Contraception and Lactation

Joyce King, CNM, FNP, PhD

The benefits of breastfeeding for both the infant and the mother are undisputed. Longer intervals between
births decrease fetal/infant and maternal complications. Lactation is an effective contraceptive for the first 6
months postpartum only if women breastfeed exclusively and at regular intervals, including nighttime.
Because a high percentage of women in the United States supplement breastfeeding, it is important for these
women to choose a method of contraception to prevent unintended pregnancies. Both the method of
contraception and the timing of the initiation of contraceptives are important decisions that a clinician must
help the breastfeeding woman make. Ideally, the chosen method of contraception should not interfere with
lactation. This article reviews the research on the effect of contraceptives, including hormonal contraceptives,
on lactation. J Midwifery Womens Health 2007;52:614 620 2007 by the American College of
Nurse-Midwives.
keywords: contraception, lactation

INTRODUCTION

PHYSIOLOGY OF LACTATION

Each year, more than 100 million women worldwide

make decisions about the use of a method of contraception after childbirth.1 These decisions include not only
making a choice regarding a contraceptive method but
also deciding the best time for initiation of the chosen
method. These decisions may be more complex for
breastfeeding women, because both the choice and timing of hormonal methods of contraception may effect
both milk production and infant growth and development.2
It has been well documented that breastfeeding
provides excellent nutrition for infants as well as
protection against a variety of infectious diseases, including lower respiratory infections and otitis media.
There is also strong evidence that mothers who breastfeed have reduced postpartum bleeding, more rapid
uterine involution, and delayed resumption of ovulation
with increased child spacing. Setty-Venugopal3 observed
that a 3-year interval between births decreases neonatal
and postneonatal mortality as well as child mortality for
the second child. Longer birth intervals also decrease
maternal complications such as third-trimester bleeding,
postpartum endometritis, and anemia.4 Therefore, spacing of births by using contraception after childbirth
provides important health benefits for mothers as well as
their offspring. This article provides a brief review of the
physiology of lactation and the contraceptive effect of
lactation. The literature regarding the use of contraception in lactating women is reviewed. One important
caveat is that most of the research on this topic was
conducted during the 1970s and 1980s; little additional
research has been conducted in the past 20 years.

The two primary hormones that are needed for lactation

are prolactin and oxytocin. Prolactin stimulates milk
biosynthesis within the alveolar cells of the breast and
oxytocin stimulates contraction of the myoepithelial cells
that surround the alveoli, causing the milk to be ejected
into the ducts leading to the nipple. Breast growth is
stimulated by increasing prolactin secretion throughout
pregnancy. Lactation is inhibited during pregnancy by
progesterone produced by the placenta. Progesterone
interferes with prolactin binding to the receptors on the
alveolar cells within the breast, thereby directly suppressing milk production.5,6 The hormonal trigger for the
initiation of lactation after birth is primarily the rapid
decline in the level of placental progesterone. Pharmacologic levels of estrogen (estrogen from exogenous
sources vs. endogenous sources) also block prolactin
activity.5,6
Milk secretion begins 3 to 4 days postpartum, after the
steroid hormones have been cleared from maternal circulation. Suckling stimulates an increase in prolactin levels,
which is important for the initiation of milk production as
well as the maintenance of milk production once lactation
has been established. The amount of milk produced is
correlated with the amount that is removed with suckling.
The optimal quantity and quality of breast milk are also
dependent on other factors, such as the availability of
thyroid hormone, insulin and insulin-like growth factors,
cortisol, and the intake of nutrients and fluids.5,6

Address correspondence to Joyce King, CNM, FNP, PhD, Assistant

Professor, Clinical Emory University School of Nursing, Atlanta, GA
30322. E-mail: Jking01@emory.edu

614
2007 by the American College of Nurse-Midwives
Issued by Elsevier Inc.

