The most traumatic situation for a woman can be an unwanted pregnancy when she has a very young baby. Since menstruation is often delayed during breastfeeding, a woman may not even realize that she is pregnant again till the pregnancy is advanced and too late to abort. Recognizing the special needs of breastfeeding women and their concerns about contraceptive methods available, the WHO Selected Practice Recommendations for Contraceptive Use (WHO WHOSPR) released guidelines based on scientific evidence in 2004.

Women generally feel that they are protected against another pregnancy as long as they do not have periods after childbirth. The return of menstruation is often the first sign of returning fertility but sexual activity before the first menstrual period after delivery may put many women at risk of pregnancy. Breastfeeding delays the return of egg release and can be used as an important method of contraception. This is known as the Lactational Amenorrhoea Method (LAM). The 3 essential features of LAM are: If your baby is less than 6 months old, if you have had no menstrual period after delivery and the baby is fully breast fed, then your protection against pregnancy is as high as 98%. Each of these 3 parts is important and needs to be understood. ‘Full breastfeeding’ is defined as exclusive breast feeding with no or very occasional liquids in form of vitamins, water or juice, but no solids. An infant is considered fully breastfed when breast milk is the only source of nutrition. Reducing the frequency of breastfeeding, stopping the night feeds or if the baby sleeps through the night, separation from baby (e.g. returning to work), introducing supplements which include extra fruit juice or even small amounts of solids, anxiety, stress or illness in either mother or baby – all these constitute partial breast feeding and decrease the effectiveness of LAM as a contraceptive method.

The effectiveness of LAM further depends upon the menstrual period. A woman may continue to have some amount of bleeding for 56 days after delivery. Then how will she know whether she has resumed her periods: a ‘true period’ is any bleeding lasting for at least 2 days, requiring the use of sanitary protection for at least 1 day, followed by a second bleeding episode within the next 21-70 days. Therefore women using LAM must know that the risk of pregnancy is increased if frequency and duration of suckling decreases (particularly stopping night feeds and return to work), when menstruation recurs, or when she is more than 6 months from delivery.

All contraceptive methods have lower failure rates in breastfeeding women provided they are used consistently and correctly. Barrier methods like condom work well immediately after delivery. Some studies show that oral contraceptive pills may decrease the breast milk volume. It is advisable to wait till the baby is 6 months of age before taking these pills. However, the progesterone-only-pills (POP), which do not contain any estrogen hormone, are very safe. In situations where new mothers cannot stick to the criteria for effective LAM, they are recommended these POPs, easily available in India, which can be started even immediately after delivery. Progesterone-only Emergency Contraception is safe in breastfeeding women in case of unprotected intercourse or potential contraceptive failure. For intrauterine contraceptive devices like Copper-T, it is best to wait till 4 weeks after delivery. All women need to be counseled about contraception after the delivery, the various options available, and along with the many oft repeated benefits, the contraceptive advantages of breastfeeding need to be highlighted.

Dr Nirja Chawla