Priorities for Contraception and Lactation Among Breast Pump-Dependent Mothers of Premature Infants in the Neonatal Intensive Care Unit

Abstract

Objective:

Determine the knowledge and priorities for postpartum contraception and lactation in mothers of premature infants.

Design:

Twenty-five mothers of premature infants (mean gestational age = 29.9 weeks) hospitalized in a tertiary neonatal intensive care unit (NICU) participated in a multi-methods study using a multiple-choice contraceptive survey and qualitative interview in the first 2 weeks postpartum. Data were analyzed using content analysis and descriptive statistics.

Results:

Although 60% of mothers planned to use contraception, all questioned the timing of postpartum contraceptive counseling while recovering from a traumatic birth and coping with the critical health status of the infant. All mothers prioritized providing mothers' own milk (MOM) over the use of early hormonal contraception because they did not want to “take any risks” with their milk. They had limited knowledge of risks for repeat preterm birth (e.g., prior preterm birth: n = 13, 52%; multiple birth: n = 9, 36%; no knowledge: n = 3, 12%); only two mothers (0.08%) were counseled about the risks of a short interpregnancy interval.

Conclusion:

The context of the infants' NICU admission and the mother's desire to “do what is best for the baby” by prioritizing MOM should be integrated into postpartum contraceptive counseling for this population.

Introduction

Providing mothers' own milk (MOM) and reducing repeat preterm birth are evidence-based strategies that target the health and economic burdens of preterm birth. MOM feedings decrease the risk of multiple potentially preventable morbidities and their short- and long-term costs in premature infants, including necrotizing enterocolitis, late onset sepsis, bronchopulmonary dysplasia, rehospitalization, and neurodevelopmental problems.^1–5 Equally important is reducing the risk of repeat preterm birth by lengthening the interpregnancy interval (IPI) or the time period between a live birth and conception of the next pregnancy to at least 18 months.^6–8 Shorter IPIs are significantly associated with poor perinatal outcomes, including preterm birth, stillbirth, low birth weight, and small for gestational age infants, and can be avoided with acceptable, convenient, and effective contraception.^9,10

Thus, both MOM feedings and contraception are worthy public health priorities that should be achievable in the same mother. However, contraception that had traditionally been initiated at the 6-week postpartum visit is currently offered during the postpartum hospitalization in the United States^6–8,11due to initiatives for the immediate use of early hormonal contraception (EHC). These contraceptive methods contain progesterone as the active ingredient and include both short-term methods (e.g., mini pills and progestin only pills [POP]) and long-acting reversible contraception (LARC) (e.g., depot medroxyprogesterone acetate [DMPA], levonorgestrel intrauterine systems [IUSs], etonogestrel implants). Although these EHC methods have been endorsed by the American College of Obstetricians and Gynecologists (ACOG),¹² the American Academy of Pediatrics,¹³ and the U.S. Medical Eligibility Criteria for Contraceptive Use,¹⁴ all previous studies about their impact on lactation have excluded mothers who deliver <37 weeks of gestation and/or are breast pump-dependent.^15,16 Typically, mothers of NICU infants are completely breast pump-dependent, meaning that the mother relies on a breast pump rather than the infant for milk removal and the regulation of lactation processes.

In the study neonatal intensive care unit (NICU) we sought to initiate a new NICU-obstetrics quality improvement initiative for breast pump-dependent mothers that combined maternal education and an option for delayed contraception until 1 month postpartum. However, we realized that we had no formal knowledge about the mothers' understanding of the risk for repeat preterm birth, the importance of the IPI, or the potential effect of EHC on providing MOM. Thus, the primary purposes of this research were to determine the mothers' knowledge about these topics and to identify the mothers' priorities for EHC and MOM provision.

Methodology

This multi-methods study, conducted between January and May 2016, incorporated a demographic questionnaire, a contraceptive survey instrument, and an in-depth semi-structured interview. Data were collected during a single session in the infant's NICU room within the first 2 weeks postpartum, a time frame chosen to capture maternal recollections about contraceptive counseling during the postpartum hospitalization.

