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Postpartum Contraception Counseling


Goal of Presentation
What is different about contraception in

postpartum period? When should we counsel? What are the options? How do we use them? Why do we recommend using them in this way?

What is different about contraception in postpartum period?

breastfeeding hypercoagulable state different contraceptive needs

Breastfeeding Physiology

Prolactin secretion in pregnancy -> breast growth, milk biosynthesis Progesterone (and estrogen) ->interferes with prolactin binding, inhibits lactation Rapid decline placental progesterone -> initiation of lactation Suckling -> oxytocin release -> contraction of the myoepithelial cells -> milk ejection Steroid hormones cleared -> maintenance of milk production High serum prolactin -> inhibits pulsatile GnRH -> prevent ovulation -----> maintained?


Day 2-4 postpartum,

Nutritional research 1970s-1980s OCPs

Sig changes in concentration of total protein, milk protein, and daily milk volume (Lonnerdal 1980) Magnitude of changes w/in normal range, not of nutritional importance to newborn (Kowetsawang 1987)

WHO Task Force (1984)

Prospective RCT of COC vs POP vs non-hormonal placebo. Milk volume: 41.9% decline in COC group vs 12.0% in POP group vs 6.1% in non-hormonal controls. Comparable prevalence of complementary feeding and withdrawals due to inadequate milk supply **No sig differences in growth of infants between treatment groups.

Postpartum Hypercoagulable State

Physiology coagulation factors and fibrinogen, resistance to anticoagulants protein C and S Risk of VTE (Gherman 1999) 22-84-fold high in first 6 weeks of postpartum period greatest in first 21 days, after which risk sharply drops off

Family planning needs?

Survey (Cwiak 2004) extremely important qualities ANTE-PARTUM: reliability, efficacy, and safety during breastfeeding POST-PARTUM SIG: ease of use, long-term protection, and no need for monthly pharmacy trips

> 80% using contraception prior to pregnancy, nearly 20% not satisfied with the method used. > 40% thought IUC seemed somewhat or much better than their most recent method, yet < 1% chose

When should we counsel?

Standard part of discharge discussion? (Glazer 2010) 77% (134) discussed contraception antepartum 87% (153) discussed postpartum. 1/3 discussing IUDs at any point. Initiation of sexual activity? (Ford 1998, Barret


32-66% sexually active within first month, 62-88% within second month

How effective are we at counseling?

Effectiveness of antenatal counseling (Smith


Expert advice vs routine standard advice in prenatal period Pregnancy rates at 1 year not significantly different, even when considering intention Contraceptive practice differed significantly (only because those not intending to get pregnant chose sterilization)
Not many great studies out there..

How effective are we at counseling?

Cochrane Review of effects of postpartum

interventions (Lopez 2002, 2010)

Increased contraception use, decreased unplanned pregnancies in 2/4 interventional trials, More effective when interventions longer (beyond hospital stay period), incorporating home visits

Part 2

What are the options? How do we use them?

Why do we recommend using them in this way?

Lactational Amenorrhea

Ovulation within 3 months in exclusive breastfeeders, As early as 3-6 weeks in women who are not exclusively breastfeeding May precede menstruation

EBM < 2% failure rate in women exclusively or mostly breastfeeding (DEF - feeding both night and day, ammenorheic, infant less than 6 months old and receiving >90% nutrition from breastmilk) (WHO)

ACOG NONBr Feed NOT recommended WHO (AAFP) NOT recommended

Br Feed

Clinical Judgment Menstruation/ovulation is unpredictable Duration of breastfeeding Resumption of sexual activity

Combination contraceptives- COCs, Nuvaring, Orthoevra

EBM In nonlactating women-risk of pregnancy related thrombosis reduced to acceptable level after three weeks (Gherman 1999) Decreases median lactating period (WHO 1984) Effectiveness varies by method

