Protocol 13: Contraception During Breastfeeding




Purpose


The purpose of this protocol is to outline considerations in assisting breastfeeding families to achieve optimal birth spacing by selecting a contraceptive method that is effective, unlikely to disrupt lactation, and satisfactory for the mother and her partner. The protocol covers the use of contraceptive methods during breastfeeding and provides guidance on the lactational amenorrhea method (LAM).


This protocol assumes that the practitioner is well versed in the risks and benefits of different types of contraception, including all pharmaceutical, permanent, and periodic abstinence/natural family planning methods.




Issues in Counseling and Selection of Contraceptives During Breastfeeding


Considerations for Clinician Counseling and Method Use


Postpartum contraception, like breastfeeding, should be discussed with women during their own obstetric prenatal and postpartum visits and the infant’s pediatric well-baby visits. A woman’s contraceptive choice depends on many factors such as previous experience with contraceptives, future childbearing plans, husband or partner’s attitude, level of user attention required for use, medical considerations, return of menses, and the woman’s lactation status. If a woman is not comfortable with a method, she may not use it effectively.


Advantages and Disadvantages of Available Options


Contraceptive counseling during breastfeeding extends beyond issues of efficacy, because the selected method must be appropriate for a woman’s breastfeeding expectations. Table J-14 provides useful information for counseling the breastfeeding mother. Considerations include the potential for hormonal methods to either disrupt milk synthesis or expose the infant to synthetic hormones. Because a falling progesterone level after birth is necessary for onset of milk production, initiation of hormonal contraception before lactation is established is of particular concern. Published evidence is insufficient to exclude these risks. At the same time, long-acting reversible hormonal methods have high contraceptive efficacy. Health care providers should discuss the limitations of the available data within the context of a mother’s desire to breastfeed, her risk of low milk production, and her risk of unplanned pregnancy, so that she can make an autonomous and informed decision.



Table J-14

General Principles for Counseling Breastfeeding Women Concerning Contraceptive Selection and Birth Spacing

























Issues Considerations
1. Breastfeeding patterns, status, and plans


  • Consider both short- and long-term breastfeeding intent as well as well birth spacing plans. There is the potential for hormonal methods to have an impact depending on when they are started



  • Mothers may plan to exclusively breastfeed; some may do so to use LAM, others may use LAM because they are already fully breastfeeding. LAM users should be counseled to have another method in hand for when menses return or breastfeeding patterns change. Effectiveness of LAM in exclusively breastmilk pumping mothers may not be equivalent to direct breastfeeding



  • Many women who intend to breastfeed exclusively are not able to achieve their goals

2. Child’s age/time postpartum


  • Many methods should not be introduced until breastfeeding is well established (i.e., at 4-6 weeks), as there may be potential for hormonal methods to directly impact lactogenesis and/or to impact the infant

3. Maternal age and future childbearing plans


  • Choices depend on desire to space births or desire to limit family size. Globally recommended interpregnancy intervals are at least 18 months to 2 + years for maternal health, depending on the setting, and about 3-5 years for child health outcomes

4. Previous contraceptive experience


  • Discussion of previous contraceptive experience, including compliance, satisfaction, side effects, and social issues, is essential. These issues can influence compliance and satisfaction, particularly as they pertain to prior lactation experiences

5. Partners/interactions


  • Partner’s experiences and opinions may impact compliance, particularly for barrier methods, LAM, and natural family planning



  • The woman’s social and behavioral considerations, such as number of partners and sexual activity, should be explored. A woman’s history of unplanned pregnancy and short interpregnancy interval should be reviewed and discussed

6. Previous lactation experience/medical conditions


  • Prior insufficient milk supply or inadequate infant growth



  • Prior breastfeeding experience did NOT meet goals (either exclusivity or duration), AND supply was a potential reason



  • Physical examination suggestive of insufficient glandular tissue



  • Prior breast surgery



  • Medical conditions potentially adversely affecting supply (polycystic ovary syndrome, infertility, obesity)



  • Multiple gestation



  • Preterm infant(s)


LAM, Lactational amenorrhea method.




LAM for Contraception in the Early Postpartum Period and for the Introduction of Other Methods


Background


Data published in the 1970s showed that women who breastfed were less likely to ovulate early postpartum and that if breastfeeding were more intensive, they were less likely than partial or nonbreastfeeders to experience a normal ovulation prior to the first menstrual-like bleed. In 1988, at a Bellagio Conference, a group of expert scientists proposed three criteria as sufficient to predict fertility return. This three-criteria approach described in further detail below as the “Lactational Amenorrhea Method” was subsequently tested. Studies of the acceptability and contraceptive efficacy of active LAM use continue to confirm the original findings, demonstrating that LAM is acceptable, learnable, user-friendly, and as effective as many other alternatives. (II-2) (Quality of evidence [levels of evidence I, II-1, II-2, II-3, and III] is based on the U.S. Preventive Services Task Force Appendix A Task Force Ratings and is noted throughout this protocol in parentheses.)