CONTRACEPTIVE EFFECT OF LACTATION

Lactation itself has a contraceptive effect and is a vitally
important factor in child-spacing and limiting family size
in developing countries. Elevated levels of prolactin that
occur with breastfeeding inhibit the pulsatile secretion of
gonadotropin-releasing hormone from the hypothalamus.5 This in turn interferes with the hypothalamic
pituitary ovarian axis, preventing estrogen secretion and
Volume 52, No. 6, November/December 2007
1526-9523/07/$32.00 doi:10.1016/j.jmwh.2007.08.012

ovulation. With weaning, prolactin levels decline and

ovulation resumes within 14 to 30 days.5
The lactational amenorrhea method (LAM) relies on
breastfeeding as a contraceptive method. The effectiveness of this method is dependent on the intensity and
frequency of infant suckling and the extent to which
supplemental food is added to the infants diet. Women
who are amenorrheic and exclusively breastfeed at regular intervals have the same protection against pregnancy
for the first 6 months postpartum as women taking
combined oral contraceptives (98% efficacy).7 Effective
use of this method depends on several important points:
1) regular intervals are defined as no intervals greater
than 4 hours between feedings during the day or 6 hours
at night; and 2) exclusive breastfeeding means that
supplemental food should not exceed 5% to 10% of total
feedings. Supplemental feeding increases the risk of
ovulation and pregnancy, even in women who are not
menstruating.7,8 Expressing milk by hand or by pump is
less vigorous than suckling and may reduce the maternal
neuroendocrine response and increase the risk of ovulation and fertility.9 Visness et al.10 observed that 50% of
women who are not fully breastfeeding ovulate before 6
weeks, the time of the typical postpartum visit.
After 6 months, or with the resumption of menstruation, the chance of ovulation and risk of pregnancy
increase (although with exclusive breastfeeding the contraceptive efficacy of lactation at 1 year is still high [94%
efficacy]).7 LAM is a transitional method of contraception and is most appropriate for women who plan to fully
breastfeed for at least 6 months (Figure 1).9 Women who
choose to use this method need counseling during the
prenatal, perinatal, and postnatal periods to improve
efficacy. Health care providers should provide another
method of contraception for the LAM user to self-initiate
if she decides to supplement breastfeeding or if she
begins menstruating before 6 months postpartum.
For women who do not breastfeed exclusively, the
return of menstruation and ovulation is unpredictable;
therefore, the choice of contraception and the timing of
contraceptive initiation are critical.
EARLY INITIATION OF A CONTRACEPTIVE METHOD
An important factor to consider when initiating contraception in postpartum women is the typical breastfeeding
pattern of women in the United States. In a prospective,
nonrandomized trial of 319 women, Halderman et al.11
reported that by week 6 postdelivery, 23.5% of women
had discontinued breastfeeding, and of those who had
continued breastfeeding, 64.5% were supplementing. In

Joyce King, CNM, FNP, PhD, works part-time in a full-scope obstetrician/

gynecologist nurse-midwifery practice and teaches full-time in both the
undergraduate and graduate nursing programs at Emory University.

Journal of Midwifery & Womens Health www.jmwh.org

Have your menses

returned?
No

Are you supplementing

regularly or allowing long
periods without
breastfeeding?

Yes

Yes

The risk of pregnancy is

increased. Advise another
method of contraception.

No
Yes

Is you baby more than 6

months old?
No

Yes

There is a 1-2% risk of

pregnancy.

Figure 1. Use of the lactational amenorrhea method for contraception.

Reprinted with permission from Labbok et al.9

the 2005 National Immunization Survey, the Centers for

Disease Control and Prevention reported that at 7 days
postpartum, the rate of exclusive breastfeeding was
59.4%, and by 42 days postpartum, the rate had dropped
to 46.4%.12 This underscores the need for early initiation
of a contraceptive method. Ideally, during the last trimester of pregnancy, the provider will review contraceptive options with the pregnant woman. Having this
opportunity to discuss the pros and cons of each contraceptive option will help her make the most appropriate
choice.
METHODS OF CONTRACEPTION
In choosing a method of contraception, it is important
that it not interfere with lactation or have negative effects
on the infant. Nonhormonal methods of contraception,
such as barrier methods or the copper intrauterine device
(IUD), are the preferred choice for nursing mothers,
because hormones in some contraceptive methods may
interfere with lactation, and the transfer of hormones into
milk poses a theoretical risk to the infant.2 There are
numerous nonhormonal methods available that have no
effect on production of milk or on infant growth and
development. Methods like the diaphragm, condoms,
spermicidal foams and jellies, and copper IUDs provide
reversible contraception, while vasectomy and tubal
ligation are permanent methods.
Intrauterine Devices
IUDs are long-term contraceptive methods with high
efficacy. Some have raised concerns that the uterine
contractions that accompany breastfeeding may cause
expulsion of an IUD. The results of an early study
showed that breastfeeding does not increase the risk of
IUD expulsion whether the device is inserted within 10
minutes of delivery or more than 42 days postdelivery.13
The copper IUD has no effect on breast milk copper
615

