New Guidance on Contraception While Breast-Feeding

Feature |
September 26, 2016

New Guidance on Contraception While Breast-Feeding

  1. Melissa J. Chen and
  2. Eleanor Bimla Schwarz, MD, MS

Helping women balance the potential for contraceptive-associated concerns against the chances of undesired pregnancy is the challenge.

  1. Melissa J. Chen and
  2. Eleanor Bimla Schwarz, MD, MS

The CDC recently updated the U.S. Medical Eligibility Criteria for Contraceptive Use (US MEC), which provides guidance on the safety of available contraceptives for women with specific health conditions.1 Updates for breast-feeding women include revised recommendations categorized by risk for venous thromboembolism (VTE) and postpartum day (<21 days, 21 to <30 days, 30 to 42 days, and >42 days). In addition, guidance on placement of levonorgestrel intrauterine contraceptives within 10 minutes of placental delivery has been updated for women who want to breast-feed.

Evidence supporting these revised recommendations is summarized in two systematic reviews2,3 on breast-feeding performance (i.e., duration and exclusivity) and infant health outcomes (growth and development). Most evidence is limited, showing inconsistent effects on breast-feeding performance and infant health when either progestin-only contraceptives or combined hormonal contraceptives (CHC) are used. All progestin-only methods are rated category 1 (no restriction on use) or category 2 (advantages of the method generally outweigh its theoretical or proven risks) for breast-feeding women, regardless of other vascular risk factors and time since delivery. A new option available outside the U.S. for lactating mothers is a progestin-only vaginal ring that is effective for ≤1 year.4

Given the excess risk for VTE during the postpartum period, CHC use within 21 days of delivery is rated category 4 (an unacceptable health risk) for all women. For those women who have other VTE risk factors and are >21 to <42 days postpartum, CHC use is rated category 3 (theoretical or proven risks usually outweigh the advantages of using the method).

Comment

Given that breast-feeding has documented benefits for both maternal and child health (e.g., NEJM JW Womens Health Jul 9 2014; [e-pub] and Am J Obstet Gynecol 2014; 211:424.e1), any potential adverse effect of hormonal contraception on breast-feeding performance deserves close consideration. While recognizing the limitations of the current evidence, when mothers are highly motivated to breast-feed — especially if they have risk factors conferring difficulties with breast-feeding (e.g., obesity, gestational diabetes, preterm delivery) — it's important to discuss what we do and do not know regarding the effects (if any) of hormonal contraception on breast-feeding performance. The challenge remains to help women balance these theoretical risks against the chances of undesired pregnancy.

For women who are breast-feeding exclusively, lactational amenorrhea offers an effective temporary method of contraception (until menses return or milk substitutes are introduced). When women desire additional protection against undesired pregnancy, all available methods should be offered. For many new mothers, reassurance that hormonal contraception does not curtail postpartum weight loss is important. When safety, convenience, or superior effectiveness is a priority, prompt placement of subdermal or intrauterine contraception is ideal.

Dr. Chen is Assistant Professor, Department of Obstetrics and Gynecology, University of California Davis Health System.

Editor Disclosures at Time of Publication

  • Disclosures for Eleanor Bimla Schwarz, MD, MS at time of publication Grant / Research support Office of Adolescent Health Editorial boards Contraception; Journal of General Internal Medicine

Citation(s):

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