Method: What is LAM?


LAM is presented as an algorithm ( Figure J-3 ) and includes three criteria for defining the period of lowest pregnancy risk. If one of these criteria is not met, women should immediately initiate another method. Clinically, the mother is asked these three questions:




  • “Are you amenorrheic?” meaning that you have not had a menstrual bleed or any bleed of > 2 days in duration (discounting any bleed in the first 2 months).



  • “Are you fully or nearly fully breastfeeding?” This includes not giving your baby any supplementary foods or fluids in addition to breastfeeding (greater than once or twice a week)?



  • “Is your infant less than 6 months of age?”




Figure J-3


The lactational amenorrhea method (LAM).


If she answers “yes” to all three questions, she meets the requirements for LAM. If any of the above three questions is answered “no,” then her chance of pregnancy is increased, and she should be advised to initiate another form of contraception to prevent pregnancy. If the mother is interested in and qualifies for LAM, she should review these three questions regularly. Clinicians should ensure that she has chosen her next method of contraception and either has it on hand or knows how to obtain it if it is an implant or intrauterine device (IUD).


Definitions for LAM Use


To use LAM correctly, it is important that the patient understand each of the three criteria, which can be remembered using the letters “LAM” to indicate Lactation, Amenorrhea, and the number of Months:



  • 1.

    Lactation. Full or nearly full breastfeeding includes exclusive, nearly exclusive, and some irregularly provided supplements, as long as they do not disrupt the frequency of feeds.


  • 2.

    Amenorrhea. For the purposes of LAM use, menses return is defined as any bleeding that occurs after 56 days postpartum that is perceived by the patient as a menses or any two consecutive days of bleeding.


  • 3.

    Months. The “6 months” criterion is added primarily because this is the time that complementary feeding should begin. If breastfeeding continues at the same frequency and complementary foods are offered after the breastfeed, efficacy apparently remains high as long as amenorrhea continues. In Rwanda, the method was used up to 9 months, by maintaining the breastfeeding frequency experienced during month 6. This was achieved by feeding before each complementary feeding. Another study in Pakistan found a continued high efficacy under these conditions for up to 12 months. (II-2)



Efficacy


A Cochrane Review (and assessed as up-to-date in 2008) concluded that fertility rates are low among fully breastfeeding, amenorrheic women. In controlled studies of LAM, pregnancy rates for 6 months ranged from 0.45% to 2.45%. In six uncontrolled studies of LAM users, pregnancy ranged from 0% to 7.5%. The World Health Organization (WHO) carried out a prospective trial on lactational amenorrhea and fertility return; although this was not a study of women selecting and using LAM, the findings confirmed the physiological potential for high efficacy as seen in the LAM trials. Subsequently, studies of method use have consistently found a 6-month pregnancy rate averaging 2% (I, II-2)


LAM Management Issues


Suggested behaviors contributing to method success and duration include:



  • 1.

    Number of feedings. One controlled study found exclusively breastfeeding women using LAM are more likely to be amenorrheic at 6 months than exclusively breastfeeding controls (84% vs. 69.7%, respectively). Women using LAM had a higher feeding frequency and a shorter interfeeding interval than other exclusively breastfeeding women.


  • 2.

    LAM can be used beyond the sixth month. The two studies mentioned above in Rwanda and Pakistan have indicated that the efficacy of LAM can be maintained during the 6- to 12-month period, provided the mother continues to breastfeed before giving complementary foods at less than 4-hour intervals during the day and 6-hour intervals at night while remaining amenorrheic. (II-2)


  • 3.

    LAM effectiveness has not as yet been adequately tested to offer the method with confidence to women who are giving supplemental feedings daily or expressing milk by hand or pump instead of breastfeeding. (II-2) Women who are expressing milk more than a few times per week should be counseled to initiate an additional contraceptive method. (III)



Transition to Other Methods


LAM may also be used as an introductory method to inform the user when it is time to initiate use of another method. Of note is that fully breastfeeding women are very unlikely to conceive in the first 56 days postpartum so secondary methods can be delayed until at least 8 weeks postpartum. When LAM criteria no longer apply or whenever a breastfeeding woman wishes to use an alternate family planning method, she should have an alternative method readily available. Alternative methods are discussed in terms of advantages and disadvantages and special issues related to breastfeeding.




Additional Comments on Individual Methods


Table J-15 provides additional specific information for many individual methods, including advantages, disadvantages, and potential issues related to breastfeeding for each.



