Last year I asked on my facebook page for experience of using contraception whilst breastfeeding using a googledoc survey. I had just under 80 responses in 24 hours and here I have tried to analyse the results. Five mothers reported that their supply was affected by the use of contraception. Many more were unhappy with the information that was given before prescription of the contraceptive. Food for thought

Please see https://www.breastfeedingnetwork.org.uk/contraception/ 

for information on the contraceptives and 

https://www.breastfeedingnetwork.org.uk/ehc/ 

on emergency hormonal contraception which I wrote for BfN.

Contraception and breastfeeding. What mothers want doctors to know analysis

A Googledoc survey was added to the facebook page Breastfeeding and Medication on 14.6.21. In the following 48 hours it received 78 responses from mothers reporting their experiences on their use of contraception whilst breastfeeding. It provides just a snapshot of a self-selecting group of women breastfeeding and using contraception. The numbers involved do not make it statistically significant and more work is needed. It may provide a template for hospitals who plan to initiate LARC prescription immediately after birth to use as an audit. It may also provide information for professionals who prescribe contraception as to what mothers want to discuss.

1. Were you prescribed contraception after the birth of your baby?

12.8% of the mothers (10) had chosen not to use contraception, 1 had been unable to book an appointment due to non-availability of appointment during COVID, 1 was using LAM (Lactational amenorrhoea method), 18 were using condoms and one used the contraceptive patch, no one used the diaphragm. The most frequently cited method of contraception was not surprisingly the mini pill (37.2%).

Contraception method	n=77	%
Mirena or lovosert coil	7	9
Depot Provera or similar	2	2.6
Mini Pill	29	37.2
Combined pill	3	3.8
Nexplanon or similar implant	6	7.7
chose not to use contraception other than LAM or natural FP	10	12.8
condom	18	23
contraceptive patch	1
still waiting for app	1

Number of responses: 77 responses.

The age of the baby when contraception was initiated ranged from a few days to 25 months. Twenty-eight (36%) initiated contraception between 6 and 8 weeks, the time of the normal post-natal check.

Did you notice any effect on your baby or milk supply after beginning the contraception?

52 (66.7%) responses highlighted no effect on the baby or milk supply, 21 not applicable but 5 (6.4%) reported difficulties.

• Depot Provera given 3 days Postpartum. Not sure as she was my first baby, but breastfeeding was a dream up until that point. Afterwards she kept coming off and never seemed satisfied. Perhaps one has nothing to do with other not sure. No idea if one influenced the other as was given no info on how the jag may affect my milk. Breastfeeding became a nightmare almost overnight and I was forced to give up feeding myself when my daughter was 3 weeks old.
• Combined pill at 2 months Postpartum. Milk supply dropped from 10oz down to 4oz per pump. I stopped sooner than I planned. My doctor assured me it wouldn’t affect my feeding/supply. After my supply dropped, I researched and found I wasn’t the only one
• Mini pill initiated at 8 weeks Postpartum. Decline noted but it could have been supply regulating. I continued to meet my babies needs and stopped when ready to do so.
• Mini pill initiated at 7 weeks Postpartum. Given no information on compatibility with breastfeeding by the GP. I stopped contraception after one month so I could continue breastfeeding
• Combined pill initiated after 25 months. Lost supply & toddler stopped breastfeeding. The prescription was initiated by a nurse and the mother was not happy with the information provided. She stopped sooner than she had planned

Were you happy with the information you were given before beginning contraception?

That only 27 out of 69 of the women prescribed contraception described as satisfied with the information provided is of concern. The vast majority of consultations were with GPs. It is acknowledged by most doctors that time available within consultations particularly at the post-natal check is pressurised.

Do you think that your contraception influenced how long you breastfed for?

Of the 78 responses 40 (51.3%) said that contraception had not affected how long they had breastfed. Three stated that they had stopped sooner than they planned. 18 (23.1%) responded that the question was not applicable whilst a further eleven comments (14%) were that they were still breastfeeding

Respondents were offered the opportunity to add open comments about contraception and breastfeeding.

