I work in a prenatal clinic for Medicaid-eligible recipeints and we also
have a Title X funded family planning clinic. We are updating our Title
X protocols. I am a nurse practitioner who is also an IBCLC. I am aware
of the recommended protocols for starting hormonal methods after
breastfeeding is established or, even more preferable, use of a method
other than hormonal.

Our old protocol now states that the combination pill can be used after
3 weeks postpartum. The depoprovera protocol is written to wait until 6
weeks.
We also recommend the progestin only pill for Moms who wish to use the
pill and breastfeed and to wait until 6 weeks. However we also have many
women who are at high risk for getting pregnant soon after delivery so
we will sometimes write for DMPA within 5 days of delivery for those
Moms. Just to give you an example, a high risk woman for delivery might
be a 19 y/o gr 5 para 3. Even though i am a strong advocate for
breastfeeding, I must see the woman's total situation and help this
person avoid another pregnancy.

Now what about the woman who does not want the progestin only method and
is at high risk for pregnancy. Is it preferable to  choose to not
breastfeed over using the combined oral contraceptive? Dr. Hale's new
book on Clinical Guidelines indicates that combined OCs are (don't have
the book here at home) ? contraindicated and the progestin only methods
are preferred. Again, i need accurate information for the other health
care providers seeing our patients of low income and high risk for
repeat pregnancy. I see that the AAP drugs and breastfeeding statement
is from 1994. Thanks for your input.

Cindy Church, RNC, IBCLC
Lansing MI

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