birth control and breastfeeding what does the evidence say n.
Download
Skip this Video
Loading SlideShow in 5 Seconds..
Birth control and breastfeeding What does the evidence say? PowerPoint Presentation
Download Presentation
Birth control and breastfeeding What does the evidence say?

Loading in 2 Seconds...

play fullscreen
1 / 48

Birth control and breastfeeding What does the evidence say? - PowerPoint PPT Presentation


  • 106 Views
  • Uploaded on

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

loader
I am the owner, or an agent authorized to act on behalf of the owner, of the copyrighted work described.
capcha
Download Presentation

Birth control and breastfeeding What does the evidence say?


An Image/Link below is provided (as is) to download presentation

Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author.While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server.


- - - - - - - - - - - - - - - - - - - - - - - - - - E N D - - - - - - - - - - - - - - - - - - - - - - - - - -
Presentation Transcript
mark twain
Get your facts straight,

Then you can distort ‘em any way you want

Mark Twain
objectives
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
slide4
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?
answer
Answer

An IUD

birth control and breastfeeding
Birth control and breastfeeding
  • Public health issue of global importance
  • 100 million postpartum women/yr decide:
    • What method
    • When to start it
oral contraceptive use worldwide
Oral contraceptive use worldwide
  • 1980 53.4 million
  • 1988 62.9 million
  • 2000 84.0 million
2 good things
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
global strategy on infant and young child nutrition
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

us commitment to breastfeeding
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
factors affecting breastfeeding
Favorable factors

Older age

Higher income

More education

Unfavorable factors

Teens

Lower income

Less education

Smoking

Factors affecting breastfeeding
family planning in nm
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

lactation during pregnancy
Lactation: During pregnancy

Placenta

Estrogen

Progesterone

GnRH

FSH/LH

PIF

NO MILK

PROLACTIN

lactation after birth
Lactation: After birth

Delivery of placenta

Estrogen

Progesterone

Infant suckling

PI F

MILK

PROLACTIN

Oxytocin

potential harms of hormonal contraception
Potential harms of hormonal contraception
  • Quality of milk
  • Passage of hormones to the infant
  • Infant growth, milk quantity, duration of breastfeeding
potential harms of hormonal contraception1
Potential harms of hormonal contraception
  • Quality of milk
  • Passage of hormones to the infant
  • Infant growth, milk quantity
quality of milk
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
potential harms of hormonal contraception2
Potential harms of hormonal contraception
  • Quality of milk
  • Passage of hormones to the infant
  • Infant growth, milk quantity, duration of breastfeeding
passage of hormones to infant
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
long term effects nilsson 1986
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
potential harms of hormonal contraception3
Potential harms of hormonal contraception
  • Quality of milk
  • Passage of hormones to the infant
  • Infant growth, milk quantity, duration of breastfeeding
combined pills 3 rcts
Combined pills: 3 RCTs
  • 2: COC vs. placebo
  • 1: COC vs. progestin-only
problems with rcts
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
semm 1966
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
miller 1970
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
who 1984 1986 1988
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
who outcomes
WHO outcomes
  • Breast milk volume @ 4 wk intervals x 6 mos
  • Breast milk composition
  • Infant growth
    • 6, 9, 12, 16, 20 and 24 weeks
who results
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
who disclaimer
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.”

who conclusions
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.”

2 rcts progestin only pills
2 RCTs: Progestin-only pills
  • 1: Progestin-only vs. placebo
  • 1: Progestin-only vs. progestin-only, timing of start
velasquez 1976
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
were 1997
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
dmpa no rcts
DMPA: no RCTs
  • WHO non-randomized trial, 1994:
    • 2466 mother-infant pairs
      • POP
      • DMPA
      • Norplant
      • Non-hormonal
  • Results:
    • No differences in infant growth
progestin only
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)

halderman 2002
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
acog recommendations for hormonal contraception if used
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

acog practice bulletin 2000
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

levels of evidence
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
cochrane review 2003
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

what do providers prescribe
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
survey of new mexico ob gyns and cnms
Survey of New Mexico OB-GYNs and CNMs
  • Questions
    • Prescribing practices
    • Attitudes about OCs for BFing women
    • Knowledge questions
what do the residents prescribe
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)

rct choice of oc for bf postpartum women
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