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## Complete Summary

#### GUIDELINE TITLE

Contraception during breastfeeding.

#### BIBLIOGRAPHIC SOURCE(S)

Academy of Breastfeeding Medicine Protocol Committee. ABM clinical
protocol #13: contraception during breastfeeding. Breastfeed Med 2006
Spring;1(1):43-51. \[18 references\]
[PubMed](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=17661561)

#### GUIDELINE STATUS

This is the current release of the guideline.

### COMPLETE SUMMARY CONTENT

 SCOPE\
 METHODOLOGY - including Rating Scheme and Cost Analysis\
 RECOMMENDATIONS\
 EVIDENCE SUPPORTING THE RECOMMENDATIONS\
 BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS\
 CONTRAINDICATIONS\
 QUALIFYING STATEMENTS\
 IMPLEMENTATION OF THE GUIDELINE\
 INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT
CATEGORIES\
 IDENTIFYING INFORMATION AND AVAILABILITY\
 DISCLAIMER

### SCOPE

#### DISEASE/CONDITION(S)

Unintended pregnancy

#### GUIDELINE CATEGORY

Counseling\
Evaluation\
Management\
Prevention\
Risk Assessment

#### CLINICAL SPECIALTY

Family Practice\
Internal Medicine\
Nursing\
Obstetrics and Gynecology\
Pediatrics\
Preventive Medicine

#### INTENDED USERS

Advanced Practice Nurses\
Allied Health Personnel\
Nurses\
Physician Assistants\
Physicians

#### GUIDELINE OBJECTIVE(S)

To outline the contraceptive methods available for use during
breastfeeding, and to provide additional background on the Lactational
Amenorrhea Method (LAM) and its use

#### TARGET POPULATION

Breastfeeding mothers

#### INTERVENTIONS AND PRACTICES CONSIDERED

1.  Assessment of criteria for the period of lowest pregnancy risk

2.  Prenatal assessment of mother\'s choice for postpartum contraception

3.  Assessment of likelihood of success with lactational amenorrhea
    method (LAM) as a method of family planning

4.  Patient education on the correct use of LAM as a method of family
    planning

5.  Discussion of alternative methods of contraception

    -   Natural family planning

    -   Barriers

    -   Intrauterine devices (IUDs)

    -   Progestin-only methods

    -   Estrogen-containing contraceptives

6.  Discussion of optimal child spacing

#### MAJOR OUTCOMES CONSIDERED

-   Incidence of unwanted pregnancy

-   Effect of hormonal contraception on lactation, breast feeding

### METHODOLOGY

#### METHODS USED TO COLLECT/SELECT EVIDENCE

Searches of Electronic Databases

#### DESCRIPTION OF METHODS USED TO COLLECT/SELECT THE EVIDENCE

An initial search of relevant published articles written in English in
the past 20 years in the fields of medicine, psychiatry, psychology, and
basic biological science is undertaken for a particular topic. Once the
articles are gathered, the papers are evaluated for scientific accuracy
and significance.

#### NUMBER OF SOURCE DOCUMENTS

Not stated

#### METHODS USED TO ASSESS THE QUALITY AND STRENGTH OF THE EVIDENCE

Expert Consensus (Committee)\
Weighting According to a Rating Scheme (Scheme Given)

#### RATING SCHEME FOR THE STRENGTH OF THE EVIDENCE

**Levels of Evidence**

I Evidence obtained from at least one properly randomized controlled
trial

II-1 Evidence obtained from well-designed controlled trials without
randomization

II-2 Evidence obtained from well-designed cohort or case-control
analytic studies, preferably from more than one center or research group

II-3 Evidence obtained from multiple time series with or without the
intervention. Dramatic results in uncontrolled experiments (such as the
results of the introduction of penicillin treatment in the 1940s) could
also be regarded as this type of evidence.

