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.

Postpartum: Life AFTER life after birth control

One of my midwifery professors calls it "the forgotten period," due mainly to the fact that in traditional obstetrical management, a new mother doesn't see her care provider again until six weeks after giving birth. Plus, it somewhat lacks the excitement and novelty of pregnancy and birth. Rixa at Stand and Deliver, who had a baby herself not long ago at all, recently opened an honest discussion of feeling "dumpy and frumpy in one's postpartum body." I was still pregnant when she posted it (5 days before I had Eden), and so I admit most of my attention was taken in by this excerpt:

For the first few weeks after giving birth, I feel incredibly attractive. Every day, especially during the first week, I look thinner and more shapely. My breasts get bigger, my stomach gets smaller, and when I see myself in the mirror each morning, I think, "Wow! I look good!"

I find newly postpartum bodies incredibly beautiful. Very feminine--or perhaps the better word is womanly. I love the empty, rounded belly; the soft bread-dough skin; the flush of hormones.

It seemed too good to be true. But like a prophecy, that was pretty much how I felt in the days after giving birth. Losing 32 pounds in under a week (10-lb baby, 3-lb placenta, and evidently about 19 lbs of fluid) didn't hurt at all, and neither did getting back those ankle bones I'd been pining for.

Rixa went on to say that a few weeks later, the dramatic body changes hit pause for awhile, and she's left feeling less than pleased with her appearance. By way of perspective, though, she posted a link a couple of days later to an article entitled "Maternity leave--or reprieve?" in which the author calls for the "need to respect the time parents spend with newborns." The author notes, "It would be a shame to lose reverence for those gentle, maddening months after a child is born, when you are in a sleep-drained reverie, stitched to a baby's rhythms and sweet suckling; when you watch them unfurl, watch their eyes focus on the world, their lips curl into smiles, their startled limbs jerk and then grow strong."

So, right now, are the days of our lives. While I am getting past the honeymoon stage of no longer being pregnant, and I am struggling a little to come to peace with the idea of all the things about my body that will never quite be the same, I'm also inclined to marvel that the price of creating human life--of suddenly producing into our living room a whole new ten-pound being, our daughter--isn't in fact any steeper. And I try to remember to be amazed, as well, at what my body can do: create a baby, efficiently discharge a baby, and now continue to feed and nourish a baby (no less, after being up all night with said baby).

And on the whole, I've felt remarkably good: despite the exhaustion, optimistic and energetic the majority of the time. The day Eden was born, we took her for her first walk outside; my coworkers are still surprised that I haven't felt at all teary or bluesy since she was born. The closest I've come was a surprising torrent of tears when we buried the placenta, when she was a little over a week old. I think in large part that was because of the sense of closure it gave me, the feeling that this pregnancy and birth--which were such a wild and beautiful and spiritual adventure--were really over. As Matt put it, "You've put so much work into this pregnancy and this birth, and growing such a good strong baby--and now all of that seems like it's forgotten." Not that I'm not overjoyed to be moving on to the next step, because I am, but goodbyes, for me, are always hard.

Other than that, though, I'm doing my best to identify with and take comfort in the final sentence of the previous article:

When you delight in the life you have created, it becomes a lot less important to get your own life back the very next day.

Then here's to delight.

Ode to my cloth pads

I have a lot to catch up on with this blog--Eden's birth story, for one, but also all of the postpartum-y things I've become intimately aware are part of "life after birth control"--but I can't help myself from taking the quick opportunity while Eden is sleeping to share my deep and abiding passion for cloth postpartum pads. Matt and I were actually cutting them out (loosely following this pattern, but there are tons of others out there) before we went to bed the night I went into labor, so obviously we didn't have time to sew them ("we" meaning "Matt" because I can't sew) by the time I gave birth. I was almost ready to throw in the towel and just keep using disposables, as my motivation was largely environmental and I figured the planet would understand, just this once--but Matt, bless his heart, sat down a few days ago and finished them, and I am now the proud owner of about 16 of the softest fleece-backed flannel pads with snaps on the wings that I have ever seen. The comfort is absolutely out of this world--to go from feeling like I was wearing a crinkly, sweaty, leaky plastic diaper and being constantly aware of that fact to being essentially unaware of the whisper-soft flannel lying absorbently next to my skin is one of the closest things I know of to postpartum heaven. They're slim, they're soft, they breathe, and they don't leak!

I'm sure the next question on everyone's mind is what you do with a used cloth postpartum pad. We've rigged up a nice system wherein we have a 1-gallon bucket under the bathroom sink that has several inches of water and a splash of Biz thrown in (upon my mother's recommendation, Biz is about the only thing we can find that gets out tough "human" stains like blood, sweat, and ring around the collar; we figure that in our largely chemical-free lifestyle, it's a concession we can make). I put the used pads in there and then dump the bucket in the wash when it's full. A little Biz and laundry detergent gets them sparkling clean again.

Plus, at $16-23 a pop to buy cloth pads (which you can do on Etsy or many other places if you don't have a sewing-inclined husband), we've saved literally hundreds of dollars by making them at home from a flannel sheet we got at Goodwill for a couple of dollars, a fleece blanket we picked up at KMart, and snaps we got for under $2. Plus, they were custom-made by my loving husband. It just doesn't get better than that!