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Postnatal contraception: what are the choices?

Jane Knight
RGN SCM FPCert
DipFertilityCounselling
Fertility Nurse/Researcher
and Director
Fertility UK
Oxford

Cecilia MM Pyper
MB BS
NHS Primary Care Career Scientist
Health Services Research Unit
Department of Public Health
University of
Oxford
GP
Oxford
E:jknight@fertilityuk.org
E:cecilia.pyper@public-health.oxford.ac.uk

The natural contraceptive effect of breastfeeding has been recognised for centuries. In 350BC, Aristotle observed that while women are suckling children menstruation does not occur, nor do they conceive.(1)
Traditionally babies were breastfed from birth and supplements were introduced after the milk teeth had erupted, at around 6onths.(2) This temporary reduction in fertility, also known as lactational amenorrhoea, is known to lengthen intervals between pregnancies in developing countries, where women often breastfeed for two years or longer. Elsewhere, changes in lifestyle, and the need to study or work outside the home, can interfere with women's breastfeeding patterns.(3)
So how can we make effective use of nature's contraceptive with current breastfeeding patterns? It is important to understand how breastfeeding suppresses ovulation.(3) During pregnancy the levels of prolactin rise, but the high levels of oestrogen and progesterone prevent the prolactin stimulating milk production in the breasts. Immediately after delivery the prolactin level peaks, oestrogen and progesterone levels fall, and the prolactin stimulates the breasts to produce milk. Prolactin acts on the pituitary gland, interfering with the action of follicle-stimulating hormone and luteinising hormone, reducing the production of oestrogen, and suppressing follicular growth, hence suppressing ovulation. Each act of suckling stimulates the production of prolactin, but the level falls again after 3ours. Provided the baby suckles frequently, the level of prolactin remains high and ovulation is suppressed. 
Following an international meeting in Italy in 1988, it was formally recognised that breastfeeding was effective to use as a family planning method when certain conditions were met. This method of family planning was called the lactational amenorrhoea method (LAM  see Figure 1).(4) It stated that a woman is 98% protected from pregnancy when fully breastfeeding a baby under six months. This means she must breastfeed at regular intervals day and night; give no other liquids or solids as a substitute for breastfeeding; and have no periods (no bleeding after the first eight weeks postpartum). Once any of these conditions is not being met, the chances of pregnancy increase (even if a woman continues to fully breastfeed and remains amenorrhoeic after six months).

[[NIP05_fig1_23]]
 
A recent WHO multicentre study reported that in the first six months after childbirth the cumulative pregnancy rate ranged from 0.9% to 1.2% during full breastfeeding,(5) providing further evidence that fully breastfeeding a baby gives 98% protection against pregnancy. Yet practitioners still lack confidence in reassuring women that breastfeeding can act as an effective contraceptive.(6)

