Abstract
Introduction:
The lactational amenorrhea method (LAM) of postpartum contraception is more effective than typical use of condoms or birth control pills. However, LAM may be underutilized due to incomplete perinatal counseling.
Methods:
We compared perceptions of the effectiveness of postpartum contraceptives including LAM among U.S.-born nulliparous pregnant women recruited using social media for a trial (NCT04601987). We used descriptive statistics to summarize data.
Results:
Of 760 individuals screened, 627 were invited to participate, and 451 (72%) were enrolled. Most (81%) had a college degree; 79% intended to breastfeed for at least 1 month. Only 8% believed exclusive breastfeeding reduces the chance of pregnancy “a lot” within 6 months of delivery and 2% indicated that exclusive breastfeeding is typically more effective than birth control pills or condoms. Compared with those planning to use other postpartum contraceptives, the 17% of respondents who planned to use LAM were more likely to know that breastfeeding delays return of menses (84% versus 44%, p ≤ 0.0001) and provides protection from pregnancy until menses return (54% versus 22%, p ≤ 0.0001). Although 25% of those planning to use LAM believed exclusive breastfeeding reduces pregnancy risk by “a lot,” only 5% thought LAM is more effective than birth control pills and only 9% thought that it is more effective than condoms.
Conclusions/Implications:
First-time U.S. mothers are often unaware of breastfeeding's effects on menses and fertility. Clinicians providing counseling about postpartum contraceptive options should include more information on LAM.
Keywords: lactational amenorrhea, contraception, postpartum, breastfeeding, human milk
Introduction
Family planning is an essential component of postpartum health care, as interpregnancy intervals <18 months have been associated with adverse maternal and infant health.1,2 However, up to one-third of all U.S. pregnancies follow a short interpregnancy interval,3 and disparities in access to postpartum care and contraception vary by race, ethnicity, and insurance coverage.4,5 Improved access to postpartum care through Medicaid expansion is associated with lower rates of short interval pregnancy,6 particularly for Black individuals.7
Lactational amenorrhea method (LAM) is the original form of postpartum contraception. To use this method effectively, individuals should be exclusively feeding their infants their own breast milk, within 6 months of birth, and remain amenorrheic.8 When these criteria are met, LAM is highly effective.9,10 To best utilize lactational amenorrhea as a contraceptive method, individuals must be well informed about the criteria for use of LAM. We, therefore, assessed understanding of the comparative effectiveness and intended use of LAM for postpartum contraception among nulliparous pregnant women in the United States.
Materials and Methods
To assess knowledge and perceptions of the effectiveness of LAM compared with other postpartum contraceptives, we conducted a secondary analysis of baseline data from individuals recruited for a randomized trial comparing the effects of two prenatal counseling interventions. This study was reviewed and approved by the UC Davis IRB (institutional review board) and registered on ClinicalTrials.gov (Identifier: NCT04601987). Information regarding perceptions of the effectiveness of LAM was collected at study enrollment before receipt of any counseling interventions.
Individuals were recruited using social media advertisements on Facebook and Instagram. Interested individuals completed a screening questionnaire before enrollment. Inclusion criteria were U.S.-born nulliparous women with a singleton gestation of 27–37 weeks' gestation, age 18–40 years, able to read English, have reliable access to a telephone that can send and receive text messages, and have access to a device with internet. Exclusion criteria were multiple gestation, maternal conditions that might prevent breastfeeding (such as HIV, breast reduction surgery, mastectomy, conception occurring through assisted reproductive technology), surrogacy, or planning not to parent the infant after delivery. Participants were compensated for completing this survey with a $20 gift card.
Surveys collected sociodemographic information, infant feeding plans, and postpartum contraceptive plans. We assessed intentions to breastfeed by asking how long participants planned to breastfeed, in months. Participants who responded “0 months” or who did not respond to this question were categorized as not planning to breastfeed. To assess understanding of LAM criteria and effectiveness, we asked the following questions:
-
(1)
How much do you believe exclusive breastfeeding reduces a mother's chance of becoming pregnant within 6 months of delivery? Response options were “a lot,” “a little,” “not at all,” or “I do not know.”
-
(2)
Breastfeeding will delay my menstrual period after birth. Response options were “true,” “false,” or “I do not know.”
-
(3)
For breastfeeding to protect a mother from pregnancy, her baby cannot be fed anything but the mother's milk. Response options were “true,” “false,” or “I do not know.”
