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General Guidelines for Breastfeeding Women

Contraception and Lactation
Spacing children at least two or three years apart has several advantages. Your first infant can enjoy the luxury of your undivided attention throughout his babyhood before having to share your time and energies with a sibling. Sibling adjustments usually are easier when the older child has acquired sufficient language skills to communicate his natural ambivalence about a baby brother or sister. Two or three years between births gives couples ample time to renegotiate their relationship before the family dynamics shift once again. And spacing pregnancies allows a mother time to replenish her nutrient stores. Most new parents agree that family planning gives them the peace of mind to thoroughly enjoy their new role before contemplating another pregnancy.

Breastfeeding and contraception are very interwoven. For one thing, breastfeeding has an effect on a woman's fertility. The return of menstrual periods is delayed in breastfeeding women compared with women who formula-feed their babies. In addition, various contraceptive methods can have an effect on breastfeeding by diminishing a mother's milk supply. Finally, becoming pregnant during lactation has an effect on breastfeeding because the prenatal hormones markedly diminish milk production. The following information should help you, together with your partner and your physician, select a contraceptive method that is most suited to your needs.

Lactational Amenorrhea Method
It has long been recognized that breastfeeding has an inhibitory effect on ovulation and fertility after childbirth. Fully breastfeeding women sometimes go a year or longer without having a menstrual period. Until recently, however, the contraceptive effect of breastfeeding had not been formally studied. Recent research has documented that a woman who continues to fully breastfeed her infant and who has no vaginal bleeding after fifty-six days postpartum (i.e., her menstrual periods have not returned) has less than a 2 percent risk of pregnancy during the first six months postpartum. The delay in both ovulation and return of menstrual periods after childbirth that is attributed to breastfeeding has been called "lactational amenorrhea." Using lactational amenorrhea as an introductory method of contraception after childbirth is known as the Lactational Amenorrhea Method (LAM). LAM is now recognized as a highly effective temporary family planning method for breastfeeding women in the early months after delivery. By providing natural protection against pregnancy for up to six months postpartum, LAM gives a nursing mother time to choose a more permanent method of contraception with which she is comfortable. It is critical that a woman meet all three criteria for LAM before using it as protection against pregnancy. The three conditions are: (1) less than six months postpartum; (2) amenorrheic (no periods yet); and (3) fully breastfeeding. It must be emphasized that when any one of these three conditions change, the woman needs to begin using another family planning method to continue her protection against pregnancy. You also should use another family planning method if you are unwilling to accept even a small risk of pregnancy.

Nonhormonal Methods of Family Planning
In addition to LAM, other nonhormonal methods of preventing pregnancy include condoms, diaphragms, cervical caps, vaginal sponges, spermicides, intrauterine devices (IUDs), and natural family planning (rhythm method or periodic abstinence). Permanent options include tubal ligation or vasectomy. These nonhormonal family planning methods have no effect on breastfeeding and pose no risk to the nursing infant. You will want to discuss the respective pros and cons of these options in greater detail with your health care provider and your partner.

Combination Oral Contraceptive Pills
Combination birth control pills contain both estrogen and progestin and are the most effective method of birth control. The main concern about using combination oral contraceptives during breastfeeding is the fact that estrogens may reduce a mother's milk supply. Although hormones may pass into breast milk, no immediate or long-term negative effects on infants have been proved. Ideally, combination birth control pills should be delayed at least six months to minimize their potential impact on breastfeeding. I also believe that mothers who take these pills should be warned about the possibility that their milk supply could decrease. Despite the possible risk of diminished milk production, some nursing mothers choose this method of family planning because of its effectiveness. If you decide to take combined oral contraceptives, try to avoid other behaviors that could decrease your milk supply. For example, I have encountered women who started taking a combined oral contraceptive just as they went back to work, started giving their baby supplemental formula, and allowed their baby to sleep through the night. When their milk supply diminished significantly, it was difficult to sort out which of the various "insults" was most responsible.

From Dr. Mom's Guide to Breastfeeding by Marianne R. Neifert. Copyright © 1998 by Marianne R. Neifert. Used by arrangement with Plume, a member of Penguin Group (USA) Inc.

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