By Dr Marie-Therese (Terri) Lovis, General Practitioner DFSRH, Faculty Trainer
Contraception, if required, is needed from 21 days after delivery1. 50% of women have had sex by the 6 week postnatal check. There are increased rates of complications if a pregnancy starts within 12 months of giving birth.
Below are highlighted some of the key contraceptive issues which relate to infant feeding.
Breastfeeding provides contraception with a 2% failure rate (as good as condoms) but only if:
- The infant is less than 6 months old
- Breastfeeding is exclusive with no long gaps between feeds and no formula top-ups (expressing breastmilk does not afford the same high level of contraceptive protection)2
- Periods haven’t restarted
NICE CKS: Contraception – Natural Family Planning Lactational Amenorrhoea Method Last revised April 2016
Progesterone Only Hormonal Contraception (POC)*
All of the progesterone only hormonal contraceptive (POC) methods are considered safe from birth including when breastfeeding. This includes:
- Progesterone only pill (eg Desogestrel)
- Progesterone implant (Nexplanon)
- Intramuscular injection (DMPA-IM) (Depo-Provera)
- Self-administered subcutaneous injection (DMPA-SC) (Sayana-Press)
UKMEC 2016 Look at the ‘Progesterone Only Contraception’ section, then in the sub-section ‘Personal Characteristics’ for information on POC initiation, including while breastfeeding.
Combined Hormonal Contraception (CHC)*
- If breastfeeding and otherwise healthy the CHC can be started from 6 weeks. In past versions of UKMEC the advice was to delay starting CHC until 6 months when breastfeeding, but there is no good quality evidence showing effects on either milk production or baby’s development so the FSRH reduced the deferral period.
- If NOT breastfeeding with no VTE risks The earliest the combined hormonal contraceptive (CHC) pill/patch/ring can be started is 3 weeks
UKMEC 2016 Look at the ‘Combined Hormonal Contraception’ section, then in the sub-section ‘Personal Characteristics’ for information on CHC initiation.
*HOWEVER– there have been concerns raised by lactation specialists that for some women use of hormonal contraception (CHC and POC) can reduce breastmilk supply. In a recent US survey 10.6% of women who initiated hormonal contraception in the first 12 weeks postpartum reported that it caused reduced milk production (62.8% reported no effect, 26.4% did not know, 0.2% reported increased production)3.
GPIFN therefore encourages GPs to Yellow Card any concerns about decreased milk supply while taking hormonal contraception and consider this as a cause. If a patient is having difficulties with breastfeeding, it may be advisable to defer starting hormonal contraception until feeding is well established, choosing an alternative contraceptive method until then.
Where a woman is considering using DMPA injections, the GP might wish to consider recommending an initial trial of the POP, prior to starting DMPA, as once given DMPA cannot be removed for 3 months if there are issues with milk supply. This is a clinical decision to be made after considering the possible risks versus considerable benefits of long acting methods of contraception for mothers.
Intrauterine Contraception (IUC)
The IUS (Mirena) and the IUD (Copper Coil) are now considered safe to insert at the time of delivery or C-Section by a competent practitioner. This is not widespread practice at present but several studies have shown it to be safe and it is likely to become more common. If not inserted within 48 hours, intrauterine contraception (IUC) can subsequently be inserted from 4 weeks postnatal.
- There is a 2/1000 risk of perforation to the uterus at the time of insertion of the IUS/IUD, which would require laparoscopic removal. It is a rare complication but it is important to be aware that studies have shown that breastfeeding and recent delivery increases the risk of perforation by six times. This is not a reason not to have the IUS/IUD but should be explained to the patient.
UKMEC 2016 Look at the ‘Intrauterine Contraception’ section, then in the sub-section ‘Personal Characteristics’ for information on IUC initiation.
Family Planning Association Website (FPA) features patient leaflets which are being updated in line with the changes to UKMEC 2016
The Breastfeeding Network: Contraception and Breastfeeding September 2016
- FSRH CEU Clinical Guidance: Contraception after Pregnancy January 2017
- Institute for Reproductive Health Georgetown University: Lactational Amenorrhoea Method (LAM)- Top 12 Most Frequently Asked Questions
- Abstracts fromThe Academy of Breastfeeding Medicine 21st Annual International Meeting Washington, DC October 13–16, 2016. Breastfeeding Medicine. 2016;11(S1):S-1-S-26.