Monday, May 08, 2006

Breastfeeding and the Pill--Different methods, same results?

A post by Phantom Scribbler led me to this article from the New York Times on Contra-Contraception, by Russell Shorto.

The article discusses the links between abortion, contraception, and a person's view about sex itself. It highlights well the inconstency of being against a morning after pill like Plan B while supporting other forms of hormonal birth control, making the valid point that ALL forms of hormonal birth control, as well as the IUD, have a small chance of preventing the implantation of a fertilized egg.

But the paragraph that Phantom Scribbler pointed out is what really drew me in:

What's more, Dr. Trussell added: "There is evidence that there is a contraceptive effect of breast feeding after fertilization. While a woman is breast feeding, the first ovulation is characterized by a short luteal phase, or second half of the cycle. It's thought that because of that, implantation does not occur." In other words, if the emergency contraception pill causes abortions by blocking implantation, then by the same definition breast feeding may as well.

I found a website about ecological breastfeeding from a natural family planning standpoint that actually cites a study:

"Several studies have indicated that fertility and ovarian activity return step by step (Ellison 1996, p. 326-327):

  1. "Follicular activity without ovulation (No chance of pregnancy.)
    1a. Menstruation without ovulation (This does not always occur--see below.)
  2. Ovulation without luteal competence (After the egg is released, fertilization may take place. During the luteal phase, the uterine lining is prepared for implantation as the egg travels down the fallopian tube and into the uterus. If the uterine lining is not adequately prepared for implantation, the implantation will probably not be successful.)
  3. Full luteal competence (Full fertility -- at this point breastfeeding no longer has any effect on your chance of pregnancy.)"



The site has a chart with information about these stages, including a notation that a study by Gray showed that 41% of breastfeeding mothers showed "First ovulation without luteal competence"--in other words, ovulation with likelihood of creating a fertilized egg that is unable to implant due to changes in the uterine lining from breastfeeding.

A little further down the page:

"Do I need to wean to get pregnant?
Probably not. If you are still transitioning to full fertility (as discussed above), breastfeeding may affect the success of implantation. Once implantation is successful, breastfeeding should not affect a healthy pregnancy (see A New Look at the Safety of Breastfeeding During Pregnancy for more information). "

An earlier article from the New York Times says,

"Trussell said he supports doctors who say women need to know it's possible that emergency contraception may affect embryo implantation. But that's true for nearly all methods of contraception, he added--including breast-feeding.

Breast-feeding, which can have a contraceptive effect up to six months after the birth of a child, also causes changes in the uterine lining. In that respect, it carries the same possibility of interfering with implantation.

"If you're talking about informed consent," said Trussell, "then it's not right to withhold evidence that breast-feeding may work in the same way."


Here's a summary of a study done on rats, looking at the relationship between lactation and ovulation. They found that if the timing was right, lactation did inhibit implantation of a fertilized egg.

Here's an interesting and thought-provoking paper by a group of Christian physicians that examines the studies and information about various forms of contraception. It analyzes the way hormone contraceptives work and compares that to the way a woman's fertility works when not on the pill. The paper makes the point that studies show "spontaneous pregnancy wastage" at 73% between fertilization and 6 weeks.

The article makes a pretty good case that hormonal contraceptives work primarily by preventing ovulation, then by thickening the cervical mucous, and also thin the uterine lining. There is a small theoretical risk of the pill preventing implantation of a fertilized egg, but numerically this doesn't seem to happen more often with the pill than it does without it.

So, essentially, it seems that progesterone is progesterone is progesterone, at least when it comes to avoiding pregnancy (we know the pill carries other health risks and side effects not entailed in breastfeeding). Breastfeeding apparently prevents conception in the same ways the pill does, because both methods operate by producing hormones that have the same effects. The pill is essentially designed to mimic the effect of pregnancy and/or breastfeeding on the body's response to ovulation and pregnancy.

The difference, of course, is that breastfeeding is almost never done solely for the purpose of contraception, although even Catholic organizations such as The Couple to Couple League actively promote its use and effectiveness as a contraceptive. The pill, though it is often used to treat other issues, and though it can have a positive effect on breastfeeding (causing better milk production, etc), is usually used with the goal of preventing pregnancy.

That seems quite relevant to our earlier discussion on Mark's blog about contraception and the relationship between sex and reproduction. As I mentioned there, if the desire to prevent a pregnancy is in itself wrong (which I don't think it necessarily is), then it could be equally wrong for a person to take an extra-hot bath to try to minimize chances of a successful pregnancy or to time intercourse only during infertile times to avoid having children.

