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ABM Clinical Protocol #13: Contraception During Breastfeeding, Revised 2015
Abstract
A central goal of The Academy of Breastfeeding Medicine is the development of clinical protocols for managing common medical problems that may impact breastfeeding success. These protocols serve only as guidelines for the care of breastfeeding mothers and infants and do not delineate an exclusive course of treatment or serve as standards of medical care. Variations in treatment may be appropriate according to the needs of an individual patient .
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
1
Considerations for clinician counselling 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.
2
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 1 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. Healthcare 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 1
General Principles for Counseling Breastfeeding Women Concerning Contraceptive Selection and Birth Spacing
| Issues | Considerations |
|---|---|
|
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. | |
|
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. |
|
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. |
|
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. |
|
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. | |
|
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 Introduction of Other Methods
A
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, learn-able, 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.)
B
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