must be able to introduce NFP during lactation and do so in a manner that is efficacious. Previous studies show that women learning the method during lactation are at risk of increased unplanned pregnancy rates. The period of lactational menses (i.e., the time when lactation continues but after menses have returned) is apparently the time when unplanned pregnancy is most likely to occur. The second issue that will be discussed is whether better understanding of lactational amenorrhea could be part of the solution to the problem noted above and incorporated into NFP teaching. We know that breastfeeding patterns can have a profound effect on fertility and that the lactational amenorrhea method (LAM) is an efficacious and natural method for postpartum lactating women. Many commonalities exist between NFP and the LAM. First, both are natural methods that reFrom The Department ofObstetrics and Gynecology, Georgetown University, IISNFP lISNFP 1/IRH: IRH: and The Department of Obstetrics and Gynecology, University of Dundee Medical School.' Reprint requests: Miriam H. Labbok, MD, Director, IISNFP lISNFPIIRH, /IRH, Georgetown University, 3800 Reservoir Rd., Washington, DC 20007. 20007 . 610134250 6/0/34250
quire no additional medication or insertion of a medical device. Also, both are highly user dependent and require instruction and counseling of the acceptor. Neither method is logistics dependent, and once taught and fully understood, these methods belong to the client for life. Thus these methods are extremely desirable in situations in which other family planning methods are not readily available or are not acceptable. During this session, a clear consensus emerged among all the speakers and the discussants that LAM should be incorporated into NFP programs. The practical problem is to provide support and counsel to those mothers who wished to use lactational amenorrhea as an important contribution to effective birth spacing. Another issue identified during this session was the difficulty of interpreting classic signs of NFP during breastfeeding. The difficulty of interpreting NFP signs was a particular problem after the return of menstruation during breastfeeding but before the resumption of regular cycles, which is generally the phase between the end of LAM and the resumption of regular cycles. It is also clear that in some communities, lactational amenorrhea will be an important method of fertility control for much longer than the 6 months recommended in the Bellagio guidelines. More work is required to identify those individuals or communities and the breastfeeding practices that are associated with the 2013
Labbok and Howie
longer lactational amenorrhea. These issues only served to reinforce the consensus among all speakers that the LAM must be incorporated more closely into current NFP programs throughout the world. It is important to recognize that breastfeeding, especially exclusive breastfeeding, has a profound effect on fertility and on the estrogenic changes that create the signs and symptoms used in various NFP methods. Lactation after menses has returned is not nearly as
December 1991 Am J Obstet Gynecol
protective against unplanned pregnancy. Better understanding of the fertility suppressive effects of lactation and its incorporation into NFP teaching could be part of the solution to this problem. The following articles and discussions explore these and related issues. It is hoped that the conclusions of this session will provide guidance for NFP policy makers and trainers in the introduction of NFP during breastfeeding.
Is the lactational amenorrhea method a part of natural family planning? Biology and policy Barbara A. Gross, PhD Westmead, Australia The lactational amenorrhea method is a natural method of family planning for women who breastfeed their infants. The underlying physiology results in a natural suppression of ovulation, and the concomitant infants. breastfeeding. This in addition to the infant's age amenorrhea, induced by exclusive (or almost exclusive) breastfeeding. of 6 months or less and specific feeding pattern are the parameters used to identify the possible return of fertility. fertility. The lactational amenorrhea method provides at least 98% protection against pregnancy. Data from a recent multicenter study of breastfeeding support the use of the lactational amenorrhea method as a natural family planning method. method. The lactational amenorrhea method can be incorporated into natural family planning programs and teaching. (AM J OSSTET GVNECOL 1991;165:2014-9.) 1991 ;165:2014-9.)
