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Breastfeeding, Sexuality and Contraception During the Postpartum Period Article  in  Current Pediatric Reviews · November 2012 DOI: 10.2174/157339612803307723

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Currellt Pediatric Reviews, 2012, 8, 332-338

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Breastfeeding, Sexuality and Contraception During the Postpartum Period Dat Van Duong' United Nations Population Fund in Vietnam Abstract:

Jt is generally agreed that contraception after childbirth improves the health of mothers and children by length-

ening birth intervals. Every year, it is estimated over 100 million women make decision about beginning or resuming contraception after childbirth. The timing of contraception initiation is important since the return of menstruation and ovulation can be unpredictable in breastfceding women. This review discusses the relationship between breastfeeding. sexuality and contraception during the postpartum period.

Evidence shows that many couples resume sexual intercourse before the sixth postpartum week. Yet information on the relationship between sexuality and breastfeeding is limited and conflicting. While some studies reported positive etleets of breastfeeding on sexuality, many studies showed a delay in the resumption of sexual activities among breastfeeding compared with bottle-feeding women. Since many women become sexually active earlier than 6 weeks post-partum, they should use a method of contraception before the sixth week, especially if they are not breastfeeding. Evidence confirms the recommendations of Bellagio Consensus Conference in 1988 on Lactational Amenorrhea Method (LAM) that fully breastfeeding women who remain amenorrheic have a very small risk of becoming pregnant in the first 6 months after delivery (less than 2%). As soon as the baby is 6 months old or as soon as supplementary feeding is started or menses is resumed, LAM no longer provides effective contraception, and other family planning methods should be introduced if pregnancy is not desired. Despite its demonstrated efficacy, many women, however, decide' not to use LAM due to concerns of its efficacy and uptake of this method is low in many countries. Given the demonstrated efficacy of LAM as a contraceptive in the postpartum period, the method should be more strongly promoted for its effective use in developing countries, in particular where access to or the acceptability of other forms of contraception may be limited. Keywords: Lactational amenorrhea method, breastfeeding, sexual resumption, contraception, postpartum, family planning. INTRODUCTION Every year, approximately 360,000 women die from pregnancy related causes and 10-15 million suffer severe or long-lasting morbidities caused by complications during pregnancy or childbirth worldwide. Nearly all maternal mortalities and morbidities, 99 per cent, occur in developing countries [1]. It is estimated that annually 215 million women who want to avoid a pregnancy are not using an effective method of contraception; instead they are using either a traditional method or no method at all [2, 3]. Globally, coverage of contraception is 61 %, whereas unmet need for contraception ranges from 6% in Europe to 23% in sub-Saharan Africa. It is also estimated that 41% of pregnancies are unwanted, with 22% resulting in induced abortion [4]. Women who had an unmet need for effective contraception account for 82% of all unintended pregnancies [2, 3]. Data also suggests that between a quarter and twofifths of maternal deaths could be eliminated if unplanned and unwanted pregnancies were prevented. Ensuring access to voluntary family planning could reduce maternal deaths by more than one third and child deaths by as much as 20 per cent [4].

It is generally agreed that contraception after childbirth improves the health of mothers and children by lengthening birth intervals. Women are more likely to report births or pregnancies as unintended when they occur within 24 months or less after delivery. Preventing such unintended pregnancies helps avoid financial, psychological and health costs [5]. Longer birth intervals also decrease the risk of major maternal complications including death, third-trimester bleeding, puerperal endometritis and anemia [6]. Contraception for women who are breastfeeding is a global public health issue. It is estimated over 100 million women annually make decisions about beginning or resuming contraception after childbirth [5]. These decisions include both the contraceptive choice and the time to start its use. The choice of contraception could be limited for lactating women due to concerns about hormonal effe..:ts on quality and quantity of breast milk and the passage of hormones to the infant. It is expected that the chosen contraceptive method will not interfere with lactation. The timing of contraception initiation is also important, since the return of menstruation and ovulation can be unpredictable in breastfeeding women [7]. This review discusses the relationship between breastfeeding, sexuality and contraception during the postpartum period. Sexual Resumption

