CONTRACEPTION & BREASTFEEDING

Offering breastfeeding mothers advice on contraception

By Renee A. Milligan, PhD, CRNP, Gordon Low, RN, CRNP, Diane L. Spatz, PhD, RNC, Lindsey M. Brooks, BA, Janet R. Serwint, MD, and Linda C. Pugh, PhD, RNC

Ob/gyns should ensure that women have the information they need to make an informed decision about breastfeeding. This article addresses the two key concerns that new mothers most express about contraception and breastfeeding.

Ob/gyns who treat new mothers are in an ideal position to advise them about postpartum contraception and prescribe an effective yet safe method. Tradition dictates limiting medication during breastfeeding, but questions remain about how stringent the limits should be, especially for hormonal contraception.¹ Understanding the physiology of breast milk production and changes in postpartum female anatomy can help you—and a new mother—make appropriate decisions about contraception. Your goal should be to support and enhance breastfeeding, as promoted by Healthy People 2010,² ACOG Guidelines,³ and endorsed by the American Academy of Pediatrics,⁴ yet also ensure that your patients have effective contraception. This article addresses the two issues in this area that ob/gyns and new mothers alike seem most concerned about: contraception's effects on the mother's milk supply, and its potential impact on the infant.

Factors that impact the need for contraception

Women become sexually active early in the postpartum period.^5,6 Researchers have reported that 66% of postpartum women are sexually active in the first 4 weeks postpartum, and 88% become sexually active within the first 8 weeks postpartum.⁷ The median time to initiation of intercourse and contraception is 6 weeks postpartum.⁵ Other authors have suggested that women may choose to abstain from sexual activity for longer periods.¹ Although lactation can suppress fertility if a woman exclusively breastfeeds for 6 months postpartum, by that time, fewer than 14.3% of new infants are exclusively being breastfed.^6,8,9

In choosing a method of contraception, a woman who is breastfeeding and her clinician must consider how frequently she has sex, whether she is exclusively breastfeeding, and what type of method would be acceptable to her and her partner. You both must also remember that an unplanned pregnancy is possible if a sexually active woman breastfeeds and does not use contraception. Should the patient become pregnant, it may influence her desire and ability to continue breastfeeding.

Lactating women have many of the same contraceptive options available to them as women who are not lactating.⁶ The choice should rest on informed joint decision-making between the mother, her partner, and her ob/gyn, and should take into consideration the woman's goals and priorities for breastfeeding and the urgency of her need for contraception. Table 1 may be helpful in counseling. It is based on published empirical evidence and is a tool used by a multidisciplinary team with a great deal of experience in promoting exclusive breastfeeding for 6 months in low-income women.^10,11

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Hormones, lactation, and contraception

A review of existing randomized controlled trials reveals that the existing evidence about the effect of hormonal contraceptives on lactation is sparse and of poor quality.^12,13 Questions remain about whether hormonal contraception affects milk quality and quantity. However, an ongoing community-based randomized clinical trial of a support program for low-income breastfeeding women shows that addressing contraception is imperative to promoting breastfeeding success. To help fill the information gap, we developed two brochures on contraception in lactation, one for clinicians and the other for patients. The clinician brochure, which is summarized in Table 1, presents specific recommendations about use of hormonal contraceptives in lactating women, based on theory, physiology, and what is known about best practices. The patient brochure presents similar information, but in simplified language.

Another concern that clinicians and new mothers often express is how additional medication or hormones will affect the mother's already hormone-laden system. Lactation starts early in pregnancy and estrogen is essential to mammary growth. Cells with estrogen receptors secrete a factor responsible for proliferation of ductile cells, while progesterone secretion influences branching of the mammary ducts.¹⁴ From 16 weeks' gestation, the breast is capable of full lactation, but milk production is largely prevented until delivery by the inhibitory effects of progestin and estrogen on circulating prolactin.¹⁵ Prolactin is the hormone most important to lactation because it directly stimulates the alveolar cells to secrete milk. Prolactin levels increase dramatically during pregnancy, under the stimulatory effects of estrogen. Once the placenta is delivered, progestin and estrogen levels rapidly decline, eliminating their inhibitory effects on prolactin.¹⁵ However, the sudden decline in estrogen also removes the primary stimulus for prolactin secretion.¹⁵ Without direct breast stimulation following delivery, prolactin levels drop precipitously. Newborn suckling stimulates the pituitary gland to continue secreting prolactin, therefore ensuring adequate levels for milk production.¹⁵ Suckling also leads to release of oxytocin, which is responsible for milk ejection.¹⁵

The first weeks following delivery are critical for establishing milk supply. Without frequent and regular breast stimulation and emptying, or if estrogen and progesterone do not decrease, a mother's milk supply may be impaired. The concern about hormonal contraceptives stems from their potential to either blunt the stimulating effect of progestin withdrawal or inhibit prolactin secretion. Breast milk already contains maternal hormones similar to those in oral contraceptives, so any small addition as a result of contraception appears to make little difference.¹

