Progestogen-only pill (POP) vs combined oral contraceptive (COC) initiated at < 6 weeks postpartum |
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Breastfeeding continuation | 1 RCT (n=127) | Serious limitations (1 fair) | Cannot determine (1 study) | Serious imprecision | No indirectness | NA | Low | Norethindrone vs ethinyl estradiol (EE) COC (1 RCT): 64% vs 64%, RR 0.99 (95% CI 0.76–1.3) at 8 weeks; 41% vs 44%, RR 0.94 (95% CI 0.63–1.4) at 6 months |
Use of supplementation | 1 RCT (n=127) | Serious limitations (1 fair) | Cannot determine (1 study) | Serious imprecision | No indirectness | NA | Low | Norethindrone vs EE COC (1 RCT): no difference at 8 weeks (data not provided) |
Infant growth | 1 RCT (n=127) | Serious limitations (1 fair) | Cannot determine (1 study) | Serious imprecision | No indirectness | NA | Low | Norethindrone vs EE COC (1 RCT): no difference in percent change in weight (P = 0.56), length (P = 0.41), or head circumference (P = 0.79) from weeks 2–8 |
LNG-IUD initiated at < 6 weeks postpartum vs non-hormonal contraception | | | | |
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Breastfeeding continuation | 1 RCT (n=110) | Very serious limitations (1 poor) | Cannot determine (1 study) | Serious imprecision | No indirectness | NA | Very low | LNG-UD (30 mcg/d or 10 mcg/d) vs Cu-IUD (1 RCT): 58% vs 79% at 8 months, RR 0.74 (95% CI 0.57–0.95) |
Breastfeeding duration | 1 RCT (n=110) | Very serious limitations (1 poor) | Cannot determine (1 study) | Serious imprecision | No indirectness | NA | Very low | LNG-IUD 30 mcg/d vs LNG IUD 10 mcg/d vs Cu-IUD (1 RCT): 197 vs 182 vs 208 days (P > 0.05) |
Infant growth | 1 RCT (n=110) | Very serious limitations (1 poor) | Cannot determine (1 study) | Serious imprecision | No indirectness | NA | Very low | LNG-IUD (30 mcg/d or 10 mcg/d) vs Cu-IUD (1 RCT): no differences through 12 months |
Progestogen-only injectable initiated at < 6 weeks postpartum vs non-hormonal | | | |
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Breastfeeding continuation | 3 cohort studies (n=617) | Very serious limitations (1 fair, 2 poor) | Cannot determine (1 study) | Serious imprecision | No indirectness | Variability in interventions and outcomesa | Very low | No clear differences in 2 studies; in a 3rd study weaning occurred later with DMPA or NET-EN |
Use of supplementation | 5 cohort studies (n=1370) | Very serious limitations (1 fair, 4 poor) | No serious inconsistency | No serious imprecision | No indirectness | Variability in interventions and outcomesa | Low | All 5 studies found DMPA or NET-EN associated with similar or lower likelihood of exclusive breastfeeding |
Duration of breastfeeding | 5 cohort studies (n=1732) | Very serious limitations (1 fair, 4 poor) | No serious inconsistency | No serious imprecision | No indirectness | None | Low | All 5 studies found DMPA associated with no difference or increased duration of breastfeeding vs non-hormonal methods |
Infant growth | 6 cohort studies (n=4403) | Very serious limitations (5 poor) | No serious inconsistency | No serious imprecision | No indirectness | None | Low | None of 5 studies found DMPA or NET-EN associated with decreased infant growth; 1 study found progestogen-only injectable associated with increased weight gain through 3 months |
POPs initiated at < 6 weeks postpartum vs non-hormonal | | | | |
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Breastfeeding continuation | 1 non-randomized trial (n=273) 3 cohort studies (n=756) | Serious limitations (1 fair-quality cohort study, 3 poor-quality studies) | No serious inconsistency | No serious imprecision | No indirectness | Variability in interventions and outcomesa | Low | None of 4 studies found various POPs associated with lower likelihood of breastfeeding continuation; 2 studies found POPs associated with higher likelihood of breastfeeding continuation |
Breastfeeding initiation | 1 RCT (n=20) and 1 nonrandomized trial (n=20) | Very serious limitations (2 poor) | No serious inconsistency | Very serious imprecision | No indirectness | Variability in interventions and outcomesa | Very low | 1 RCT found no difference between norethisterone at ≤ 14 hours postpartum (PP) vs placebo in breastfeeding initiation; 1 non-randomized trial found lynestrenol at 2 days PP associated with initiation of breastfeeding at 3 vs 5 days PP with placebo |