Table J-15

Use of Contraceptive Methods During Lactation: Advantages, Disadvantages, and Impact on Lactation






























































Method Advantages Disadvantages Effects Related to Breastfeeding
Lactational amenorrheic method
Natural family planning
• Billings ovulation
• Creighton model
• Marquette
• Symptothermal
• No side effects
• Effectiveness rates comparable with other user-directed methods of birth control (i.e., pills or barriers)
• Low cost for most methods
• Requires special instruction for use during breastfeeding
• ClearBlue fertility monitor expense with Marquette
• May require long periods of abstinence
• None
Barrier methods
• Diaphragm/cap
• Spermicide
• Condoms
• Few side effects
• Effective with diligent and appropriate use
• Easily accessible as “back-up”
• Low cost
• Also provide protection from sexually transmitted infection
• Potential for user error
• Allergy possible
• May be inconvenient and limit spontaneity
• Cervical cap and diaphragm require fitting
• None
• Use of lubricant may be beneficial with condoms in setting of vaginal atrophy
Other contraceptive options
IUDs
• Copper IUD (ParaGard T380A), 10 years
• Levonorgestrel IUD (Mirena), 5 years
• Levonorgestrel IUD (Skyla), 3 years
• Highly effective
• Reversible
• Long-term contraceptives
• Little user attention required (typical use and perfect use are similar)
• Small risk of infection, perforation, expulsion
• Requires provider insertion and removal
• Copper contraindicated with Wilson’s disease and copper allergy
• Short-term use costly; long-term use cost-effective
• Copper IUD: no known impact on lactation
• Possible risk of perforation at insertion requiring surgical removal, which may necessitate short interruption in breastfeeding
• Levonorgestrel IUD (Mirena) placed immediately postpartum may be associated with shorter duration of breastfeeding. No adverse effect on breastfeeding reported when placed 6 weeks postpartum or later
Sterilization
• Male (vasectomy)
• Female: postpartum; laparoscopic; hysteroscopic
• Highly effective
• Male vasectomy and female hysteroscopic occlusion may be performed on an outpatient basis
• Permanent; risk of regret
• Surgical procedural risks
• Cost related to surgery
• Requires surgeon
• Risk of ectopic pregnancy with female procedures
• Male sterilization: none
• Female sterilization: postpartum procedure separates mother and infant and may require use of maternal narcotics (ideally avoid procedures in first 1-2 hours to allow skin-to-skin, initial breastfeeding, etc.)
Progestin-only hormonal options a
• Injectible (DMPA) every 3 months
• Oral daily pills (norethindrone)
• Progestin-releasing IUD (see above): LNG IUD (Mirena), 5 years; LNG IUD (Skyla), 3 years
• Progestin vaginal rings
• Implants: etonogestrel (Implanon/Nexplanon), 3 years (Jadelle), 5 years
• Long-term options highly reliable • Common side effect of irregular bleeding may be less problematic in breastfeeding mothers
• Potential for user failure with daily pills
• Other progestin side effects: headache, acne, weight gain, bloating, depressed mood
• DMPA may have delayed return to fertility
• Implant and IUDs require provider insertion and removal
• Theoretical potential to adversely impact milk supply when started in the early postpartum period prior to establishing a milk supply. Insufficient data to determine risk at this time
• If milk supply decreases with DMPA, cannot be discontinued or removed
• LNG IUD (Mirena) placed immediately postpartum may be associated with shorter duration of breastfeeding (single study). No adverse effect on breastfeeding reported when placed 6 weeks postpartum or later
Estrogen-containing combined hormonal options
• COC pills, daily
• Estrogen-containing vaginal ring (NuvaRing), monthly
• Estrogen-containing transdermal patch (Ortho-Evra), weekly
• Options can be self-administered
• Regular menstrual cycles (extended cycle options have more breakthrough bleeding)
• Noncontraceptive benefits: decreased bleeding, less anemia, improved acne, improved dysmenorrhea
• Potential for user failure (especially with COCs)
• Increased risk of blood clots
• Potential for drug interactions
• Multiple medical contraindications
• Ideally avoid until lactation/milk supply well established
• Potential for adverse effect on milk supply. Risk appears more pronounced with higher estrogen levels than used in contemporary products
• If used by a breastfeeding mother, begin lowest possible dose as late as possible into well-established breastfeeding
Emergency contraceptives
• Combined estrogen/progestin pills (Preven, Yuzpe method)
• Progestin-only pills—LNG (Plan B)
• Mifepristone
• Ulipristal
• Copper IUD
• Most effective within 72 hours of exposure
• LNG options appear to have superior efficacy to COC with fewer side effects
• Copper IUD most effective and provides continued contraception
• Mifepristone similar or superior to LNG in efficacy
• Estrogen-containing options cause nausea/vomiting and often require use of antiemetics
• No data for ulipristal in lactation currently available
• Limited data on mifepristone in lactation
• LNG preferred over estrogen-containing options in breastfeeding mothers owing to previously described concerns related to estrogen and milk supply

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Jul 13, 2019 | Posted by in PEDIATRICS | Comments Off on Protocol 13: Contraception During Breastfeeding
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