Combination Contraceptives
ACOG NONBr Feed > 4 weeks WHO (AAFP) < 3 wks not rec unless no other method avail > 3 wks use freely AAP No earlier than 3-6 weeks

Br Feed

> 4 weeks, waiting until br feeding well established

< 6 wks do NOT use 6 wks- 6 mo not rec unless no other method avail > 6 mo use freely

No earlier than 3 to 6 wks, wait until infant not relying pred on br milk

Combination contraception
Clinical Judgment Acceptable reduction of risk of thrombosis Perceived effect on establishment of breastfeeding patterns Ease of use for mother

Progesterone only: Minipill, Depo-Provera, Mirena IUD, Implanon

Theoretical effect based on understanding of physiology Existing data of poor quality

EBM Progesterone little effect on coagulation factors, BP, lipids NOT been shown to effect milk quality sig, NO effect on infant growth and development (Truitt 2003,WHO 1994,) Early initiation had NO effect on short-term breastfeeding patterns (Halderman 2003)

MirenaProgesterone only IUD

Expulsion rates? Use: insert 20 minutes within delivery of placenta, using special technique OR 4-6 weeks postpartum, once uterus has involuted (24-48 hour interval not recommended) 0.1%/0.1% one year failure rate (WHO) RCT of post-NVD insertion- Postplacental group 24% expulsion rate, Interval group 4.4% expulsion rate (Chen 2010)

Depo-ProveraProgesterone only injection

Breastfeeding (Hannon, 1997) NON-sig effect on duration or frequency of lactation NON-sig effect on timing of introduction of formula Adolescents (Templeton 2000) 55% Depo vs 24% OC users continued method at 1 year. Total incidence of repeat pregnancy 10.6% at 1 year. 24% in OC users and 2.6% in Depo users pregnant at 1 year.

Progesterone only
NONBr Feed Br Feed Anytime > 3 weeks if partially br feeding > 6 weeks if fully br feeding MIRENA Br Feed

WHO 2008 (AAFP)

Anytime < 6 weeks not rec unless no other method avail > 6 weeks use freely < 48 hrs not rec unless no other method avail 48hrs- 4 weeks not rec unless no other method avail > 4 weeks use freely

Anytime Anytime

Progesterone only
Clinical judgment Concerns for newborn potential effects on newborn brain, liver unknown (animal studies) Ease of use- timing of POPs Rate of expulsion of Mirena- timing of insertion? Complication rate for postplacental insertion- no quality data Prolonged/irregular bleeding

ParaGaurd- Copper IUD

EBM May insert 20 minutes within delivery of placenta, using manual insertion OR 4-6 weeks postpartum once uterus has involuted 0.6%/0.8% first year failure rate (WHO) No effect on breastmilk production, nutritional value Expulsion rate at six months 6.7 times more likely when placed postplacentaly (7-15%) vs interval (Kapp 2009, Cochrane database 2010)

Paraguard Copper IUD

< 48 hrs generally use 48hrs- 4 weeks not rec unless no other method avail > 4 weeks use freely

Br Feed

< 48 hrs generally use

48hrs- 4 weeks not rec unless no other method avail

> 4 weeks use freely

ParaGaurd- Copper IUD

Clinical Judgment Review of safety of postpartum insertion based off of poor to fair quality trials (Kapp 2009) Expulsion risks

Other methods
Sterilization (Tubal, Essure, Vasectomy) Can be done at any immediatly after delivery/CS, within 24-48 hours or at an interval of 4-6 weeks, effective immediately, no effect on breast milk, NOT reversible Condoms Can be used at any time, effective immediately, no effect on breast milk, protects against STIs, NOT always practical?

Plan B (and now ella.)

EBM No increased risk of VTEs for mom No effect on breastmilk Clinical Judgment Availability

In summary
What is different about contraception in

postpartum period? When should we counsel? What are the options? How do we use them? Why do we recommend using them in this way?