That's quite debatable, as we previously established, and I know there's disagreement among members of this blog on this topic. I'd love to pick up the discussion again about whether intercourse can morally be separated from the goal of procreation or not.

I do tend to feel that purposely preventing the implantation of a fertilized egg is morally wrong, although this information is making me reconsider where I might draw the line on this issue. That has seemed a more clear-cut issue to me than the contraception debate in itself.

But, of course, it could be very difficult to draw a line there, too. There are so many things one could do that might inhibit implantation or cause early miscarriage--including overdosing on vitamin C or parsely, taking ginger or rosemary, having an eating disorder, taking drugs to treat rheumatic disease (such as lupus), having endometriosis, using acupressure/acupuncture, not to mention all the things that people think prevent implantation and really don't--like taking a hot bath or jumping up and down after intercourse. Any of those things would be very hard to regulate or prove damage from, and some are unavoidable.

Even if something is wrong, it is not necessarily right (or even possible) to regulate it by law. That's one of the reasons I see big problems with laws that would prosecute women for causing damage to their baby by taking drugs or drinking during pregnancy. If you're going to prosecute a woman for hurting her baby by drinking alcohol or taking drugs during pregnancy, where are you going to draw the line? Could a woman be prosecuted for drinking caffeine? Eating sushi? Not taking prenantal vitamins? Overexercising? Any of the other myriad things that could possibly be harmful during pregnancy?

Regulating things that prevent implantation is just as problematic. If we make Plan B illegal for that reason, we would also have to make the IUD and hormonal birth control illegal to be consistent. But if we did that, then what about breastfeeding or taking too much Vitamin C?

What do you all think?

23 comments:

Phantom Scribbler said...

You know that I disagree with a lot of things, Purple Kangaroo, but this is a really thoughtful, nuanced piece. It's really helpful to me to see your side of the debate presented with such a clear recognition of the ambiguities involved. Thanks!

purple_kangaroo said...

Thanks, Phantom Scribbler.

I hope you'll check back and see (maybe join in on?) the discussion as it develops, if it interests you. I'm hoping there will be a number of differing views represented here for discussion.

Bridget said...

You hit the nail on the head when you said even if something is wrong it's not possible to regulate it by law.
That's because "wrong" is subjective, whether the baby is inside or outside it's mother. Do you smoke around your baby? Let the baby watch tv? Use a microwave with the baby in the room?
So have your opinions and act accordingly in your own life people, and trust me to be able to plan my life and my family with tools that you might not choose to use in yours.
This is a great piece and thank you for presenting such a well thought out argument.

purple_kangaroo said...

Bridget, thanks for visiting and commenting.

The discussion of right and wrong and of law and societal pressure is an interesting one. Where and how should we draw the line between what is merely a personal decision and what should be regulated in some way by law?

I plan to start a post sometime in the next few days discussing that in a more general context, so look for a post on legislation and regulating people's actions soon.

steviepinhead said...

My understanding is that breastfeeding as a birth control or child-spacing technique works much more reliably in circumstances where the mother is living much closer to the borderline between adequate and inadequate health and nourishment than is likely in the good ol' USA (or other relatively well-off western-style cultures). In other words, breastfeeding the current baby more reliably suppresses pregnancy when the mother's body is over-stressed by the competing demands of providing nutrition for herself and the current baby. If health and nutrition are not so overstressed, breastfeeding becomes a very unreliable means of "family planning."

A dense and technical, but extremely interesting book in this area is Mother Nature,
A History of Mothers, Infants, and Natural Selection
, by Sarah Blaffer Hrdy. A warning, though: this book is emphatically not written from a traditional family values perspective at all--instead it examines, from an evolutionary and ecological prespective, how mothers--and not just human mothers, but females of other ape, primate, and animal species--balance the competing demands of surviving themselves while attempting to insure that at least some of their children/offspring will also survive and thrive.

Again, some of the parenting strategies that Hrdy argues have evolved in various species and cultures do not necessarily make for comforting reading. But the breadth and depth of coverage is fascinating, however unsettling, and amounts to taking a long step back from the usual nose-against-the-windowpane of US cultural and political stances.

Douglas_Coombs said...

Stevie,

'If health and nutrition are not so overstressed, breastfeeding becomes a very unreliable means of "family planning."'

