Is a Lactational Amenorrhea Method ( ) C ff (LAM) User Card an effective strategy for improving LAM uptake and facilitating the transition to other FP methods? methods? Justine A. Kavle, Donald Cruz, Miriam Betancourt, Rebecka LundgrenGeorgetown University, IRH and MOH, Guatemala

Presenter: Rebecka Lundgren2011 International Conference on Family Planning Dakar Senegal2011 International Conference on Family Planning Dakar, Senegal

E X P A N D I N G F A M I L Y P L A N N I N G O P T I O N S

What is LAM

• Modern and effective method of family planning (FP), Modern and effective method of family planning (FP), based on natural effect of breastfeeding on fertility

• LAM criteria1. Menstruation has not returned2. Mother is only breastfeeding 3 Baby is less than 6 months3. Baby is less than 6 months

LAM Efficacy LAM Efficacy 6m Post-partum

90%

100%99.6% 99.5% 99.4% 99.0% 98.8% 98.5%

LAM Efficacy

70%

80%

90%

50%

60%

(Rwanda measured LAM effectiveness at 9-months post-partum)

LAM supports exclusive breastfeeding: Dual benefits for mother and babyDual benefits for mother and baby

Supports growth and developmentSupports growth and development

Stimulates oxytocinrelease causing

Stimulates oxytocinrelease causing

Prevents neonatal and infant mortalityPrevents neonatal

and infant mortality

guterine contraction

to reduce postpartum blood

loss

guterine contraction

to reduce postpartum blood

losslossloss

LAM ti LAM ti Prevents neonatal and infant illness

(diarrhea, respiratory

Prevents neonatal and infant illness

(diarrhea, respiratory

LAM promotion increased

percentage of women that

l l

LAM promotion increased

percentage of women that

l l

Leon-Cava et al, 2002 Horta et al, 2007, McKaig, C., Baqui A, et al., MCHIP, 2010

respiratory infection)

respiratory infection) exclusively

breastfeed exclusively breastfeed

LAM users were more likely to use contraceptives at 12 months postpartum Jordanat 12 months postpartum, Jordan

*Multicenter: ~ 68% use FP at 9 and 12 months

8090100 *Brazil: After LAM introduction, at 12 months, lower % women

not using FP (pre-post) p<0.0001.

4140506070

2313 14

10203040

0LAM BFFP Traditional No FP Use

Bongiovanni et. al 2005, Hardy et al, 1998, Hight-Laukaran et al, 1997BFFP = Breastfeeding for family planning

Challenges in Recording LAM UseChallenges in Recording LAM Use

Zambia 2007Mali 2006

Full Breastfeeding Rates v. LAM use

M li 2006

Nigeria 2003

Guinea 2005

Haiti 2005-2006

Madagascar…

India 2005-2006

Ghana 2003

Madagascar 2003-2004

Guinea 2005

Rwanda 2005

Ethiopia 2005

Tanzania 2004-…

Rwanda 2005

Ghana 2003

Mali 2006

Uganda 2006

Ethiopia 2005

Malawi 2004

Nigeria 2003

India 2005-2006

Kenya 2003

Malawi 2004

Pakistan 2006-…

Uganda 2006

p

Tanzania 2004-2005

Bangladesh 2007

DR Congo of 2007

Pakistan 2006-2007

Zambia 2007

0 20 40 60 80 100

Bangladesh 2007

Congo, DRC 2007

India 2005-2006

0 20 40 60 80 100

Kenya 2003

Haiti 2005-2006

Tanzania 2004-2005

Percent of women 3.0 to 5.9 months postpartum who are full breastfeedingDHS Analysis, 2003-2007

Percent of women using LAMDHS Analysis, 2003-2007

Challenges for integrating LAM into g g gFP and MCH programs

Demographic Health Survey (DHS) analysis ACCESS‐FPDemographic 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

L l t f LAM b tf di f f il l i‐ Local term for LAM  = breastfeeding for family planning

LAM is an underutilized method despite effectiveness‐ Providers’ knowledge and training are lowProviders 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

Study Background

• LAM is offered in Guatemala, but health LAM is offered in Guatemala, but health providers and users often mistakenly believe breastfeeding = LAM.

• Confusion exists among providers and • Confusion exists among providers and users regarding LAM effectiveness and the 3 criteria for use.

P d l f h LAM • 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 p glikely misreported as LAM users.

