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Contraception while breastfeeding

10 October, 2003

Question:

I gave birth to my third child 10 weeks ago. At four weeks, my bleeding had stopped (confirmed by my gynecologist), and I began taking Femulen (I am fully breast-feeding). Femulen caused a great deal of spotting, and I was unable to complete 7 clean days. As a result, I stopped the Femulen, and finally went to the Mikva last week. In the course of the Femulen I achieved day 5 twice & day 7 once.

After speaking to a yoetzet, I used spermicide: I have CMV, so its important not to get pregnant, and my doctor felt that the combination of spermicide and breastfeeding would provide sufficient birth control.

Unfortunately, I seem to be allergic to the spermicide, and I understand that all spermicides have the same ingredient, although the yoetzet suggested I try a different type to check.

My second child is allergic to milk, eggs and as a baby also soya. When he stopped nursing, he used Pregestimil. While feeding him, I also stopped eating the allergens, which stopped him vomiting. The new baby also vomits a lot, and I have just started to cut out milk and eggs, to see whether that helps – it is a little better, but too soon to know for sure. I am mentioning this because it is important to me – and to the baby – that I nurse as long as possible.

Any advice you can give on suitable birth control given this situation would be gratefully received! I understand that in many circumstances an IUD is acceptable halachically, but I am not very attracted to this solution. My gynecologist felt that Femulen was the only oral alternative for nursing mothers.

thank you


Answer:

It is worth trying one other formulation of the spermicide as you may be allergic to one of the inactive ingredients that make up the base rather than the active ingredient of Nonoxynol 9, which is the same in every formulation. The IUD would be halachically acceptable although it may also cause bleeding problems.

As an IBCLC lactation consultant and pediatrician, I do not agree with your doctor that there are no other oral options for nursing mothers. Femulen is better, but if other methods of birth control do not work, then combination oral contraceptives can be used by nursing mothers. There are two reasons that physicians fear to do this. The first is potential harm to the baby. This has not been demonstrated despite millions of infants exposed to the estrogen in the pill. The American Academy of Pediatrics states that oral contraceptive pills are approved for use in breastfeeding mothers. The other concern about the combination pill is that is can reduce the amount of milk. This is a real concern. The amount of reduction depends on the mother. Some barely experience any. Some experience it but by increasing breastfeeding frequency and duration are able to compensate. Others have to start supplementing. If you do not find a spermicide that you can use, I would suggest in fact using a combination pill with low dose estrogen (this can sometimes cause spotting but often improves by the second month).  Have the baby weighed before you start and after a week to help assure that he/she still has reasonable weight gain. Breastfeed often.

If you are having real difficulty counting seven clean days, it is worth discussing the situation with your rabbi. He may be able to suggest ways to alleviate the situation halachically. If you don't have a rabbi with whom you can discuss this, please get back to us and request an individual psak.

After you have gone to the mikveh, wear colored underwear and don't look at toilet paper. This may help you avoid becoming niddah again from spotting, since stains make you niddah only if they meet specific criteria (see the article on ketamim for a detailed explanation).


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