Contraceptive choices for lactating women: suggestions for postpartum family planning

Both the fertility inhibiting effects of breastfeeding and the lactation inhibiting effects of hormonal contraceptives should be considered in developing postpartum family planning programs for lactating women. Because a high percentage of female contraceptive acceptors discontinue use within a year, the largest birth intervals may be achieved by delaying the initiation of contraception to take advantage of lactational infertility in the first postpartum months. Although evaluation of existing data on the effects of oral contraceptives on lactation is difficult, findings suggest that low-dose progestins may have a less detrimental effect on lactation than combined oral contraceptives. Depo-provera appears to enhance milk volume and duration of lactation, but the unknown side effects of transmission of steroids to the infant and changes in milk composition suggest caution in recommending it for nursing mothers. Results of research on possible effects of IUDs on lactation are conflicting and difficult to interpret, but possible mechanisms through prolactin secretion or oxytocin have been suggested for such an effect. Numerous methodological problems hamper efforts to evaluate evidence of the relationship of contraception to lactation to provide recommendations for family planning programs. The most prudent course where possible is to avoid giving hormonal contraceptives to the lactating woman. Where only hormonal contraceptives are acceptable, the best approach is probably to delay their use for at least 3 months postpartum to allow lactation to become established and the infant to mature.     

Reassessing Unmet Need for Family Planning in the Postpartum Period

Despite renewed interest in postpartum family planning programs, the question of the time at which women should be expected to start contraception after a birth remains unanswered. Three indicators of postpartum unmet need consider women to be fully exposed to the risk of pregnancy at different times: right after delivery (prospective indicator), after six months of amenorrhea (intermediate indicator), and at the end of amenorrhea (classic indicator). DHS data from 57 countries in 2005–13 indicate that 62 percent (prospective), 43 percent (intermediate), and 32 percent (classic) of women in the first year after a birth have an unmet need for contraception (40 percent when including abstinence). While the protection afforded by postpartum abstinence and lactational amenorrhea lowers unmet need, further analysis shows that women also often rely on these methods without being actually protected. Programs should acknowledge these methods’ widespread use and inform women about their limits. Also, the respective advantages of targeting the postnatal period, the end of six months of amenorrhea/exclusive breastfeeding, or the resumption of sexual intercourse to offer contraceptive services should be tested.     

The contraceptive benefit of breastfeeding

Breastfeeding has long been a means of fertility regulation in traditional communities but only recently have attempts been made to characterize and quantify this attribute. Breastfeeding encompasses behavioral, geographical, and cultural factors, which account for the differences in the prevalence and practice of breastfeeding in different communities. Ovarian activity is suppressed in the breastfeeding mother. Initially the suppression is complete and the woman is amenorrheic. This is followed by anovulatory menstrual cycles or ovulatory cycles that manifest luteal phase deficiency or normal ovulatory cycles. The duration of ovarian follicular suppression is variable and recent work suggests that lactation suppresses ovarian activity by disturbing the pulsatile pattern of luteinizing hormone (LH) secretion. During lactational amenorrhea, prolactin levels are high, LH levels are low to normal. Follicle stimulating hormone concentrations are normal by four weeks postpartum, and estrogen and progesterone levels are low. The degree of ovarian suppression is enhanced by increased frequency of suckling, longer duration of feeds, and more frequent night-time feeds. Introduction of supplementary feeds inhibits ovarian suppression. These and other factors account for variations in the length of lactational amenorrhea in an individual and between populations. The Bellagio Consensus Statement affirms that the risk of pregnancy in a fully breastfeeding, amenorrheic woman in the first six months of lactation is less than 2%. After the sixth month it is increasingly likely that ovulation will precede the first menstruation. The Bellagio Consensus has given scientific validity to birth-spacing in developing countries and the lactational amenorrhea method (LAM) as a means of contraception. If breastfeeding ceases to be full, menstruation resumes, or the baby is more than six months old, alternative methods of contraception should be used. Breastfeeding should feature more prominently in fertility regulation programs and counseling, especially in developing countries.     