III Opinions of respected authorities, based on clinical experience,
descriptive studies and case reports; or reports of expert committees

#### METHODS USED TO ANALYZE THE EVIDENCE

Review of Published Meta-Analyses\
Systematic Review with Evidence Tables

#### DESCRIPTION OF THE METHODS USED TO ANALYZE THE EVIDENCE

An expert panel is identified and appointed to develop a draft protocol
using evidence based methodology. An annotated bibliography (literature
review), including salient gaps in the literature, are submitted by the
expert panel to the Protocol Committee.

#### METHODS USED TO FORMULATE THE RECOMMENDATIONS

Expert Consensus

#### DESCRIPTION OF METHODS USED TO FORMULATE THE RECOMMENDATIONS

Not stated

#### RATING SCHEME FOR THE STRENGTH OF THE RECOMMENDATIONS

Not applicable

#### COST ANALYSIS

A formal cost analysis was not performed and published cost analyses
were not reviewed.

#### METHOD OF GUIDELINE VALIDATION

External Peer Review\
Internal Peer Review

#### DESCRIPTION OF METHOD OF GUIDELINE VALIDATION

Draft protocol is peer reviewed by individuals outside of lead
author/expert panel, including specific review for international
applicability. Protocol Committee\'s sub-group of international experts
recommends appropriate international reviewers. Chair (co-chairs)
institutes and facilitates process. Reviews submitted to committee Chair
(co-chairs).

Draft protocol is submitted to The Academy of Breastfeeding Medicine
(ABM) Board for review and approval. Comments for revision will be
accepted for three weeks following submission. Chair (co-chairs) and
protocol author(s) amends protocol as needed.

Following all revisions, protocol has final review by original author(s)
to make final suggestions and ascertain whether to maintain lead
authorship.

Final protocol is submitted to the Board of Directors of ABM for
approval.

### RECOMMENDATIONS

#### MAJOR RECOMMENDATIONS

**[General Principles]{.underline}**

**Table. Principles for Consideration in Contraception During
Lactation**

  -----------------------------------------------------------------------
  **When helping a breastfeeding       **In regards to:**
  mother choose a method of family     
  planning, consider her:**            
  ------------------------------------ ----------------------------------
  1.  Breastfeeding patterns, status,  Issues concerning lactational
  and plans                            amenorrhea method (LAM) and
                                       hormonal methods

  2.  Child\'s age                     Issues concerning LAM, hormonal
                                       methods, intrauterine device (IUD)
                                       insertion, and barrier sizing

  3.  Age                              Issues concerning hormonal methods

  4.  Previous contraceptive           Social and use issues, as well as
  experience                           sensitivities

  5.  Husband\'s (partner\'s) opinions Social and use issues
  on various methods                   

  6.  Childbearing plans               Spacing versus limiting methods

  7.  Health status                    Spacing versus limiting methods
                                       and hormonal methods

  8.  Accessibility of family planning Local access, availability issues,
  methods, health care personnel, and  and affordability issues
  socio-economic status                
  -----------------------------------------------------------------------

**[Lactational Amenorrhea Method (LAM) of Postpartum
Contraception]{.underline}**

**Method: What is LAM?**

The Lactational Amenorrhea Method (LAM) is presented as an algorithm
(see Figure 1 in the original guideline document) and includes three
criteria for defining the period of lowest pregnancy risk. Furthermore,
it advises the immediate commencement of other methods if any one of the
three criteria is not met. Clinically, the mother is asked:

-   Have you had a menstrual bleed?

-   Are you giving any supplementary foods or fluids in addition to
    breastfeeding?

-   Is your infant older than six months of age?

If she answers negatively to all three criteria, she meets the
requirements for LAM efficacy. She should be advised to initiate another
form of contraception if any of the above three questions are answered
affirmatively to achieve adequate efficacy for birth spacing or
fertility limitation. If the mother is interested in and qualifies for
LAM, she is advised to ask herself the same three questions in an
ongoing manner. It is advisable to ensure that she has her next method
on hand, and initiates its use whenever her answer to any of the three
questions changes. She should be advised to contact her health care
professional immediately if she has any questions as to whether or not
the method still applies.