*

Address correspondence to this author at the Dat Van Duong 10 Ngo 18 Nguyen Dinh Chieu Street, Hanoi, Vietnam; Tel: +84-4-37198328; Fax; +84-4-8232822; Email: [email protected]

1 C"7'l "7Q'JOll 'J ~CQ flfl-<. fill

After Delivery

It has been often emphasized that many couples should not resume sexual intercourse before the sixth postpartum

Breastjeedillg,

Current Pediatric Reviews, 2012, Vol. 8, No.4

Sexuality alld COlltraceptioll Durillg tlte Postpartum

week. However studies in various countries indicate a different picture. Von Sydow in a meta-content review of 59 studies found that intercourse is resumed, on average, 6-8 weeks after the birth in Europe and the USA. Before the sixth week postpartum, only 9-17% of the couples practice intercourse, in the sixth week 50-62%, in the second month 66-94%, in the third month 88-95%, in the seventh month 95-100% and in the thirteenth month 97% [8]. In a study conducted in USA, 57% of women resumed intercourse by the sixth postpartum week [9]. In Thailand, 35% of women reported resumption of sexual activity before the sixth postpartum week, and no differences were noted comparing those with vaginal or cesarean deliveries or those with and without episiotomies [10]. In Nigeria, 32% of breastfeeding mothers resumed sexual activity by 6 weeks postpartum [I I]. When analysing data of demographic and health surveys conducted in 17 developing countries during 2003-2007, Borda and Winfrey indicated a substaintial proportion of women in different countries resumed sexual activity at 3.0-5.9 months postpartum. At the low end is Guinea, where about 10% of women resumed sexual activity at 3.0-5.9 months postpartum while at the high end is Bangladesh and Rwanda, where almost 90% of women resumed sexual activity at this time period. Over 50% of women in ] 3 countries and over 70% in 7 countries had sexual resumption at 3.0-5.9 months after delivery [12]. Relationship Between Breastfeeding and Sexuality It is discussed that the physical as well as psychological aspect of a woman's sexuality is altered by breastfeeding. In the current literature, information on the relationship between sexuality and breastfeeding is limited and conflicting. While some studies report positive effects of breastfeeding on sexuality, evidence on negative effects outweighs the former. An increase e in sexual desire over pre-pregnancy levels and increased eroticism has been observed amongst breastfeeding women [13- I 5]. Tn a study conducted by Masters and Johnson, breastfeeding women reported significantly higher sexual activity levels as compared to their nonpregnancy state and expressed a desire for rapid return to sexual activity [16]. Women with more children and those who had breastfed longer felt it was safe to resume sex earlier and reported earlier return of sexual interest [17]. This can be explained by a larger breast size, increased sensitivity and direct stimulation by suckling [18]. Nevertheless, when compared to non-breastfeeding women, most studies reported that breastfeeding women are significantly more likely to report a lack of sexual desire [18-23]. In a prospective survey of 316 Canadian women attending their first postpartum visit, Rowland found a significant delay in resumption of sexual activity among breastfeeding women compared with bottle-feeding women [24]. Von Sydow suggested that incidence of breastfeeding is not consistently related to sexuality. Duration of breast feeding is an influential factor: women who breastfeed for a longer period resume intercourse at a later time, are less sexually interested, suffer from coital pain more often and enjoy intercourse to a lesser degree. The cessation of breastfeeding has a positive effect on sexual activity, but no effect on sexua\ responsiveness or orgasm [8]. Decreased sexual activity may be due to reduced interest in sex, tender breasts, post-

