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Optimizing Maternal and Neonatal Outcomes with Postpartum Contraception: Impact on Breastfeeding and Birth Spacing Aparna Sridhar1* and Jennifer Salcedo2

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Optimizing Maternal and Neonatal Outcomes with Postpartum Contraception: Impact on Breastfeeding and Birth Spacing Aparna Sridhar1* and Jennifer Salcedo2 Sridhar and Salcedo Maternal Health, Neonatology, and Perinatology Maternal Health, Neonatology, (2017) 3:1 DOI 10.1186/s40748-016-0040-y and Perinatology REVIEW Open Access Optimizing maternal and neonatal outcomes with postpartum contraception: impact on breastfeeding and birth spacing Aparna Sridhar1* and Jennifer Salcedo2 Abstract Postpartum contraception is important to prevent unintended pregnancies. Assisting women in achieving recommended inter-pregnancy intervals is a significant maternal-child health concern. Short inter-pregnancy intervals are associated with negative perinatal, neonatal, infant, and maternal health outcomes. More than 30% of women experience inter-pregnancy intervals of less than 18 months in the United States. Provision of any contraceptive method after giving birth is associated with improved inter-pregnancy intervals. However, concerns about the impact of hormonal contraceptives on breastfeeding and infant health have limited recommendations for such methods and have led to discrepant recommendations by organizations such as the World Health Organization and the U.S. Centers for Disease Control and Prevention. In this review, we discuss current recommendations for the use of hormonal contraception in the postpartum period. We also discuss details of the lactational amenorrhea method and effects of hormonal contraception on breastfeeding. Given the paucity of high quality evidence on the impact on hormonal contraception on breastfeeding outcomes, and the strong evidence for improved health outcomes with achievement of recommended birth spacing intervals, the real risk of unintended pregnancy and its consequences must not be neglected for fear of theoretical neonatal risks. Women should establish desired hormonal contraception before the risk of pregnancy resumes. With optimization of postpartum contraception provision, we will step closer toward a healthcare system with fewer unintended pregnancies and improved birth outcomes. Keywords: Breastfeeding, Contraception, Inter-pregnancy interval, Lactation, Postpartum Background on breastfeeding must be appropriately weighed against Postpartum contraception is important to prevent unin- well-supported impacts on inter-pregnancy intervals and tended pregnancies and short intervals between preg- the woman’s informed decisions regarding her repro- nancies. The appropriate method and timing of ductive health. contraception initiation following a birth, miscarriage or pregnancy termination depends on multiple factors such Inter-pregnancy interval and perinatal outcomes as a patient’s personal preferences, medical history, risk Assisting women in achieving recommended inter- for pregnancy, breastfeeding preferences, and access to pregnancy intervals (IPIs), defined as the time interval contraceptive services. The most important role of post- between a live birth and the beginning of the next preg- partum contraception is to help a woman achieve the nancy, is a significant maternal-child health concern. desired interval before the next pregnancy in order to Short IPIs are associated with negative perinatal, neo- optimize her health and that of her young children. The- natal, infant, and maternal health outcomes. The con- oretical concerns regarding the impact of contraception cept of an ideal inter-pregnancy interval emerged from a report published by World Health Organization (WHO) * Correspondence: [email protected] in 2005. Based on the best available evidence at that 1Department of Obstetrics and Gynecology, David Geffen School of Medicine at University of California Los Angeles, California, USA time, the experts reached a consensus of 24 months as Full list of author information is available at the end of the article the IPI. This interval was consistent with the joint WHO © The Author(s). 