**Definitions for LAM Use**

To use LAM correctly, it is important that the patient understand each
of the three criteria. Menses return, for the purposes of LAM use, is
defined as any bleeding that occurs after 56 days postpartum that is
perceived by the patient as a menses, or any two consecutive days of
bleeding. Full or nearly full breastfeeding is shown in Figure 2 in the
original guideline document, and includes exclusive, nearly exclusive,
and some irregularly provided supplements, as long as they do not
disrupt the frequency of feeds. This method of family planning is now
used in more than 30 countries and has been included in the family
planning and Maternal and Child Health policy in several countries. It
has been widely accepted as a natural family planning method that
demands no abstinence. It is used as an introductory method for the
postpartum period, or for the woman who hesitates to use a
commodity-based method. It has the added benefit of encouraging optimal
breastfeeding behavior, providing synergistic support for primary health
of the mother and the child.

**Considerations for Physician Counseling and Method Use**

Postpartum contraception, like breastfeeding, should be discussed with
patients during prenatal visits. The contraceptive choice a woman makes,
with or without her partner\'s input, depends on factors such as
previous experience with contraceptives, future childbearing plans,
husband or partner\'s attitude, and her lactation status. If a patient
is not comfortable with a method, she may use it ineffectively or not at
all, even if she does not wish to become pregnant.

There are several common reasons why a woman may choose LAM: she may
prefer a period of time without taking medicine or using any devices,
she may prefer more time for selection of a long-term or permanent
method, or she may wish to try something based on her natural
physiology.

Frequent nursing and milk expression alters the hypothalamic pulsatility
of gonadotropin releasing hormone (GnRH) production, which in turn
mediates follicle stimulating and luteinizing hormones, so that
effective ovulation is less likely to occur. Several milk expression
studies confirmed that the hormonal response is not identical to
breastfeeding, so if the milk expression is a regular occurrence, some
of the physiological responses may be modified. This is not directly
mediated by prolactin. A patient, who has had a spontaneous or induced
abortion prior to 20 weeks, usually will have spontaneous ovulation that
results in the secretory portion of the menstrual cycle leading to
menses. The patient will usually ovulate before any vaginal bleeding. If
she delivers at term and is fully breastfeeding, however, vaginal
bleeding (once the 6 weeks of lochia has stopped) nearly always occurs
prior to first adequate ovulation during the first 6 months. Once
regular feeding begins, there is an increase in fertile first cycles.
Ovulation in the non-lactating woman may occur as early as 3 weeks
postpartum.

**LAM Management Issues**

There are several suggested behaviors that would contribute to method
success and duration.

-   LAM is not meant for patients who are giving regular supplemental
    feedings.

-   Women can use LAM while working if they pump their breasts and
    provide milk to the baby\'s caregiver during their absence. However,
    in one study using this approach, the efficacy was about 95%,
    slightly lower, but not significantly different than efficacy in
    women not separated from their infants. Further research is needed
    on this issue; however, if this is the only method a woman is
    willing to accept and is well informed of the possibility of
    decreased efficacy, LAM should remain an option for women who are
    regularly separated from their infants.

-   One set of studies found that exclusively breastfeeding women using
    LAM are more likely to be amenorrheic at 6 months than exclusively
    breastfeeding controls (84% vs. 69.7%, respectively). Women who use
    LAM actively, have a higher feeding frequency, and, hence, shorter
    inter-feeding intervals, than other exclusive breastfeeders (see
    Figure 4 in the original guideline document). However, even with
    short inter-feeding intervals, some women experience earlier menses
    return. While we do not know whether these cycles are adequate for
    conception, no other sign of imminent fertility return are evident.
    Therefore, whether or not breastfeeding continues to be frequent,
    another method must be used for birth spacing when menses return.

