Breastfeeding and Natural Contraception

Breastfeeding, Postpartum Infertility, and Natural Contraception
Written for Leida website by
Michal Schonbrun, MPH, CHES

: Michal Schonbrun*

If you answered yes to any of these questions, you are invited to read a timely article which could change your (quality of) life.

FACT 1: Breastfeeding, when practiced in a specific way, can be used as a highly effective method of birth control.
Your chances of getting pregnant are practically nil during the first six months if you breastfeed your baby frequently (every 2-4 hrs- day and night), avoid bottle feeds, give minimal supplements and have no menstrual bleeding.

FACT 2: There is a direct relationship between a womans breastfeeding pattern (frequency and duration of feeding) and her natural secretion pattern.
Women experience discernable changes in the quality and quantity of their natural secretions throughout their reproductive years. These changes are caused by fluctuating
hormone levels. Through daily observation and charting of these secretions- breastfeeding women receive additional contraceptive protection during and beyond the six months stated above. Any woman can learn how to interpret these changes and then use the information for either achieving or preventing a pregnancy. Natural secretions come from crypts or crevices in the cervix and gravity leads them downward through the vagina and out of the body. Most women notice these secretions as dry or wet stains on underclothes.

FACT 3: Regardless of a womans hormonal phase, she can know exactly when her body is fertile, infertile, or trying to ovulate.
Three primary fertility signs (basal body temperature, cervical secretions and cervical position) enable a woman to map out her fertile and infertile days, regardless of whether or not she is: breastfeeding (with or without menses), menstruating regularly; perimenopausal; coming of the pill; or after a miscarriage or abortion.

FACT 4: The methods which promise you this protection while breastfeeding are nearly 100% effective. Yet like most contraceptive methods, the effectiveness rate depends on the degree of correct and consistent use by the woman/couple utilizing it.

NOTE: IT MUST BE FIRMLY UNDERSTOOD THAT ONLY WHEN LEARNED WITH A QUALIFIED TEACHER CAN THIS INFFORMATION BE APPLIED AND USED AS AN EFFECTIVE AND SAFE METHOD OF CONTRACEPTION. The learning process requires a two-session, instructional class, and includes phone follow-up. If someone tries to implement this on her own, she will be at risk for unintended pregnancy.

General Background
Fertility Awareness Method (FAM) and Lactational Amenorrhea Method (LAM), refer to two, scientifically-validated and researched methods of natural contraception; both are recognized and endorsed by the International Planned Parenthood Federation, the World Health Organization, and many other health organizations around the world. FAM was adapted as a method of natural birth control in the late 70s-early 80 by American and European reproductive health experts (even though the scientific facts upon which it is based have been known since the 1930s and 1960s). LAM was developed as an interim family planning method in the late 1980s after undergoing clinical trials in South America. It was later approved as a guide or model for developing culturally-appropriate, international family planning programs. These programs proved successful as they rely on the traditional practice of prolonged breastfeeding.

FAM and LAM offer women an opportunity to learn about and connect to their bodys unique fertility language, while gaining a sense of personal power, autonomy, confidence and peace of mind. When these two methods are combined, a breastfeeding mother can know on a daily basis whether or not she could be fertile. These methods work by informing you when your body is trying to ovulate and when your hormonal see-saw is shifting. Despite what many physicians and women might still believe, breast-feeding mothers do not have to resort to birth control pills or IUDs in order to effectively prevent pregnancy during the breastfeeding period.
This article explains how breastfeeding can be used to prevent pregnancy. It will summarize the professional literature regarding lactational infertility, fertility and hormones, and natural birth control methods. It will provide you with helpful, hands on information for how you can maximize the practice of contraceptive breastfeeding while controlling your fertility naturally and safely, without hormones, devices, side effects, or medical intervention. Conventional birth control methods will also be discussed.

