Contraception

What are my birth control choices while I am breastfeeding?

There are many birth control methods. The choice depends on factors including a mother’s breastfeeding and child-bearing plans, risk factors for a low milk supply, medical situation, and the child’s age. It’s possible to become pregnant before a mother has her first period after delivery, so mothers who want to prevent pregnancy should not wait until the periods return to begin contraception. The main choices are between hormonal and non-hormonal methods. Some research suggests that hormonal contraceptives and especially ones containing estrogen decrease milk supply. Non-hormonal barrier methods do not. Some mothers rely on lactational amenorrhea, the period of infertility that may accompany breastfeeding.

A) Considerations for birth control choices

There are many birth control methods, each with pros and cons. The choice depends on a variety of factors including:

  • Breastfeeding status and plans
  • Age and child-bearing plans
  • Risk factors for a low milk supply
  • Child’s age
  • Contraceptive experience
  • Lactation experience
  • Medical conditions

Mothers who want to prevent a pregnancy should not wait until their periods return to begin using contraception. It is possible to become pregnant before you have your first period after a delivery (McNeilly 1983). This is because ovulation (the release of an egg) happens two weeks before the period starts. Fertility can return within one month from the end of pregnancy if mothers are not breastfeeding.

Contraception can be non-hormonal or hormonal. Many breastfeeding specialists have cared for mothers whose milk supply decreased when they used hormonal contraception but research on this is mixed (Berens 2015). 

B) Non-hormonal contraception

Breastfeeding generally delays the return of ovulation and periods, creating a condition known as lactational amenorrhea, the absence of menstruation. During this time, pregnancy is not possible. Lactational amenorrhea can be used as a method of birth control called the lactational amenorrheic method (LAM).

Another type of contraception is the barrier method. These methods have no effect on breastfeeding and include:

  • Condoms
  • Spermicidal gels and foams
  • Diaphragms used with contraceptive gels
  • Cervical caps used with contraceptive gels

Barrier methods are generally considered less effective than hormonal methods. Barrier methods can be combined with LAM.

Intra-uterine devices (IUDs) are placed in the uterus by a health-care provider. Some types release hormones and others do not.  

Surgery to tie a mother’s Fallopian tubes and prevent pregnancy permanently should not affect breastfeeding unless it causes a mother to miss feeds and she does not express.

C) Hormonal contraception

1) Types of hormonal birth control

Hormonal birth control methods can be divided into two groups based on the type of hormones used:

  1. Combination (estrogen and progesterone) contraceptives (CCs)
    1. Pills (combination oral contraceptives) 
    2. Estrogen- and progesterone-releasing rings
    3. Birth control patches
  2. Progesterone-only contraceptives (PCs):
    1. Pills (progesterone-only pills) (POPs)
    2. Progesterone-releasing intra-uterine devices (medicated IUDs)
    3. Progesterone-releasing rings
    4. Progesterone-releasing implants inserted under the skin
    5. Progesterone injections

These methods differ in effectiveness, cost, the risks of side-effects, and acceptability.

2) Breastfeeding and hormonal birth control

There is not much research of the effect of hormonal birth control on breastfeeding and the growth of babies (Lopez 2015). 

Hormonal birth control has been reported to decrease milk supply but other studies show no effect (Berens 2015; Bryant 2019; Ispas-Jouron 2020). As such, their use may be discouraged if mothers:   

a) Combination contraceptives 

For breastfeeding mothers who wish to use hormonal birth control, PCs are preferred over CCs because of concerns that the estrogen in CCs may decrease milk supply (Goulding 2018). However, there are no reports of consistent effects of CCs on the growth and health of babies (Pieh Holder 2015).

The World Health Organization recommends that breastfeeding mothers avoid CCs until the baby is at least six months old (WHO 2015). Other organizations allow earlier use (CDC 2016).

b) Progesterone-only contraceptives

While a small number of mothers have reported a decrease in milk supply when using medicated IUDs and implants (Stuebe 2016; WHO 2019), most studies do not report any effects of PCs on the (Phillips 2016; NIH):

  • Composition of milk.
  • Growth and development of the baby.
  • Milk supply.

There have been concerns that inserting medicated IUDs or progesterone-releasing implants right after delivery instead of at four to six weeks may decrease a mother’s milk supply or keep the milk from coming in (Parker 2021). The evidence, however, seems to show that early insertion does not affect breastfeeding (Averbach 2018; WHO 2015).