I can't say that I agree with the author's conclusions on the topic. Breastfeeding works well to extend amenorrhea and to delay the return of fertility when there is a mother-baby closeness and a time for the new mom to relax that one doesn't find in fast-paced western society. It is our western lifestyle, not the improvement in nutrition that has dramatically altered the how modern western women experience a return of fertility compared to other societies. Contrary to the author's conclusions, my own experience has been that women with health issues have an earlier return of fertility than those whose "health and nutrition are not so overstressed"

I'm somewhat surprised that someone would write a book on the topic while not researching the applicable medical literature. However, from your description, the author appears to be approaching the situation more as a philosophical Darwinist than as a scientist. Either way, if you want to know more than Sarah Blaffer Hrdy, I would suggest any one of the following journal articles: Journal of Biosocial Science, January 1986; The Lancet, November 19, 1988; and the American Journal of Obstetrics and Gynocology, December 1991, 2039-2040. I left out titles and authors for the sake of space, but one should be able to find them easily with access to a good library journal database.

Doug

Douglas_Coombs said...

Angela,

You raise some interesting questions regarding post fertilisation effects of hormones. I find the reference in the NYT particularly interesting given the timing of Boven's recent article in the Journal of Medical Ethics (2006; 32: 355-356) on the death of embryos due to the rhythm method of natural family planning. http://jme.bmjjournals.com/cgi/eletters/32/6/355
While the misinformation prevalent in Boven's article in particular is discouraging, I think it is a good sign overall that breastfeeding and NFP are starting to come under the microscope. It seems that certain criticisms of the morning after pill in particular and other hormonal contraceptives acting sometimes as abortifacients must be making headway among the medical profession for those folks to start looking around for ways to criticize the groups articulating those concerns. Criticism can be beneficial when based on fact and when both parties have a real desire to learn and improve.

While the Boven's article is mostly malarky (the author is an economist for crying out loud), the breastfeeding question is one that deserves more attention. Caution would dictate that until this is resolved further one concerned about fetal life and using NFP should not rely solely on breastfeeding, but also learn other signs of fertility that warn of an oncoming ovulation.

That said, this is a very complicated issue. While it is true that the body doesn't care how hormones get there, as long as they are present, the equating of a women on the pill with a breastfeeding woman is tenuous in many ways. There is a difference physiologically (as well as morally) between a woman who is nursing and someone who is medicating herself with hormonal contraceptives. Since you're interested in the relationship of ovulation and luteal phase deficiencies, perhaps you will appreciate this *long* paper on the subject by Sioban Harlow, funded by the Population Council:

https://www.popcouncil.org/pdfs/ebert/MenstrualPaper.pdf

Moving on, the article by Crocket, et. al. was an interesting read. I also found a response by Larimore, et. al. to be informative. There surely isn't a concensus on the issue among medical professionals. For one thing, it is very difficult question to study in an ethical manner. For another, there is no motivation among manufacturers to spend the money on a study. It's kind of like trying to convince vaccine manufacturers to avoid the use of aborted fetuses. Why? Developing drugs and studying their effects is expensive. For better or worse, not enough people care enough to dent the pocketbook and get the attention of the drug manufacturers.

I did find it interesting that while Larimore later responded directly and cited the Crocket article, Crocket did not cite any peer reviewed journal by Larimore or Stanford. Such indirect engagement does not bode well in my book. That is merely an indirect assessment, though. By and large, much of the technical argumentation is beyond my ability to form confident opinions. At least Crocket, et. al. avoid the inaccurate drivel that Bovens spouts. Their article deserves some attention.

Doug

steviepinhead said...

Doug, what is a "philosophical Darwinist"?

Hrdy is a Radcliffe and Harvard-trained nathropologist with many years of specialization in the sexual and reproductive strategies employed by humans and their closest relatives, so her book is very much written from a scientific perspective, if not from a strictly medical one.

It doesn't seem to me that only M.D.'s are qualified to speak to this topic, particularly where, as you have suggested, there are non-medical factors going on, including cultural background and lifestyle pace...

Of course, my B.A. was in anthro too, so I may just be feeling a twinge of professional pride.

Douglas_Coombs said...

Stevie,

Having read statistics from several studies and having known several people who reliably used breastfeeding to space children, I can confidently say that Hrdy is out of her league. On a personal level, my wife experienced 14+ months of amenorrhea with out first child. With our second she is at 11 months and counting. Spacing our children is not the reason my wife breastfeeds (there are many other reasons which are much better), but it is an established medical fact that breastfeeding can be a very effective form of spacing children, even among well nourished women.

Will working mothers or crib users get that side effect? That's a question that opens another can of worms, the answer of which explains why many people have never known anybody who experienced such a long amenorrhea.

