Policy considerations for the introduction and promotion of the lactational amenorrhea method: advantages and disadvantages of LAM.

Some attributes of LAM are unquestionably positive, such as the fact that it is effective. Clinical trials of LAM have upheld the Bellagio Consensus that the chance of pregnancy is less than 2% in the first 6 months postpartum in amenorrheic women who are fully or nearly fully breastfeeding. Secondary data analyses in numerous settings have drawn the same conclusion. Whether as a strategy or a method, used correctly or even if used imperfectly, LAM is a reliable way to avoid pregnancy. To the extent that LAM represents an additional contraceptive option, this is also clearly positive since a broad array of contraceptive options maximizes the likelihood of finding a good fit between user and method, and increases contraceptive use. Other characteristics of LAM represent potentially positive impacts. If LAM is shown to be an effective conduit to other modern methods, the implications are profoundly positive. If LAM is cost effective, for households and/or for programs, this will also make the method extraordinarily attractive. Conversely, some aspects of LAM are negative, such as the fact that it affords no protection against STDs, it requires counseling from a well-informed provider, and intensive breastfeeding can make heavy demands on the woman's time. Many of the remaining attributes of LAM may not be important to a policy decision about LAM promotion. For example, whether LAM is actualized as a strategy or a method may not be important to a decision to promote LAM, although it has a huge impact on how services are delivered. Some factors may be profound on a local or individual level. For example, one simple factor, such as the absence of full/nearly full breastfeeding, can rule out the method as an option, while another, such as the fact that it provides the needed waiting period during vasectomy counseling, can make LAM the method of choice. Although LAM seems unlikely to have widespread popularity in societies like the United States, within such settings are breastfeeding women for whom other contraceptive choices are not satisfactory and to whom LAM is attractive. Although clinicians cannot be expected to directly provide LAM education in every setting, women should be informed about LAM as an effective contraceptive choice, and clinicians should be prepared to make referrals to competent sources. The future of LAM, especially in terms of formal, programmatic initiatives, may continue to be focussed in transitional and less developed settings. Comparative cost/benefit analyses for both the family planning program and the household will contribute meaningfully to decisions about whether to use LAM and whether to include LAM in national and local family planning policies and programs. The most important call to action is to implement operations research designed to determine what factors, if any, will maximize the uptake of a second modern contraceptive method after LAM protection expires among never-users of family planning, to compare this with other contraceptive strategies, and to evaluate the cost aspects. If the potential of LAM to be a conduit to other modern contraceptive methods is effectively realized, the method can be profoundly important in the development of communities and in family formation. Because LAM is effective in preventing pregnancies, and because it extends the range of contraceptive choices, considering LAM on the policy level is always appropriate. Despite the array of drawbacks to LAM, as with any other family planning method, the potential assets of LAM, especially the promise to introduce nonusers to contraception, are sufficiently important to warrant the introduction of LAM within an operations research framework to both capitalize on its intrinsic strengths and determine its programmatic robustness. In the 10 years since the concept of LAM was pronounced as the Bellagio Consensus, claims have been made both for and against its use. During this time, program and policy leaders have been giv