Lactational amenorrhea as a method of family planning in Egypt

Because of the potential importance of the lactational amenorrhea method (LAM) as a family-planning option in Egypt, we analyzed data from the 1995 Egyptian Demographic and Health Survey (EDHS) to study breastfeeding practices, use of contraception, reproductive history and sociodemographic factors for 5504 mothers with children under 3 years. According to the EDHS data, about 80% of Egyptian women breastfed for at least 6 months, and 40% breastfed for 15-18 months. Over half of breastfeeding mothers used no additional contraception. Thirty-six percent of mothers breastfeeding children younger than 6 months who reported using no additional contraception were exclusively breastfeeding and amenorrheic, but only 4% reported relying on breastfeeding for family planning. We also held eight focus group discussions with breastfeeding mothers from urban and rural Upper and Lower Egypt on their use of contraceptive methods, breastfeeding, lactational amenorrhea and LAM. Participants showed strong recognition of the contraceptive effects of breastfeeding but differed widely in their understanding of lactational infecundability and knowledge of LAM as a method. These results suggest that LAM would be widely acceptable to Egyptian women, but that an educational program about the method is needed.     

Breastfeeding and contraception: why the inverse association?

Recent research results on infant feeding practices in developing countries have consistently shown a strong negative association between breastfeeding and contraceptive use. This relationship is explored in-depth with a detailed analysis of Taiwanese data and supplementary evidence from 20 developing country populations. Implications for appropriate policies relating to family planning programs and the encouragement of breastfeeding are discussed.     

Statement on breast feeding,fertility and contraception

An important part of the human reproductive process, breastfeeding also plays a key role in infant nutrition while protecting the infant from exposure to infection. Breastfeeding also plays a major role in the natural regulation of fertility, but breastfeeding patterns are changing along with urbanization and lifestyle changes. These changes are tending towards a shortening of the duration of breastfeeding, a reduction in the daily frequency of breastfeeding episodes, and an earlier introduction of food supplements. Consequently, the risk of pregnancy during lactation has increased. The literature suggests considerable variability in the length of breastfeeding and postpartum amenorrhea and in the duration of lactational infertility among different populations. Both the return of ovarian activity and fertility depends on the time elapsed since delivery. Variables that play a primary role in the length of amenorrhea and infertility include: the duration of breastfeeding the frequency and duration of suckling; the administration of supplements to the infant; the mother's nutritional status; and geographic, social, and cultural factors. Knowledge of local breastfeeding practices and the associated risks of pregnancy should be a prerequisite for those counseling nursing women. All women should be advised and encouraged to breastfeed fully, as far as is practicable. Women also need to be informed that it is difficult to predict exactly the duration of lactational infertility for each woman. The timing of the introduction of contraception depends on the risk factors and some programmatic aspects, such as the possibility that the woman may not return after delivery or after the 1st postpartum visit as well as the type of contraceptive chosen. Current information on the influence of contraceptive methods -- IUDs, oral contraceptives, injectable contraceptives, norplant, barrier methods, periodic abstinence, and sterilization -- upon breastfeeding are summarized.     

Breastfeeding, contraception, and birth intervals in developing countries

Numerous studies have demonstrated a strong correlation between breastfeeding and the duration of amenorrhea and between breastfeeding and the birth interval at the individual level. In the present study, both these correlations are shown to hold at the national level, in developing countries. In countries where the median durations of breastfeeding are relatively long or the rates of contraceptive use are relatively high, median birth intervals are longer than in countries where the median breastfeeding durations are shorter and contraceptive use is less widespread. In countries where fertility is moderate or high, however, the incidence of very short birth intervals is higher when median breastfeeding durations are relatively short. The findings suggest that contraception as it is presently practiced is an inadequate substitute for breastfeeding.     

Breastfeeding: its relationship with postpartum amenorrhea and postpartum sexual abstinence in a Nigerian community

Breastfeeding, together with its two related postpartum variables--amenorrhea and abstinence--govern both the tempo and quantum of fertility in traditional African societies. Decline in breastfeeding also implies decline in postpartum amenorrhea and abstinence practice. Changes in breastfeeding practices in tropical Africa, therefore, has fertility implications and consequences. This paper examines how breastfeeding is functionally related to postpartum amenorrhea and abstinence in Ilorin, an urban community in Nigeria. Results indicated that the effect of breastfeeding on fertility, through its relationship with postpartum abstinence, might be more important than its effect through lactational amenorrhea in this society. This is more true among women with little or no education than among women with secondary or higher education. The population or family planning implications of these relationships are discussed.     

