Gestational Diabetes: Birth Control Decisions

by KMom

Copyright 1998 KMom@Vireday.Com. All rights reserved.


DISCLAIMER: The information on this website is not intended and should not be construed as medical advice. Consult your health provider. This web section on gd is designed to present more than one view of a controversial subject, pro and con. It should be re-emphasized that nothing herein should be considered medical advice.

 

CONTENTS

 

 

Birth Control Decisions After GD

 

Sources vary as to how often gd recurs in subsequent pregnancies; some research literature shows rates less than is usually quoted in most gd books. However, gd books aimed at laypeople generally state that women who have had gd have about a 2 of 3 chance of developing it in subsequent pregnancies, and it often recurs earlier and more severely in subsequent pregnancies, though there may be steps you can take to help prevent or minimize its recurrence. It is also possible for a former gd mom to progress to full-blown type II diabetes (NIDDM) before the next pregnancy, which puts a subsequent baby at very serious risk if not caught and treated.

For this reason, it is extremely important to prevent accidental pregnancies. If blood sugar is high at conception, the rate of miscarriages and birth defects such as serious heart problems and neural tube defects is comparatively quite high. You will want to be sure through testing that your blood sugar is normal before conceiving next time, and then you will probably want to start on a diabetic food plan before beginning to attempt to conceive. (See the websection on 'Planning a Subsequent Pregnancy'.) This does not mean dieting, just using the diabetic food plan to be sure your blood glucose levels are completely EVEN at all times during the important conception and first trimester time period.

In order to avoid the dangers of accidental pregnancy when bG levels are unknown, you will want a very reliable form of birth control. There are many options out there, but birth control has a fairly significant failure rate in the first year after a pregnancy for many reasons, often psychological. You will want to take special care to be vigilant in your use of birth control, no matter what, until you are ready to prepare to conceive again. Spacing pregnancies too close together is a stress on your body, although it can be done. It is unknown whether that can add to gd or affect it at all, but it would seem prudent to allow your body at least a year to recover before trying again, and to of course be sure that your bG is normal beforehand as well.

 

 

Birth Control Choices

 

There are many forms of birth control available, and only you and your partner can decide what is right for you. Some types of birth control are not recommended for women who have had gd, although not all the research agrees. You and your doctor will need to do some research of your own to confirm what is appropriate for you. It is also important to remember that many doctors do not understand or know of the research that shows that certain types of birth control can interfere with breastfeeding, especially in the beginning. Considering the benefits that breastfeeding offers to gd mothers and babies, this ignorance is inexcusable. You may need to be assertive about your breastfeeding concerns; many providers will tell women that a certain contraceptive is not contraindicated for breastfeeding when the research states otherwise. Find a provider who is familiar with the research and who is VERY pro-breastfeeding and very knowledgeable about it. A lactation consultant can also help you answer questions or concerns for your doctor, and supply breastfeeding research citations to him.

 

1. Barrier Methods (such as condoms, diaphragms and cervical caps) tend to be the best choice for post-partum birth control, at least until breastfeeding has been going well for quite some time. Remember that diaphragms and cervical caps need to be refitted after the birth of a baby or any significant weight loss, and that spermicide is important to use in conjunction with these products. It should be noted that condoms can be used without having to worry about changes in a woman's body that may make other barrier methods less effective, and are often an excellent transitional birth control choice until oral contraceptives or a new diaphragm/cervical cap can be used. Barrier methods of whatever type have several decided advantages:

However, barrier methods have the disadvantages of being less spontaneous to use and having a higher user failure rate. The spontaneity issue can be dealt with by being more creative (!). The 'failure' rate is more serious but is generally more attributible to people who use barriers incorrectly, inconsistently, or in ignorance. People who are more responsible about birth control and protection can significantly lower the 'failure' rate to very acceptable levels by always using spermicide with the barrier and paying close attention to following the 'rules' for using that type of barrier. Again, an unexpected pregnancy has more risks for a woman with a history of gd but ANY type of birth control has 'User Failure' potential, not just barriers. With careful use, the surprise pregnancy rate for barriers is very low. And unlike most of the other birth control methods, there is little risk with it, it does not affect breastfeeding supply or give hormones to the newborn, it will not increase your risks for diabetes or high cholesterol, and it will not interfere with your body's natural systems.

It is Kmom's (non-expert) opinion that barrier methods are the most optimal choice in general for women with prior gd, especially at first. Later on, the woman and her partner may want to re-evaluate their birth control choice, but at first, barrier methods seem to offer the most protection and least danger to breastfeeding establishment and risk of subsequent health problems like diabetes. However, every woman must choose the method that is best for her in her circumstances.

 

2. Oral Contraceptives - The pill is a very popular form of birth control, but caution must be used in choosing which type, due to concerns that some types of the pill can worsen or bring on diabetes, worsen blood lipids (cholesterol, etc.), or interfere with breastfeeding supply (a concern that few doctors pay attention to). Though this is not often acknowledged by doctors, it is probably best to avoid all oral contraceptives if you plan to breastfeed and have had gd; substitute a barrier method or other choice instead. After weaning, some types of the pill can be used, though some women may want to switch to barrier methods permanently.