If you are considering medicated IUDs, implants, or progesterone injections, think about using POPs or progesterone-releasing rings for two months to ensure that your milk supply is unaffected by progesterone. POPs can be quickly stopped and progesterone rings are easily removed if the milk supply decreases. Medicated IUDs and progesterone-releasing implants need to be removed by a health-care provider and progesterone injections are usually designed to be active for 12 to 14 weeks, making it difficult to quickly stop their effect on the milk supply. 

c) Our experience

CCs are not commonly used by breastfeeding mothers in our area. Rather the mothers in our clinic who choose to use hormonal birth control, use PCs (POPs and medicated IUDs):

A small number of them noticed clear signs that their milk supply decreased within a few days or weeks of starting PCs:

D) Emergency contraception

The options for emergency contraception after unprotected sex include:

  • Progesterone-only pills (levonorgestrel)
  • Combination pills (estrogen and progesterone)
  • Antiprogestins (ulipristal acetate and mifepristone)
  • IUDs

They are compatible with breastfeeding and do not appear to affect the breastfeeding baby’s growth and development (Shaaban 2018). The availability of these items varies among countries.

All of these are time sensitive. Mothers have fewer unplanned pregnancies when the lactational amenorrhea method is combined with obtaining emergency contraceptive pills ahead of time (Shaaban 2017).

References

Averbach S, Kakaire O, McDiehl R, et al. The effect of immediate postpartum levonorgestrel contraceptive implant use on breastfeeding and infant growth: a randomized controlled trial. Contraception. 2018 Nov 5
 
Berens P, Labbock M, and the Academy of Breastfeeding Medicine. ABM Clinical Protocol #13:Contraception During Breastfeeding. Breastfeeding Medicine 2015:10(1) Revised 2015
 
Bryant AG, Bauer AE, Muddana A, et al. The Lactational Effects of Contraceptive Hormones: an Evaluation (LECHE) Study. Contraception. 2019 Jul;100(1):48-53

Centers for Disease Control and Prevention (CDC). eBook: U.S. Selected Recommendations for Contraceptive Use, 2016. Atlanta: Centers for Disease Control and Prevention; 2016 [cited 2018 Nov 11]
 
Goulding AN, Woud K, Steube AM. Contraception and Breastfeeding at 4 Months Postpartum Among Women Intending to Breastfeed. Breastfeeding Medicine 2018:13(1);75

Ispas-Jouron S, Seuc A, Northstone K, et al. Effects of maternal use of hormonal contraception during breastfeeding: Results from a British birth cohort. Eur J Obstet Gynecol Reprod Biol. 2020;250:143‐149

Lopez LM, Grey TW, Stuebe AM, et al. Combined hormonal versus nonhormonal versus progestin-only contraception in lactation. Cochrane Database Syst Rev. 2015 Mar 20;(3):CD003988
 
McNeilly AS, Glasier AF, Howie PW, et al. Fertility after childbirth: pregnancy associated with breast feeding. Clin Endocrinol (Oxf). 1983 Aug;19(2):167-73

Parker LA, Sullivan S, Cacho N, et al. Effect of Postpartum Depo Medroxyprogesterone Acetate on Lactation in Mothers of Very Low-Birth-Weight Infants. Breastfeed Med. 2021 Apr 28

Phillips SJ, Tepper NK, Kapp N, et al. Progestogen-only contraceptive use among breastfeeding women: A systematic review. Contraception. 2016;94:226-52
 
Pieh Holder KL. Contraception and Breastfeeding. Clin Obstet Gynecol. 2015 Dec;58(4):928-35
 
Shaaban OM, Abbas AM, Mahmoud HR, et al. Counseling and in-advance provision of levonorgestrel emergency contraceptive pills decrease the rate of unplanned pregnancy during breastfeeding: a randomized controlled trial. J Matern Fetal Neonatal Med. 2017 Nov 8:1-111
 
Shaaban OM, Abbas AM, Mahmoud HR, et al. Levonorgestrel emergency contraceptive pills use during breastfeeding; effect on infants' health and development. J Matern Fetal Neonatal Med. 2018 Feb 20:1-5

Stuebe AM, Bryant AG, Lewis R, et al. Association of Etonogestrel-Releasing Contraceptive Implant with Reduced Weight Gain in an Exclusively Breastfed Infant: Report and Literature Review. Breastfeed Med. 2016;11(4):203‐206 

United States National Institute of Health (NIH). National Library of Medicine, Toxnet, Drugs and Lactation Database (LactMed) [Internet]. Bethesda: U.S. National Library of Medicine; [date unknown] [cited 2019 May 27]
 
World Health Organization (WHO). Department of Reproductive Health and Research. Medical eligibility criteria for contraceptive use: Executive summary. Fifth ed. Geneva. 2015. PMID: 26447268
 
WHO Pharmaceuticals Newsletter No.5, 2019: World Health Organization; 2019. Licence: CC BY-NC- SA 3.0 IGO