Section 4: Special Topics
During the last half of pregnancy and early postpartum visits, obstetricians will discuss family planning options with mothers, including any potential effects of choices on breastfeeding. When counseling nursing mothers, it is important to review the following key points to ensure effective family planning without negatively affecting breastfeeding.51
Hormonal Methods and IUDs
- Mothers should avoid estrogen-progesterone contraceptives if at all possible until lactation is completed. Combination contraceptives can sometimes decrease milk supply and reduce lactation duration, especially when started early postpartum. The negative impact on the infant is more likely due to reduced milk supply and, therefore, reduced weight gain, rather than from exposure to contraceptive hormones.
- Similar to oral contraceptive pills, other combination products such as etonogestgrel/ethinyl estradiol vaginal ring (NuvaRing™) and noreigestromin/ethinyl estradiol transdermal system (OrthoEvra™ patch) should be avoided while breastfeeding.
- Progesterone-only oral contraceptives rarely reduce milk supply; however other considerations include that:
- They should only be started in patients who have well-established lactation.
- Giving a mother a dose of medroxyprogesterone (Depo-Provera™) immediately postpartum in the hospital is more likely to negatively impact breastfeeding success and duration. Mothers should wait until 6 weeks postpartum to receive the injection if possible. This should be balanced with her risk of conceiving a pregnancy in the early postpartum period, which for some women, may be very high. In addition, some women are at high risk for not returning for follow up care, thus, they may benefit from early initiation of contraception.
- For emergency contraception, mothers should choose a progesterone-only option such as levonorgestrel (e.g., Plan B™, Next Choice™) over combination products such as levonorgestrel/ethinyl estradiol (e.g., Preven™
- Emergency Contraception Kit); however, a one-time dose of any combination emergency contraception would not likely have a major impact on overall milk supply.
- Intrauterine devices such as Mirena™ (Levonorgestrel), Nexplanon™ (Etonogestrel), and ParaGard™ (copper IUD) are acceptable contraceptive choices for nursing mothers; however, postplacental placement of a levonorgestrel intrauterine device compared with delayed placement of the device was associated with lower rates of exclusive breastfeeding at 3 months and 6 months.65
Lactational Amenorrhea Method (LAM)
LAM is the natural infertility a new mother experiences while amenorrheic and nursing her baby.51 A mother who meets all of the following three criteria has a low risk of pregnancy when using LAM as a family planning method:
- her menses have not returned since delivery (bleeding or spotting during the first 56 days postpartum is not considered menstrual bleeding)
- she is exclusively breastfeeding her baby day and night without using a pacifier
- her baby is less than six months of age
If any of these three conditions is not met, additional birth control is recommended. It is imperative that a mother understands that the return of menses requires additional contraception and that LAM, even under the three conditions listed above, is not 100% effective. The introduction of solid foods reduces the frequency of breastfeeding and therefore reduces the effectiveness of LAM. The risk of pregnancy varies according to feeding practice during the first six months:
- Exclusive breastfeeding: 0.5%
- Full breastfeeding (i.e., occasional food or liquids): 2%
- Working mothers pumping milk at work: 5%