Breastfeeding and contraception

There have been many studies and articles telling us that babies need only breastmilk for around the first 6 months of life, and that this should be continued until at least 2 years of age alongside complementary foods (http://www.who.int/topics/breastfeeding/en/).  This is the best way to support the health, development and growth of the baby.

Before having another baby, it is also recommended that the mother has a chance to regain her normal level of health following the demands of being pregnant, giving birth and feeding her baby.  The healthier the mother is before she has her next baby, the better it will be for the pregnancy, her health and her family.  It is therefore considered that the optimum space between babies is 39 months:  24 months of breastfeeding, a 6 month break to ensure mother’s health is at it’s optimum, plus 9 months of pregnancy; the minim gap considered adequate for maternal recovery is 18 months.  Of course, in developed countries where women are able to have a good diet and a healthy lifestyle, parents may choose to have a shorter gap between their children with no apparent impact to the mother’s health.

Contraception isn’t something automatically at the top of everyone’s list of “things to do” immediately after having their baby… for many couples the idea of sex isn’t even on the horizon, let alone the thought of having another baby 🙂  Usually the mother’s health care provider/midwife will have discussed contraceptive options with the mother before the baby is born, together with the impact of each option on breastfeeding.

Women who breastfeed are less likely to ovulate early after having their baby, whilst women who don’t breastfeed may ovulate as early as 3 weeks after giving birth.  Since data published in early 1970’s suggested that women who breastfeed don’t ovulate early postpartum, studies and meetings between various researchers from several centres have taken place (1998 and 1995), all indicating that breastfeeding women have a time of natural contraception, known as the Lactational Amenorrhea Method (LAM).

This method of contraception is considered to be 98% effective, and therefore may be considered more effective than the progesterone only pill.  In order to use LAM effectively there are three questions that the mother needs to ask herself on an ongoing basis.

  1. Have your periods returned?  For the purposes of LAM, this means any bleed after 56 days postpartum that you believe is a period, or that lasted for 2 consecutive days.
  2. Are there long periods of no breastfeeding during the day or night, or do you regularly supplement your baby?
  3. Is your baby more than 6 months old?

If the answer to any of these questions is yes, or becomes yes over a period of time, then other methods of contraception should be used.  Because of the impact of fully breastfeeding on a women’s fertility, a woman is unlikely to ovulate before her first period.  However, once the first period has taken place, other contraception should be used.  LAM is used in over 30 countries and is widely accepted as a natural family planning method.  LAM is considered to be adequate for 6 months as this is often when complementary foods are added to the baby’s diet, however in some countries it has been shown to work for up to 9 months as the women maintain breastfeeding frequency by breastfeeding before offering other foods.

A study of women who had returned to work the place, showed that LAM was around 95% – 96.5% effective when the mothers expressed milk when they weren’t with their baby – expressing needs to take place at least as often as the mother would have fed her baby had they been together.  This shows a slight increase in risk of pregnancy.

Exclusively breastfeeding mothers often find their periods don’t return for 6 months or more, however some find that even though they breastfeed exclusively and often, their periods return after 2 or 3 months.  In this case, it is not clear whether these menstrual cycles are adequate for ovulation to take place so other methods of contraception should be used if the mother wishes to not get pregnant.

As soon as LAM no longer applies to a mother’s situation, other contraception should be used.  Barrier methods (ie. condom, diaphragm) are considered to be 94% to 97% effective when used perfectly and the next best option to LAM when breastfeeding.  The progesterone only pill may be taken by breastfeeding women from 6 weeks postpartum, however there is much anecdotal evidence to suggest that it may have an impact on milk supply, so it may be prudent to delay using this method until milk supply and breastfeeding is well established.  The combined contraceptive pill is not generally considered a suitable contraceptive while the baby is still breastfeeding.

More information can be found about LAM here:  http://www.kellymom.com/bf/normal/fertility.html

and here:  http://www.waba.org.my/resources/lam/

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