Which type of pill is appropriate? Care must be taken and the latest research consulted, since studies sometimes contradict each other. It is clear that the old, high-estrogen pills were associated with cardiac complications in some women, increased rates of development of diabetes, and interference with breastfeeding. These pills are rarely used now. The new pills are usually either low-dose combination pills (estrogen and progestins) or low-dose 'mini-pills' (progestins only). The latest research is contradictory as to whether these can be safely used by women who have had gd, and definitive answers at this point are not possible. It is extremely important to emphasize that types and doses of contraceptive pills vary strongly and need to be researched carefully, taking into account other risk factors (such as hypertension, age, smoking, etc.), and also whether the woman plans to breastfeed. Frequent follow-up after beginning an oral contraceptive is extremely important for the gd mom.

A longer discussion of the concerns about oral contraceptives and gd moms is below, but the most important points are:

  1. Women with previous gd can take low-dose combination (estrogen and progestin) pills provided she has no medical contraindications and does not plan to nurse her baby. Combination pills can significantly affect milk supply and are best avoided if a woman plans to breastfeed her child.
  2. The medical research on the low-dose progestin-only minipills is contradictory. Some reports find it safe for gd mothers, while the latest research finds that it significantly increases the risk of subsequent development of diabetes, at least in one group of high-risk women. The advantage of the minipill is that it can be safely used during breastfeeding (unlike the combo pills) as long as it is started after about 8 weeks postpartum. However, the new data connecting it to higher rates of diabetes development means that until further data can clarify the issue, most breastfeeding gd mothers should probably avoid contraceptive pills totally, either combo or mini-pill.
  3. If a woman does plan to nurse her baby (please do!), then a barrier or other method is definitely the first choice for protection as of now. However, should a woman and her provider decide upon using a contraceptive pill anyhow, then care must be taken for it not to interfere with breastfeeding milk supply. A barrier method should be employed for the first 2 months or so, after which the progestin-only mini-pills can be used (with recognition of the possible risks for diabetes), OR a barrier method can be used for the first 6 months, after which the combination pills may be able to be used with great care. Care should be taken upon starting any oral contraception at any time to note whether it affects breastmilk supply negatively since some moms are more affected than others.
  4. Frequent follow-up testing in the first few months/years after starting an oral contraceptive is important, and especially so for women who have had gd. Problems with blood pressure, various cholesterol levels, etc. are sometimes found in women on birth control pills, and since gd mothers may have a predisposition towards these already, they should be carefully monitored.

For women who have had gd yet want to use the pill again, it may seem the breastfeeding complicates things too much and isn't worth trying. Every woman's choice on this matter must be respected, but it's important to make a carefully informed choice. Remember that the health benefits (for mother and baby) of breastfeeding are quite significant, including decreased risks for various cancers in the mother and decreased risks of ear infections, gastrointestinal illnesses, allergies, and asthma in the child. In addition, breastfeeding may be especially beneficial for gd moms and babies.

Breastfeeding is recognized as an anti-diabetogenic factor, and a study of short-term breastfeeding found improvements in both blood glucose and HDL cholesterol and half the rate of immediate postpartum diabetes among women who breastfed as opposed to those who did not (Kjos, 1993). Yang et al., 1994 found that breastfeeding insulin-dependent gd mothers needed less insulin postpartum and returned to normoglycemic status earlier than non-breastfeeding insulin-dependent gd mothers, though the study sample was quite small. Cordero et al, 1998 found that "routine care failures were...less frequent among breastfed infants" of diabetic mothers of any kind, and they required less admittance to the NICU for hypoglycemia, jaundice, etc. Pettit et al., 1997 found that "exclusive breastfeeding for the first 2 months of life is associated with a significantly lower rate of NIDDM in Pima Indians" in later life. Several studies have found that children that had little or no breastfeeding had higher rates of obesity later in life (Strbak et al, 1991; Kramer MS, 1981; Kramer et al., 1985), though many other factors of course influence rates of obesity, including genetics. Finally, Wallensteen et al., 1991, found that "in formula-fed infants the insulin response to a meal is enhanced compared to that in breast-fed infants. The finding of similar blood glucose values in the two groups may also indicate an insulin resistance in the formula-fed infants following a meal." In other words, more insulin had to be produced by the formula-fed infants in order to achieve the same bG results, which could be a sign of early insulin-resistance, though obviously more research is needed.

It's important to note that research into breastfeeding, gd, and NIDDM has been largely ignored until now and these findings are just preliminary; much more needs to be done. However, the preliminary work has been enough for the Fourth International Workshop-Conference on GD to issue a call to increase research into breastfeeding and gd. This will be an interesting and evolving field of research in the near future. The weakness of the studies so far is that they are small and do not adequately examine the effect of breastfeeding very extensively. Most studies are for a very short time only--- 2-3 months or less, and some do not distinguish between exclusively-breastfed infants versus infants being fed both breastmilk and formula. It will be important to examine the methodology of these new studies as they are done; it may turn out that breastfeeding has less effect than these preliminary studies indicate or it might turn out that extended breastfeeding has even more benefits than indicated by these limited studies. Only time will tell.

Regardless, the preliminary evidence indicates that it is important that gd moms be encouraged to breastfeed as much as possible, and not be given medical barriers to its establishment (like the pill, improperly used). It's also important to note that the benefits of nursing far outweigh any temporary inconvenience from using a different form of birth control, either temporarily or for the duration of nursing, but many providers do not counsel mothers about this important tradeoff. Mothers who might consider weaning early or omitting breastfeeding entirely in favor of using the pill should be carefully counseled so that they completely understand the tradeoffs involved and can make their decision with truly informed consent. Whatever decision they then make, of course, should be completely supported and followed.