concentrations.14 Shikary et al.15 noted that levonorgestrel in the levonorgestrel-releasing intrauterine system
Mirena (Bayer HealthCare Pharmaceuticals, Wayne, NJ)
does transfer from maternal serum into the breast milk,
and that 11.8% of that transfers into the infant circulation.
They found less of the hormone transferred into the infant
from the oral form of levonorgestrel than from either a
subdermal levonorgestrel implant or the levonorgestrel
IUD.
Tubal Ligation
If a tubal ligation is performed using general anesthesia,
the mother should breastfeed just before the procedure to
minimize the length of infant fast, and can then resume
breastfeeding immediately following surgery with the
following guidelines: 1) the mother should be awake
and alert; 2) short-acting benzodiazepines (e.g., Ativan),
muscle relaxants, inhalation agents, and local anesthetics
are most likely safe, but meperidine (Demerol) or prolonged use of diazepam (Valium) should be avoided.16 18 It is important that the anesthesiologist be aware
that the surgical patient is breastfeeding in order to make
the best decision about the choice of anesthesia.
Natural Family Planning Methods
Natural family planning may be a contraceptive option
for lactating women who prefer such a method. Studies
of cervical secretions in breastfeeding women indicate
that mucus changes indicating fertility are reliable during
lactation, and that charting should be carried out in the
usual manner.19 In a study of 419 postpartum breastfeeding women who evaluated and charted the characteristics
of their cervical mucus each day, Perez19 observed that
50% of the women detected mucus by the fourth month;
mucus was noted approximately 2 months before the first
menses. It was also noted that as the women moved from
total breastfeeding to partial breastfeeding or to complete
weaning, the number of days of cervical mucus increased.
Hormonal Methods
There are some concerns about the use of hormonal
contraceptive methods in lactating women. It is hypothesized that hormones ingested by the infant in breast milk
may result in circulating levels that are higher than
expected because of an immature liver that cannot
metabolize the hormones, immature kidneys that may not
be able to excrete the hormones, and a plasma-binding
capacity that may be low, resulting in higher levels of
free and biologically active hormones.11 It is also important to note, however, that hormones are not well
absorbed from breast milk in the newborn infant.11 Patel
et al.20 studied 30 breastfeeding women using levonorgestrel-containing oral contraceptives and their breast616

feeding infants at 4, 12, and 24 weeks of age. At 4 weeks,

the infants could neither absorb nor metabolize the
levonorgestrel; at 12 weeks, the infants could metabolize
the hormone more efficiently than it could absorb it; by
24 weeks of age, the infants could both absorb and
metabolize the drug. Virutamasen et al.21 observed that
no metabolites of medroxyprogesterone acetate were
found in the urine of infants whose mothers were given
Depo-Provera (Pfizer, Inc., New York, NY) on days 42
and 126 postpartum. Another study examining progestinonly pills concluded that very low amounts of the
hormones are transferred into breast milk.22 According to
Halderman,11 there is minimal evidence that exposure to
exogenous hormones is harmful to the infant, but also
there is no evidence to support its safety.
When to initiate hormonal contraception in the postpartum woman is also debated. Most experts have traditionally delayed starting hormonal contraception until the
6-week postpartum visit, after lactation is well established. This delay has been based on the theoretical
concern that hormonal contraceptives containing estrogen and progestin may impair lactation through their
effect on the action of prolactin on the breast. As noted
above, placental estrogen and progesterone inhibit prolactin activity during pregnancy. After delivery of the
placenta, when estrogen and progesterone levels markedly decrease, prolactin levels increase and milk production is initiated.4 There is a theoretical concern that
giving hormones before 6 weeks postpartum, or before
breastfeeding is well established, could interfere with
optimal lactation.2
Progestin-only contraceptives, including oral contraceptives, the Depo-Provera contraceptive injection (DMPA;
Pfizer, Inc., New York, NY), and etonogestrel-releasing
implant Implanon (Organon USA, Inc., Roseland, NJ) do
not have adverse effects on lactation, although there is
still controversy regarding early use in breastfeeding
women.11 Product labeling for DMPA recommends initiation at 4 to 6 weeks after delivery, regardless of
breastfeeding status. This recommendation is based on
research conducted in family planning clinics where the
patients initial visit after delivery was scheduled at that
time.11 The World Health Organization (WHO) noted in
multinational prospective studies that followed 2466
breastfeeding mothers and their infants that progestinonly methods of contraception started 6 weeks postpartum did not adversely affect infant development23 or
infant growth.24
Another WHO study compared progestin-only contraceptive methods that were initiated at 6 weeks postpartum to nonhormonal methods of contraception (e.g.,
IUD). After 6 weeks of treatment, there was no decrease
in milk volume in the women using a progestin-only
minipill when compared to the nonhormonal methods.
Milk volume was measured using the pump-extraction
method for milk collection. What is interesting is that at
Volume 52, No. 6, November/December 2007

