What birth control methods are safe to use during breastfeeding?

Safe Contraception Options During Breastfeeding

Progestin-only contraceptives and non-hormonal methods are the safest and most effective contraception options for breastfeeding women, while combined hormonal contraceptives containing estrogen should be avoided until at least 6 weeks postpartum due to their potential impact on milk production. 1

Recommended Options for Breastfeeding Women

First-Line Options (Safest)

• Non-hormonal methods:
  • Copper IUD - Can be inserted at any time postpartum (Category 1), providing up to 10 years of protection with <1% failure rate 1
  • Lactational Amenorrhea Method (LAM) - Highly effective temporary method for the first 6 months if:
    • Mother is exclusively or nearly exclusively breastfeeding (≥85% of feeds)
    • Mother remains amenorrheic
    • Baby is less than 6 months old 2, 1
  • Barrier methods (condoms, diaphragms) - Can be used immediately postpartum but have higher failure rates (18% for male condoms, 12% for diaphragms with typical use) 1

Second-Line Options (Safe)

• Progestin-only methods:
  • Levonorgestrel IUD - Category 2 if inserted <1 month postpartum, Category 1 if ≥1 month postpartum, providing 3-5 years of protection 2, 1
  • Progestin implant - Category 2 if <1 month postpartum, Category 1 if ≥1 month postpartum, providing 3 years of protection with <1% failure rate 1
  • Progestin-only pills (POPs) - Can be started at 6 weeks postpartum, 9% failure rate with typical use 1, 3
  • DMPA (injectable) - Category 2 if <1 month postpartum, 6% failure rate with typical use 1

Third-Line Options (Use with Caution)

• Combined hormonal contraceptives (pills, patches, rings):
  • Not recommended before 6 weeks postpartum due to effects on milk production 4
  • Category 4 (contraindicated) in first month postpartum, Category 3 (risks usually outweigh benefits) from 1-6 months postpartum while breastfeeding 2

Timing Considerations

• Immediate postpartum (0-48 hours):

  • Copper IUD can be inserted safely 1
  • Non-hormonal barrier methods can be used 5
  • LAM is effective if criteria are met 2

• Early postpartum (48 hours to 4 weeks):

  • Progestin-only methods can be used but are Category 2 (benefits generally outweigh risks) 2, 3
  • Combined hormonal methods are contraindicated (Category 4) 2

• 4 weeks to 6 months postpartum:

  • Progestin-only methods become Category 1 (no restriction) after 1 month 2
  • Combined hormonal methods remain Category 3 (risks usually outweigh benefits) if breastfeeding 2

Clinical Pearls and Pitfalls

• Key pitfall: Starting combined hormonal contraceptives too early can decrease milk production and lead to early weaning 3, 6

• Optimal timing: Ideally, progestin-only methods should be started at 6 weeks postpartum if the woman is fully breastfeeding, as contraceptive protection is already provided by LAM, and this delay will decrease infant exposure to exogenous hormones 3

• Important consideration: When LAM is used, another method of contraception must be initiated as soon as any of the criteria are no longer met (menstruation resumes, breastfeeding frequency/duration decreases, supplemental feeds are introduced, or baby reaches 6 months) 2

• Practical approach: For women planning to gradually wean their infant, combined hormonal contraceptives may provide an easier transition to bottle-feeding, but should be used with caution by women who cannot obtain supplemental milk 3