Sample and setting

All eligible subjects were invited to participate, were enrolled in the study, provided consent, and completed all aspects of data collection. Maternal inclusion criteria were: ≥18 years of age; ability to speak and read English; mother of a premature (<37 weeks) infant hospitalized in the NICU; and the provision of MOM with a breast pump. The study was conducted in an urban, midwestern, 72-bed single-patient room Level 3 NICU that prioritizes the feeding of MOM and provides personalized, daily lactation care from NICU-based breastfeeding peer counselors (BPCs).^17,18 At the request of the mothers and bedside NICU RNs and in accordance with ACOG guidelines that women should be counseled about the theoretical risks of decreased duration of breastfeeding,¹² the BPCs provided a brief overview of the use of EHC, informing mothers of the theoretical and anecdotal risks to the initiation of lactation in breast pump-dependent mothers of NICU infants. The purpose for this approach was to provide each mother with information so that she could make a decision with her health care provider about MOM provision and contraception based on her priorities and values, and long-term breastfeeding and reproductive goals. Institutional review board approval and written informed consent were obtained.

Data collection

Participants completed two survey instruments: a demographic questionnaire adapted from those previously used by this NICU human milk research team, and an investigator-developed contraceptive survey. Following completion of these instruments, a qualitative interview was conducted.

The demographic questionnaire provided information on infant and maternal characteristics, prenatal feeding goals, current method of feeding, and social support. The contraceptive survey was developed after a thorough review of the contraceptive and IPI literature for mothers of term and premature infants and was structured specifically for mothers with an infant in the NICU and who are at risk for a repeat preterm birth. The self-administered, multiple-choice Contraceptive Survey for Mothers of Infants in the NICU (CSMIN) focused on mothers' knowledge and experience with contraceptive methods, source of contraceptive and family planning information, and risk factors for repeat preterm birth, including IPI. The 9-question CSMIN could be completed within 2–3 minutes. Two clinical research experts in instrument development and postpartum contraception for lactating mothers of NICU infants reviewed and suggested minor revisions. The final CSMIN (Table 1) was piloted with the first two participants and minor word changes were made for clarity. After completing the CSMIN, mothers were asked specific questions during the individual interviews that integrated their responses to the CSMIN. For example, mothers were asked to describe factors that influenced their past contraceptive choices and how they rated contraceptive information they received from various sources.

Table 1.

Contraceptive Survey for Mothers of Infants in the Neonatal Intensive Care Unit

Have you ever heard of any of the following birth control methods:
Pill	25 (100)
Patch	22 (88)
Ring	19 (76)
Depo-Provera^®	21 (84)
Implant	16 (64)
IUD	21 (84)
Tubal ligation	12 (48)
Vasectomy	16 (64)
Condoms	25 (100)
Withdrawal	18 (72)
Rhythm method/natural family planning	5 (20)
Have you ever used any of these birth control methods:
Pill	15 (60)
Patch	9 (36)
Ring	5 (20)
Depo-Provera	8 (32)
IUD	3 (12)
Tubal ligation	3 (12)
Condoms	25 (100)
Withdrawal	18 (72)
Natural family planning	5 (20)
Where do you get your information about birth control?
Family (immediate and extended)	10 (40)
Friend	9 (36)
Health care provider (doctor, nurse, midwife)	23 (92)
Pharmacist	2 (8)
Mass media (e.g., Google, television, magazines)	9 (36)
When do you want to be pregnant again?
In the next year	2 (8)
1–2 years	7 (28)
Unsure	9 (36)
Do not want to get pregnant again	7 (28)
Have you heard of any of the following risk factors for preterm birth?
Prior preterm birth	13 (52)
Short IPI	4 (16)
Twins, triplets, or other multiples	9 (36)
Smoking	10 (40)
Cervical, uterine, or placental problems	10 (40)
Infection	9 (36)
Maternal medical conditions (e.g., high blood pressure, diabetes)	15 (60)
No knowledge of any risks	3 (12)
Are you planning to use birth control?
Yes	15 (60)
No	0
Unsure	10 (40)
Are you currently using any form of birth control?
Yes	6 (24)
No	19 (76)
Have you had sex (intercourse) since you've had your baby?
Yes	0
No	25 (100)
Have you had a postpartum visit to discuss contraception?
Yes	25 (100)
No	0

IPI, interpregnancy interval; IUD, intrauterine device.

Following collection of questionnaire data, individual, in-depth, semi-structured interviews were conducted, using an interview guide developed for this study. The interview guide was based on a review of the contraceptive and MOM provision literature and previous research conducted by this research team with mothers of (very low birth weight; ≤ 1,500g [VLBW]) infants hospitalized in the NICU.^17,18 After developing rapport with the participant by asking about experiences with pregnancy, birth, and breast pump use, the interviews focused on the dynamics involved in mothers' weighing of the potential competing interests of lengthening the IPI and providing MOM. The following areas of inquiry were targeted: previous and current contraceptive experience; the importance of effective contraception; desire for future pregnancies; the importance of providing MOM; and mothers' priorities for lactation and contraception. Sample questions are included in Table 2. Data collection and recruitment ended when thematic saturation was reached. Interviews were digitally recorded and lasted an average of 43 minutes (20–87 minutes).

