Recommendations for Contraceptive Use
RH TOC		How to Be Reasonably Sure the Woman Is Not Pregnant

You can be reasonably sure the woman is not pregnant if she has no symptoms (see "History") or signs (see "Physical exam") of pregnancy, and any of the conditions below:

• has not had intercourse since last normal menses, or
• has been correctly and consistently using another reliable method, or
• is within the first seven days after onset of normal menses, or
• is within four weeks postpartum (for NON-lactating women), or
• is within the first seven days postabortion, or
• is fully breastfeeding, amenorrheic, and less than six months postpartum (see "Relying on Lactational Amenorrhea").

History of symptoms of pregnancy

• absent (or altered) menses,
• nausea (with or without vomiting),
• fatigue (persistent),
• breast tenderness (and breast enlargement),
• increased frequency of urination,
• weight and mood changes,
• maternal perception of fetal movements (late symptom: at 16 to 20 weeks gestation).

Physical exam is seldom necessary, except to rule out pregnancy of greater than six weeks when uterine enlargement begins to be noticeable. Later (around 18 weeks), the fetal heart beat can be heard with a stethoscope and fetal movements can be perceived by the examiner.

Laboratory

In certain settings, pregnancy tests are not very helpful or practical because highly sensitive tests (positive +/- 10 days after conception) are not usually affordable. However, in cases where the possibility of pregnancy is difficult to rule out, a highly sensitive pregnancy test may be helpful, if readily available and not too expensive, and if part of routine clinic practice.

Relying on Lactational Amenorrhea Method

The Lactational Amenorrhea Method (LAM) is a highly effective contraceptive (98% protection during the first six months postpartum in women who are fully or nearly fully* breastfeeding and amenorrheic)^1-3. The effectiveness of LAM in the second six months postpartum has been studied, though more research is needed⁴. (See LAM: Question 3)

A service provider can be reasonably sure that a woman is not pregnant if she is still amenorrheic, within the first six months postpartum, fully or nearly fully* breastfeeding and has no clinical symptoms of pregnancy. When an accurate pregnancy test is not easily available or affordable, and a woman more than six months postpartum requests an intrauterine device** or NORPLANT^® Implants or injectables, you can still be reasonably sure she is not pregnant if the woman has kept her breastfeeding frequency high***, and she is still amenorrheic.

It should be noted that bleeding in the first eight weeks (56 days) postpartum is NOT considered "menstrual" bleeding in fully or nearly fully breastfeeding women⁵.

1. Labbok M, Cooney K, Coly S. Guidelines: breastfeeding, family planning, and the Lactational Amenorrhea Method - LAM. Washington, DC: Institute for Reproductive Health, 1994.
2. Labbok MH, Perez A, Valdes V, Sevilla F, Wade K, Laukaran VH, et al. The Lactational Amenorrhea Method (LAM): a postpartum introductory family planning method with policy and program implications. Advances in Contraception 1994;10:93-109.
3. Labbok M, Krasovec K. Toward consistency in breastfeeding definitions. Studies in Family Planning 1990;21:226-30.
4. Cooney KA, Nyirabukeye T, Labbok M, Hoser P, Ballard E. Assessment of the nine-month Lactational Amenorrhea Method (MAMA-9) in Rwanda. Studies in Family Planning 1996;24:162-71.
5. Kennedy KI, Rivera R, McNeilly A. Consensus statement on the use of breastfeeding as a family planning method. Contraception 1989;39(5):477-96.

* "Fully" breastfeeding includes exclusive or almost exclusive breastfeeding (only occasional tastes of foods or water) day and night^1-3. "Nearly fully" breastfeeding means that supplemental feedings are given but comprise a minimal part of the infant's diet^1-3.

* * It is more important to rule out pregnancy before inserting an IUD than before starting hormonal methods, because of the risk of septic miscarriage.

* ** A woman who breastfeeds 10 times per day or more, or who gives more than 80% of her infant's meals as breastfeeds, is at less risk of being fertile². Breastfeeding before giving each supplement is optimal.

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Any part of Recommendations for Updating Selected Practices in Contraceptive Use may be reproduced or adapted to meet local needs without prior permission from the TG/CWG Secretariat, provided the TG/CWG is acknowledged and the material is made available free of charge or at cost.