According to National Institute for Health and Care Excellence (NICE) guidelines, contraceptive methods and advice about when to start them should be discussed within the first postpartum week, and this is usually delivered by hospital or community midwives.Further discussion and provision of contraception is an integral part of the six-week postpartum GP check. There is great variation in the return to fertility and sexual activity following childbirth but the earliest known time of ovulation is 27 days after delivery. Therefore, no contraception is needed until 21 days postpartum, which is nonetheless ahead of the six-week check. Advise all women that they may become fertile ahead of the return of their periods and should not delay the use of contraception if they do not wish to become pregnant again.
The puerperium and lactation make particular demands on the safe choice of contraception - there is an increased risk of venous thromboembolic disease in the few weeks following childbirth. Postpartum, a woman's contraceptive needs may have changed and discussions may occur regarding 'spacing' future pregnancies (very close intervals between babies are generally thought to increase risk to mother and future infants) or preventing further pregnancies where a family is considered complete (sterilisation may be requested as a 'final' method, but alternatives should be raised).
In order for a woman to make an informed choice about her future contraceptive method, discuss:
- Beliefs, attitudes and personal preferences. Establish whether there are cultural considerations.
- Contraceptive needs. Ask whether she has resumed sexual activity. Ask whether there are any new or ongoing sexual problems. Discuss what degree of efficacy is required: whether she wants another child soon or considers her childbearing period has been completed.
- Whether ovulation may have restarted based on when the was baby delivered, method of feeding and recurrence of menstruation. This can affect the starting regime of the contraceptive chosen and also whether extra contraceptive measures are needed initially.
- Feeding methods - until 2016 combined hormonal contraception was contra-indicated whilst breast-feeding. Further research has shown little evidence of adverse effect on mother or child, so breast-feeding between 6 weeks and 6 months postpartum is now a category 2 in the UK medical eligibility criteria (UKMEC) ie benefits generally outweigh the risks.A woman may wish to consider the lactational amenorrhoea method (LAM) but it is important to elicit the pattern of breast-feeding (frequency, duration of feeds, demand feeding) to determine whether or not this is an option.
- Social factors such as return to full-time employment may influence feeding method and breast-feeding frequency and, therefore, contraceptive choice.
- Present or past medical problems, such as hypertension, venous thromboembolism (VTE) or previous trophoblastic disease, which may dictate choices. Determine whether there are any contra-indications to a particular contraceptive. The UK Medical Eligibility Criteria (UKMEC) can be consulted for advice about specific conditions where caution should be taken.
|Contraceptive methods available to women postpartum|
|Unrestricted methods||Methods not usually recommended, or used with restriction|
|Non breast-feeding women <21 days postpartum|
|Non breast-feeding women ≥21 days postpartum|
|Breast-feeding women <6 weeks postpartum|
|Fully or almost fully breast-feeding women between 6 weeks and 6 months postpartum|
Progestogen-only injectables can generally be used where their advantages generally outweigh the risks
|Partially or "token" breast-feeding women between 6 weeks and 6 months postpartum|
May be used where benefits outweigh risks:
|Breast-feeding women >6 months postpartum|
This is a method of avoiding pregnancy, based upon the natural postpartum infertility associated with fully breast-feeding: suckling an infant reduces the release of gonadotrophins, which suppress ovulation but, as suckling reduces, ovulation returns. It is over 98% effective in preventing pregnancy if a woman is:
- Less than six months postpartum.
- Amenorrhoeic (no vaginal bleeding after the first 56 days postpartum).
- Fully breast-feeding day (at least four-hourly feeds) and night (at least six-hourly feeds).
The risk of pregnancy is increased if:
- Breast-feeding decreases, particularly stopping night feeds, or with the introduction of formula or solids and where pumping rather than nursing occurs.
- Menstruation resumes.
- The woman is more than six months postpartum.
Current eligibility criteria in the UK allow use of the progestogen-only contraceptive pill postpartum, in both breast-feeding and non-breast-feeding women.
Starting regime for the POP
- Commence up to day 21 postpartum without the need for extra contraception.
- If started after day 21, additional contraception is needed for 2 days and need to exclude pregnancy.
- If regular menstrual cycles have returned, start POP up to and including day 5 of period without the need for extra barrier methods.
Current eligibility criteria in the UK allows use of the contraceptive implant postpartum, in both breast-feeding and non-breast-feeding women.
The etonogestral implant (Nexplanon®) is currently the only one available in the UK.
- Start 21-28 days after delivery.
- If later than day 21, extra barrier methods of contraception are needed for 7 days.
These are licensed for use only after 6 weeks postpartum. However, UK guidelines and eligibility criteria state the benefits may outweigh the risks, and it may be started from 21 days postpartum:
- If started on or before day 21 postpartum, no extra precautions are needed.
- If started after day 21, extra barrier methods of contraception are needed for 7 days.
Combined hormonal contraceptives (CHC)
These include the combined pill, the patch and the vaginal ring. For breast-feeding women:
- Previous concerns about hormonal effects on the quality and quantity of milk, passage of hormones to the infant and adverse effects on infant growth if COC are used in breast-feeding women before 6 months postpartum have not been proven. This led to the UK Medical Eligibility Criteria (UKMEC) being changed in 2016.
