EXECUTIVE SUMMARY

While the contraceptive injection DMPA is a popular birth control option for many women, there is no definitive evidence on its immediate postpartum effect on breastfeeding.

• The National Institute of Child Health and Human Development has awarded funding to Ohio State University researchers to evaluate the effects of immediate postpartum initiation of DMPA on breastfeeding and on long-term patterns of contraceptive use.

• Many U.S. women choose to breastfeed their infants. According to 2018 data, of the approximately 4 million babies born in 2015, 83.2% started out breastfeeding.


New mothers are definite candidates for family planning. Statistics indicate that more than 30% of women in the United States experience interpregnancy intervals of less than 18 months.1 While the traditional time to initiate contraception has been at the six-week postpartum visit, many women fail to attend this important visit, especially in high-risk populations.2

Many new mothers are adjusting to breastfeeding their infants. According to 2018 data from the CDC, of the approximately 4 million babies born in 2015, 83.2% started out breastfeeding.3 The American College of Obstetricians and Gynecologists has issued guidance recommending exclusive breastfeeding for the first six months, with continued breastfeeding as complementary foods are introduced during the infant’s first year of life, or longer, as mutually desired by the woman and her infant.4 Key 2020 public health goals set by the U.S. Department of Health and Human Services include increasing numbers for infants initially breastfed, exclusively breastfed through six months of life, and continuing to breastfeed through at least one year of life.5

“We are pleased that most U.S. babies start out breastfeeding and over half are still breastfeeding at six months of age,” said Ruth Petersen, MD, MPH, director of CDC’s Division of Nutrition, Physical Activity, and Obesity in a press statement issued with the 2018 data. “The more we support breastfeeding mothers, the more likely they will be able to reach their breastfeeding goals.” (The statement and data are available online at: https://bit.ly/2moCH7V.)

Is Shot Appropriate for New Moms?

While the contraceptive injection depot medroxyprogesterone acetate (DMPA) is a popular birth control option for many women, there is no definitive evidence on its immediate postpartum effect on breastfeeding. The National Institute of Child Health and Human Development awarded funding to Ohio State University researchers to evaluate the effects of immediate postpartum initiation of DMPA on breastfeeding and on long-term patterns of contraceptive use.

Researchers hope the new inquiry will provide definitive answers on use of the contraceptive injection immediately postpartum. While the U.S. Medical Eligibility Criteria for Contraceptive Use ranks its use as Category 2 (a condition for which the advantages of using the method generally outweigh the theoretical or proven risks), international guidance from the World Health Organization differs.6 Because of the theoretical concern of neonatal exposure to steroid hormones, use is classed as Category 3 (a condition where the theoretical or proven risks usually outweigh the advantages of using the method).7

The American College of Obstetricians and Gynecologists endorses the U.S. Medical Eligibility Criteria, stating that the advantages of progestin-only pills, injectable contraception, contraceptive implant, and intrauterine devices outweigh the risks for use any time in the postpartum period, including immediately after birth.4

Observational studies have demonstrated the safety of DMPA when administered before discharge home to women who plan to breastfeed,8,9 says Anita Nelson, MD, professor and chair of the obstetrics and gynecology department at Western University of Health Sciences in Pomona, CA.

Study to Provide Answers by 2023

Determining advisable timing of DMPA initiation among breastfeeding mothers is a critical step for Ohio State University researchers, who are leading the way on further study of DMPA. The five-year, $1.88 million study will be directed by principal investigator Maria Gallo, PhD, associate professor of epidemiology in Ohio State’s College of Public Health, and co-investigators Lisa Keder, MD, director of Ohio State’s Division of General Obstetrics and Gynecology. The Ohio State Center for Clinical and Translational Science, which received a multi-year Clinical and Translational Science Award from the National Institutes of Health, will aid with recruitment and retention assistance, as well as data safety and monitoring, for the project.

The postpartum family planning study will evaluate the effects of immediate postpartum initiation of DMPA on breastfeeding and on long-term patterns of contraceptive use. The randomized controlled trial will follow 429 adult women who have delivered a healthy, full-term infant at Wexner Medical Center, who intend to breastfeed for at least six months, and who want to use DMPA. The study will randomize women to receive within 48 hours of delivery DMPA, a placebo injection or no injection. Scientists will then collect data on lactogenesis, infant feeding and growth, and contraception use during 12 follow-up months. Investigators expect to report study results in 2023.

Providers should not delay comprehensive contraception discussions with breastfeeding women. The Lactational Amenorrhea Method (LAM) relies on the new mother feeding her baby only breast milk for up to six months and having no periods or spotting during that time. It requires exclusive, frequent breastfeeding, which is defined as at least every four hours during the day and at least every six hours during the night of an infant less than six months of age.

Women who wish to use LAM must be counseled that another method of contraception is necessary when one or more of these events occur:

  • menstruation resumes,
  • less frequency or duration of nursing;
  • bottle feeding is introduced;
  • the baby reaches six months of age.

REFERENCES

  1. Copen CE, Thoma ME, Kirmeyer S. Interpregnancy intervals in the United States: Data from the Birth Certificate and the National Survey Of Family Growth. Natl Vital Stat Rep 2015;64:1-10.
  2. Lu MC, Prentice J. The postpartum visit: Risk factors for nonuse and association with breastfeeding. Am J Obstet Gynecol 2002;187:1329-1336.
  3. Centers for Disease Control and Prevention. Breastfeeding Report Card, 2018. Available at: https://bit.ly/2wmcqqo.
  4. ACOG committee opinion no. 756: Optimizing support for breastfeeding as part of obstetric practice. Obstet Gynecol 2018;132:e187-e196.
  5. U.S. Department of Health and Human Services. Healthy People 2020: Maternal, Infant, and Child Health Objectives. Washington, DC: HHS; 2015.
  6. Curtis KM, Tepper NK, Jatlaoui TC, et al. US medical eligibility criteria for contraceptive use, 2016. MMWR Recomm Rep 2016;65:1-103.
  7. World Health Organization (WHO). Medical Eligibility Criteria For Contraceptive Use. 5th edition Geneva: WHO; 2015.
  8. Halderman LD, Nelson AL. Impact of early postpartum administration of progestin-only hormonal contraceptives compared with nonhormonal contraceptives on short-term breast-feeding patterns. Am J Obstet Gynecol 2002;186:1250-1256; discussion 1256-1258.
  9. Lopez LM, Grey TW, Stuebe AM, et al. Combined hormonal versus nonhormonal versus progestin-only contraception in lactation. Cochrane Database Syst Rev 2015; 20(3):CD003988.