18 weeks post-initiation of treatment, the progestin-only

pill group had a 12% decline in milk volume compared
to only a 6.1% decline in women who were using
nonhormonal methods of contraception. This same
study showed that women using DMPA had an increase
in milk production between the 16- and 20-week visits
when compared to women using progestin-only minipills
or nonhormonal methods of contraception.25
Taneepanichskul et al26 compared the effects of Implanon, a single-rod, etonogestrel-releasing contraceptive
implant, with a nonmedicated IUD on lactation and infant
growth (n 80). Healthy lactating women chose either the
contraceptive implant or the IUD for insertion 28 to 56
days postpartum. The data showed that etonogestrel had
no effect on infant growth during the 3-year follow-up
period of the study. The researchers concluded that
Implanon appears to be a safe contraceptive option for
breast-feeding women and their infants.26
Shaamash et al.27 conducted a prospective, controlled,
randomized trial (n 320) comparing the levonorgestrel-20 g intrauterine system Mirena (Bayer HealthCare Pharmaceuticals) with the copper T380A intrauterine device and their effect(s) on breastfeeding
performance, as well as infant growth and development
during the first year postpartum. No statistical differences
were found between the two groups with regard to
duration of breastfeeding, infant growth (i.e., weight,
length, head circumference, mid-arm circumference, and
skin fold thickness) or development (i.e., ability to pass
the various developmental tests, such as reaching for a
dangling object or visually locating a sound).
Another study conducted at two public hospitals in
Santiago, Chile, evaluated four methods of contraception: a progesterone vaginal ring (n 187); progestinonly pills (n 117); Norplant (Wyeth Pharmaceuticals,
Madison, NJ) implants (n 120); and copper T 380A
IUDs (n 122) in lactating women. The study examined
contraceptive performance, duration of lactation, infant
growth, duration of lactational amenorrhea, and menstrual patterns during the first year of use. All contraceptives were initiated at day 57 3 postdelivery. All
methods were highly effective, with only two pregnancies occurring among users of progestin-only pills during
the first 6 months postpartum. The duration of lactation
was similar in users of all the methods, as were measurements of infant growth. Women using the progesterone
ring, progestin-only pills, and Norplant (Wyeth Pharmaceuticals) implants had a prolonged period of lactational
amenorrhea; this was not seen with users of the copper T
380A IUD. Prolonged or frequent bleedings occurred
infrequently with all the methods, and very few women
discontinued their contraceptive method because of bleeding problems.28 In response to these numerous studies, the
WHO states that there is no restriction on the utilization of
progestin-only methods of birth control in breastfeeding
women initiated after 6 weeks postpartum.11
Journal of Midwifery & Womens Health www.jmwh.org