Some moms do use this postpartum opportunity to permanently switch to another form of birth control, but that decision can only be made by the mother and her partner in consultation with her health provider. However, the pill does not have to be abandoned forever as a form of birth control once you've had gestational diabetes, just approached with more caution and in consideration of a number of different factors, such as medical history and desire to breastfeed. The mother should be well-informed about all of these factors before making her decision, and unfortunately, not all health providers do an adequate job of this. This is why Kmom feels it is important to include such a detailed section on this concern in this FAQ.

[Kmom would also like to re-note here that occasionally, some women have difficulty breastfeeding and need supplementation; these women should never be made to feel guilty about needing to use formula. Other women, for their own reasons, simply choose not to breastfeed, and while they should be encouraged to choose carefully, they should not be badgered either. Breastfeeding remains the most optimal form of infant nutrition available, but each woman must choose what is right for her needs and situation, and all women deserve support, not judgment. Kmom is in the delicate position of strongly encouraging women to consider breastfeeding (especially in the context of a gd pregnancy), yet remaining supportive of women who choose not to and of women who need extra assistance in feeding their babies. Kmom's advocacy for women to strongly consider breastfeeding should not be taken as criticism of those who do not, nor lack of support for those who end up needing assistance.]

 

Further Information about the Pill and GD Mothers

Concerns in the research literature about oral contraceptives for women with previous gd generally fall into three categories: their effect on glucose metabolism, their effect on blood lipids, and their effect on breastfeeding. With respect to the first two concerns, doctors and researchers generally seem to favor the low-dose pills that combine estrogen and progestins. The concern is that progesterone can worsen blood-glucose levels, increase insulin resistance, and unfavorably influence blood lipids. The estrogen in low-dose combination pills tends to counteract this effect, so combination pills are generally favored, though frequent follow-up is a must, and many doctors fail to note that they can interfere with breastfeeding. So, in general, it is best not to use combination pills unless you are adamantly against breastfeeding your child, but once your baby is weaned, a combination pill can be used, as long as careful follow-up is maintained.

Dr. Siri Linda Kjos, in her research article, Contraception in Diabetic Women (Obstetrics and Gynecology Clinics of North America, March 1996) notes that:

Progestins decrease glucose tolerance by increased insulin resistance and secretion...Estrogens, in turn, oppose the peripheral action of progesterone and increase insulin sensitivity in muscle and adipose cells. When prescribed in combination, the net effect on carbohydrate metabolism seems to be dependent on the molar concentration ratio of estrogen to progestin. Current low-dose combination oral contraceptives...tend to be estrogen-dominant in their metabolic effect. They have been shown to have minimal effect on glucose tolerance, serum insulin, or glucagon levels in healthy women...Selection of the proper progestin dosage for diabetic and previously gestationally diabetic women also should be geared toward minimizing adverse lipid effects...In combination oral contraceptives, estrogen counterbalances this...by favorably altering the lipid levels...Women using progestin-only mini-pills also had no adverse lipid changes...the lowest dose combination oral contraceptive or progestin-only oral contraceptive should be prescribed.

Unfortunately, Dr. Kjos does not mention the negative effects of combination oral contraceptives on breastfeeding, a significant omission from such an important treatise, although she probably presumes that most doctors would already know this. However, many doctors do remain ignorant or dismissive of such concerns, and certainly some breastfeeding women have had their nursing unknowingly sabotaged by the prescription of combination pills in the early postpartum period.

No breastfeeding woman should be given a prescription for combination pills in the first 6 months post-partum, and preferably should avoid them altogether. However, there is some evidence that combination pills can be started much later, if the mother is adamant about using them and great care is taken to monitor supply issues and the health of the baby. The Breastfeeding Answer Book (La Leche League, 1997), one of the definitive breastfeeding references, states that "if chosen, it is recommended that methods containing estrogen not be started until after the baby is at least six months old and consuming other foods." Again, it is best not to use combination pills at all during breastfeeding, but under carefully timed and controlled conditions, some mothers have been able to use them.

As noted above, the situation with the progestin-only minipills is more complex. Earlier research seemed to show that minipills did not significantly increase subsequent development of diabetes, but recent research (Kjos et al., Journal of the American Medical Association, 1998) showed that the mini-pill nearly tripled the risk of developing diabetes later. However, this research was done on mostly Hispanic women (who are at much greater risk of diabetes anyhow), and many of them were also obese (another risk factor for diabetes), so it is uncertain how well this data applies to other women. Critics want more examination of the role of ethnicity, parity (number of children), degree of obesity, and length of use of the pill before uniformly recommending that the minipill not be used in all women who have had gd.

Some doctors will continue to recommend the minipill to their gd patients until further research is done clarifying the issue.This should be done with full recognition of the possible effects, and with full informed consent on the part of the mother. Once the woman weans, her provider would probably want her to switch to a combination pill, but women should not wean early for this purpose, since the very act of breastfeeding has an anti-diabetogenic effect as well. It is probably best if breastfeeding gd mothers completely avoid all types of the contraceptive pill, but information is provided here about the minipill in case some moms and their providers decide to go ahead with its use anyhow.

