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In a letter1 published in the July 2016 issue of this journal, the Breastfeeding Network's approach to postpartum contraception was advocated and described as: (i) avoidance of all hormonal contraception in the first 21 days postpartum; (ii) after that, a month's trial of the “mini-pill” to check milk supply is unaffected; and (iii) initiation of hormonal long-acting reversible contraception (LARC) methods (e.g. the subdermal implant), after this and only if breastfeeding is going well. The letter expresses concern among breastfeeding counsellors, based solely on anecdotal reports, regarding “the impact of hormonal contraception on milk supply” (including progestogen-only methods). The Breastfeeding Network's ‘Breastfeeding and Contraception’ factsheet2 asserts that initiation too early after delivery “may interfere with priming of prolactin receptors” and refers to anecdotal reports from “quite a few women” of a rapid drop in milk supply post-initiation of the progestogen-only pill (POP). During our efforts to reintroduce a postnatal contraception service into University Hospital Lewisham,3 we have encountered similar resistance from infant feeding health professionals.
We believe it is vital for the successful delivery of postnatal contraception that we engage with breastfeeding specialists to communicate the case for immediate postnatal contraception and the safety of progestogen methods for breastfeeding women. The UK rate of unplanned pregnancy is approximately 50%, and adverse health effects to mother and child of rapid repeat pregnancy include preterm delivery and neonatal death. Postnatal contraception is therefore a key public health priority, particularly relevant to our young, inner-city population with high conception, teenage pregnancy and termination rates. While we agree with Panzetta and Pickett1 that the lactational amenorrhoea method (LAM) should be included in a tailored discussion of all methods and recognise that many women will choose to decline or delay initiation of hormonal methods, this should be an informed choice based on up-to-date, evidence-based information.
The postnatal contraception approach outlined above1 goes against the Royal College of Obstetricians and Gynaecologists' Best Practice Paper on postpartum family planning,4 which recommends starting a chosen method, including LARC, before discharge from place of delivery. All progestogen-only methods (including pills, injection, implant and intrauterine methods) can almost always be safely initiated immediately post-delivery as outlined in UKMEC 2016.5 Available evidence, including multiple systematic reviews,6 ,7 has failed to demonstrate adverse effects on breastfeeding duration, breast milk composition, infant growth or development. Moreover, LARC options such as the implant and intrauterine system have significantly lower doses of progestogen as compared to the POP so can be effective first line, with quick and guaranteed access to removal if wanted. Newer methods such as the progestogen-releasing vaginal ring, Progering®, are also being specifically designed for breastfeeding women in the first postpartum year.
Since new mothers are faced with multiple barriers to accessing effective, timely contraception in the community and 50% of women resume sexual activity before their 6-week general practitioner check, immediate postnatal contraception advice and provision is most convenient for women, not health professionals, as alluded to in Panzetta and Pickett's letter.1 We must also not overlook the most vulnerable women, such as those with substance misuse, mental health problems or who have repeat removals of their children into care. These women often have chaotic lives, do not access contraception subsequently and have low rates of breastfeeding. The immediate postnatal period is the common window of opportunity for counselling women about the benefits of breastfeeding and contraception. Health professionals specialising in both areas must work together to ensure women are supported to make positive, informed choices, and reassure breastfeeding women who wish to start progestogen-only hormonal methods, including LARC, immediately postnatally that this is safe. LAM, like LARC, is not for every woman.
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