Family Planning for the Nursing Mother
By Michele St. Martin
The mother of a newborn baby has her hands full, juggling competing needs and adjusting to her new role and her new family structure. While getting pregnant when her baby is still an infant may not be part of her plan, birth control is often the last thing on her mind.
Fertility while Mom is lactating is a confusing and often misunderstood subject. Can a woman get pregnant while she’s breastfeeding an infant? What forms of birth control are safe for a breastfeeding mother? Do “natural” methods really work?
What Is LAM and How Does It Work?
Some women do get pregnant while nursing.
Lactation Amenorrhea Method (LAM) is a form of birth control that relies on natural ovulation suppression. Here’s how it works: As an infant breastfeeds, prolactin is released. Prolactin inhibits the release of follicle stimulating hormone (FSH) and luteinizing hormone (LH). These hormones are responsible for ovulation (the development and release of eggs).
Used correctly, the risk of pregnancy with LAM is low, according to Dr. David Barrere, an OB/GYN in Cincinnati, Ohio, and Northern Kentucky. Dr. Barrere says that the duration of ovulation suppression varies and can be influenced by several factors.
“LAM can be utilized provided that the baby is less than 6 months old, Mother has exclusively breastfed Baby (no supplements have been used) and she has not resumed her menstrual period,” Dr. Barrere says. “If these guidelines are met, then the risk of pregnancy is 1 to 2 percent. Another form of contraception should be used if these three conditions cannot be met.” La Leche League (http://www.llli.org/) adds that mothers should be nursing or pumping at least every four hours during the day and six hours at night to make LAM the most effective.
Kerry Seure of Cleveland, Ohio, relies heavily on LAM. “I used LAM after all three of my children were born,” she says. “I have very predictable cycles, I nurse on demand – including at night in the family bed – and I never so much as spot until my babies reached 18 months to 2 years old. I feel very confident that this is the way nature intended the cycle of birth to end. As long as I don’t interrupt what nature perfected, I know I will be free to concentrate on one baby at a time.”
Some women do get pregnant while nursing, and it can seem like it comes out of nowhere. Because menstruation can return just a few months after giving birth or may be suppressed for a year or longer, you may not have any idea when your period will come back. Therefore, it can be difficult to determine when your first fertile cycle will be until after you have ovulated.
Natural Family Planning (FAM/NFP)
The basic tenet of natural family planning is avoiding intercourse around the times when a woman is most fertile. Dr. Barrere also points out that “sperm can live for four to five days within the mucous glands in the cervix, resulting in delayed fertilization.” According to Dr. Barrere, there are three methods of natural family planning:
- The calendar method – evaluating your cycle over several months to judge average cycle length; assuming that ovulation occurs at the midpoint of the cycle, and avoiding intercourse for one week prior to, and three days following, estimated ovulation. “The calendar method is the least effective method [of natural family planning], with a 9 percent pregnancy rate,” Dr. Barrere says.
- The mucous method – feeling your cervical mucous with your fingers to determine when you are fertile. This method results in a 3 percent pregnancy rate with perfect use. “Prior to ovulation, increasing amounts of estrogen production stimulate mucous production,” Dr. Barrere says. “There is a progressive increase in the quantity of mucous, and it becomes more slippery just prior to ovulation. (After ovulation, the mucous dries up.) Couples are taught that their ‘safe’ days are the dry days.”
- The symptothermal method – a combination of the calendar and mucous methods; you monitor your cervical mucous in combination with taking your temperature every morning to detect the temperature rise that comes with ovulation. “Once the temperature rise occurs, intercourse is avoided for an additional three days,” says Dr. Barrere, who notes that the symptothermal method has a 2 percent pregnancy rate.
In addition to being used as a method of birth control, FAM/NFP is often used to help maximize the chances of conception. “[My husband and I] are now more aware of FAM/NFP to help us avoid conception just as we used it as part of our plan to conceive both our children,” says Denise Thomas of Chicago, Ill., who breastfed her son for 22 months and is currently exclusively breastfeeding her 14-week-old daughter.
FAM/NFP isn’t for everyone. “I was not able to use natural family planning due to a long history of irregular periods and a very long cycle (33 to 40 days), plus chronic sinus and allergy medications, which affect cervical mucous,” says Dr. Cindy McClain Pearman, a family practice physician from Knoxville, Tenn. She has breastfed all three of her children.
Most women are at least somewhat familiar with the better-known barrier methods: condoms, diaphragms and the cervical cap. “With perfect use and combined with spermicide, the pregnancy rate varies from 3 percent to 30 percent. However, with typical use, the pregnancy rates are much higher, ranging from 1 to 40 percent,” Dr. Barrere says, adding that cervical caps “by far” have the most failures.
Denise Thomas and her husband use condoms in combination with FAM/NFP to increase both methods’ effectiveness. “The diaphragm or gel-based spermicides are not an option, as I suffer from bladder infections when I use them,” she says.
One reason for the high failure rate of barrier methods is that their inconvenience and messiness may mean that they are not always used. “Of course [the diaphragm] interferes with spontaneity and is messy and a little uncomfortable,” Dr. Pearman says. “Also, you must be religious about using it if it’s to work – I was.”
Hormonal methods are among the most effective contraceptive choices for a woman – and the most controversial for a nursing mother.
There’s not much difference of opinion about a lactating woman using the standard combination estrogen-progestin birth control pill. “It has been well documented that taking contraceptives containing estrogen markedly reduces the quality and quantity of breast milk,” says Dr. Barrere, summing up the prevailing opinion.
It’s the mini-pill and other methods such as Depo-Provera injections and Norplant implant, that is subject to differing opinions. Michelle Bailey is currently using the mini-pill. “This particular brand does not reduce my milk supply,” she says. “Once I’m not breastfeeding, I’ll go back to a regular birth control pill because it is more effective.”
But current research and the experience of many lactation consultants and nursing mothers shows a different side. “I went back to my diaphragm until my husband had a vasectomy when [our daughter] was several months old,” Dr. Pearman says. “Mini-pills and Depo are not supposed to affect [milk] supply, but I have seen it happen often, especially with the mini-pill.”
How do you know if your milk supply could be at risk? “There are no absolutes here, but it is probably the better part of wisdom for breastfeeding mothers to wait until lactation is well established (at least six weeks) before introducing these progestin-only contraceptives, and then try a month of oral contraceptives before having the shot of Depo Provera,” says Melissa Clark Vickers, international board certified lactation consultant.
The Right Choice
No contraceptive method is right for every woman. Personal beliefs, willingness to risk pregnancy and comfort levels with the various methods vary from woman to woman. But all women have a choice in planning their families according to what’s right for them.