Breast or bottle?
Breastfeeding has many health benefits for mother and baby. It provides the baby with complete nutrition, a safe food source, and immunological defence against infectious diseases. It also reduces the mother's risk of ovarian and breast cancer. WHO commissioned a systematic review of the published scientific literature on the optimal duration of exclusive breastfeeding, evaluating over 3,000 references. It now recommends exclusive breastfeeding for six months, with the introduction of complementary foods and continued breastfeeding thereafter.(9) Recommendations for best breastfeeding practice can be found at UNICEF UK's baby- friendly initiative.(10) The infant feeding survey 2000 confirmed that those most likely to breastfeed are women who are older, better educated (18-plus) and from social classes I and II.(11) However, there was a significant increase in social class V (50% in 1995 to 62% in 2000). Therefore the opportunity for using breastfeeding as a fertility suppressant tends to be restricted to a select group.
The return of fertility has been compared between breast- and bottlefeeders.(12) In the breastfeeding group, ovulation was delayed for up to 15 months compared with bottlefeeding mothers, who had all resumed ovulation and menstruation by 15 weeks, averaging a return of fertility between nine and 13 weeks postpartum. (Menstruation can return as early as five weeks after the birth in bottlefeeders). In around 50% of women ovulation occurs before the first menstrual period, so a woman who is bottlefeeding could conceive again within one month postnatally. Women who are not protected by LAM will therefore need to have access to another appropriate and effective method of contraception.
The choice of method after childbirth needs to take into account the woman's plans, if any, to have further children. Guillebaud splits the postnatal ages into: during breastfeeding; family spacing after breastfeeding; and after the (probable) last child.(13) The postnatal contraceptive consultation needs to distinguish carefully between short-term, longer-term or permanent methods. Women who have experienced a delay in conceiving in the past need particularly careful counselling. 
The general advice for resuming sexual activity postnatally is as soon as the woman and her partner feel ready, although almost 50% of women have reduced levels of sexual interest for at least three months postnatally.(14) Physical problems include breast and nipple tenderness, dyspareunia from pain at the site of an episiotomy or a caesarean section wound. Many women will report reduced vaginal lubrication - generally more marked for breastfeeding women due to low oestrogens. Primary care nurses should be alert for signs of postnatal depression, which affects one in 10 women in the first year following childbirth. Symptoms include anxiety, irritability, fatigue and a demoralising sense of failure to cope, with consequent feelings of guilt and reduced confidence and self-esteem. It can also cause loss of libido.

Choice of contraceptive method

Family planning when still breastfeeding but LAM guidelines no longer apply
In the first six months postpartum, the majority of women who are fully breastfeeding will be able to rely on LAM (see Figures 1 and 2). An additional family planning method should be started at a time when the LAM guidelines no longer apply.

[[NIP05_fig2_24]]

Women wishing to delay their next conception may be well suited to a fertility awareness method (FAM)(15) by observing signs of returning fertility: cervical secretions, temperature and changes in the cervix (optional). A woman should start observing her fertility signs about two weeks before it is expected that the LAM criteria will no longer apply. This will require the support of a qualified FAM practitioner (see Resources). 
The personal hormone monitoring system (Persona; Unipath) is not recommended for use while breastfeeding. A woman should wait until she has had at least two normal menstruations with cycle length 23days before using the monitor with the beginning of the third period. 
Barrier methods - condoms or diaphragms - may be appropriate for breastfeeding women who are spacing their births. The diaphragm fit should be rechecked postnatally. Women who experience dyspareunia may find that barrier methods are uncomfortable. Lubricants must be water- based if rubber barriers are used.
Any progestogen-only method is suitable during breastfeeding. POPs, the IUS or an implant may be suitable for family spacers, but the injection Depo-Provera is appropriate only if a long gap is expected between pregnancies, due to the possible delay in returning fertility. For breastfeeding mothers, the dose of progestogen to the baby is believed to be harmless - the quantity being equivalent to one POP in two years and considerably less than the progesterone level in dried cow's milk. 
Combined oral contraception is not currently considered suitable for breastfeeding women as the oestrogen may affect the quantity and constituents of breast milk. However, this issue is currently being reviewed by the Cochrane Collaboration. An IUD is generally suited to family spacers and can be used during breastfeeding.
In practice, many women who have breastfed for long periods will have difficulties planning their next conception if they are still breastfeeding, even infrequently, despite the resumption of menstruation.

Family spacing after breastfeeding
Women spacing their next pregnancy are ideally suited to using a FAM after breastfeeding, provided they have adequate instruction (see Resources). 
Oestrogen-containing methods (COCs) can be used after breastfeeding where increased effectiveness is required. The IUD, IUS or implant, combines the least long-term health hazards, efficacy and reversibility. Careful consideration of sexual history is always required for women considering an IUD, particularly in a new relationship or where there may be issues related to exposure to STIs. Injectables may be appropriate if a longer gap is required between pregnancies.
Generally a FAM or barrier method will combine protection of fertility with absence of health risks.

