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Indian Journal of Community Medicine

Knowledge and Attitude on Lactational Amenorrhoea Method as a Contraceptive Device among Nursing Students

Author(s): A.K. Brogen1, Hmingthanzuala1, T. Anichari1, T. Achouba1, N.N. Singh2

Vol. 31, No. 2 (2006-04 - 2006-06)

Introduction

It has been estimated that 50% of pregnancies are unwanted and/or unplanned. For several reasons including difficulty in obtaining contraceptives, no or ineffective contraception is used to prevent these unwanted pregnancies.1 Even though women have known for centuries that breast feeding has a contraceptive effect, family planning has only recently promoted it.2 At a consensus conference in Bellagio, Italy, sponsored by Family Health International, the Rockfellar Foundation and the World Health Organisation it was agreed that breast feeding confers more than 98% protection from pregnancy during the first 6 months postpartum.3 The lactational amenorrhoea method (LAM) is a highly efficient tool for the women to utilise; physiology to space births as suckling induces a reduction in gonadotropin releasing hormone, luteinizing hormone and follicle stimulating hormone release, resulting in amenorrhoea, through an intracerebral opiod pathway.4

However the efficacy and effectiveness of LAM is affected by its correct usage and there are certain criteria which must be fulfilled.3 The present cross sectional study was undertaken to assess the knowledge and attitude on LAM among the nursing students.

Material and Methods

This cross sectional study was conducted during the month of August and September 2003. The only two biggest nursing schools of Manipur, Bethesda School of Nursing, Churachandpur and GNM School of Nursing, Imphal was included in the study. The study population comprised of only the third year students as the topic has already been covered in their academic courses and they are more likely to have contact with people soon. After obtaining permission from the concerned authority the semi-structured (open ended/ closed ended) questionnaires were distributed to the students and collected soon after they finished it. Then the answers were explained and lectures were given on the importance of breast feeding and LAM. The questionnaire comprised of 22 questions regarding the various aspects of knowledge and attitude regarding LAM. However, 2 questions were not used in the scoring and analysis. A score was constructed for knowledge based on the 20 questions. The total possible score a respondent could get was 25. The score on knowledge was assessed at different levels of percentage score. The mean score was calculated and average knowledge taken as the score that falls above the mean score minus one standard deviation. In this article percentage score are presented. Data were analysed using SPSS statistical software. Descriptive statistics and independent sample ttest was used.

Results

There were 168 nursing students responding to the questionnaires. Out of which, 107 were from lmphal and 61 from Churachandpur. The mean age of the students was 22 years. The mean percentage score of the respondent was 49.6%. The slight variation that was seen in the mean score of the two schools was found to be statistically insignificant (p=0.23). Only three respondents scored above 80% and seventy-nine respondents (47.0%) scored above 50 percent.

Table I: Knowledge of the respondent on LAM

Question * Correct
response
Partially
correct
Incorrect
response
Don't
Know
n (%) n (%) n (%) n (%)
1. 62 (36.9) - 96 (57.1) 10 (5.9)
2. 10 (5.9) 60 (35.7) 80 (47.6) 18 (10.7)
3. l07 (63.7) - 59 (35.1) 2 (1.2)
4. 81 (48.2) - 85 (50.5) 2 (1.2)
5. 43 (25.5) - 125 (74.4)   -
6. 116 (69.9) - 52 (30.9)   -
7. 96 (57.2) - 72 (42.85)   -
8. 98 (58.3) - 57 (33.9) 13 (7.7)
9. 62 (36.9) - 106 (63.1)   -
10. 47 (27.9) - 120 (71.6) 1 (0.59)
11. 111 (66.1) - 57 (33.9)   -
12. 57 (33.9) - 111 (66.1)   -
13. 109 (64.8) - 8 (4.8) 32 (19)
14. 77 (45.8) - 69 (41.1) 22 (13)

*

  1. What do you understand by LAM?
  2. What are the criteria for effective practice of LAM?
  3. Does the use of LAM affect the health of Mother?
  4. Does the use of LAM affect the health of the infant?
  5. How effective is LAM?
  6. Till how many months will LAM be fully effective?
  7. Does LAM user need to change to other method after sometime?
  8. When can LAM be initiated?
  9. Can woman who is separated from her baby use LAM?
  10. How does LAM work?
  11. Does LAM provide protection against HIV infection or STI?
  12. Can LAM use continue after the supplementation of Infant's diet begins?
  13. What are the advantages of LAM?
  14. What are the disadvantages of LAM?

However when the average score was taken as those who scored above the mean score minus one standard deviation, 152 respondent (90.5 %) were found to have average knowledge. Responses of the nursing students on the knowledge of LAM, breast feeding and contraception are shown in Table I and II.

Discussion

We found that the mean score of the respondents was only 12.4 (49.6%) out of the total possible score of 25. Not even half of them scored above fifty percent. This may be because the topic as such has not been much emphasised on. Among the 168 nursing students, 96 (57.1%) could give the correct definition of LAM. Varul B and colleagues also reported in their study on women of reproductive age group in India that almost 52% of the women were not aware of the contraceptive effect of breast feeding and that only 25.7% knew that lactation has a contraceptive effect. Lactation was accepted as a contraceptive method by 48.2% of the women.5 Susu B and others also reported that only 17% of women who used traditional method relied on LAM. Women mainly asked about what contraception method were available, when to start use and where to obtain contraception.6 In this present study, we found that 80 (47.6%) respondents knew the criteria for effective practice of LAM that requires three conditions of the women - 1) remain ammenorrhoic; 2) being within 6 month, of delivery and 3) fully or nearly fully breast feeding.

