Definitions of the grades of recommendation based on levels of evidence (A-C, Good Practice Point), are provided at the end of the "Major Recommendations" field.
What should a clinician assess when considering contraception for a breastfeeding woman?
- A clinician should assess a woman's postpartum contraceptive needs by taking account of her personal choice, sexual activity, breastfeeding pattern, menstruation, and medical and social factors (Good Practice Point).
- Breastfeeding women should be given information about all hormonal and non-hormonal contraceptive methods (Good Practice Point).
- Breastfeeding women should be offered information and support to use their chosen method of contraception effectively (Good Practice Point).
What are the effects of breastfeeding on ovulation and fertility?
- Women should be advised that breastfeeding delays the return of ovulation (Grade B).
- Women should be advised that because breastfeeding delays the return of ovulation, all contraceptive methods have low failure rates when used consistently and correctly (Grade C).
- Women should be informed that awaiting the onset of menstruation before starting contraception is not advised, as it might put them at risk of unintended pregnancy (Grade B).
What do women need to know about their contraceptive choices: efficacy, effect on breast milk or infant growth?
Lactational Amenorrhoea Method
- Women may be advised that if they are less than 6 months postpartum, amenorrhoeic, and fully breastfeeding, the lactational amenorrhoea method (LAM) is over 98% effective in preventing pregnancy (Grade B).
- Women using the LAM should be advised that the risk of pregnancy is increased if breastfeeding decreases (particularly stopping night feeds), when menstruation recurs, or when more than 6 months postpartum (Grade C).
Hormonal Contraception
- Women should be informed that the level of hormone in breast milk when using a hormonal method of contraception is comparable to levels observed when they have an ovulatory cycle (Grade C).
- Women should be advised that the available evidence is unable to prove if hormonal contraception has any effect on breast milk volume (Grade C).
- Women should be advised that the available evidence indicates that hormonal contraception has no adverse effect on infant growth (Grade A).
Combined Hormonal Contraception
- Women should be advised that use of combined oral contraception (COC) in the first 6 weeks postpartum may have an adverse effect on breast milk volume (Grade B).
- Breastfeeding women should be advised to avoid COC in the first 6 weeks postpartum (Grade B).
- Breastfeeding women should be advised that COC can be used without restriction from 6 months postpartum (Grade C).
Breastfeeding women should be advised that COC is not recommended between 6 weeks and 6 months postpartum. However, if breastfeeding is established, COC may be considered if other contraceptive methods are unacceptable (Good Practice Point).
Progestogen-Only Contraception
- Women should be advised that the use of progestogen-only methods in the first 6 weeks postpartum does not appear to have an adverse effect on breast milk volume (Grade B).
- Women should be advised that the use of progestogen-only methods when breastfeeding provides over 99% efficacy (Grade B).
- Women should be advised that the problematic bleeding associated with progestogen-only methods appears to be more acceptable than that experienced by women who are not breastfeeding (Grade B).
After counselling, breastfeeding women may choose to use a progestogen-only method of contraception before 6 weeks postpartum if other contraceptive methods are unacceptable (Good Practice Point).
Non-Hormonal Methods
Intrauterine Device (IUD)
- Unless an IUD can be inserted within the first 48 hours postpartum, insertion should be delayed until 4 weeks postpartum (Grade C).
Barrier Methods, Spermicides, and Fertility Awareness
- Women can be advised that the use of diaphragms and cervical caps should be delayed until uterine involution is complete (from 6 weeks postpartum) (Grade C).
When can breastfeeding women be advised to start contraception?
Advice from the Clinical Effectiveness Unit (CEU) on starting contraception postpartum is given in the Table below. This has been adapted from World Health Organization Selected Practice Recommendations for Contraceptive Use (WHOSPR) and the United Kingdom version of this document.
