Dolores, Dawn

I completely agree with what Dawn writes - we need more research.

When I was practising in Harare (a long time ago!) the African 
mothers delivering at the large government hospital would often be 
given Depo before discharge.  Breastfeeding was universal and 
continued til 18-24 months or so, but exclusive breastfeeding rates 
in the first 6 months were quite low (increasing from 11% to 16% to 
23%, but still not good enough).
Is there a difference between Depo and other progestin-only oral 
contraceptives - maybe not much, except that you can't stop Depo if 
it proves to cause problems - and I believe that's risky.  I found 
similar research on oral contraceptives to that cited by Dawn for an 
injectible.

My private practice clients were often prescribed progestin-only 
contraceptives quite early - from 0-6 weeks, and I'd be consulted a 
lot for "colic" and low weight gain, which appeared to resolve quite 
miraculously if the mother elected to stop the oral contraceptives 
and use another method of birth control.   I became so concerned 
about what looked like the adverse effect on lactation that I started 
digging around.  This wont help you either Dolores, because I can't 
give you the references (my files were burned when I left the 
country), but I learned/found:
1. One of the OBs who was very into the journals and studies told me 
that different formulations have different effects on different 
women, ie some will not notice a negative effect on milk production 
with some progestin-only meds, others will.
2.  Some progestins behave more like estrogen in the body, ie are 
more likely to suppress lactation, than others.  This may be because 
some of the synthetic progestins are more likely to reduce the 
protein and fat content of the milk, and this may be tied in to the 
possibility that they negatively effect the mother's prolactin levels.
3.  Many of the studies showing no apparent negative effects of Depo, 
and other oral formulations (perhaps such as the one Dawn excerpts) 
are very old.  Importantly, at the time they were conducted, 
"breastfeeding" was not well defined, and the importance of exclusive 
breastfeeding was probably not even known, and certainly wasn't 
acknowledged, so may not have been mentioned, eg "ever-breastfed" was 
called "breastfed" (could have been once a day, or the baby could 
have had caloric needs topped up  by other foods and liquids.)
4.  Many of the studies "proving" that a particular progestin-based 
contraceptive had no negative effect on breastfeeding duration 
compared the new formulation with another formulation, and there were 
no placebo controls and certainly no exclusively breastfed + placebo controls.
5.  The formulations which seemed to give me (the LC) the most 
trouble the most often were those that were subsidized by USAID - 
there were two brand names in particular, which used the same drug in 
the same dose but had different brand names, one for the "poorer" 
market, distributed in the government healthcare system, and one for 
the "richer" market, sold through the private pharmacies at a much 
lower price than other progestin-only contraceptives - naturally they 
seemed to be the most popular!   Sometimes drugs can be sold or 
distributed in a developing country, and it's counted as part of an 
aid package, which wouldn't be permitted to be sold in the home 
country (?dumping?) - I don't know if this was the case with these 
two pills, but naturally, I did wonder.
6.  It was the frequency and similarity of the cases I had - the 
fussy, unsatisfied, crying babies, and the babies limping along on 
low weight gain in spite of by-the-book breastfeeding, coupled with 
the consistent history of the mother taking these pills on the dot of 
six weeks postpartum or sometimes much earlier - and the quick 
resolution of problems if she stopped taking the pill(s) - that made 
me start thinking of this as a trend rather than a series of isolated 
coincidences.
7.  The topic of contraception has become quite politicized, and 
strays into women's rights, and I also learned that one method of 
increasing contraception acceptance is to call it a woman's 
right.  This blurs the distinction between medical issues (poorer 
health outcomes for babies whose mothers "cannot"breastfeed, or 
cannot breastfeed exclusively due to the negative effect of oral 
contraceptives on lactation) and social issues (women's rights to 
limit pregnancies and to choose alternatives to breastfeeding).

The thing about Depo-Provera is that it's irreversible, unlike 
progestin-only-pills (POPs) which the mother can just discontinue if 
she notices negative consequences for breastfeeding.  As Dawn cites, 
in any event, it shouldn't be prescribed until lactation is 
"well-established", ie after 6 weeks.  The other thing is that Depo 
can cause on-going bleeding.  Maybe one of the research questions 
should be what happens to a mother's Hb levels, and if Hb levels 
exert an effect on milk production - maybe that is already 
known?   We also need new, up to date studies with more stringent 
definitions of "breastfeeding" to see if babies whose mothers are on 
Depo, or any other POPs can achieve normal weight gain on exclusive 
breastfeeding.

Sorry, this just raises more questions than answers.  But Dawn is 
quite right -  perhaps WE are the ones who could show that this 
research is way overdue.

Pamela Morrison IBCLC
Rustington, England
---------------------
Date: Wed, 11 Apr 2012 08:26:32 -0400
From: Dawn Kersula <[log in to unmask]>
Subject: Depo-provera research

Dolores and Colleagues,

None of us is going to be able to help you very much - I am speaking on the
basis of what Lactmed, The National Institutes of Health website, has for
info and references. (You can easily access this at
http://toxnet.nlm.nih.gov/cgi-bin/sis/search/f?./temp/~toR6lt:1

One paragraph (which will be one you will be quoted I'm sure) says

In a nonrandomized, nonblinded study comparing women who were breastfeeding
at discharge, 102 postpartum women received depot medroxyprogesterone
acetate (dosage not stated) in the early postpartum period (average 51.9
hours postpartum; range 6.25 to 132 hours), 181 received another
progestin-only contraceptive and 138 used nonhormonal contraception. No
differences in breastfeeding rates were seen at 2 and 6 weeks, but women
receiving any hormonal contraceptive were breastfeeding at a lower rate
(72.1% vs 77.6%) at 4 weeks postpartum. The authors concluded that
progestin-only contraception initiated in the early postpartum period had
no adverse effects on breastfeeding rates.[31]

I don't have my Hale book here in my office (we use it lots on the floor)
-- Dr. Hale's website is also a good place to look at things. There is a
search feature on his site, which I used to look up Depo. He discusses this
here
http://www.infantrisk.com/content/safe-use-birth-control-while-breastfeeding
and it looks like he has some questions.

The problem is - if we are seeing the problem WE should be doing a study.
(In our spare time, right?) But if you have ANY students in your facility
who need a project - this would be a place to direct them.

I can't very well say "I hope this is helpful" because it won't be - but it
may help us all to see where the confidence of midwives and doctors is
coming from when they prescribe Depo early on.

Dawn Kersula in Vermont

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