Postpartum and Contraception

Postpartum And Contraception

Postpartum contraception refers to the use of contraceptive methods after childbirth to prevent unintended pregnancies and allow optimal spacing between births. Choosing an appropriate method depends on multiple factors including breastfeeding status, medical history, and individual preferences.

Why is postpartum contraception important?

1. Prevents short interpregnancy intervals (<6 months), which are associated with adverse maternal and neonatal outcomes (e.g., preterm birth, low birth weight).

2. Supports maternal recovery and caregiving.

3. Allows informed reproductive planning.

When to start contraception postpartum

Timing	Suitable method
Immediate postpartum (within 48 hours)	IUD (intrauterine device ), Implant, Progesterone only pills, Injectable progesterone (DMPA), sterilization
6 weeks postpartum	All methods, including combined oral contraceptive (if not breast feeding)

CONTRACEPTIVE OPTIONS

1. Lactational Amenorrhea Method (LAM)

It is a temporary natural method of contraception based on exclusive breastfeeding, which suppresses ovulation due to hormonal changes associated with lactation.

Mechanism of Action

1. Suckling suppresses the hypothalamic-pituitary-ovarian axis by Inhibiting GnRH (Gonadotropin-releasing hormone) and lowering LH (Luteinizing hormone) pulsatility. This in turn prevents ovulation. Anovulation and amenorrhea, together provides contraceptive protection.

Eligibility Criteria (All 3 Must Be Met)

Criteria Description

1. Baby should be <6 months old After 6 months, ovulation can resume even with breastfeeding.

2. Exclusive or near-exclusive breastfeeding - the baby be given only breast feeds day and night - No regular supplemental feeds.

3. Amenorrhea - No vaginal bleeding or regular periods.

If any of these 3 criteria are not met, LAM is no longer effective, and another contraceptive method should be started.

Effectiveness

Typical use failure rate: ~2%

Perfect use effectiveness: 98%

Advantages

1. Hormone-free and natural- hence doesn't effect breast feeding, is safe for the baby and doesn't hamper postpartum recovery.

2. No cost, widely accessible- no additional cost of effort for contraception, hence is widely acceptable.

3. Promotes breastfeeding-LAM is a added advantage of breast feeding.

4. Encourages birth spacing.

Limitations

1. Short duration of protection (up to 6 months)- once periods resume or the baby is off exclusive breast feeds, this method is less effective.

2. Requires strict adherence to breastfeeding criteria.

3. No protection against STIs.

Transitioning from LAM

1. Another contraceptive method has to be started if:

At 6 months postpartum, OR

When periods return, OR

When supplemental feeding begins

Can be safely switched over to -Progestin only pills (POP), IUD, Injectables, Barrier methods.

1. Progestin-only Pills (POP)

Progestin-only pills (POPs), also known as the "mini-pill", are a safe and effective contraceptive option in the postpartum period, especially for breastfeeding mothers.

Mechanism of Action

1. Inhibits ovulation (in ~50% of cycles).

2. Thickens cervical mucus which prevents sperm penetration.

3. Alters endometrial lining – reduces likelihood of implantation.

POPs are safe and recommended at any time postpartum, irrespective of breastfeeding status.

Advantages in Postpartum Use

1. Safe during lactation – no effect on quantity or quality of breast milk.

2. Can be started immediately postpartum (within 48 hours).

3. Non-invasive, easily reversible.

Disadvantages

1. Strict timing required – must be taken at the same time every day (delay >3 hours reduces efficacy).

2. May cause irregular bleeding or spotting.

Efficacy

1. Typical use: ~91% effective

2. Perfect use: ~99%

Availability in India

1. Cerazette- 200-300rs /month-easily available

2. Exluton -60-100 Rs/month-easily available

3. Noriday-50-80 Rs/month-Available in public health system

1. INJECTABLES (DMPA )

DMPA (Depo-Provera) is a long-acting progestin-only injectable contraceptive administered every 3 months. It is highly effective and suitable for postpartum contraception, particularly in women who prefer non-daily methods.