Contraceptive Starting Regimens for Breastfeeding Women
| Time postpartum |
Contraceptive method |
Advice for breastfeeding women on when to start contraceptive method |
| Immediately |
Lactational amenorrhoea method (LAM) |
Start immediately postpartum to provide effective contraception. Remind women that the LAM is an interim method effective for the first 6 months postpartum only. |
| Intrauterine device (IUD) |
Insert within the first 48 hours postpartum to provide immediate protection. |
| Condoms and spermicides |
Can be used immediately. |
| Female sterilisation |
Can be performed at the time of Caesarean section if there has been appropriate counselling and consent antenatally. |
| Under 4 weeks |
Progestogen-only pill (POP) |
May start any time postpartum. If started up to Day 21 postpartum no additional contraceptive protection required. If started after Day 21 additional contraceptive protection is required for 2 days. |
| Progestogen-only implant |
Insert up to Day 28 postpartum without the need for additional contraceptive protection. If inserted after Day 28 additional contraceptive protection is required for 7 days. May be considered before Day 21 if a woman is unlikely to return for insertion, if the risk of pregnancy is high, and if other methods are unacceptable. Counsel regarding bleeding. |
| Emergency contraception (EC) |
Indicated if there has been unprotected intercourse or potential contraceptive failure after Day 21. Progestogen-only EC can be used without restriction in breastfeeding women. |
| From 4 weeks |
Intrauterine device (IUD) |
Insert from 4 weeks postpartum. |
| Levonorgestrel-releasing intrauterine system (LNG-IUS) |
Insert from 4 weeks postpartum with additional contraception for 7 days. |
| From 6 weeks |
Progestogen-only injectable |
Give from 6 weeks postpartum if reasonably certain woman is not pregnant with additional contraceptive protection for 7 days. May be considered at less than 6 weeks if the risk of subsequent pregnancy is high and other contraceptive methods are unacceptable. |
| Combined oral contraception (COC)
| May be started from 6 weeks if breastfeeding is established and other contraceptive methods are unacceptable. Additional contraceptive protection is required for 7 days. |
| Diaphragms and cervical caps |
Fit for a new diaphragm or cap from 6 weeks when uterine involution is complete. |
| Sterilisation |
Male and female sterilisation can be considered after an appropriate interval following pregnancy. |
Lactational Amenorrhoea Method
- Women should be advised to start the LAM immediately postpartum (Good Practice point).
Combined Hormonal Contraception
- If breastfeeding is established, a woman who is more than 6 weeks postpartum may start COC at any time if it is reasonably certain she is not pregnant. Additional contraceptive protection is required for 7 days (Good Practice Point).
- Breastfeeding women who are more than 6 weeks postpartum and having regular menstrual cycles can start COC as for non-breastfeeding women (Good Practice Point).
- Women should be advised that the use of COC while breastfeeding is outside product licenses (Good Practice Point).
Progestogen-Only Pills (POP)
- A breastfeeding woman can start a POP up to Day 21 postpartum without the need for additional contraceptive protection (Good Practice Point).
- A breastfeeding woman can start POP after Day 21 postpartum if it is reasonably certain she is not pregnant. Additional contraceptive protection is required for 2 days (Good Practice Point).
- A breastfeeding woman who chooses to use a POP before 6 weeks postpartum should be informed that this is outside the product license for some pills (Good Practice Point).
Progestogen-Only Injectable
- Breastfeeding women should be advised that depot medroxyprogesterone acetate (DMPA) use before 6 weeks postpartum is not usually recommended (Grade C).
- Women should be advised that troublesome bleeding can occur with DMPA use in the early postpartum period (Grade C).
Breastfeeding women who choose DMPA will not require the injection until Day 21 postpartum, but if the risk of immediate subsequent pregnancy is high it may be given before this time (Good Practice Point).
Breastfeeding women who choose to use DMPA before 6 weeks postpartum should be informed that such use is outside the product license (Good Practice Point).
Progestogen-Only Implants
- Breastfeeding women may choose to use a progestogen-only implant before Day 28 without the need for additional contraceptive protection (Good Practice Point).
- Breastfeeding women should be advised that the use of a progestogen-only implant before Day 21 postpartum is outside the product license (Good Practice Point).
Levonorgestrel-Releasing Intrauterine System (LNG-IUS)
- Breastfeeding women may have a LNG-IUS inserted from 4 weeks postpartum (Grade C).
Intrauterine Device
- Breastfeeding women may have an IUD inserted within the first 48 hours postpartum, otherwise insertion should be delayed until 4 weeks postpartum (Grade C).
Diaphragms and Cervical Caps
- Breastfeeding women who choose a diaphragm or cervical cap should be advised to wait until at least 6 weeks postpartum before attending for assessment of size required (Grade C).
When do breastfeeding women require emergency contraception (EC)?
- Breastfeeding women can be advised that unprotected sexual intercourse or contraceptive failure before Day 21 postpartum is not an indication for EC (Good Practice Point).
- Breastfeeding women can be advised that once hormonal contraception has been initiated, potential contraceptive failures should be managed in the same way as for women not breastfeeding (Good Practice Point).
- Breastfeeding women may be offered an IUD as EC from 4 weeks postpartum (Good Practice Point).
What follow-up is required for breastfeeding women using contraceptive methods?
- Breastfeeding women should be advised to return at any time to discuss side effects or other problems, or if they want to change their contraceptive method (Grade C).
Definitions
Grades of Recommendation are based on levels of evidence as follows:
A: Evidence based on randomised controlled trials (RCTs)
B: Evidence based on other robust experimental or observational studies
C: Evidence is limited but the advice relies on expert opinion and has the endorsement of respected authorities
Good Practice Point where no evidence exists but where best practice is based on the clinical experience of the Expert Group
