Postpartum contraception is important to prevent unintended pregnancies. Assisting women in achieving recommended inter-pregnancy intervals is a significant maternal-child health concern. Short inter-pregnancy intervals are associated with negative perinatal, neonatal, infant, and maternal health outcomes. More than 30% of women experience inter-pregnancy intervals of less than 18 months in the United States. Provision of any contraceptive method after giving birth is associated with improved inter-pregnancy intervals.
However, concerns about the impact of hormonal contraceptives on breastfeeding and infant health have limited recommendations for such methods and have led to discrepant recommendations by organizations such as the World Health Organization and the U.S. Centers for Disease Control and Prevention. In this review, we discuss current recommendations for the use of hormonal contraception in the postpartum period. We also discuss details of the lactational amenorrhea method and effects of hormonal contraception on breastfeeding. Given the paucity of high quality evidence on the impact on hormonal contraception on breastfeeding outcomes, and the strong evidence for improved health outcomes with achievement of recommended birth spacing intervals, the real risk of unintended pregnancy and its consequences must not be neglected for fear of theoretical neonatal risks. Women should establish desired hormonal contraception before the risk of pregnancy resumes. With optimization of postpartum contraception provision, we will step closer toward a healthcare system with fewer unintended pregnancies and improved birth outcomes.
BackgroundPostpartum contraception is important to prevent unintended pregnancies and short intervals between pregnancies. The appropriate method and timing of contraception initiation following a birth, miscarriage or pregnancy termination depends on multiple factors such as a patient’s personal preferences, medical history, risk for pregnancy, breastfeeding preferences, and access to contraceptive services. The most important role of postpartum contraception is to help a woman achieve the desired interval before the next pregnancy in order to optimize her health and that of her young children.
Theoretical concerns regarding the impact of contraception on breastfeeding must be appropriately weighed against well-supported impacts on inter-pregnancy intervals and the woman’s informed decisions regarding her reproductive health. Inter-pregnancy interval and perinatal outcomesAssisting women in achieving recommended inter-pregnancy intervals (IPIs), defined as the time interval between a live birth and the beginning of the next pregnancy, is a significant maternal-child health concern. Short IPIs are associated with negative perinatal, neonatal, infant, and maternal health outcomes. The concept of an ideal inter-pregnancy interval emerged from a report published by World Health Organization (WHO) in 2005. Based on the best available evidence at that time, the experts reached a consensus of 24 months as the IPI. This interval was consistent with the joint WHO and United Nations Children’s Emergency Fund (UNICEF) recommendation that women breastfeed for at least 2 years.Recommendations from the WHO report, “Effect of Interpregnancy Interval on Adverse Perinatal Outcomes,” were evaluated using the Perinatal Information System Database of the Latin American Center for Perinatology and Human Development from 1985 to 2004.
Compared to infants with IPIs of 18–23 months, those born to women with intervals shorter than 6 months had an increased risk of many adverse neonatal and perinatal outcomes. A systematic review by Conde-Agudelo et al.
That included 77 studies conducted in countries across six continents analyzed the association of IPIs with outcomes such as preterm birth, low birth weight, small size for gestational age (SGA) at birth, fetal death, and early neonatal death. For IPIs shorter than 6 months, there were significantly increased risks for preterm birth (Odds Ratio = 1.40), SGA (Odds Ratio =1.26), and low birth weight (Odds Ratio = 1.61). Intervals of 6 to 17 months were also associated with a significantly greater risk for these three adverse perinatal outcomes. Additionally, among women with previous low-transverse caesarean sections who underwent trials of labor, there was noted to be increased risk of uterine rupture with IPIs less than 16 months. Another recent study analyzing all live births between 1991 and 2010 in California concluded that women with IPIs of less than 1 year following live birth were at increased risk for preterm birth. No conclusions on the impact of IPI on maternal mortality and morbidity were able to be drawn in the WHO’s report due to limited available data.Unfortunately, data from the 2015 National Vital Statistics Report and the National Survey of Family Growth demonstrate that in the United States 30% of women experience IPIs of less than 18 months.
