Birth Control for Breastfeeding Mothers

The decision about birth control is very personal. When deciding, you may think about your past experience with different types of birth control. You may also consider your future plans for children, religious beliefs, and whether or not you are exclusively breastfeeding. Health factors such as if you smoke, have liver disease, have blood clots or a family member that has had blood clots, and if you are taking medications or herbal products are all very important to discuss with your care provider. By learning about birth control, you can choose methods that work best for you and your family at each stage of your childbearing years.

Barrier Methods

Barrier methods prevent pregnancy by blocking sperm from entering the uterus and reaching the egg. They are widely used by nursing mothers because there is no worry about medications that could pass into the breastmilk or affect milk supply. Male and female condoms, contraceptive sponges with spermicide, cervical caps with spermicide, and contraceptive gels are sold over-the-counter. The diaphragm is a dome-shaped flexible disk with a flexible rim to cover the cervix. Spermicidal jelly is put on the inside of the diaphragm before it is put into the vagina. A doctor or midwife fits it to the cervix at least six weeks after the baby is born. The diaphragm must be refitted after each pregnancy and after any weight loss or gain of more than 15 pounds. Barrier methods are not as reliable in preventing pregnancy compared to birth control pills and other hormonal contraceptives.

Non-Hormonal Intrauterine Devices (IUDs)

The copper IUD is a reliable, long-term, reversible method of birth control. Unlike hormone containing IUDs, the copper IUD has no effect on breastfeeding (1). It releases copper, causing the lining of the uterus to shed more often than normal. This blocks the implantation of fertilized eggs. In a few women, the copper IUD may cause heavy vaginal bleeding and anemia (low blood count). Compared to non-nursing mothers, breastfeeding mothers experience less pain during insertion of the copper IUD and have lower removal rates due to bleeding or pain (2).

Hormonal Methods

Combination Contraceptives
Combination birth control pills contain the hormones estrogen and progesterone. The monthly shot, the patch, and the vaginal ring also contain both estrogen and progesterone.

The estrogen and progesterone in birth control pills has not been found to be harmful to nursing babies. However, studies show estrogen causes reduced milk supply and let-down even when started after the breastmilk supply is well established (3,4). Another study showed a 41.9 % drop in milk volume in nursing mothers using estrogen-containing birth control (5). Because of their effects on milk supply, these contraceptives should be avoided until the baby is at least six months old and eating solid foods regularly.

Progestin-Only Contraceptives
The mini-pill, the Depo Provera shot, the Implantable Rod and some IUDs contain only the hormone progesterone. These are good choices for breastfeeding mothers who wish to use birth control medication.

Each Depo-Provera shot provides contraception for up to 12 weeks and is highly effective in preventing pregnancy. It may cause spotting between periods or other undesired side effects in some women.

The progestin-containing intrauterine device (IUD) works by keeping eggs from implanting in the lining of the uterus. Unlike other progestin-only contraceptives, the IUD delivers its hormone directly to the uterine lining. As a result, it is very effective and has fewer side effects. It should be placed at least four to six weeks after the baby is born.

Progestin-only pills have a higher rate of failure than combination pills. They must be taken at the same time each day to work. Even taking the mini-pill a few hours late could result in pregnancy. Because of this, some mothers use a barrier method as extra protection while taking the mini-pill. If the mini-pill is used, the mother should contact her doctor or midwife when the baby is weaned. At that time it may be best to switch to combination birth control pills.

There is considerable controversy about whether progesterone-only contraceptives affect breastmilk supply. In one study, women taking the mini-pill actually had a higher than average milk supply (1). Another study found that the mini-pill caused a 12% drop in milk supply (5). There is some concern that even progestin-only birth control can cause low milk supply in certain women. A natural drop in the hormone progesterone after childbirth stimulates the milk making process. Women may wish to wait at least three days after the baby is born before starting progestin-only birth control (6). If desired, waiting six weeks may prevent even more milk supply problems.

The shot, implantable rod and IUD contain long-acting progesterone. A recent study showed that the Depo Provera shot had no impact on short-term breastfeeding success when given in the first few days after the baby is born (7). However, some still are concerned that women who use these birth control methods cannot easily stop if their milk supply goes down. Breastfeeding specialist Dr. Jack Newman recommends trying the mini-pill first to see how the milk supply reacts. If there is no drop in milk supply after one month, contraceptives containing long-acting progesterone are probably safe to use (8).

Lactational Amenorrhea and Natural Family Planning

The Lactational Amenorrhea Method (LAM) is a good option for mothers who do not want to take birth control pills during the early months after the baby is born. LAM has been found to be 98% effective (9) as long as all of these are true:

When these conditions are not all met, another birth control method must be used if contraception is desired. LAM cannot be used as birth control if breastfeeding and formula feeding are combined.

LAM prevents pregnancy when all or most of baby’s sucking is on the breast. Exclusive breastfeeding means no supplemental feedings and little or no pacifier use. The baby feeds regularly, day and night. The return of fertility varies from mother to mother. Even with 100% breastfeeding, some mothers have their first period within a few months after childbirth. Others will not have a period for twelve months or longer even if the baby does not breastfeed regularly.

Vaginal bleeding after delivery (lochia) normally lasts two to four weeks. After that, nursing mothers may not have a period for several months. The first period (or any spotting that lasts more than a couple days) is a sign that fertility has returned. Irregular periods are common during breastfeeding. No matter the age of the baby, once a mother has her first period, she must use another form of birth control if she does not want to become pregnant (10).

Some women who use LAM also use Natural Family Planning (NFP). NFP is a method of tracking ovulation by charting changes in vaginal discharge and body temperature. With correct use, NFP can work as well as birth control pills. It takes time to learn NFP. Those interested in NFP should learn the method from a qualified teacher. Call Intermountain Fertility Care Services at (801) 364-7662 and visit www.aafcp.org, or www.creightonmodel.com for more information.

Emergency Contraception

There are two kinds of "morning-after pills" available. These are used when condoms break or a couple has unprotected sex and should be taken within 72 hours. There are combination estrogen-progestin pills and a progestin-only pill. Both types of pills may be used while nursing a baby. They work by stopping the ovaries from releasing an egg or stop sperm from joining the egg. The combination estrogen-progestin pill may cause a temporary drop in milk supply. If the mother continues to nurse her baby often, the amount of milk should return to normal within a few days. Emergency contraceptive pills should only be used as a last resort, not as a regular method of birth control.

Male and Female Sterilization

Sterilization is a highly effective form of permanent birth control. It should only be considered if the couple does not want to have any more children. Reversal is costly and does not always work. Male sterilization (vasectomy) is easier and costs less than female sterilization (11). It is also less risky. The risks of female sterilization (tubal ligation) are similar to other abdominal surgeries. Women who have their tubes tied in the hospital after giving birth may nurse as soon as they feel able to do so after the surgery (10).

There are many methods of birth control that are safe and effective to use while nursing a baby. For your health and the health of your children, it is best to space pregnancies at least two years apart. Take the opportunity to discuss your plans for birth control or pregnancy spacing during your prenatal care visits. Together, you and your care provider can find the method that will work best for you.

Last updated: August 2011