Health Care Issues: Breastfeeding & Birth Spacing
Breastfeeding and Birth spacing: Complementary support for women
Optimal birth spacing is at least 2 years, preferably 3-5 years. In populations that practice optimal breastfeeding, the impact of the breastfeeding on fertility naturally results in about 2 years of birth spacing on average. This means that many women who are breastfeeding will still experience less than the minimum recommended birth intervals.
How then might we support every woman to achieve both optimal spacing and optimal breastfeeding? The Lactational Amenorrhea Method was developed to optimize both optimal breastfeeding for both its health and fertility impacts, and the timely introduction of a complementary family planning method to ensure adequate spacing for health of mother and child.
It is vital that another method be introduced within 4- 6 weeks postpartum or as indicated by LAM in order to achieve adequate birth spacing. Contraceptive methods used during breastfeeding might be considered in three categories:
- Those that either have no impact on breastfeeding or might support it;
- Those that may have a negative impact, depending on the time of administration, and;
- Those that have been proven to have a negative impact on breastfeeding, no matter when they are given.
The methods that fall under each category are as follows:
- Have no impact on breastfeeding or might support it
- Lactational amenorrhoea method (LAM) – supports optimal breastfeeding while offering birth spacing
- NFP – no negative impact on breastfeeding, but some methods may be hard to use during breastfeeding
- Barrier methods
- Copper-bearing intrauterine devices (Cu-IUDs) – preferably at birth or after several weeks to avoid the strong uterine contractions early postpartum
- Have a negative impact, depending on the time of administration
- Progestin-only methods: since prolactin release and milk production are dependent on the fall in progestins that occur with delivery of the placenta, it is logical that these methods should not be administered early postpartum. Data on later impact are mixed.
- Have been proven to have a negative impact on breastfeeding, no matter when they are given: Estrogenic methods reduce milk supply.
WHO offered recommendation on the use of contraception during breastfeeding using a ranking system found in the Medical Eligibility Criteria. Methods are ranked 1-4 (See first figure, below) The second figure shows the rankings for method use during breastfeeding.
WHO Medical Eligibility Criteria (MEC)
and Simplified Two Category System
Where a doctor or nurse is not available to make clinical judgements, the 4-categories can be simplified into 2-categories system as shown in this table:
|Category||With Clinical Judgement||With Limited Clinical Judgement|
|1||Use the method in any circumstances||Use the method|
|2||Generally use the method||Use the method|
|3||Use of the method not usually recommended unless other, more appropriate methods are not available or acceptable||Do not use the method|
|4||Method not to be used||Do not use the method|
WHO- Medical Eligibility Criteria for use of methods during breastfeeding
|0 – 6 weeks
6 weeks – 6 months
more than 6 months
|0 – 6 weeks
6 weeks – 6 months
more than 6 months
|Levonorgestrel-releasing IUDs (LNG – IUD)||3
|Less than 48 hours
48 hours – 4 weeks
more than 4 weeks
|Copper-bearing intrauterine devices (Cu-IUDs)||1
|Less than 48 hours
48 hours – 4 weeks
more than 4 weeks
LAM- The Lactational Amenorrhea Method
The Lactational Amenorrhea Method (LAM)
It is a well known fact that breastfeeding suppresses a woman’s fertility in the early months after delivery. However, many women do not feel comfortable relying on breastfeeding as a form of birth control because they have been told it is unreliable, or perhaps because they know someone who became pregnant while breastfeeding.
The Lactational Amenorrhea Method (LAM) was created to allow women to safely rely on breastfeeding as a family planning method. Based on scientific research, the method uses three measures of a woman’s fertility: 1) the return of her menstrual period, 2) her patterns of breastfeeding, and 3) the time postpartum.
Breastfeeding Habits that Improve LAM
Optimal breastfeeding is the key to successful LAM. The suggestions below maximize the health and nutrition benefits of breastfeeding and improve LAM.
- After delivery, baby should be placed skin to skin with mom and supported to begin breastfeeding within the first hour. Allow the infant to remain with the mother for at least several hours and to room-in with the mother.
- Breastfeed frequently whenever the baby is hungry, both day and night. During the first few weeks, this may be every two-three hours, sometimes even more. Signs of hunger include snuggling or rooting at the breast, making sucking sounds, or sucking on the hands. Crying is a late sign of hunger.
- Breastfeed exclusively for the first six months. Human milk is all a baby needs to eat or drink for about six months.
- Start giving the baby complementary foods at about six months. At each feeding, breastfeed first then give other foods and liquids.
