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.

Lindsey M. Brooks, BA

 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.

   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,

   and endorsed by the American Academy of Pediatrics,

 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.

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.

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

 Other authors have suggested that women may   choose to abstain from sexual activity for longer periods.

 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.

 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.

 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.

PLEASE NOTE: If you are using Internet Explorer version 6 or   higher, after clicking to enlarge the graphic, click the picture icon that appears   in the lower right-hand corner of the graphic. 

 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.

 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.

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.

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.

 However, the sudden decline in estrogen also   removes the primary stimulus for prolactin secretion.

 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.

Suckling   also leads to release of oxytocin, which is responsible for milk ejection.

 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.

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.

 Barrier or spermicidal products have no known effect on lactation.

 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.

 but to prevent expulsion they should not be inserted until at least 4 weeks postpartum.

 During breastfeeding, estrogen levels drop, leading to an increased progesterone effect, which results in thinner vaginal mucosa and uterine lining.

 As a result, the minimal risk of uterine perforation during IUD insertion is increased tenfold in breastfeeding women.

 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.

 Thus, it is recommended that a mother's milk supply be established before she starts taking POPs.

 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.

 Some data indicate that POPs may even increase milk volume.

 POPs also do not affect the amount or composition of breast milk.

 The main caution is to wait to initiate use of these products until lactation is fully established, usually by 6 weeks' postpartum.

 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 met

: (1) The mother has not resumed menstruating; (2) She is breastfeeding exclusively (no supplementation); and (3) The child is less than 6 months old.

 The frequency of breastfeeding and amount of sucking by the infant greatly affect LAM's reliability as a form of contraception.

 Its  efficacy "is a result of hormonal suppression during lactation".

Although it may be difficult for some women to adhere to LAM, it is highly effective in simultaneously meeting contraceptive and breastfeeding goals. 

 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,

 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).

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.

 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.

 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. 

The Ultimate Breastfeeding   Book of Answers.

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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. 

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 17th revised ed. New York. NY: Ardent Media Inc; 1998. 

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 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. 

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Medications and Mothers' Milk: A Manual   of Lactational Pharmacology.

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 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. 

 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. 

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 25.	Schwallie PC. The effect of depot-medroxyprogesterone   acetate on the fetus and nursing infant: a review. 

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.

 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. 

Articles

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.