REVIEW

CURRENT
OPINION Postpartum hormonal contraception in
breastfeeding women
Taylor A. Stanton and Paul D. Blumenthal

Purpose of review
To provide an overview of recent research and guidelines regarding contraception and breastfeeding.
Recent findings
Recent studies assessed lactogenesis, breastfeeding rates, and milk supply concerns in patients starting
postpartum hormonal contraception. One study showed a small but statistically significant increase in milk
supply concerns between users and nonusers of postpartum hormonal contraception. Mean time to
lactogenesis and breastfeeding rates were similar between patients with immediate and delayed insertion
of the levonorgestrel (LNG) implant in one study and the LNG intrauterine device (IUD) in another study.
Two studies assessed nursing knowledge and attitudes toward postpartum contraception in breastfeeding
women, showing that postpartum nurses had incorrect knowledge of contraceptive safety in this patient
population. Both studies demonstrated persistent erroneous beliefs that depot medroxyprogesterone acetate
(DMPA) adversely affects breastfeeding. In postpartum patients intending to breastfeed, more than half
intended to initiate contraception within 6 weeks postpartum and few indicated effect on breastfeeding as
a factor in their decision.
Summary
There are no significant differences in lactogenesis, breastfeeding, and infant growth parameters between
immediate postpartum (IPP) and delayed insertion of LNG implants and IUDs. Labor and delivery and
postpartum nurses have persistent erroneous beliefs that DMPA negatively affects breastfeeding. Patients
desire to use contraception postpartum but prenatal counseling rates and practices are of variable content
and quality.
Keywords
birth control, breast feeding, contraception, postpartum

INTRODUCTION Postpartum contraception is an essential tool to

Short interval pregnancies have detrimental effects
on women and infants. The WHO recommends
24 months between delivery and conception of a
subsequent pregnancy [1]. Similarly, the American
College of Obstetricians and Gynecologists (ACOG)
recommend an interpregnancy interval of
18 months to 5 years [2]. Healthy People 2020 aims
to reduce the proportion of pregnancies within
18 months of each other [3]. The reason for these
generally consonant recommendations is because
short interval pregnancies are associated with
increased risk of preterm birth, low birth weight,
small for gestational age, infant mortality, neonatal
ICU admissions, and specific birth defects (includ-
ing gastroschisis and neural tube defects [4,5]). They
are also associated with maternal risks including
obesity, gestational diabetes, labor dystocia, placen-
tal abruption, and uterine rupture from prior cesar-
ean sections [6].
help women achieve optimal birth spacing; how-
ever, conventional initiation of contraception at the
traditional 6-week postpartum visit may not serve
large numbers of patients. Nearly 40% of women do
not present to this visit [2] and among those who do,
over half have resumed intercourse by that time [7].
Initiation of immediate postpartum (IPP) contracep-
tion, including long-acting reversible contraception
(LARC), protects women from rapid repeat preg-
nancy. ACOG recommends IPP LARC as a best
Department of Obstetrics and Gynecology, Stanford University, Stan-
ford, California, USA
Correspondence to Taylor A. Stanton, Department of Obstetrics and
Gynecology, Stanford University, 300 Pasteur Drive HG332, Stanford,
CA 94305-5317, USA. Tel: +1 650 725 6079;
e-mail: stantont@stanford.edu
Curr Opin Obstet Gynecol 2019, 31:441–446
DOI:10.1097/GCO.0000000000000571

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Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

