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Breastfeeding, Sexuality and Contraception During the Postpartum Period

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332 Currellt Pediatric Reviews, 2012, 8, 332-338

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 con-
traception after childbirth. The timing of contraception initiation is important since the return of menstruation and ovula-
tion 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 in-
troduced 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 It is generally agreed that contraception after childbirth

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 mor-
talities 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 ef-
fective 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 two-
fifths 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].
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 ma-
jor 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 resum-
ing contraception after childbirth [5]. These decisions in-
clude both the contraceptive choice and the time to start its
use. The choice of contraception could be limited for lactat-
ing women due to concerns about hormonal effe..:ts on qual-
ity 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 con-
traception initiation is also important, since the return of
menstruation and ovulation can be unpredictable in breast-
feeding women [7]. This review discusses the relationship
between breastfeeding, sexuality and contraception during
the postpartum period.

Sexual Resumption After Delivery

* Address correspondence to this author at the Dat Van Duong 10 Ngo 18
It has been often emphasized that many couples should
Nguyen Dinh Chieu Street, Hanoi, Vietnam; Tel: +84-4-37198328;
Fax; +84-4-8232822; Email: dat@unfpa.org not resume sexual intercourse before the sixth postpartum

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


Breastjeedillg, Sexuality alld COlltraceptioll Durillg tlte Postpartum
week. However studies in various countries indicate a differ-
ent picture. Von Sydow in a meta-content review of 59 stud-
ies 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 post-
partum week [9]. In Thailand, 35% of women reported re-
sumption 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 postpar-
tum 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 be-
tween 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 Mas-
ters and Johnson, breastfeeding women reported signifi-
cantly higher sexual activity levels as compared to their non-
pregnancy 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 ear-
lier 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 sig-
nificant delay in resumption of sexual activity among breast-
feeding 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 in-
tercourse to a lesser degree. The cessation of breastfeeding
has a positive effect on sexual activity, but no effect on sex-
ua\ responsiveness or orgasm [8]. Decreased sexual activity
may be due to reduced interest in sex, tender breasts, post-
Current Pediatric Reviews, 2012, Vol. 8, No.4 333
partum pain, decreased vaginal secretions, and leaking milk
[13,25]. It is hypothesized that the decrease in sexual inter-
est by breastfeeding women may be hormone dependent.
Alder prospectively investigated the hormones of primipa-
rous women for 6 months postpartum and found that breast-
feeding 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 dura-
tion 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 [26-
28].
LACTATIONAL AMENORRHEA METHOD
Efficacy of Lactational Amenorrhea 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]. Particu-
larly, 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 preg-
nancy 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 breast-
feeding 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 in-
fluencing the duration of postpartum infertility. The variabil-
ity in the duration of lactational amenorrhea between moth-
ers is related to the variation in suckling stimulus, but the
precise mechanism whereby the suckling suppresses ovula-
tion is still unknown [44, 45]. Because the introduction of
complementary foods and fluids may reduce the frequency
334 Currellt Pediatric Reviews, 2012, Vol 8, NO.4
I. Has your menses returned?
NO
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])
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 [48-
52]. Early initiation of breastfeeding and refraining from
providing the infant with glucose or other fluids after deliv-
ery are also strongly associated with longer duration of post-
partum amenorrhea [53].
Actual LAM's Applicatiou
Despite its demonstrated evidence, many women, how-
ever, 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 inter-
ested 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].
Dot Vall Duollg
YES
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
~ _
:
a menstrual bleed. Intervals between breastfeeds should not exceed 4 hours during the days and 6
Khella ef al. in a study in Egypt found that many breast-
feeding 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 lacta-
tional amenorrhea when some respondents bel ieved that
pregnancy could not occur as long as a woman was breast-
feeding. 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 concep-
tion. 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 pro-
motion 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 giv-
ing 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 fol-
lowing parturition. With reference to breastfeeding women,
the concept of postpartum contraception can be applied to
the entire period of lactation. Conversely, for non-
breastfeeding women, it may be desirable to contract the
Breast/eedillg, SexuaHty alld Contraceptioll Durillg tlte Postpartum
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 post-
partum-, the time for the postpartum care checkup, they
should use a contraceptive before the sixth week, especially
if they are not breastfeeding [58].
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 protec-
tion against pregnancy for as long as possible and contracep-
tive alternatives will be introduced once the risk of preg-
nancy increases. This strategy has been widely promoted
under the LAM's promotion approach, in which contracep-
tion is promoted at the resumption of menses, after six
months postpartum or the time of introduction of comple-
mentary 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].
MODERN CONTRACEPTIVE ALTERNATIVES
BREASTFEEDING WOMEN
Intrauterine 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 endometri-
tis [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
Currellt Pediatric Reviews, 2012, Vol. 8, No.4 335
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) classi-
fied as category "I" for by 10 minute or less after delivery of
placenta [71].
Hormonal Contraceptives
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 mecha-
nisms by which progestin-only methods prevent pregnancy
are thickening of the cervical mucus; trimming the uterine
lining, and, sometimes, suppressing ovulation [72-74]. Pro-
gestin-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 hor-
monal contraception on milk quality and quantity. The exist-
ing evidence is inadequate to make evidence-based recom-
mendations regarding hormonal contraceptive use for lactat-
ing women. No adverse effect of hormonal contraceptives on
infant growth has been documented [7]. Nevertheless, for
FOR breastfeeding women, WHO gives combined hormonal con-
traception 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 recom-
mendations on selected modern contraceptive. methods for
postpartum women in Table 1 (70,71].
Regarding minimizing physiologic impact on breastfeed-
ing, 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
 Dot Vall Duong
336 Current Pediatric Reviews, 201 2, Vol. 8, No.4

