Postpartum contraception should be customized for each individual woman, according to a recent review published in the International Journal of Gynecology Obstetrics.1
Takeaways
- Personalized contraceptive counseling is crucial during pregnancy to understand a woman's future pregnancy wishes and preferences for available options.
- Various guidelines, including those from WHO, US Medical Eligibility Criteria, and FRSH, generally agree on recommendations for postpartum contraception with minor variations.
- Progestin-only contraceptives are considered the safest hormonal options for postpartum women and can be used without time restrictions according to most guidelines.
- Lactational Amenorrhea Method is a natural contraceptive method dependent on exclusive and frequent breastfeeding, effective until 6 months postpartum or the return of periods.
- Long-acting reversible contraceptives, including subcutaneous implants and intrauterine devices, are viable postpartum options, with recommendations varying slightly on the optimal timing of insertion.
The postpartum period as an effective time for contraception initiation, with the most optimal evaluation occurring during pregnancy. During contraceptive counseling, clinicians gain an understanding of a woman’s future pregnancy wishes and preferences for available contraceptive options.
A person-centered approach is recommended for contraceptive counseling, with considerations including the timing of initiation, medical comorbidities, and breastfeeding status. As shorter interpregnancy intervals (IPI) are linked to increased adverse outcomes, the World Health Organization (WHO) recommends at least 24 months between pregnancies.1
Investigators conducted a review to compare guidelines about postpartum contraception. The first guidelines discussed were the WHO 2015 guidelines, which recommend against use of combined hormonal contraceptives (CHCs) within 6 weeks of delivery. Additionally, CHC use is discouraged in women who breastfeed between 6 weeks and 6 months after birth.
The WHO also states CHCs should not be used by women with risk factors for venous thromboembolism (VTE). Non-breastfeeding patients without risk factors for VTE can use CHCs 21 days after delivery.1
Additionally, the US Medical Eligibility Criteria Chart for Contraceptive Use noted CHCs can be used in breastfeeding women without VTE risk factors 30 days after delivery. However, FRSH 2020 guidelines recommend breastfeeding women or those with VTE risk factors wait 42 days after delivery until using CHCs.
These guidelines are mostly consistent with one another, with some variations. The recommendations about waiting when breastfeeding are related to the risk of slowed or stopped milk protection from estrogens and progesterone caused by early CHC administration.1
Some studies contradict current assumption about how CHCs impact breastfeeding, stating that hormonal levels passed to the neonate during breastfeeding are minimal. As literature about this topic is conflicting, further research is needed.
Lactational amenorrhea (LAM) is also considered as a natural contraceptive method. However, this method requires exclusive and frequent breastfeeding, with time between feedings not exceeding 4 hours during the day and 6 hours at night. Additionally, LAM can only be used until either 6 months after birth or the return of the woman’s period.1
Progestin is currently considered the safest postpartum hormonal contraceptive steroid, often administered in the immediate postpartum period through the progestin-only pill (POP). POPs are agreed as safe to use with no time limit in postpartum women by all guidelines, with no restrictions identified in UK guidelines.
Currently progestin-only contraceptives are not recommended in breastfeeding women before 4 weeks postpartum by the WHO, with US guidelines extending this period to 6 weeks. However, the benefits often outweigh the risks even in these patients.1
POPs have also been recommended for use in transgender populations.2 One study of transgender participants reported a 45% interest rate in POPs, with increased odds of interest among those aged 18 to 24 years.
Long-acting reversible contraceptive (LARC) methods were also discussed in the review.1 These include the progestin-releasing subcutaneous implant, which is commonly used 4 to 8 weeks after delivery. Studies have indicated no harmful effects on neonate health from use under 6 weeks postpartum, but these studies had poor quality or inadequate design.
The importance of contraceptive use before discharge has also been reported by studies. In one study, 1 in 3 women assigned to standard insertion never received their implants, vs only 3% of those assigned to early insertion. However, significant differences have not been observed in continued contraceptive implant use at 6 months.1
Intrauterine devices (IUDs) are another type of LARC that has been indicated as viable for postpartum contraception. However, the timing of insertion remains debates.
All guidelines agree that insertion should occur at least 4 weeks after delivery in all cases except puerperal sepsis. WHO and UK guidelines state insertion from 48 hours of delivery onward is safe, but US guidelines state the risk of expulsion is increased when IUDs are inserted up to 72 hours after delivery.
These guidelines show similar recommendations for the timing of insertion for various contraceptive methods. The guidelines should be understood to offer patients the best customized contraceptives.1
Reference
- Grandi G, Del Savio MC, Tassi A, Facchinetti F. Postpartum contraception: A matter of guidelines. Int J Gynaecol Obstet. 2024;164(1):56-65. doi:10.1002/ijgo.14928
- Krewson C. Survey finds interest in progestin-only pills among transgender populations. Contemporary OB/GYN. June 25, 2024. July 19, 2024. https://www.contemporaryobgyn.net/view/survey-finds-interest-in-progestin-only-pills-among-transgender-populations