Short IPIs in the U.S. Are inversely associated with maternal age, with more than two thirds (67%) of teenagers between ages 15–19 experiencing IPIs of less than 18 months. Postpartum endocrine changesTo understand the timing and mechanisms by which women resume risk of pregnancy following delivery, it is important to review the cascade of endocrine changes that take place after parturition. Immediately following delivery, the inhibitory effect of the estrogen and progesterone levels of pregnancy decreases and the pulsatile activity of the pituitary follicular stimulating hormone (FSH) and luteinizing hormone (LH) resumes. In non-lactating women, studies evaluating urinary pregnanediol levels have reported a mean first ovulation ranging from 45 to 94 days postpartum, with the earliest ovulation reported 25 days after delivery ,. Consequently, women are assumed to be protected from pregnancy for 4 weeks following delivery.
Similarly, studies looking at ovulation after abortion suggest that most women ovulate before resuming menses, with mean time to ovulation of 22 days. Lactation extends the period of postpartum infertility. Nerve impulses arising from the nipple and areola due to infant suckling release prolactin from the hypothalamus.
This, in turn, suppresses the pulsatile release of gonadotropin-releasing hormone (GnRH) by the hypothalamus, likely by increasing beta-endorphin production. The pulsatile secretion of GnRH is necessary to stimulate the cells in anterior pituitary to produce FSH and LH needed for ovulation. Thus continued suckling and lactation provide protection from pregnancy. Lactational amenorrhea methodThe lactational amenorrhea method (LAM) is the specific name given to use of breastfeeding as a dedicated method of contraception. For breastfeeding to serve as an effective method of contraception, the woman must be exclusively or nearly exclusively breastfeeding (at least 85% of infant feeding coming from breastfeeding), be within the first 6 months following delivery, and remain amenorrheic.
Some experts additionally believe that milk expression by hand or pump does not retain the same fertility-inhibiting effect as infant nursing. Clinical studies of the contraceptive effect of LAM have demonstrated cumulative 6-month life-table perfect-use pregnancy rates of 0.5 – 1.5% among women who relied solely on LAM.
A Cochrane review published in 2015 estimated the typical use failure rate of LAM to be 0.45 – 7.5% –.Although LAM is a highly effective temporary method of contraception, rates of the exclusive breastfeeding required for its effectiveness are low in the United States. Data from the National Immunization Survey describes an 80% incidence of breastfeeding initiation, declining to a 4 weeks postpartum exclusive breastfeeding rate of 54%, which declines to 20% at 6 months. According to this data, exclusive breastfeeding rates at 3 months were lower in non-white, unmarried women with lower socio-economic status compared to non-Hispanic white, well educated, married women.
Among the individual states, Montana had the highest (60%) and Mississippi the lowest (21%) exclusive breastfeeding rates at 3 months in 2013.Historically, women have also been assumed to experience protection from pregnancy during the traditionally recommended 6-week period of pelvic rest following delivery. While 6-weeks may have been historically recommended to accommodate the expected time period of uterine involution, and due to its concurrent timing with the historically recommended 6-week postpartum visit, no evidence supports any specific interval of post-delivery abstinence. McDonald et al. analyzed a prospective cohort of approximately 1500 nulliparous women to investigate the timing of resumption of vaginal sex after childbirth and noted that 41% of women admitted to resuming intercourse by 6 weeks, while 65 and 78% endorsed vaginal sex by 8 and 12 weeks postpartum, respectively. Spontaneous vaginal birth with an episiotomy or laceration, forceps- or vacuum-assisted vaginal birth, cesarean section, and breastfeeding are negatively associated with resumption of intercourse following delivery, while young age (. Contraception provision postpartumGiven that women resume risk for pregnancy from 4 weeks to 6 months postpartum, effective contraceptive methods must be available to assist women in reaching recommended IPIs. Figure demonstrates currently available contraceptive methods in the U.S.