2017 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Sridhar and Salcedo Maternal Health, Neonatology, and Perinatology (2017) 3:1 Page 2 of 10 and United Nations Children’s Emergency Fund looking at ovulation after abortion suggest that most (UNICEF) recommendation that women breastfeed for women ovulate before resuming menses, with mean time at least 2 years [1]. to ovulation of 22 days [9]. Lactation extends the period Recommendations from the WHO report, “Effect of of postpartum infertility. Nerve impulses arising from Interpregnancy Interval on Adverse Perinatal Outcomes,” the nipple and areola due to infant suckling release pro- were evaluated using the Perinatal Information System lactin from the hypothalamus. This, in turn, suppresses Database of the Latin American Center for Perinatology the pulsatile release of gonadotropin-releasing hormone and Human Development from 1985 to 2004. Compared (GnRH) by the hypothalamus, likely by increasing beta- to infants with IPIs of 18–23 months, those born to endorphin production. The pulsatile secretion of GnRH women with intervals shorter than 6 months had an is necessary to stimulate the cells in anterior pituitary to increased risk of many adverse neonatal and perinatal produce FSH and LH needed for ovulation. Thus contin- outcomes [2]. A systematic review by Conde-Agudelo et ued suckling and lactation provide protection from preg- al. that included 77 studies conducted in countries across nancy [10]. six continents analyzed the association of IPIs with out- comes such as preterm birth, low birth weight, small size Lactational amenorrhea method for gestational age (SGA) at birth, fetal death, and early The lactational amenorrhea method (LAM) is the specific neonatal death. For IPIs shorter than 6 months, there were name given to use of breastfeeding as a dedicated method significantly increased risks for preterm birth (Odds Ratio of contraception. For breastfeeding to serve as an effective = 1.40), SGA (Odds Ratio =1.26), and low birth weight method of contraception, the woman must be exclusively (Odds Ratio = 1.61). Intervals of 6 to 17 months were also or nearly exclusively breastfeeding (at least 85% of infant associated with a significantly greater risk for these three feeding coming from breastfeeding), be within the first adverse perinatal outcomes. Additionally, among women 6 months following delivery, and remain amenorrheic. with previous low-transverse caesarean sections who Some experts additionally believe that milk expression by underwent trials of labor, there was noted to be increased hand or pump does not retain the same fertility-inhibiting risk of uterine rupture with IPIs less than 16 months [3]. effect as infant nursing [11]. Clinical studies of the contra- Another recent study analyzing all live births between 1991 ceptive effect of LAM have demonstrated cumulative 6- and 2010 in California concluded that women with IPIs of month life-table perfect-use pregnancy rates of 0.5 – 1.5% less than 1 year following live birth were at increased risk among women who relied solely on LAM. A Cochrane re- for preterm birth [4]. No conclusions on the impact of IPI view published in 2015 estimated the typical use failure onmaternalmortalityandmorbiditywereabletobedrawn rate of LAM to be 0.45 – 7.5% [12–15]. in the WHO’s report due to limited available data [1]. Although LAM is a highly effective temporary method Unfortunately, data from the 2015 National Vital of contraception, rates of the exclusive breastfeeding Statistics Report and the National Survey of Family required for its effectiveness are low in the United Growth demonstrate that in the United States 30% of States. Data from the National Immunization Survey women experience IPIs of less than 18 months. Short IPIs describes an 80% incidence of breastfeeding initiation, in the U.S. are inversely associated with maternal age, with declining to a 4 weeks postpartum exclusive breastfeed- more than two thirds (67%) of teenagers between ages ing rate of 54%, which declines to 20% at 6 months [16]. 15–19 experiencing IPIs of less than 18 months [5]. According to this data, exclusive breastfeeding rates at 3 months were lower in non-white, unmarried women Postpartum endocrine changes with lower socio-economic status compared to non- To understand the timing and mechanisms by which Hispanic white, well educated, married women [16]. women resume risk of pregnancy following delivery, it is Among the individual states, Montana had the highest important to review the cascade of endocrine changes (60%) and Mississippi the lowest (21%) exclusive breast- that take place after parturition. Immediately following feeding rates at 3 months in 2013 [17]. delivery, the inhibitory effect of the estrogen and proges- Historically, women have also been assumed to experi- terone levels of pregnancy decreases and the pulsatile ence protection from pregnancy during the traditionally activity of the pituitary follicular stimulating hormone recommended 6-week period of pelvic rest following (FSH) and luteinizing hormone (LH) resumes [6]. In delivery. While 6-weeks may have been historically non-lactating women, studies evaluating urinary
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