Contraceptive options

Barrier methods, intrauterine devices (IUDs), and low-dose progestin-only products (POPs) are the three forms of contraception consistently recommended to mothers who want to be protected from pregnancy while maintaining a supply of breast milk. It is beyond the scope of this article to discuss general side effects and precautions for specific methods of contraception, such as lack of protection from sexually transmitted diseases with OCs and use of IUDs in those in monogamous relationships. But information on those types of recommendations is readily available elsewhere.⁶

Barrier methods. Barrier or spermicidal products have no known effect on lactation.^14,16 However, some of these methods cannot be used for several weeks postpartum because of changes in anatomy after childbirth. Diaphragms, for example, cannot be adequately fitted for 6 to 8 weeks postpartum.¹⁴

IUDs also have no effect on lactation,¹⁴ but to prevent expulsion they should not be inserted until at least 4 weeks postpartum.¹⁷ During breastfeeding, estrogen levels drop, leading to an increased progesterone effect, which results in thinner vaginal mucosa and uterine lining.¹⁴ As a result, the minimal risk of uterine perforation during IUD insertion is increased tenfold in breastfeeding women.¹⁴

Progestin-only products. POPs are generally considered compatible with breastfeeding, but the literature in this area can be confusing. Early postnatal use may prevent the dip in progestin that triggers lactation, reducing a mother's milk supply.¹³ Thus, it is recommended that a mother's milk supply be established before she starts taking POPs.¹³ Once milk is established, low-dose POPs have no effect on the duration of breastfeeding or on an infant's general condition or weight gain.^8,14,16,18 Some data indicate that POPs may even increase milk volume.^1,8,14,17 POPs also do not affect the amount or composition of breast milk.¹⁸ The main caution is to wait to initiate use of these products until lactation is fully established, usually by 6 weeks' postpartum.

Lactational amenorrhea. The Lactational Amenorrhea Method (LAM) is another form of contraception that has no known adverse impact on breastfeeding or breastfed infants. This method is considered 98% effective when three conditions are strictly met¹⁴: (1) The mother has not resumed menstruating; (2) She is breastfeeding exclusively (no supplementation); and (3) The child is less than 6 months old.^1,17 The frequency of breastfeeding and amount of sucking by the infant greatly affect LAM's reliability as a form of contraception.¹⁴ Its efficacy "is a result of hormonal suppression during lactation".¹⁴ Although it may be difficult for some women to adhere to LAM, it is highly effective in simultaneously meeting contraceptive and breastfeeding goals.

Other options. LAM, barrier, and progestin-only methods of contraception may not be realistic options for some women and their partners, regardless of the mother's commitment to breastfeeding. Although combined estrogen/progestin products are commonly prescribed to new mothers, they may impact lactation. Combined OCs (COCs) decrease milk production,^1,8,14,19,20 but milk composition remains unchanged.²¹ While there are no reports that this has a long-term effect on infants, some reports suggest breastfed infants of mothers on COCs may gain weight more slowly (perhaps because of the reduced milk supply).^21-23

If a mother is going to use COCs, she should not start them for a minimum of 3 weeks after delivery, so as to reduce the risk of a thromboembolic event. And waiting until 6 weeks postpartum is optimal to ensure that the milk supply is not affected.⁸ In fact, the World Health Organization recommends that breastfeeding women wait at least 6 months before using COCs, possibly because by then, infants are more likely to be eating a variety of foods.²⁴

Conclusion

Clinicians must work closely with breastfeeding mothers to avoid pitting their sexuality and need for contraception against breastfeeding or vice versa. Being sensitive to the issues will increase the likelihood that new mothers who want effective contraception get an appropriate method, and that they can continue to breastfeed for as long as possible.

REFERENCES

1. Newman J, Pitman T. The Ultimate Breastfeeding Book of Answers. Roseville, Calif: Prima Publishing; 2000.

2. U.S. Department of Health and Human Services. Healthy People 2010, 2nd ed. With Understanding and Improving Health and Objectives for Improving Health. 2 vols. Washington, DC: U.S. Government Printing Office, November 2000.

3. American College of Obstetrics and Gynecology. (2000 July). ACOG Issues Guidelines on Breastfeeding. Retrieved September 9, 2004, from http://www.acog.org/from_home/publications/press_releases/nr07-01-00.cfm.

4. American Academy of Pediatrics. Breastfeeding and the use of human milk. Pediatrics. 1997;100:1035-1039.

5. Glazener CM. Sexual function after childbirth: women's experiences, persistent morbidity and lack of professional recognition. Br J Obstet Gynaecol. 1997;104:330-335.

