Is Lactational Amenorrhea Method (LAM) User Card an effective strategy for improving LAM uptake and facilitating the transition to other FP methods?
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This document discusses a study evaluating whether introducing a Lactational Amenorrhea Method (LAM) user card improves uptake of LAM and facilitates transition to other family planning methods. The study found that while knowledge of LAM criteria was high among providers, recording of actual LAM users was low. Introducing a LAM user card showed potential to improve monitoring but faced challenges with stockouts and lack of official guidance. Fidelity testing found the intervention was not fully implemented as intended. Overall the study highlights the importance of strong health systems and leadership to support accurate reporting.
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Is Lactational Amenorrhea Method (LAM) User Card an effective strategy for improving LAM uptake and facilitating the transition to other FP methods?
- 1. Is a Lactational Amenorrhea Method (LAM) User Card an effective strategy for improving LAM uptake and facilitating the transition to other FP methods? Justine A. Kavle, Donald Cruz, Miriam Betancourt, Rebecka Lundgren Georgetown University, IRH and MOH, Guatemala Presenter: Rebecka Lundgren 2011 International Conference on Family Planning Dakar, Senegal EXPANDING FAMILY PLANNING OPTIONS
- 2. What is LAM • Modern and effective method of family planning (FP), based on natural effect of breastfeeding on fertility • LAMMenstruation has not returned 1. criteria 2. Mother is only breastfeeding 3. Baby is less than 6 months
- 3. LAM Efficacy LAM Efficacy 6m Post- partum 99.6% 99.5% 99.4% 100% 99.0% 98.8% 98.5% 90% 80% 70% 60% 50% (Rwanda measured LAM effectiveness at 9-months post- partum)
- 4. LAM supports exclusive breastfeeding: Dual benefits for mother and baby Supports growth and development Stimulates oxytocin release causing Prevents neonatal uterine contraction to and infant mortality reduce postpartum blood loss LAM promotion Prevents neonatal increased percentage and infant illness of women that (diarrhea, respiratory exclusively infection) breastfeed Leon-Cava et al, 2002 Horta et al, 2007, McKaig, C., Baqui A, et al., MCHIP
- 5. LAM users were more likely to use contraceptives at 12 months postpartum, Jordan *Multicenter: ~ 68% use FP at 9 and 12 months 100 *Brazil: After LAM introduction, at 12 months, lower % 90 women not using FP (pre-post) p<0.0001. 80 70 60 50 41 40 30 23 20 13 14 10 0 LAM BFFP Traditional No FP Use Bongiovanni et. al 2005, Hardy et al, 1998, Hight-Laukaran et al, 1997 BFFP = Breastfeeding for family planning
- 6. Challenges in Recording LAM Use Full Breastfeeding v. LAM use Mali 2006 Rwanda 2005 Rates Zambia 2007 Madagascar… Guinea 2005 Haiti 2005-2006 Madagascar 2003-2004 Guinea 2005 Ghana 2003 Nigeria 2003 India 2005-2006 Mali 2006 Nigeria 2003 Ghana 2003 Malawi 2004 Rwanda 2005 Ethiopia 2005 Tanzania 2004-… Uganda 2006 Ethiopia 2005 Zambia 2007 Uganda 2006 Pakistan 2006-2007 Pakistan 2006-… DR Congo of 2007 Malawi 2004 Bangladesh 2007 Kenya 2003 Tanzania 2004-2005 India 2005-2006 Haiti 2005-2006 Congo, DRC 2007 Kenya 2003 Bangladesh 2007 0 20 40 60 80 100 0 20 40 60 80 100 Percent of women 3.0 to 5.9 months Percent of women using LAM postpartum who are full breastfeeding DHS Analysis, 2003-2007 DHS Analysis, 2003-2007
- 7. Challenges for integrating LAM into FP and MCH programs Demographic Health Survey (DHS) analysis, ACCESS-FP - High levels full breastfeeding, yet low LAM use - Poor breastfeeding practices require reinforcement for LAM use Confusion that breastfeeding = LAM - Women believe breastfeeding protects them from pregnancy - Local term for LAM = breastfeeding for family planning LAM is an underutilized method despite effectiveness - Providers’ knowledge and training are low - Women and health workers believe LAM is not effective - Few programs offer LAM Winfrey and Borda, 2010, Tilley et al. 2009
- 8. Study Background • LAM is offered in Guatemala, but health providers and users often mistakenly believe breastfeeding = LAM. • Confusion exists among providers and users regarding LAM effectiveness and the 3 criteria for use. • Providers rarely confirm that LAM users know and meet the criteria. • LAM users may not use LAM correctly or do not transition to another FP method when any of the criteria change. • Postpartum, breastfeeding women are likely misreported as LAM users.