Duration of breastfeeding | 2 cohort studies (n=572) | Very serious limitations (2 poor) | No serious inconsistency | Serious imprecision | No indirectness | Variability in interventions and outcomesa | Low | 2 studies found POPs associated with somewhat longer duration of breastfeeding vs non-hormonal comparators |
Use of supplementation | 2 cohort studies (n=1000) | Very serious limitations (1 fair, 1 poor) | Serious inconsistency | No serious imprecision | No indirectness | Variability in interventions and outcomesa | Very low | 1 fair-quality study found norgestrel associated with more frequent supplementary feeding but no difference in proportion of women supplementing; 1 poor-quality study found LNG associated with somewhat later initiation of supplementation (5.4 vs 4.6 months PP) |
Infant growth | 1 RCT (n=20), 1 non-randomized trial (n=20); 3 cohort studies (n=1083) | Serious limitations (2 fair-quality cohort studies, 3 poor-quality studies) | No serious inconsistency | No serious imprecision | No indirectness | Variability in interventions and outcomesa | Very low | 4 studies found no difference on measures of infant growth; 1 small, poor-quality, non-randomized study found greater increase with lynestrenol than placebo |
Progestogen-containing implants initiated at < 6 weeks postpartum vs non-hormonal | | |
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Breastfeeding continuation | 3 cohort studies (n=520) | Very serious limitations (1 fair, 2 poor) | Serious inconsistency | Serious imprecision | No indirectness | Variability in interventions and outcomesa | Very low | 3 studies reported conflicting findings regarding effects of progestogen-containing implants on measures of breastfeeding continuation; the 1 fair-quality study found no difference between nomegestrol implant in 2nd month PP vs Cu-IUD |
Breastfeeding episodes | 2 cohort studies (n=392) | Very serious limitations (1 fair, 1 poor) | No serious inconsistency | Serious imprecision | No indirectness | Variability in interventions and outcomesa | Very low | 2 studies found no differences in breastfeeding frequency |
Duration of breastfeeding | 1 cohort study (n=80) | Serious limitations (1 fair) | Cannot determine (1 study) | Very serious imprecision | No indirectness | None | Very low | 1 fair-quality cohort study found no difference between etonogestrel (ETG) implant at 28–56 days PP vs Cu-IUD in duration of breastfeeding |
Use of supplementation | 3 cohort studies (n=430) | Very serious limitations (1 fair, 2 poor) | Serious inconsistency | Serious imprecision | No indirectness | Variability in interventions and outcomesa | Very low | 2 studies found no difference in use of supplementation; 1 study found norethindrone associated with increased likelihood of supplementation at 3 months |
Infant growth | 6 cohort studies (n=870) | Serious limitations (2 fair, 4 poor) | No serious inconsistency | No serious imprecision | No indirectness | Variability in interventions and assessment of outcomesa | Low | 2 fair-quality and 2 poor-quality studies found no difference in measures of infant growth; 1 poor-quality study found LNG associated with more weight gain than Cu-IUD; 1 poor-quality study found LNG associated with slower weight gain than Cu-IUD or barrier/no method |
Multiple progestogen-only methods initiated at < 6 weeks postpartum vs non-hormonal | | |
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Breastfeeding continuation | 1 cohort study (n=319) | Very serious limitations (1 poor) | Cannot determine (1 study) | Serious imprecision | No indirectness | None | Very low | 1 study found no difference between LNG implant or POP prior to discharge vs non-hormonal contraception in breastfeeding continuation at 2–6 weeks PP |
Use of supplementation | 1 cohort study (n=319) | Very serious limitations (1 poor) | Cannot determine (1 study) | Serious imprecision | No indirectness | None | Very low | 1 study found no difference between LNG implant or POP prior to discharge vs non-hormonal contraception in use of supplementation at 2–6 weeks PP |
Non-orally available progesterone initiated at < 6 weeks postpartum vs non-hormonal | | |