Table 2.

Sample Questions from Interview Guide

Topic	Question
CSMIN 1	I'm going to name the birth control methods that you marked that you have heard about and/or have used. Could you please tell me what you liked or didn't like about them?
CSMIN 1	Probes: sides effects; access; cost; clinic visit; ease of use
CSMIN 2	I know you mentioned that you get most of your contraceptive information from——, but is there someone in particular or someplace that you trust that helps you makes the decision about what method to use that is right for you?
Qualitative interview questions current contraceptive use	What are your thoughts about using birth control after this baby?
Qualitative interview questions current contraceptive use	Probes: use/nonuse; short-term/long-acting/reversible; health considerations
Desire for future pregnancies	I'd like you to fantasize for a minute and tell me what your ideal family would look like.
Desire for future pregnancies	Probes: number of children; age difference; discussion of IPI
Postpartum contraceptive counseling	Has anyone been in to talk with you about birth control since you've had your baby? (Who? When?) Could you please tell me about that conversation?
Postpartum contraceptive counseling	Probes: recommendations; lactation; IPI; reproductive goals; timing
Provision of MOM	You're providing MOM now. What does it mean to you to provide milk for your baby?
Prioritizing MOM or contraception	In terms of providing milk or having effective birth control to prevent a repeat preterm birth, which is more important to you right now? Why? If providing milk: If you were to have sex now, how would you prevent another pregnancy?

MOM, mothers' own milk; CSMIN, Contraceptive Survey for Mothers of Infants in the Neonatal Intensive Care Unit.

Analysis

Descriptive statistics were used to describe demographic data and CSMIN responses. Qualitative data were analyzed by content and thematic analysis, inductive and data-driven approaches involving systematic identification and integration of patterns in the data to answer the research question.^19,20 Interviews were transcribed verbatim and checked for accuracy. Two researchers independently coded the first five interviews to develop a preliminary list of codes, which describe or assign meaning to topics discussed by the participants. To ensure fidelity, the codes were then compared with the transcripts to ensure they were the best fit for the data. The two researchers then separately coded the remaining interviews and met regularly with the research team to discuss adding, eliminating, revising, or combining codes. Relevant codes were further analyzed and compared and contrasted within each interview and then across all interviews to identify patterns common to all participants. These shared patterns were then combined into larger unifying units of analysis or themes. Analytic review continued by relating the themes back to the research question and current literature.¹⁹

Results

Characteristics of the sample

Characteristics of the 25 mothers and their infants are summarized in Table 3. Participants were racially and ethnically diverse, mostly married or partnered, educated beyond high school, and most (84%) had prenatal intentions to breastfeed. All infants were receiving exclusive MOM (n = 23) or a combination of MOM and donor human milk (n = 2).

Table 3.

Descriptive Statistics for Study Participants (n = 25)

Characteristic	n (%)
Race
Black	12 (48)
Non-Hispanic White	5 (20)
Hispanic	7 (28)
Asian	1 (4)
Marital status
Married	13 (52)
Not married	3 (12)
Not married, living with partner	9 (36)
Education
High school or less	4 (16)
Some college	9 (36)
College graduate	12 (48)
Economic status
WIC eligible	10 (40)
Non-WIC eligible	15 (60)
Employment
Employed full-time	12 (48)
Employed part-time	2 (8)
Not employed	11 (44)
Parity
Primipara	13 (52)
Multipara	12 (48)
Breastfeeding experience
Prior experience	8 (32)
No experience	17 (68)
Prenatal feeding plans
Breastfeeding	21 (84)
Formula-feeding	1 (4)
Combination	3 (12)
Mode of birth
Caesarean	18 (72)
Vaginal	7 (28)
	M ± SD (Min–Max)
Maternal age (years)	26.8 ± 5.3 (18–39)
Infant birthweight (g)	1352 ± 455.8 (539–2012)
Gestational age at birth (weeks)	29.9 ± 2.5 (24–33)

SD, standard deviation; WIC, Special Supplemental Nutrition Program for Women, Infants, and Children.

