Breastfeeding and Natural Contraception: Guest Post

In this guest post, women’s health educator Michal Schonbrun outlines common approaches toward fertility during breastfeeding, and criticizes reliance on LAM. For more information see her website, Poriut Tivit.

Postpartum Infertility, Breastfeeding, and Natural Contraception

By Michal Schonbrun, MPH, CHES

Many women who believe in a natural approach to pregnancy, childbirth and breastfeeding are also interested in a natural approach to contraception and family planning.

Below I describe three such approaches:

  1. Lactation Amenorrhea Method (LAM). LAM is an algorithm, developed and promoted by scientists during the past twenty years, and based on a simple behavioral formula:  If a woman has no menses, nurses frequently with few or no supplements, and her baby is under six months old, her risk of getting pregnant is estimated at only 2%. Frequent nursing is defined as placing the baby at the breast at least every four hours during the day and six hours at night. This is associated with increased prolactin levels in the blood and amenorrhea. Frequent breastfeeding is believed to cause a suppression of ovarian function and ovulation.
    I do not recommend LAM as a method of birth control for the following reasons:

    • In western societies, most women don’t meet the criteria of LAM. Exclusive breastfeeding for six months requires a nearly complete form of “mother-baby” togetherness. Most moms introduce supplemental bottles and begin solids earlier. They have parallel and competing demands on their time, attention and energy. Finally, few women have family and social support for a more traditional form of breastfeeding.
    • LAM implies that frequent breastfeeding is the single, primary factor for extending infertility and achieving contraceptive effect. The method was tested primarily in developing countries, where breastfeeding is prevalent and practiced in a way that enables frequent stimulation of the breasts. In traditional cultures, babies are carried in a sling close to the mother’s body 24/7, and take three or four “sips” an hour. This results in natural spacing of two to three years between births.
    • Many women mistakenly assume that “full” breastfeeding prevents ovulation, menstruation and pregnancy. Giving women the overall message that breastfeeding is in itself protective sets them up for risk of  unwanted pregnancy.
    • My own professional experience in working with breastfeeding women for nearly 25 years in Israel completely confirms the critical view of LAM.  While “frequent nursing’” will usually delay a woman’s first ovulation, menses and pregnancy, it cannot be trusted as an effective method of contraception. I believe the number of Israeli women who ovulate before their first period is closer to 20%.
    • Women should not pin their fertility on a dry formula. The best approach involves knowing one’s fertility status on a daily basis, based on an understanding of infertile patterns while breastfeeding. (See below.)
    • The LAM model ignores the many biological and physiological factors that also play a role in determining postpartum return to fertility. Field research throughout the world has shown that these factors include a woman’s general health, weight, diet and caloric intake, fat and energy reserves, amount of physical exercise, her relative metabolic load,* stress (emotional and physical), fatigue, and competing demands on a mother’s time (other children, work, economic and domestic pressures).
      Field studies show that well-nourished women who nurse their young as often as under-nourished women experience postpartum amenorrhea for half as long. Healthier women consume more calories and have more body weight and fat, tipping the metabolic scale and enabling her to get pregnant sooner.
  2. Billings or Ovulation Method (O-M). The Billings or Ovulation Method relies on a woman’s natural secretion pattern and vaginal sensations to gauge her fertility during the breastfeeding stage. There is a direct relationship between a woman’s secretion pattern and her breastfeeding pattern. Women who are fully breastfeeding at high frequency (every 2-3 hours day and night) during the first 4-6 months postpartum can expect to experience continuous dryness and/or dry secretions for weeks if not months at a time. With the help of a qualified teacher, a woman learns to recognize true dryness (no secretion), unchanging dry secretions, and wet, potentially fertile secretions. Once she learns how to establish her basic infertile pattern (BIP), she applies simple rules that enable frequent relations on “safe” days.
  3. Fertility Awareness Method (FAM). Once a woman begins to see fertile-type secretions, it is a sign that her body may be trying to ovulate. This usually occurs when a mother returns to a workplace outside the home, when her baby begins eating solids, or when the baby begins sleeping for longer intervals at night. When fertile secretions are observed and/or when a first menstrual bleed appears, FAM expands or extends the O-M model by including two other signs of fertility: basal body temperature and cervical position. By monitoring these signs in parallel, a woman can know exactly when her window of fertility opens and closes.

