Written by: Dr. Teng
In 2012, a systematic review of the research on the effectiveness of postpartum contraception counseling found that patient education results in more family planning use and fewer unplanned pregnancies. Family planning is integral to our roles as OBGYNs. Though planning your next pregnancy may be the last thing on your mind while you are pregnant, the best time to discuss contraceptive options with your doctor may be during your prenatal visits.
I generally like to discuss contraceptive options with my patients during the second and third trimester. Having a plan in place will save you some time and discussion after your delivery, and each extra minute spent with your baby or in sleep is golden! Several factors such as breastfeeding, prior medical history, and desired duration of contraception, can impact the decision between you and your provider regarding the method that is right for you and when to start. We want to choose the best option that is safe, easy to use, and tailored to your needs. While some methods, such as surgical sterilization and intrauterine devices, can be initiated at the time of delivery, contraception is traditionally initiated 4-6 weeks after delivery at the time of postpartum follow-up.
Why does contraception matter?
Several studies have shown that short interval pregnancies (intervals <18 months between delivery and the next conception) are associated with increased risks of adverse perinatal outcomes, such as low birth weight. The World Health Organization (WHO) currently recommends a 2-year pregnancy interval. The decision of future pregnancy is ultimately up to the parents and can be based on several factors, including the woman’s age, social and financial needs, and prior cesarean delivery.
If I am breastfeeding isn’t that enough?
In the postpartum period, evaluating fertility based on the traditional methods of tracking menstrual cycles, body temperature, and cervical mucus is not as reliable. Even if a woman is breastfeeding, the postpartum period of infertility may be brief. Depending on the frequency of breastfeeding, women may ovulate prior to the return of menses. Basal body temperature cannot reliably be evaluated unless a woman has at least 6 hours of uninterrupted sleep, and patterns of cervical mucus also change in the postpartum period.
The Lactational Amenorrhea Method (LAM) can provide effective and reliable contraception for up to 6 months postpartum if the woman has not yet had her first menses. This method relies on frequent stimulation of the breast from nursing to disrupt the hormonal cycle leading to ovulation. It is important to note that milk expression in the form of pumping and hand expression is not a substitute for breastfeeding in this method, and supplemental milk should be given only infrequently, and not by a bottle. Once the frequency and duration of breastfeeding is reduced, menstruation resumes, or bottle feeds are introduced, another method of contraception should be started. If used correctly, LAM provides more than 98% protection from pregnancy in the first 6 months after birth.
When used improperly or all defined conditions of the method are not met, unintended pregnancy rates are over 25%. Due to this limitation of LAM, many women are recommended to use additional protection. Effective options that can be further reviewed on our website include: intrauterine devices, hormonal birth control pills, permanent sterilization, and barrier methods. See link here: https://www.elcaminowomen.com/patient-education/women-s-health/contraception
Hormonal vs. Non-hormonal Methods for breastfeeding mothers
Any non-hormonal method, including sterilization, copper IUD, and barrier method, is safe for breastfeeding mothers and can be started immediately. Due to the increased risk of venous thromboembolic disease in the immediate postpartum period, combined oral contraceptives and other estrogen-containing methods should be delayed until 4-6 weeks postpartum. There is also concern regarding the small amount of steroids found in combined estrogen and progestin-containing contraception that can pass through the breastmilk to the infant. This includes the combined pill, patch, and vaginal ring. For this reason, the WHO and the Academy for Breastfeeding Medicine do not consider them first line choices. Although no human studies have demonstrated any adverse health outcomes for infants of mothers taking combined hormonal contraception, some studies have shown decreased durations of breastfeeding.
Multiple large studies have shown that progesterone-only contraceptives (implant, intrauterine device, injectable, and progestin only pill) do not have adverse effects on lactation, and do not appear to have negative impact on infant growth and development. As in making any other medical decision, one has to weigh the benefits vs. the risks. Most progestin-only methods have advantages that outweigh the risks and are considered safe for use during breastfeeding.
What if I am not breastfeeding?
For reasons where a woman cannot breastfeed, it is recommended to begin using a contraceptive method immediately or by the fourth postpartum week. Most non-lactating women will resume menses within 4 to 6 weeks of delivery, and initiation of contraception prior to this time is important. Again, due to the increased risk of developing blood clots in the immediate postpartum period, combined oral contraceptives and other estrogen-containing methods should be delayed until 4-6 weeks postpartum. Otherwise, there are few restrictions on which method mothers can choose.
It is a wonderful thing that we can offer a variety of contraceptive methods soon after delivery. The importance of questioning what is right for you and your baby cannot be overstated, and mothers will face these decisions even before their pregnancy. Ultimately, our goal is to guide women to make an informed choice that is right for her.