The World Fertility Survey and Contraceptive Prevalence Surveys: a comparison of substantive results

This paper deals with the findings of the World Fertility Survey (WFS) and Contraceptive Prevalence Surveys (CPSs) in five areas of common interest: fertility, contraceptive use, measuring the effect of the availability of contraceptives on levels of use, the unmet need for family planning services, and breastfeeding. The comparisons have several implications for those designing surveys of fertility and family planning in developing countries, among them, that women should be asked for the dates of at least their last two births (not just the last birth as in the CPSs) in order to ensure accurate estimates of fertility and duration of breastfeeding.     

Contraceptive use and annual acceptors required for fertility transition: results of a projection model

Major fertility declines in developing countries are invariably accompanied by large increases in contraceptive prevalence and in the annual number of new acceptors. This article applies a target-setting model to make hypothetical projections of trends in prevalence and number of acceptors over the course of a full fertility transition. The sensitivity of these trends to variations in proximate determinants such as the marriage pattern and the duration of lactational amenorrhea, as well as in the discontinuation rate and the method mix, are examined. It is concluded that a contraceptive prevalence of around 75 percent is needed to achieve replacement-level fertility and that variations in proximate determinants other than contraceptive prevalence have only a modest effect on this result. On the other hand, trends in new acceptors are demonstrated to be very sensitive to discontinuation rate changes. As a consequence, it is generally difficult to draw conclusions about trends in fertility from trends in acceptors.     

New strategies for providing hormonal contraception in developing countries

Even with progress in increasing access to effective contraception over the past decades, and the growing range of contraceptive methods available on the market, women in developing countries continue to report an unmet need for family planning. This constraint continues to challenge reproductive health policies and programs, while the momentum of population growth and the young age structure in developing countries leads to larger numbers of potential contraceptive users and increasing global demand in contraceptive markets. Of late, there is a renewed focus on increasing access to long-acting hormonal methods to effectively meet this need, establishing and effectively implementing new service delivery strategies. A number of processes have profoundly affected the procurement and use of hormonal contraceptive methods in developing countries: a supportive policy environment, evidence-based practices and an increasing diversity of delivery strategies play a significant part in increasing number of contraceptive users and the demand for hormonal contraception.     

上海市产后妇女避孕方法选择的定性研究

目的:了解上海市产后妇女避孕措施的选择及其影响因素,并了解妇幼保健和计划生育机构对产后避孕服务提供情况。方法:采用个人访谈和小组讨论的研究方法,对上海市分娩1年内的产妇以及参与产后家庭访视的妇幼保健和计划生育工作人员进行访谈。结果:妇女产后早期倾向选择对身体康复和哺乳没有影响的避孕套和安全期避孕,一段时期之后倾向选择避孕效率更高的方法。选择避孕方法的种类受妇产科医生的建议和亲戚朋友避孕经验的影响较大。产妇避孕知识整体水平不高,普遍不了解哺乳避孕法以及口服避孕药、皮下埋植剂等避孕方法。由于产后访视员避孕知识的不足使得产后访视几乎未开展有效的避孕指导。结论:采取多种措施,提高产妇避孕知识,扩大产后避孕方法的选择,改善产后访视的避孕指导。     

Lactation and fertility.

During the last decade there have been many reports indicating a decline in breast feeding practices in the urban areas of developing countries. This decline might have adverse effects on maternal and child health. A study of 1079 urban hospital attending women was undertaken to evaluate their breast feeding practices. Prolonged (mean duration of lactation 19.8 months) and successful lactation (failure of lactation occurred in only 3.5%) was common among this group. But a trend toward shorter duration of breast feeding was found among educationally and economically better off segment. There was very good correlation between mean duration of lactation, lactational amenorrhea, and interpregnancy interval. Therefore, it is possible that decrease in duration of lactation might result in shorter interpregnancy interval. The duration of lactation appeared to be "fixed" for each individual irrespective of age and parity. This in turn resulted in "fixed" duration of lactational amenorrhea and interpregnancy interval under conditions of unhindered lactation and uncontrolled fertility. Conception during lactational amenorrhea was low (7.7%) but once periods were reestablished lactation offered very little protection against conception.     