-   Three studies have indicated that the efficacy of LAM can be
    maintained during the 6 to 12 month period, provided the mother who
    originally followed this method, continues to breastfeed before
    giving complementary foods at less than 4 hours intervals during the
    day and 6 hours intervals at night while remaining amenorrheic.

**Transition to Other Methods**

When LAM no longer applies, or whenever a breastfeeding woman wishes to
use an alternate family planning method, not all other methods have
equal consequences for breastfeeding success. Therefore, alternative
methods are presented ranked by increasing potential impact on
breastfeeding success (see Table below). While not equally efficacious,
the first choice methods are those that do not interfere with lactation.
While studies show no major problems when progestin-only methods are
introduced, the weight of anecdotal evidence, as well as the possible
postpartum impact of progestins on prolactin, merits the second choice
rating. Estrogen containing pills are known to reduce milk quantity.
Optimal child spacing for maternal recovery, the support of lactation
duration, and for child growth, development and survival may be
influenced by particular demographics. A minimum of 18 months between
births is recommended under all circumstances and at least three years
or longer is recommended in developing countries.

+-----------------------------------------------------------------------+
| **Table. Family Planning During Lactation: Minimizing Physiologic     |
| Impact on Breastfeeding**                                             |
+=======================================================================+
| -   First Choice Methods                                              |
|                                                                       |
|     -   LAM                                                           |
|                                                                       |
|     -   Natural Family Planning                                       |
|                                                                       |
|     -   Barriers                                                      |
|                                                                       |
|     -   Intrauterine Device (IUD)                                     |
|                                                                       |
| -   Second Choice Methods                                             |
|                                                                       |
|     -   Progestin-only methods                                        |
|                                                                       |
| -   Third Choice Methods                                              |
|                                                                       |
|     -   Estrogen containing contraceptives                            |
+-----------------------------------------------------------------------+

**[Issues In Counseling Selection of Contraceptives During
Breastfeeding]{.underline}**

**Advantages and Disadvantages**

The issues to be considered in counseling a pregnant or postpartum woman
concerning contraceptive choice for use during breastfeeding extend
beyond issues of efficacy. She will also wish to ensure that the
selected method is appropriate for breastfeeding expectations (as listed
in \"General Principles,\" above) in addition to the considerations for
the non-lactating woman. The Table 3 in the original guideline document,
titled \"Use of Contraceptive Methods During Lactation: Advantages,
Disadvantages and Impact on Lactation,\" provides useful information for
counseling the lactating mother and is not generally considered in
contraception handbooks.

#### CLINICAL ALGORITHM(S)

A clinical algorithm for the lactational amenorrhea method (LAM) is
provided in the original guideline document.

### EVIDENCE SUPPORTING THE RECOMMENDATIONS

#### TYPE OF EVIDENCE SUPPORTING THE RECOMMENDATIONS

The type of evidence supporting the recommendations is not specifically
stated.

The recommendations were based primarily on a comprehensive review of
the existing literature. In cases where the literature does not appear
conclusive, recommendations were based on the consensus opinion of the
group of experts.

### BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS

#### POTENTIAL BENEFITS

-   Appropriate use of contraception during breastfeeding

-   Lactational amenorrhea method (LAM) has the added benefit of
    encouraging optimal breastfeeding behavior, providing synergistic
    support for primary health of the mother.

#### POTENTIAL HARMS

Side effects associated with contraceptive use (see Table 3 in the
original guideline document for disadvantages and side effects
associated with various methods)

### CONTRAINDICATIONS

#### CONTRAINDICATIONS

Copper intrauterine devices are contraindicated with Wilson\'s disease
or copper allergy.

### QUALIFYING STATEMENTS

#### QUALIFYING STATEMENTS

A central goal of the Academy of Breastfeeding Medicine is the
development of clinical protocols for managing common medical problems
that may impact breastfeeding success. These protocols serve only as
guidelines for the care of breastfeeding mothers and infants and do not
delineate an exclusive course of treatment or serve as standards of
medical care. Variations in treatment may be appropriate according to
the needs of an individual patient.

