Start postpartum contraception early
The next woman in your examination room is a young mother who has come in for the standard six-week postpartum visit included in your facility's protocol. She tells you that while she has used no contraception since her delivery, she has had unprotected intercourse. She is not breast-feeding her infant. What is your next move?
Many women resume sexual activity before the sixth postpartum week, research findings indicate.1-5 Since ovulation frequently occurs before six weeks, the obstetrical tradition of scheduling the postpartum visit at six weeks should be changed, advocates a recent commentary in the reproductive health journal Contraception.6 A three-week visit would be more effective in preventing postpartum conception by initiating effective contraception at this time, instead of after the six-week visit, which commentary authors term an "anachronism."6
Robert Hatcher, MD, MPH, professor of obstetrics and gynecology at Emory University, agrees with the call for a change in the timing of the routine postpartum visit. "Research findings indicate that in mothers who do not breast-feed, about half ovulate before the sixth postpartum week, and at least two-thirds ovulate before their first menstrual period,7 notes Hatcher, who presented on contraceptive practices at the 2009 Contraceptive Technology conferences.8 Therefore, sexual intercourse can result in pregnancy much sooner than previously recognized, he notes.
How about women who breast-feed? While exclusive breast-feeding results in delay to return of ovulation, research indicates that contraception should begin early, Hatcher notes. The onset of menses and the introduction of supplemental feedings are independent predictors for the resumption of ovulation in breast-feeding women.9
What are contraceptive options for the new mother? A new review advises that the contraceptive injection depot medroxyprogesterone acetate (DMPA, Depo Provera) can be administered prior to hospital discharge and no later than the third postpartum week.10
Many women who intend to fully breast-feed at time of hospital discharge do not do so, and thus are at risk for ovulation and unintended pregnancy by the third postpartum week, says Maria Isabel Rodriguez, MD, a fellow in family planning at the University of California San Francisco Bixby Center for Global Reproductive Health and lead author of the research. The traditional postpartum visit occurs at six weeks, so this subset of women would be at risk of unintended pregnancy during that interval, she notes.
While the World Health Organization's classifies use of DMPA postpartum in breast-feeding women as Class 3, a condition where the theoretical or proven risks usually outweigh the advantages of using the method,11 U.S. family planning experts have endorsed the safety of administering DMPA immediately postpartum in women, regardless of breast-feeding status.6 "After reviewing all of the evidence, the risks to an infant of DMPA immediately postpartum are theoretical, and the risks to a woman of unintended pregnancy are real and significant," says Rodriguez. "Minimizing risk to the mother by early provision of contraception — if desired — should be a priority."
Consider other factors when reviewing contraceptive options, says Rodriguez. Many uninsured or underinsured women lose access to care shortly after their delivery, and are unable to readily access contraceptive services postpartum.12
References
- Glazener CMA. Sexual function after childbirth: Women's experiences, persistent morbidity, and lack of professional recognition. Br J Obstet Gynaecol 1997; 104:330-335.
- Connolly A, Thorp J, Pahel L. Effects of pregnancy and childbirth on postpartum sexual function: A longitudinal prospective study. Int Urogynecol J Pelvic Floor Dysfunct 2005; 16:263-237.
- Woranitat W, Taneepanichskul S. Sexual function during the postpartum period. J Med Assoc Thai 2007; 90:1,744-1,748.
- Rowland M, Foxcroft L, Hopman WM, et al. breast-feeding and sexuality immediately post partum. Can Fam Physician 2005; 51:1,366-1,367.
- Egbuonu I, Ezechukwu CC, Chukwuka JO, et al. Breastfeeding, return of menses, sexual activity, and contraceptive practices among mothers in the first six months of lactation in Onitsha, South Eastern Nigeria. J Obstet Gynaecol 2005; 25:500-503.
- Speroff L, Mishell DR. The postpartum visit: It's time for a change in order to optimally initiate contraception. Contraception 2008; 78:90-98.
- Campbell OM, Gray RH. Characteristics and determinants of postpartum ovarian function in women in the United States. Am J Obstet Gynecol 1993; 169:5,560.
- Hatcher RA. Back to basics: The fundamentals of hormonal contraception. Presented at the 2009 Contraceptive Technologyconferences. San Francisco; March 2009, and Washington, DC, April 2009.
- McNeilly AS, Howie PW, Houston IMJ. "Relationship of Feeding Patterns, Prolactin, and Resumption of Ovulation Postpartum." In: Zatuchni GI, Labbok MH, Scirra JJ, eds. Research Frontiers in Fertility Regulation. Hagerstown (MD): Harper & Rowe; 1981.
- Rodriguez MI, Kaunitz AM. An evidence-based approach to postpartum use of depot medroxyprogesterone acetate in breastfeeding women. Contraception 2009; 80:4-6.
- World Health Organization. Medical Eligibility Criteria for Contraceptive Use. Third ed. Geneva: World Health Organization; 2004.
- Culwell KR, Feinglass J. Changes in prescription contraceptive use, 1995-2002: The effect of insurance status. Obstet Gynecol 2007; 110:1,371-1,378.
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