The advantage of the minipill has always been that it has much less effect on nursing supply, especially if started after 8 weeks post-partum. Many doctors contend that low-dose, progestin-only oral contraceptives do not affect supply and are safe during breastfeeding at any time. Research on this has been mixed, however, probably owing to the inconsistent amount of time after the birth that the various studies are started. Those women who started them soon after birth tended to report a negative effect on their milk supply, while women who started mini-pills later reported less effects on supply (though some women anecdotally report effects later as well; some women seem to be more sensitive to it).

If you choose a progestin-only mini-pill, The Breastfeeding Answer Book recommends that you delay starting it "until after the first six to eight weeks of breastfeeding, as earlier introduction may decrease milk supply." Many doctors are not familiar with the research showing problems in the early stages of breastfeeding and may discredit the need to delay, so you may have to be assertive in avoiding low-dose pills in the first few weeks. After that, the research seems to indicate that starting the 'mini-pill' will not negatively effect supply in most women. It should be noted that a few women do report being affected by the mini-pill, even when starting on it later. Any woman who starts on birth control pills of any type should pay special attention to supply issues as she begins the medication, realizing that there are a few women whose bodies are more sensitive and will be affected regardless.

 

Further Concerns about Oral Contraceptives

Other concerns about oral contraceptives during breastfeeding include concern whether a baby's immature liver is able to metabolize the hormones adequately in the first few weeks of life, or whether the extra hormones present from the pills are harmful to the baby. Research seems to indicate that the newer pills do not have any negative effect on child growth, but at least one source also states that "the pill can significantly reduce the protein content of breastmilk" (The Art of Natural Family Planning from the Couple to Couple League), although it does not specify which type of pill this refers to and does not cite research to back up this claim. The New Our Bodies, Ourselves also lists this as a concern, stating that "the pill decreases the amounts of protein, fat and calcium in the milk." It also is concerned about the child's ability to handle extra doses of hormones, especially in the newborn period; this a serious and legitimate reservation to the use of oral contraceptives during early nursing. More long-term studies are needed, but it probably is wiser to err on the side of caution for now and avoid oral contraceptives, especially at first.

Because the pill in its various forms can theoretically impact blood glucose and blood lipid levels negatively, Dr. Kjos (in the same article cited above) recommends frequent follow-up shortly after the prescription. "Periodic or annual testing for diabetes mellitus in women with prior GDM is recommended...When oral contraceptives are prescribed, an additional OGTT after 6 months may be performed...In addition to annual metabolic evaluation, a schedule of more frequent refill visits is recommended--initially after 3 and 6 months of use, and then every 6 months to monitor weight and blood pressure." In the June 1996 news release from the American Diabetes Association's 56th Annual Scientific Sessions, she clarifies this by saying "blood pressure, blood glucose and cholesterol levels should be checked a month after starting the pills and three to four times a year thereafter." So frequent monitoring is important when using birth control pills, especially for women with previous gestational diabetes.

Many women certainly have gone on to use low-dose pills, breastfeed successfully, and apparently suffer no ill side-effects, but in light of the most recent research, it is probably wise to consider this cautiously. It is your decision whether the possible risks are worth the convenience and benefits of oral contraceptives. It is Kmom's personal opinion that if you plan to breastfeed, it is most optimal to find another form of birth control if possible. Of course, your opinion may vary!

 

 

3. Injections/Implants such as Norplant or Depo-Provera are not a good option for larger women and/or for women who have had gd. When Norplant came out on the market several years ago, it was noted at the time that it was much less effective in larger women (for whatever reason) after a year or two, and so is not recommended for them. An additional factor is that the progesterone hormone in injections and implants come in a high enough dose that they may bring back the diabetes into your non-pregnant state, although the research is not clear how significant its impact is. Dr. Kjos (in the above article) states that "in the absence of data, neither DMPA [Depo-Provera] nor Norplant can be recommended as first-line methods of contraception in women with diabetes." Dr. Lois Javonovic-Peterson, in her book, Managing Your Gestational Diabetes, states that "the hormone in these injections or implant is a high enough dose that it may bring back your diabetes. Therefore, these usually are not first-choice contraceptives for women with previous gestational diabetes."

 

 

4. IUDs (IntraUterine Devices) offer an effective, long-acting contraceptive that does not involve any hormonal or metabolic disturbance and a very low failure rate, though it is contraindicated in some cases. Women who have multiple sex partners, have had chronic pelvic infections, a history of ectopic pregnancies, or who have had a sexually transmitted disease (or are at risk for one) should not use an IUD. If you plan on having another child in the near future, the IUD is probably not the most optimal choice. In addition, some women will have religious/moral objections to the IUD, since it prevents the implantation of a fertilized egg, in effect aborting a pregnancy. In the past, IUDs have been discouraged because of the high rate of pelvic infection in one type of IUD. Dr. Kjos feels that this risk is overrated for most types of IUDs and that an IUD should not be excluded from consideration based on this alone. Since diabetics as a group have a high rate of infections and are quite slow to heal, it's worth considering the issue more closely in consultation with your own provider. If you do decide to choose an IUD, Dr. Kjos (in the same article as above) states that:

...unless special indications for the Progestasert IUD exist, the copper T380A should be selected. Its 10-year efficacy avoids the need for repeated insertion and the increased exposure to infection. The IUD provides an important reversible contraception option for diabetic women, particularly for those who are older, parous, and not planning another pregnancy in the near future...Care should be taken to select an appropriate candidate at low risk for sexually transmitted desease, such as monogamous women in a stable relationship who are multiparous and with no history of active, recent, or recurrent pelvic infection. Antibiotic prophylaxis at time of insertion may be of benefit in reducing postinsertion infection and probably should be considered...A 4 to 6 weeks postinsertion examination allows the detection of infection and identifies expulsions.