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partum pain, decreased vaginal secretions, and leaking milk [13,25]. It is hypothesized that the decrease in sexual interest by breastfeeding women may be hormone dependent. Alder prospectively investigated the hormones of primiparous women for 6 months postpartum and found that breastfeeding women have significantly lower testosterone and androstenedione levels than those feeding artificially [23]. On the other hand, Desgrees-du-Lou and Brou analysed demographic surveys in several countries in West Africa and reported long durations of post-partum sexual abstinence. The mean duration was estimated by 12 months and II months in Ivory Coast in 1997 and 2005 respectively, 16 months in Burkina Faso in 2003 and 9 months in Ghana in 2003 [26]. The resumption of sexual relations that takes place only after weaning was associated with shorter duration of breastfeeding and longer duration of post-partum abstinence and often followed immediately after weaning. Sexual relations are believed to poison breast milk and would trigger a hormonal mechanism that would cause a decrease in the quality of breast milk. In these cultures, sperm and breast milk are believed to be incompatible [2628]. LACTATIONAL

AMENORRHEA

Efficacy of Lactational

Amenorrhea

METHOD Method

Lactational Amenorrhea Method (LAM) was defined during the Bellagio Consensus Conference in 1taly in 1988 as the informed use of breastfeeding as a contraceptive method by a woman who is still amenorrheic and who does not feed her baby with supplements for up to 6 months after delivery. Amenorrhea is defined as no vaginal blood loss for at least 10 days after postpartum bleeding [29]. This would provide more than 98% protection from pregnancy in the first 6 months postpartum [30, 3 I]. Three criteria of the LAM's algorithm are described in Fig. (1). In 1995, during the second conference in Bellagio, it reconfirmed that women who use LAM at 6 months had a life table pregnancy rate less than 2% [32, 33]. Several international studies have demonstrated the effectiveness of LAM [33-41]. Particularly, WHO conducted a multinational study to clarify the relationships between infant feeding practices, lactational amenorrhea, and pregnancy rate that demonstrates that women who met the LAM criteria had a cumulative pregnancy rate from 0.9% to 1.2%, which is equivalent to the protection provided by many non-permanent contraception methods [42]. Tn addition, the contraceptive effect of LAM increases when three additional criteria are met: 1) there are no supplemental feedings; 2) the duration of every breastfeeding episode is longer than 4 minutes; and 3) the interval between each breastfeeding episode is no more than 3 hours during the day and no more than 6 hours at night [42, 43]. Relationship Between Breastfeeding and Amenorrhea It is well known that breastfeeding is a major factor influencing the duration of postpartum infertility. The variability in the duration of lactational amenorrhea between mothers is related to the variation in suckling stimulus, but the precise mechanism whereby the suckling suppresses ovulation is still unknown [44, 45]. Because the introduction of complementary foods and fluids may reduce the frequency

334

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Currellt Pediatric Reviews, 2012, Vol 8, NO.4 I. Has your menses returned? YES

NO 4. The mother's chance ofpregnancy is increased. For continued protection, advise the mother to begin using a family planning method that will not interfere with breastfeeding

2. Are you supplementing regularly or allowing long periods without brcastfeeding, either day or night?

NO 3. Is your baby older than 6 months?

NO There is only a 1-2% chance of pregnancy at this time : When the answer to anyone ofthrec : questions becomes YES.. 1

Spotting or bleeding during the lirst 8 weeks (56 days) postpartum is not considered hours at night. Supplemental foods and liquids should not replace a breaslfeed (Adapted from Labbok e/ ai, 1997 [33])

~ _

_

:

a menstrual bleed. Intervals between breastfeeds

should not exceed 4 hours during the days and 6

Fig. (I). The LAM's algorithm. and duration of breastfeeding, logically it can be assumed that this could increase the chances of ovulation and menses resumption during lactation [46] through the suppression of hormones stimulating the maturation and release of the ova [47]. In fact, a large body of literature has shown that the duration of the postpartum amenorrhea period is positively correlated with duration and frequency of breastfeeding [4852]. Early initiation of breastfeeding and refraining from providing the infant with glucose or other fluids after delivery are also strongly associated with longer duration of postpartum amenorrhea [53]. Actual LAM's Applicatiou Despite its demonstrated evidence, many women, however, decided not to use LAM due to concerns of its efficacy and uptake of this method is actually low in many countries. Romero-Gutierrez followed up women who claimed to use LAM and found that few of the respondents who were interested actually applied the method [54]. Turk ef al. in a study conducted amongst women with six month old infants in eastern Turkey found that 34% of the women applied LAM to prevent pregnancy after childbirth. However, only 17.2% of the women using LAM fulfilled the LAM's criteria with success, and 82.8% did not fulfill one or more of the LAM's criteria. The pregnancy rate amongst women using this method was 32.8%. Two of the three basic criteria necessary for LAM to be effective were not met by the women: having menses (43.8%) and starting supplemental feeding (70.3%) [55]. Borda and Winfrey (2010) reported very low rates of LAM's application in all 17 investigated countries. With the exception of Zambia where the rate of LAM's use is less than 10%, in the remaining countries, the rate is nearly at zero and it could be argued that the reported use of LAM is, in terms of health care programming, insignificant [12].

Khella ef al. in a study in Egypt found that many breastfeeding mothers who reported no contraceptive ~se were in fact relying on lactational amenorrhea for birth spacing while their babies were older than 6 months. Qualitative data from this study revealed an apparent overreliance on lactational amenorrhea when some respondents bel ieved that pregnancy could not occur as long as a woman was breastfeeding. Particularly .some respondents reported relying on lactational amenorrhea for as long as 18 months postpartum [34]. In another study in Egypt, Tilley ef al found that the majority of women (81.5%) with unplanned pregnancies within 2 years after delivery were breastfeeding at conception. Among the breastfeeding women, 61.2% failed to usc contraception because they believed breastfeeding would prevent pregnancy [56]. Van der Wijden et at. in a recent systematic review on LAM argued that as the time when amenorrhea is likely to end is unpredictable, for countries where it is difficult to obtain contraceptives, waiting for the end of amenorrhea before starting to use contraception is not acceptable. He suggested using the first months after childbirth for the promotion of breastfeed ing and motivation of the mother to use other contraceptive methods if needed [57]. Contraceptive Options During the Postpartum

Period

Current discussion on contraception for women after giving birth extends the postpartum period beyond the sixth week in many instances, although in obstetrics the term 'postpartum' traditionally refers to only the first 42 days following parturition. With reference to breastfeeding women, the concept of postpartum contraception can be applied to the entire period of lactation. Conversely, for nonbreastfeeding women, it may be desirable to contract the

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Currellt Pediatric Reviews, 2012, Vol. 8, No.4

Durillg tlte Postpartum

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First choice methods LAM Barriers IUDs Natural Family Planning Second choice methods - Progestin only methods Third choice methods - Estrogen containing contraceptives (Adapted from Academy of Breastfeeding Medicine Protocol Commitee 2006) (75] Fig. (2). Minimizing physiologic impact on breastfceding: contraception options. postpartum period to as little as 3 or 4 weeks. Since many women become sexually active earlier than six weeks postpartum-, the time for the postpartum care checkup, they should use a contraceptive before the sixth week, especially if they are not breastfeeding [58].

be equally successful [69]. WHO (2010) classified Cu-IUD as category "1" by 48 hours or less postpartum (70] while the Centre for Disease Control and Prevention (CDC) classified as category "I" for by 10 minute or less after delivery of placenta [71].

Postpartum contraception has been debated in literature. Some studies advocate an immediate postpartum strategy, where contraceptive adoption is promoted within 40-45 days after childbirth. Since it is impossible to predict when an individual woman will regain fecundity, it is argued that delaying the initiation of contraception puts women at risk of an unwanted pregnancy and results in an unacceptably high proportion of short birth intervals [59, 60]. In contrast, other studies have advocated reliance on natural lactational protection against pregnancy for as long as possible and contraceptive alternatives will be introduced once the risk of pregnancy increases. This strategy has been widely promoted under the LAM's promotion approach, in which contraception is promoted at the resumption of menses, after six months postpartum or the time of introduction of complementary foods to the child's diet, whichever occurs earliest [30]. It is generally argued that use of contraception soon after childbirth often results in wasteful "double protection", and that delays to subsequent pregnancy will be longer if the periods of natural and artificial protection come one after another, rather than simultaneously [61-63].

