The Center for Disease Control 2024 Updates on Breastfeeding and Contraceptive Use
by Anne Eglash MD, IBCLC, FABM
The 2016 CDC Medical Eligibility Criteria (MEC) had the goal of ‘…choosing the most appropriate contraceptive method for individual circumstances and using that method correctly, consistently, and continuously to maximize effectiveness’ and to decrease unintended pregnancies.
The 2024 CDC MEC use gender-inclusive language and embrace the concept of equitable access and shared decision-making by stating that ‘evidence-based guidance can support healthcare providers when providing person-centered counseling and contraceptive services, including assisting persons in selecting and using contraceptive methods safely and effectively…contraceptive services should be offered in a noncoercive manner that supports a person’s values, goals and reproductive autonomy…’.
There are several updates that include the addition of newer forms of contraception and several other health conditions. There are a few updates regarding breastfeeding and contraceptive use, including the recommendation to breastfeed for 2 years postpartum.
Contraceptives are rated as category 1,2,3, or 4, depending on the medical condition.
1= no restriction, 2= advantages generally outweigh the theoretical or proven risks, 3= theoretical or proven risks outweigh the advantages and 4= unacceptable health risk if the contraceptive method is used.
What do you know about contraception and breastfeeding? See the question!
- The MEC state that 2 studies conflict as to whether immediate placement of a progesterone IUD within 10 minutes after delivery of the placenta will interfere with breastfeeding, resulting in category 2 recommendation.
- Depot medroxyprogesterone acetate (DMPA) is category 2 during lactation from 30-42 days postpartum.
- The combined hormonal contraceptive pill (CHC) is a category 3 after 42 days postpartum due to risk of lower milk production.
- The lactational amenorrhea method guidelines include fully breastfeeding with no more than a 4-hour break in the day or 6 hours at night (in addition to amenorrhea and being less than 6 months postpartum)
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Summary
The 2024 U.S. Medical Eligibility Criteria for Contraceptive Use (U.S. MEC) comprises recommendations for the use of specific contraceptive methods by persons who have certain characteristics or medical conditions. These recommendations for health care providers were updated by CDC after review of the scientific evidence and a meeting with national experts in Atlanta, Georgia, during January 25–27, 2023. The information in this report replaces the 2016 U.S. MEC (CDC. U.S. Medical Eligibility Criteria for Contraceptive Use, 2016. MMWR 2016:65[No. RR-3]:1–103). Notable updates include 1) the addition of recommendations for persons with chronic kidney disease; 2) revisions to the recommendations for persons with certain characteristics or medical conditions (i.e., breastfeeding, postpartum, postabortion, obesity, surgery, deep venous thrombosis or pulmonary embolism with or without anticoagulant therapy, thrombophilia, superficial venous thrombosis, valvular heart disease, peripartum cardiomyopathy, systemic lupus erythematosus, high risk for HIV infection, cirrhosis, liver tumor, sickle cell disease, solid organ transplantation, and drug interactions with antiretrovirals used for prevention or treatment of HIV infection); and 3) inclusion of new contraceptive methods, including new doses or formulations of combined oral contraceptives, contraceptive patches, vaginal rings, progestin-only pills, levonorgestrel intrauterine devices, and vaginal pH modulator. The recommendations in this report are intended to serve as a source of evidence-based clinical practice guidance for health care providers. The goals of these recommendations are to remove unnecessary medical barriers to accessing and using contraception and to support the provision of person-centered contraceptive counseling and services in a noncoercive manner. Health care providers should always consider the individual clinical circumstances of each person seeking contraceptive services. This report is not intended to be a substitute for professional medical advice for individual patients; when needed, patients should seek advice from their health care providers about contraceptive use.
For lactating individuals who are 30-42 days postpartum, DMPA was category 1 in 2016, and is now category 2, while etonogestrel implant and the progesterone-only pill (POP) remain as category 1. After 42 days, DMPA is considered category 1. The MEC state ‘Overall, studies found that initiation of POPs, injectables, and implants at >6 weeks postpartum compared with nonhormonal use had no detrimental effect on breastfeeding outcomes or infant health, growth, and development in the first year postpartum. In general, these studies are of poor quality, lack standard definitions of breastfeeding or outcome measures, and have not included premature or ill infant’.
For lactating individuals who are >42 days postpartum, combined hormonal contraception (CHC) (estrogen-containing pill, ring, patch) was category 2 in 2016 and remains so in 2024. Even though estrogen appears clinically to be associated with decreased milk production, the MEC state: ‘Clinical studies demonstrate conflicting results regarding effects on breastfeeding continuation or exclusivity in women exposed to COCs during lactation. No consistent effects on infant growth or illness have been reported. Adverse health outcomes or manifestations of exogenous estrogen in infants exposed to CHCs through breast milk have not been demonstrated; however, studies have been inadequately designed to determine whether a risk for either serious or subtle long-term effects exists.’
There is a slight change in the recommendations for lactation amenorrhea method. In 2016, they suggested no more than 4-6 hour breaks between breastfeeds, and in 2024, they recommend no more than a 4-hour break in the day and 6 hours at night.
The World Health Organization continues to be more protective of breastfeeding than the CDC, despite interpreting the same data. DMPA is category 3 under 6 weeks postpartum for the WHO and category 2 for the CDC. Estrogen- containing contraceptives are category 3 until 6 months for the WHO and category 2 after 42 days postpartum for the CDC.