CSMIN survey and CSMIN related interview questions

Results from the CSMIN and related interview questions indicated that mothers had an extensive awareness of their contraceptive options and overwhelmingly preferred receiving personalized recommendations from their health care provider rather than friends, family, and mass media. However, mothers had limited knowledge of the IPI and other risk factors for preterm birth (Table 1).

When asked about decision making for choice of contraception, mothers ranked their options on the basis of three priorities: convenience; lack of side effects; and ease of access. Mothers wanted contraception that was easy to use and required minimal personal action, such as the IUS or DMPA. They were very aware of common side effects of hormonal contraception, provided examples of emotional lability, weight gain, headaches, and intermenstrual bleeding, and wanted to avoid these problems. Ease of access meant that the contraceptive method was easily available, inexpensive, and did not require a clinical visit. However, mothers' prior experiences (n = 22, 88%) were most influential. For example, although 60% had tried oral contraception, side effects were common and distressing (“I was just so moody I didn't even like myself!”), adhering to a dosing schedule was difficult (“I'm so forgetful”), and a clinical visit and prescription were required. Condoms, used by all of the mothers, were the most accessible and convenient (“Anybody can just go and get them”), and easiest to use. However, this group of mothers considered condoms to have the highest failure rate. Twenty-two (88%) mothers were very definitive that contraceptive use and type was their choice: “It is my body, always my choice.” The three remaining mothers reported making this decision with their partners. Forty percent of the mothers (n = 10) were unsure whether they would use any postpartum contraception other than the possibility of condoms (Table 1).

Summary of qualitative interview

Data from the qualitative interviews provided insight into the mothers' priorities for contraceptive use and MOM provision. The mothers' experiences are captured in three primary themes: Maternal Perceptions of the Postpartum Contraceptive Counseling, Tension Related to the Timing of the Contraceptive Counseling, and Prioritization of MOM over EHC.

Maternal perceptions of postpartum contraceptive counseling

Content of contraceptive counseling

Contraceptive counseling was provided during the postpartum hospitalization by hospital-based obstetric residents, but the content of the counseling varied among providers. Three mothers requested immediate postpartum tubal ligations, thus counseling was provided for the remaining 22 mothers.

All mothers were providing MOM by breast pump at the time of first contraceptive counseling, but only 12 of the 22 (55%) were asked about lactation, and of these 12 mothers, 10 (n = 10/12, 83%) were told that EHC would not affect their lactation. All mothers who received postpartum counseling (n = 22) related that they felt some degree of pressure to accept a contraceptive method before postpartum discharge and six (27%) were specifically told they should have immediate contraception to avoid becoming pregnant. The methods offered most frequently were the levonorgestrel IUS, DMPA, or POP.

Mothers denied being asked about family planning issues, such as planned birth spacing of subsequent children or fertility concerns during these counseling sessions. Although nine mothers (41%) hoped to give birth to another child within the next 1–2 years, only 2 of the 22 had been informed during postpartum counseling of the heightened risk of preterm birth following a short IPI. A mother of two premature infants born 15 months apart asserted: “That's something they should tell moms most definitely. Nobody wants to have preterm babies. It's just hard.” However, at the time of the interview, this mother prioritized the provision of MOM over EHC and was unsure about what type of contraceptive method she was going to use, other than condoms. Three participants with histories of infertility were unsure about using any postpartum contraception, despite claiming they understood the risk (another preterm birth) of not using contraception.

Questioning the immediate need for contraception

The majority of mothers (n = 17, 68%) did not understand the urgency for choosing a contraceptive method, as typified by this mother's exclamation: “I am closed for business right now! I don't even want to think about the word sex!” They also emphasized that they had previously been counseled to abstain from sexual intercourse until 6–8 weeks postpartum. Sixteen mothers (64%) stated they were waiting until the postpartum visit with their personal health care provider to finalize contraceptive options, and would use condoms if needed before that time.

Tension related to timing of contraceptive counseling

When approached for contraceptive counseling, most mothers (n = 18, 72%) reported they were recovering from cesarean births for acute and/or chronic health conditions, felt emotionally and physically overwhelmed, and were still in shock, confused, and concerned about their infant's prognosis: “I've been so stressed; I've probably cried a million rivers since he's been born.” These feelings often prevented them from fully engaging in and remembering content of the contraceptive discussion. When asked about the timing of the counseling, one mother replied somewhat indignantly: “Like, really? I just had him. Give me a break.” Other mothers agreed, as illustrated by the following comment: “To be honest, I really don't remember much. I was in the ‘too much information’ mode at the time.” Other mothers simply “turned down everything they offered” or requested time to evaluate their options and “look into methods that don't affect my milk.”