What Happens to our Bodies Before and During Pregnancy?
During the four decades of our fertile-bearing years, our bodies are computer-programmed to create the conditions necessary for pregnancy. Unlike men who are fertile round-the-clock, womens fertility is cyclical and limited to an approx. 5-7 day period. A womans fertility cycle resembles the moon cycle, an average of 29.5 days. A womans computerized program utilizes a complex web of hormones, or chemical messengers, whose job is to relay specific instructions to various organs in the body. These hormones are activated according to an intricate timetable. FSH (follicle stimulating hormone), and LH (luteinizing hormone), are secreted in the brain; they travel through the blood stream to the ovaries, giving it instructions to secrete other hormones needed for ovulation and fertilization. Estrogen, produced in the ovary, stimulates the ovarian follicles, or eggs, to develop. Estrogen is also responsible for producing special changes in our natural secretion pattern. When we are infertile, our bodies produce a thicker and drier secretion whose acidic properties act as natural spermicides. As ovulation approaches, increased amounts of estrogen produces a very wet, watery, stretchy, and lubricative fluid resembling egg-white whose job is to nourish and transport the sperm while they swim through the chambers and tunnels of our reproductive tract. When the timing and hormonal conditions are right, the sperm and egg cells have the opportunity to meet. Estrogen prepares the lining of the uterus for implantation. It builds a warm nest composed of layers of blood vessels, sugars, proteins and fluids. Estrogen enables a ripe egg to burst from the ovary and into the fallopian tube so that fertilization can occur. The egg will only live 12-24 hrs but the sperm can live up to 5 days. Together, these two facts create a window of fertility which is open for up to a weeks time. After ovulation, another hormone, progesterone, becomes dominant. It is also secreted by the ovary, and its job is to further prepare the uterus for the nine month incubation journey we call pregnancy. Our breasts also undergo cyclical changes as they too are preparing for pregnancy and breastfeeding function.

If women are not suppressing this natural hormone cycle by taking birth control pills or other hormonal preparations, they can experience these wonderous changes on a daily basis.

When women are pregnant, the brain-ovarian- hormonal interplay described above is suspended (even though hormones continue to secrete in the ovary by the corpus luteum). Progesterone is essential for holding together the uterus during the first trimester of pregnancy. Later on, when the placenta develops, other hormones play a dominant role in supporting the pregnancy in the uterus. Luteal and placental steroids naturally suppress circulating levels of FSH and LH in the bloodstream and disrupt its release from the pituitary gland in the brain. During childbirth and after the placenta is delivered, the inhibiting effects of estrogen and progesterone are removed and levels of FSH and LH gradually rise and the pituitarys release of these hormones returns.

What Happens After Childbirth?
If a woman does not breastfeed, her first period will most likely return within 4-6 weeks of delivery. In two out of three women, the first bleeds will occur in the absence of a proper ovulation because of a still shifting hormonal imbalance. This means that is highly unlikely that a woman could get pregnant so soon after giving birth and before getting her first period. By the second and third cycles, approx 85% of women will be ovulating normally.

Lactational Infertility
Lactation, or breastfeeding, is what extends the period of infertility and depresses ovarian function. While blood levels of FSH return to normal levels after two months, the LH stimulation and release is depressed in the brain, thereby confusing the body and preventing a proper ovulation. 80-90% of breastfeeding women will have one or more annovulatory (non-ovulating) cycles before their fertility resumes.

Infant suckling helps to stimulate the nerve endings in the nipple. These nerve impulses are passed to the hypothalamus (brain), which in turn stimulate the release of prolactin- a hormone which increases during pregnancy twenty-fold and which controls the rate of milk production. The more the baby sucks, the more milk and prolactin are produced. Another hormone, oxytocin, helps regulate the milk flow or let-down reflex. Suckling stimulates oxytocin, by causing contractions in the breast cells which help push forward the stored milk in the lobes so that it can reach the ducts and nipples.

