Changes to Contraceptive Use Guidelines Could Compromise Breastfeeding

Last Month the U.S. Centers for Disease Control and Prevention (CDC) released new birth control guidelines, which could undermine mothers who want to breastfeed. By sanctioning the use of progesterone injections, progestin-only pills, as well as combined (progestin-estrogen) oral contraceptives within the first month after giving birth, nursing women may encounter adverse effect to their breastfeeding experience.

"The new guidelines ignore basic facts about how breastfeeding works," says Dr. Gerald Calnen, President of the Academy of Breastfeeding Medicine (ABM). "Mothers start making milk due to the natural fall in progesterone after birth. An injection of artificial progesterone could completely derail this process."

The CDC report, "U.S. Medical Eligibility Criteria for Contraceptive Use, 2010," released in the May 28 issue of Morbidity & Mortality Weekly Report (MMWR), contains important changes in what constitutes acceptable contraceptive use by breastfeeding women. The criteria advise that by one-month postpartum the benefits of progesterone contraception (in the form of progestin-only pills, depot medroxyprogesterone acetate (DPMA) injection, or implants), as well as the use of combined (progestin-estrogen) oral contraceptives outweigh the risk of reducing breastfeeding rates. Previously, progesterone birth control was not recommended for nursing mothers until at least six weeks after giving birth, and combined hormonal methods were not recommended before six months.

Based on clinical experience, breastfeeding support providers report a negative impact on breastfeeding when contraceptive methods are introduced too early. One preliminary study demonstrated dramatically lower breastfeeding rates at the six-month mark among mothers who underwent early insertion of progesterone-containing IUDs, compared with breastfeeding rates of mothers who underwent insertion at six to eight weeks postpartum.

"The data are limited," says Calnen, "but for now, the state of the science suggests that early progesterone exposure undermines breastfeeding."

Family planning specialists argue that early hormonal birth control is needed to reduce unplanned pregnancies. However, the most commonly used early contraceptive method, a DPMA injection, prevents pregnancy for only 12 weeks at a time. "There is no evidence that immediate postpartum injections delay the next pregnancy beyond the first three months," says Calnen.

Dr. Miriam Labbok, Director of the Carolina Global Breastfeeding Institute and an expert on the interface between breastfeeding and fertility, notes, "The mother should have the final decision on her birth control method, with full information. Unfortunately, these methods are often given to women with little counseling. Women deserve to know that there is a potential risk."

ABM wrote to CDC Director Thomas Frieden in January urging reconsideration of the guidelines. In his reply, Dr. Frieden described the new recommendations as "the best interpretation of the existing evidence."

Calnen is less confident. "Physicians and mothers should proceed with caution," he says. "There are plenty of birth control methods that are proven to be safe for breastfeeding. Early progesterone is not one of them."

More information can be obtained through the Academy of breastfeeding Medicine. The Academy of Breastfeeding Medicine is a global organization of physicians dedicated to the promotion, protection and support of breastfeeding and human lactation through education, research, and advocacy. An independent, self-sustaining, international physician organization and the only organization of its kind, ABM's mission is to unite members of various medical specialties through physician education, expansion of knowledge in breastfeeding science and human lactation, facilitation of optimal breastfeeding practices, and encouragement of the exchange of information among organizations. It promotes the development and dissemination of clinical practice guidelines. The Academy has prepared clinical protocols for the care of breastfeeding mothers and infants that are available on the Agency for Healthcare Research and Quality's (AHRQ) National Guideline Clearinghouse website. (NL)