Contraceptive Counseling for Postpartum Breastfeeding Mothers
For breastfeeding mothers, progestin-only methods (pills, implants, or IUDs) are the recommended first-line contraceptive options, as they do not affect milk production and can be initiated safely in the postpartum period. 1
Contraceptive Method Hierarchy for Breastfeeding Women
First-Line: Progestin-Only Methods
Progestin-only pills (POPs) are the preferred oral contraceptive for breastfeeding women because they have no negative effect on lactation and can be started immediately after delivery 1. The CDC and ACOG both endorse POPs as the optimal choice for women desiring oral contraception while breastfeeding 1.
- Timing: POPs can be inserted at any time postpartum (U.S. MEC 2 if <1 month postpartum, U.S. MEC 1 if ≥1 month postpartum) 2
- Back-up contraception: If the woman is <6 months postpartum, amenorrheic, and fully or nearly fully breastfeeding (≥85% of feeds are breastfeeds), no additional contraceptive protection is needed 2
- If started >5 days after menses return, only 2 days of additional contraception is required 1
Etonogestrel implant serves as an excellent long-acting alternative that does not negatively affect lactation 1.
- Can be inserted at any time postpartum with the same timing and back-up contraception guidelines as POPs 2
- Provides highly effective contraceptive protection with no negative effect on breastfeeding or infant growth 3
- Fewer than 1 in 100 women become pregnant in the first year of typical use 2
Intrauterine devices (copper or levonorgestrel) are also appropriate first-line options for breastfeeding women 4.
Methods to AVOID: Combined Hormonal Contraceptives
Combined hormonal contraceptives (containing estrogen) should NOT be used during the first 3 weeks postpartum (U.S. MEC 4) due to increased venous thromboembolism risk 2.
- Generally should not be used during the fourth week postpartum (U.S. MEC 3) due to potential negative effects on breastfeeding performance 2
- Breastfeeding women with additional VTE risk factors generally should not use combined hormonal contraceptives from 4-6 weeks postpartum (U.S. MEC 3) 2
- Combined methods are considered only a third-line option after 6 weeks, requiring monitoring of milk production 1, 5
- Estrogen-containing preparations have been associated with reduction in milk production and should be avoided altogether during lactation 6
Lactational Amenorrhea Method (LAM)
If a woman is <6 months postpartum, amenorrheic, and fully or nearly fully breastfeeding (exclusively breastfeeding or ≥85% of feeds are breastfeeds), she has natural contraceptive protection and does not need additional contraception when initiating progestin-only methods 2.
- Once menses return, the contraceptive protection of exclusive breastfeeding is no longer reliable 1
- LAM can be used to time the commencement of a more permanent contraceptive method 6
Critical Timing Considerations
For Progestin-Only Methods:
- Can be started immediately postpartum 2
- Ideally postponed for 6 weeks in breastfeeding women to avoid transferring steroids to the newborn, though can be used earlier if needed 3
- No waiting for return of menses is necessary 2
For Combined Hormonal Methods:
- Absolutely contraindicated in first 3 weeks (U.S. MEC 4) 2
- Generally not recommended in fourth week (U.S. MEC 3) 2
- May be considered after 6 weeks in breastfeeding women without other VTE risk factors 2, 7
- Require 7 days of back-up contraception if started >5 days after menses 2, 1
Common Pitfalls to Avoid
Do not prescribe combined hormonal contraceptives before 6 weeks postpartum in breastfeeding women, as this can compromise milk production and increase thromboembolism risk 2, 6, 7.
Counsel patients about variable bleeding patterns with progestin-only methods, as this is the most commonly reported complaint and may affect compliance 8.
Do not delay contraception counseling until the postpartum visit, as many women resume sexual activity before 6 weeks and may become pregnant 6.