Doug

Mark Congdon said...

Doug,

I would hesitate to say that Hrdy is "out of her league". Those are strong words. She may well bring a different perspective to the discussion, and it is possible that her conclusions are wrong... it does not follow that she is out of her league.

Having had (through my wife) many discussions with your wife on this issue, I think we may have a terminology issue going on. I think that everyone, you included, would agree that breastfeeding by itself the way it is generally done in America today is not particularly useful at preventing pregnancy. The key is "ecological breastfeeding", if I understand things correctly, which involves a great deal more than just breastfeeding (as you implied). This consideration needs to be taken into account in reading studies, evaluating statistics... and most of all discussing.

Maybe we can try to use "breastfeeding" to refer to nursing as it is generally performed by American women, and "ecological breastfeeding" (or some other term you would prefer) to speak of the full system of lifestyle practices that can possibly provide reliable amenorrhea.

Mark

Douglas_Coombs said...

Mark,

Good suggestion on terminology. I would probably use "American breastfeeding" or "cultural breastfeeding" to differentiate between what most people do and what some call "ecological breastfeeding." I tried to make clear that mere breastfeeding per se has little effect, but consistent use of more 'technical' terms would probably be a good idea in the general discussion.

Perhaps part of the problem is that I've not read Hrdy directly myself. Perhaps her statements are not as broad as I am taking them to be. Honestly, though, anybody who would make a blanket statement that breastfeeding is effective for malnourished or under nourished women but has little effectiveness for well nourished women strikes me as very ignorant of the relevant medical studies and (most importantly) underlying physiology. Perhaps "out of her league" is too strong a phrase, perhaps not. She is an anthropologist, and I can see how from an anthropological point of view one could come to that incorrect conclusion. It takes a physiological understanding of the issue to sort through the various causes.

Doug

steviepinhead said...

Helpful comments, Doug and Mark!

And it's certainly been a couple of years since I read Hrdy, so my characterization of one of her (many) interesting conclusions may have gone astray.

And I have certainly not read most of the studies Doug has alluded to.

I have no doubt, Doug, that breastfeeding does work relaiably to postpone the next pregnancy for some women in some circumstances. My sons were all breastfed, and we noticed at least some of the effect (my wife was working, doing her own anthropological fieldwork among Native American women (thus in more relaxed and "traditional" circumstances than the typical EuroAmerican nursing mother).

But my third son wouldn't be here at all if the "effect" had worked as well as we might (then) have wished (now, of course, I could not imagine the world without my third son in it, as I prepare to attend his college graduation!).

My point, I think (and recognizing that I need to know more than I do), is that a family who seriously intend to rely on nursing--and other associated arrangements--as a family planning, child spacing, or birth control method--need to educate themselves a lot more deeply, and take on a certain ackowledged risk of failure (be it higher, as I might contend, based on what I know so far) or lower (as Doug might contend, based on his study), and be financially and mentally prepared to take on the responsibilities attendant on that "failure," than the superficial mantra that "breastfeeding prevents pregnancy" implies.

I fully realize that Doug is not promoting that simple mantra. But I think we have some responsibility to emphasize the depths of this issue to a wider--potential, perhaps, at this point!--reading audience that may skim through this thread at some point.

And who may not have done all the homework that Doug has done, and would recommend doing.

purple_kangaroo said...

That article is really interesting, Doug. I'm about halfway through it; thanks for sharing the link.

I wonder how much of a connection there might be between spotting during pregnancy and early return of fertility, or at least lack of amennorrhea?

I wonder this because I've always had a lot of spotting in the first trimester, and also have not gotten amennorhea even with ecological breastfeeding. It makes sense that they might be related to me.

Interestingly enough, it does seem that, at least for me, successful amennorhea has seemed to coincide somewhat with more rest and better health, nutrition, etc. The same things that triggered spotting in the first trimester and early contractions in the third trimester in my pregnancies (overexertion, fatigue, not eating and drinking enough) seem to be somewhat related to not achieving amenorrhea for me. However, at the same time illness, stress or poor nutrition have sometimes resulted in skipped or delayed periods. So who knows?

It was only after Baby E was eating quite a few solids and sleeping more in her own crib that I actually got a few months of real amenorrhea for the first time ever with all three babies.

(This may very well be TMI, so anyone feel free to skip the rest of this post if they don't want to read personal examples of how amenorrhea and ecological breastfeeding have worked out in my life, LOL. But it does illustrate the point I'm trying to make, that you can't always draw a correlation between amenorrhea and ecological breastfeeding.)