6. Hatcher RA, Trussell J, Stewart F, et al. Contraceptive Technology. 17th revised ed. New York. NY: Ardent Media Inc; 1998.

7. Ford K, Labbok M. Contraceptive usage during lactation in the United States: an update. Am J Public Health. 1987;77:79-81.

8. American College of Obstetricians and Gynecologists. Contraception while breastfeeding. ACOG Educational Bulletin, 2000, No. 258.

9. Mothers Survey, Ross Products Division, Abbott Laboratories.

10. Pugh LC. Support for low-income breastfeeding: cost and outcomes. Funded by NINR funding period, 2003-2007.

11. Pugh LC, Milligan R, Sharps P, Serwint J, et al. Reducing Health Disparities: Promoting Breastfeeding Duration in Urban Families. Paper presented at Howard University Research Conference (March 2004). Washington, D.C.

12. Truitt ST, Fraser AB, Grimes DA, et al. Combined hormonal versus nonhormonal versus progestin-only contraception in lactation. The Cochrane Library 4, 2003.

13. Laukaran VH. Contraceptive choices for lactating women: suggestions for postpartum family planning. Stud Fam Plann. 1981;12:156-163.

14. Lawrence RA. Breastfeeding: A Guide for the Medical Profession. 5th ed. St. Louis, Mo: Mosby; 1999.

15. Gabbe SJ, Niebyl JR, Simpson JL. Obstetrics: Normal and Problem Pregnancies. 3rd ed. New York, NY: Churchill Livingston; 1996.

16. Diaz S, Croxatto HB. Contraception in lactating women. Curr Opin Obstet Gynecol. 1993;5:815-822.

17. Nichols-Johnson V. The breastfeeding dyad and contraception. Breastfeeding Abstracts. 2001;21:11-12.

18. Bjarnadottir RI, Gottfredsdottir H, Sigurdardottir K, et al. Comparative study of the effects of a progestogen-only pill containing desogestrel and an intrauterine contraceptive device in lactating women. BJOG. 2001;108:1174-1180.

19. Hale TW. Medications in breastfeeding mothers of preterm infants. Pediatr Ann. 2003;32:337-347.

20. Croxatto HB, Diaz S, Peralta O, et al. Fertility regulation in nursing women: IV. Long-term influence of a low-dose combined oral contraceptive initiated at day 30 postpartum upon lactation and infant growth. Contraception. 1983;27:13-25.

21. Hale TW. Medications and Mothers' Milk: A Manual of Lactational Pharmacology. Amarillo, Tx: Pharmasoft Publishing; 2002.

22. Diaz S, Peralta O, Juez G, et al. Fertility regulation in nursing women: III. Short-term influence of a low-dose combined oral contraceptive upon lactation and infant growth. Contraception. 1983;27:1-11.

23. Peralta O, Diaz S, Juez G, et al. Fertility regulation in nursing women: V. Long-term influence of a low-dose combined oral contraceptive initiated at day 90 postpartum upon lactation and infant growth. Contraception. 1983;27:27-38.

24. Improving Access to Quality Care in Family Planning: Medical Eligibility Criteria for Contraceptive Use. Geneva: World Health Organization; 1996.

25. Schwallie PC. The effect of depot-medroxyprogesterone acetate on the fetus and nursing infant: a review. Contraception. 1981;23:375-386.

DR. MILLIGAN is an Adjunct Faculty of Johns Hopkins School of Nursing, Baltimore, Md; a nurse practitioner and Director of Research and Evaluation at Pregnancy Aid Center Clinic, College Park, Md; and Associate Professor at Georgetown University School of Nursing, Washington, D.C.

MR. LOW is Clinical Director and nurse practitioner at Pregnancy Aid Center Clinic, College Park, Md.

DR. SPATZ is an Associate Professor at the University of Pennsylvania School of Nursing, The Children's Hospital of Philadelphia, Philadelphia, Pa.

MS. BROOKS was a Research Assistant at Johns Hopkins University School of Nursing, Baltimore, Md., and is currently working on her PhD at Lehigh University, Allentown, Pa.

DR. SERWINT is an Associate Professor of Pediatrics at Johns Hopkins University School of Medicine, Baltimore, Md.

DR. PUGH is an Associate Professor at Johns Hopkins University School of Nursing, Baltimore, Md.

Take-home messages

• The median time to initiation of intercourse and contraception is 6 weeks postpartum.

• Breastfeeding women have an increased risk of uterine perforation during IUD insertion.

• Frequency of breastfeeding and amount of infant sucking greatly affect the reliability of the Lactational Amenorrhea Method for contraception.

• Wait to prescribe progestin-only pills until lactation is fully established.

 

Janet Serwint. Offering beastfeeding mothers advice on contraception. Contemporary Ob/Gyn Oct. 1, 2004;49:72.