-
(4)
Breastfeeding only protects mothers from pregnancy until her menstrual periods have returned. Response options were “true,” “false,” or “I do not know.”
-
(5)
Typically, which does a better job protecting a mother from pregnancy? Response options were “exclusive breastfeeding,” “condoms,” or “I do not know.”
-
(6)
Typically, which does a better job protecting a mother from pregnancy? Response options were “exclusive breastfeeding,” “birth control pills,” or “I do not know.”
Consideration of LAM as a contraceptive method
-
(7)
Have you considered using breastfeeding to protect against pregnancy after delivery? Response options were “no, I have not considered it,” “no, it does not work,” “yes, I would like to use it as my only method,” or “yes, but I would also use condoms or another method.”
We categorized individuals considering LAM as those who selected “yes, I would like to use it as my only method” or “yes, but I would also use condoms or another method.” We used descriptive statistics to summarize these data and chi-square tests to assess the significance of differences in participant awareness of benefits of LAM by consideration of LAM as a contraceptive method. Statistical significance was defined as p < 0.05. All statistical analyses were conducted using SAS Enterprise Guide, Version 7.1. Copyright 2017 SAS Institute, Inc., Cary, NC.
Results
Sociodemographic characteristics
Of 760 individuals screened, 627 were invited to participate, and 451 (72%) enrolled (Table 1). The largest proportions of participants resided in the U.S. south (42%), identified as White (59%) or Black (20%), and held college degrees (81%). The average age of participants was 32 (±5) years and most (79%) intended to breastfeed for >1 month (Table 1).
Table 1.
Sociodemographic Characteristics of Nulliparous Pregnant Participants, 2021 (n = 451a)
| n (%) or mean ± SD | |
|---|---|
| Age, years | 32 ± 5 |
| Geographic region of residenceb | |
| Northeast | 68 (15.1) |
| Midwest | 81 (18.0) |
| South | 192 (32.6) |
| West | 87 (19.3) |
| Race/ethnicity | |
| African American/Black | 91 (20.2) |
| Asian | 25 (5.5) |
| Hispanic or Latina | 21 (4.7) |
| Mixed race | 33 (7.3) |
| Native American, Alaskan, Other | 7 (1.6) |
| White | 257 (58.5) |
| Education | |
| College or graduate degree | 364 (81.0) |
| Some college or 2-year degree | 59 (13.1) |
| High school or less | 26 (5.8) |
| Health insurance | |
| Private or employer | 326 (72.3) |
| Medicaid | 96 (21.3) |
| Military/Tricare or otherc | 29 (6.43) |
| Postpartum contraception pland | |
| Barrier methods | 150 (33.3) |
| Hormonal methods | 100 (22.2) |
| LAM | 76 (16.9) |
| Undecided | 68 (15.1) |
| Long-acting reversible contraception | 63 (14.0) |
| None | 61 (13.5) |
| Other | 16 (3.5) |
| Permanent contraception | 14 (3.1) |
| Intention to breastfeed | |
| Do not plan to breastfeed | 51 (11.3) |
| Plan to breastfeed 1 or more months | 358 (79.3) |
| Plan to breastfeed ≥12 months | 228 (50.6) |
Data were missing on age for n = 14, race/ethnicity for n = 7, education for n = 2, geographic regions for n = 23 participants, and birth control plan for n = 1 participant.
Geographic regions defined as follows: northeast (Connecticut, Maine, Massachusetts, New Hampshire, Rhode Island, Vermont, New Jersey, New York, and Pennsylvania), midwest (Illinois, Indiana, Michigan, Ohio, and Wisconsin, Iowa, Kansas, Minnesota, Missouri, Nebraska, North Dakota, and South Dakota), south (Delaware, Florida, Georgia, Maryland, North Carolina, South Carolina, Virginia, Washington, DC, West Virginia, Alabama, Kentucky, Mississippi, and Tennessee, Arkansas, Louisiana, Oklahoma, and Texas), and west (Arizona, Colorado, Idaho, Montana, Nevada, New Mexico, Utah, and Wyoming, Alaska, California, Hawaii, Oregon, and Washington).
Other includes answer responses of “military insurance,” “other,” or “I do not know.”
Percentage does not add to 100 as participants could select multiple responses.
LAM, lactational amenorrhea method.