Contraceptive Benefits of Breastfeeding: LAM Method
For up to six months, a woman can enjoy a fertility-free honeymoon (98% effective) if she meets the following criteria:
a) She is fully or nearly fully breastfeeding (Frequent stimulation of the breast accompanied by long feeds, short intervals between feedings, and night feeds are the most important factors which produce a contraceptive effect).
b) If no other liquids or solids are given to the baby on a routine basis, or if vitamins, mineral water, and juices are given infrequently.
c) If she has not experienced a first, postpartum menses or bleeding.

*(A woman should consult with a certified LAM or FAM teacher if she has questions about this criteria)

LAM is a highly effective method of contraception because it enables the infant to obtain nearly all nutritional requirements through breastfeeding and maximal suckling stimulation at the breast. As long as additional foods do not decrease the duration or intensity of suckling, small amounts of supplements should have little or no effect on the return of fertility.

Extending the Benefits of Natural Contraception During and After Six Months
Near the six- month postpartum time, most women will not be able to adhere to the criteria defined by the LAM method alone, and therefore will need to rely on additional contraceptive tools. Most women will already have begun to introduce solids to the infants diet, usually in the form of cereals or puree fruits and vegetables. Artificial milk, juice, or bottled water are often included in the diet by this time. If a woman wants to maintain her milk supply and delay the return of fertility, she should always nurse first and offer solids/supplements afterwards. If supplements are given first, the baby will experience satiation earlier and have a reduced appetite for breast milk. This will lead to a decreased milk supply. Most babies at this time are sleeping longer hours, which means there is decreased stimulation to the breast. The breastfeeding hormones, prolactin and oxytoxin, may lose their grip and within a short time, a woman might experience a first bleed, wet secretions, and attempted ovulation. Weaning a baby or toddler, whether gradually or suddenly, could also result in ones fertility returning quickly. Fortunately, there is a full-proof way of knowing in advance how and when this will happen.

LAM Combined with Fertility Awareness Method (FAM)
While ecological breastfeeding offers one line of postpartum protection, Fertility Awareness provides an additional tool. For women who want to prevent pregnancy during and beyond the six-month window of time, FAM provides the additional, perfect solution.

FAM involves the observation and charting of three primary fertility signs which signal when the window of fertility opens and closes. Only one of these signs, cervical secretions, is reliable and relevant for the postpartum, breastfeeding woman.

Few women have been taught that there is a distinct and clear relationship between natural secretions and fertility, and between secretions, fertility status and breastfeeding. Most women in developing countries understand and take advantage of this because they practice a culturally-accepted form of breastfeeding on demand. Their lifestyle includes staying in close proximity to their infant (often attached to the mother by a sling) and nursing frequently, even if only for a minute at a time. The on-going stimulation of the breast makes it possible to space pregnancies in 2-3 year intervals, on average.

Although rare and extremely difficult to implement, western women, as a group, are not able to reap the long-term, contraceptive benefits of breastfeeding (The cultural and lifestyle barriers involved are too numerous and deserve discussion elsewhere).

Postpartum Secretion Checks
Once the bleeding and lochia from childbirth end, a woman can start observing and charting her (cervical) secretion pattern. With the help of a qualified teacher, she will learn how to recognize true vaginal dryness, dry, infertile secretions, and wet, fertile ones. Secretions can be checked externally or internally by any woman.
A womans secretion pattern follows her breastfeeding pattern in a parallel track. Women who are fully breastfeeding on a set or almost set schedule will experience continuous dryness and/or dry secretions for weeks if not months at a time. Once a woman identifies her basic infertile (secretion) pattern (BIP), she can apply some very simple (and liberal) rules which will allow her to have frequent, unprotected intercourse.
These rules must also be learned together with a qualified teacher.

* Women with dryness will also experience discomfort or pain during intercourse. Because of low levels of estrogen, water-based vaginal lubricants are recommended to remedy this problem.

