Combined hormonal versus nonhormonal versus progestin-only contraception in lactation

Breastfeeding and contraception counseling: a qualitative study

BACKGROUND

The objectives of this qualitative study were to better understand women's experiences regarding contraceptive choice, breastfeeding intentions and the relationship between the two. Women are routinely presented with counseling on breastfeeding and contraception throughout their prenatal and postpartum care, but little is published on patients' own priorities, desires and experiences of this peripartum counseling. This article aims to address this gap in the literature.

METHODS

Semi-structured interviews were conducted with patients in the immediate postpartum period. The interview guide explored: 1) timing and content of contraceptive counseling; 2) breastfeeding goals and expectations; 3) reasons for contraceptive choices; and 4) recommendations for counseling. Interview transcripts were coded to identify themes and analyzed.

RESULTS

Twenty interviews were conducted. The participants were reflective of our patient population in the Bronx, with ninety percent using Medicaid for insurance and fifteen percent concerned about food security in the past month, well-validated questions reflective of poverty and socioeconomic status. Three themes emerged from the interviews: (1) using contraception was described as a selfish decision by the mother without benefit to the newborn; (2) women felt pressure to breastfeed and saw the inability to breastfeed as a personal failure; and (3) medical providers were viewed as more trustworthy when it came to information regarding breastfeeding as opposed to contraceptive options, where decisions relied on anecdotes from friends or family.

CONCLUSIONS

Most decision-making regarding breastfeeding and contraception relied on the personal experiences of the participants and their friends and family. A clear need for support for women who are unable to breastfeed and education about the benefits of contraception for the newborn was identified.

Chemical Effects on Breast Development, Function, and Cancer Risk: Existing Knowledge and New Opportunities

Population studies show worrisome trends towards earlier breast development, difficulty in breastfeeding, and increasing rates of breast cancer in young women. Multiple epidemiological studies have linked these outcomes with chemical exposures, and experimental studies have shown that many of these chemicals generate similar effects in rodents, often by disrupting hormonal regulation. These endocrine-disrupting chemicals (EDCs) can alter the progression of mammary gland (MG) development, impair the ability to nourish offspring via lactation, increase mammary tissue density, and increase the propensity to develop cancer. However, current toxicological approaches to measuring the effects of chemical exposures on the MG are often inadequate to detect these effects, impairing our ability to identify exposures harmful to the breast and limiting opportunities for prevention. This paper describes key adverse outcomes for the MG, including impaired lactation, altered pubertal development, altered morphology (such as increased mammographic density), and cancer. It also summarizes evidence from humans and rodent models for exposures associated with these effects. We also review current toxicological practices for evaluating MG effects, highlight limitations of current methods, summarize debates related to how effects are interpreted in risk assessment, and make recommendations to strengthen assessment approaches. Increasing the rigor of MG assessment would improve our ability to identify chemicals of concern, regulate those chemicals based on their effects, and prevent exposures and associated adverse health effects.

Woman's contraceptive needs and preferences in the postpartum period: an Italian study

AIMS AND OBJECTIVES

To describe what puerperal women know about postpartum contraception and to identify their related needs and expectations.

BACKGROUND

Puerperal women face the problem of beginning or resuming contraception, the choice of the right method of contraception and the right time to start it. This choice becomes particularly important in case they breastfeed since the contraceptive method should not interfere with breastfeeding. Different factors, such as the level of knowledge women have about various contraceptive methods, their individual preferences or their desire to have a baby, can strongly influence this choice.

DESIGN

A cross-sectional study had been carried out within the period of six months, from November 2011-February 2012.

METHODS

Three hundred puerperal women were interviewed before their discharge from a Maternity Home. The women were asked for their personal characteristics, their maternity history, the information they had received, their knowledge and expectations about postpartum contraception and their intention to use contraception.

RESULTS

During pregnancy and postpartum, 45.5% of the women reported that they had received adequate information about contraception. Of these ones, 64.3% reported their intention to use contraception either to avoid pregnancy or to space out future births, even if they did not always have appropriate knowledge about fertility and the use of contraceptive methods during postpartum. During this study, we also discovered that women's intention to use contraception was proportional to their level of education.

CONCLUSION

Women need more and appropriate information about postpartum contraception, to make a conscious choice in relation to their needs and without putting their health at risk.