*Relative metabolic load (RML): The proportion of the mother’s metabolic budget devoted to milk production. This varies according to the amount of metabolic energy available to her.

Michal Schonbrun, MPH, CHES, is a women’s health educator. Her website, in Hebrew and English, is called Poriut Tivit.

Thank you, Michal, for sharing this information with readers. Readers, please leave questions in the comments.

See also: Breastfeeding: The Optimal Way to Space Babies

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Comments

  1. I don’t understand how you can do NFP with taharat hamishpacha. You can have relations for about a week per month in that combo.

    • mominisrael says:

      Abbi, I believe that for most women a good number of days overlap. Still, it is not for everyone, frum or not.

  2. But what would you do if you’re fertile on the day you go to the mikveh, which for most women on a 28 day cycle is usually the case? How would that work out emotionally and halachically?

  3. This is a very interesting post

  4. mominisrael says:

    Abbi, it’s not an issue if they both agree. A husband can’t require his wife to have relations, even on the mikvah night. FAM requires cooperation and good communication whether one is frum or not. My friend, who teaches it, has discussed it with rabbis. Rabbi Cherlow has written that it’s not recommended, but for emotional reasons and not halachic.

  5. Yes, it’s not an issue if both systems agree. However, I agree with R. Cherlow. Niddah is onerous enough on a couple, even with the best of communication and cooperation. Adding another system that requires that much more discipline doesn’t seem recommended for most frum couples.

  6. Katherine says:

    so I could google this but I’m lazy. So orthodox couples do not use contraception at all, unless allowed by a Rabbi? Or in practice they do and just don’t say they do? Because in any case, I guess it is either to be separated for longer, or to not be, and risk another kid quickly after the previous one.

  7. mominisrael says:

    Katherine, glad you asked instead of Googling. Rabbi Cherlow (and Abbi!) would recommend certain types of conventional birth control instead. Rabbi Cherlow permits it for spacing of children, within certain general guidelines.

  8. Katherine says:

    yup, these sorts of methods seem very onerous to me, and if you’re allowed to use regular birth control (and there are kinds which are non hormonal), then I don’t see why not. Then again I guess if you’re already doing some sort of checking with Taharat Mishpaha laws, then maybe it isn’t too onerous.

  9. I’m hardly on R’ Cherlow’s level. ;).

    However, in my limited experience (only 8 years of marriage) it’s hard for me to imagine juggling this, niddah and the demands of small children.

    But I guess different things work for different people.

  10. why is a success rate missing for nos. 2 and 3?
    i’d want any type of non-medical birth control method to match the best medical methods.

  11. and is 2% based on clinical trials?

    • mominisrael says:

      Unfortunately Michal has chosen to to reply to questions. The success rate varies by how carefully it is followed. If the rules are followed carefully, it has a very high rate of safety. The couple has to be motivated. Don’t have info on studies.

  12. Ariella says:

    I agree with what Abbi pointed out. Some women find just plotting their days on a calendar to track the onos, etc. to be too much. That is why there are now online sites to make it a no-brainer for women who plug in their dates and customs, like 30 and 31 days, the or zarua, etc. So to come up with yet another calendar could become rather onerous. I’m wondering if from a halchic perspective it is considered preferable to not use contraception and skip relations on mikvah night or to use pills and not have to skip. Barrier methods raise other issues, though. In any case, no form is 100% guaranteed. Even women who have had their tubes tied (not usually halachically permitted) have sometimes found themselves pregnant.

    • mominisrael says:

      They also have online calendars for calculating fertility. I think that this is something that all women should be aware of, whether or not they use artificial contraception.

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