Family planning
KEY POINTS
 There are no significant differences with respect to
effects on breastfeeding or infant growth parameters
with IPP vs. delayed placement of LNG implants
and IUDs.
 Educational programs and exposure to IPP long-acting
reversible contraception increase nursing contraceptive
counseling rates and likelihood to recommend long-
acting reversible contraception.
 Misinformation regarding DMPA and breastfeeding is
pervasive, despite evidence of no adverse affect
on breastfeeding.
 Convenience is one of the top reasons for women
choosing a specific postpartum contraception method.
practice [8] and in 2016 the Center for Medicaid and
CHIP services outlined changes to improve access to
IPP LARC for Medicaid patients, including unbun-
dling payments for LARC from labor and delivery
services, removing logistical barriers for supply man-
agement of LARC, and doing away with logistical
barriers such as preauthorizations and scheduling
requirements [9].
Controversy has long surrounded postpartum
hormonal contraception due to theoretical con-
cerns of exogenous progestins affecting lactogenesis
stage II or decreasing breast milk supply. Studies in
the past have failed to show adverse effects of hor-
monal contraception on breastfeeding [10–12]. A
2015 Cochrane review reported inconsistent results
across trials, low-to-moderate quality of studies,
and, overall, no major differences between users
and nonusers of hormonal contraception postpar-
tum with respect to any lactation-related issues [13].
Few studies have focused on immediate vs. delayed
initiation of LARC; however, those that have did not
show significant differences regarding initiation or
duration of breastfeeding or infant growth [14].
RECENT TRIALS INVESTIGATING
HORMONAL CONTRACEPTION AND
BREASTFEEDING
Effect on lactogenesis, breastfeeding, and
infants
Time to lactogenesis stage II, breastfeeding rates, and
infant parameters were evaluated by Averbach et al.
&&
and Turok et al. (Table 1). In the Averbach et al.’s [15 ]
study, which took place in Uganda, patients were
randomized to immediate (within 5 days postpar-
tum) or delayed (6–8 weeks postpartum) placement
442 www.co-obgyn.com
Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.
of a two-rod levonorgestrel (LNG) implant. In the
&&
Turok et al.’s [16 ] report, patients were randomized
to immediate (within 30 min of delivery of placenta)
or delayed (4–12 weeks postpartum) placement of
LNG intrauterine device (IUD). Mean time to lacto-
&&
genesis was similar in Uganda [15 ] (65 vs. 63 h,
P ¼ 0.84) and Turok et al.’s [16 ] report (65.4  25.7
&&
vs. 63.6  21.6 h, P ¼ 0.22). Also in Turok et al.’s [16 ]
&&
study, there were no significant difference in delayed
lactation (9 vs. 6%, P ¼ 0.84) however there were two
women who experienced lactogenesis failure in the
immediate group.
Exclusive breastfeeding rates were similar
between immediate and delayed groups at postpar-
tum months 3 (74 vs. 71%, P ¼ 0.74) and 6 (48 vs.
52%, P ¼ 0.58) in the Averbach et al.’s study [15 ].
&&
Ninety-six percentage of total women reported
some degree of breastfeeding at 6 months. At 8 weeks
&&
postpartum in Turok et al.’s [16 ] report, breastfeed-
ing rates in the immediate group [79%, 95% confi-
dence interval (CI): 70–86%] were found to be
noninferior (P ¼ 0.28) to the delayed group (84%,
95% CI: 76–91%) using a per-protocol analysis. A
post-hoc analysis showed similar rates of exclusive
breastfeeding in both groups at 6 months postpar-
tum (33 vs. 40%, P ¼ 0.27). Patient satisfaction was
similar between groups (86 vs. 87 on scale 0–100)
although IUD expulsion was higher in immediate
group (19 vs. 2%, P < 0.001) similar to previous
studies. Of the 24 expelled IUDs in the immediate
group, 17 (71%) of them were replaced at the post-
&&
partum visit [16 ].
Infant parameters were assessed in the Averbach
&&
et al.’s [15 ] study. Of the patients included in the
study, 60/96 infants (63%) in the immediate group
and 43/87 infants (49%) in the delayed group were
present for evaluation at the 6-month postpartum
visit. There were no significant differences found for
weight (4632  1020 vs. 4407  957.3 g, P ¼ 0.26),
head circumference (9.3  2.6 vs. 9.5  2.7 cm,
P ¼ 0.70), or length (14.7  5.3 vs. 15.2  5.1 cm,
P ¼ 0.63). Additional analyses showed an increase
in weight for premature infants in the immediate vs.
delayed group (6033 vs. 4563 g, P ¼ 0.006).
Nursing knowledge, attitudes, and practices
Two studies assessed nursing knowledge of, atti-
tudes toward, and current practices of counseling
on postpartum contraception (Table 2). Cohen et al.
&
[17 ] implemented a survey sent to postpartum
nurses at one point in time. Nurses were presented
with the Center for Disease Control and Preven-
tion’s US Medical Eligibility Criteria Categories 1–
4 and asked to rate safety of contraceptives within a
low-risk population of breastfeeding mothers within
Volume 31  Number 6  December 2019
 Table 1. Studies evaluating effect of contraception on breastfeeding
Hormonal contraceptive
Study type Follow-up Inclusion criteria exposure Lactogenesis effects Breastfeeding impact Infant parameters Strengths Limitations