RELEVANCE TO CLINICAL PRACTICE

To promote awareness of the choices related to postpartum contraception, it is important to understand the personal characteristics that influence or hinder this choice. Midwives can play a very important role in informing women and in developing educational interventions to support a safe contraceptive choice.

Effect of progestin compared with combined oral contraceptive pills on lactation: a randomized controlled trial

OBJECTIVE

To estimate the effect of progestin-only compared with combined hormonal contraceptive pills on rates of breastfeeding continuation in postpartum women. Secondary outcomes include infant growth parameters, contraceptive method continuation, and patient satisfaction with breastfeeding and contraceptive method.

METHODS

Postpartum breastfeeding women who desired oral contraceptives were randomly assigned to progestin-only and combined hormonal contraceptive pills. At 2 and 8 weeks postpartum, participants completed in-person questionnaires that assessed breastfeeding continuation and contraceptive use. Infant growth parameters including weight, length, and head circumference were assessed at 8 weeks postpartum. Telephone questionnaires assessing breastfeeding, contraceptive continuation, and satisfaction were completed at 3-7 weeks and 4 and 6 months. Breastfeeding continuation was compared between groups using Cox proportional hazards regression. Differences in baseline demographic characteristics and in variables between the two intervention groups were compared using χ tests, Fisher exact test, or two-sample t tests as appropriate.

RESULTS

Breastfeeding continuation rates at 8 weeks (progestin-only 63.5%; combined hormonal 64.1%), contraceptive continuation, and infant growth parameters did not differ between users of progestin-only and combined hormonal contraceptive pills. Infant formula supplementation and maternal perception of inadequate milk supply were associated with decreased rates of breastfeeding in both groups.

CONCLUSION

Choice of combined hormonal or progestin-only contraceptive pills administered 2 weeks postpartum did not adversely affect breastfeeding continuation.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov, www.clinicaltrials.gov, NCT01465022.

Controversies in postpartum contraception: when is it safe to start oral contraceptives after childbirth?

The timely initiation of contraception postpartum is an important consideration for breastfeeding and non-breastfeeding women; many women prefer oral contraceptive pills to other methods. In breastfeeding women, combined hormonal pills are not recommended prior to 6 weeks postpartum, due to effects on milk production. Although progestogen-only pills do not adversely affect milk, lack of data regarding possible effects on infants exposed to progestogens in breastmilk renders timing of initiation of this method controversial. In non-breastfeeding women, elevated risk of venous thromboembolism restricts use of combined hormonal pills prior to 21 days postpartum. From 21 to 42 days, use of combined hormonal pills should be assessed based on a woman's personal venous thromboembolism risk profile; after 42 days postpartum there is no restriction in the use of combined hormonal pills for otherwise healthy women. Non-breastfeeding women may safely use progestogen-only pills at any time during the postpartum.

Improving the use of human milk during and after the NICU stay

The feeding of human milk (milk from the infant's own mother; excluding donor milk) during the newborn intensive care unit (NICU) stay reduces the risk of costly and handicapping morbidities in premature infants. The mechanisms by which human milk provides this protection are varied and synergistic, and appear to change over the course of the NICU stay. The fact that these mechanisms include specific human milk components that are not present in the milk of other mammals means that human milk from the infant's mother cannot be replaced by commercial infant or donor human milk, and the feeding of human milk should be a NICU priority. Recent evidence suggests that the impact of human milk on improving infant health outcomes and reducing the risk of prematurity-specific morbidities is linked to specific critical exposure periods in the post-birth period during which the exclusive use of human milk and the avoidance of commercial formula may be most important. Similarly, there are other periods when high doses, but not necessarily exclusive use of human milk, may be important. This article reviews the concept of "dose and exposure period" for human milk feeding in the NICU to precisely measure and benchmark the amount and timing of human milk use in the NICU. The critical exposure periods when exclusive or high doses of human milk appear to have the greatest impact on specific morbidities are reviewed. Finally, the current best practices for the use of human milk during and after the NICU stay for premature infants are summarized.

Initiation of postpartum contraception: a survey among health centre physicians and nurses in Finland

OBJECTIVE

To examine self-reported professional practices of postpartum contraceptive counselling at Finnish community health centres.

DESIGN

A survey study with self-administered online questionnaires.

SETTING

All local municipalities (n = 107) in the Expert Responsibility Area of Tampere University Hospital in Western Finland in 2005.

