Contraceptive effects of extended lactational amenorrhoea: beyond the Bellagio Consensus

doi:10.1016/0140-6736(91)90288-Z

The Lancet

Volume 337, Issue 8743, 23 March 1991, Pages 715-717

https://doi.org/10.1016/0140-6736(91)90288-Z Get rights and content

Abstract

We have recorded the duration of lactational anovulation and amenorrhoea in a well-nourished group of Australian women who breastfed their babies throughout the study. The data enabled us to compare the theoretical cumulative probability of conception among breastfeeding women who had unprotected intercourse irrespective of their menstrual status with that of those who had unprotected intercourse only during lactational amenorrhoea. Breastfeeding alone is not an effective form of contraception, since all the women in our study resumed normal ovulation while still breastfeeding. However, among women who have unprotected intercourse only during lactational amenorrhoea but adopt other contraceptive measures when they resume menstruation, only 1·7% would have become pregnant during the first 6 months of amenorrhoea, only 7% after 12 months, and only 13% after 24 months. Thus for our women it would be possible to extend the Bellagio Consensus Conference guidelines which stated that lactational amenorrhoea can only be relied on as a contraceptive for the first 6 months post-partum in women who are fully or almost fully breastfeeding. The lactational amenorrhoea method can be relied on for excellent contraceptive protection in the first 6 months of breastfeeding, irrespective of when supplements are introduced into the baby's diet; for women who continue to breastfeed the method can also give good protection for up to 12 months post partum. Once menstruation has returned, other forms of contraception are essential to prevent pregnancy.

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Cited by (90)