A less conservative approach is early initiation of progestin-only contraceptive methods. Several studies that
evaluated early administration of progestin-only methods,
progestin-only pills at 1 week postpartum29 and DMPA
injected at 2 days30 and 7 days31 found no differences in
infant growth or breastfeeding practices, such as duration
of breastfeeding or supplementation, between users of
the different progestin-only contraceptives. Boudraoui
et al.32 found that immediate administration of DMPA
postpartum in 772 lactating women followed from delivery to 1 year postpartum actually resulted in an increase
in the amount of milk and an increase in protein
concentration. Karim et al.33 found that administration of
DMPA 7 days postpartum was not only associated with
no adverse effects on the amount of milk production or
duration of lactation, but the treatment group showed
greater infant weight gain than did the control subjects. A
2002 study showed that breastfeeding women using
progestin-only methods of contraception that were initiated before hospital discharge had no significant differences in their continuation rates of breastfeeding when
compared to breastfeeding women who used nonhormonal methods of contraception. Supplementation because of the perception of insufficient milk production
also did not differ between the two groups.11 This study
supports the earlier findings that early initiation of
progestin-only methods of contraception has no adverse
impact on breastfeeding practices.
It is generally recommended that breastfeeding mothers not use hormonal methods of contraception that
contain estrogen (e.g., combined oral contraceptives,
the vaginal contraceptive ring, and the contraceptive
patch).34 A WHO trial reported a statistically significant
decrease in milk volume in women who took combined
oral contraceptives when compared to women who took
progestin-only contraceptives.35 However, there were no
significant differences between combined hormone pills
and progestin-only pills in milk composition or infant
growth.35 The International Planned Parenthood Federation recommends that combined hormonal contraceptives
not be used at all by breastfeeding women. The WHO
recommends that if combined hormonal methods are
going to be utilized, they should not be initiated until at
least 6 months postpartum after breastfeeding skills and
patterns are well established.34 Because of a hypercoaguable state during the early postpartum period, even
nonbreastfeeding women should avoid estrogen-containing hormonal contraceptives for at least 3 weeks after
delivery.21,34 A recent systematic review of randomized
controlled trials evaluated the effect of combined oral
contraceptives and progestin-only contraceptives on lactation.2 The authors concluded that the data are insufficient to establish any effect of hormonal contraception on
either milk quantity or quality and that existing data are
inadequate to make an evidenced-based recommendation
regarding hormonal contraceptive use for lactating women.
617

After reviewing 50 articles written from 1967 to 2002, only

seven reports from five trials met the inclusion criteria set
by the review group.2 Their evaluation of these five trials
found that the methodologic quality of all five was poor, and
results should be interpreted with caution. The method of
measuring milk output, the number of breastfeedings reported in a 24-hour period, and the addition of supplemental
foods were not consistent.2 Small sample sizes and loss to
follow-up also were problematic for several studies. Well
conducted randomized controlled trials of adequate size are
urgently needed to address the effect of hormonal contraception on milk quality and quantity. Within these limitations however, this Cochrane review found no evidence that
hormonal contraceptives cause adverse effects on infant
growth.2
The American College of Obstetricians and Gynecologists (ACOG)36 and WHO35 recommendations for hormonal contraception in breastfeeding women are listed in
Table 1. The ACOG recommendations are based on the
manufacturers prescribing information. Because it has
been shown that in certain populations of breastfeeding
Table 1. ACOG and WHO Recommendations for Hormonal Contraception
Used by Breastfeeding Women
ACOG

WHO

Progestin-only oral contraceptives

prescribed or dispensed at
discharge from the hospital
to be started 23 weeks
postpartum (e.g., the first
Sunday after the newborn is
2 weeks old).
Depot medroxyprogesterone
acetate initiated at 6 weeks
postpartum*
Hormonal implants inserted at
6 weeks postpartum*
The levonorgestrel intrauterine
system can be inserted at
6 weeks postpartum.
Combined estrogenprogestin
contraceptives, if prescribed,
typically should not be started
before 6 weeks postpartum,
and only when lactation is well
established and the infants
nutritional status is
appropriate

Progestin-only methods of
contraception (i.e., oral
contraceptives, levonorgestrel-IUD,
levonorgestrel implant, DepoProvera injection) are not usually
recommended before 6 weeks
postpartum unless other more
appropriate methods are not
available or not acceptable.
Progestin-only methods can be used
in any circumstances after 6
weeks postpartum.