Understanding of LAM
About half (50.3%, 227/451) of respondents were aware that breastfeeding can delay the return of menses. However, only 11.3% understood that exclusive breastfeeding is necessary to rely on LAM, and many (47.3%) did not know that exclusive breastfeeding is needed to reduce pregnancy risk. About one-third (28%) were aware that LAM is only effective until menses return; 42.4% indicated LAM was “a little” and 8.4% indicated “a lot” effective to protect against pregnancy in the first 6 months postpartum (Table 2).
Table 2.
Knowledge of the Lactational Amenorrhea Method of Postpartum Contraception Among Nulliparous Pregnant U.S. Women, 2021 (n = 451a)
| All participants |
Considering LAM as a postpartum contraceptiveb |
|||
|---|---|---|---|---|
| n = 450 (% of total) | No (n = 374, % of column) | Yes (n = 76, % of column) | p | |
| Breastfeeding will delay my menstrual period after my baby is born | <0.0001 | |||
| True | 227 (50.4) | 163 (43.6) | 64 (84.2) | |
| False | 63 (14) | 62 (16.6) | 1 (1.3) | |
| I do not know | 160 (35.6) | 149 (39.8) | 11 (14.5) | |
| For breastfeeding to protect a mother from pregnancy, her baby cannot be fed anything but the mother's milk | <0.0001 | |||
| True | 51 (11.3) | 28 (7.5) | 23 (30.1) | |
| False | 186 (41.3) | 158 (42.3) | 28 (36.8) | |
| I do not know | 213 (47.3) | 188 (50.3) | 25 (32.9) | |
| Breastfeeding only protects mothers from pregnancy until her menstrual periods have returned | <0.0001 | |||
| True | 126 (28) | 85 (22.7) | 41 (54) | |
| False | 148 (32.9) | 131 (35) | 17 (22.4) | |
| I do not know | 176 (39.1) | 158 (42.3) | 18 (23.7) | |
| How much do you believe exclusive breastfeeding reduces a mother's chance of becoming pregnant within 6 months of delivery? | <0.0001 | |||
| A lot | 38 (8.4) | 19 (5) | 19 (25) | |
| A little | 191 (42.4) | 138 (36.9) | 52 (69.7) | |
| Not at all | 101 (22.4) | 100 (26.7) | 1 (1.3) | |
| I do not know | 120 (26.7) | 117 (31.3) | 3 (4) | |
Data were missing for birth control plan for n = 1.
When asked, “have you considered using breastfeeding to protect against pregnancy after delivery?” those we categorized as considering LAM answered, “yes, I would like to use it as my only method,” or “yes, but I would also use condoms or another method.”
LAM, lactational amenorrhea method.
When asked to compare the effectiveness of LAM with condoms or birth control pills, most participants believed that condoms (87.3%) were more effective than exclusive breastfeeding and that birth control pills (87.8%) were more effective than breastfeeding to prevent pregnancy. Respondents who intended to use LAM as their primary method of postpartum contraception (76/451, 17%) had significantly greater understanding of the effects of breastfeeding on fertility than respondents intending to use other forms of contraception (Table 3).
Table 3.
Perceptions of the Comparative Effectiveness of Postpartum Contraceptives, 2021 (n = 451a)
| All participants |
Considering LAM as a postpartum contraceptiveb |
|||
|---|---|---|---|---|
| n = 450, % of total | No (n = 374, % of column) | Yes (n = 76, % of column) | p | |
| Typically, which does a better job protecting a mother from pregnancy? Condoms or exclusive breastfeeding? | <0.0001 | |||
| Exclusive breastfeeding | 10 (2.2) | 3 (0.8) | 7 (9.2) | |
| Condoms | 392 (87.3) | 330 (88.5) | 62 (81.6) | |
| I do not know | 47 (10.5) | 40 (10.7) | 7 (9.2) | |
| Typically, which does a better job protecting a mother from pregnancy? Birth control pills or exclusive breastfeeding? | 0.06 | |||
| Exclusive breastfeeding | 9 (2) | 5 (1.3) | 4 (5.3) | |
| Birth control pills | 395 (87.8) | 329 (88) | 66 (86.8) | |
| I do not know | 46 (10.2) | 40 (10.7) | 6 (7.9) | |
Data were missing for birth control plan for n = 1.
When asked, “Have you considered using breastfeeding to protect against pregnancy after delivery?” those we categorized as considering LAM answered “yes, I would like to use it as my only method” or “yes, but I would also use condoms or another method.”
LAM, lactational amenorrhea method.