Effectiveness of fertility awareness-based methods for pregnancy prevention during the postpartum period
2022, Contraception
Citation Excerpt :
Even after the first ovulation, the times of high fecundity in the next several cycles are less predictable than usual [9]. The Lactation Amenorrhea Method (LAM) is one non-hormonal, non-device method that is highly effective for avoiding pregnancy during the first 6 months postpartum, but only if users are exclusively breastfeeding and have not started menstruating [10–12]. One small analysis suggests it may be less effective for those who express or pump milk to feed their infants [13].
To summarize the evidence on typical and perfect-use effectiveness of fertility awareness-based methods for avoiding pregnancy during the postpartum period, whether breastfeeding or not.
We conducted a systematic review of studies published in English, Spanish, French, or German by November 2021 in MEDLINE, EMBASE, CINAHL, Web of Science, and ClinicalTrials.gov. Abstract and full text reviews were completed by 2 independent reviewers. Study inclusion: at least 50 subjects who enrolled prior to experiencing 3 cycles after childbirth and were using a specific fertility awareness-based method to avoid pregnancy; unintended pregnancy rate or probability calculated; postpartum amenorrheic and postpartum cycling individuals analyzed separately; and prospectively measured pregnancy intentions and outcomes. Outcomes were abstracted and study quality was systematically assessed by 2 independent investigators.
Four studies provided effectiveness data for 1 specific fertility awareness-based method among postpartum individuals. Of these, there were zero high quality, 1 moderate quality, and 3 low quality for our question of interest. Typical-use pregnancy probability for the first 6 cycles postpartum for Marquette Method users was 12.0 per 100 women years (standard error [SE] not reported) and for Billings Ovulation Method users ranged from 9.1 (SE 3.9) for non-lactating women <30 years old to 26.8 (SE 4.6) for lactating women <30 years old. Typical-use pregnancy probabilities for the first 6 months post-first menses for the Postpartum Bridge to Standard Days Method users was 11.8 (95% confidence interval 6.01-17.16) and for Billings Ovulation Method users was 8.5 per 100 women (SE 1.7).
The current evidence on the effectiveness of each fertility awareness-based method for postpartum persons is very limited and of mostly low quality. More high quality studies on the effectiveness of fertility awareness-based method in postpartum persons are needed to inform clinical counseling and patient-centered decision-making.
Although postpartum individuals may desire to use fertility awareness-based methods to avoid pregnancy, the evidence of the effectiveness of fertility awareness-based methods in this population is limited. More high-quality studies are needed to inform shared decision-making.
Breastfeeding factors and risk of epithelial ovarian cancer
2019, Gynecologic Oncology
Citation Excerpt :
Breastfeeding suppresses gonadotropins (particularly luteinizing hormone), which reduces estrogen levels and leads to anovulation and amenorrhea [14]. In the absence of breastfeeding, ovulation typically resumes six weeks postpartum, whereas ovulation can be suppressed for several months with lactation [28,29]. Alterations in the maternal hormonal milieu and/or metabolism are other potential biologic mechanisms whereby breastfeeding may impact EOC risk.
Previous studies suggest that breastfeeding reduces epithelial ovarian cancer (EOC) risk. However, the effects of age, timing and episode details on the EOC-breastfeeding relationship have not been examined. The objective of this study was to examine the association between breastfeeding factors and epithelial ovarian cancer.
We examined breastfeeding factors among parous women in a population-based, case-control study conducted in Pennsylvania, Ohio, and New York from 2003 to 2008. We compared 689 incident EOC cases to 1572 community controls. Multivariable unconditional logistic regression was used to calculate odds ratios (ORs) and 95% confidence intervals (CIs) associated with breastfeeding patterns adjusting for potential confounders.
Compared to never breastfeeding, breastfeeding any offspring was associated with a 30% reduction in EOC risk (OR = 0.70; 95%CI = 0.58–0.85). That association lasted more than 30 years (OR = 0.69, 95%CI = 0.53–0.88). An average breastfeeding episode of 3 months was also associated with reduced risk (OR = 0.73, 95%CI = 0.58–0.80). A greater number of breastfeeding episodes was associated with greater risk reduction (OR = 0.78, 95%CI = 0.64–0.96 and OR = 0.49, 95%CI = 0.36–0.68 1–2 and 3+ episodes, respectively, compared to never breastfed, trend p = 0.01). Longer breastfeeding duration was also associated with reduced risk (OR = 0.75 and 0.62 for less than and greater than 1-year total duration, respectively, compared to never breastfed). An earlier age at first breastfeeding was further associated with increased protection (OR = 0.50–0.80, for first episode at age <25, 25–29, and 30+, respectively, trend p = 0.001).
Breastfeeding for as few as 3 months is associated with reduced EOC risk. Although this association decreases over time, it persists for more than 30 years. Longer cumulative duration, increasing number of breastfeeding episodes, and earlier age at first breastfeeding episode are each associated with increased benefit.
Canadian Contraception Consensus Chapter 4 Natural Family Planning
2015, Journal of Obstetrics and Gynaecology Canada
Factors associated with poor attendance at the postpartum clinic six weeks after delivery in Cameroon
2015, International Journal of Gynecology and Obstetrics
Citation Excerpt :
