The Practice of Lactational Amenorrhea as a Method of Contraception among Women in Upper Egypt: A Cross- Sectional Study View PDF

Family planning is critical for the health of women and their families and it can accelerate a country’s progress towards reducing poverty and achieving development goals. Because of its importance, universal access to reproductive health services, including family planning, is identified as one of the targets of Sustainable Development Goals (SDGs) [1].

It is estimated that among the annual 150 million pregnancies in the world, about 40% of them are unintended and that the major part of these are unwanted [2]. Epidemiological studies suggest that postpartum women are among the most highly vulnerable to unintended pregnancy [3].

The intersection between family planning and breastfeeding creates an opportunity to improve both maternal and child health outcomes during the postpartum period and to encourage women to practice healthy timing and spacing of pregnancies [4]. An evidence suggests that LAM practicing may result in better breastfeeding practices [5].

Lactational Amenorrhea Method is a family planning option of potential importance in low-resource communities and developing countries, including Egypt [6], where the mother is informed and supported in how to use breastfeeding for contraception. This method is available and accessible to many women [7].

Scientists proposed that women who breastfeed fully or nearly fully while they remain amenorrhoeic in the first six months’ postpartum experience high rate of protection from pregnancy. This means that 5 of 100 women who used LAM typically may become pregnant unintended within the first six months after child birth, whereas less than one to two may become pregnant within the same period with perfect use [8].

In order to provide double benefit of exclusive breastfeeding and prevention of pregnancy, it is necessary to improve practice of lactational amenorrhea method among women in reproductive age to improve its effectiveness. The present study aims to determine the proportion of the studied women attending El-Waledia Health Center, Assiut city who use lactational amenorrhea method and investigate factors determining knowledge, attitude and practice of LAM among the studied women.

Study Design

The study was a cross sectional study.

Study Site

The study conducted at El-Waledia Health Center, Assiut city.

Study Population

The target was women in the reproductive age (15-45 years) who have at least one living child less than 5 years’ old and had attended El Walidia health care center for family planning, gynecological or antenatal care within the study period.

Study Duration

The study started in 1^st November 2017 till 30^th April 2018.

Sample Size and Sample Technique

Sample size was calculated using EPI INFO version 7 software (Center for Disease Control and Prevention, Atlanta, Georgia USA). Calculation resulted in a sample of 384 women (confidence interval 95% and power 80%) and it was increased to 400 to safeguard dropouts.

The data were collected in selected three days per week (where the researcher was available). All eligible women who came to the center at those days were invited to participate in the study.

Study Tool

A structured questionnaire was used which included questions about: Socio-demographic characteristics of women: (e.g. age, residence, employment, education, religion and type of family (nuclear or extended) etc.).

Practice of LAM: the women were asked first about breastfeeding practice then women who currently or ever breastfed their children were asked about using LAM. Also, the women were asked about getting pregnant while using LAM to detect malpractice and failure rate of LAM. The questionnaire was prepared after reviewing the literature. It was pretested by a pilot test with 15 women who were not included in the research. It was pretested for any difficulties and to estimate time needed to complete the questions and it was revised accordingly.

Data Collection

Data were collected through personal interview with each woman. The interview took 15-20 minutes.

Operational Definitions

Lactational amenorrhea method (LAM): It is a modern and temporary contraceptive method that is based on the natural infertility that results from breastfeeding [9].

LAM is defined by three criteria:

• The baby is under six months of age.
• The mother is still amenorrheic.
• Practicing exclusive breastfeeding on demand, day and night.

Current LAM user: Breastfed woman who use LAM at the time of interview.

Previous LAM user: Woman who currently not breastfed but have an experience of breastfeeding and LAM using.

Ever LAM user: Woman who currently or previously breastfed and reported use of LAM.

Correct LAM user: Self- reported LAM user who meet practice criteria.

Incorrect LAM user: Self-reported LAM user but did not meet the practice criteria [10].

Passive LAM user: Woman who satisfied the three elements of LAM, did not report use of another method and did not report relying on prolonged breastfeeding as a method of family planning [6].

Method failure: When woman get pregnant while using LAM correctly.

User failure: When woman get pregnant while using LAM incorrectly [11,12].

Reviewing the proposal was carried out before starting data collection via the Ethical Review Committee of Assiut Faculty of Medicine. Official approval was obtained from the Assiut Directorate of Health and Population. The aim of the study was explained to the participants before filling the questionnaire. An oral informed consent was obtained from the study participants prior to the interview and this was not in any way influenced their clinical services or treatment. Privacy and confidentiality of all data was assured.