I had three normal periods after she was born, starting when she was just a few weeks old. This is while she was sleeping with us, I was wearing her in a sling most of the time during the day, napping with her, nursing every hour or two on demand night and day, sleep-nursing for hours at a time, not supplementing, not using a paci (unless you count the couple of times over 2 days we used one, once), not even feeding expressed milk, and not being separated from her even for church or anything. I think that qualifies as ecological breastfeeding.

I've been told that what we were doing didn't "really count" as cosleeping and thus nullified the ecological breastfeeding because we were using the crib as an extension to our bed. ("Cheating!" I was told.)

But honestly I don't see how having her 6 inches away from me in the bed on one side or the other makes a difference. She was pretty much the same distance away from me and nursing with the same frequency whether she was between DH and me in the bed, or between me and the crib rail on the other side.

We did both pretty interchangeably and she usually nursed and dozed for several hours, if not most of the night, either place. Half the time I was halfway in the crib or she was halfway in the bed. The crib was essentially turning our queen-sized bed into a king with rails on one side.

So I don't think it was an issue, really. And if that's what messed up my amennorhea, then ecological breastfeeding is an extremely touchy thing that's nearly impossible to do "correctly;" that's all I can say.

Anyway, then in November I started giving Baby E expressed milk occasionally, skipping feedings every now and then, and we left her once or twice for an outing without her. I also got a stomach virus and a cold that month, and was severely ill. That month and for the next few months I had light spotting every couple of weeks, but no actual period.

By the middle of February Baby E was eating large amounts of solids, and we moved her into a crib in her own room instead of having her cosleeping. She started sleeping a lot more, and so did I.

It was after that when I got complete amenorrhea, with no more spotting, for 2-3 months.

This past month things were really rough on the sleep front and Baby E has ended up sleeping in our bed a lot again. Last month I had a completely normal period with all the signs of fertility.

We've yet to see what this month will bring.

Strange, huh?

purple_kangaroo said...

Just to clarify for those who may be confused about the crib thing: we had it in a sidecar setup, attached to our bed with one side off and the mattresses joining together until February when we moved it to Baby E's room. So it was an extension to our mattress, that looked like this.

Douglas_Coombs said...

Stevie,

Good point about not repeating mantras without explanation. Just as it is irresponsible to make blanket statements that breastfeeding doesn't work, it is irresponsible to make blanket statments that it does work to space babies. Cultural breastfeeding using schedules etc, has been shown to not be effective in spacing kids. I would never contend that breastfeeding will work for the a majority of women in America. Frankly, ecological breastfeeding just doesn't fit in with most people's lifestyles and there's alot that goes into it that people just don't understand. If people want to rely on it *at all*, they at a minimum need to read a book about it and prefereably both read and talk to somebody who has practiced it successfully.

"And who may not have done all the homework that Doug has done, and would recommend doing."

Just to clarify, I don't expect everyone to read medical studies and journal articles as a matter of course. I did lay them out there to prove a point. Namely, that Hrdy (no matter her qualifications) was missing important information and (it seems to me) was making an inaccurate blanket statement. Nobody is going to believe my word vs. a Harvard trained doctor. They'd be nuts if they did. However, when one can furnish a study in a peer reviewed journal, it is no longer a matter of Peon Doug vs. Harvard Goddess, but PhD claim vs. PhD claim. In my mind the peer reviewed nature of the ecological breastfeeding journal articles wins out. That said, I am admittedly biased toward evidence I present... even if I can't spell and my blogs are riddled with grammar errors.

Doug

Douglas_Coombs said...

"But it does illustrate the point I'm trying to make, that you can't always draw a correlation between amenorrhea and ecological breastfeeding."

Angela,

I have a reputation for being brusque and sticking my foot in my mouth when blogging, so it is with great trepidation that I venture a comment on your own personal experience. However, fearless (and tactless) as always, I will try!

There are a couple things that just seem a bit contradictory to me about that particular comment.

First, there is no doubt that you were surely trying to follow all of the rules correctly (perhaps trying too hard). Also, your amenorrhea was associated with behaviors that are typically associated with an early return of menses.

However, at the same time you say, "Interestingly enough, it does seem that, at least for me, successful amennorhea has seemed to coincide somewhat with more rest and better health, nutrition, etc."

When I have read about ecological breastfeeding (and I am a demented soul who has), one of the primary points that is emphasized is rest. Kippley (for instance) states that she has seen fatigue associated with an early return of menses and recommends a daily nap for both mother and baby to help combat the fatigue problem.

