Monday, June 6, 2016

Breastfeeding and Contraception

Breastfeeding and Contraception

First Principles

Breastfeeding is as good as combined contraceptive pills (about 2% failure
rate) if all the following conditions apply (no exceptions):

1. the baby is younger than 6 months

2. the mother has not yet had a normal menstrual period

3. the baby is exclusively breastfeeding (or near exclusively)

4. there is no prolonged period (greater than 6 hours?) when the baby does
not nurse

For those of little faith, breastfeeding can be combined with other
contraceptive methods. However, the "other methods" do not have to be the
pill.  the pill is often used because it is easy for the physician and too
often the needs of the couple are not taken into account or even discussed
 breastfeeding is hardly ever a consideration in the equation
 contraception is an intimate issue, and has complex and multiple facets
 the question of when to return to sexual relations, and what that might
 understanding, sacrifice, compromise
 a father might not want to use a condom
 a mother might not want to have an iud inserted, or have to take the pill
 it takes longer for a man to become a father than for a woman to become a

Options:  abstinence
 sexual activity other than intercourse
 natural planning methods
 non artificial methods (coitus interruptus)
 barrier methods
 progestin only pills
 medroxyprogesterone injections (DepoProvera)
 combined pills

When to start contraception?  Conception before about 4 weeks postpartum
must be extremely uncommon
 there is virtually no risk of ovulation in the fully breastfeeding woman
up to about 6 weeks

If there is no option to the pill:  wait at least 6 weeks postpartum
 use progestin only pills, which have not been shown to decrease milk supply
 combined pills should not be used until at least the baby is feeding
other foods (not usually earlier than 4 months of age) so that a decrease
in the milk supply can be compensated by an intake in food

CAVEAT!!  Babies respond to milk flow, not the "amount of milk in the
breast". Thus, they may not breastfeed well, even if the decrease in
supply is relatively minor

progestin only pills  a little harder to use, and may result in pregnancy
if not taken consistently
 they may result in menstrual irregularities, not usually a problem in the
first few months as women are amenorrheic anyway

Medroxyprogesterone (DepoProvera)?  in theory should not cause problems
 Hartmann has theorized that the sensitization of alveolar cells to the
stimulating effect of prolactin happens in response to a fall in
progesterone levels
 this might have great significance in situations where the injection is
given on hospital discharge
 there have been anecdotal reports of women's milk supply decreasing with
progesterone and/or medroxyprogesterone injections
 the manufacturer recommends waiting six weeks postpartum before giving
the injection


If the mother is to be given medroxyprogesterone injections:

1. do not give injection on discharge from hospital

2. start progestin only pill at 6 weeks  if there is no obvious decrease
in milk supply after first cycle, give medroxyprogesterone
 if there is, stop progestin only pill immediately and do not give


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