After the (probable) last child
Breastfeeding women who decide that they have completed their family may want more protection than lactational amenorrhoea can offer. They may prefer not to rely on highly user-dependent methods such as a FAM or barrier methods. Any other method may be more appropriate. 
After the (probable) last child, there is less concern about protecting fertility or planning the next child, so a longer-term method (IUD, IUS, COC, implant or injectable) may be more appropriate. Sterilisation of either partner should not be considered immediately postnatally as decisions are more likely to be regretted at this time. Requests for sterilisation at a young age or at the time of birth require particularly effective counselling.
The authors have had experience of the extreme ambivalence of some women where the presenting concern is whether to opt for sterilisation or a FAM (natural family planning). The two methods are generally viewed as opposite ends of the effectiveness scale. Such couples (or individuals) require careful counselling about their desires for future children.

Conclusion
Effective communication skills are especially important for the postnatal family planning consultation. Active listening and allowing sufficient time for open-ended questions can provide the necessary space to help women or couples to explore issues related to the recent birth, the resumption of sexual activity, plans for future children and help regarding the choice of method suited to the needs of the woman, the couple and her young family.

References

  1. Thapa S, et al. Breast-feeding, birth spacing and their effects on child survival. Nature 1988;335:679-82.
  2. Potts M, Short R. Ever since Adam and Eve: the evolution of human sexuality. Cambridge: Cambridge University Press; 1999. p. 150-4.
  3. IPPF. Family planning handbook for health professionals. IPPF; 1997. p. 172.
  4. Kennedy KI. Breast-feeding as a family planning method. Lancet 1988; 19 Nov:1204-5 (Report by Kathy Kennedy from the Bellagio Study and Conference Centre in Italy).
  5. WHO Task Force on Methods for the Natural Regulation of Fertility. The World Health Organisation multinational study of breast-feeding and lactational amenorrhoea. III. Pregnancy during breast-feeding. Fertil Steril 1999;72:431-40.
  6. FPA. Contraceptive education bulletin. Winter 2000. London: FPA. p. 2.
  7. Labbok M, et al. Guidelines:breast-feeding, family planning, and the lactational amenorrhoea method - LAM. Washington, DC: Institute for Reproductive Health , Georgetown University; 1994.
  8. Kennedy KI, Trussel J. Postpartum contraception and lactation. In: Hatcher RA, Trussell J, Stewart F, editors. Contraceptive technology. New York: Ardent Media; 1998. p. 589-614.
  9. WHO. The optimal duration of exclusive breast-feeding - results of a WHO systematic review. WHO; 2001. Available from URL: http//www.who. int/inf-pr-2001/en/note2001-07.html
  10. UNICEF. UK Baby friendly initiative. Available from URL: http://www.babyfriendly.org.uk
  11. Department of Health. Infant feeding survey 2000. Available from URL: http//www.doh.gov.uk
  12. Howie PW. Effect of supplementary food on suckling patterns and ovarian activity during lactation. BMJ 1981;283.
  13. Guillebaud J. Contraception - your questions answered. 3rd edn. London: Churchill Livingstone; 1999.
  14. Andrews G. Women's sexual health. London: Baillière Tindall; 2001.p. 178-84.
  15. Clubb E, Knight J. Fertility - fertility awareness and natural family planning. Newton Abbot: David & Charles; 1996. p. 84.
  16. Guillebaud J. Contraception today. London: Martin Dunitz; 1995. p. 44.

Resources
Fertility UK provides an information and referral service on fertility awareness methods including LAM. Also provides university-accredited courses for health professionals W:www.fertilityuk.org.
Family Planning Association (FPA) produces client leaflet - After you've had your baby - your contraceptive choices. Also provides information on contraception and sexual health plus training and resources for health professionals
Helpline: 0845 310 1334
W:www.fpa.org.uk

Further reading
Andrews G. Women's sexual health. London: Bailli¨¨re Tindall; 2001.
Guillebaud J. Contraception - your questions answered. 3rd ed. London: Churchill Livingstone; 1999.