By Leanna Mantella
August 21, 2019
Editor’s Note: During national breastfeeding month, we share the story of a couple that was thrilled to learn about lactational amenorrhea when other options for family planning did not meet their needs. This interview is part of our series that highlights the reality of using fertility awareness based methods (FABMs), including benefits as well as challenges of the various methods. Leanna Mantella, a 4th year medical student, conducted this interview as part of a two-week online elective with Dr. Marguerite Duane, executive director and co-founder of FACTS.
Introduction
During the preclinical years in medical school, my classmates and I learned about breastfeeding and its role in preventing ovulation—we call this lactational amenorrhea. The hormonal pathways were clearly outlined to us, and from an evolutionary perspective this all made sense. In order for a newborn to survive, a mother must direct her metabolic reserve toward nutrition for both herself and her offspring. During this time, a mother would not be able to meet the demands of nourishing herself and her baby while supporting another pregnancy.
Although I understood the mechanism behind lactational amenorrhea, it was not until Dr. Duane’s elective on FABMs that I gained a deeper understanding of its applications in the post-partum setting.
The Road to FABMs
I had the pleasure of working with a young couple, Mary-Anne and Stephen, toward the end of their second pregnancy. Mary-Anne was proactive about family planning and started to inquire about how she could delay her next pregnancy. However, along with her prudence came an element of discouragement. After her first pregnancy, the couple had asked about ways to delay a subsequent pregnancy. They expressed interest in lactational amenorrhea, as they had heard breastfeeding has the potential to delay ovulation, but she was only provided with a prescription for the “mini-pill” (a progestin-only pill that can be used for post-partum contraception). Her physician reassured her that the mini-pill would prevent pregnancy adequately, but only if she took it at the exact same time every day.
The couple encountered challenges with this method, as the stressors of a newborn and the busy schedule of a first-time mom prevented her from adhering to the mini-pill’s strict timing requirements. Consequently, the couple chose to abstain from sexual activity during the fertile window to delay pregnancy. When it came time for Mary-Anne and Stephen’s second pregnancy, they sought out more information about the Lactational Amenorrhea Method (LAM). They knew the mini-pill was not an ideal option for them, so they committed to learning about LAM.
Benefits of LAM
The Lactational Amenorrhea Method is a tool women may use to postpone pregnancy during the first six months of the post-partum period. LAM requires a mother to breastfeed exclusively or nearly exclusively, day and night, which may delay ovulation. In order to use this method successfully, her menstrual periods must not have returned (i.e., amenorrhea must be present), and the infant must be under six months of age. When these three criteria are met, LAM is 99.5% effective with perfect use and 98% effective with typical use. This degree of efficacy was comforting to Mary-Anne and Stephen, and they were excited about additional benefits of breastfeeding, including enhanced bonding and protection against neonatal infections. The couple also liked that this method can be used immediately after childbirth and does not interfere with sexual activity, unlike some of the other methods of natural family planning which rely on abstinence during the fertile period.
Challenges of LAM
As much as Mary-Anne and Stephen were looking forward to using LAM, this method was not without difficulty for the couple. Mary-Anne struggled with a poor milk supply in the early post-partum period. She felt stressed that she would not be successful with LAM and feared she would not be able to provide her newborn with adequate nutrition to grow and thrive. Yet, she was determined to breastfeed and worked diligently with a lactation consultant to increase her milk supply. It is important to note that in the setting of decreased breastfeeding, the risk of ovulation and subsequent pregnancy increases. The support and guidance of a lactation consultant can be extremely beneficial in this situation.
Mary-Anne and Stephen were content with their decision to use LAM and were successful with this method. This six-month period gave them time to adjust to the busy schedule of having a new infant in the home. It also provided time to ponder and educate themselves on the most suitable method to delay pregnancy to meet their needs.
Insights from a Future Physician
This elective has given me an interesting perspective on how women can recognize signs of fertility and use them to plan or delay pregnancy. Many women now delay pregnancy to achieve personal or career goals. As a future physician, it is reassuring to be informed about many of the natural methods of family planning available to meet the needs of patients who are interested in FABMs. I feel hopeful that I will be able to empower women through education, enabling them to identify their signs of fertility when they feel the time is right to become pregnant.
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Author Bio: Leanna Mantella is a 4th year medical student at Georgetown University School of Medicine who recently completed the FACTS elective. She is pursuing a career in family medicine, with a particular interest in women’s health.
PHYSICIANS AND MEDICAL STUDENTS!
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Here’s what your peers are saying about this unique elective…
“I highly recommend this elective to other medical students! Now that I have a much better understanding of the various FABMs, I am prepared to counsel and assist my future patients in determining which method is right for them.”
–Emily Krach, DO (participated in elective as a 4th year medical student)