Kmom's personal opinion is that the IUD is not a very woman-friendly form of birth control. Its users have a higher rate of Pelvic Inflammatory Disease, increased bleeding and cramping during and between periods, more ectopic pregnancies, and in some women, increased infertility, as well as other rarer complications (including uterine perforation and death). Kmom urges caution in its use. However, that is just her own personal opinion and each mother must make her own informed decision.

 

 

5. Natural Family Planning/Fertility Awareness Method (Sympto-Thermal Method) can also be used effectively when there is a strongly committed, monogamous partnership where both partners are extremely well-trained and disciplined in its use. The disadvantage of this method is that it provides no protection against sexually transmitted diseases and requires strong devotion to observation and charting, but its advantage is that it involves no hormonal interference with a woman's body and no artificial barriers or chemicals. Natural Family Planning (NFP) is the name of the method as taught by the Catholic Church, and in keeping with their opposition to artificial birth control, requires abstinence during fertile periods. The Fertility Awareness Method (FAM) is very similar to NFP, but without the religious trappings, and it permits the use of barrier methods during a woman's fertile days. There are essentially two subgroups within these methods, the Billings method and the Sympto-Thermal method. The Billings method relies mostly on observation of cervical mucus and involves less charting; it also has a slightly higher surprise pregnancy rate. The Sympto-Thermal method involves the observation of fertility symptoms such as cervical position and mucus plus the daily charting of basal body temperatures in order to further cross-check fertile times. If you are going to choose NFP or FAM, you should plan on using the Sympto-Thermal method and GET THOROUGHLY TRAINED IN IT. As with the other birth control methods, user failure rates in this method are largely related to user ignorance or misuse, or to deliberate risk-taking. Used correctly and knowledgeably, this is a very successful and body-friendly method.

Many gd sources and researchers strongly discourage the use of natural family planning, likening it to the old rhythm method, and condemning it as ineffective and foolish. This shows a deplorable lack of understanding of true NFP/FAM, which has an extremely high success rate (comparable to that of the pill) if used properly. It is NOT the same as the Rhythm Method, which was not reliable. Do not let the uninformed prejudices of some health providers dissuade you from this method, if you are willing to do the training and charting involved, and if you are willing to abstain or use barrier methods during fertile periods. But it must be approached in the most serious manner, since accidental pregnancy presents more concern in former gd moms who may have developed type II diabetes between pregnancies.

The key is the thoroughness of the training, which should include a section on how to use it effectively in the post-partum and breastfeeding period. The management of this period is not easy, so it is probably best not to start this birth control method during the anovulatory breastfeeding months, but it can certainly be learned and used once menstrual periods restart on a regular basis (an interim method would of course be needed in the meantime) and then used from then on. However, couples who are well-trained in all aspects of its use and are quite committed to it do have quite a good success rate (definitely comparable to the best artificial birth control methods), even during the more difficult post-partum period. It can be done.

Breastfeeding is also a form of birth control ("Lactation Amenorrhea") but only under extremely exacting conditions. This type of breastfeeding management is called "ecological breastfeeding" and if followed exactly and in conjunction with NFP/FAM fertility awareness techniques can be quite effective as well. However, it must be noted that the majority of Americans do not follow the protocols of ecological breastfeeding (no pacifiers, no bottles or supplements whatsoever, no solids or other liquids until 6 months, co-sleeping with the parents and frequent night nursing, nursing on demand throughout the day, little or no separation of mother and baby, etc.), so it is probably not a wise choice for most Americans unless they are willing to be educated about ecological breastfeeding and follow its methods strictly. Most women are able to space their children between 18-30 months apart using strict ecological breastfeeding alone as birth control. If NFP/fertility awareness is added to ecological breastfeeding, the rates of unplanned pregnancies are very low and quite comparable to the surprise pregnancy rates of traditional artificial birth control forms. It should be noted that women can ovulate before the return of menstruation, but if a woman is taught to be aware of her fertility signals in the interim and abstinence or barriers are then employed once fertile mucus etc. signs are noted, the rate of pregnancy is low.

The key to success with ecological breastfeeding and/or Natural Family Planning is education and awareness and a very serious commitment to the method's requirements. Daily charting of basal temperatures and mucus is a necessity, as is abstinence or barriers during fertile periods. The devotion and discipline this requires is not for many people, although NFP points out correctly that this can be part of your commitment to each other and to your marriage. A class in the interpretation of the various signs and dealing with unexpected variables is also very important to making this system work effectively.

So while the out-of-hand dismissal of natural methods by many doctors is unjustified, it is also true that to make these systems work requires more than most couples are willing to give, and to start NFP/FAM during the difficult-to-interpret postpartum period is probably not optimal. Another method may be desirable at first. However, it IS an excellent option IF you are willing to do the education and monitoring necessary for its success, and if you practice first during normal menstrual cycles. Once the technique has been learned and mastered under normal conditions, it can then be used at any time, even under the more exacting conditions of the postpartum period, and has a very high efficacy rate when used properly.

