Commenter and guest poster Ariela asked me to write about breastfeeding and birth control. Since other methods generally don’t impact breastfeeding, I’ll limit the discussion to hormonal methods.
Hormonal methods include the pill, some IUDs, and patches. They contain either progestin alone or a combination of progestin and estrogen. Progestin is a synthetic form of progesterone.
Most breastfeeding mothers begin using birth control after their six-week checkup, when the milk supply has already been established. In the early weeks milk supply is more sensitive to disruption by hormones and other factors, sometimes with long-term effects.
The mini-pill, or progestin-only pill (POP), is usually recommended for breastfeeding mothers. Here in Israel it has been sold under the brand names Femulen and (the expensive) Cerazette. According to studies progestin-only methods do not affect milk supply, but some women have reported a drop in supply when beginning the mini-pill.
A mother who senses lower supply while on the mini-pill can nurse and/or pump more frequently for a few days to see if that helps, before switching to another method of birth control. She should keep in mind that softer breasts, frequent nursing, fussiness, or a drop in pumping output may have other causes.
The mini-pill is not considered as effective as the standard combination pill in preventing pregnancy. You need to take it at the same time every day for best results. Cerazette appears to be more reliable than Femulen.
The mini-pill can cause spotting because of thinning of the endometrial lining. Doctors often tell mothers not to expect bleeding while on the mini-pill. This confusion could stem from the fact that at six weeks, most breastfeeding mothers are still experiencing lactation amenorrhea. It seems that such a mother can expect bleeding to return at around the same time she would have without the mini-pill. But I could not find concrete information on this issue.
Wikipedia on Progestin-Only Pills: “With no break in the dosage, flow does not initially occur at a predictable time. Most women tend to establish, over a few months, light spotting at approximately regular intervals.”
According to another article, “Cerazette may initially cause irregular bleeding. Some women may also have amenorrhea. However, after a few months most women will have less frequent bleeding episodes.”
The combination pill, containing estrogen and progestin, has been shown to reduce milk supply. Sometimes women believe they must wean to go on the combination pill. However, the risk is only to the milk supply and not to the baby’s health (except as it may be impacted by supplements). So a mother who wants added protection or other benefits of the combination pill has the option of continuing to breastfeed and supplementing with formula or extra solids, depending on the baby’s age.
Please share your experience in the comments. You can be anonymous if you like, but it’s easier if you give yourself some kind of nickname.
How Breastfeeding Affects Fertility: Breastfeeding: An Optimal Way to Space Babies
The September/October edition of New Beginnings, La Leche League International’s magazine, contains an article by Sheila Kippley about her new book The Seven Standards of Ecological Breastfeeding: The Frequency Factor
I recognize this approach is not for everyone. However, many couples wish to minimize the use of artificial birth control for a variety of reasons, and it can be difficult to find information about the relationship between breastfeeding and fertility.
In the article Kippley distinguishes between exclusive breastfeeding and ecological breastfeeding. Exclusive breastfeeding means that the baby receives all nourishment from the breast. It’s common for mothers to conceive three or four months after birth, even if they are exclusively nursing. As she writes, “Research shows that almost half of the exclusively breastfeeding mothers using the above rule [of exclusive breastfeeding, see #1 below] will experience menstruation prior to six months.”
Both exclusive breastfeeding and ecological breastfeeding are different from LAM, the lactation amenorrhea method of birth control. LAM works when the mother is exclusively nursing, the baby nurses at least every four hours during the day and every six hours at night, and the mother has not had a return of menses before the age of six months. If the mother has any bleeding after 56 days, she must consider herself fertile. LAM is a simple way to determine whether a mother is fertile, but it only works until she gets a period or the baby turns six months old. It is based on the fact that ovulation is extremely rare before the first period if the minimum spacing of feedings is maintained. That first period then serves as a warning sign of fertility so a mother can take precautions. Until the return of menses or six months postpartum, whichever comes first, LAM provides a 98-99% rate of protection from pregnancy.
The seven standards of ecological breastfeeding are meant to push off the return of that first period to six months and even longer. The standards are:
I followed these standards for all but one of my children, with the exception of the daily nap, and experienced breastfeeding infertility for one to two years.
More details about each standard can be found in the full article and the book.