When Secretion Patterns Change
The BIP will continue as long as the breastfeeding pattern is constant and stable.
Eventually, when solids and supplements are introduced and when the baby sleeps for longer periods, the hormonal triggers from breastfeeding which suspend our fertility will decrease and weaken. To reiterate, nursing mothers will notice a change in their secretion pattern (to a more fertile one) when:
1. the baby begins to sleep longer intervals and through the night
2. the mother returns to work or is separated from baby for parts of the day
3. other foods/solids/supplements (even pacifiers) are introduced
4. the breastfeeding schedule and pattern change- weaning begins, traveling, illness, etc...

Despite these changes, you will have the knowledge and tools to diagnose your fertility status every day!!

** This method is not recommended for women who suffer from untreated, or chronic yeast/candida infections. The presence of yeast will mask a womans normal secretions.
Women who notice unfamiliar secretions accompanied by symptoms should have a vaginal culture done to correctly diagnose the infection, and then choose a conventional or natural treatment approach.

Natural Contraception (FAM) When Fertility and Menses Return
Once menstruation resumes, the two additional fertility signs are added in order to identify the fertile and infertile days of the cycle. These signs are basal body temperature and cervical position. BBT refers to the temperature of the body at rest. When measured for one minute with a special digital thermometer, women can learn how to identify the shift in temperature which occurs after ovulation and which stays high until the next period. Safe and unprotected sex can take place for 1 --2 weeks on average. The second sign, cervical position, also changes at the time of ovulation, By checking internally with a middle finger, a woman can feel how the cervical opening rises (toward the uterus), opens and softens to allow sperm into the reproductive tract. Immediately after ovulation, it lowers, closes and hardens.

FAM can also be used to plan your next pregnancy and even increase your chances of choosing the gender of your baby.

Other Contraceptive Options for Breastfeeding Women
Almost all contraceptive methods are effective when used perfectly- consistently and correctly. Yet because human behavior tends to be irrational and inconsistent, women and couples who use contraceptives often use them imperfectly. Women and their spouses should carefully consider the advantages and disadvantages of each method, as well as their own values and priorities, before choosing a method.

Oral contraceptives containing estrogen are not recommended for nursing mothers. Many health professionals are concerned that all hormone combinations that suppress ovulation may have short- and long-term adverse effects on breastfeeding infants because small amounts of hormones make their way into the breast milk. Furthermore, many types of pills containing estrogen will reduce your milk supply.

Pills that contain progestin only are considered compatible with breastfeeding. Femulin is a progestin-only pill which is considered safe because it is a low-dose preparation. Low dose pills though can cause sporadic bleeding in some women and they are statistically less effective than estrogen pills.

IUDs are effective methods and carry no risk to the infant, nor do they have any effect on breastfeeding and milk supply. Insertion can take place within 48 hrs or four-to-six weeks after delivery. Some IUDs can be inserted after the sixth week postpartum. IUDs usually increase menstrual flow and blood loss and carry a certain risk of pelvic infection which can affect future fertility. A newer IUD model (Merena) proports to reduce bleeding by the sixth month of use.

Barrier Methods & Spermicides
Barrier and spermicidal methods are available OTC (Over the counter- when you can find them. It is become increasingly difficult to find these methods in Israeli pharmacies). This group of methods is considered to be 80-90% effective when used consistently and properly. Methods such as condoms, diaphragms and caps are safe and reliable methods, when used perfectly by responsible and unambiguous users. They should not be initiated until at least six weeks after delivery, as they cannot be fitted properly until the uterus returns to its pre-pregnancy size and the risk of infection drops. Spermicides such as Delfen (gel, foam or cream form), Glovan suppositories or VCF (Vaginal Contraceptive Film) should also only be used after the six week mark.