- 9. Study Purpose To examine if introducing a LAM user card can improve… • LAM users‟ and providers‟ knowledge of the three criteria and when to transition another FP method • uptake of LAM • recording of LAM users by providers • stakeholder perceptions regarding LAM
- 10. Study Design Counseling and Training of MOH recording LAM Providers users Intervention: Control: Materials LAM user card MOH LAM brochure MOH LAM brochure LAM LAM knowledge, use, timely knowledge, use, timel transition y transition Outcomes: Provider Provider User, provider, sta knowledge, counselin knowledge, counselin keholder g, recording g, recording Stakeholder Stakeholder perceptions perceptions
- 11. Family planning user card • LAM assigned a separate code in 2008 • Card frequently out-of-stock
- 12. LAM User Card – Intervention Group
- 13. MOH LAM Brochure Standard card given to both Front page groups Inside page
- 14. Study Implementation: Intervention challenges 2011 2012 April July Sept. March LAM provider training X (some cards distributed) Refresher training X (revised card distributed) Fidelity check X Service statistics X (April 2010 through March 2012) Interviews with X providers, users, stakeholders
- 15. Data collected to check intervention fidelity In-Depth Structured Interviews Focus interviews Groups Stakeholder with LAM s (#) LAM Health users Users Providers (#) (#) (#) Control 10 30 1 Group Intervention 26 44 1 Group Total 6 36 74 2
- 16. Perceptions of LAM and user card In-depth interviews with stakeholders (N=6) Potential Many women breastfeed to and are likely to adopt integrate another FP method later. LAM Even with training providers may still not understand the 3 criteria. Provider bias – “Depo Provera is most Barriers to used and most discreet.” implemen- ting LAM Time for counseling – “easier to give injection.” Different forms are used, which can be lost. Difficulties Quality and timeliness of data recording reporting is lacking for all FP. LAM Tendency to record all post- partum women as LAM users Visual resonates with women, most (5) thought would improve recording, monitoring is + and – of possible with tracking appointments of user LAM user card Printing is expensive and getting providers to use it would be challenging
- 17. Provider interviews Knowledge of conditions for LAM use and transition Intervention Group N = 44 Control Group N = 30 96 93 93 93 89 83 Period not returned Fully / nearly fully BF Baby less than 6 months **When a woman no longer meets LAM criteria, all providers, in both groups, gave advice to “immediately use another method”
- 18. Provider interviews Offering LAM – when and how Intervention Group = 44 Control Group = 30 91 87 86 77 80 77 70 66 15.9 Offer LAM- Offer LAM Offer LAM MOH LAM user last 3 months antenatal postpartum Brochure to card to talk care talk about about LAM LAM
- 19. Provider interviews Impact on counseling and recording Use of LAM card to counsel • 27% of providers had LAM cards in stock at time of interview • < ½ showed the card during counseling and most of these providers gave women cards to take home Reasons for not using LAM card to counsel • Had stock-out of LAM cards • Had no time to counsel • No directive from the health authorities. • Were not present for the training Recording of LAM users weak, though better in intervention group • „Ever recorded‟ a LAM user (18 % vs. 13%) • Recorded LAM users in daily register (30% vs 20%)
- 20. LAM user interviews When women received LAM messages • Most received LAM messages during prenatal care • 63% - intervention • 75% - control • About half received LAM messages during postnatal care • 50% - intervention • 60% - in control
- 21. LAM user interviews Knowledge of conditions for LAM use and transition (n=36) 70 60 25 11 Breastmilk only Until 6 months Until menses returns New method at 6 months
- 22. Fidelity Testing: Intervention not implemented • LAM user cards not distributed to providers • FP user cards out of stock • Providers report lack of time to record FP users • Few LAM users reported (although improved) • Providers report no official guidance received regarding user card • Not all staff trained (rotation, vacation)
- 23. Next steps • Provide feedback to MOH authorities • Share results with providers • Monitoring visit facilities to ensure stock of reporting forms and user card • Continue collecting service statistics from control and experimental health centers • At 6 months conduct interviews with
- 24. Lessons Learned • Measuring intervention fidelity is critical • Health system weaknesses trump stakeholder buy-in and best intentions • Challenges of relying on print materials (design, stock-outs, distribution) • Key factor in associated with correct reporting is strong MOH leadership • Knowledge of LAM criteria, including transition high among providers
- 25. Thank you For more information www.irh.org
Notas del editor
- LAM has multiple benefits….Emerging evidence from the healthy fertility study indicate that within the context of LAM promotion, higher percentage of women exclusively breastfeed in intervention area (integrated MNCH care with FP), compared to a control group (MNCH) (p <0.01)
- There is evidence of LAM’s impact in increasing and sustaining contarceptive use in the late postpartum period. This was statistically significant – relationship….Looking at the multicenter study, 68% of women used FP at 9 and 12 months PP, and in Brazil, at 12 months PP, following LAM introduction, a significantly lower % of women were not using FP after the LAM introduction into postpartum care, than before. After controlling for age, number of living children marital status and years of schooling. LAM users had high rates of modern contraceptive use than those using breastfeeding for FP, but did not know all the LAM criteria, and vs women that used traditional methods ( withdrwal, abstinence) and no family planning at all…. Characteristics related to transition among LAM users are: more likely to have used a modern modern, less likely to have only one childMore likely to either be poor or highly education than non-transitioners/
- “ Do ability” of LAM is shown by DHS in several countries, however accurate perceptions and measurement of LAM is problematic, and there are barriers that contribute to the underutilization of LAM.
- Questions 5,6,7 in provider interview form.
- Less than half ( 43%). These data are from quesitons 37-41 (provider interview).Recording -
- The high ever use of LAM (higher than intervention group) could help explain the higher knowledge of LAM in the control area.
- – from asking women to tell what they know about LAM (Question 26), and the frequency with which they could spontaneously cite the 3 conditions and what they know of the method. Though intervention group were able to recall less often only breastmik, LAM lasts 6 months of age, and LAM protects against pregnancy, this is because they also cited additional benefits such as LAM is natural, LAM has no side efects, LAM is affordable (4%) – not on slide27% of women in intervention could not recall (when asked tell me what you know about LAM) and 20% of women in the control group – so there are women not characterized here – that didn’t know or couldn’t remember. Reason why higher in control group for the first 3? – need to ask Donald…