Barrett, G., Pendry, E., Peacock, J., Victor, C., Thakar, R. and Manyonda, I. (2000), Women's sexual health after childbirth. BJOG: An International Journal of Obstetrics & Gynaecology, 107: 186195.

Chen BA Reeves MF, Hayes JL, Perriera LK, Creinin MD. Postplacental or delayed insertion of the levonorgestrel intrauterine device after vaginal delivery: a randomized controlled trial. Obstet Gynecol. 2010 Nov;116(5):1079-87.
Cwiak C, Gellasch T, Zieman M. Peripartum contraceptive attitudes and practices. Contraception. 2004 Nov;70(5):383-6.

Gherman RB, Goodwin TM, Leung B, Byrne J, Hethemumi R, Montoro M. Incidence, Clinical Characteristics, and Timing of Objectively Diagnosed Venous Thromboembolism During Pregnancy. Obstetrics & Gynecology: 1999 Nov ; 94, 5. 730-4
Glazer, AB, Wolf A, Gorby N. Contraception: needs vs. reality.
Guiloff E, Ibarra A, Zanartu J, Toscanini C, Mischler TW, Gomez-Rogers C. Effect of contraception on lactation. Am J Obstet Gynecol. 1974 Jan 1;118(1):42-5. Halderman LD, Nelson AL.. Am Impact of early postpartum administration of progestin-only hormonal contraceptives compared with nonhormonal contraceptives on short-term breast-feeding patterns. J Obstet Gynecol 2002;186:12506; discussion 12568. (Level

Hannon PR, Guddan AK, Serwing JR, Vogelhut JW, Witter F, DeAngelis C. The influence of medroxyprogesterone on the duration of breast-feeding in mothers in an urban community. Arch Pediatr Adolesc Med. 1997 May;151(5):490-6.
Kapp N, Curtis KM. Intrauterine device insertion during the postpartum period: a systematic review. Contraception. 2009 Oct;80(4):327-36. Epub 2009 Aug 29. Koetsawang S. The effects of contraceptive methods on the quality and quantity of breast milk. Int J Gynaecol Obstet 1987;25 suppl:11527.

Resources, contd.
Lonnerdal B, Forsum E, Hambraeus L. Effect of oral contraceptives on composition and volume of breast milk. Am J Clin Nutr. 1980 Apr;33(4):816-24. Lopez LM Hiller JE, Grimes DA. Postpartum education for contraception: a systematic review. Obstet Gynecol Surv. 2010 May;65(5):325-31. Lopez LM Hiller JE, Grimes DA Education for contraceptive use by women after childbirth. Cochrane Database Syst Rev. 2010 Jan 20;(1):CD001863. Progestogen-only contraceptives during lactation: I. Infant growth. World Health Organization Task Force for Epidemiological Research on Reproductive Health; Special Programme of Research, Development, and Research Training in Human Reproduction. Contraception . 1994;50:3553. Smith KE, vad der Spuv ZM, Cheng I, Elton R, Glasier AF. Is postpartum contraceptive advice given antenatally of value? Contraception. 2002 Mar;65(3):237-43. Tankeyoon M, Dusitsin N, Chalapati S, Koetsawang S, Saibiang S, Sas M, Gellen JJ, Ayeni O, Gray R, Pinol A, et al. Effects of hormonal contraceptives on milk volume and infant growth. WHO Special Programme of Research , Development and Research Training in Human Reproduction Task Force on Oral Contraceptives. Contraception. 1984 Dec;30(6):505-22. Templeman CL, Cook V, Goldsmith LJ, Powell J, Hertweck SP. Postpartum contraceptive use among adolescent mothers. Obstet Gynecol. 2000 May;95(5):770-6 Truitt ST, Fraser AB, Grimes DA, Gallo MF, Schulz KF. Hormonal contraception during lactation: systematic review of randomized controlled trials. Contraception 2003;68:2338.