Why Doctors Dont Recommend Natural Methods
Fertility Awareness tools (basal body temperature (BBT), cervical secretions, and cervical position) have been known for many decades. Gynecologists use BBT and secretion changes for diagnosing and treating infertility, but they are largely unfamiliar with FAM as an effective method of birth control. Many doctors and health professionals mistakenly confuse scientific, natural methods with the ineffective rhythm method (based on calculations of past cycle lengths), or they are misinformed or biased about their use. Although scientifically-validated and researched, these methods are not taught in medical school as methods of contraception.
It is a fair characterization to say that in the present medical culture, hi-tech methods are preferred over low-tech ones. The fact that women can learn and apply these methods without medical intervention and the fact that pharmaceutical companies cant profit from them, may be additional reasons why physicians show little interest or faith in them.
When we look at cultural and lifestyle preferences, most people seem to prefer quick fixes, which make oral contraceptives and IUDs look easier and better to use.
It is only in the last fifteen-twenty years that women have begun demanding safer and effective alternatives to hi-tech, modern methods.
A growing number of holistic and complementary practitioners as well as rabbis, niddah and breastfeeding counselors are becoming informed about the benefits of natural methods. The only hitch is that these methods cannot be learned from a friend or a book. The process requires two learning sessions, couple cooperation and communication, and an initial investment of time and cost. Natural methods are not suitable for every one.

Back to Nature
Fertility Awareness is something we all should have learned in high school biology class. Men and women alike would be more comfortable, knowledgeable and accepting of their bodies had they learned this vital information at an earlier age. For the anthropologically-minded, it is worth noting that there are tribes in Africa and Indians in North America which have been teaching natural fertility for generations! When celebrating a young girls first menstruation, all the females in the tribe, representing all the generations, gather upon the highest hilltop and participate in a festival lasting a few days. Utilizing storytelling, dance, special foods, costume and song, the tribal women celebrate the young girls coming of age. The peak of the ceremony occurs when the girls grandmother removes a flat, smooth stone from a leather pouch. She then proceeds to show her granddaughter how to wipe her vaginal opening so she can know when she is and is not fertileso she can take charge of her fertility at the outset of her becoming a woman

The mere existence of this traditional ceremony both highlights and confuses our definitions of primitive vs. modern cultures. It is strangely paradoxical that as our society advances in terms of medical science, technology and research, an individuals personal understanding and control over their bodies seems to be waning or weakening. We live in a world where external experts are expected to know more about our bodies than we are. It is ironic that amidst the information explosion and the freedom to choose mantras which pervade our culture, so many women have lost touch with or become estranged from their feminine selves. Perhaps it is time to reconsider the sacred and honored place of primitive customs, if only to enable women in the post modern world to feel empowered in and by their bodies. Perhaps the time has come for women to question the medicalization model of fertility and the body- if only for the purpose of gaining greater self-confidence, control, and autonomy. Women can be their bodys best experts-if they so choose.

It must be stated clearly that a natural approach to anything involves time, effort, commitment, responsibility and discipline. While the pay-offs and benefits can be of great worth and have a positive, direct impact on quality of life, each couple must weigh the advantages and disadvantages these methods offer, based on their values and present needs. They require a few minutes work a day for correct practice, in addition to partner support, communication, and cooperation. Natural methods are not recommended for couples in non-monogamous or casual relationships. They can be used during a womans entire reproductive life.

You the reader are invited to deepen the historic connection to your natural rhythms, bodies and feminine essence. Learning to tune in to the ebbs and flows of female cycling can help all women better trust their instincts, make wiser choices, and ultimately take fuller responsibility for their health and well-being.

Bibliography & References

1. Postpartum Contraception and Lactation, in: Contraceptive Technology,
(17th Revised Edition), 2001
2. The Breastfeeding Handbook,(Revised Edition), (Handbook for health professionals) J. Goldfarb and E. Tibbetts, 1989
3. Taking Charge of Your Fertility, (Revised Edition) Toni Weschler, 2002.
4. Statement on Breast-Feeding, Fertility and Post-Partum Contraception,
International Planned Parenthood Federation, 1996.
5. Family Health International, International Studies in Natural Family Planning at Georgetown University, Washington, D.C., the Population Council,


Michal Schonbrun, MPH, CHES, is a womans health educator in Jerusalem who has been teaching and training lay women and health professions in the areas of fertility and womens health for the past 15 years. She is a certified Fertility Awareness instructor and has a masters degree in public health and community health education. She is a certified health education specialist. She can be reached at