Birth Control During Breastfeeding

By Jasna Cameron and Dr. Melinda Boss

As a new mom, you are probably using every free moment you can find to brush up on the latest developments in this “baby-raising field” you've just plunged into. You are trying to stay on top of the most eco-friendly disposable diaper range while looking up the pros and cons of formula top-ups.  You may also be struggling to lose that baby weight and trying to figure out the best diet options while breastfeeding. And then, somewhere in between all those Google clicks and research quests, you realize that you need to find a suitable birth control method for breastfeeding.  

Schedule time with a Lactation Consultant 

Many doctors strongly recommend waiting about six weeks after giving birth before you start having sex again to give your body enough time to heal.   Whenever you are ready to engage in sexual activity, it is important to think about birth control. You can get pregnant even before your period starts.

Choices about birth control are individual and depend on your personal needs and preferences. This includes things like your plans for future babies, feeding choices, previous experience with contraceptives and your own health and well-being. Breastfeeding suppresses fertility in some circumstances, but not all, and some contraceptives can reduce milk supply.

For many of us, the realization that you need to be on some form of birth control only materializes a few weeks after bringing our bundle home.  I remember distinctly when my husband started glancing my way with his bedroom eyes. 

"But, I'm not back on the pill yet," I said in an exhausted "leave-me-alone" voice. "I am still breastfeeding."

"Yes, I know, but I heard," he said sheepishly," You actually can't get pregnant while breastfeeding! Did you know that??” The expectant smile was as wide as his head.

Non-Hormonal Birth Control

Breastfeeding (The Lactational Amenorrhea Method, LAM)

He was partially correct in the sense that this birth-control method has been supported by extensive research around the contraceptive effects of breastfeeding (called lactational amenorrhea method (LAM)). Breastfeeding has the effect of suppressing ovulation and if this method is used correctly, it is 98-99% effective as birth control. To be effective there are a few requirements you need to ensure. You need to:

• Be exclusively breastfeeding with no long intervals (more than 4-6 hours) between feeds, day or night.

• Have not had your menses return (excluding the first 8 weeks after birth).

• Have a baby less than six months of age.

If using this method, it is important to frequently review the above points to make sure they still apply. If any no longer apply, it is important to start another form of contraception to adequately limit your fertility.

Natural methods

If you are concerned that you may fall pregnant but are also worried about any additional chemicals in your body that may impact your breast milk, you may want to look at other options. 

Natural methods of contraception are free, do not interfere with breastfeeding and can be added to other forms of birth control to increase effectiveness. You may be the dare-devil, risk-taker kind of person and choose alternative hormone-free “trusted”  methods such as withdrawal or natural planning. 

Most of these methods require substantial periods of abstinence to avoid conception: 

• It can be difficult to judge signs of ovulation, particularly if your menses have not yet returned. Signs and symptoms of ovulation during lactation vary between women and can be hard to interpret, even for those moms who were previously experienced with the technique. Natural planning is not advisable for women with irregular periods. Additionally, you have to keep a daily record of your fertility indicators, such as your temperature and the fluids coming from your cervix. The problem with this method is that your cycle may not be regular after pregnancy, or you may not have even started your period yet. Oh, and it's only about 76% effective.

• The withdrawal method is one of the least effective methods of natural birth control. Sperm can be present in pre-ejaculation fluid, so there is the risk of pregnancy even if your partner withdraws and timing can be difficult.

Barrier And Non-Hormonal  Methods

Barrier methods of birth control include condoms, a diaphragm, a cervical cap, or spermicides, and do not interfere with your milk supply. They are effective if used consistently and correctly, but user error is common. Condoms provide some additional protection against sexually transmitted infections. If you have previously used a diaphragm or cervical cap, this can be refitted at 6 weeks postpartum. Check with your care provider if you select this as an option, as  you may need a larger size after having a baby.

IUD (intrauterine device)

IUDs are more than 99% effective. There are two types available, and both are suitable for breastfeeding moms.

The hormone-free IUD uses a small amount of copper to interfere with fertilization and implantation.

The other IUD has a minimal amount of progestin in it and will not interfere with your milk supply, milk composition or your baby’s health. Progestin is a synthetic form of the hormone progesterone, which protects the entrance to the uterus by inhibiting the movement of sperm.

If using these devices, it is recommended they be inserted before 48 hours, or after 4 weeks postpartum. Some common IUDs you may have heard of are Mirena, and Skyla.  

Hormonal contraceptives

Progestin-only contraceptives are the hormonal contraceptives of choice during all stages of breastfeeding.

Implants

Implants involve insertion of a flexible rod in your upper arm. This form of birth control also has the hormone progestin and can provide up to 3 years of almost 100% protection. Implants may be preferred by moms who don’t like IUD insertion or having to remember to take a pill every day.  Implanon and Nexplanon are currently available in the United States. Some side-effects include irregular menstrual cycles or spotting or bleeding several days a month.

Injections

Progestin depo-injections contain more progestin than implants or IUDs and involve an injection every three months. They are safe to use while breastfeeding. Since the injections have more progestin, they may have other side effects like stomach discomfort, headaches and mood changes.

Oral contraceptives

Oral hormonal contraceptives are the birth control method of choice for many women and are very effective in preventing unplanned pregnancy. They can contain either progestin-only (often called the mini pill) or a combination of progestin and estrogen (combined pill).

Mini-pill

The mini-pill only contains progestin and can be started right after delivery.  According to the American College of Obstetricians and Gynecologists and Planned Parenthood Federation of America, contraceptives that contain only progestin are compatible with breastfeeding and are a safe option.

The hormone progestin works by thickening cervical mucus so sperm can't get through, and it also thins the lining of the uterus and sometimes suppresses ovulation, fertilization, and implantation.

However, to ensure the effectiveness of the mini-pill, it has to be taken at the same time every day. Typical use is usually imperfect and decreases effectiveness. This regime may be strenuous for already overwhelmed new moms. If it is difficult for you to make sure to take every pill within 3 hours of the same time every day, you may want to think about other methods of birth control. 

Combination pill

Combination pills contain both progesterone and estrogen. They also need to be taken every day but will remain effective as long as doses are no more than 24 hours late. Combination pills should not be taken immediately after birth as they can reduce milk supply and increase your risk of blot clots. Recommendations about when to start vary from 6-8 weeks (United States) after delivery to 6 months (World Health Organization).

Conclusion

As advised by health care professions, waiting for six weeks after giving birth will not only let your body heal sufficiently but also ensure that your milk supply is firmly established. When you decide to start using contraceptives, consult with your infant’s pediatrician and your gynecologist to help decide what is best for you and your baby first. From personal experience, those months of breastfeeding are also no easy feat. Maintaining your supply is important , so you want to make a birth control choice that does not interfere but also works for your needs, health, and lifestyle.