Combined estrogenprogestin
contraceptives (i.e., oral
contraceptives, transdermal path,
or vaginal ring) are not to be
used before 6 weeks postpartum.
Combined estrogenprogestin
contraceptives are not usually
recommended between 6 weeks
and 6 months postpartum unless
other more appropriate methods
are not available or not
acceptable.
Combined estrogenprogestin
contraceptives can be generally
used after 6 months postpartum

ACOG American College of Obstetricians and Gynecologists; IUD intrauterine

device; WHO World Health Organization.
*There are certain clinical situations in which earlier initiation might be considered.
Adapted from ACOG36 and WHO.35

618

Table 2. Clinical Guidelines for Contraceptive Initiation and Use in

Breastfeeding Women
Breastfeeding women should receive information about all methods of
contraception to assist them in their choice of an appropriate method.
Breastfeeding women should be advised that breastfeeding delays the
return of both ovulation and menstruation.
Breastfeeding women should be advised that if they are 6 months
postpartum, amenorrheic, and exclusively breastfeeding that their risk
of pregnancy is approximately 2%.
Breastfeeding women need to be advised that the risk of pregnancy
increases when they are beyond 6 months postpartum, or if
menstruation recurs, or if they begin to supplement breastfeeding.
Breastfeeding women should be advised that the current evidence
indicates that progestin-only contraceptives do not appear to have an
adverse effect on breast milk volume during the first 6 weeks
postpartum and also have no adverse effect on infant growth and
development throughout the duration of their use.
Breastfeeding women may choose to use a progestin-only method of
contraception before 6 weeks postpartum if they are at risk for
ovulation and an unplanned pregnancy and no other method of
contraception is acceptable.
Breastfeeding women should be advised to avoid combined hormonal
contraception for at least the first 6 months postpartum.
Breastfeeding women can use both types of intrauterine devices,
although insertion should be delayed until uterine involution is
complete (approximately 6 weeks postpartum).
Breastfeeding women should be advised that barrier methods of
contraception and fertility awareness can be utilized while
breastfeeding. These methods may be more effective in breastfeeding
women since breastfeeding is already associated with reduced fertility.
Breastfeeding women should be advised that they can return at any time
if contraceptive side effects occur or if they want to change their
contraceptive method.
Adapted with permission from FFPRHC Guidance, July 2004.37

women there are low continuation rates of breastfeeding

and high rates of bottle supplementation,11,15 and because early initiation of progestin-only methods of contraception do not appear to affect infant growth,29 31 it
may be appropriate to initiate progestin-only methods of
contraception for women who may be at risk for early
return to fertility and unintended pregnancy.
Conclusion
All providers of prenatal care should evaluate the patients need and desire for postpartum contraception
during the last trimester of pregnancy. The choice of
contraceptive method and the timing of contraceptive
initiation is an essential consideration for the breastfeeding woman. Women who are breastfeeding should be
counseled that supplementation, the resumption of menstrual bleeding, and reaching the sixth postpartum month
are all associated with increased fertility. The patients
personal contraceptive preferences and lifestyle also
must be considered when choosing a method of contraception. Table 2 summarizes the clinical guidelines for
provision of contraception to breastfeeding women.37
The ideal situation is one in which the woman is informed
Volume 52, No. 6, November/December 2007

of all the contraceptive alternatives and that she will choose

to use a method that has no effect on lactation or the
newborn.

circulation into the newborn infants circulation via breast milk.

Contraception 1987;35:477 86.

REFERENCES

17. American Academy of Pediatrics Committee on Drugs. The

transfer of drugs and other chemicals into human milk, 1994;93:
13750.

