Editorials

Lactational amenorrhoea method for family planning

It has long been known that breast feeding can delay the return of fertility, but until recently the conditions under which women could rely on this phenomenon were unclear. In August 1988 an international group of scientists gathered in Bellagio, Italy, to review the scientific evidence related to the effect of breast feeding on fertility.^{1 2} In what came to be known as the "Bellagio consensus," they concluded that women who were fully or nearly fully breast feeding and amenorrhoeic had a less than 2% risk of pregnancy in the six months after delivery.

Subsequently, several groups have collected further data on risks of pregnancy among breast feeding women in relation to time after delivery and feeding patterns.^{3 4 5 6 7} Their results, including those from Ramos and colleagues reported in this week's BMJ (p 909)⁷ as well as other relevant research,^{8 9 10} were reviewed in December 1995 at a second Bellagio conference. This confirmed the conclusions of the original Bellagio consensus¹¹: women who are fully or nearly fully breast feeding are at very low risk of becoming pregnant in the first six months after delivery as long as they remain amenorrhoeic--indeed, the observed cumulative life table rates of pregnancy at six months were less than 2%. In studies that included the promotion of appropriate breast feeding practices, the percentage of women still amenorrhoeic and fully breast feeding at six months after delivery was higher than in control groups not receiving such support.^{12 13}

From the research done to date, the experts participating in the second Bellagio conference (who included two authors of the paper by Ramos et al) also concluded that whereas amenorrhoea is an absolute requirement for ensuring a low risk of pregnancy, it might be possible to relax the requirement of full or nearly full breast feeding.^{4 10 14 15} It may also be possible to extend the duration of use beyond six months without jeopardising effectiveness.^{10 14 15} Additional research is needed to establish the conditions under which these modifications to the Bellagio consensus could be made.

In 1989 a method of family planning for women was defined, based on the Bellagio consensus. It was called the lactational amenorrhoea method, and guidelines for its use were developed.¹⁶ These guidelines include the three criteria mentioned above--amenorrhoea, full or nearly full breast feeding, and protection limited to the first six months postpartum--all of which must be met to ensure adequate protection from an unplanned pregnancy. The guidelines include the advice that women who no longer meet these three criteria, or no longer wish to use the lactational amenorrhoea method, should immediately start to use another method of family planning if they wish to avoid pregnancy.

As well as the study by Ramos et al, several other reports have been published on the lactational amenorrhoea method,^{6 12 13 14 15 16 17 18} but experience is still limited. Additional research is needed to determine its effectiveness and acceptability under field conditions, to evaluate the implications of running a programme of the lactational amenorrhoea method for services catering for mothers, and to assess the impact of reliance on lactational amenorrhoea on subsequent use of other family planning methods, especially among women who would not otherwise attempt family planning. As indicated earlier, the guidelines for use of lactational amenorrhoea promote the adoption of other methods of family planning as soon as the six month period of protection has ended,¹⁶ and it is therefore conceivable that using lactational amenorrhoea may increase subsequent use of contraception.¹⁹

PAUL FA VAN LOOK Associate director

UNDP/UNFPA/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction, World Health Organisation, 1211 Geneva 27, Switzerland

Paul Fa Van Look 

1. Consensus statement. Breastfeeding as a family planning method. Lancet 1988;ii:1204-5.
2. Kennedy KI, Rivera R, McNeilly AS. Consensus statement on the use of breastfeeding as a family planning method. Contraception 1989;39:477-96. [Medline]
3. Kennedy KI, Visness CM. Contraceptive efficacy of lactational amenorrhoea. Lancet 1992;339:227-30. [Medline]
4. Lewis PR, Brown JB, Renfree MB, Short RV. The resumption of ovulation and menstruation in a well-nourished population of women breastfeeding for an extended period of time. Fertil Steril 1991;55:529-36. [Medline]
5. Diaz S, Aravena R, Cardenas H, Casado ME, Miranda P, Schiappacasse V, et al. Contraceptive efficacy of lactational amenorrhea in urban Chilean women. Contraception 1991;43:335-52. [Medline]
6. Kazi A, Kennedy KI, Visness CM, Khan T. Effectiveness of the lactational amenorrhoea method in Pakistan. Fertil Steril 1995;64:717-23. [Medline]
7. Ramos R, Kennedy KI, Visness CM. Effectiveness of the lactational amenorrhoea method in preventing pregnancy in Manila, the Philippines. BMJ 1996;313:909-12. [Abstract/Free Full Text]
8. Gray RH, Campbell OM, Apelo R, Eslami SS, Zacur H, Ramos RM, et al. Risk of ovulation during lactation. Lancet 1990;335:25-9. [Medline]
9. Diaz S, Miranda P, Cardenas H, Salvatierra AM, Brandeis A, Croxatto HB. Relative contributions of anovulation and luteal phase defect to the reduced pregnancy rate of breastfeeding women. Fertil Steril 1992;58:498-503. [Medline]
10. Short RV, Lewis PR, Renfree MB, Shaw G. Contraceptive effects of extended lactational amenorrhoea; beyond the Bellagio consensus. Lancet 1991;337:715-7. [Medline]
11. Kennedy KI, Labbok MH, Van Look PFA. Consensus statement: lactational amenorrhoea method for family planning. Int J Gynaecol Obstet 1996;54:55-7. [Medline]
12. Perez A, Valdes V. Santiago breastfeeding promotion program: preliminary results of an intervention study. Am J Obstet Gynecol 1991;165:2039-44. [Medline]
13. Valdes V, Perez A, Labbok M, Pugin E, Zambeano I, Catalan S. The impact of a hospital and clinic based breastfeeding promotion programme in a middle class urban environment. J Tropical Pediatrics 1993;39:142-51. [Abstract/Free Full Text]
14. Weis P. The contraceptive potential of breastfeeding in Bangladesh. Stud Fam Plann 1993;24:1008.
15. Cooney KA, Nyirabukeye T, Labbok MH, Hoser PH, Ballard E. An assessment of the nine-month lactational amenorrhea method (MAMA-9) in Rwanda. Stud Fam Plann 1996;27:162-71.
16. Labbok MH, Perez A, Valdes V, Sevilla F, Wade K, Laukaran VH, et al. The lactational amenorrhea method (LAM): a postpartum introductory family planning method with policy and program implications. Adv Contracept 1994;10:93-109. [Medline]
17. Perez A, Labbok M, Queenan J. Clinical study of the lactational amenorrhoea method of family planning. Lancet 1992;339:968-70. [Medline]
18. Wade KB, Sevilla F, Labbok MH. Integrating the lactational amenorrhea method into a family planning program in Ecuador. Stud Fam Plann 1994;25:162-75. [Medline]
19. Winikoff B, Mensch B. Rethinking postpartum family planning. Stud Fam Plann 1991;22:294-307. [Medline]