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Birth control and breastfeeding What does the evidence say?

Birth control and breastfeeding What does the evidence say? . Eve Espey, MD MPH. Get your facts straight, Then you can distort ‘em any way you want. Mark Twain. Objectives. Understand the current evidence related to the impact of hormonal contraception on breastfeeding

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Birth control and breastfeeding What does the evidence say?

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  1. Birth control and breastfeedingWhat does the evidence say? Eve Espey, MD MPH

  2. Get your facts straight, Then you can distort ‘em any way you want Mark Twain

  3. Objectives • Understand the current evidence related to the impact of hormonal contraception on breastfeeding • Describe current expert opinion about the appropriate choice of hormonal contraceptives for breastfeeding women • Be aware of future directions for research in this area

  4. Case • 18 y/o G1P1 s/p NSVD yesterday is ready for discharge. You note on the chart that she is breastfeeding. You have counseled her about birth control pills. • What should you prescribe?

  5. Answer An IUD

  6. Birth control and breastfeeding • Public health issue of global importance • 100 million postpartum women/yr decide: • What method • When to start it

  7. Oral contraceptive use worldwide • 1980 53.4 million • 1988 62.9 million • 2000 84.0 million

  8. Postpartum contraception Birth interval < 24 months rarely desired Maternal/infant mortality Breastfeeding Complete nutrition Safe food source Immunological defense Saves money Reduces risk of breast and ovarian cancer 2 Good Things

  9. Global strategy on infant and young child nutrition Revitalization of the global commitment to appropriate infant and young child nutrition, and in particular to breastfeeding WHO, 4/02

  10. US commitment to breastfeeding • American Academy of Pediatrics • Breastfeeding is the ideal method of feeding and nurturing infants • Healthy People 2010 • Increase rates of breastfeeding initiation and continuation

  11. Breastfeeding statistics

  12. Favorable factors Older age Higher income More education Unfavorable factors Teens Lower income Less education Smoking Factors affecting breastfeeding

  13. Family planning in NM • 44% pregnancies unintended in 2000 • Half to couples using no method • Half used a method inconsistently, incorrectly or a method with a high failure rate PRAMS, 2001

  14. Lactation: During pregnancy Placenta Estrogen Progesterone GnRH FSH/LH PIF NO MILK PROLACTIN

  15. Lactation: After birth Delivery of placenta Estrogen Progesterone Infant suckling PI F MILK PROLACTIN Oxytocin

  16. Potential harms of hormonal contraception • Quality of milk • Passage of hormones to the infant • Infant growth, milk quantity, duration of breastfeeding

  17. Potential harms of hormonal contraception • Quality of milk • Passage of hormones to the infant • Infant growth, milk quantity

  18. Quality of milk • WHO, 1988 • “10 cc aliquots expressed, freeze-dried and transported to London by air” • Some differences in micro-nutrients and fat content • Conflicting interpretation of significance • Infant growth a better, but elusive outcome

  19. Potential harms of hormonal contraception • Quality of milk • Passage of hormones to the infant • Infant growth, milk quantity, duration of breastfeeding

  20. Passage of hormones to infant • Case reports • Measuring steroid content of breast milk • Estradiol in breast milk AND in maternal serum after ingestion of pill (50mic) • 600 cc breastmilk/day from mother taking a 50 mic COC: • 10 ng of estradiol compared with • 3-6 ng during anovulatory cycles • 6-12 ng during ovulatory cycles

  21. Long term effects: Nilsson, 1986 • 48 children exposed to COCs in breastmilk • 48 controls • 8 year follow-up • No differences in • Growth • Disease • Intellectual development • Psychological behavior

  22. Potential harms of hormonal contraception • Quality of milk • Passage of hormones to the infant • Infant growth, milk quantity, duration of breastfeeding

  23. Combined pills: 3 RCTs • 2: COC vs. placebo • 1: COC vs. progestin-only

  24. Problems with RCTs • Methods of randomization unclear • Methods for allocation concealment unclear • Small sample sizes • Large loss-to-follow-up rates • Methods for measuring milk output may not reflect breastmilk production

  25. Semm, 1966 • N = 100 women • Munich, Germany • 50 – high dose COC on PP days #1-10 • 50 – identically packaged placebos • Outcomes • No differences in milk volume, lactation initiation or infant growth during the first 10 postpartum days

  26. Miller, 1970 • N= 50 women – Iowa • 25 – high dose COC begun at 2 wks x 21 days • 25 – identically packaged placebos • Outcome • Less milk volume as measured by supplemental feeds and duration of breastfeeding • Prior successful BFing best determinant of BFing to 3 mos