To further explore these methods, read the books, The Art of Natural Family Planning by John and Sheila Kippley, Taking Charge of Your Fertility by Toni Weschler, and Breastfeeding and Natural Child Spacing by Sheila Kippley. The Kippley books involve a religious point of view and require abstinence during fertile periods; more information can be obtained from the Couple to Couple League's website at www.ccli.org. The Weschler book is a secular approach and gives the option for abstinence or using barrier methods during fertile times. Both approaches are excellent and well-researched; either can be chosen. However, Kmom strongly recommends that the books be supplemented by class instruction. Interpreting fertility charting can be particularly difficult during the post-partum breastfeeding period; it really should not be undertaken at that time except by those already well-trained in the method by expert instructors and thoroughly versed in using it.

 

 

References

 

Kjos, SL. Contraception in Diabetic Women. Obstetrics and Gynecology Clinics of North America. 23(1): 243-258. March 1996.

Excellent overview of the concerns and considerations for contraception in diabetic women. Covers women with pre-existing diabetes before pregnancy as well as women who had gestational diabetes but does not lump them together for consideration. Has one brief mention only of breastfeeding considerations when prescribing oral contraceptives; certainly needs to cover more thoroughly the potential effects on milk supply and concerns about hormonal influence on infants. However, this is certainly not an unusual omission in this type of article. A very valuable resource in spite of this.

Kjos, SL et al. Contraception and the Risk of Type 2 Diabetes Mellitus in Latina Women with Prior Gestational Diabetes Mellitus. Journal of the American Medical Association. August 12, 1998. 280:533-538. Available for viewing at www.ama-assn.org/special/contra/library/readroom/joc72148.htm

Most recent research on the use of the progestin-only minipill and its relationship to the subsequent development of full-blown diabetes. Found that mini-pill users had nearly triple the risk of developing subsequent diabetes, while the standard low-dose combination pill seemed to be safe. However, the study concentrated mostly on Hispanic women, who have a much higher rate of development of diabetes anyhow, and many of the participants were also obese, which could affect the results as well. Although this is the first *large-scale* study to look at the effects of oral contraceptives on diabetes, the authors acknowledge that it's not clear how the results should be applied to other ethnic groups.

Meyers-Seifer, C. and Vohr, B. Lipid Levels in Former Gestational Diabetic Mothers. Diabetes Care. 19(12):1351-6. December 1996.

Found that "at 5-6 years postpartum, former gestational diabetic mothers demonstrate changes in lipid levels that differ from control mothers and that specific lipids correlate with cardiovascular risk factors." In particular, the study found increased triglyceride levels, total cholesterol levels, and LDL cholesterol levels in gd mothers, as well as increased glucose levels and systolic blood pressure. However, the abnormal levels were not related directly to fasting glucose levels during pregnancy or need for insulin therapy. Study notes that underlying inherited genetic predisposition to dyslipidemia may be a factor, as well as lifestyle differences such as diet and exercise status, and that the role of these other factors needs to be investigated more thoroughly. .

Kjos, SL et al. The Effect of Lactation on Glucose and Lipid Metabolism in Women with Recent Gestational Diabetes. Obstetrics and Gynecology. 82(3):451-5. September 1993.

Landmark study that shows that even after only 4-12 weeks of breastfeeding, gd moms that were bfing had lower fasting glucose and better HDL cholesterol levels than gd mom who did not bf. Also found that women who did not bf developed early postpartum diabetes at *twice* the rate of those who did bf, both in the diet-treated group and the group that needed insulin in pregnancy. "Lactation, even for a short duration, has a beneficial effect on glucose and lipid metabolism in women with gestational diabetes. Breast-feeding may offer a practical, low-cost intervention that helps reduce or delay the risk of subsequent diabetes in women with prior gestational diabetes." And this studied ONLY 4-12 weeks of breastfeeding.

Pettit, DJ et al. Breastfeeding and Incidence of Non-Insulin-Dependent Diabetes Mellitus in Pima Indians. Lancet. July 19, 1997. 350(9072):166-168.

Examined the association between NIDDM and bfing in a population with a high prevalence of NIDDM. Studied the effects of infant feeding methods (for the first 2 months only). Those who had formula only had somewhat higher weights than those who had been partially or fully breastfed. Those who had been exclusively bfed for 2 months had significantly lower rates of NIDDM in all age-groups. "The odds ratio for NIDDM in exclusively breastfed people, compared with those exclusively bottlefed, was .41" (less than half). "Exclusive breastfeeding for the first 2 months of life is associated with a significantly lower rate of NIDDM in Pima Indians." The weaknesses of the study is that it is done in a population known for its ultrahigh rates of diabetes; it is unknown whether these findings would apply to other groups. Also, the number of people exclusively bfed for at least 2 months was not extremely high (144/720, about 20%) which weakens the power of the conclusions. However, it should also be noted that the study only examined those exclusively bfed for *2* months, which may show a lower overall effect than if infants exclusively bfed much longer were compared. [The American Academy of Pediatrics now recommends that infants be exclusively breastfed for at *least* one year, and longer if desired.]

Cordero, L et al. Management of Infants of Diabetic Mothers. Arch Pediatr Adolesc Med. March 1998. 152(3):249-254.