1. Tsui AO, Wasserheit JN, Haaga JG. Reproductive health in

developing countries: Expanding dimensions, building solutions.
Panel on Reproductive Health, Committee on Population, Commission on Behavioral and Social Sciences and Education, National Research Council. Washington, DC: National Academy
Press, 1997.
2. Truitt ST, Fraser AB, Grimes DA, Gallo MF, Schulz KF.
Combined hormonal versus nonhormonal versus progestin-only
contraception in lactation. Cochrane Database Syst Rev 2003;2:
CD003988.
3. Setty-Venugopal V, Upadhyay UD. Birth spacing. Three to
five saves lives. Popul Rep L 2002;13:123.
4. Conde-Agudelo A, Belizan JM. Maternal morbidity and
mortality associated with interpregnancy interval: Cross sectional
study. BMJ 2000;321:12559.
5. Speroff L, Fritz MA. Clinical gynecologic endocrinology
and infertility, 7th ed. Philadelphia, PA: Lippincott Williams &
Wilkins, 2005.
6. Lawrence RA, Lawrence RM. Breastfeeding: A guide for the
medical profession. Philadelphia, PA: Elsevier Mosby, 2005.
7. Perez A, Labbok MH, Queenan JT. Clinical study of the
amenorrhea method for family planning. Lancet 1992;339:968 70.
8. Kennedy KI, Visness C. Contraceptive efficacy of lactational
amenorrhoea. Lancet 1992;339:22730.
9. Labbok MH, Hight-Laukaran V, Peterson AE, Fletcher V,
von Hertzen H, Van Look PFA. Multicenter study of the lactational amernorrhea method (LAM): I. Efficacy, duration, and implications for clinical application. Contraception 1997;55:32736.
10. Visness CM, Kennedy KI, Gross BA, Parenteau-Carrequ S,
Flynn AM, Brown JB. Fertility of fully breast-feeding women in
the early postpartum period. Obstet Gynecol 1997;89:164.
11. Halderman LD, Nelson AL. Impact of early postpartum
administration of progestin-only hormonal contraceptives compared with nonhormonal contraceptives on short-term breast-feeding patterns. Am J Obstet Gynecol 2002;186:1250 8.
12. Centers for Disease Control and Prevention Web site.
Breastfeeding trends and updated national health objectives
for exclusive breastfeedingUnited States, birth years 2000
2004. Available from: www.cdc.gov/mmwr/preview/mmwrhtml/
mm5630a2.htm [Accessed August 31, 2007].
13. Cole LP, McCann MF, Higgins JE, Waszak CS. Effects of
breastfeeding on IUD performance. Am J Public Health 1983;73:
384 8.
14. Rodrigues da cunha AC, Dorea JG, Cantuaria AA. Intrauterine device and maternal copper metabolism during lactation. Contraception 2001;63:379.
15. Shikary ZK, Betrabet SS, Patel ZM, Patel S, Joshi JV,
Toddywala VS, et al. Transfer of levonorgestrel (LNG) administered through different drug delivery systems from the maternal
Journal of Midwifery & Womens Health www.jmwh.org

16. Lee JJ, Rubin AP. Breast feeding and anaesthesia. Anesthesia 1993;48:616.

18. Hatcher RA, Trussel J, Stewart F, Nelson AL, Cates W,

Guest F, et al. Contraceptive technology, 18th ed. New York:
Ardent Media, Inc, 2004.
19. Perez A. Natural family planning: Postpartum period. Int J
Fertil 1981;26:219 21.
20. Patel SB, Toddywalla VS, Betrabet SS, Kulkarni RD, Patel
ZM, Mehta AC, et al. At what infant-age can levonorgestrel
contraceptives be recommended to nursing mothers? Adv Contracept 1994;10:249 55.
21. Virutamasen P, Leepipatpaiboon S, Kriengsinyot R,
Vichaidith P, Muia PN, Sekadde-Kigondu CB, et al. Pharmacodynamic effects of depot-medroxyprogesterone acetate (DMPA) administered to lactating women on their male infants. Contraception
1996;54:1537.
22. Fraser IS. A review of the use of progestogen-only minipills
for contraception during lactation. Reprod Fertil Dev 1991;3:
24554.
23. World Health Organization, Task Force for Epidemiological
Research on Reproductive Health, Special Programme of Research, Development, and Research Training in Human Reproduction. Progestogen-only contraceptives during lactation, II: Infant
development. Contraception 1994;50:55 69.
24. World Health Organization, Task Force for Epidemiological
Research on Reproductive Health, Special Programme of Research, Development, and Research Training in Human Reproduction. Progestogen-only contraceptives during lactation, I: Infant
growth. Contraception 1994;50:3553.
25. Tankeyoon M, Dusitsin N, Chalapati S, Koetsawang S,
Saibiang S, Sas M, et al. Effects of hormonal contraceptives on
milk volume and infant growth: WHO Special Programme of
Research, Development, and Research Training in Human Reproduction Task force on oral contraceptives. Contraception 1984:30:
50522.
26. Taneepanichskul S, Reiinprayoon D, Thaithumyanon P,
Praisuwanna P, Tosukhowong P, Dieben T. Effects of the etonogestrel-releasing implant Implanon and a nonmedicated intrauterine device on the growth of breast-fed infants. Contraception
2006;73:368 71.
27. Shaamash AH, Sayed GH, Hussien MM, Shaaban MM.
A comparative study of the levonorgestrel-releasing intrauterine
system Mirena versus the Copper T380A intrauterine device during lactation: Breast-feeding performance, infant growth and infant
development. Contraception 2005;72:346 51.
28. Diaz S, Zepeda A, Maturana X, Reyes MV, Miranda P,
Casado ME, et al. Fertility regulation in nursing women IX:
Contraceptive performance, duration of lactation, infant growth,
and bleeding patterns during use of progesterone vaginal rings,
progestin-only pills, Norplant implants, and Copper T 380-A intrauterine devices. Contraception 1997;56:22332.