SUBJECTS

A total of 69 (64% of 107) health centre physicians and 80 (75%) nurses performing postpartum check-ups.

MAIN OUTCOME MEASURES

Contraceptive method most often initiated or recommended to breastfeeding women at postpartum visit; timing of postpartum initiation of hormonal and intrauterine contraceptive methods in relation to breastfeeding and resumption of menses.

RESULTS

The most common contraceptive method initiated or recommended to breastfeeding women by both physicians (41%) and nurses (45%) was the condom, followed by progestin-only pills and intrauterine contraception. Few professionals recommended breastfeeding (lactational amenorrhea) as the only contraceptive method. Only eight (12%) physicians inserted a copper-releasing intrauterine device and five (7%) a levonorgestrel-releasing intrauterine system typically at the postpartum visit; the majority delayed the insertions until the resumption of menses. Fifty-three (77%) physicians initiated combined oral contraceptives mostly when breastfeeding was terminated and menses had returned. Over half of the municipalities involved in the study did not provide any medical contraceptives free of charge postpartum.

CONCLUSION

Professionals' reports indicate that initiation of effective contraceptive methods is delayed after childbirth. In order to promote better postpartum contraception practices, updated evidence-based guidelines are needed.

GDM: postpartum management to reduce long-term risks

Diabetes prevalence has increased dramatically, with 1.3 million new cases diagnosed annually. Women with gestational diabetes mellitus (GDM) are at increased risk for developing overt diabetes later in life. In addition, their offspring, exposed to the diabetic environment in utero, are also at increased risk for developing obesity, glucose intolerance, and type 2 diabetes later in life. Diabetes begets diabetes. The GDM diagnosis provides the medical community with an opportunity to intervene with strategies to prevent and/or delay the onset of diabetes and its associated long-term complications. This article reviews the roles of medical nutrition therapy, physical activity, and pharmacotherapy in preventing type 2 diabetes in women with a GDM history.

After Pregnancy Complicated by Diabetes: Postpartum Care and Education

The postpartum period in women with pregestational or gestational diabetes allows the physician and mother to switch from intensive medical and obstetric management into a proactive and preventive mode, and to jointly develop a reproductive health plan. The woman's individual needs regarding contraception and breastfeeding, an appropriate diet to achieve healthy weight goals, the medical management of diabetes, daily exercise, and future pregnancy planning must be considered. Essential is the active participation of the woman, who, through education, gains an understanding of the far-reaching effects her active participation will have on her subsequent health, her newborn child's health, and possibly that of her future children.

Medical Barriers to Effective Contraception

Medical barriers to contraception can prevent women from obtaining, initiating, and continuing their contraceptive method of choice. The barriers include lack of appropriate counseling, delaying initiation for menses or laboratory tests, inappropriate contraindications or mandated warnings, untrained clinicians, and financial or regulatory barriers preventing access by low-income, undocumented, or adolescent women. These barriers may partially explain why almost half of pregnancies in the United States are unintended and occur predominantly in the small proportion of sexually active women not using contraception.

Contraceptive Implants: An Overview and Update

Contraceptive implants are safe, highly effective, and long-term methods of contraception that are widely applicable to any reproductive-aged woman. Implants require minimal user compliance and are cost-effective. The new single-rod system simplifies insertion and removal, making implants more accessible for both providers and patients. Specifically, progestin-only implants are safe options for various women including adolescents, postpartum, breast-feeding, those who are medically complicated, or those who have contraindications to or intolerance of estrogen-containing contraceptives.

Barriers to contraceptive use in product labeling and practice guidelines

Many contraceptives are encumbered with potentially unnecessary restrictions on their use. Indeed, fear of side effects, fostered by alarmist labeling, is a leading reason that women do not use contraceptives. In the United States, hormonal methods currently require a prescription, although research suggests that women can adequately screen themselves for contraindications, manage side effects, and determine an appropriate initiation date, leaving little need for routine direct physician involvement. Sizing, spermicidal use, and length-of-wear limits burden users of cervical barriers and may be unnecessary. Despite recent changes in the labeling of intrauterine devices, clinicians commonly restrict use of this method and in some countries may limit the types of providers authorized to insert them. Although in some cases additional research is necessary, existing data indicate that evidence-based demedicalization of contraceptive provision could reduce costs and improve access.