- Studies have not shown an adverse effect on infant growth or development.
- CHC can now be used after 6 weeks postpartum in fully or almost-fully breast-feeding women.
- Use in breast-feeding women before 6 months postpartum is currently outside the product licence but this should change following the change in guidance.
For non-breast-feeding women:
- Pregnancy is a thrombophilic state; by about 2 weeks postpartum, these changes have reversed in most women.
- COC can be started from 21 days postpartum, assuming no other risk factors for VTE exist.
- If started later than 21 days, additional barrier methods of contraception are needed for 7 days (unless starting within the first 5 days of a menstrual period once cycles have returned).
IUCD and levonorgestrel-releasing IUS
- These have no effect on breast milk production.
- There is a 1 in 20 expulsion risk.
- Review 4-6 weeks after insertion or after the first period.
- Teach the woman to feel threads after each period.
Timing of insertion:
- NICE guidance suggests that both the IUCD and IUS may be fitted from 4 weeks postpartum. The Mirena® IUS's product licence however specifies fitting from 6 weeks postpartum.
- Ideally delay fitting of the IUS (or Jaydess) until 6 weeks, but may be used off license from 4 weeks in certain situations in accordance with NICE advice.
- A 2009 systematic review suggests that there is no increased risk of complications of insertion in the postpartum period compared with outside of it. However, risk of expulsion is greater with delayed compared with immediate (<10 minutes following delivery of the placenta) insertion and with immediate compared with interval insertion.
- Advantages to immediate insertion include high motivation, assurance that the woman is not pregnant, and convenience; however, this is balanced against increased risk of expulsion compared with interval insertion after the immediate postpartum period. Cumulative 1-year expulsion rates in one study were 12.3%[10, 11].
- These include condoms, diaphragms and cervical caps.
- Diaphragm and cap use should be delayed until uterine involution is complete after 6 weeks postpartum.
- Always re-check size postpartum, as this may have changed from the pre-pregnant state. Any change in weight of 3 kg or more should prompt a review of fit. Diaphragms and caps should be fitted by a trained practitioner and replaced on an annual basis.
- Condoms and spermicides can be used safely by breast-feeding women.
Fertility awareness methods
- These methods should be used with caution, even after menstruation has resumed, because of possible delay in return to regular, ovulatory menstrual cycles.
- Only women who are already familiar with the method should practise it after 4 weeks postpartum and in advance of the return of their periods. It is not recommended for breast-feeding women.
- Guidance from the Royal College of Obstetricians and Gynaecologists (RCOG) states that women should be made aware of increased regret and possible increased failure rate of sterilisation immediately postpartum and, ideally, sterilisation should follow at an appropriate interval after childbirth.
- Female sterilisation can be performed at the time of caesarean section provided there has been appropriate counselling and consent antenatally.
- Male sterilisation and other effective, but reversible, methods (such as the IUCD or IUS, implants and depot injections) should also be considered.
- Emergency contraception is not needed before day 21 postpartum.
- Progestogen-only emergency contraception can be used even if breast-feeding.
- The IUCD can be fitted for this indication, after 4 weeks postpartum.
Regardless of the contraceptive choice made:
- Written information about contraceptive choices should be provided. This has been shown to increase a woman's ability to make an informed decision about birth control postpartum.
- Provide detailed advice about what to do if things go wrong, preferably with written information to take away - eg, missed pill advice, IUCD expulsion advice.
- A follow-up appointment should be arranged.
Further reading and references
; Faculty of Sexual and Reproductive Healthcare (January 2017)
; Contraception for women: an evidence based overview. BMJ. 2009 Aug 7339:b2895. doi: 10.1136/bmj.b2895.
; Faculty of Sexual and Reproductive Healthcare (Feb 2014)
; NICE Clinical Guideline (December 2014, updated February 2015)
; Faculty of Sexual and Reproductive Healthcare (2009)
; Faculty of Sexual and Reproductive Healthcare (2016)
; NICE CKS, February 2015 (UK access only)
; Effect of progestin compared with combined oral contraceptive pills on lactation: a randomized controlled trial. Obstet Gynecol. 2012 Jan119(1):5-13. doi: 10.1097/AOG.0b013e31823dc015.
; NICE CKS, December 2014 (UK access only)
; NICE Clinical Guideline (September 2014)
; NICE CKS, June 2012
; Intrauterine device insertion during the postpartum period: a systematic review. Contraception. 2009 Oct80(4):327-36. Epub 2009 Aug 29.
; Clinical outcomes of early postplacental insertion of intrauterine contraceptive devices. Contraception. 2004 Apr69(4):279-82.
; Immediate post-partum initiation of intrauterine contraception and implants: a review of the safety and guidelines for use. Aust N Z J Obstet Gynaecol. 2013 Aug53(4):331-7. doi: 10.1111/ajo.12095. Epub 2013 May 2.
; NICE CKS, June 2012 (UK access only)
; Faculty of Sexual and Reproductive Healthcare (September 2014)
; Patient satisfaction and the impact of written material about postpartum contraceptive decisions. Am J Obstet Gynecol. 2003 May