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29. McCann MF, Moggia AV, Higgins JE, Potts M, Becker C,

et al. The effects of oral progestin-only oral contraceptive
(levonorgestrel 0.03 mg) on breast-feeding. Contraception 1989;
40:635 48.

33. Karim M, Ammar R, el-Mahgoub S, el-Ganzoury B, Fikri F,

Abdou I. Injected progestogen and lactation. BMJ 1971;1:200 3.

30. Moggia AV, Harris TS, Dkunson TR, Diaz R, Moggia MS,
Ferrer MA, et al. A comparative study of progestin-only oral
contraceptive versus non-hormonal methods in lactating women in
Buenos Aires, Argentina. Contraception 1991;44:31 43.

35. World Health Organization, Division of Reproductive

Health and Research. Medical Eligibility Criteria for Contraceptive Use, 2004. Available from: www.who.int/reproductive-health/
publications/mec/ [Accessed August 31, 2007].

31. Guiloff E, Ibarra-Polo A, Zanartu J, Toscanini C, Mischler

TW, Gomez-Rogers C. Effects of contraception on lactation. Am J
Obstet Gynecol 1974;118:425.

36. American College of Obstetricians and Gynecologists. Special report from ACOG: Breastfeeding: Maternal and infant aspects. ACOG Clinical Review 2007;12:1S16S.

32. Badraoui MH, Hefnawi F, Bahgat R, Fawzi G, El Gaali O,

Ismail H, et al. Contraception during lactation. Reproduccion
1982;6:9 18.

37. Faculty of Family Planning and Reproductive Health Care

Guidance (July 2004). Contraceptives choices for breastfeeding
women. J Fam Plann Reprod Health Care 2004;30:1819.

34. Queenan JT. Contraception and breastfeeding. Clin Obstet

Gynecol 2004;47:734 9.

Need More CEUs?

You can receive 3.0 CEUs in this issue, but if you need more, log on to
www.jmwh.org (if you are a subscriber) or www.ShopACNM.com for several
continuing education opportunities, including:
Liability and Risk Management in Midwifery Practice (expires 12/31/07) Featured
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Environmental Hazards in Womens Health (expires 2/28/08) Featured in January/
February 2006 issue, 1.5 CEUs (15 contact hours)
Primary Health Care For Women (expires 6/30/08) Featured in May/June 2006
issue, 2.0 CEUs (20 contact hours) inclusive of 1.0 CEUs of pharmacology credit (10
contact hours that includes 10 contact hours of pharmacology credit)
Topics in Gynecology and Reproductive Health (expires 12/31/2008) Featured in
Nov/Dec 2006 issue, 2.0 CEUs inclusive of 2.0 CEUs of pharmacology credit (20
contact hours that includes 20 contact hours of pharmacology credit)
Intrapartum Care (expires 6/30/09) Featured in May/June 2007 issue, 2.0 CEUs (20
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Volume 52, No. 6, November/December 2007