Mechanism of Action

1. Inhibits ovulation

2. Thickens cervical mucus to block sperm

3. Alters endometrial lining to prevent implantation

Timing of Initiation - Immediately postpartum (within 48 hours): Allowed only in non-breastfeeding women (MEC 1). - After 6 weeks: Can be used safely in all women, including those breastfeeding.

Recommendation: Delay DMPA till 6 weeks postpartum if breastfeeding, as a precaution (though studies show minimal impact on milk and infant growth).

Efficacy

Typical use: ~94%

Perfect use: >99%

Begins working within 24 hours if given during the first 5 days postpartum or menstrual cycle

Advantages

1. No effect on breastfeeding after 6 weeks.

2. Infrequent dosing – once every 3 months-very beneficial for women who don't want to take pills on a regular basis.

3. Highly effective and reversible.

Disadvantages

1. Irregular bleeding or spotting can occur especially when started after 6 weeks postpartum.

2. Delayed return to fertility (average 9–10 months after last injection).

3. Weight gain, mood changes in some users.

4. Requires regular clinic visits for injection.

Cost and Availability in India

1. Depo-Provera -150mg -Rs 150–300/injection - available in both private and public sector.

2. Sayana Press - 104 mg (self-injectable) - ₹350–500 Limited availability.

3. Antara 150 mg IM-Free-Through public health facilities.

1. Intrauterine device (IUDs)

IUDs are a safe, effective, and long-acting reversible contraceptive option in the postpartum period. They can be classified as:

1. Copper IUD (Cu-IUD) – non-hormonal

2. Levonorgestrel-releasing IUD (LNG-IUD) – hormonal

Timing of IUD Insertion Postpartum

1. Immediate Postpartum Insertion (within 10 minutes of placental delivery)

Can be done after both vaginal and cesarean delivery.

High expulsion rates (10–27%) compared to delayed insertion but good for ensuring contraception before discharge.

1. Early Postpartum Insertion (within 48 hours)

Similar profile to immediate insertion.

1. Delayed Postpartum Insertion (after 6 weeks)

Lower expulsion rates.

Suitable for women attending postpartum follow-up.

Advantages

1. Does not affect breastfeeding.

2. Highly effective (failure rate <1%).

3. Long-acting (up to 5–10 years).

4. Convenient: Can be inserted before hospital discharge.

Considerations

1. Requires trained personnel for immediate postpartum insertion.

2. Slightly higher risk of expulsion with immediate insertion.

3. Infection risk is low when aseptic technique is followed.

4. For cesarean delivery, insertion through uterine incision can be done safely before closure.

Cost and availability in India

1. Cu T 380 A-effective for 10 yrs - 100-300 Rs-available free under government schemes in India.

2. CuT 375-effective for 5 years -200-300rs- Available widely.

3. Mirena (LNG-IUS )-effective for 5 yrs -6000-8000Rs-Available in private sector.

4. Emicell (Indian LNG-IUS )-3000-4000 Rs-Available widely.

5. Contraceptive consideration based on breastfeeding status.

Methods	Breastfeeding	Non -breast feeding
Lactational amenorrhea	Effective for upto 6 months if exclusive breast feeding and not menstruating	Not applicable
Progesterone only pills	MEC1 -safe	MEC 1 -safe
Injectables (DMPA	MEC 1 -safe	MEC 1 -safe
Implants	MEC 2 (0-6 weeks, MEC 1 after	MEC 1
IUDs (CuT, LNG-IUS)	MEC1 after 4 weeks	MEC 1
Combined pills	MEC 3 (0-6 weeks), MEC 2 after	MEC 3 (0-21 days), MEC 2 after
Barrier method	Safe	Safe

References

1. World Health Organization (WHO). Medical eligibility criteria for contraceptive use – 5th edition. Geneva: WHO; 2015. https://www.who.int/publications/i/item/9789241549158

1. Ministry of Health and Family Welfare, Government of India. Operational Guidelines on Postpartum IUCD Services. 2010.

1. Government of India, Ministry of Health and Family Welfare Guidelines for Postpartum Family Planning (2016)