And their associated effectiveness in typical use. Provision of any contraceptive method within 90 days of giving birth is associated with improved IPIs. However, use of long-acting reversible contraception methods (LARC) such as intrauterine devices (IUDs) and the subcutaneous contraceptive implant, both with effectiveness that is generally not reduced by user error, have been shown to substantially improve IPIs compared to other methods. More specifically, women using LARC methods after delivery have 3.89 times the likelihood of reaching recommended birth spacing intervals compared to women using condoms only, while women using user-dependent hormonal methods (pill, patch, vaginal ring and injection) have 1.89 times the likelihood of achieving recommended spacing compared to barrier method users ,. Recommendations by the World Health Organization and Centers for Disease Control and PreventionDespite evidence that early initiation of postpartum contraception increases IPIs, concerns about the impact of hormonal contraceptives on breastfeeding and infant health have limited recommendations for such methods and have lead to discrepant recommendations by organizations such as the World Health Organization (WHO) and the U.S.
Centers for Disease Control and Prevention (CDC). A CDC & WHO Category 3 for women with other risk factors for VTE: 35 years old or older, previous VTE, thrombophilia, immobility, peripartum transfusion, peripartum cardiomyopathy, obesity, peripartum hemorrhage, cesarean delivery, preeclampsia, or smokingb Refers to 28 days for intrauterine device insertion timingc Refers to women who are primarily breastfeedingd WHO Category 4 for women with other risk factors for VTEIn the following sections we provide a detailed review of the impact of each hormonal contraceptive method on breastfeeding outcomes.
A) Combined oral contraceptivesA CDC review of combined oral contraceptives from 2015 included 15 articles from 13 studies evaluating the impact of estrogen-containing oral contraceptive pills on breastfeeding and associated infant outcomes. Unfortunately, applicable studies were noted to be of only poor to fair methodological quality and many were from earlier decades when the estrogen-content of combined oral contraceptives was substantially higher than in modern pills. In this review, no studies found significant impact on infant weight gain when combined oral contraceptives (COCs) were initiated at 6 weeks or later postpartum, and none found negative impact on other infant health outcomes regardless of the timing of COC initiation. However, the results of studies examining the impact of COCs on breastfeeding performance were inconsistent.
A study by the WHO in 1984 assigned women to a COC containing 30 micrograms of ethinyl estradiol and 150 micrograms of levonorgestrel or a progestin-only pill containing 75 micrograms of norgestrel, started after 6 weeks postpartum. Breast milk volume was quantified following pump expression.
Mean breast milk volume was lower in the COC group at 9, 16 and 24 weeks by 18–25 mL. However, no differences were noted between groups on use of supplemental infant nutrition. In 2012, Espey et al. Performed a randomized controlled trial of breastfeeding women following term delivery who desired to initiate oral contraception. At two weeks postpartum women initiated either a combined pill of 35 mcg ethinyl estradiol and 1 mg norethindrone ( n = 64) or a progestin-only pill (POP) containing 35 micrograms of norethindrone ( n = 63). There was no significant difference between the COC and POP groups in the primary outcome of breastfeeding continuation over the 6 months of follow-up, nor were there differences found in infant growth parameters, satisfaction with breastfeeding or oral contraceptive use, perception of milk supply adequacy, formula supplementation, or reasons cited for discontinuing breastfeeding or oral contraceptive pills. Given that in non-breastfeeding women without contraindications to estrogen, combined oral contraceptives have been found to have better efficacy, higher continuation rates, and fewer side effects than POPs, and that 35 micrograms is the highest estrogen content in commonly used COCs, the authors conclude that it is reassuring that combined pills do not have a major impact on breastfeeding continuation or infant growth and a larger equivalency study should be performed to clarify the clinical impact of COCs on lactation.
No randomized controlled trials are available that evaluate the other estrogen-containing contraceptives available in the U.S., the contraceptive patch and vaginal ring, which have different hormonal content and absorption profiles than combined oral contraceptive pills. B) Progestin only contraceptivesIn contrast to estrogen-containing contraceptives, the WHO considers the benefits of progestin-only oral contraceptives and the progestin-containing contraceptive implant to generally outweigh risks of these methods during the first 6 postpartum weeks for breastfeeding women (Category 2), but recommends that the contraceptive injection (depot medroxyprogesterone acetate DMPA in the U.S.) be initiated no sooner than 6 weeks postpartum.