Key words: Natural family planning, breastfeeding, lactational amenorrhea method, postpartum infertility The natural child-spacing effect of breastfeeding has been long recognized to be associated with amenorrhea and the duration of breastfeeding, particularly full breastfeeding. Furthermore, in population studies only about 5% to 10% of women have been reported to become pregnant while in lactational amenorrhea. 6 This effect received little attention among populations where breastfeeding was not a common practice. However, the incidence and duration of breastfeeding have been changing in both developed and developing countries, particularly since the early 1970s. In developed countries there has been a return to breastfeeding, and well-educated mothers in the higher socioeconomic groups are more likely to breastfeed and breastfeed breast feed longer than those from the lower socioeconomic or imFrom the Endocrine Unit, Department of Medicine, Westmead Hospital. Reprint requests: Barbara A. Gross, PhD, Endocrine Unit, Department of Medicine, M edicine, Westmead Westmead Hospital, Westmead, New South Wales, 2145. Australia, 2145. 6/0/34381 610134381
2014
migrant groups.' groups.7 In some developing countries, particularly in the urban areas, the pattern is the opposite; the more highly educated are less likely to initiate breastfeeding or to breastfeed for only short periods. In rural areas breastfeeding is more prolonged, but there has been a suggestion of a decline in the initiation and duration of breastfeeding in many populations. Economic changes and recent programs for the promotion and support of breastfeeding are associated with abatement and reversal of the decline in many settings. The duration oflactational amenorrhea in urban and rural populations also differs markedly from country to country, with a range varying from 2 to 3 months up to 2 to 3 years. In many of these populations breastfeeding has provided the major control of fertility; it delays the return of bleeding/menstruation bleeding / menstruation and ovulation, but it does not permanently prevent pregnancy. The impact of a decline in the duration of breastfeeding and its concomitant effect on lactational amenorrhea, particularly in developing countries, has been high-
Overview and summary: The interface of breastfeeding, natural family planning, and the lactational amenorrhea method Miriam H. Labbok, MD, MPH: and Peter W. Howie, MDb MDb Washington, D.C., and Dundee, Scotland This session explores the use of natural family planning during breastfeeding and the operationalization of the research findings related to the breastfeeding-natural family planning interface into training programs. Worldwide, the vast majority of women breastfeed their infants; in many countries breastfeeding continues for several months. Studies show that women learning natural family planning during lactation, particularly pregnancy. Altered hormonal those whose menses have returned, returned , have an increased risk of unplanned pregnancy. levels may make interpretation of the signs of fertility return (mucus, and so forth) difficult during this time. time. The lactational amenorrhea method may be a useful adjunct to natural family planning training. (AM J OBSTET OBSTET GVNECOL 1991 ;165:2013-4.)
Key words: Natural family planning, breastfeeding, lactational amenorrhea method This session explores two issues. The first is the use of natural family planning (NFP), especially the ovulation method, during breastfeeding. Worldwide, nearly 100% of women will breastfeed their infants for some period of time. Therefore we must be able to introduce NFP during lactation and do so in a manner that is efficacious. Previous studies show that women learning the method during lactation are at risk of increased unplanned pregnancy rates. The period of lactational menses (i.e., the time when lactation continues but after menses have returned) is apparently the time when unplanned pregnancy is most likely to occur. The second issue that will be discussed is whether better understanding of lactational amenorrhea could be part of the solution to the problem noted above and incorporated into NFP teaching. We know that breastfeeding patterns can have a profound effect on fertility and that the lactational amenorrhea method (LAM) is an efficacious and natural method for postpartum lactating women. Many commonalities exist between NFP and the LAM. First, both are natural methods that reFrom The Department ofObstetrics and Gynecology, Georgetown University, IISNFP lISNFP 1/IRH: IRH: and The Department of Obstetrics and Gynecology, University of Dundee Medical School.' Reprint requests: Miriam H. Labbok, MD, Director, IISNFP lISNFPIIRH, /IRH, Georgetown University, 3800 Reservoir Rd., Washington, DC 20007. 20007 . 610134250 6/0/34250