Hormonally impregnated intrauterine systems (IUSs) versus other forms of reversible contraceptives as effective methods of preventing pregnancy

BACKGROUND

In the 1970s a new approach to the delivery of hormonal contraception was researched and developed. It was suggested that the addition of a progestogen to a non-medicated contraceptive device improved its contraceptive action. An advantage of these hormonally impregnated intrauterine systems (IUS) is that they are relatively maintenance free, with users having to consciously discontinue using them to become pregnant rather than taking a proactive daily decision to avoid conception.

OBJECTIVES

To assess the contraceptive efficacy, tolerability and acceptability of hormonally impregnated intrauterine systems (IUSs) in comparison to other reversible contraceptive methods.

SEARCH STRATEGY

Literature was identified through database searches, reference lists and individuals/organisations working in the field. Searches covered the period from 1972 to November 2003.

SELECTION CRITERIA

All randomised controlled trials comparing IUSs with other forms of reversible contraceptives and reporting on pre-determined outcomes in women of reproductive years. The primary outcomes were pregnancy due to method/user failure and continuation rate.

DATA COLLECTION AND ANALYSIS

The quality assessment of studies and data extraction were completed independently by two blinded reviewers. A quality checklist was designed to identify general methodological and contraceptive specific factors which could bias results. Events per women months and single decrement life table rates were extracted where possible for pregnancy, continuation, adverse events and reasons for discontinuation. Events per total number of women at follow up were collected for hormonal side effects and menstrual disturbance. When appropriate, data were pooled at the same points of follow up to calculate rate ratios in order to determine the relative effectiveness of one method compared to another. For the single decrement life table rates, the rate differences were pooled to determine the absolute difference in effectiveness of one method compared to another. Interventions were only combined if the contraceptive methods were similar. Non-hormonal IUDs were divided into three categories for the purpose of comparison with IUSs: IUDs >250mm2 (i.e. CuT 380A IUD and CuT 380 Ag IUD), IUDs <=250mm2 (i.e. Nova-T, Multiload, CuT 200 and CuT 220 IUDs) and non-medicated IUDs.

MAIN RESULTS

Twenty-one RCTs comparing hormonally impregnated IUSs to a reversible contraceptive method met the inclusion criteria and it was possible to include eight of these in the meta-analyses, four comparing LNG-20 IUSs with non-hormonal IUDs, one comparing the LNG-20 IUS with Norplant-2 and three comparing Progestasert with non-hormonal IUDs. No significant difference was observed between the pregnancy rates for the LNG-20 users and those for the IUD >250mm2 users. However, women using the LNG-20 IUS were significantly less likely to become pregnant than those using the IUD <=250mm2. Women using the LNG-20 IUS were more likely to experience amenorrhoea and device expulsion than women using IUDs >250mm2. LNG-20 users were significantly more likely than all the IUD users to discontinue because of hormonal side effects and menstrual disturbance, which on further breakdown of the data was due to amenorrhoea. When the LNG-20 IUS was compared to Norplant-2, the LNG-20 users were significantly more likely to experience amenorrhoea and oligomenorrhoea, but significantly less likely to experience prolonged bleeding and spotting. No other significant differences were observed. Progestasert users were significantly less likely to become pregnant and less likely to continue on the method than non-medicated IUD users after one year, but no significant difference was noted for these two outcomes when Progestasert users were compared to IUD<=250mm2 users. The only other significant differences found in the meta-analyses were that Progestasert users were less likely to expel the device and more likely to discontinue the method because of menstrual bleeding and pain than users of IUDs <=250mm2. REVIEWERS' CONCLUSIONl the device and more likely to discontinue the method because of menstrual bleeding and pain than users of IUDs <=250mm2.

REVIEWERS' CONCLUSIONS

Current evidence suggests LNG-20 IUS users are no more or less likely to have unwanted pregnancies than IUD >250mm2 and Norplant-2 users. The LNG-20 IUS was more effective in preventing either intrauterine or extrauterine pregnancies than IUDs <=250mm2. The contraceptive effectiveness of Progestasert was significantly better than non-medicated IUDs, but no difference was observed when compared to IUDs<=250mm2. Continuation of LNG-20 IUS use was similar to continuation of the non-hormonal IUDs and Norplant-2. Amenorrhoea was the main reason for the discontinuation for the LNG-20 IUS and women should be informed of this prior to starting this method.