Bryant et al. Cross-sectional None 18 Years old, singleton Any (852/2922) vs. none Not assessed Milk supply concern in Not assessed Large sample size, novel Sample not representative
(LECHE) survey infant 3–9 months old, (2070/2922) 44% hormonal reporting of order of of population, selection
breastfed for any contraceptive users vs. events in time bias, recall bias
amount of time, English 40% nonusers
(P ¼ 0.05)
Averbach RCT, secondary 3 and 18 Years old, desired LNG 2 rod implant Mean time to onset 65 h Exclusive breastfeeding No significant difference Study design, low loss to Planned secondary
et al. analysis 6 Months contraceptive implants, placement, immediate in immediate group vs. similar in immediate found between follow-up with women analysis, small number
PP delivery within 5 days, (96/183) vs. delayed 63 h in delayed group and delayed groups at immediate and delayed (<10%) of infants at 6-month
working phone, English (87/183) (P ¼ 0.84) 3 months (74 vs. 71%, groups for weight visit for measurement
or Luganda No cases of P ¼ 0.74) and 6 months (4632  1020 vs.
lactogenesis failure (48 vs. 52%, P ¼ 0.58) 4407  957.3 g,
P ¼ 0.26), head
circumference
(9.3  2.6 vs.
9.5  2.7 cm, P ¼ 0.70),
or length (14.7  5.3
vs. 15.2  5.1 cm,
P ¼ 0.63)

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Turok et al. RCT 8 Weeks and 18–40 Years old, term LNG IUD placement, Mean time to onset Breastfeeding at 8 weeks Not assessed Study design, per-protocol Loss to follow-up, lack of
6 months neonate, intending to immediate (132/259) 65.4  25.7 h in in immediate group analysis, integration of infant outcomes, sample
PP breastfeed, desiring vs. delayed (127/259) immediate group noninferior to delayed IPP LARC prior to study size too small to power
LNG IUD, English or noninferior to group (79 vs. 84%, initiation subgroup analyses
Spanish 63.6  21.6 h in P ¼ 0.28)
delayed group No significant
(P ¼ 0.22) difference in
2 Women with breastfeeding at
lactogenesis failure in 6 months between
immediate group immediate and delayed
groups (33 vs. 40%,
P ¼ 0.27)

IPP, immediate postpartum; IUD, intrauterine device; LARC, long-acting reversible contraception; LNG, levonorgestrel; PP, postpartum; RCT, randomized control trial.

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Postpartum hormonal contraception in breastfeeding women Stanton and Blumenthal

443
 444
Family planning

Table 2. Perceptions and intentions regarding postpartum contraception in breastfeeding patients

Patient intention Identifying risk/safety
to use contra- within 3 weeks PP in Effects of contraception
Study design Study population ception breastfeeding women on breastfeeding Contraception counseling Strengths Limitations

