by Jamie Hatcher CNM~

You may have heard your midwife or doctor recommend spacing your children 2 years apart or waiting at least 18 months after birth before becoming pregnant again. It’s important to allow time for your body to heal and recharge after having a baby. Pregnancy and birth place a lot of physical demand on a woman’s body, and becoming pregnant too quickly after giving birth can increase the risk of complications in the subsequent pregnancy including having preterm birth and an infant with low birthweight. Although you may feel back to normal within a few months of giving birth, your body is still going through more subtle changes and recharging. The consensus is that allowing 18 months between birth and the next pregnancy gives your body ample time to recover and boost your chances of having a healthy, normal pregnancy. Fortunately, there are a number of approaches to preventing pregnancy postpartum that are safe to use while breastfeeding.

 

Breastfeeding: So, you’re saying I can get pregnant while breastfeeding?!

 

A common misconception is that you cannot get pregnant while breastfeeding. Lactation Amenorrhea Method, or LAM, can indeed provide protection from pregnancy under three conditions: 1) menstrual periods have not resumed, 2) the infant is fully breastfed on-demand, and 3) the infant is less than 6 months old. So long as these three criteria are met, ovulation is suppressed. As a general guideline, if you’re breastfeeding at least every 4 hours during the day and at least every 6 hours at night, then your hormone levels should remain steady and prevent ovulation. If you are feeding less frequently than this or supplementing breastfeeding with formula, your hormone levels will fluctuate and potentially stimulate ovulation. The critical point of knowledge is that you will ovulate before you get your first menstrual period. Many women assume that if they haven’t had a menstrual period yet then they cannot possibly get pregnant, when in fact it’s the hormone shift precipitating ovulation that leads to the resumption of menstruation. LAM can be an easy, effective means of contraception as long as the three conditions are kept in mind – infant is breastfed on-demand, less than 6 months of age, and the woman’s menstrual periods have not resumed. If any of these three criteria are not met, then an additional method must be used to provide protection from pregnancy.

 

Family planning methods can be categorized into non-hormonal and hormonal methods. All non-hormonal methods are compatible with breastfeeding, while only some hormonal methods are known to be okay to use with breastfeeding. Non-hormonal methods include withdrawal, condoms, diaphragm, and the copper IUD. Hormonal methods include. In general, the progesterone-only contraceptive options are considered compatible with breastfeeding, which include oral contraceptives (mini-pill), the implant, the shot, and hormonal IUDs. When deciding what method is right for you, you’ll want to consider your lifestyle, personal habits, and goals for family planning. Following is a description of the non-hormonal and hormonal methods, their efficacy rates, benefits and drawbacks which should get you started on the path to finding what will work best for you!

 

Withdrawal (aka “Pulling out”)

Method: The penis is withdrawn (pulled out) from the vagina prior to ejaculation so that semen does not enter the vagina. If any semen gets on the vulva or vagina during ejaculation there is a risk of getting pregnant.

There is high user error with the withdrawal method. Your partner must know his body very well and have good self-control to remove his penis from the vagina before ejaculating. There also must be a strong degree of trust in the relationship that he will withdraw before ejaculating. It’s generally recommended that withdrawal be used in conjunction with another method rather than being the sole method used. For example, using withdrawal along with LAM can be a good combination to preventing pregnancy.

Efficacy: 78%

Approximately 22 out of 100 women using the withdrawal method will become pregnant each year.

Benefits

§  Convenient and free.

§  No side effects.

 

Drawbacks

§  High risk for user error. Timing is important as well as high level of self-control to avoid ejaculation in the vagina.

 

 

Diaphragm

Method: A barrier method involving a soft silicone cup that is placed in the vagina covering the cervix. Must be used with a spermicidal agent for maximum effectiveness.

The diaphragm is making a bit of a comeback these days with a new one-size-fits-all version available called the Caya. The Caya is easy to insert and remove, is resuable, and most likely covered by insurance. It can be used with a traditional nonoxynol-9 spermicide or Contragel, which is a natural spermicide. Read more about the Caya diaphragm here: https://www.caya.us.com/

postpartum contraception

Efficacy: 88%

Approximately 12 out of 100 women using the diaphragm will become pregnant each year.

Benefits

§  Convenient.

§  Easy to use and gives woman control over fertility.

§  One diaphragm lasts for 2 years.

§  Non-hormonal.

§  No side effects.

 

Drawbacks

§  Must be inserted before intercourse and not removed until at least 6 hours after intercourse.

§  Must be used with a spermicide.

 

Condoms

Method: A barrier method that is placed on the penis prior to intercourse that prevents semen from entering the vagina. Must be used properly every time in order to be effective.

Efficacy: 85%

Approximately 15 out of 100 women using condoms will become pregnant each year.

Benefits

§  Convenient.

§  Easy to obtain and use.

§  Non-hormonal.

§  No side effects.

 

Drawbacks

§  Moderate risk for user error. Must be used correctly every time to be effective.

§  May be disruptive to intercourse.

 

 

Paragard (Copper IUD)

Method: A small, flexible t-shaped plastic and copper device is placed in the uterus. The intrauterine device (IUD) creates an unfavorable environment for an egg to implant and the copper acts as a spermicide.

Paragard IUD is an excellent non-hormonal long-term contraceptive. However, it is not recommended for women with a history of dysmenorrhea, heavy menstrual periods, or endometriosis due to the side effect of heavier menstrual cycles. The Paragard is effective for up to 10 years once inserted, with almost immediate return to fertility once it’s removed.

Postpartum contraception

Efficacy: 99%

Approximately 1 out of 100 women using the Paragard IUD will become pregnant each year.

Benefits

§  “Set it and forget it.”

§  Highly effective, no user error.