However, even among those intending to rely on LAM, understanding of the three components of LAM was incomplete (Table 2). For example, 60% of those considering LAM were not aware that exclusive breastfeeding is a requirement of LAM, and 46% were unaware that breastfeeding is only protective until menses return.
Discussion
In this national survey of highly educated nulliparous pregnant U.S. women, we found that most were unaware of the essential components of the LAM contraceptive method. Even among individuals intending to rely on LAM as postpartum contraception, knowledge of the essential three components of LAM was incomplete, potentially increasing risk of unplanned pregnancy. Incomplete knowledge of LAM was also demonstrated in prior study where only 8% of postpartum Turkish women were aware of all three criteria for the LAM, and a majority (61%) stated that no health professional had ever provided any information about LAM as a contraceptive method.11
Worldwide, it has been estimated that 1.5 million women utilize LAM inappropriately, potentially leading to unplanned pregnancies.12 Comprehensive education about postpartum contraceptive options is important to prevent unplanned pregnancies and has been demonstrated to improve uptake of contraception after delivery.13 To improve awareness of LAM, pregnant and postpartum individuals should be counseled on all forms of postpartum contraception including LAM.14
Although LAM has been demonstrated to be an effective contraception in exclusively breastfeeding individuals for the first 6 months postpartum,8 few participants were aware that LAM is more effective than typical use of birth control pills or condoms.15 This is unfortunate, as breastfeeding has multiple long-term benefits for the health of both women and children.16 In a large multinational study, LAM users in multiple countries reported high satisfaction with LAM and that LAM was highly effective, preventing pregnancy with >98% efficacy.17,18 In contrast, our data indicate that even highly educated U.S. women underestimate the effectiveness of LAM compared with other postpartum contraceptives.
Strengths and limitations
This study is strengthened by the national sample of pregnant primiparous individuals recruited from all regions of the United States. Most participants (79%) intended to breastfeed for at least 1 month, which is similar to U.S. population estimates that 78% of U.S. infants are breastfed for at least 1 month.19 However, participants in this study differed from the U.S. population in important ways, which could potentially limit generalizability. Most participants were college educated. In addition, this study had less representation from Hispanic and mixed-race women than the U.S. population at large20; in contrast, the study had greater representation from Black and Indigenous women, who have historically been under-represented in clinical research.
Participation was limited to primiparous individuals who are comfortable communicating in English, reducing generalizability in some parts of the United States. Finally, the survey design did not allow for clarification of responses provided by individuals who may not have been familiar with LAM terminology, resulting in underestimation of intended users of LAM.
Conclusions
In conclusion, few U.S. pregnant women are currently aware of LAM, or its effectiveness compared with other postpartum contraceptives. This indicates that many patients may benefit from comprehensive counseling about postpartum contraception, including information regarding LAM. For those planning to rely on breastfeeding as a method of contraception, the essential components of LAM should be carefully and clearly explained.14
Acknowledgments
We thank and acknowledge Jonathan Ballard, Marykate Miller, and Angel Anene, who all assisted with this research study and provided administrative and operational support for the HealthyMoms study.
Authors' Contributions
A.H.-A. contributed to conceptualization, writing—original draft (lead), and writing—review and editing; M.J.C. was involved in conceptualization and writing—review and editing (equal); C.I. carried out writing—review and editing (equal); S.D.B. carried out writing—review and editing (equal); M.F. took charge of methodology, software, formal analysis (lead), and data curation; L.R.K. was in charge of conceptualization and writing—review and editing (equal); and E.B.S. was in charge of conceptualization (lead), methodology, investigation, resources, supervision, funding acquisition, and writing—review and editing.
Disclaimer
The contents of this publication are solely the responsibility of the authors and do not represent the official views of HRSA or the National Institutes of Health.
Disclosure Statement
No competing financial interests exist.
Funding Information
This study was supported by the HRSA R40MC35364 (PI: E.B.S.). A.H.-A. is supported by the National Institutes of Health (NOSI supplement to K23HD101550). A.H.-A. and L.R.K.'s work is supported by the National Center for Advancing Translational Sciences, National Institutes of Health (UL1 TR001860). L.R.K.'s effort was also supported by a Building Interdisciplinary Research Careers in Women's Health award, National Institutes of Health (K12 HD051958, PI Nancy Lane, MD]. S.D.B.'s work was supported in part by the HEAL-HER (Heart, BrEast, and BrAin Heath Equity Research) Program funded by a Wyeth Settlement award to UC Davis.
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