Breastfeeding and Contraception

First Principles

Breastfeeding is as good as combined contraceptive pills (about 2% failure rate) if all the following conditions apply (no exceptions):

1. the baby is younger than 6 months

2. the mother has not yet had a normal menstrual period

3. the baby is exclusively breastfeeding (or near exclusively)

4. there is no prolonged period (greater than 6 hours?) when the baby does not nurse

For those of little faith, breastfeeding can be combined with other contraceptive methods. However, the "other methods" do not have to be the pill.

• the pill is often used because it is easy for the physician and too often the needs of the couple are not taken into account or even discussed

• breastfeeding is hardly ever a consideration in the equation

• contraception is an intimate issue, and has complex and multiple facets including:

• the question of when to return to sexual relations, and what that might entail

• religious

• understanding, sacrifice, compromise

• a father might not want to use a condom

• a mother might not want to have an iud inserted, or have to take the pill

• it takes longer for a man to become a father than for a woman to become a mother

Options:

• abstinence

• sexual activity other than intercourse

• natural planning methods

• non artificial methods (coitus interruptus)

• barrier methods

• IUD

• progestin only pills

• medroxyprogesterone injections (DepoProvera)

• combined pills

When to start contraception?

• Conception before about 4 weeks postpartum must be extremely uncommon

• there is virtually no risk of ovulation in the fully breastfeeding woman up to about 6 weeks

If there is no option to the pill:

• wait at least 6 weeks postpartum

• use progestin only pills, which have not been shown to decrease milk supply

• combined pills should not be used until at least the baby is feeding other foods (not usually earlier than 4 months of age) so that a decrease in the milk supply can be compensated by an intake in food

CAVEAT!!

• Babies respond to milk flow, not the "amount of milk in the breast". Thus, they may not breastfeed well, even if the decrease in supply is relatively minor

Progestin only pills

• a little harder to use, and may result in pregnancy if not taken consistently

• they may result in menstrual irregularities, not usually a problem in the first few months as women are amenorrheic anyway

Medroxyprogesterone (DepoProvera)?

• in theory should not cause problems

• Hartmann has theorized that the sensitization of alveolar cells to the stimulating effect of prolactin happens in response to a fall in progesterone levels

• this might have great significance in situations where the injection is given on hospital discharge

• there have been anecdotal reports of women’s milk supply decreasing with progesterone and/or medroxyprogesterone injections
• the manufacturer recommends waiting six weeks postpartum before giving the injection

Suggestion:

If the mother is to be given medroxyprogesterone injections:

1. do not give injection on discharge from hospital

2. start progestin only pill at 6 weeks

• if there is no obvious decrease in milk supply after first cycle, give medroxyprogesterone

• if there is, stop progestin only pill immediately and do not give medroxyprogesterone

References:

References:

1. WHO task force on oral contraceptives. Effects of hormonal contraceptives on breastmilk composition and infant growth. Studies in Family Planning. 1988;19:361-9

2. Fraser IS. A review of the use of progesteron-only minipills for contraception during lactation. Reprod Fertil Dev 1991;3;245-54

3. Visness CM, Rivera R. Progestin only pill use and pill switching during breastfeeding. Contraception 1995;51:279-81

4. Labbok M, Cooney K, Coly S. Guidlines: Breastfeeding, Family Planning and the Lactation Amenorrhea Method. Washington, DC: Institute for Reproductive Health, 1994

About the Author:

JACK NEWMAN, MD, FRCPC is a pediatrician, a graduate of the University of Toronto medical school. He started the first hospital-based breastfeeding clinic in Canada in 1984. He has been a consultant with UNICEF for the Baby Friendly Hospital Initiative in Africa. Dr. Newman has practiced as a physician in Canada, New Zealand, and South Africa.

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