Hormonal Contraceptives

MODERN CONTRACEPTIVE BREASTFEEDING WOMEN Intrauterine

ALTERNATIVES

FOR

Device

Current evidence shows that postpartum insertions of an intrauterine device (IUD) including immediate postpartum insertion are generally safe and effective. Compared with interval insertions, postpartum insertions do not increase the risk of infection, bleeding, uterine perforation, or endometritis [64-66]. The progesterone-releasing vaginal ring (PVR) for breastfeeding women has also been found to be safe and effective. An advantage ofPVR is that the method is safe for the child, since progesterone is inactive by the oral route, and it has no systemic effects on the mother [65, 67, 68]. Studies indicate that expulsion was higher for immediate compared to delayed insertion. Modifications of existing IUD designs have not been helpful in reducing expulsion rates. Insertions of IUDs by hand or by instruments appear to

Progestin-only methods are suggested as a preferable hormonal contraception since they are safe for mother and infant. They include progestin-only pill, sub-dermal implant, Norplant and injectables with norethisterone enanthate and depot-medroxyprogesterone acetate (DMPA). The mechanisms by which progestin-only methods prevent pregnancy are thickening of the cervical mucus; trimming the uterine lining, and, sometimes, suppressing ovulation [72-74]. Progestin-only methods are classified as category "3" by WHO when the baby is less than six weeks and category "2" by CDC when the baby is less than one month old. However, after these periods, the risk category was ranked as level I by both agencies [70, 71]. On the other hand, the existing randomized controlled trials are insufficient to establish effects of combined hormonal contraception on milk quality and quantity. The existing evidence is inadequate to make evidence-based recommendations regarding hormonal contraceptive use for lactating women. No adverse effect of hormonal contraceptives on infant growth has been documented [7]. Nevertheless, for breastfeeding women, WHO gives combined hormonal contraception category "4" rating when the baby is less than 6 weeks old and CDC gives category "3" when the baby is less than one month old. See details of WHO and CDC's recommendations on selected modern contraceptive. methods for postpartum women in Table 1 (70,71]. Regarding minimizing physiologic impact on breastfeeding, the Academy of Breastfeeding Medicine Protocol Comm ittee suggests contraceptive options for breastfccding women as outlined in Fig. (2) [75]. LAM is the first choice together with other modern contraceptive methods such as barriers and IUDs. The second choice is progestin-only methods. Estrogen containing contraceptives are considered as the third option (see Fig. 2 for details). Speroff and Mishell suggested a rule of 3's on the use of contraceptives during the postpartum period. In the presence of full breastfeeding, a contraceptive method should be used

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Current Pediatric Reviews, 201 2, Vol. 8, No.4

Table].

Contraceptive

Classification

us Medical

for Breastfeeding

Criteria

Women WHO Medical Criteria

2010

Combined

Category

Contraceptives

Category

Contraceptives

20]0

Hormonal

Contraceptives

For Breastfeeding

Women .

<1 month postpartum

3

<6 weeks postpartum

4

1 month to <6 months postpartum

2

2:6 weeks to <6 months postpartum

)

2:6 months postpartum

2

2:6 months postpartum

2

For Non-breastfeeding

Women

<21 days

3

<21 days

2:21 days

1

Without other risk factors for VTE

3

With other risk factors for VTE

3/4

2:21 days to 42 days

Progestin-Only

Without other risk factors for VTE

2

With other risk factors for VTE

2/3

>42 days

1

Contraceptives

For Breastfecding

Women

<1 month postpartum

2

<6 .weeks postpartum

3

1 month to <6 months postpartum

1

2:6 weeks to <6 months postpartum.