Data entry and analysis were carried out using Statistical Package for the Social Sciences (SPSS) for windows version 16 (SPSS Inc., Chicago, Illinois, USA). The descriptive statistics included percentages, means and standard deviations were calculated. Investigation of factors determining the practice of women were carried out by bivariate analysis (using chi-square test/ fisher exact test) and multivariate logistic regression. The dichotomous summary variables ever using LAM were the dependent variables. The results were considered significant at P-value <0.05.

The current study is a cross sectional study so it allows recall and reported bias and generalizability of its findings cannot be applicable.

Table 1 shows breastfeeding practice of studied women, there were 42.5% of studied women currently breastfed their children. The results found that the vast majority of multiparous women (97.7%) previously breastfed at least one of their children. Generally, the majority of studied women (92.5%) reported that they ever breastfed their children. Practice of LAM among breastfed studied women is shown in Table 2. There were 15.3% of currently breastfed women using LAM for contraception, while among previously breastfed women 38.5% used LAM before. Approximately 36% of ever breastfed women ever use LAM for contraception. Out of currently breastfed women there were 1.2% fulfilled the criteria of LAM but did not report relying on it for contraception and did not use another method. Figure 1 shows that only 9.1% of women who ever using LAM (currently and previously users) were correct LAM users. Table 3 presents relationship between practice of LAM and sociodemographic characteristics of the studied women. The table shows that the percentage of women who practiced LAM decreased with increase age (p-value=0.276) and with increasing level of husband education but the difference was not statistically significant (p-value=0.103).

Table 1: Breastfeeding practice among studied women attended El Waledia Health Center, Assiut City, 2018.

Table 2: Lactational amenorrhea method practice among breastfed women attended El Waledia Health Center, Assiut City, 2018.

*Lactational Amenorrhea Method.

** Women who fulfilled the three elements of LAM, did not report use of another method and did not report relying on breastfeeding as a method of family planning.

Table 3: Pattern of lactational amenorrhea method practice among previously users' women attended El Waledia Health Center, Assiut City, 2018.

*Lactational Amenorrhea Method

The percentage of women who practiced LAM was decreasing with increased level of the women education (p-value=0.024). On the other hand, LAM use was significantly increased among rural residents (p-value=0.000) and not working women (p-value=0.013).

As regard religion, the researchers found that 40.8% of Muslims practiced LAM before, while 82.4% of Christians did not practice LAM before with statistically significant difference (p-value=0.009). The pattern of LAM practice among the women who previously used this method is shown in Table 4. Only 9.2% of them were correct LAM users. About one third of reported LAM users had unintended pregnancy due to incorrect use (user failure). Table 5 shows that the only significant predictors of practice of lactational amenorrhea method were residence and number of children as women living in rural area had significantly greater odds of practicing LAM than urban women (OR=2.37, CI=1.15 to 3.98, p=0.017) and mothers had more than three children significantly had greater odds of LAM use in comparison with those had one to three children (OR=2.45, CI=1.37 to 4.51, p=0.003).

Table 4: Relationship between practice of lactational amenorrhea method and the sociodemographic characteristics of studied ever breastfed women attended El Waledia Health Center, Assiut City, 2018.

N.B. Ever breastfed women (n=370)

Table 5: Factors affecting practice about lactational amenorrhea method of studied women attended El Waledia Health Center, Assiut City, 2018.

*OR: Odds Ratio

 **CI: Confidence Interval

The Lactational Amenorrhea Method (LAM) is a modern, temporary family planning method that has been developed as a tool to help support both breastfeeding and family planning use. In the current study about 98% of the studied women breastfed their children before, this was in agreement with the results of many studies. According to EDHS 2014, 96% of last-born children born in two years preceding the survey were ever breastfed [13]. A cross sectional study conducted in Isfahan urban health centers showed that 81.9% of children were fed by breastfeeding [14]. The study which was conducted among women in Leon, Mexico, showed a high rate of breastfeeding following the delivery (92.8%) [15].