A study of breastfeeding and the return of menses and pregnancy in Karachi, Pakistan

A longitudinal study of breastfeeding women was conducted to determine whether breastfeeding frequency is associated with the length of postpartum amenorrhea. The data are also conducive to testing the guidelines of the "Bellagio Consensus" (i.e., that there is no more than a 2% chance of pregnancy during breastfeeding in the first six months postpartum in the absence of vaginal bleeding and regular supplements). Twenty-eight breastfeeding women were followed-up weekly in Karachi, Pakistan. The frequency of breastfeeding was found to be a poor correlate of the duration of amenorrhea. Thirty-six percent of the women became pregnant during the study. However, all were having menses and/or giving regular supplements before the estimated date of conception, consistent with the Bellagio Consensus. In countries such as Pakistan, where contraceptive use is low, active promotion is needed to prevent the further decline of breastfeeding in order to retain its contraceptive as well as other maternal and child health benefits.     

Contraceptive efficacy of lactational amenorrhea in urban Chilean women.

The contraceptive efficacy of breastfeeding was assessed in 236 healthy urban women who were followed at monthly intervals during the first postpartum year. Proportional hazard models were used to evaluate the influence of time postpartum, menstrual status and breastfeeding pattern upon the risk of pregnancy. Time and menstrual status had a highly significant effect on this risk. Those women who remained in amenorrhea had cumulative probabilities of pregnancy of 0.9% and 17% at 6 and 12 months postpartum, respectively. In those who recovered menstrual cycles, the risk rose to 36% and 55% at 6 and 12 months, respectively. Milk supplementation also increased significantly the risk when considered alone but not when time and/or menstrual status were included in the analysis. However, amenorrheic women who introduced bottle feeding, had a higher risk of pregnancy after 6 months postpartum than those who remained fully nursing. The analysis was unable to detect a significant influence of the nursing frequency. The results confirm that lactational amenorrhea is an effective contraceptive during the first six months postpartum. The first postpartum bleeding marks a great increase in the risk of pregnancy. Supplementation also increases the risk, particularly in amenorrheic women.     

Consensus statement on the use of breastfeeding as a family planning method

An interdisciplinary international group of researchers in the area of lactational infertility gathered with the purpose of coming to a consensus about the conditions under which breastfeeding can be used as a safe and effective method of family planning. The consensus of the group was that the maximum birth spacing effect of breastfeeding is achieved when a mother "fully" or nearly fully breastfeeds and remains amenorrheic. When these two conditions are fulfilled, breastfeeding provides more than 98% protection from pregnancy in the first six months. Data are reviewed from thirteen prospective studies in both developed and developing countries supporting the consensus. The rationale for the consensus is given in detail. Recommendations are made based on what is currently known of the antifertility effects of breastfeeding. Research should continue to measure a broad spectrum of variables so that these guidelines can be refined as new information becomes available.     

Lactational amenorrhoea and family planning

Scientists and policymakers at an international meeting in Bellagio, Italy, have concluded that the lactational amenorrhea method of family planning (LAM) can be recommended to help women space births. Based on a study of data from several thousand women in more than a dozen countries, including Nigeria and Rwanda, the group decided the following conditions were required to be simultaneously present to achieve a high degree of protection: 1) remaining amenorrheic; 2) being within six months of delivery; and 3) full or nearly full breastfeeding. Used in this manner, LAM was 98% effective. If any of the conditions should change, another method of contraception would have to be used. Infants older than 6 months need supplemental feeding, which typically decreases breastfeeding; however, in many of the reviewed studies, women who continued to breastfeed after 6 months together with supplemental feeding had a low rate of pregnancy, although higher than at six months. This may allow the extended use of LAM. Additional research is needed.     