Examined the clinical outcome of infants born to mothers with gd and mothers with pre-existing type one diabetes. Experimented with routine care and normal feedings for these babies (vs. the usual hospital policy of automatic admission to the NICU for observation, testing, and supplementation). Found that most gd babies assigned to routine care did fine, but that breastfed babies had fewer routine care failures that resulted in the baby having to be admitted to the NICU. States that "breastfeeding among women with GDM and IDDM should be encouraged" but does note that many of the routine policies in the past for babies of diabetic mothers (extended admission to the NICU, lapse time to the first breastfeeding, lack of breastpumps and proactive encouragement and assistance) has made bfing rates lower. Actually brags about its 37% rate of exclusively or partially breastfed infants as a satisfactory measure of its 'success'! [Seems like if its lactation program and proactive encouragement were really satisfactory, it ought to have a much higher rate than 37%. Demonstrates that if this is considered high, bfing rates among diabetics must have been particularly pitiful in the past and attests to the many obstacles some diabetic mothers can face.]

Yang, JQ et al. Breastfeeding in Reducing Regular Insulin Requirement in Postpartum for Insulin-Dependent Diabetes Mellitus and Gestational Diabetes Mellitus. Chung Hua Fu Chan Ko Tsa Chih. March 1994. 29(3):135-137.

Looked at the insulin requirement in IDDM and gd moms immediately post-partum. Found a significant decrease of regular insulin (RI) requirement among breastfeeding mothers overall. Among gd mothers who breastfed, insulin requirements disappeared almost immediately, while those that did not breastfeed often required further insulin for 4-7 days postpartum. However, the sample used is extremely small and limits the power of the study. The authors concluded, "BF can reduce the RI requirement of IDDM and GDM mothers in the postpartum period. It is thought that more energy is needed in the process of producing milk, and serum glucose is the main substance for lactose synthesis, thus blood glucose level of BF mother is decreased, and so is the RI requirement. Therefore, mothers with diabetes mellitus are encouraged to breast feed their babies."

Wallensteen, M et al. Acute C-Peptide, Insulin, and Branched Chain Amino Acid Response to Feeding in Formula and Breast Fed Infants. Acta Paediatr Scand. February 1991. 80(2):143-148.

Very technical article detailing c-peptides, branched chain amino acids, and fasting and post-meal bG response in both breastfed and formula-fed infants (small sample). The authors summarize at the end, "these results confirm that in formula-fed infants the insulin response to a meal is enhanced compared to that in breast-fed infants. The finding of similar blood glucose values in the two groups may also indicate an insulin resistance in the formula-fed infants following a meal." In other words, f-fed infants produced more insulin in response to feeding than bfed infants did, yet their blood sugar was the same, implying that insulin resistance was occurring. In insulin resistance, greater amounts of insulin must be produced in order to provide energy to the cells; as resistance increases, more and more insulin must be produced and eventually the pancreas is overwhelmed (if kmom understands correctly).

Kramer, MS. Do Breastfeeding and Delayed Introduction of Solid Foods Protect Against Subsequent Obesity? Journal of Pediatrics. June 1981. 98(6):883-887.

Previous studies examining whether breastfeeding was protective against later obesity tended to find mixed results. This study faults previous studies for methodologic flaws (Type II error, confounding variables, and non-blinding) and conducted its own case-control study of 1172 adolescents. Raw data revealed a significantly elevated risk in 'overweight' subjects of not being breastfed. Delaying solid foods was found to be irrelevant. "We conclude that breast-feeding does protect against later obesity and attribute the conflicting results of previous studies to insufficient attention to methodologic standards."

Kramer, MS et al. Determinants of Weight and Adiposity in the First Year of Life. Journal of Pediatrics. January, 1985. 106(1):10-14.

Examined 462 full-term healthy infants in the first year of life. Examined the roles of various factors in 'adiposity' in the first year. Found that birth weight, duration of bfing, gender, etc. did influence BMI somewhat, though "the ability to preduct which babies will be heavy or obese during the first year is limited" [and Kmom doubts the value of such a task]. However, it did find that even after adjusting for confounding factors, breastfeeding did offer some protective effect against 'obesity'.

Strbak, V et al. Late Effects of Breast-Feeding and Early Weaning: Seven-Year Prospective Study in Children. Endocr Regul. June 1991. 25(1-2):53-57.

"The effect of breastfeeding on some clinical and thyroid function parameters was studied in a prospective longitudinal study from birth up to 7 years of age. At the ages 1-7 years, the obesity rates observed in children breast-fed for less than 3 months were substantially higher than in children who had been breast-fed over longer intervals." [Notes other findings but this is the relevant one here.]

Engelking, Cynthia and Judith Page-Lieberman. Maternal Diabetes and Diabetes in Young Children: Their Relationship to Breastfeeding. Lactation Consultant Series, La Leche League International. Avery Publishing Group, Garden City Park, NY. 1986. Available from www.lalecheleague.org.

Excellent review of the concerns of a diabetic pregnancy and its impact on breastfeeding practices. Good overview of the possible complications of diabetic pregnancy, though more relevant to type I pregnancies than gd. Covers type I, II, and GD pregnancies, as well as development of type I diabetes in young children who might still be breastfeeding. Written in 1986 so its information is a bit dated on gd, but still a valuable resource.

Mohrbacher, Nancy and Julie Stock. The Breastfeeding Answer Book. La Leche League International. 1997 Revised Edition. Available from www.lalecheleague.org.