  27. WHO, 1984, 1986, 1988 • Hungary, Thailand • N = 171 women choosing oral contraceptives • Age 25-35 • Multips (2-4 live births) • Prior successful breastfeeding • Infants 2700 – 3700 gms • 86 – low-dose COC begun 6 wks PP • 85 – progestin-only begun 6 wks PP

  28. WHO outcomes • Breast milk volume @ 4 wk intervals x 6 mos • Breast milk composition • Infant growth • 6, 9, 12, 16, 20 and 24 weeks

  29. WHO results • Milk volume decreased in both groups from wk 6-24 • 41% COC • 12% progestin-only • No differences in • Supplementation • “inadequate milk production” • breastfeeding continuation • infant growth • milk composition

  30. WHO disclaimer “… our method of measuring milk output… may have little relationship to the amount actually ingested by the baby during that or any other 24-hour period.”

  31. WHO conclusions “Combined oral contraceptives cannot be recommended for use during early lactation. The age at which it seems safe to recommend them will be a subject for debate and controversy.”

  32. 2 RCTs: Progestin-only pills • 1: Progestin-only vs. placebo • 1: Progestin-only vs. progestin-only, timing of start

  33. Velasquez, 1976 • N = 20 women • Mexico • 12 – NET (progestin only) on PP days #1-14 • 8 – identically packaged placebos • Outcomes • No differences in milk volume, infant growth or milk composition during 14 days of the study

  34. Were, 1997 • N = 200 women • Eldoret, Kenya • 100 – progestin-only begun 6 weeks PP • 100 – progestin-only begun 6 months PP • Outcomes • No effect on contraceptive continuation rates • No effect on pregnancy rates

  35. DMPA: no RCTs • WHO non-randomized trial, 1994: • 2466 mother-infant pairs • POP • DMPA • Norplant • Non-hormonal • Results: • No differences in infant growth

  36. Progestin-only • Halderman, 2002 • Compare breastfeeding continuation in women given DMPA before discharge, POPs, vs. non-hormonal methods • 319 women • 102 DMPA • 77 POPs • 138 Non-hormonal (barriers, abstinence) • DMPA received at mean 52 hours after delivery (range: 3 hrs to 132 hrs)

  37. Halderman, 2002 • 2 weeks: No difference in BF continuation or supplementation • 60% supplementing across all groups • 56% cited insufficient milk • 4 weeks: 77% DMPA BF vs. 83% non-horm BF (p=.02) • No differences in insufficient milk • 6 weeks: No differences in BF continuation

  38. ACOG Recommendations for Hormonal Contraception “if used” • POPs to start 2-3 weeks postpartum • DMPA to start at 6 weeks postpartum • COCs, if prescribed, should not be started before 6 weeks postpartum, and only when lactation is well established and the infant's nutritional status well-monitored ACOG bulletin: Breastfeeding: Maternal and infant aspects 7/00

  39. ACOG Practice bulletin 2000 • “Progestin-only preparations are safe and preferable forms of hormonal contraception for lactating women. Combination OCs are not recommended as the first choice for breastfeeding mothers because of the negative impact of contraceptive doses of estrogen on lactation.” • Level A evidence The use of hormonal contraception in women with coexisting medical conditions, ACOG, 7/00

  40. Levels of evidence • Level A: Recommendations are based on good and consistent scientific evidence • Level B: … based on limited or inconsistent scientific evidence • Level C: …based on consensus and expert opinion

  41. Cochrane Review 2003 • Evidence from RCTs is limited and of poor quality • No established link between hormonal contraception and milk quality/quantity • Evidence inadequate to make recommendations regarding hormonal contraceptive use for breastfeeding women Hormonal contraception & lactation

  42. What do providers prescribe? • Single study – Rochat 1981 • Survey: 3697 doctors in 72 countries • 831 responses - 22% response rate • 45% ever prescribed COCs for BF women • Woman’s preference • Previous BF history • International Planned Parenthood guidelines

  43. Survey of New Mexico OB-GYNs and CNMs • Questions • Prescribing practices • Attitudes about OCs for BFing women • Knowledge questions

  44. What do the residents prescribe? • 10/10 RX hormonal contraceptives • 10 start DMPA prior to hospital discharge • 8 start COCs at 2 weeks PP • 2 start COCs at 6 weeks PP • None discourage COCs in BF women • 3: Recommend if factors favorable (2-6 wks) • 6: Recommend routinely as benefits outweigh risks (2-6 wks)

  45. RCT: Choice of OC for BF postpartum women • Women to be randomized to POPs vs. COCs • Double-blind RCT (pills packaged identically) • Begin at 2 weeks PP • Outcome measures: • Breastfeeding continuation at 2 months PP • Infant weight • Method continuation

  46. Successful breastfeeding

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