Consequently, it seems reasonable to suggest that all women should be offered a suitable method of contraception before discharge from hospital after delivery. When used correctly, the lactational amenorrhea method has a 98% protection rate within 6 months of delivery [17], given that ovulation can occur in 1.7% of all breastfeeding women during this timeframe [18]. Both younger women (< 20 years) and older women (≥ 35 years) displayed a tendency to miss the 6-week postpartum clinic in the present study.
To identify reasons why women do not attend the 6-week postpartum clinic in Cameroon.
A retrospective cross-sectional cohort survey was undertaken among women who had delivered at the University Teaching Hospital in Yaoundé between November 15 and December 31, 2013. Their medical files were retrieved and reviewed. Women who had not attended the 6-week postpartum clinic were contacted by telephone 2 months after delivery to establish reasons for non-attendance.
Among 120 included women, 85 (70.8%) did not attend the 6-week postpartum clinic. Compared with women who had attended the 6-week visit, more women who had not attended the visit had delivered vaginally, had no postpartum complications, and had not been counseled to attend the visit (P < 0.001 for all). The main reason given for not attending this clinic was the feeling of well-being (n = 36 [42.4%]).
The benefits of attending the 6-week postpartum clinic should be emphasized in Cameroon, especially to women who have experienced uncomplicated vaginal delivery.
Antenatal contraception - Simple, feasible, but is it safe and ethical in resource-poor environments?
2013, Contraception
In developing countries, antenatal care is used by more women than any other reproductive health services available and many women who receive antenatal care will not receive intrapartum care by a trained provider and even fewer will receive postnatal care. At present, antenatal care provides contraceptive counselling but not contraceptive provision. An important reason for this is the perceived absence of a suitable method that could be distributed or started during antenatal care. In this article, we discuss the available options. We conclude that antenatal insertion of subdermal contraceptive implants is very likely to be safe and ethically defensible where access to contraceptive services is poor.
Postpartum birth control: State-of-the-art
2010, Revue Sage - Femme
Le retour de couches survient en moyenne six semaines après l’accouchement. Cependant, une ovulation peut se produire dès le vingt-cinquième jour, notamment en l’absence d’allaitement maternel. Par conséquent, la contraception du post-partum constitue une priorité en suites de couches. Médecins et sages-femmes doivent s’efforcer de délivrer une information actualisée sur les différentes stratégies contraceptives, d’en dépister les éventuelles contre-indications et de prescrire à chaque femme qui le souhaite une contraception efficace avant sa sortie de la maternité. Les récentes publications ont permis de faire évoluer certaines idées rec¸ues, mais il n’existe pas actuellement de réel consensus encadrant cette prescription. En l’absence de facteur de risque surajouté, les estroprogestatifs minidosés peuvent être prescrits dès le vingt et unième jour suivant l’accouchement sans occasionner de sur-risque thromboembolique. Leur prescription est également possible si la femme allaite, sans risque d’entraîner d’effets indésirables significatifs sur la lactation. Seule la date d’introduction reste sujette à controverses (dès le vingt et unième jour ou dès la fin de la sixième semaine suivant l’accouchement). Les microprogestatifs conservent une place de choix en cas de contre-indication aux estroprogestatifs. Par ailleurs, il est maintenant admis que les dispositifs intra-utérins puissent être posés quatre à six semaines après l’accouchement. Ces nouvelles recommandations visent à simplifier au maximum la prise en charge pour favoriser l’accès des patientes à une méthode contraceptive efficace, dans les délais nécessaires pour les prémunir contre la survenue d’une grossesse trop rapprochée.
It takes some six weeks for menstrual ﬂow to come back after delivery, but an ovulation may occur from the twenty-fifth day, especially in the absence of bottle feeding. That is the reason why postpartum birth control must be gets onto in maternity wards. Obstetricians and midwives are supposed to deliver update information about variant contraceptive means. They have to be able to diagnose any risk factor and to prescribe an efficient contraceptive option to every woman who wishes for it, before she leaves the maternity ward. Recent studies incite us to amend our medical behavior regarding postpartum contraception, even if there is no consensus at present. In a normal context, without any add on risk factor, it is possible to prescribe a birth control pill containing low dosage of combined oral contraceptives. Doing that, you will not expose the patient to an increased risk of deep venous thrombosis nor to significant breast feeding disruption. Low-dose progestin-only pills are also a good choice because there are no risks during the lactation. When the patient suffers from some disease which stops you from giving combined oral contraceptives, it is still possible to resort to progestin-only. It is now admitted to insert an intra-uterine device from the fourth or sixth week following the delivery. In certain conditions, it can be inserted over the 48 hours following a delivery, some obstetrician would even insert it during the caesarean section. The main purpose of these recent references is to simplify the contraceptive outline in order to ease its prescription and to avoid unwanted pregnancies.

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Contraceptive effects of extended lactational amenorrhoea: beyond the Bellagio Consensus

Abstract

Contraception

Lancet

Breastfeeding as a family planning method

Lancet