C) Emergency contraceptive pillsIn addition to routine contraception, emergency contraception is a promising component of a comprehensive contraceptive strategy to reach recommended birth spacing intervals. Emergency contraceptive pills (ECPs) are pills taken as soon as possible, and within 120 h, after unprotected or inadequately protected intercourse in order to reduce the risk of pregnancy when a routine contraceptive method was not used or was not used correctly.
Two types of dedicated ECP products are available in the U.S. They are progestin-only ECPs comprised of 1.5 mg levonorgestrel, and 30 mg of ulipristal acetate, which is a progestin-receptor modulator. Both medications work by delaying or preventing ovulation and neither has evidence for post-fertilization effects. Ulipristal acetate has been found to be more efficacious overall, and specifically for overweight and obese women and women who require ECPs for intercourse occurring close to ovulation ,. In both the WHO and CDC MEC, levonorgestrel ECPs are classified as Category 1 for all users ,.
However, the WHO MEC classifies use of ulipristal acetate by breastfeeding women as Category 2 and recommends that women avoid breastfeeding for 1 week following use, discarding breast milk during that time, based on the package labeling for UPA which states that, “Use of ella® by breastfeeding women is not recommended,” since it is “unknown if ulipristal acetate is excreted in human milk ,.” In contrast, the CDC MEC classifies ulipristal acetate use by breastfeeding women as Category 1, but recommends that breast milk be expressed and discarded for 24 h following use. Since there are no studies evaluating the impact of ulipristal acetate exposure on infants , the recommendation to discard breast milk for 24 h is based on rapidly declining levels of ulipristal acetate and its metabolite measured in breast milk during this time period.Professional organizations such as the ACOG and the American Academy of Pediatrics (AAP) recommend advance prescription of emergency contraceptive pills to all reproductive aged women ,.
In a randomized trial of breastfeeding Egyptian women who planned to use LAM and delay a next conception by at least 1 year, women in the standard LAM counseling group were significantly more likely than women in the levonorgestrel ECP advanced provision group to experience pregnancy within 6 months postpartum (of which 80% were unplanned and/or undesired), despite similar rates of unprotected intercourse after expiration of LAM criteria in both groups. Unfortunately, knowledge of emergency contraception by postpartum women is low. In a study of inner city postpartum women, only 36% had heard of emergency contraception, only 19% could name or describe a method of emergency contraception, and only 7% could identify correct timing of ECP use.
Of those who were aware of emergency contraception, only 44% thought it was safe, despite CDC MEC Category 1–2 classification, and 32% incorrectly believed that it served as an abortifacient. However, two-thirds of women in the study stated that they would be willing to use emergency contraception in the future.
System based barriers for postpartum contraception useDespite the effectiveness of currently available contraception, U.S. Women seeking to establish postpartum contraception currently face a myriad of systems barriers. Of women who indicate a plan for postpartum IUD placement, only 23–60% undergo insertion as planned ,.
Women are often denied inpatient LARC placement due to the fact that reimbursement for all delivery-related care is generally based on a global fee that does not carve out the cost of LARC devices or insertions ,. This reimbursement scheme severely disincentivizes hospitals to supply and dispense LARC devices, which typically have wholesale costs upwards of $600. While Medicaid and most private insurance plans have been able to separate out reimbursement for sterilization during a delivery-related hospitalization, currently only a small minority of states have been able to address the issue for LARC devices, and primarily only for Medicaid-covered patients ,. Interestingly, this slow systems-based change takes place in a setting in which substantial cost-savings to public programs facilitating inpatient LARC placement has been demonstrated. Further barriers are encountered by women who receive delivery-related care in Catholic hospitals, which currently represent one-sixth of all hospital beds in the U.S., as these facilities do not permit placement of LARC devices for the purpose of contraception.Additionally, postpartum women often receive inconsistent, and sometimes incorrect, information from various members of the healthcare team regarding the safety and impact of contraception on breastfeeding.
