Check contraception options for postpartum
Your next patient in the clinic examination room is a 22-year-old who has just delivered her first child three weeks ago. She tells you that she wants a reversible contraceptive to delay future births for the next four to five years. She is breast-feeding her new baby, and she has no current medical complications. What options can be safely provided to her?
Women in the postpartum especially need effective contraception, notes Mary Dolan, MD, MPH, associate professor of gynecology and obstetrics and division director of gynecology and obstetrics at Emory University in Atlanta. Results from the most recent cycle of the National Survey of Family Growth indicate that 49% of all pregnancies were unintended, and 21% of women gave birth within 24 months of a previous birth.1
A new review of the types of contraception being used by women two to nine months postpartum shows that 88% of postpartum women report current use of at least one birth control method.2 Furthermore, 61.7% report using a method defined as highly effective, 20% use a method defined as moderately effective, and 6.4% use less effective methods. Contraceptive effectiveness was categorized as:
- highly effective — less than 10% of women experience an unintended pregnancy. This category includes sterilization, intrauterine device, shot, pill, patch, and ring;
- moderately effective — 10%-15% failure rate. This category includes condoms;
- and less effective — greater than 15% failure rate. This category includes diaphragm, cervical cap, sponge, rhythm, and withdrawal.
Rates of using highly effective contraceptive methods postpartum were lowest among women who had no prenatal care (54.5%).2
What about an IUD?
What options are available to our hypothetical patient? Consider a Copper-T 380 intrauterine device (ParaGard IUD, Duramed Pharmaceuticals; Pomona, NY) or the levonorgestrel intrauterine contraceptive (Mirena IUC, Bayer HealthCare Pharmaceuticals; Wayne, NJ). Both birth control devices represent two effective options, says Dolan, who presented information on postpartum contraception at the recent Contraceptive Technology Quest for Excellence conference.3
Both forms of intrauterine contraception do not cause a negative impact on the quality of breast milk.4 Both offer long-term effectiveness and do not require behavior changes related to the method. Disadvantages include risk of perforation, expulsion, and infection; however, a just-published review of evidence indicates that there is no increase in risk of complications among women who had an IUD inserted during the postpartum period.5 The review notes some increase in expulsion rates occur with delayed postpartum insertion when compared to immediate insertion, and with immediate insertion when compared to interval insertion.5
There are several advantages to postpartum placement of an IUD, notes Nathalie Kapp, MD, MPH, medical officer in the Department of Reproductive Health and Research at the World Health Organization (WHO) in Geneva. These advantages include the ease of insertion, the ready availability of skilled staff and appropriate facilities, and the convenience and possible decrease in insertional pain for the woman who has just given birth, states Kapp, lead author of the review.
When is the best timing for insertion of an intrauterine contraception in a postpartum woman who plans to breast-feed her infant? The WHO Medical Eligibility Criteria rates placement of a Copper-T IUD before six weeks postpartum as a "2" in breast-feeding women, which means the advantages outweigh the theoretical or proven risks.6 However, the criteria rates placement of a Mirena LNG IUS before six weeks as a "3," which means the theoretical or proven risks outweigh the advantages. However, after the six-week postpartum time period, both devices are rated as a "1" — no restrictions on contraceptive use — in lactating women.6
These numbers for postpartum women are being carefully scrutinized for the U.S. version of the Medical Eligibility Criteria, which will be published in early 2010, says Robert Hatcher, MD, MPH, professor of gynecology and obstetrics at Emory University.
Think POP for pills
What if the hypothetical patient prefers to take pills for contraception? Look at progestin-only pills (POPs), says Dolan. Advantages include:
- familiarity with taking a daily pill, with ability to discontinue easily;
- high efficacy;
- possible improvement of menstrual symptoms, such as dysmenorrhea and premenstrual syndrome;
- no effect on infant growth, and possible increase in milk volume;
- very little of the progestin entering the breast milk.
What are the disadvantages of POPs? These include hormonal issues; a recommended delay of six weeks postpartum in lactating women; the need for daily pill taking and timing; and irregular bleeding.2
Clinically, the most important disadvantage patients are faced with is taking a POP every day around the same time, says Dolan. Patients need to be counseled on the importance of taking the POP within two hours of the same time each day.
"That's hard with a new baby and new schedules," Dolan observes. "The most important advantage is its effectiveness if taken appropriately."
Although some authorities and organizations, including the WHO, have been guarded about use of the contraceptive injection depot medroxyprogesterone acetate (DMPA, Depo Provera), immediately postpartum prior to hospital discharge, the evidence is reassuring that immediate postpartum initiation of DMPA is safe from a maternal and infant health perspective, says Andrew Kaunitz, MD, professor and associate chair in the Obstetrics and Gynecology Department at the University of Florida College of Medicine — Jacksonville.
Existing data are not sufficient to limit DMPA use postpartum in women at high risk for unintended pregnancy, according to a recently published review of scientific literature.7 To minimize the maternal and neonatal risks of unintended pregnancy, DMPA should be administered prior to hospital discharge and no later than the third postpartum week in well-counseled women choosing to use DMPA as their contraceptive, regardless of lactation status, the review states.7
References
- Chandra A, Martinez GM, Mosher WD, et al. Fertility, family planning, and reproductive health of U.S. women: Data from the 2002 National Survey of Family Growth. Vital Health Stat 23 2005; (25):1-160.
- Centers for Disease Control and Prevention (CDC). Contraceptive use among postpartum women — 12 states and New York City, 2004-2006. MMWR 2009; 58:821-826.
- Dolan M. Births, babies, and beyond: Contraceptive management for postpartum and lactation. Presented at the 2009 Contraceptive Technology Quest for Excellence conference. Atlanta; October 2009.
- Shaamash AH, Sayed GH, Hussien MM, et al. A comparative study of the levonorgestrel-releasing intrauterine system Mirena vs. the Copper T380A intrauterine device during lactation: Breast-feeding performance, infant growth, and infant development. Contraception 2005; 72:346-351.
- Kapp N, Curtis KM. Intrauterine device insertion during the postpartum period: A systematic review. Contraception 2009; 80:327-336.
- World Health Organization. Medical eligibility criteria for contraceptive use. Geneva; 2009.
- Rodriguez MI, Kaunitz AM. An evidence-based approach to postpartum use of depot medroxyprogesterone acetate in breast-feeding women. Contraception 2009; 80:4-6.
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