Because ecological breastfeeding is dependant upon several things, an association with one factor (being rested) and a lack of association with other factors (use of solids, etc) is interesting, but I don't think it says that one can't draw a "correlation between amenorrhea and ecological breastfeeding" in your case. It certainly says that some factors typically associated with amenorrhea aren't as important as others. I'm not sure it says that there one can't draw a correlation. Indeed, you seem to draw the correlation yourself with your earlier comments about "overexertion" and "fatigue."

Please, note that I am not blaming you for not being able to practice ecological breastfeeding. For many women, it is a lifestyle choice. Ecological breastfeeding doesn't fit their lifestyle. That's sometimes the only choice and not unoften the better choice for couples to make. However, from my very distant knowledge of your own case, it would appear to not be a lifestyle choice, but instead a case of fatigue. Given your past history with fibromyalgia (sp?), one could speculate that it is a medical condition. I think its safe to say that fibromyalgia is a medical condition that contributes to/causes your fatigue, but I'm on the outside looking in, so correct me if I'm wrong.

With that in mind, it is certainly clear that ecological breastfeeding doesn't work for you. I don't think that says anything about the method itself when practiced properly or about your own personal commitment to practicing it properly. You certainly are a motivated person. It seems (to me) to say more about the particular health history and medical problems that contribute to your fatigue and overexhaustion.

It is clear from comments on your post that you have been offended in the past in this area. I've tried to be tactful, but in case I haven't you can give me an earful when I'm in town in a couple weeks. 10 days and a 20+ hour drive are all that's keeping me away from the old tramping grounds right now.

Doug

purple_kangaroo said...

Doug,

I was napping during the day, nearly every day. It's just that a 1 or 2 hour nap plus 2 to 5 hours of sleep at night still doesn't add up to sufficient sleep.

It is quite possible that my health issues contribute to the fact that ecological breastfeeding doesn't result in reliable amennorhea for me.

My post last night was an ofersimplification of the sleep issue. I had months at a time of poor sleep during the spotting and amenorrhea, and weeks at a time of much better sleep during the total lack of amenorrhea. My nutrition and other factors probably fluctuated just as much--as I mentioned, the first time I had spotting instead of a period was when I had a severe stomach virus--no sleep, food, etc. at all, pretty much.

So it's certainly not an obvious and direct correlaton to any particular factor or combination of factors that I can see.

I was realizing last night that weight loss could also be a contributing factor, as the time when I got the total amennorhea was also the time when I started thinking, "I really have to stop losing weight now." But I didn't get amennorhea after one of my other babies was born when I had a much more extreme weight loss--going from 150 or 160 lbs to 99 lbs in 4 months.

It is quite possible that my health issues contribute to my lack of amennorhea. But my mother had exactly the same issue, and she doesn't have fibromyalgia and chronic fatigue syndrome. She is, however, a DES daughter (her mother was given DES when pregnant with my mother), so it is conceivable that the DES has an effect on both her and me (studies show it affects the next generation, also).

Besides, I know lots of people who don't cosleep or do any of that stuff, and they get years of amennorhea--2-3 years of it, until a few months after they completely wean. Then there are people like me who, no matter what they do, can't seem to control whether they get amennorhea with breastfeeding or not.

What bothers me is this: with both NFP and ecological breastfeeding, even the studies show that the methods are not 100% effective in 100% of women. Yet if I say they're not 100% effective for everyone, your response and that of other strong proponents of those methods is basically, "That's impossible. You must be doing it wrong."

Even in your last post, you said, "Please, note that I am not blaming you for not being able to practice ecological breastfeeding" and then later commented that maybe I failed because I was "trying too hard."

The point is, I was practicing ecological breastfeeding. It's not that I was "not able to practice ecological breastfeeding." It was that, at least for the most part, ecological breastfeeding simply did not work for me to produce reliable amenorrhea.

Also, as you have mentioned, both ecological breastfeeding and NFP can be difficult to practice "correctly" to the point of creating undue hardship or making it not the best choice for some couples, often because of issues currently beyond their control. Especially since it's not just breastfeeding; it's an entire lifestyle with standards almost impossible for a normal person to reach (i.e. getting enough rest with a newborn and other young children in the house??)!

Interestingly enough, it may be true that in many cases the people who are most likely to have a valid, real need to delay conception--those with fairly serious health problems--may be the ones for which NFP and ecological breastfeeding are the most unreliable and difficult methods of family planning.