Progesterone vaginal ring for contraceptive use during lactation

The progesterone vaginal ring (PVR) has been shown to be effective as a contraceptive in breastfeeding women who need a better method of spacing pregnancies, and previous clinical trials of 1-year duration demonstrated its efficacy to be similar to that of the IUD during lactation. The duration of lactational amenorrhea is significantly prolonged in PVR users in comparison to IUD users with fewer median numbers of bleeding/spotting (B/S) episodes and B/S days. This long-acting delivery system designed for 3-month use needs to be renewed every 3 months as long as breastfeeding continues. The system designed as a matrix ring delivers 10 mg/day of the physiological hormone progesterone. Various factors such as comfort, ease of use, user control, rather than provider-dependent, and the fact that it contains a natural hormone have contributed to a high acceptability of the PVR method by breastfeeding women. The frequency of breastfeeding, breast milk volume and infant growth were not different in PVR users or IUD users, and the safety of this new method has been well documented. This article describes the available information and the results of the studies that led to approval of this method in several countries in Latin America so far. Further evaluation of the PVR acceptability in different populations where breastfeeding is popular and highly recommended for the infant's benefit is warranted.     

Lactational Amenorrhea Method as a Contraceptive Strategy in Niger

If used properly, the lactational amenorrhea method (LAM) can be a valuable family planning tool, particularly in low-income countries; however, the degree to which LAM is used correctly and characteristics associated with its use have not been well documented. We therefore sought to use nationally representative data from Niger, where fertility rates are high and women may have limited access to alternative contraceptive methods, to describe the proportion of women who use LAM correctly and the characteristics associated with LAM use. We utilized cross-sectional data from the 2006 Niger Demographic Health Survey. Our sample included all sexually active, non-pregnant, breastfeeding women using some form of contraception (N = 673, unweighted). We used weighted frequencies to describe the correct use of LAM and logistic regression models to describe women who chose LAM for contraception. Among our sample, 52 % reported LAM as their primary method of contraception, but only 21 % of the women who reported using LAM used it correctly. Women who reported using LAM were more likely to live in certain regions of the country, to have no formal education, and to have delivered their most recent baby at home. They were also less likely to have discussed family planning at a health facility or with their husband/partner in the past year. Results indicated that few women in Niger who reported using LAM used it correctly. Our findings reinforce the need to address this knowledge gap, especially given Niger’s high fertility rate, and may inform efforts to improve family planning in Niger and in other low-income countries.     

New IPPF statement on breastfeeding,fertility and post-partum contraception

The International Planned Parenthood Federation International Medical Advisory Panel drew up the following statement in November, 1989. Breastfeeding is good for the infant. Antibodies passed to it from the mother protect it from infection. Patterns of breastfeeding are changing. Therefore, the risk of pregnancy is increased. Postpartum amenorrhea plays a major role in natural fertility regulation. Studies from around the world show a positive correlation between the length of breastfeeding and the length of lactational amenorrhea. Amenorrhea lasts longer in those who breastfeed more often at night and during the day. There is controversy over the effect of nutrition on postpartum infertility. Pregnancy and the puerperium are a good time for counseling on maternal nutrition, child spacing, breastfeeding, and contraceptive methods. Counseling nursing mothers about potential fertility during lactation should be based on local information. All women should be advised to fully breastfeed. Family planning programs should cooperate with maternity services in providing counseling and education for postpartum women who need contraception, for providing referral services, for producing educational resources, and in training health personnel. Postpartum contraception should be included in the training of traditional birth attendants. Women who do not breastfeed can select any contraceptive method. Mothers who nurse must not hurt success of lactation or the infant's health. Nonhormonal contraception should be the 1st choice for lactating women. IUDs do not harm infant growth or lactation. Postpartum insertions are appropriate, though care must be taken. Female sterilization can be conveniently done at this time. Barrier methods are reliable when used regularly. The failure rate should be lower when used after delivery. Progestagen-only contraception consists of progestagen-only pills, injectables, and Norplant. These do not affect quality and quantity of breast milk or length of lactation. They are suitable for those who do not wish nonhormonal methods. There are possible consequences, however, of the transfer of the steroid to breast milk. Hormonal methods should not be used earlier than 6 weeks postpartum. High and low dose oral contraceptives adversely affect the quality and quantity of breast milk. They also reduce duration of lactation. They should be withheld until 6 weeks after delivery, or until the infant is weaned--whichever comes first. The efficacy or periodic abstinence in nursing women requires further analysis.