Mothers reported that being approached more than once by the provider after declining to accept contraception increased their already-elevated stress levels. A mother recovering from multiple emergency surgeries after a complicated birth exemplified this frustration: “They came in, and then they came in again even after I said I didn't want the shot (DMPA) because it interfered with breastfeeding. They don't understand. I'm not having sex. I don't even have a partner!”

Prioritizing MOM over EHC

In contrast, counseling about providing MOM fully engaged the mothers and providing MOM was considered an “easy choice.” Mothers learned about the importance of MOM for reducing the risk of complications of prematurity from the attending neonatologists in predelivery counseling and received similar messaging from the NICU-based BPCs within hours after birth. Every mother in this study prioritized the infant's wellbeing by providing MOM and spoke of the importance of MOM for her infant: “My body was made to do this. I'll give her my milk to make her eyes stronger, to make her brain stronger, to make her stronger.” Mothers characterized providing MOM as a “job” they were dedicated to and passionate about, but also as something they felt “compelled” to do: “I'll do whatever I have to. She didn't ask to be here so early, so it's my obligation to supply her with the healthiest nutrients I can to help her grow. It's about what's best for the baby.”

Once mothers decided to provide MOM, they did not want anything to interfere with their efforts. To the mothers in this study, that meant prioritizing the provision of MOM over EHC. One mother described her decision-making process quite simply: “My milk is more important than some birth control. I can just not have sex.” Another mother echoed that thought: “I'm not going to risk my milk. Sex can wait. I have a premature baby who needs my breast milk right now.” When queried about resumption of sexual activity, all mothers were very clear that sex and contraception were not priorities. None of the mothers had resumed sexual intercourse at the time of data collection.

Discussion

To our knowledge, this is the first study to describe the knowledge, experiences, and decision making with respect to contraceptive use and MOM provision in breast pump-dependent mothers of premature infants. In this mostly minority sample, participants revealed considerable knowledge of and experience with contraceptive options and the majority (60%) indicated they planned to use contraception following the preterm birth. However, all mothers questioned the timing of contraceptive counseling, explaining that they were still recovering from pregnancy and birth complications while trying to cope with the overwhelming stress of the infant's NICU admission. The mothers reported “information overload,” the inability to recall conversations with care providers, and prioritizing decision-making that involved infant treatment considerations. Our findings suggest that the decision to provide MOM met this last criterion because it was essential for the infant's treatment, needed to begin immediately, and was consistent with maternal role identity of nurturing the infant. Although the mothers questioned the timing of EHC counseling apart from MOM provision, they were adamant that they did not want to “take any risk with their milk” by accepting EHC. Thus, in this vulnerable population, it appears that mothers prioritize the maternal caretaking role over that of sexual partner in the early postpartum period. These findings merit further study with respect to the timing of comprehensive contraceptive counseling.

Our findings and those of other researchers raise questions as to whether the recommendations and guidelines for EHC counseling from multiple professional societies should be generalized to this population of mothers.^12,13 Even in healthy full-term populations, studies have revealed contraceptive counseling during the maternity hospitalization may be ineffective, misunderstood, perceived as directive, or not remembered by mothers who are focused on their own health, breastfeeding, and infant care.^21,22 ACOG²³ recommends that comprehensive postpartum support and counseling services be part of an ongoing process, rather than a single encounter, and that timing be individualized according to an assessment of each woman's needs and priorities.

Although several studies report that women prefer to receive multiple pre- and postnatal contraceptive counseling sessions with their obstetric care providers,^23–25 mothers who deliver very prematurely miss the opportunity to have these late pregnancy discussions.²⁶ The mothers in our study recognized that their reproductive priorities had changed with the preterm birth and infant's NICU hospitalization and expressed their desire to defer comprehensive contraceptive counseling until their 6-week postpartum visit. They did indicate that they would either abstain from sexual intercourse or use condoms in the interim.