Table II: Knowledge of the respondents regarding breast-feeding and contraception

Question * Correct
response
Partially
correct
Incorrect
response
Don't
Know
n (%) n (%) n (%) n (%)
1. 117 (69.6) 39 (23.2) 12 (7.1) -  
2. 133 (79.1) -   30 (17.8 ) 5 (2.9)
3. 47 (28.0) -   118 (70.2) 3 (1.8)
4. 28 (16.6) -   140 (83.3) -  
5. 77 (45.8) -   66 (39.3) 25 (14.9)
6. 139 (82.7) 23 (13.7) 6 (3.6) -  

*

  1. What are the contraceptive devices that can be used in the post partum period?
  2. What does exclusive breast-feeding mean?
  3. What does nearly fully breastfeeding mean?
  4. For how long a woman will not become pregnant without using contraceptive device after delivery?
  5. How do you know that a woman's menstruation has resumed?
  6. Do you think that any lactating woman can practise LAM effectively?

Kennedy and colleagues reported that even among the LAM user only 75% of them could consistently recite the LAM guidelines for a full year post-partum in their study in Pakistan and Philippines,7 Regarding LAM's effect on the health of the mother and infants, 107 (63.7%) and 81 (48.2%) said that LAM improves the health of the mother, and infant respectively. This low score on LAM effect on infant health could be due to the lack of adequate knowledge of LAM that it is effective only till 6 months. After six months mother has to continue breast feeding with use of other contraceptive method.

Our respondents clearly underestimated the effectiveness of LAM as only 43 (25.5%) could give the correct answer of 98% when the 3 criteria are met. Similar finding were reported by Fehring and colleagues and reported that LAM ranked the eight most effective family planning method with an average perceived effectiveness ranging from 70%-80%.8 Although LAM is still effective after 6 month post partum with different findings regarding its effectiveness. In this study, we took 6 month as the duration for LAM to be fully effective, 166 (69.9%) respondents did give correct answer, with 96 (57.1%) said that LAM users need to change to other method after sometime.

If the three criteria for successful practice of LAM are fulfilled, LAM can be initiated anytime during the first 6 month postpartum and 98 (50.3%) of our respondents knew it. One hundred thirty three (79.1 %) and 47 (27.9%) of the students could also give correct answer of exclusive breast feeding and nearly fully exclusive breast feeding respectively. The mechanism by which LAM works as a contraception device is that ovarian activity is suppressed in the breast feeding mother. Initially suppression is complete and the women is amenorrhoic.2 Here only 47 (27.9%) gave correct answer. One hundred and eleven (66.1%) of our respondents knew about the disadvantages of LAM regarding its protection against HIV and STI. This is presumed to be due to the fact that the prevalence HIV/STI is high in our study area and most of the health provider/community workers are aware of this issue.

The knowledge of Lactational Amenorrhoea Method as a contraceptive device is not satisfactory as less than half of the nursing students scored above 50% in their knowledge regarding LAM and only a few knew the criteria that must be fulfilled for its effective practice. Promotion of natural family planning method like LAM is needed to the health care provider as well as to the general population and should also include chapter on LAM.

References

  1. Wijden C, Kleijnen J, Berk T. Lactational amenorrhoea for family planning. Cochrane Database Syst Rev. 2003; (4):CD001329.
  2. Townsend S. A new contraceptive method: breast feeding. Imbonezamuryango. 1993; 9(27):8-12.
  3. Lactational amenorrhoea method: experts recommend full breast feeding as child spacing method. Network. 1998; 10(1):12.
  4. Vekemans M. Fur J Contracept Reprod Health Care. 1997; 2(2):105-11.
  5. Vural B, Vural F, Erk A, Karabacak O. Knowledge on lactational amenorrhoea and contraception in Kocaeli, Turkey. East Afr Med J. 1999; 76(7):385-9.
  6. Susu B, Ransjo-Arvidson AB, Chintu K, Sandstorm K, Christensson. Family Planning Practice before and after Child birth in Lusaka, Zambia. East Afr Med J. 1996; 73(11):708-13.
  7. Kennedy KL, Kotelchuck M, Visness CM, Kazi A, Ramos R. User understanding of the lactational amenorrhoea method and the occurrence of Pregnancy. J Hum Lact. 1998; 14(13):209-18.
  8. Fehring RJ, Hanson L, Stanford JB. Nurse-midwives' Morbidity Profile among Jute Mill Workers knowledge and promotion of lactational amenorrhoea and other and natural family planning methods for child spacing. J Midwifery Womens Health. 2001; 46(2):68-73.
  9. Kennedy KL, Visness CM. Contraceptive efficacy of lactational amenorrhoea. Lancet, 1992; 339: 227-30.
  10. Valdes V, Labbok MH, Pugin L, Perez A. The efficacy of lactational amenorrhoea method (LAM) among working women. Contraception. 2000; 62(5): 217-9.

1. Deptt. of Community Medicine.
2. Deptt. of Obstetrics and Gynecology, RIMS, Imphal, 795004.
Received: 8.12.2004

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