quire no additional medication or insertion of a medical device. Also, both are highly user dependent and require instruction and counseling of the acceptor. Neither method is logistics dependent, and once taught and fully understood, these methods belong to the client for life. Thus these methods are extremely desirable in situations in which other family planning methods are not readily available or are not acceptable. During this session, a clear consensus emerged among all the speakers and the discussants that LAM should be incorporated into NFP programs. The practical problem is to provide support and counsel to those mothers who wished to use lactational amenorrhea as an important contribution to effective birth spacing. Another issue identified during this session was the difficulty of interpreting classic signs of NFP during breastfeeding. The difficulty of interpreting NFP signs was a particular problem after the return of menstruation during breastfeeding but before the resumption of regular cycles, which is generally the phase between the end of LAM and the resumption of regular cycles. It is also clear that in some communities, lactational amenorrhea will be an important method of fertility control for much longer than the 6 months recommended in the Bellagio guidelines. More work is required to identify those individuals or communities and the breastfeeding practices that are associated with the 2013
Labbok and Howie
longer lactational amenorrhea. These issues only served to reinforce the consensus among all speakers that the LAM must be incorporated more closely into current NFP programs throughout the world. It is important to recognize that breastfeeding, especially exclusive breastfeeding, has a profound effect on fertility and on the estrogenic changes that create the signs and symptoms used in various NFP methods. Lactation after menses has returned is not nearly as
December 1991 Am J Obstet Gynecol
protective against unplanned pregnancy. Better understanding of the fertility suppressive effects of lactation and its incorporation into NFP teaching could be part of the solution to this problem. The following articles and discussions explore these and related issues. It is hoped that the conclusions of this session will provide guidance for NFP policy makers and trainers in the introduction of NFP during breastfeeding.
Is the lactational amenorrhea method a part of natural family planning? Biology and policy Barbara A. Gross, PhD Westmead, Australia The lactational amenorrhea method is a natural method of family planning for women who breastfeed their infants. The underlying physiology results in a natural suppression of ovulation, and the concomitant infants. breastfeeding. This in addition to the infant's age amenorrhea, induced by exclusive (or almost exclusive) breastfeeding. of 6 months or less and specific feeding pattern are the parameters used to identify the possible return of fertility. fertility. The lactational amenorrhea method provides at least 98% protection against pregnancy. Data from a recent multicenter study of breastfeeding support the use of the lactational amenorrhea method as a natural family planning method. method. The lactational amenorrhea method can be incorporated into natural family planning programs and teaching. (AM J OSSTET GVNECOL 1991;165:2014-9.) 1991 ;165:2014-9.)
Key words: Natural family planning, breastfeeding, lactational amenorrhea method, postpartum infertility The natural child-spacing effect of breastfeeding has been long recognized to be associated with amenorrhea and the duration of breastfeeding, particularly full breastfeeding. Furthermore, in population studies only about 5% to 10% of women have been reported to become pregnant while in lactational amenorrhea. 6 This effect received little attention among populations where breastfeeding was not a common practice. However, the incidence and duration of breastfeeding have been changing in both developed and developing countries, particularly since the early 1970s. In developed countries there has been a return to breastfeeding, and well-educated mothers in the higher socioeconomic groups are more likely to breastfeed and breastfeed breast feed longer than those from the lower socioeconomic or imFrom the Endocrine Unit, Department of Medicine, Westmead Hospital. Reprint requests: Barbara A. Gross, PhD, Endocrine Unit, Department of Medicine, M edicine, Westmead Westmead Hospital, Westmead, New South Wales, 2145. Australia, 2145. 6/0/34381 610134381
2014
migrant groups.' groups.7 In some developing countries, particularly in the urban areas, the pattern is the opposite; the more highly educated are less likely to initiate breastfeeding or to breastfeed for only short periods. In rural areas breastfeeding is more prolonged, but there has been a suggestion of a decline in the initiation and duration of breastfeeding in many populations. Economic changes and recent programs for the promotion and support of breastfeeding are associated with abatement and reversal of the decline in many settings. The duration oflactational amenorrhea in urban and rural populations also differs markedly from country to country, with a range varying from 2 to 3 months up to 2 to 3 years. In many of these populations breastfeeding has provided the major control of fertility; it delays the return of bleeding/menstruation bleeding / menstruation and ovulation, but it does not permanently prevent pregnancy. The impact of a decline in the duration of breastfeeding and its concomitant effect on lactational amenorrhea, particularly in developing countries, has been high-