Study PurposeStudy PurposeTo examine if introducing a LAM user card can improveimprove…• 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 stakeholder perceptions

regarding LAM

Study Design

Training of MOH P id

Counseling and recording LAM users Providers recording LAM users

MaterialsIntervention:

LAM user cardMOH LAM brochure

Control:MOH LAM brochure

LAM knowledge, use, LAM knowledge, use,

Outcomes:User, provider, stakeholder

LAM knowledge, use, timely transition

Provider knowledge, counseling, recording

LAM knowledge, use, timely transition

Provider knowledge, counseling, recordingstakeholder

Stakeholder perceptions Stakeholder perceptions

Family planning user card

• LAM assigned a separate code in 2008• LAM assigned a separate code in 2008 • Card frequently out-of-stock

LAM User Card – Intervention Group

Standard card given to both groupsMOH LAM BrochureInside page Front page

Study Implementation: Intervention challenges2011 2012

April July Sept. March

LAM provider training (some cards distributed)

X

Refresher training XRefresher training (revised card distributed)

X

Fidelity check X

Service statistics (April 2010 through March 2012)

X

March 2012)

Interviews with providers, users, stakeholders

X

stakeholders

Data collected to check intervention fidelity

In-Depth Structured Interviews Focus

y

interviews Stakeholders

(#)

Groups with LAM

users(#)

LAM Users

HealthProviders (#)Users

(#) Providers

(#)

Control 10 30 1Control Group

10 30 1

InterventionGroup

26 44 1Group

Total 6 36 74 2

Perceptions of LAM and user card

P i l P i l

In-depth interviews with stakeholders (N=6) Potential

to integrate

LAM

Potential to

integrate LAM

Many women breastfeed and are likely to adopt another FP method later.

stakeholders (N 6)

Barriers to

i l

Barriers to

i l

Even with training providers may still not understand the 3 criteria.

Provider bias – “Depo Provera is most implemen-ting LAM

implemen-ting LAM

pused and most discreet.”

Time for counseling – “easier to give injection.”

Different forms are used, which

Difficulties recording

LAM

Difficulties recording

LAM

can be lost.Quality and timeliness of data reporting is lacking for all FP.Tendency to record all post-

t LAM partum women as LAM users

+ and – of LAM user + and – of LAM user

Visual resonates with women, most (5) thought would improve recording, monitoring is possible

i h ki i f LAM user card

LAM user card

with tracking appointments of userPrinting is expensive and getting providers

to use it would be challenging

Provider interviewsKnowledge of conditions for LAM use and transition

96

Intervention Group N = 44 Control Group N = 30

93

89

93 93

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”

Provider interviews

Intervention Group = 44 Control Group = 30

Provider interviewsOffering LAM – when and how

7786 91

667080

8777

p p

66

15.9

Offer LAM-last 3 months

Offer LAM antenatal care

Offer LAM postpartum

MOH Brochure to

talk about LAM

LAM user card to talk about

LAM

Provider interviewsImpact on counseling and recording

Use of LAM card to counsel • 27% of providers had LAM cards in stock

Impact on counseling and recording

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 homewomen 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%)

R d d LAM i d il i (30% 20%) • Recorded LAM users in daily register (30% vs 20%)

When women received LAM messages

LAM user interviewsg

• Most received LAM messages during prenatal care • 63% - intervention

75% l• 75% - control

• About half received LAM messages during postnatal care • 50% - intervention• 60% - in control

LAM user interviews

(n=36)

Knowledge of conditions for LAM use and transition

60

70

25

11

Breastmilk only Until 6 months Until menses returns New method at 6 months

Fidelity Testing: I l d Intervention not implemented

LAM d di ib d • 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 Few LAM users reported (although

improved)• Providers report no official guidance

received regarding user cardreceived regarding user card• Not all staff trained (rotation,

vacation)

Next steps

• Provide feedback to MOH authorities

• Share results with providers

• Monitoring visit facilities to ensure stock of reporting forms and user cardp g

• Continue collecting service statistics from gcontrol and experimental health centers

• At 6 months conduct interviews with stakeholders, providers and users

Lessons LearnedLessons 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)( g )

• Key factor in associated with correct reporting is strong MOH leadershipp g g p

• Knowledge of LAM criteria, including transition high among providerstransition high among providers

Thank youThank you

For more information

www.irh.org