Basically, my point is, again, that it does not work 100% of the time for 100% of people, even when done as "correctly" as humanly possible.

Douglas_Coombs said...

Angela,

You clearly misunderstood or read into several statements. It's unfortunate, since you have obviously taken offense. I'll try to address that here.

"I was napping during the day, nearly every day. It's just that a 1 or 2 hour nap plus 2 to 5 hours of sleep at night still doesn't add up to sufficient sleep."

When did I claim that you weren't taking naps? I didn't. I did mention naps, but only in the context of combatting fatigue. Of course, naps can't make up for 2 hours sleep the night before. Dugh.

"Yet if I say they're not 100% effective for everyone, your response and that of other strong proponents of those methods is basically, "That's impossible. You must be doing it wrong.""

I NEVER ONCE SAID WHAT YOU CLAIM. Not only that, but I didn't imply it either. I have said things like, "It seems to me" and "but I'm on the outside looking in, so correct me if I'm wrong" Do those sound like a "That's impossible" statement to you? I don't know where you get such forcefulness out of statements that were couched in terms of uncertainty.

"and then later commented that maybe I failed because I was "trying too hard."" Once again you read into my comments something I NEVER said. I didn't say you "failed" because you were trying too hard. My point was that from what you've posted in the past, you seem to make a point of emphasizing awfully hard you tried to make it work. I look at LAM as one of those, "if it works for you great" kind of things. From my POV, extended amenorrhea is a side effect of a certain parenting style. If one is changing their routine and trying so hard that it is causing stress, is it really worth it? In retrospect I shouldn't have said what I did. It is too open to misinterpretation. Also, even though I said "perhaps" and you've written about the stress/difficulty of implementing the rules, the statment probably reads too much into your past comments. Mea culpa. I retract it.

I'm still a bit unclear as to whether you think you are the exception to the rule.
On the one hand you emphasize very heavily that you are sure you are the exception, "The point is, I was practicing ecological breastfeeding. It's not that I was "not able to practice ecological breastfeeding."" On the other hand, you emphasize that you think the rules are darn near impossible to follow. "it's not just breastfeeding; it's an entire lifestyle with standards almost impossible for a normal person to reach (i.e. getting enough rest with a newborn and other young children in the house??)" I don't see how both can be applicable to your case. Either the rules where too difficult to implement given your family and health situation, or you were able to implement them and it still didn't work.

Yet again you said that I said something which I didn't say. "Also, as you have mentioned, both ecological breastfeeding and NFP can be difficult to practice "correctly" to the point of creating undue hardship or making it not the best choice for some couples," While I did say that it is often the best choice for some couples to do something other than ecological breastfeeding, I NEVER said or implied the same thing about NFP. This is a discussion that we've had elsewhere, and I'd rather not rehash it here. I will simply point out that ecological breastfeeding is different than NFP for numerous reasons; foremost being that in one case parenting styles are statistically correlated with better "success" rates and in the other case they are not.

"Basically, my point is, again, that it does not work 100% of the time for 100% of people, even when done as "correctly" as humanly possible."

You are correct. No doubt about it. In closing, I just want to mention this statistic which I stumbled across by accident today. To summarize, the user effectiveness rates of LAM are
a hell of a lot better than the user effectiveness rates of condoms by an order of magnitude (2% vs 15/21%). The user effectiveness rates are even just as good or better than the method/perfect use effectiveness rates of condoms (2% vs. 2/5%). Somehow, despite widely available studies and statistics stating otherwise, it still get's a bad rap. Those stats brought to you by the world's leading supplier of contraception and abortion.
http://www.plannedparenthood.com/pp2/portal/files/portal/medicalinfo/birthcontrol/pub-birth-control-02.xml

Doug

purple_kangaroo said...

Sorry, Doug. I was responding not just to you, but also to other sources. I apologize for attributing things from other sources to you or assuming that you shared their opinions and attitudes. And I shouldn't have mentioned NFP in this context. Sorry I misunderstood some of your comments, also.

Basically, we weren't trying to use ecological nursing as a form of birth control, so I wasn't stressing out about that. This season of life with young children, a baby who doesn't sleep much, and severe fatigue is pretty good at minimizing any chances of pregnancy all on its own, without worrying about adding any other contraceptive methods. :)

I am getting tired of sleep deprivation after 10 months of it, but that has nothing to do with family planning--just the side effects of a baby who doesn't sleep much.

As you said, the benefits of delayed return of fertility that many people get are more a side effect of a parenting style than anything else.