For instance, in a recent survey by Dunn et al., while 77% of lactation consultants reported offering advice about postpartum contraception and its impact on breastfeeding, the vast majority stated that progestin-only methods used in the first 21 days following delivery had theoretical or proven risks that outweighed benefits or presented unacceptable health risks (equivalent to MEC Category 3 or Category 4), which is inconsistent with medical professional guidelines and the best available evidence. Specifically, 76.3% stated that progestin-only pills ought to be avoided during this time period, while 90.1% stated the same for DMPA and 92.1% for the etonogestrel implant. The inconsistencies found in this study are particularly concerning, given that lactation consultants are generally considered the premier experts on breastfeeding on postpartum inpatient units where many women are finalizing contraceptive choices for initiation before discharge.
ConclusionRegardless of age and intended family size, unintended pregnancy can occur at any point in a woman’s reproductive life. As women spend the majority of their reproductive years attempting to avoid unintended pregnancy, contraception counseling is an important aspect women’s healthcare, especially for those who have recently experienced pregnancy. There are very few non-hormonal contraceptive options available in the United States, and most are associated with high failure rates in typical use. Healthcare providers must communicate with women about the typical use failure rates of contraceptives and assist patients in initiating the most effective method that best fits their medical situation and preferences.
Providers must also be familiar with USMEC and US Selected Practice Recommendations for Contraceptive Use in order to initiate and manage post-pregnancy contraception safely and appropriately. Further, many women use contraceptive methods for their non-contraceptive benefits and may need to initiate or resume methods for such purposes postpartum. The USMEC clarifies that recommendations refer to the safety of contraceptive methods when used for contraceptive purposes and do not apply to the use of contraceptive methods for treatment of medical conditions (as the eligibility criteria may differ in such circumstances).Women may wish to discuss contraception both prenatally and after hospital discharge.
Postpartum Contraception Patient Handout
A multicenter randomized controlled study evaluating antenatal discussion of planned postpartum contraception failed to demonstrate significant effect on contraceptive use or subsequent pregnancy rates. An evaluation of postpartum contraception educational method by the Cochrane database also failed to identify specific strategies that work universally to improve awareness of women in this regard. Author’s contributionBoth authors Dr. Aparna Sridhar and Dr. Jennifer Salcedo have made equal contribution to the conception and design, or acquisition of data, or analysis and interpretation of data. They both have been involved in drafting the manuscript or revising it critically for important intellectual content. Both authors haven given final approval of the version to be published.
Each author has participated sufficiently in the work to take public responsibility for appropriate portions of the content. Both authors have agreed to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. Both authors read and approved the final manuscript.
ResultsWe surveyed a total of 194 lactation consultants. Seventy-seven percent (137/177) stated they offer advice about postpartum contraception and its impact on breastfeeding. The majority of lactation consultants felt the theoretical or proven risks outweighed the benefits or there was an unacceptable health risk for the progestin-only pill 76.3% (100/131), progestin injection 90.1% (118/131) and progestin implant 93.1% (122/131) if used within 21 days of delivery. Although 68.7% (92/134) reported prior education on postpartum contraception, 82.1% (110/134) reported wanting more education on this topic, specifically in the form of a webinar 61.9% (83/134). Only 29.9% (40/134) reported knowledge of the United States Centers for Disease Control and Prevention 2011 Medical Eligibility Criteria for Contraceptive Use (USMEC) guidance for postpartum contraception. IntroductionPostpartum contraception is an important component of a woman's pregnancy care.
One goal of postpartum contraception is to provide adequate birth spacing. In the United States, approximately half of all pregnancies are unintended and approximately one-third of all repeat pregnancies are conceived within 18 months of the previous birth. Women who have short-interval pregnancies are at higher risk of preterm birth as well as low birth weight infants.
Contraception becomes especially important for more vulnerable populations as adolescent, minority and low-income women are more likely to have unintended and short-interval pregnancies ,.The traditional timing to initiate postpartum contraception has been at the 6-week postpartum visit. Unfortunately, many women fail to attend this important visit, especially in high-risk populations ,.
For this reason, earlier initiation of contraception can be beneficial. Previous studies have demonstrated that initiation of contraception within the first 90 days postpartum was associated with the optimal interpregnancy interval of 18 months.