- Continue breastfeeding for up to two years or more. Human milk continues to provide important immunities, is still good food, and keeps protecting your baby from diseases.
- Avoid using bottles or pacifiers. Artificial nipple use in the early days may reduce an infant’s desire to suck at the breast, reducing frequency, and thus reducing both milk production and fertility suppression.
- Breastfeeding should continue even if the mother or baby becomes ill. The nutrients and immunological protection provided by breastfeeding are even more important when the mother or baby is ill. However, if the mother has a potentially terminal, transmittable disease–such as AIDS or active tuberculosis–she should consult her health care provider for advice.
Women who are breastfeeding need to satisfy their own hunger and thirst and get rest when possible. No special food is required to create good quality milk and no foods are forbidden.
F.A.Q About LAM
Q. How does LAM work?
A. When a baby suckles frequently at the breast it stimulates the nipple, sending signals to the brain, which then releases hormones that interrupt a woman’s normal ovulation cycle. This effect is particularly strong in the early months after delivery when the baby is breastfeeding often. As the baby grows and starts to eat other foods (around 6 months) the time suckling at the breast decreases. When this happens the woman’s body begins to return to its regular cycling and ovulation and menstrual periods return.
In more technical terms, LAM is based on the hypothalamic-pituitary-ovarian feedback system. As the baby suckles at the breast neural signals are sent to the hypothalamus which mediates the level and rhythm of secretion of the GnRH hormone. GnRH influences pituitary release of follicle stimulating hormone (FSH) and luteinizing hormone (LH), the hormones responsible for follicle development and ovulation. Regular and frequent breastfeeding results in disorganization of follicular development.
Q. Should women who are HIV+ or who have AIDS use LAM?
A. This is a decision each woman must make herself based on the information provided to her. There is a chance that a mother can pass the virus to her baby by breastfeeding. If a safe alternative to breastfeeding is available and affordable, a woman who is HIV+ or has AIDS should be informed of the risks of breast and bottle feeding and advised that breastmilk substitutes may be safer for her baby. However, current WHO guidance calls for treatment along with a call for exclusive breastfeeding, which both reduces the risk of HIV passage compared to mixed feeding, and provides protection against other health risks. As WHO guidance may change, please always check the latest guidance for up to date suggestions.
Q. Can women who work outside of the home use LAM?
A. There is only one study of LAM use when mothers and child are separated. This study found an increase in unplanned pregnancy when women returned to work or school and began to express and store milk for daytime use, leaving the child with another caretaker. However, if a woman to be separated from her child still wishes to use LAM she may need special support. She should begin using LAM in the first weeks after childbirth while she is able to be with the child. When she returns to the work place, she can express her milk, preferably using manual stimulation of the breast and nipple in much the same way as the baby does. She needs to express her milk at least as often as her infant would be nursing and not have more than four hours between expressing. The working mother also should be advised to increase her frequency of breastfeeding when at home with the infant, especially during the night. Employers can be supportive of working women by giving the mother time and a private area to express, or even better, allowing the baby to be with the mother at work in the early months.
Q. Why is breastfeeding at night important?
A. Prolactin levels are more responsive to each feeding at night than they are during the day, which means that each feeding at night has more of an impact than a daytime feeding towards suppressing fertility even though women nurse a greater number of times during the day. A mother relying on LAM should breastfeed at least once during the night.
Q. What do you mean by exclusive breastfeeding?
A. Exclusive breastfeeding means that no other food or liquid is given to the infant. It is recommended for the first six months of the baby’s life to increase the many health benefits of breastfeeding. However, LAM is still effective even if a woman is not exclusively breastfeeding. Guidelines suggest that a woman relying on LAM practice full or nearly full breastfeeding, which means she is breastfeeding when the baby wants, both day and night, and other foods or liquids do not replace a feeding at the breast and are given only in small amounts. She does not permit intervals between breastfeeds of longer than four hours during the day and six hours at night.
Contraindications to LAM use
Medical conditions that affect the use of LAM are few. Generally, the WHO provides recommendations on the few medical conditions that contraindicate optimal breastfeeding, which in turn makes LAM use impossible.
This page was adapted from the original web site of the Institute for Reproductive Health, a project funded by the United States Agency for International Development (USAID) under the terms of Cooperative Agreement DPE-3061-A-00-1029-00. Information (photos excluded) and publications may be reproduced, adapted, and disseminated without permission, provided the Institute for Reproductive Health is acknowledged and the material is distributed free of charge, or not for profit.