I did say that I don't think the reason I didn't get amenorrhea with ecological breastfeeding was that I was doing it wrong. I think it can also be true at the same time to say, as I did, that if countless elements like getting enough rest need to be perfectly in place for it to work, then that would make the standard nearly impossible for many people to attain.

Honestly, I probably am a little hypersensitive about it at this point. I don't really care all that much that I don't get reliable amenorrhea with breastfeeding (although it seems a little unfair sometimes, LOL). I just get tired of people assuming that it must be because I am doing something wrong rather than considering that it could be because ecological breastfeeding just doesn't reliably achieve amennorhea for me.

Now I don't think I'm making much sense, anyway. I'm really tired and the baby is asleep, so I'm going to bed. Goodnight.

purple_kangaroo said...

I think maybe our difficulty communicating may be partially because we're talking about two different things. The Lactational Amennorhea Method is something different from ecological breastfeeding, although they are related. Ecological Breastfeeding does not necessarily result in Lactational Amennorhea.

In the studies about LAM as birth control, the study only addresses women who meet ALL of the following criteria. According to the page you linked:

Breast-feeding as birth control can be effective for six months after delivery only if a woman

* has not had a period since she delivered her baby

* suckles her baby at least six times a day on both breasts

* suckles her baby "on demand" at least every four hours during the day

* provides nighttime breast-feedings at least every six hours — does not let her baby sleep through the night

* does not substitute other foods for a breast-milk meal

* does not rely on the method after six months


So, IF a woman has not had a single period after the baby's birth, she has only a 1-2% chance of getting pregnant in the first 6 months postpartum.

If a woman had any bleeding or spotting at all after a certain amount of time postpartum, then she would be eliminated from the study group, right?

So these kinds of studies don't tell us anything at all, really, about the effectiveness of ecological breastfeeding at inducing complete amenorrhea. They just tell us that if there IS complete amenorrhea (no spotting allowed!) confluent with ecological breastfeeding, than there's a 98-99% chance that the woman is infertile for as long as amennorhea lasts or until the baby is 6 months old, whichever comes first.

Here's an interesting article looking at studies that suggest that as long as there is amenorrhea, much more flexible standards of breastfeeding can confer these benefits, not just strict ecological breastfeeding.

As all the studies seem to agree, once a woman's periods return, there is little to no likelihood that breastfeeding will do anything to delay pregnancy, no matter how ecological it is.

It's the amennorhea, not the breastfeeding, that seems to be the deciding facor here. The breastfeeding is instrumental in delaying conception only if it causes amennorhea and suppresses ovarian activity, it seems.

What I'd be interested in seeing is a study about what percent of women successfully attain amenhorrhea with ecological or other types of breastfeeding. I expect the number of women who fail to attain amennorhea is quite a bit higher than the number who become pregnant during amennorhea.

Also, I wonder if the study is comparing the various methods during the same time periods in a woman's life--i.e. the first 6 months after a baby is born are going to be less likely to result in a pregnancy no matter what birth control method or lack therof a couple is using, so if we're comparing breastfeeding to, say, condoms being used at a time other than within 6 months of a baby's birth, then that would make a comparison between various birth control methods less accurate.

Especially since most couples aren't having nearly as much marital activity of the type that leads to pregnancy during the first few months after a baby is born than at other times of life. :)

Douglas_Coombs said...

Good point that LAM is different than ecological breastfeeding. Since that particular statistic doesn't go out beyond 6 months, it isn't as useful (or interesting) as other studies on ecological breastfeeding. I just happened to stumble across a link to it today and thought I'd throw it out there as food for thought. In general, it's a bad idea to refer to different methods interchangably. Thanks for pointing that out.

"Especially since most couples aren't having nearly as much marital activity of the type that leads to pregnancy during the first few months after a baby is born than at other times of life. :)"

Yet another advantage of c-sections. :-)

purple_kangaroo said...

Here's a paper I just found (PDF format) which deals with studies examining the effects of nutrition, caloric intake, stress, and even general health of the mother on amennorhea and the return of fertility. Interesting reading.

Essentially, they found that the women with less stress, less physical expenditure and better nutrition were statistically a bit more likely to get an earlier return of fertility. But they concluded that a woman's general health status did not have a clear and direct effect on return of fertility.

purple_kangaroo said...

LOL. on the C-section comment. My impression (from comments made at moms group and similar contexts about young children and sleep deprivation as birth control) is that most couples have less sex in the few months after a baby is born no matter how it was born.