The present study revealed that more than one third of the breastfed mothers practiced LAM. It shows that 39.8% of LAM users were in the age group 25 and less than 30 years and 37.4% aged from 30 to less than 40 years. This finding agrees with the results of Chris E, et al. (2013) [16], as 32.4% of LAM users in their study were between the ages of 25 and 30 and 50.7% were between the ages of 31 and 35 and 12.7% were between the ages of 36 and 40 years. On the other hand, the percentage of women who practiced LAM in the current study was significantly decreasing with the increased level of women education, urban residents and working women. It was found that 40.8% of Muslims practiced LAM before compared to 82.4% of Christians and LAM users had more than children (45.3%). These findings were in disagreement with the results of the previous study as they found that most of their studied women had high education (66.2%), employed (71.8%), from nuclear family (62.0%), Christians 95.8%, and resides in the urban (60.6%) and multi-parous (78.9%) [16].

Also, in Sub-Saharan Africa rural women practiced the lactational amenorrhea method significantly more often than urban residents while the use of LAM method was significantly increased with the number of living children in both religious groups [17]. In a study done in South-Eastern Hungary with the use of postpartum contraceptives, 40.2% of women were relying on lactational amenorrhea [18].

In the present study most of previous LAM users did not satisfy the three criteria of LAM (90.8%). This result in agreement with the findings of other studies. In a study conducted in Amman, Jordan one-third of the respondents relied on breastfeeding as the first method of family planning in the six months following the birth of their child. Of these women, those who satisfied all three LAM criteria were which represent 7% of all respondents used LAM and this was in line with the results of the current study [19].

In a study conducted in Eastern Turkey by Türk R, et al. (2010) [20], and his team, 34% of their studied women used LAM to prevent pregnancy after childbirth. However, only 17.2% of those women fulfilled the LAM criteria with success, and 82.8% did not fulfill one or more of the LAM criteria [20].

Fabic MS, et al. (2013) [21], found that 0.8% of all women in data of 73 DHS conducted in 45 countries between 1998 and 2011 were LAM use and only 25.5% of them met the correct practice criteria. While, 3.7% of all respondents met the correct LAM practice criteria [21].

These results may be approximately similar in the low-income countries as Egypt that have similar social and cultural dynamics, with high fertility rates, similar breastfeeding behaviors, low per capita income, and societies where women have little control over their own fertility. These findings may be broadly generalizable to similar populations in these countries [10].

The current study found that 1.2% of studied women were not using any of the contraceptive methods and fulfill all of LAM criteria (passive LAM users) while in a study in Cairo there was 16.9% had unacknowledged (passive) LAM [22]. Khella AK, et al. (2004) [6], and his colleagues reported a widespread use of what they called "passive LAM" [6]. A study conducted in Egypt revealed that women of low empowerment index in household decisions were more likely to use passive LAM as of 152 nursing mothers met LAM criteria, of them passive LAM users constituted 79.1% [23]. This may be similar to the rural women in the present study.

Pregnancies occurred when all the prerequisites of the lactational amenorrhea method of contraception were present. This “failure rate” is in keeping with that described by the WHO. The number of pregnant women who implemented the three components were significantly lower than those who implemented one or two of the components effectively [16].

In the current study the failure rate among studied women who practiced LAM correctly (method failure) was zero. On the other hand, the incidence of pregnancy was 30.8% among LAM users (users’ failure). In another study in rural Egypt, the incidence of unintended pregnancy among LAM users was 29% while the method failure was 1.5% [24]. Also, in Turkey, the incidence was recorded as 32.8% [20]. Etuk SJ, et al. (2003) [25], reported 30% incidence of unintended pregnancy in a survey in Calabar, Nigeria. All these results were in agreement with current results.

On the other hand, the incidence of unintended pregnancy was 14.3% among LAM users as found by Chris E, et al. (2013) [16]. This value is relatively lower than that of the present study, this difference observed could probably be due to variations in some socio-demographic variables among the different populations under study.

This study revealed that the vast majority of the participants mentioned that they can depend on breastfeeding as a method of family planning up to return of menstruation). About one third of studied women reported ever using LAM. Practicing of LAM was higher in women from rural residence, not working women and women with low educational level. Unintended pregnancy was reported in about one third of LAM users due to incorrect practicing.

According to the findings of the study, the followings are recommended that health care providers should encourage mothers to breastfeed their children under an umbrella of Maternal and Child Health care (MCH) program by providing women counseling on the benefits of LAM as a family planning method. Health care providers should give the women good counseling about lactational amenorrhea method (LAM) that should remain one of the options offered to breastfeeding women with stress on its criteria and when it becomes ineffective.

The authors declare that they did not receive any funds in design of the study and collection, analysis, and interpretation of data and in writing the manuscript.

There is no conflict of interest.

The researchers acknowledge all the women who participated in this study for their time.

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