What are the recommended pregnancy options and birth control methods postpartum?

Postpartum Contraception Options

For postpartum women, progestin-only methods and IUDs are the safest and most effective contraceptive options in the immediate postpartum period, while combined hormonal contraceptives should be avoided until at least 3 weeks after delivery due to increased thrombosis risk. 1

Timing of Contraception Initiation by Method

Immediate Postpartum (0-21 days)

Safe Options:

• Progestin-Only Methods

  • Progestin-only pills (POPs): Can be started immediately postpartum (US MEC 1) 1
  • Implant (Nexplanon): Can be inserted immediately postpartum (US MEC 1 if non-breastfeeding, US MEC 2 if breastfeeding) 1, 2
  • DMPA (Depo-Provera): Can be started immediately postpartum, though slightly more restrictive for breastfeeding women (US MEC 1 if non-breastfeeding, US MEC 2 if breastfeeding) 1

• Intrauterine Devices (IUDs)

  • Can be inserted within 10 minutes after delivery of the placenta (US MEC 2) 1
  • If not inserted immediately, should wait until ≥4 weeks postpartum (US MEC 1) 1
  • Note: Immediate postpartum insertion has higher expulsion rates but better long-term continuation rates 1

Contraindicated:

• Combined Hormonal Contraceptives (CHCs) including pills, patch, and vaginal ring:
  • Absolutely contraindicated in first 21 days postpartum (US MEC 4) due to increased risk of venous thromboembolism 1, 3

21-42 Days Postpartum

• Progestin-Only Methods: Continue to be safe options (US MEC 1-2) 1
• IUDs: Can be inserted at ≥4 weeks postpartum (US MEC 1) 1
• Combined Hormonal Contraceptives:
  • With VTE risk factors: Should be avoided (US MEC 3) 1, 2
  • Without VTE risk factors: May be used with caution (US MEC 2) 1

>42 Days Postpartum

• All methods generally become available options:
  • Progestin-only methods (US MEC 1) 1
  • IUDs (US MEC 1) 1
  • Combined hormonal contraceptives (US MEC 1) for women without risk factors 1, 2

Special Considerations for Breastfeeding Women

• Lactational Amenorrhea Method (LAM): Effective if all three criteria are met 2, 4:

  1. <6 months postpartum
  2. Exclusively or nearly exclusively breastfeeding (≥85% of feeds)
  3. Amenorrheic (no menstrual periods)

• Progestin-Only Methods: Safe during breastfeeding (US MEC 1-2) 1, 2

  • No negative effects on breastfeeding have been demonstrated with LARC methods 1, 2

• Combined Hormonal Contraceptives:

  • Should not be used in the first 3 weeks postpartum (US MEC 4) 1
  • Generally should not be used in weeks 3-6 postpartum (US MEC 3) 1, 3
  • May affect milk production 4, 3

Need for Backup Contraception

• Progestin-Only Pills: Need 2 days of backup unless started within first 5 days of menses 1, 2
• Combined Hormonal Methods: Need 7 days of backup unless started within first 5 days of menses 1, 2
• LARC Methods: No backup needed if inserted within timing guidelines 2

VTE Risk Factors to Consider

Risk factors that increase postpartum thrombosis risk with hormonal methods include 1, 2:

• Age ≥35 years
• Previous VTE
• Thrombophilia
• Immobility
• Transfusion at delivery
• BMI ≥30 kg/m²
• Postpartum hemorrhage
• Cesarean delivery
• Preeclampsia
• Smoking

Common Pitfalls to Avoid

1. Delaying contraception initiation: Many women resume sexual activity before the traditional 6-week postpartum visit 2, 5

2. Overreliance on breastfeeding: LAM is not reliable beyond 6 months or if not exclusively breastfeeding 2, 4

3. Ignoring VTE risk: Combined hormonal methods significantly increase thrombosis risk in the early postpartum period 1, 2, 3

4. Missing the opportunity for immediate postpartum LARC: Immediate insertion has higher continuation rates despite higher expulsion rates 1, 2

5. Inadequate counseling on backup methods: Additional protection is needed for most methods if not started within the first 5 days of menses 1, 2

Recommended Approach

1. Discuss contraception during prenatal care to allow informed decision-making before delivery 1, 5

2. For women at high risk for medical complications, strongly recommend LARC methods (IUDs or implants) due to their superior efficacy and safety 1

3. Consider immediate postpartum LARC placement when possible, especially for women at high risk of short interpregnancy intervals 1, 2

4. Use a shared decision-making framework that considers the woman's preferences, medical history, and breastfeeding intentions 1, 5