One potential barrier to initiating earlier contraception is the concern regarding interference with breastfeeding, however the 2015 World Health Organization (WHO) Medical Eligibility for Contraceptive Use and the 2011 Centers for Disease Control and Prevention (CDC) Medical Eligibility Criteria for Contraceptive Use guidelines largely support early initiation of postpartum contraception ,. According to these guidelines, progestogen-only contraception is safe in breastfeeding women and does not interfere with breastfeeding performance.Postpartum women interact with a wide range of healthcare providers during their hospital stay and may receive contraceptive counseling from multiple sources. Lactation consultants interact with women in the postpartum period and may give advice regarding contraception and breastfeeding. Many lactation consultants have had previous clinical experience as nurses, midwives, dieticians or other healthcare providers and undergo additional educational coursework to become certified lactation consultants. Lactation consultants are most often International Board Certified Lactation Consultants (IBCLC), but others may be Certified Lactation Educators (CLE) or Certified Lactation Counselors (CLC).
IBCLC providers function as healthcare providers in a clinical setting, while CLEs or CLCs traditionally offer more of an advisory or educational role ,. Little is known regarding lactation consultants’ knowledge and beliefs regarding postpartum contraception.The aims of this exploratory study were 1) to assess lactation consultants’ education and knowledge about postpartum contraception and 2) to assess lactation consultants’ interest in training on postpartum contraception. Materials & methodsWe designed an exploratory cross-sectional online survey with input from practicing lactation consultants at the University of California San Diego. Between December 1, 2014 and February 23, 2015, we distributed the survey via email listservs, social media groups such as the International Lactation Consultants Association (ILCA) Facebook page and in-person at the 2015 California Breastfeeding Summit.
The survey included a total of 30 questions and took approximately 10 min to complete. All responses were completely anonymous and participation in the study was voluntary and non-incentivized. Inclusion criteria were age older than 18, fluent in English and self-identified as a lactation consultant. The University of California San Diego's Human Research Protection Program approved this study.We collected demographic information using single item measures. We assessed participants’ past education and desire for future knowledge on postpartum contraception by asking the following questions: (1) During your training as a lactation consultant, have you had coursework covering postpartum contraception?
(2) Do you want more course-work on contraception? (3) How would you like to learn more about postpartum contraception? We also assessed whether lactation consultants were offering advice on postpartum contraception and breastfeeding with the use of a 5-point Likert scale, with 5 indicating strongly agree,1 indicating strongly disagree and 3 indicating neutral (neither agree/disagree), to evaluate the following statements: (1) I offer mothers advice about postpartum contraception and the impact on breastfeeding. (2) Mothers ask for my advice about postpartum contraception. (3) My breastfeeding advice to mothers changes depending on what type of postpartum contraceptive they choose. Demographic profileWe surveyed a total of 194 lactation consultants.
Of the 157 attendants at the 2015 California Breastfeeding Summit who were eligible to participate, we recruited 24 to complete the survey. We could not track further information regarding the source of recruitment because participation was completely anonymous and the survey was conducted online. Participants in this study were between the ages of 24 to 85 with a mean age of 44, largely white (88.1%, 171/194), female (99.5%, 193/194), and with either a college (52.1%, 101/194) or graduate degree (30.4%, 59/194).
Geographic distribution was wide with representation from all regions of the United States, however, the majority worked in western states (58.3%, 113/194). Eighty-three percent (147/177) of those surveyed were certified by the International Board of Lactation Consultant Examiners (IBLCE). The surveyed lactation consultants practiced in a variety of settings including both inpatient and outpatient. Categorization of contraceptive safetyUsing the USMEC for guidelines on postpartum contraception in breastfeeding women, we asked lactation consultants to categorize contraceptive safety. The majority of respondents felt that the theoretical risk or proven risks outweighed the benefits (category 3) or there was unacceptable health risk (category 4) for the progestin-only pill 76.3% (100/131), progestin injection 90.1% (118/131) and progestin implant 93.1% (122/131) if used within 21 days of delivery.