### IMPLEMENTATION OF THE GUIDELINE

#### DESCRIPTION OF IMPLEMENTATION STRATEGY

An implementation strategy was not provided.

#### IMPLEMENTATION TOOLS

Clinical Algorithm

For information about
[availability](#identifying-information-and-availability), see the
\"Availability of Companion Documents\" and \"Patient Resources\" fields
below.

### INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT CATEGORIES

#### IOM CARE NEED

Staying Healthy

#### IOM DOMAIN

Effectiveness\
Patient-centeredness

### IDENTIFYING INFORMATION AND AVAILABILITY

#### BIBLIOGRAPHIC SOURCE(S)

Academy of Breastfeeding Medicine Protocol Committee. ABM clinical
protocol #13: contraception during breastfeeding. Breastfeed Med 2006
Spring;1(1):43-51. \[18 references\]
[PubMed](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=17661561)

#### ADAPTATION

Not applicable: The guideline was not adapted from another source.

#### DATE RELEASED

2005 (published 2006)

#### GUIDELINE DEVELOPER(S)

Academy of Breastfeeding Medicine - Professional Association

#### SOURCE(S) OF FUNDING

Academy of Breastfeeding Medicine

A grant from the Maternal and Child Health Bureau, US Department of
Health and Human Services

#### GUIDELINE COMMITTEE

Academy of Breastfeeding Medicine Protocol Committee

#### COMPOSITION OF GROUP THAT AUTHORED THE GUIDELINE

*Committee Members*: Caroline J. Chantry MD, *Co-Chairperson*; Cynthia
R. Howard MD, MPH, *Co-Chairperson*; Ruth A. Lawrence MD, FABM; Nancy G.
Powers, MD, FABM

*Contributors*: \*Miriam H. Habbok, MD, MPH, Department of Maternal and
Child Health, School of Public Health, University of North Carolina;
\*Victoria Nichols-Johnson, MD, Department of Obstetrics and Gynecology,
School of Medicine, Southern Illinois University; \*Veronica
Valdes-Anderson, MD, Department of Pediatrics, San Joaquin Medical
Center, Pontifical Catholic University of Chile

\*Lead Authors

#### FINANCIAL DISCLOSURES/CONFLICTS OF INTEREST

None to report

#### GUIDELINE STATUS

This is the current release of the guideline.

#### GUIDELINE AVAILABILITY

Electronic copies: Available in Portable Document Format (PDF) from the
[Academy of Breastfeeding Medicine Web
site](http://www.bfmed.org/ace-files/protocol/finalcontraceptionprotocolsent2.pdf).

Print copies: Available from the Academy of Breastfeeding Medicine, 140
Huguenot Street, 3rd floor, New Rochelle, New York 10801.

#### AVAILABILITY OF COMPANION DOCUMENTS

The following is available:

-   Procedure for protocol development and approval. Academy of
    Breastfeeding Medicine. 2007 Mar. 2 p.

Print copies: Available from the Academy of Breastfeeding Medicine, 140
Huguenot Street, 3rd floor, New Rochelle, New York 10801.

#### PATIENT RESOURCES

None available

#### NGC STATUS

This NGC summary was completed by ECRI Institute on November 14, 2007.
The information was verified by the guideline developer on October 31,
2008.

#### COPYRIGHT STATEMENT

This NGC summary is based on the original guideline, which is subject to
the guideline developer\'s copyright restrictions.

Single copies may be downloaded for personal use. Copyright permission
to be requested for use of multiple copies by e-mailing requests to
<abm@bfmed.org>. An official request form will be sent electronically to
person requesting multiple copy use.

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© 1998-2008 National Guideline Clearinghouse

Date Modified: 11/24/2008