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Breastfeeding continuation | 2 cohort studies (n=1092) | Very serious limitations (1 fair, 1 poor) | Serious inconsistency | Serious imprecision | No indirectness | None | Very low | 1 fair-quality study found progesterone pellets at 30–35 days PP associated with decreased likelihood of breastfeeding at 6 months (51% vs 58%) and 12 months (11% vs 18%); 1 poor-quality study found no difference between progesterone pellets at 30 or 60 days vs Cu-IUD or placebo injection in breastfeeding rates |
Use of supplementation | 2 cohort studies (n=1092) | Very serious limitations (1 fair, 1 poor) | No serious inconsistency | Serious imprecision | No indirectness | None | Very low | 2 studies found no differences in use of supplementation |
Infant growth | 2 cohort studies (n=1092) | Very serious limitations (1 fair, 1 poor) | No serious inconsistency | Serious imprecision | No indirectness | None | Very low | 2 studies found no differences in infant growth |
LNG-IUD initiated at > 6 weeks postpartum vs non-hormonal | | | | |
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Duration of breastfeeding | 1 RCT (n=320) | Serious limitations (1 fair) | Cannot determine (1 study) | Serious imprecision | No indirectness | None | Very low | LNG-IUD at 6–8 weeks PP vs Cu-IUD (1 RCT): 149 vs 160 days |
Use of supplementation | 1 RCT (n=320) | Serious limitations (1 fair) | Cannot determine (1 study) | Serious imprecision | No indirectness | None | Very low | LNG-IUD at 6–8 weeks PP vs Cu-IUD (1 RCT): no difference in exclusive breastfeeding |
Infant growth | 1 RCT (n=320) | Serious limitations (1 fair) | Cannot determine (1 study) | Serious imprecision | No indirectness | None | Very low | LNG-IUD at 6–8 weeks PP vs Cu-IUD (1 RCT): no difference in infant growth |
Progestogen-only injectable initiated at > 6 weeks postpartum vs non-hormonal | | | |
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Breastfeeding continuation | 1 RCT (n=170) | Very serious limitations (1 poor) | Cannot determine (1 study) | Serious imprecision | No indirectness | None | Very low | DMPA at 6 weeks PP vs non-hormonal (1 RCT): no difference in rates of discontinuation |
Duration of breastfeeding | 1 cohort study (n=1538) | Serious limitations (1 fair) | Cannot determine (1 study) | No serious imprecision | No indirectness | None | Low | DMPA or NET-EN at 6–8 weeks PP vs non-hormonal contraception (1 cohort study): no difference in duration of breastfeeding |
Use of supplementation | 1 RCT (n=170); 1 cohort study (n=212) | Very serious limitations (2 poor) | No serious inconsistency | Serious imprecision | No indirectness | None | Very low | 2 studies found no differences in use of supplementation |
Infant growth | 1 RCT (n=170); 2 cohort studies (n=1750) | Very serious limitations (1 fair-quality cohort study, 2 poor-quality studies) | No serious inconsistency | No serious imprecision | No indirectness | Variability in outcomesa | Low | None of 3 studies found decreased infant growth with DMPA or NET-EN; 2 studies reported some findings suggesting greater weight gain |
POP initiated at > 6 weeks postpartum vs non-hormonal | | | | | |
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Breastfeeding continuation | 1 RCT (n=144) | Very serious limitations (1 poor) | Cannot determine (1 study) | Very serious imprecision | No indirectness | None | Very low | Norgestrel at 6 weeks PP vs non-hormonal contraception (1 RCT): no difference in discontinuation of breastfeeding |
Duration of breastfeeding | 2 cohort studies (n=1709) | Serious limitations (2 fair) | No serious inconsistency | No serious imprecision | No indirectness | Variability in interventionsa | Low | 2 studies found no difference in breastfeeding duration |
Use of supplementation | 1 RCT (n=144); 1 nonrandomized trial (n=120) | Very serious limitations (2 poor) | Serious inconsistency | No serious imprecision | No indirectness | Variability in interventions and outcomesa | Very low | 1 RCT found no difference in use of supplementation and 1 non-randomized trial found lower mean age at supplementation with lynestrenol vs IUD + placebo (11 vs 15 weeks, P not reported) |
Infant growth | 1 RCT (n=144); 3 nonrandomized studies (n=1829) | Serious limitations (2 fair-quality cohort studies, 2 poor-quality studies) | No serious inconsistency | No serious imprecision | No indirectness | Variability in interventions and outcomesa | Low | 4 studies found no difference in measures of infant growth |
Progestogen-only implant or progestogen-containing IUD initiated at > 6 weeks postpartum vs non-hormonal |