Many years ago I recommended one of Kippley’s earlier books, Breastfeeding and Natural Child Spacing, to a friend. My friend enjoyed the book despite its Christian outlook and was inspired by the loving attitude of the author toward babies. In the New Beginnings article, Kippley goes well beyond a dry description of biological mechanisms connected to fertility and hormonal shifts. She is unapologetic about babies needing their mothers and the fact that comforting is as important as feeding, if not more so. The developing relationship between mothers and babies is about much more than nutrition or delaying fertility. While some mothers will appreciate this approach, others might find it preachy.
One important issue that Kippley does not address, at least in the published article, are signs that breastfeeding fertility is nearing an end. With an older baby there is not necessarily a warning period before ovulation.
I’ve “known” Barbara for years, as the only other Jew on a message board we frequented. I didn’t realize she had been reading this blog until she left a comment on the pizzeria post. I knew she had an interesting story, so I asked her to share. It’s not only miraculous. It shows how a proactive and informed mother can cooperate with medical professionals to override standard procedures and policies and ensure optimal care.
It’s true what they say: all children are miracles– just watch PBS’s NOVA that depicts the amazing process of pregnancy and birth. There are, however, stories that transcend the definition of miracle. I would like to share my two stories with you.
“What would you want to do THAT for?”
At age 29, I made the drastic decision to lift “the girls” up off my waist and put them back where they belong–in other words, breast reduction surgery. At the initial surgical consultation, the surgeon asked about children and breastfeeding, I told him that I didn’t think I’d ever have kids, but if I did, I wished to preserve my ability to breastfeed if I could. My mother, who had accompanied me, was dumbfounded. “What on earth would I want to do THAT for?” she asked. I ignored her, and the surgeon agreed to do the best he could. A little over a pound was removed from each breast. The surgery went well, and I was thrilled with my new lightweight, perky friends.
The first miracle
At 32 I (finally) got married, and three years later my husband and I decided to try and get pregnant. Two years’ worth of trying later, we found ourselves gearing up for a round of IVF when we got a call from the clinic. “Sorry, we’re going to have to cancel this round. You only have two small follicles, and that’s not enough for us to harvest.” Fed up with the nonsense (Clomid, 3 IUI’s, and now IVF) I declared, “That’s it…I quit…we’re just going to have a really good life without kids!” My husband agreed, and we decided not to go back for another round of IVF.
A couple of months later I went to my annual OB/GYN visit. I mentioned that I hadn’t had a period in a while (a problem I’d had intermittently since going off birth control several years earlier). The doctor offered to give me a prescription medication to “force a period” if I wanted. I told him no, but asked if he’d mind doing a couple of tests “just in case.” So you remember what I said about children being miracles, right? It turns out that one of those “small follicles” that weren’t good enough for IVF harvesting got fertilized the old-fashioned way! My daughter, who apparently likes surprises and chaos, arrived a month early via c-section. She weighed only 5 lbs. 14 oz., healthy except for jaundice.
The breastfeeding miracle
The big question was: Would my artificially perky pals work? I had read as much as I could about BFAR (breastfeeding after reduction), but the bottom line was that I wouldn’t know until I tried. So I nursed. And I pumped (although I never got much using a pump). And I took Fenugreek. At her pediatrician’s insistence, we supplemented my daughter with formula, but I hated every moment of it. We kept up this crazy schedule for six weeks. Once she was past her jaundice issues and she had begun to put on weight I insisted on exclusive breastfeeding to see if it would work. The doctor was skeptical and thought it would be a huge failure (after all, the baby was taking the formula supplements, wasn’t she?), but after a nerve-wracking week that convinced me she was both starving and dehydrated, we discovered that she was perfectly fine and had gained weight. Breastfeeding worked! We never looked back and nursed for 18 months until my daughter quit on her own.
At her first birthday, I became convinced that my daughter needed a sibling. After a long anovulatory cycle, I was able to get pregnant again on my own. The baby was due around my daughter’s second birthday, but I assumed it would be a month early, just like the first. If only.
Another miracle: 500 grams
My second daughter was born via emergency c-section at 26 weeks – slightly more than three months early because of PPROM (pre-term premature rupture of the membranes). She weighed 500 grams (1 lb., 2 ozs.) and was only 11 inches long. Her head was the size of a peach, and she looked like a wrinkled old lady. Our family entered acronym hell: NICU, IUGR, PDA, ROP, PIP/PEEP, ETT, CLD, BPD and NG, to name a few. We were told that the NICU experience is like a roller coaster. Our experience was more like a very long climb up a steep mountain. We made progress, but with twisty trails and peril always at hand.
