PocketGuide: Postpartum Contraception

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PocketGuide for Family Planning Service Providers

Postpartum Contraception

Introduction | Postpartum Infertility | Lactational Amenorrhea Method | When to Start Contraception

Many postpartum women want no more children or would like to delay pregnancy for at least 2 years. Unfortunately, too few women leave obstetrical delivery services having received counseling about family planning or contraceptive methods. All postpartum women should be provided with family planning options. The International Planned Parenthood Federation (IPPF) recommends the following guidelines for counseling postpartum women:

Encourage full breastfeeding for all postpartum women.
Do not discontinue breastfeeding to begin use of a contraceptive method.
Contraceptive methods used by breastfeeding women should not adversely affect breastfeeding or the health of the infant.

Postpartum Infertility

Following delivery every woman experiences a period of infertility. In nonbreastfeeding women it may be less than 6 weeks (on average, the first ovulation occurs 45 days postpartum). For breastfeeding mothers, the period of infertility is longer because frequent suckling blocks ovulation. The return of fertility, however, is not predictable (conception can occur before the woman has any signs or symptoms of the first menses).

Lactational Amenorrhea Method (LAM)

It has long been recognized that breastfeeding could be an effective, temporary contraceptive if a woman could reliably know when she is no longer protected. LAM provides the means to do this. It provides effective contraception for a breastfeeding mother if she is fully or nearly fully breastfeeding, her menses have not returned (lactational amenorrhea), and she is less than 6 months postpartum. If these criteria are met, then LAM will provide more than 98% protection from pregnancy during the first 6 months following delivery. When any one of these criteria changes, however, another contraceptive method—one that does not interfere with breastfeeding—should be started if the woman does not want to become pregnant. In addition, use of LAM enables both mother and infant to take full advantage of the numerous other benefits of breastfeeding.

When to Start Contraception

While all methods of contraception are appropriate for postpartum women, the time for starting each method depends on a woman’s breastfeeding status. Methods that can be used whenever a couple resumes sexual intercourse, even in the immediate postpartum period, include:

Spemicides
Condoms (lubricated condoms may help overcome vaginal dryness)
Withdrawal (both condoms and withdrawal prevent seminal fluid from being deposited in the vagina)

A diaphragm cannot be used until after 6 weeks postpartum because it cannot be properly fitted. Attempting to do so earlier than this may cause discomfort, especially in women who have had an episiotomy.

Breastfeeding Women

Women who are breastfeeding do not need contraception for at least 6 weeks postpartum—up to 6 months if they are using LAM. Figure 1 shows the recommended time of starting contraception for breastfeeding women. If a breastfeeding woman decides to use contraception other than LAM, she should be counseled about the potential effect of some contraceptives on breastfeeding and the health of the infant. For example, COCs and CICs are considered to be the methods of last choice for any women who is breastfeeding. All COCs, even low-dose pills (30-35µg EE) decrease breastmilk production, and there is theoretical concern that they may affect the normal growth of a baby during the first 6 to 8 weeks postpartum.¹ Waiting at least 8 to 12 weeks postpartum before starting COCs or CICs has the added advantage of permitting breastfeeding to be better established.

Nonbreastfeeding Women

Although most nonbreastfeeding women will resume menstrual cycles within 4 to 6 weeks after delivery, only about one-third of first cycles will be ovulatory and even fewer will result in pregnancy. If a couple wishes to avoid all risk of pregnancy, however, contraception should be started at the time of (barriers, spermicides, withdrawal) or before (hormonals, IUDs or VS) the first sexual intercourse. Because the pregnancy-induced risk of blood clotting problems (elevated coagulation factors) is still present until 2 to 3 weeks postpartum, COCs and CICs should not be started before that time. By contrast, POCs can be started immediately postpartum because they do not increase the risk of blood clotting problems. Other differences in the recommended time for starting contraception in nonbreastfeeding women are depicted in Figure 2.

See the counseling outline for additional information about the use of contraceptive methods by postpartum women.

Figure 1. Recommended Time to Start for Breastfeeding Women

Figure 5. Recommended Time to Start for Breastfeeding Women (9k)

Figure 2. Recommended Time to Start for Nonbreastfeeding Women

Figure 6. Recommended Time to Start for Nonbreastfeeding Women (9k)

^aIf delivery is in a hospital or other health care facility, immediate postplacental or postpartum (48 hours) IUD insertion is appropriate under certain circumstances (i.e., with adequate counseling and a specially trained service provider).
^bVasectomy can be performed at any time.
^cNFP may be harder for breastfeeding women to use because reduced ovarian function makes fertility signs (e.g., mucus change, basal body temperature) more difficult to interpret. As a result, NFP can require prolonged periods of abstinence during breastfeeding.
^dDuring the first 6 months postpartum, COCs and CICs may affect the quantity of breastmilk and the healthy growth of the infant. If a mother is breastfeeding but not using LAM, she may start COCs or CICs as soon as 6 weeks postpartum if other methods are not available or acceptable. (WHO class 3)

Adapted from (both figures): Family Health International 1994.

¹ These restrictions do not apply to women who are only doing token (i.e., minimal) breastfeeding.

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