Life after....

photo by wellcome images

Now that Eden is four months old, I figured it was time for a post on the subject that originally launched this blog: natural family planning, or life after birth control.

Coincidentally, I'm currently taking a women's health class (basically, gynecology) in midwifery school right now and am delighted to report that one of our main textbooks, Contraceptive Technology (19th ed.), is far from the dry, medical, and, well, technology-focused tome it might initially appear to be. Instead, it's engagingly written and easy to read, and a book I would recommend for anyone who is or might someday be in the position of considering contraception of some kind. (Which is to say, just about everybody.) The thing that surprised me the most about this book was its unabashed cheerleading for breastfeeding and its respect for natural methods of birth control, such as fertility awareness-based methods, withdrawal (almost as effective as condoms when used correctly--who knew?!), and lactational amenorrhea method (LAM).

While just about any maternity discharge teaching I've ever seen has included the phrase "you CAN get pregnant right after you have a baby, even if you are breastfeeding," and we're all familiar with the argument that pre-ejaculate contains 'millions of sperm,' " along with the joke about couples who use rhythm-based methods (what do you call them? Parents!), this book deconstructs those myths and gives success-rate statistics for all of them. In fact, pregnancy is highly unlikely for the first six months of exclusive breastfeeding (however, you have to understand and practice what is really considered exclusive breastfeeding), pre-ejaculate does not contain sperm, and fertility-based awareness methods are highly effective when practiced correctly. Here are the statistics on these three methods, all of whom share the advantages of being safe, completely free, and relatively effective:



(from Contraceptive Technology, 19th ed., Hatcher et al.) Except for LAM, this information is available from the authors here.

When it comes to breastfeeding, it's generally understood that breastfeeding slows the return of a woman's menstrual periods and therefore suppresses her fertility for a time. This occurs because the hormone prolactin is released during suckling, and prolactin suppresses hormones needed to induce ovulation. This effect has recently been quantified by the lactational amenorrhea method, which consists of the following three questions:

1) Is your baby less than six months old?
2) Is your baby exclusively or very nearly exclusively breastfeeding? (Generally, this means feeding on demand, day and night, no more than 4 hours between feedings during the day and 6 hours at night, with no or very little supplemental substances given.)
3) Are you amenorrheic (no periods since the birth of your baby--or, more specifically, no bleeding after 56 days postpartum)?

If you can answer "yes" to all three questions, your risk of pregnancy is considered to be less than 1%--equal to perfect use of highly effective methods such as the pill, and in fact better than rates of typical use (since you can forget to take a pill much more easily than you can forget to breastfeed your baby).

Here is a good source of information on LAM.

What about when you don't quite meet those criteria, though? Having a four-month-old, I can tell you that those six months after the birth of your baby are going to fly by.

Then what?

Also, what about breastpumping? Can you use lactational amenorrhea if you are pumping? Most sources are very clear that only "very little" supplementation (ie formula or solid foods) are acceptable for maintaining LAM. What if your baby receives no supplementation, but is occasionally or regularly given your breastmilk in a bottle (or spoon, or cup)?

And what if your baby sometimes sleeps through the night?

Obviously the waters get a little bit murkier. It's all well and good for statistical purposes to set rules like the above, but very few of us will meet those criteria for very long. Does that mean we should give up the idea and, perhaps unnecessarily, choose another method?

Pumping is an area most sources don't address directly, and some decry altogether, but it appears as though pumping full-time only drops the success rate of the methods from 98-99% effective to 94-96% effective. Hello! That's still a lot better than typical use of most contraceptives, it's still free, and it gives considerably more leeway to those of us who are pumping some, but not full-time. Personally, I think this is the information to present to women, rather than "No, it doesn't work." If I chose to go it on nothing but LAM, and were pumping all or some of the time--I would be aware that fertility might return sooner, but if I was still feeding breastmilk exclusively and still amenorrheic, I'd be willing to chance it (with some additional precautions--see below).

As someone who works part-time (probably pumping for 6-8 feedings a week) and whose baby sometimes sleeps through the night, whose baby is rapidly approaching the 6-month mark and who has successfully used natural family planning in the past, it seems like combining the methods would be a useful way to extend lactational infertility for the duration of its natural course. As a result, I monitor fertility signals (mainly cervical fluid--though I'm trying to get back in the saddle with basal body temperature (BBT) measurements too) even though I'm still amenorrheic (I find the "65 days postpartum" rule a helpful cutoff since I experienced postpartum lochia for ~6 weeks following birth, a dry spell of about a week, and then a couple more days of spotting--but have been amenorrheic ever since).

In the past month or so, I've had the odd isolated day of stretchy mucus here and there, helpfully pointed out to me by practicing NFP. On those days, we either abstain, or... use the newly-exonerated withdrawal method.

So far, it's a system that has worked well for us. I would love to see studies done on the triangulation of these three methods because I have a hunch that they would be pretty solidly effective, especially in women who are breastfeeding up to a year or two or even three--particularly since these women are likely to be the type who would be interested in safe, natural, and effective birth control which doesn't affect one's milk supply. I also enjoy the liberation of a method that is completely within our control, which involves bodily awareness and cooperation, and which capitalizes on practices that were already important to use anyway. The addition of withdrawal is also a handy one for new parents, who will inevitably find that their "safe days" with NFP don't coincide with the days that the baby falls asleep on time! I should point out that some NFP methods allow using a barrier method OR abstinence on fertile days , others are very fervent about the point that if you choose to use a "backup" method on days you are known or suspected to be fertile, you are not practicing natural family planning. You are relying on the success (or failure) rate of the method you are using (be it condoms or withdrawal or a diaphragm or whatever), making it anything but a backup since you are using it precisely when you are most likely to become pregnant. Meaning that you are looking at the 4-27% rate (depending on how perfect your use is) of withdrawal, not the high rates of success boasted by perfectly-practiced (meaning periodically abstinent) NFP. Clearly, this may not be a method for couples who would not want to risk a pregnancy for whatever reason; however, being as we know that we want more children and have preferences but not absolute contraindications as to when, it works well for us.

The book Breastfeeding and Natural Child Spacing is an excellent one about what the author calls "ecological breastfeeding," which includes on-demand and through the night but also the concepts of babywearing, near-constant togetherness, and cosleeping as important, the proximity of the baby contributing to hormonal changes which suppress fertility as well. However, she's very strict on these matters, moreso than modern life unfortunately permits for most of us, so I am happy to see statistics on LAM alone that show a high efficacy even when these activities--though definitely a part of our lives-- are not completely constant.