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Breastfeeding continuation | 2 cohort studies (n=57) | Very serious limitations (2 poor) | No serious inconsistency | Very serious imprecision | No indirectness | None | Very low | 2 studies found no difference in breastfeeding rates |
Breastfeeding duration | 4 cohort studies (n=2329) | Serious limitations (4 fair) | No serious inconsistency | No serious imprecision | No indirectness | Variability in outcomesa | Low | 4 studies found no difference in breastfeeding duration |
Use of supplementation | 3 cohort studies (n=549) | Serious limitations (2 fair, 1 poor) | No serious inconsistency | Serious imprecision | No indirectness | Variability in interventions and outcomesa | Low | 3 studies found no difference in use of supplementation |
Infant growth | 6 cohort studies (n=2386) | Serious limitations (4 fair, 2 poor) | No serious inconsistency | No serious imprecision | No indirectness | Variability in interventions and outcomesa | Low | 6 studies found no difference in measures of infant growth |
Multiple progestogen-only methods initiated at > 6 weeks postpartum vs non-hormonal | | |
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Breastfeeding duration | 1 cohort study (n=34) | Very serious limitations (1 poor) | Cannot determine (1 study) | Very serious imprecision | No indirectness | None | Very low | DMPA, POP or LNG-IUD vs non-hormonal contraception (1 cohort study): 183 vs 183 days (P =0.38) |
Infant growth | 1 cohort study (n=140) | Very serious limitations (1 poor) | Cannot determine (1 study) | Very serious imprecision | No indirectness | None | Very low | DMPA at 6 weeks PP vs non-hormonal contraception (1 cohort study): no difference in weight through 26 weeks PP |
Non-orally available progesterone initiated at > 6 weeks postpartum vs non-hormonal | | |
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Breastfeeding continuation | 2 cohort studies (n=788) | Very serious limitations (1 fair, 1 poor) | No serious inconsistency | No serious imprecision | No indirectness | Variability in interventionsa | Very low | 1 fair-quality study found elcometrine implant associated with higher breastfeeding rate at 3 and 5 months (but not at 9 and 12 months); 1 poor-quality study found no difference between progesterone pellets vs Cu-IUD or placebo at 6 or 13 months PP |
Breastfeeding duration | 1 cohort study (n=200) | Serious limitations (1 fair) | Cannot determine (1 study) | Serious imprecision | No indirectness | None | Very low | Nesterone implant at 55–60 days PP vs Cu-IUD (1 cohort study): 273 vs 263 days (NS) |
Infant growth | 3 cohort studies (n=988) | Serious limitations (2 fair, 1 poor) | No serious inconsistency | No serious imprecision | No indirectness | Variabilty in interventions and outcomesa | Low | 3 studies found no differences in measures of infant growth |
Earlier vs later initiation of progestogen-only methods | | | | | |
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Breastfeeding continuation | 2 RCTs (n=165) and 1 cohort study (n=35) | Serious limitations (2 fair-quality RCTs, 1 poor-quality cohort study) | No serious inconsistency | Serious imprecision | No indirectness | Variabilty in interventions and outcomesa | Low | 1 RCT found immediate LNG-IUD associated with lower breastfeeding rate at 6 months vs initiation at 6–8 weeks PP (6% vs 24%, P = 0.02); 1 cohort study found norethindrone implant at 6 days PP associated with lower rate at 8 months (57% vs 67%); 1 RCT found no difference in rate of lactation failure |
Breastfeeding duration | 1 RCT (n=96) | Serious limitations (1 fair) | Not applicable 1 study) | Very serious imprecision | No indirectness | None | Very low | Immediate LNG-IUD vs 6–8 weeks PP (1 RCT): 5 vs 8.5 weeks (P=0.06) |
Use of supplementation | 3 RCTs (n=205) and 4 cohort studies (n=660) | Serious limitations (3 fair-quality RCTs, 1 fair- and 3 poor-quality cohort studies) | Serious inconsistency | No serious imprecision | No indirectness | Variability in interventions and outcomesa | Very low | Inconsistent effects on use of supplementation among 7 studies |
Infant growth | 1 RCT (n=40) and 3 cohort studies (n=543) | Very serious limitations (1 fair-quality RCT, 3 poor-quality cohort studies) | No serious inconsistency | Serious imprecision | No indirectness | Variability in interventions and outcomesa | Low | 4 studies found no differences in measures of infant growth |