Brenda, I've seen the same things in the "Depo moms" at WIC (decreased milk
supply, difficulty w/re-building supply).

It sounds to me like your questions center around the definition of "safe".
Which is really several different questions: safe for baby? for mom?
long-term? short term? for maintaining adequate milk supply? And then
there's the whole risk:benefit set of issues - is this mom/baby at greater
risk from a repeat closely-spaced pregnancy if she uses (or doesn't use!) a
different method? Etc...

My observations (NOT research-based, and I wouldn't present them as such to
client or colleague) are that for many women the Depo shots and the pill
*may* tend to decrease supply. I've noticed this especially with anyone
whose fertility/hormonal balance might be marginal to begin with - "older"
women (say >35 or so),women whose time/energy/commitment to frequent ad lib
BFing may be constricted by attitudes or other life commitments, women who
"didn't have enough milk" to nurse a previous child, women who live under
chronic high-stress situations. I might say that it's these other factors
that are causing the low supply, rather than the contraceptive itself,
except that often things improve when the hormones are stopped, without
changing anything else in the situation.

And of course there is the depression factor with any of the hormone-based
contraceptive methods - lots of mothers have described to me how depressed
or "crazy" they felt with these methods (a real problem with Depo,
obviously, because it's so long-acting). That in itself is enough of a
deterrent to make me think that for lots of women, these methods wouldn't be
*my* first choice...but then again, an unplanned, unwanted pregnancy can be
pretty depressing - in fact, downright devastating - too, and when I talk to
a young woman who tells me that no way will she be able to use a diaphragm
or a condom reliably and that no way does she want to get pregnant again any
time soon, I'd rather see her give the "mini-pill" a try than nothing at
all. I also advise that continuing to nurse as frequently as the baby wants,
*including* at night, is the best way to keep her supply up. Well, I tell
everybody that, but I especially emphasize it when a woman is using a
hormonal method of birth control. Also cutting down/eliminating as many
other "supply-busters" as possible - excessive caffeine use, heavy smoking,
separation from the baby, unecessary supplementing, etc.

Well, this probably hasn't made your writing a pamphlet any easier - but
it's not an easy question, and no one answer is right for everybody. I know
that, in our area anyway, the prescribing health care professionals say that
the mini-pill and Depo are "fine" to use while BFing, but that isn't what I
see necessarily. I'm thinking that they're probably looking at different
"risk factors" - long-term medically-measured  effects, as opposed to issues
r/t supply & continued BFing.

Cathy Bargar RN IBCLC IThaca NY

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