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Benfield Cross-sectional Labor and delivery, Not assessed Incorrectly identified DMPA Advised patients to avoid At baseline and 1 year, Evaluating real-time effects Exploratory study,
et al. survey postpartum nurses as risky (46 vs. 61%, DMPA for lactation increase in patient of implementation of IPP descriptive in nature,
completing baseline P ¼ 0.11) concerns increased over counseling (46 vs. 71%, LARC low response rate,
(59/180) and 1-year 1 year (19 vs. 44%, P ¼ 0.005) and social desirability bias
survey (56/180) P ¼ 0.003) recommendation of IPP
IUD (2 vs. 32%,
P < 0.001)
Cohen et al. Cross-sectional Postpartum nurses Not assessed Correctly identified COC Incorrectly labeled DMPA Offer counseling on PP 50% Response rate, Single site, nonresponse
survey (58/117) at Category 4 (9%) (65%), POP (26%), contraception (45%) demographics bias
Correctly identified POP implant (29%), LNG Counseling differs representative of nursing
(25%), DMPA (43%), IUD (12%), and Cu-IUD based on patient’s population
implant (48%), LNG (8%) as decreasing milk breastfeeding status
IUD (35%) as Category supply (56%)
2, and Cu-IUD (16%) as
Category 1
Universally responded ‘I
don’t know’ (19%)
Loewenberg Cross-sectional 100 Postpartum women 91% Planned to Correctly identified risk of 21% Reported considering 57% Reported prenatal Novel focus on postpartum Small sample size,
Weisband survey intending to breastfeed use, 55% CHC (43%) and safety effects on breastfeeding contraception women prior to participants highly
et al. for 6 months planned to of IPP IUD (42%), POP when choosing counseling discharge educated from single
initiate within (42%), implants (35%), contraception Increased odds of urban setting,
6 weeks PP DMPA (28%) Having Medicaid receiving counseling for interviewer bias
History of not reduced chance of non-white women (OR
using consideration (OR 0.1, 2.8, 95% CI: 1.0, 7.9),
contraception 95% CI: 0.0, 1.0) those receiving public
predicted aid (OR 5.2, 95% CI:
intention to not 1.4, 19.2), and women
use (OR 5.1, with Medicaid (OR 3.6,
95% CI: 1.0, 95% CI: 1.3, 9.9)
25.5)

CHC, combined hormonal contraception; CI, confidence interval; COC, combined oral contraception; Cu, copper; DMPA, depot medroxyprogesterone acetate; IPP, immediate postpartum; IUD, intrauterine device;
LARC, long-acting reversible contraception; LNG, levonogestrel; OR, odds ratio; POP, progestin only pills; PP, postpartum.

