3.3 Contraception
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![]() Key Points - Case Study CJoanne is discharged early on day three and comes to see you for a follow-up on day five. The day following discharge her breasts became painful and hard and Rosie is again having difficulty latching on to the breast. Is this normal? What would you suggest Joanne do?
You see Joanne and Rosie again at 10 days. Joanne's breasts have settled and Rosie is feeding well. However, she has been feeding frequently at night and Joanne's husband, Tom, has suggested bringing the baby to bed with them. Joanne has heard that this increases the risk of SIDS. What would you tell her?
Joanne had been on the combined oral contraceptive pill before becoming pregnant. She intends to not use any contraception until she is six months postpartum. Is this a realistic option?
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Joanne had been on the combined oral contraceptive pill before becoming pregnant. She intends to not use any contraception until she is six months postpartum. Is this a realistic option?
As long as Joanne remains amenorrhoeic and is fully or nearly fully breastfeeding, the chance of her becoming pregnant in the first six months postpartum is less than 2 percent – a similar failure rate to many other methods of contraception 1.
Suckling of the infant inhibits maternal release of hypothalamic GnRH, which controls the release of LH and FSH – hormones necessary for the development and maturation of the ovarian follicle. This effect is dependent on the total sucking stimulus rather than the frequency or length of feeds2. Once follicular growth occurs, there also appears to be a feedback mechanism so that ovulation is inhibited, and if ovulation does occur before six months postpartum it is usually accompanied by an inadequate luteal phase, especially prior to the first menses2. When the suckling stimulus decreases, especially after the introduction of supplementary feeds or solids, GnRH is released and ovulation occurs.
After extensive observational and controlled trials in both developed and developing countries, the conditions under which this suppression of fertility could be used as an effective form of contraception were codified in 1991. The resulting contraceptive method (Lactational Amenorrhoea Method) consists of three criteria:
- amenorrhoea (return of menses indicated by bleeding for two consecutive days, or a bleed like a menses after day 56);
- exclusive or full breastfeeding (no regular supplementation or solids; breastfeeding frequently on demand); and
- less than six months postpartum.
When any of the three criteria are no longer applicable another method of contraception should be employed as pregnancy rates increase3. The percentage of women whose menses return prior to six months varies considerably (26.569.5%)4, perhaps reflecting different cultural expectations of the frequency and length of breastfeeds and the introduction of other fluids and foods.

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Further studies suggest that the pregnancy rate when LAM is continued for up to 12 months with the addition of solid foods is still quite small, although the incidence of an adequate luteal phase with ovulation before the first menses increases3.
Non-hormonal forms of contraception, such as condoms, diaphragms and some forms of IUDs, have little or no effect on lactation and are the methods of choice when another form of contraception in addition to, or instead of, LAM is required.
Studies of progesterone-only contraceptive methods (mini-pill, progesterone-containing IUDs, depo or implants) used during lactation also show minimal effect on lactation, although some women report a reduction in milk supply. Therefore, these methods should be used cautiously in women who have, or are at risk of having, problems maintaining an adequate milk supply. There is also a theoretical risk of disturbing the initiation of lactation if progestogens are prescribed early in the postpartum period as lactogenesis II is triggered by a drop in progesterone levels.
Contraceptives containing oestrogen are known to cause a reduction in milk supply and should preferably not be used during lactation. If it is the most suitable contraceptive method for a woman, delaying its introduction until six months postpartum is recommended (1,3).
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![]() Case Study ActivityThink about what your response would be to the scenario presented, write it into the exercise, then submit it and read the suggestions given. |
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Notes
- # Labbok MH et al. (2005) Clinical protocol #13: Contraception during breastfeeding
- # McNeilly AS (2001) Neuroendocrine changes and fertility in breast-feeding women
- # Labbok M (2007) Breastfeeding, Birth Spacing and Family Planning
- # (1999) World Health Organization task force on methods for the natural regluation of fertility