Contraceptive Choices for the Postpartum Year
Women can become pregnant again almost immediately after childbirth. Ovulation may resume in as soon as one or two months. This may be longer for women who are breastfeeding. After delivery, a six-week abstinence period is generally recommended, but some couples may not observe that precaution. Thus, it is very important to have a contraception plan in place before delivery. The American Academy of Pediatrics recommends, for the health of the subsequent baby in particular, a 2 year span between births.
The following is a description of choices currently available to most postpartum (after childbirth) women. Estrogen decreases milk supply, so women who are breastfeeding must use methods that do not contain estrogen. Note that only condoms can prevent sexually transmitted infections.
Options for the Breastfeeding Woman
These birth control pills contain no estrogen and do not decrease breastmilk production. However, because of the lack of estrogen, they can be less effective than combined-hormone pills and must be taken at the same time every day. Missing a pill will greatly reduce the effectiveness of minipills. Because around-the-clock, on-demand breastfeeding has a suppressive effect on ovulation, combining minipills with breastfeeding can provide adequate pregnancy prevention for the first few months after pregnancy. As your baby begins to take food or formula, to avoid risk of pregnancy, add condoms, withdrawal or another method of birth control. When your baby is completely weaned from breastfeeding, you will want to switch to combined-hormone pills or another method for adequate pregnancy prevention.
Depo Provera is a progestin-only product like minipills, but given as an injection. Also known as “The Shot,” this method can be given immediately postpartum to women who do not have a high risk for depression. It is more than 99% effective and provides immediate protection from pregnancy. The Depo Provera shot lasts for 12 weeks, and then another shot can be given for another 12 weeks of protection. The main side effect of this method is irregular bleeding, which usually resolves after the second injection. Waiting until the 6-week postpartum visit to get your shot will reduce this side effect. Another side effect is weight gain, which averages 4 pounds per year, but can be more in women prone to be overweight. This can be controlled with diet and exercise in motivated and self-disciplined women. Long-term use of this method can have negative effects on bone density, so it is not a good permanent choice. It is a very effective short-term method and can be given prior to discharge from the hospital. Depo Provera can contribute to depression in some women.
There are 2 types of intrauterine devices (IUDs) available in the U.S. to postpartum women and both are more then 99% effective. The IUD is inserted by a health care provider, usually 6 weeks or more after childbirth. It is an office procedure. Both types of IUD are T-shaped and flexible. The arms of the T fold into a special straw from placement n the uterus. Nylon strings from the IUD are allowed to curl around the cervix so a woman can check for herself if the IUD is still in place. IUDs do not cause any reduction in long-term fertility. The IUD can be removed at any time by a health care provider in simple, painless office procedure.
This IUD is embedded with progestin, the same hormone in minipills and Depo Provera shots, but at a lower dose, which is released slowly and is locally acting. Mirena is good for 5 years of protection. Side effects include irregular vaginal bleeding for the first 1-6 months. About 95% of women who have had Mirena for a year, though, have no periods. This is not harmful to a woman’s health, and normal periods resume shortly after removal. There is no weight gain or bone loss caused by Mirena.
This IUD is wrapped in a lightweight copper coil. It is good for 10 years and causes no irregular, unpredictable bleeding. Because Paragard has no hormones, it has no effect on the timing of your cycles and women have their regular monthly period. However, period bleeding is usually heavier and causes more cramping. This is a good choice for women who prefer predictable menstrual periods.
Nexplanon is a matchstick-sized, flexible plastic rod inserted into a woman’s upper arm. It is more than 99% effective and is good for 3 years. It can be removed at any time. Nexplanon is embedded with progestin, which is slowly released. It is placed by a health care provider under local anesthetic. Nexplanon may cause light, irregular bleeding throughout the 3 year duration, but the bleeding usually stops.
Other forms of birth control for women who are breastfeeding, which can be used alone or in combination include:
Male or Female Condoms with or without spermicide
Lactational Amenorrhea Method/Natural Family Planning
Diaphragm with spermicide
Options for Women Who Are Not Breastfeeding
Most women who are not breastfeeding can use any of the birth control methods above, or, after waiting 6 weeks, may use the following methods. These all contain estrogen, which impairs milk production. All women who have just had a baby have a slightly increased risk of blood clot formation, such as pulmonary embolism, or deep vein thrombosis. All the estrogen-containing birth control methods can increase a woman’s risk of blood clots also. This is why women need to wait 6 weeks before beginning to take an estrogen-containing method. Some women should not take estrogen-containing products, particularly those with migraines with aura, insulin-dependent diabetes, hepatitis, high blood pressure, or older heavy smokers. The main significant possible (rare) side effect of the estrogen-containing methods is a blood clot, which can be experienced as pain in the back of the knee, abdominal pain, chest pain, difficulty breathing or a severe headache. If you think you might have a blood clot, go immediately to an emergency room for evaluation and contact your health care provider. Always remember to tell any health care provider you see, including your dentist, that you take an estrogen-containing birth control method. Minor side effects of all these methods, which are usually most bothersome in the first 2-3 months, might include: breast tenderness, decreased interest in sex, bloating, or mood changes. Read the entire package insert for complete information.
Estrogen + progestin combined hormonal birth control pills can be up to 99% effective if taken as directed. In actual use, studies show effectiveness is approximately 92% and falls sharply if not taken exactly as directed. There are many different recipes for the pill. If you are not happy with how you feel on one, another type might work better for you. There are quite a number of different progestin formulations. Some pills are triphasic, with different estrogen levels at different times of the cycle. Pills are rather like shoes. If you don’t like one pair, you might try on another.
The “patch” is an alternative mechanism for delivery of the same hormones found in regular birth control pills. A woman using this method places one patch on her arm, shoulder or hip for one week. She then removes it and places another patch in a different location for another week. Likewise a third patch. Then, the woman has one week of no patch, during which she will get her period. It is important to adhere the patch well, since the active medication is in the adhesive. If the patch does not stick, it is not working. Additional side effects include skin irritation and/or discoloration where the patch was. The patch is not as effective in obese women. The patch is more expensive than the pill, and may not be covered by your insurance. Currently, there is only one brand and dose of the patch.
The Nuvaring is a clear, flexible plastic circle that slowly releases the hormones into the body. The ring is placed by the woman in the top of her vagina, and left for 3 weeks. After that, the woman removes the ring and for a week, there is no ring in place and she will get her period. On the seventh day without a ring in place, a new one is inserted for another 3 weeks, and so on. It is possible for the Nuvaring to fall out, so women should check on it from time to time. Cost can be a factor with this method as well.
Permanent methods of contraception include vasectomy, bilateral tubal ligation or occlusion of the tubes with Essure coils. A full discussion of these methods is beyond the scope of this handout. Discuss these with your health care provider.