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Volume 31  Number 6  December 2019
 Postpartum hormonal contraception in breastfeeding women Stanton and Blumenthal
the first 3-week postpartum. Only 9% of nurses
correctly identified combined oral contraceptives
as ‘unacceptable risk’ and 16% identified the copper
IUD as ‘no restrictions’. Less than half of partici-
pants correctly identified progestin only pills,
injectable depot medroxyprogesterone acetate
(DMPA), etonogestrel subdermal implant, and
LNG IUD as ‘advantages of using the method gen-
erally outweigh the theoretical or proven risks’ (25,
43, 48, and 35%, respectively). Nineteen percentage
universally chose ‘I don’t know’ for all of the contra-
ceptives. Only 16% of nurses reported previous con-
traceptive training, although bivariate analysis
showed this was not associated with more correct
responses. All of the nurses reported breastfeeding
training due to the Baby Friendly Hospital Initiative.
&
The Benfield et al.’s [18 ] study evaluated nurses
prior to and 1 year after implementation of IPP
LARC via an anonymous survey. IPP LARC imple-
mentation included contraception education and
feedback sessions at 6 months and 1 year. Compared
with baseline, there was an increase in contracep-
tion counseling at 1 year (46 vs. 71%, P ¼ 0.005) and
recommendation of IPP IUDs (2 vs. 32%, P < 0.001).
More nurses were aware of correct criteria for the
lactational amenorrhea method (4 vs. 18%, P ¼ 0.01)
and they spontaneously listed more contraceptives
(4.3 vs. 5.8, P ¼ 0.001). However, fewer nurses cor-
rectly know the 24-month minimum interpreg-
nancy interval as per the WHO (57 vs. 38%,
P ¼ 0.04) and many other question scores did not
improve over the year. Incorrect beliefs regarding
DMPA were prevalent in both studies. Benfield et al.
&
[18 ] showed a persistent belief that DMPA has a
negative effect on breastfeeding (46% at baseline vs.
61% at 1 year, P ¼ 0.11) and nurses increasingly
advised patients to avoid it due to lactation concerns
(19% at baseline vs. 44% at 1 year, P ¼ 0.003). Sixty-
&
five percentage of respondents in Cohen et al.’s [17 ]
study reported belief DMPA adversely impacted
breast milk supply.
Patient perception
Two studies aimed to identify patient concerns
regarding milk supply and postpartum contracep-
&&
tion preferences. The LECHE study [19 ] recruited
participants via social media and stratified women
as using or not using hormonal contraception
within 12 weeks postpartum (Table 1). 852/2922
women (29%) were using hormonal contraception
including oral contraceptives, hormonal IUDs,
DMPA, and implants. Overall, 41% of total women
experienced milk supply concerns with the median
onset of 3 weeks postpartum. There was a small but
statistically significant increase in milk supply
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concern between users and nonusers of postpartum
hormonal contraception [44 (374/852) vs. 40%
(828/2070), P ¼ 0.05]. Of the 852 hormonal contra-
ception users, 67% (572/852) did not have milk
supply concerns prior to starting contraception
and 15% (127/852) had new or additional concerns
after starting. Reported effect of contraception
decreasing milk supply was different between those
on hormonal contraception with milk supply con-
cerns and without concerns [16 (60/374) vs. 6.1%
(29/478), P < 0.01]. A time-to-event analysis was
performed using an extended Cox proportional haz-
ards model to estimate hazard ratios for contracep-
tion initiation and milk supply concerns. This
model also controlled for known confounders,
including age, race, parity, obesity prior to preg-
nancy, mode of delivery, and whether or not infant
was in the neonatal ICU. The adjusted hazard ratio
for hormonal contraception initiation and breast
milk concerns was not statistically significant at
1.18 (95% CI: 0.94–1.47).
&
Weisband et al. [20 ] undertook an in-person
survey among postpartum patients intending to
breastfeed regarding their contraceptive intentions
(Table 2). Fifty-one percentage of patients intended
to initiate contraception prior to leaving the hospi-
tal or within 6 weeks postpartum and 21% indicated
safety of contraception method on breastfeeding for
mother and/or baby as a factor in their decision.
Having Medicaid reduced the likelihood of consid-
ering effects on breastfeeding [odds ratio (OR) 0.1,
95% CI: 0.0, 1.0]. Most common reason for choosing
a particular method was convenience (35%). Over
half reported receiving prenatal contraception
counseling (57%) and multivariate analysis showed
increased likelihood of having received counseling
if the patient was Hispanic or non-white (OR 2.8,
95% CI: 1.0, 7.9), had received public assistance in
the past year (OR 5.2, 95% CI: 1.4, 19.2), or was on
Medicaid (OR 3.6, 95% CI: 1.3, 9.9).
CONCLUSION
Recent studies are generally reassuring and show no
significant differences in lactogenesis, breastfeed-
ing, and infant parameters between IPP and delayed
insertion of LNG implants and IUDs. Nurses on
labor and delivery and postpartum units have per-
sistent erroneous beliefs that DMPA negatively
affects breastfeeding. Nurses benefit from exposure
to IPP LARC, however, they may also benefit from
more consistent dedicated contraception education
and counseling. The majority of patients report
intent to use postpartum contraception and cite
convenience as an important factor in their choice
of a specific method.
www.co-obgyn.com 445
Family planning
Acknowledgements
None.
Financial support and sponsorship
None.
Conflicts of interest
There are no conflicts of interest.
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READING
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&& of outstanding interest
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