Table]. Contraceptive Classification for Breastfeeding Women

us Medical Criteria 2010 WHO Medical Criteria 20]0

Category Contraceptives Category

Contraceptives

Combined Hormonal Contraceptives

For Breastfeeding Women

.

3 <6 weeks postpartum 4

<1 month postpartum

2:6 weeks to <6 months postpartum )

1 month to <6 months postpartum 2

2 2:6 months postpartum 2

2:6 months postpartum

For Non-breastfeeding Women

<21 days 3 <21 days

1 Without other risk factors for VTE 3

2:21 days

With other risk factors for VTE 3/4

2:21 days to 42 days

Without other risk factors for VTE 2

With other risk factors for VTE 2/3

>42 days 1

Progestin-Only Contraceptives

For Breastfecding Women

2 <6 .weeks postpartum 3

<1 month postpartum

1 2:6 weeks to <6 months postpartum. 1

1 month to <6 months postpartum

1 2:6 months postpartum 1

2:6 months postpartum

For Non-breastfeeding Women

1 <21 days 1
<21 days

1 2:21 days 1
2:21 days

Intrauterine Devices (CII-IUD)

For 80th 8reastfeeding or Non-breastfeeding Women, Including Post-cesarean Section

1 <48 hours 1
<] 0 minules after delivery of placenta

2 48 hours to <4weeks 3
10 minutes after delivery of the placenta to <4 hours

1 2:4 weeks 1
2:4 weeks

4 Puerperal sepsis 4
Puerperal sepsis

Where"
1 •• A condition for which there is no restriction for the lise of the contraceptive method.
2 •• A condition for which the advantages of using the method generally outweigh the theoretical or proven risks
3" A condition for which the theoretical or proven risks usually outweigh the advantages of using the method
4 = A condition that represents an unaceeptahle health risk if the contraceptive method is used.
VTE = Venous thromboembolism
(Adapted from WHO (2010) [70] and CDC (20 10) [71))

beginning in the third postpartum month. With partial breast- CONCLUSIONS

feeding or no breastfeeding, a contraceptive method should
begin during the third postpartum week. After the spontane-
ous or elective termination of a pregnancy of less than 12
weeks, combination oral contraception can be started imme-
diately. 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].
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. How-
ever, in many countries, postnatal care is often undcr-
resourced and under-valued, possibly due to inadequate
knowledge and understanding on sexual and contraception
needs during the postpartum period.
Breastfeeding, Sexuality 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 ef-
fective 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 in-
dividuals 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 en-
sure her adoption of another contraceptive method when
needed should be key focuses of maternal and child health
programmes. In this context, IUDs, barriers and progestin-
only 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. Pro-
grams 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 contracep-
tive in the postpartum period, this method should be more
strongly promoted for its effective use in developing coun-
tries, 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 advo-
cating 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, Pro-
fessor 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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Accepted: August 31,2012