§  Prevents pregnancy for up to 10 years.

§  Quick return to fertility once removed.

§  Non-hormonal.

 

Drawbacks

§  Must be inserted and removed by a trained midwife or doctor.

§  May cause heavier menstrual periods and/or more severe menstrual cramps.

§  Very small risk of infection or uterine perforation with insertion (less than 1%).

 

Oral Contraceptives

Method: A pill that is taken every day at the same time. Works by preventing ovulation.

A progesterone-only pill (aka “mini-pill) is most commonly prescribed for breastfeeding mothers. This pill must be taken every day within a 1-hour time window. If the pill is late or missed, then a back-up method (such as condoms) must be used for 2 days. The mini-pill can only be used as long as the woman hasn’t resumed menstrual periods.

Traditional birth control pills contain a combination of estrogen and progesterone, and therefore are not recommended for women in the initial postpartum period. Estrogen may impact breast milk supply and also increases the risk of developing blood clots or deep vein thrombosis (DVT), so for these reasons it is not recommended to start combined oral contraceptives until breastfeeding is established, or at least 4-6 weeks postpartum.

The biggest consideration with oral contraceptive pills is whether you be able to remember to take the pill every day at the same time. You need to look realistically at your lifestyle and habits to decide if this method will be effective for you.

Efficacy: 91%

Approximately 9 out of 100 women using the pill will become pregnant each year.

Benefits

§  Convenient. Midwife or doctor can prescribe and most birth control pills are covered by insurance.

§  Easy to use.

§  Easy to discontinue.

§  Quick return to fertility after stopping.

§  Progesterone-only should not impact milk supply or breastfeeding.

 

Drawbacks

§  Need a prescription.

§  Time sensitive. Pill must be taken at the same time every day otherwise it is not effective.

§  High risk for user error.

§  Must switch methods once menstrual periods resume.

 

The Shot (aka Depo-Provera, or simply, “Depo”)

Method: An injection of progestin hormone that is received every 3 months. Works by preventing ovulation.

The biggest consideration with the Depo shot are side effects. Complaints of side effects range from headaches, weight gain, mood swings to a 10-12 month delay in return of menstrual cycles and fertility after discontinuing use. There is also a risk of decrease in bone density with prolonged use. For women who have used the shot in the past and with good experiences, I am happy to prescribe it’s use again, however I don’t generally recommend the shot when there are other options available with fewer side effects.

Efficacy: 94%

Approximately 6 out of 100 women using the shot will become pregnant each year.

Benefits

§  Convenient. Midwife or doctor can prescribe and administer.

§  Less room for user error.

§  Easy to discontinue.

§  May have lighter or no periods.

Drawbacks

§  Must return every 3 months for injections.

§  Many complaints about side effects as you receive a large dose of hormones at one time.

§  Can have delayed return to fertility after stopping (up to 10 months).

 

 

Implant (aka Nexplanon)

Method: A small (2-3”) flexible plastic rod is implanted under the skin on your upper, inner arm. The rod slowly releases progestin which prevents ovulation and thickens cervical mucus to prevent pregnancy.

The implant is a great option for someone who feels uncomfortable with the idea of having a device in the uterus, but desires a long term contraceptive.

Postpartum contraception

Efficacy: 99%

Approximately 1 out of 100 women using Nexplanon will become pregnant each year.

Benefits

§  “Set it and forget it.”

§  Highly effective, no user error.

§  Prevents pregnancy for up to 5 years.

§  Quick return to fertility once removed.

§  May have lighter periods.

 

Drawbacks

§  Must be inserted and removed by a trained midwife or doctor.

§  May have irregular spotting or periods.

§  Potential for pain with insertion/removal

 

Mirena, Skyla, & Kyleena (Hormonal IUDs)

Method: A small, flexible t-shaped device is placed in the uterus. The intrauterine device (IUD) slowly releases progestin which prevents ovulation and thickens cervical mucus to prevent pregnancy.

Hormonal IUDs are great for long-term effective contraception, and because they are progesterone-only, are considered compatible to use with breastfeeding. The insertion process is relatively easy and risks are minimal. Side effects of the hormonal IUDs include spotting or irregular bleeding, headache or nausea. All side effects tend to resolve within 3-6 months of the IUD being placed as your body adjusts. Once the IUD is removed, return to fertility is almost immediate.

Postpartum contraception

Efficacy: 99%

Approximately 1 out of 100 women using an IUD will become pregnant each year.

Benefits

§  “Set it and forget it.”

§  Highly effective, no user error.

§  Prevents pregnancy for 3 years (Skyla, Kyleena) or 5 years (Mirena).

§  Quick return to fertility once removed.

§  May have lighter periods.

 

Drawbacks

§  Must be inserted and removed by a trained midwife or doctor.

§  May cause irregular bleeding/spotting.

§  Very small risk of infection or uterine perforation with insertion (less than 1%).

 

Postpartum contraception

 

Summary Comparison Chart
Method Efficacy Results (if used accurately every time)
IUD (hormonal and non-hormonal) 99% 1 in 100 women using will get pregnant
Implant 99% 1 in 100 women using will get pregnant
LAM 98% 2 in 100 women using will get pregnant
Shot 94% 6 in 100 women using will get pregnant
Pill 91% 9 in 100 women using will get pregnant
Diaphragm 88% 12 in 100 women using will get pregnant
Condoms 85% 15 in 100 women using will get pregnant
Withdrawal 78% 22 in 100 women using will get pregnant

 

 

Resources:

https://www.plannedparenthood.org/learn/birth-control

https://www.hhs.gov/opa/pregnancy-prevention/birth-control-methods/lam/index.html

https://www.acog.org/Patients/FAQs/Postpartum-Birth-Control?IsMobileSet=false

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