However, several sources of evidence support the EHC initiative in the United States. Nearly 50% of women either resume sexual activity before the 6-week visit or do not return for follow-up contraceptive care,^6,27,28 and for those who do return, systematic delays and economic barriers to obtaining LARC are common.^6,29,30 Furthermore, evidence suggests that partner influence, including the timing of sexual relations and the desire to have no contraceptive method used by either partner, contributes to unintended pregnancies.^25,31 Of particular concern for mothers with a history of preterm birth is that 35% of these women conceive again within 18 months of a previous birth, with the majority being unintended pregnancies.^6,11

There is also evidence for delay in the use of EHC until lactation is established in this population. The initiation of lactation or secretory activation is triggered by and is completely dependent on the rapid and sustained decline in progesterone that occurs with the birth of the placenta.³² Recent research by our team reveals that breast pump-dependent mothers of premature infants experience delayed and/or impaired secretory activation during the first 14 days postpartum, raising concerns about exogenous progesterone in a population that is already at risk for poor lactation outcomes.³³ This study, which was conducted with breast pump-dependent mothers of VLBW infants, revealed that milk-borne biomarkers of secretory activation either came into normal range several days later than previously described findings for mothers following healthy term birth or never achieved normal concentrations. Furthermore, these biomarkers were dynamic over the first 14 days postpartum such that many mothers who achieved secretory activation during the first 5–8 postpartum days actually reversed this process and experienced low MOM volume thereafter. While these data do not indicate that EHC causes delayed or impaired secretory activation, they highlight the additional lactation risk for this population that may be exacerbated by exogenous progesterone in any form. Furthermore, the Academy of Breastfeeding Medicine,³⁴ a Cochrane Review,²² and multiple researchers^35–37 caution that the data related to EHC and lactation are lacking for women who are breast pump-dependent or otherwise at risk for low milk production. Thus, the combined theoretical risk presented to the establishment of lactation due to preterm birth, breast pump-dependency, and EHC requires additional study.

Also noteworthy is the fact that all previous studies examining the impact of EHC on lactation outcomes have excluded mothers delivering premature infants <37 weeks of gestation,^15,16,35,38 and even studies with term healthy populations have been categorized as poor-to-moderate quality in a recent Cochrane Review.⁷ Nonetheless, the findings from these studies are commonly generalized to breast pump-dependent mothers of premature infants, which is likely the reason that mothers in our study were assured that EHC would not negatively affect lactation.

Our findings have implications for research and practice. Although a randomized trial of EHC in breast pump-dependent mothers of premature infants is ethical, our data inform the difficulty of enrollment because without exception, the mothers in our research indicated that they did not want to “take the risk” of using EHC if it might affect MOM provision. Torres and colleagues³⁹ encountered difficulties recruiting new mothers of preterm infants hospitalized in the NICU to a randomized controlled trial of contraceptive counseling during the maternity hospitalization. The authors theorized that mothers declined to participate because at the time of the proposed counseling, they were focused on coping with the stress and anxiety of their infants' NICU admission. A promising strategy recommended by ACOG²³ and WHO⁴⁰ is scheduling the postpartum visit for this population at 3 weeks versus 6 weeks. An innovative pilot program utilizing this approach revealed that mothers were receptive to receiving family planning services including the provision of contraception, within the NICU setting, thus eliminating a separate clinic visit.⁴¹ By 3 weeks postpartum, EHC should not interfere with the maintenance of established lactation and few if any mothers would be “lost to follow-up” because their infants would still be hospitalized in the NICU.

A strength of this study is the diverse sample of breast pump-dependent mothers of premature infants hospitalized in the NICU. To our knowledge, the only other studies that focused exclusively on mothers who had given birth <37 weeks gestation^39,42–44 examined in-patient postpartum contraceptive counseling and contraceptive use, but did not study lactation outcomes. This study is limited to well-educated, English-speaking participants in a clinical setting that prioritized MOM provision and included maternal education about the theoretical effect of EHC on the initiation of lactation delivered by NICU-based BPCs. We also acknowledge that the study does not include information about the timing of resumed sexual activity, the partner's perspective on contraception or his role in initiating sex and/or supporting lactation. Obstetric residents' conversations with mothers about contraception were not recorded and may have differed from the mothers' perceptions of these conversations.

Conclusion

In summary, our findings underscore the importance of discussing contraceptive options with breast pump-dependent mothers of premature infants within the context of the infants' NICU admission, the mothers' prioritization of MOM, their desire not to “take any risk with their milk,” and that sex “can wait.” These findings can inform an evidence-based counseling template for providers to use in partnership with the mother whose priorities and reproductive goals may influence her specific choice.

Footnotes

Acknowledgments

This research was partially supported by grants from Rush University Children's Hospital Department of Pediatrics (R.H.), the Family Larsson-Rosenquist Foundation (C.M.-P.), and Medela AG, Switzerland.

Disclosure Statement

No competing financial interests exist.

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