1

2:6 months postpartum

1

2:6 months postpartum

1

For Non-breastfeeding

Women

<21 days

1

<21 days

1

2:21 days

1

2:21 days

1

Intrauterine For 80th 8reastfeeding

Devices (CII-IUD)

or Non-breastfeeding

Women,

Including

Post-cesarean

Section 1

<] 0 minules after delivery of placenta

1

<48 hours

10 minutes after delivery of the placenta to <4 hours

2

48 hours to <4weeks

3

2:4 weeks

1

2:4 weeks

1

Puerperal sepsis

4

Puerperal sepsis

4

Where" 1 •• A condition 2 •• A condition 3" A condition 4 = A condition VTE = Venous (Adapted from

for which there is no restriction for the lise of the contraceptive method. for which the advantages of using the method generally outweigh the theoretical or proven risks for which the theoretical or proven risks usually outweigh the advantages of using the method that represents an unaceeptahle health risk if the contraceptive method is used. thromboembolism WHO (2010) [70] and CDC (20 10) [71))

beginning in the third postpartum month. With partial breastfeeding or no breastfeeding, a contraceptive method should begin during the third postpartum week. After the spontaneous or elective termination of a pregnancy of less than 12 weeks, combination oral contraception can be started immediately. After a pregnancy of 12 or more weeks, the third postpartum week rule should be followed if the pregnancy is term or near term [76].

CONCLUSIONS Since many women become sexually active earlier than 6 weeks post-partum, they should use contraceptive before the sixth week, especially if they are not breastfeeding. However, in many countries, postnatal care is often undcrresourced and under-valued, possibly due to inadequate knowledge and understanding on sexual and contraception needs during the postpartum period.

Breastfeeding,

Sexuality

Currellt Pediatric Reviews, 2012, VoL 8, No.4

and COIJlraceptioll Durillg tlte Postpartum

Evidence confirmed that fully breastfeeding women who remain amenorrheic have a very small risk of becoming pregnant in the first 6 months after delivery. As soon as the baby is 6 months old or as soon as supplementary feeding is started or menses is resumed, LAM no longer provides effective contraception, and other family planning methods should be introduced if pregnancy is not desired. However, while breastfeeding does provide a period of infertility, until recently, there was no reliable way for an individual woman to capitalize on this lactational infertility for her own child spacing. The duration of postpartum infertility varies between individuals and between societies and appears to depend largely on infant feeding practice. WHO recommended that breastfeeding promotion and family planning advice during lactation should be site and culture specific. Using the first months after childbirth for the promotion of exclusive breastfeeding together with motivation of the mother to ensure her adoption of another contraceptive method when needed should be key focuses of maternal and child health programmes. In this context, IUDs, barriers and progestinonly methods are preferable alternatives for lactating women. From a public health standpoint, it is equally important that a complementary long-term family planning method be timely started in order to ensure adequate child spacing. Programs may wish to minimize double coverage in order to save time and money for both the program and the client and to reduce possible side effects due to contraceptive use by lactating women. The use of LAM is a way to reduce double coverage in the first 6 months postpartum and, ideally, to increase contraceptive acceptance by encouraging the timely use of a second method. Given the demonstrated efficacy of LAM as a contraceptive in the postpartum period, this method should be more strongly promoted for its effective use in developing countries, in particular where access to or the acceptability of other forms of contraception is limited. In countries where there is no such limitation, LAM will be considered if advocating the method does not hamper the introduction of longer term methods of contraception. CONFLICT OF INTEREST The author(s) confirm that this article has no conflicts of interest. ACKNOWLEDGEMENTS The author is most grateful to the Editor-in-Chief, Professor Andy Lee and two anonymous reviewers for their helpful comments and suggestions. The views expressed in this article are those of the author and do not necessarily reflect the policies of any organizations.

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Revised: October 06, 2011

Accepted: August 31,2012