• I was pressured in to taking something at my check-up which I didn’t really need and badly affected my mood. Stopped taking after first prescription.
• Yes. I felt I could not use it for fear of a reduction in milk production and changing my hormones (get bad pms so did not want to risk ill mental health because of contraception)
• My doctor refused to give me a Mirena (I had one in before I conceived) because she said it wasn’t allowed until 9 months. I now know this is untrue but she wouldnt let me have one, so I have no choice but to wait. I didnt really want the mini pill but had no choice.
• No. I’m still breastfeeding but stopped POP after a month as it was affecting my mood
• Much more information should be given not just a leaflet
• I think very little emphasis placed on breastfeeding; in mind of GP the only important thing is not getting pregnant again, not impact on breastfeeding
• The mini pill caused me to bleed randomly which I didn’t realise until I reduced breastfeeding and my periods returned at around 12 months. I stopped it and used condoms
• Still breastfeeding but stopped mini pill as I was bleeding constantly on it which I wasn’t warned about
• I was not asked about breastfeeding when I requested mini pill.
• Still BF at 16 months but I stopped taking the mini pill after 3 months
• On my first appointment the GP actually refused to fit the coil as I told her that I’d been having unprotected sex with my husband, but due to lactational amenorrhea hadn’t had a period since before pregnancy. I told her I knew my body and that I absolutely was not pregnant. She made me do a pregnancy test (negative) and then told me to come back in 7 days, ensuring I used protection in the meantime.
• Although the information I received from the GP prior to the appointment covered postnatal, it did not cover anything for breastfeeding women whose periods had not returned.
• I had the coil which started my periods which is a massive downfall as had zero periods whilst breastfeeding without contraception
• Had POP pill from 12weeks after 1st. Massive difference! I have horrible moods on pill, much less with implant. I believe the implant made me less stressed, less emotional, and better able to deal with the disrupted sleep etc. No impact on supply whatsoever.
• I am a GP and I know that the COCP is licenced from 6weeks, but I am worried it would affect supply so didnt personally want to use it so early.
• Recently needed the morning after pill.  I chose the Ella one pill. Had to lie on the online form to be able to purchase it and the in-box leaflet instructs breastfeeding mothers to pump for a week following taking the tablet and to dispose of the breast milk.
• The Dr at the sexual health clinic tried convincing me that I didn’t need the implant, that breastfeeding alone was good enough. I am now on oestrogen cream/pessary as the combo of implant and breastfeeding meant I never healed properly due to my hormone levels and I had gynae issues e.g., soreness, dryness, scar was tender. The specialist would have preferred me to stop breastfeeding, but I wished to continue. Couldn’t change my implant to a pill as I get migraines.
• My GP advised against coil placement until breastfeeding had ceased for 2 months
• I use the Creighton Family Planning method and breastfed my first until he was 22 months. I got pregnant when he was 17 months. I knew when I was going to ovulate and chose to try then. Breastfeeding was a fantastic way for spacing out the two pregnancies.
• I would like to have more information about how contraception can affect milk production and mood post birth
• I felt very pressured by my GP to go on the pill at my 6-week appointment. She kept telling me that breastfeeding doesn’t stop you from falling pregnant, which I knew. I insisted that I did not want to go on anything as I had had a bad experience with contraception years ago.

Discussion

There are currently recommendations to initiate LARC (Long acting, reversible contraception) methods before women leave hospital after delivering their baby. This is to reduce the incidence of unwanted pregnancies and to provide a “one-stop” convenient place to receive contraceptive advice and prescription. This has become increasingly important during the COVID19 pandemic when it has been difficult to achieve [Immediate Postpartum Long-Acting Reversible Contraception https://www.acog.org/clinical/clinical-guidance/committee-opinion/articles/2016/08/immediate-postpartum-long-acting-reversible-contraception]. [FSRH CEU: Provision of contraception by maternity services after childbirth during the Covid-19 Pandemic April 2020 https://www.fsrh.org/standards-and-guidance/documents/fsrh-ceu-provision-of-contraception-by-maternity-services-after/][

In “ Guidance on the provision of contraception by maternity services after childbirth during the COVID-19 pandemic “https://www.rcog.org.uk/globalassets/documents/guidelines/2021-02-guidance-on-the-provision-of-contraception-by-maternity-services-after-childbirth-during-the-covid-19-pandemic.pdf] it states that:

POP: “Women can be reassured that it does not affect their breast milk supply. It can be started immediately after birth (or by day 21) without any requirement for additional contraceptive precautions”

Depot medroxyprogesterone acetate: “Depot medroxyprogesterone acetate (DMPA) can be administered immediately after childbirth and could be administered prior to discharge if other methods are unsuitable, unacceptable or unavailable. Women can be reassured that it does not affect their breast milk supply”

COC: “Combined hormonal contraception should not be started until 6 weeks after birth in breastfeeding women “

In Medications and Mother’s Milk Dr Thomas Hale states that:

Though the levonorgestrel data suggests minimal to no effect, we have received numerous reports at the InfantRisk centre of milk suppression following insertion of the levonorgestrel IUD.

The most sensitive time for changes in milk supply is early postpartum before lactation is established; therefore, waiting as long as possible (minimum 4 weeks) prior to use is advised. [ Queenan J. Exploring contraceptive options for breastfeeding mothers. Obstet Gynecol2012;119(1):1-2.] All mothers who take hormonal contraception should be counselled of possible effects on milk supply and monitored for such.”

Conclusion

There is currently little good research on the effect of contraception and breastfeeding. It is all too easy to dismiss a mother stating that her milk supply decreased, as one of the large proportion who couldn’t breastfeed. Breastfeeding practitioners across the UK and USA have raised concerns and advocated that breastfeeding women should receive full information of the compatibility with breastfeeding and possible effects on mood as well as supply so that they can be involved in shared decision making.

If women who notice a change in supply would complete a yellow card report that would assist in highlighting this as an issue. https://yellowcard.mhra.gov.uk/

If LARC prescriptions are issued by a maternity unit, an audit after 6-8 weeks on whether mothers are still breastfeeding would provide useful information.

In this very small, self-selecting study 4 women have reported that their breastfeeding was changed by the prescription of contraception, including one who was given a Depot medroxyprogesterone acetate 3 days after delivery, who was unable to breastfeed her baby at all after 3 weeks.

However, most importantly it has shown that many women have concerns about the information that they are provided with. This is surely a situation we should not be comfortable with.