Micro-preemies are born without the ability to nurse. Even if they could, they wouldn’t have the energy. When they’re stable and ready to begin feedings, they’re given a nasal gavage (NG) tube that goes directly from their nose to their stomach and food is pushed through. (Prior to that, they receive TPN or Total Parenteral Nutrition through an IV line). Breastmilk is critical for micro-preemies because of their immature systems, so I expressed milk from the moment my daughter was born. I remember squeezing out colostrum drop by drop into a glass container while my aunt and cousin visited – I really didn’t care if it bothered them, my daughter needed liquid gold! I already knew my breasts were capable of supporting the nutritional needs of an infant, but I stunk at pumping.
I remembered reading about the drug Domperidone on a BFAR support board, so I ordered it from a pharmacy in New Zealand. The drug is not available in the US, and the FDA has actually issued a warning about it, but for me it was a lifesaver. With the help of the Medela Symphony pump, the NICU’s lactation consultants, and Domperidone, I was able to pump enough to meet my daughter’s base nutritional needs in the NICU. Because my daughter was so small, my breastmilk was fortified to increase its calorie content and help her put on weight. Infant formula, corn oil and polycose powder (a sugar) were added to bring the per-ounce calorie count to 32 kcal. My daughter never lost weight during her time in the NICU (truly amazing), and almost always gained weight. But I hated the fact that she had to have all these supplements.
So why is breastmilk so crucial to micro-preemies if they’re just going to add formula to it anyway? Well, according to these articles, (http://crystalblue.tripod.com/papers/nec-1.html#Massoni), (http://www.smh.com.au/articles/2004/05/02/1083436476738.html), breastmilk adapts to the needs of the premature infant. Preemies have delicate, immature intestinal systems and are prone to a deadly condition called necrotizing enterocolitis (NEC). Breastfeeding does not totally eliminate the risk of NEC, but it greatly reduces the incidence. In addition, breastmilk may help prevent sepsis, a deadly infection.
My daughter spent 3.5 months in the NICU. Thanks to a wonderful nurse, her first exposure was to my breast, not a bottle. She licked and was done, but the stage was set. Each time I visited and she was awake I put her to the breast until one day she actually gave a little suck. Slowly but surely she learned how to nurse, despite the fact that she was also learning how to bottle-feed (micro-preemies must be able to bottle 100% of their feeds without negative incidents before being released). After her release we had to continue with the high-calorie supplements, but she still nursed once a day and I continued pumping. Because she was gaining weight beautifully I was able to convince her pediatrician that we needed to start dropping the supplementation. One by one, each of the offending supplements (oil, sugar, and formula) were dropped from her diet until I found myself nursing her exclusively and we never looked back.
My daughter weaned herself when she was 2.5 years old. At 5.5 she’s experienced numerous health challenges (multiple pneumonias, RSV, immune deficiencies, vision and ear difficulties), but all her doctors agree that she’s done amazingly well. One huge hurdle remains: she has been diagnosed with autism, but as each day passes we see more and more progress. She’s smart, sweet, strong, and solid. She and her older sister are truly my miracles.
Part 1: When does chinuch begin?
There is a direct connection between the type of parenting and child spacing. When the baby stays with his mother day and night, nurses on cue without bottles and pacifiers, starts solids gradually and appropriately, and spends a good deal of his time either nursing or in close physical contact with his mother, the mother’s natural postpartum infertility generally lasts for a year or two. (Six to twelve months is fairly common.) When you hear of mothers who exclusively breastfed and still had a return to fertility or a pregnancy at three months postpartum, it’s often (but not always) related to scheduled nursings, mother-baby separation, or a baby who is encouraged to sleep through the night. Because most young couples and health-care professionals lack knowledge regarding breastfeeding and fertility, the parents can’t make informed decisions. When I counsel haredi mothers they are desperate for such information. This information should be readily available to everyone, but it is especially sad when it is lacking in a community that discourages use of artificial birth control.
Here are some ways I have seen families cope with closely spaced children:
We need to question the idea that if something is good for the mother, the baby benefits (“me” time, sleeping through the night, babysitters). We instead need to be pointing out that most things that are good for our babies, ultimately benefit the mother and the entire family.
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