The ULTIMATE reference for up-to-date information about breastfeeding and medical issues. Extensively referenced and researched. Very expensive book to purchase for yourself but many local LLL chapters will have this book available in their lending libraries, or one of the Leaders will.

Asselin, BL and RA Lawrence. Maternal Disease as a Consideration in Lactation Management. Clinics in Perinatology. 14(1):71-87. March 1987.

Treatise for OBs, perinatologists, pediatricians, and internists on how to handle lactation issues in women with chronic diseases such as diabetes (mostly type I), severe asthma, kidney disease, and chronic hypertension. Written by 2 doctors/medical school professors with great expertise in lactation issues; excellent resource for the medical professional. Most lay readers will find it a bit dense for their purposes, but a few may find it useful for ideas to share with their health provider about how to preserve breastfeeding in the face of chronic maternal disease.

American Diabetes Association Position Statement: Gestational Diabetes Mellitus. Diabetes Care. Volume 21: Supplement 1, 1998. http://www.diabetes.org/diabetescare/supplement198/s60.htm

Official 1998 position statement on the definition, detection, diagnosis, and therapeutic strategies for gd. However, "Currently there is a committee considering a major revision of this position statement based on the 4th International Workshop on Gestational Diabetes Mellitus."

Metzger, BE et al. Summary and Recommendations of the Fourth International Workshop-Conference on Gestational Diabetes Mellitus. Diabetes Care. August 1998. Volume 21: Supplement 2. Can be found at the following URL, http://www.diabetes.org/diabetescare/supplement298/B161.htm

New recommendations for care from the Fourth International Workshop on GD. Very conservative, extremely interventive protocols are being endorsed now. The above URL contains a summary of overall recommendations; go to the index page to find all the other articles that came out of this conference. The entire issue of this Diabetes Care Supplement is devoted to the topic of GD.

Carr, DB and Gabbe, S. Gestational Diabetes: Detection, Management, and Implications. Clinical Diabetes. 16(1):4-24, 1998 Jan-Feb. http://www.diabetes.org/clinicaldiabetes/v16n1j-f98/pg4.htm

Outstanding article summarizing gd testing, management, and even some of the controversies involved in gd, though from a traditional medical approach. Excellent overview, but may be too technical for beginners unfamiliar with some of the terminology and issues in gd. Those more familiar with gd terms and issues will find it invaluable, and beginners will want to return to it when their understanding increases.

Diabetes and Pregnancy, ACOG Technical Bulletin (An Educational Aid to Obstetrician-Gynecologists), #200--Decemeber 1994.

The definitive summary from the American College of Obstetricians and Gynecologists; it covers pre-existing diabetes in pregnancy as well as gestational diabetes. Technical but still readable. This is the 'bible' many doctors rely on for advice, and represents the current standard of care in the field. A must-read for those seriously interested in the subject.

Jovanovic-Peterson, Lois, M.D. with Morton B. Stone. Managing Your Gestational Diabetes. Minneapolis: Chronimed Publishing, 1994. To order, write P.O. Box 59032, Minneapolis, MN 55459-9686, or call 1-800-848-2793.

A good introduction to gd issues by one of the leading researchers in the field, who also happens to be diabetic (Type I) and a mother herself. Be aware her treatment guidelines in this book are quite conservative and not all providers use the same guidelines. Her writings also contain some patronizing and fat-phobic statements (fat people "live to eat rather than eat to live"). But she is an excellent introduction to the conservative approach to gd. She happens to be a very prolific writer in the field, so she tends to dominate the available published material on gd. Many more articles and books are available under her name.

Gestational Diabetes: What to Expect, The American Diabetes Association, Inc. Alexandria, Virginia: American Diabetes Association, 1992. To order, write to the ADA, 1970 Chain Bridge Road, McLean, VA 22109-0592, or call 1-800-232-3472.

The standard intro to the subject, written by the leading authorities on diabetes. A good, easy-to-read summary for those not desiring a great deal of detail. It is, of course, the standard medical approach to gd and does not contain any discussion of the controversies involved in gd. Definitely read this text as one of your first introductions to gd, while also keeping in mind that alternative views do exist.

Kippley, Sheila. Breastfeeding and Natural Child Spacing. Available from www.lalecheleague.org. More information on Natural Family Planning and the Kippley books can also be obtained from the Couple to Couple League at (513) 471-2000, P.O. Box 111184 Cincinatti, OH 45211, or at www.ccli.org.

Kmom has not read this book but has seen some excerpts and references from it. About the use of lactation amenorrhea to space children naturally. Discusses the difference between "ecological" breastfeeding and "cultural" breastfeeding, and how each method affects fertility.

Weschler, Toni. Taking Charge of Your Fertility. Available from www.amazon.com.

EXCELLENT book on understanding your fertility cycles and using this knowledge to either achieve or avoid pregnancy. Promotes the Fertility Awareness Method (FAM), which is similar to Natural Family Planning but without the religious context or required abstinence, for those who do not choose these. Uses the sympto-thermal approach, which involves charting basal body temperatures and observing cervical mucus and position. With adequate education and strict user compliance, the failure rate is quite small and comparable with many of the artificial forms of birth control, though many women conversely use its knowledge of peak fertility times to help achieve pregnancy instead. One of the finest, most useful books Kmom has ever read.

Boston Women's Health Collective. The New Our Bodies, Ourselves: A Book By and For Women. 25th Anniversary Edition. New York: Simon and Schuster, 1992.

 

 

 


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