Timing of Postpartum Contraception Initiation
Postpartum women should initiate contraception based on their breastfeeding status, with progestin-only methods available immediately after delivery for breastfeeding women, while non-breastfeeding women should wait until 4 weeks postpartum before starting combined hormonal contraceptives due to thromboembolism risk. 1, 2
For Breastfeeding Women
Immediate Postpartum (0-3 weeks)
- Progestin-only methods can be started immediately after delivery (U.S. MEC 2 if <1 month postpartum, U.S. MEC 1 if ≥1 month) 1
- Includes progestin-only pills (POPs), implants, and injectables
- No additional contraceptive protection needed if woman is fully breastfeeding (≥85% of feeds are breastfeeds), <6 months postpartum, and amenorrheic 1
- Otherwise, abstain from intercourse or use backup method for 2 days after starting POPs
3-6 Weeks Postpartum
- Combined hormonal contraceptives should NOT be used during first 3 weeks (U.S. MEC 4) 1, 2
- Generally should not use combined methods during fourth week (U.S. MEC 3) due to:
- Concerns about effects on breastfeeding performance
- Increased risk of venous thromboembolism 1
After 6 Weeks Postpartum
- Combined hormonal methods may be considered when medically eligible 1
- Women with additional risk factors for venous thromboembolism generally should not use combined hormonal contraceptives 4-6 weeks after delivery (U.S. MEC 3) 1
For Non-Breastfeeding Women
Immediate Postpartum (0-3 weeks)
- Progestin-only methods can be started immediately after delivery (U.S. MEC 1) 1
- Combined hormonal contraceptives should NOT be used during first 3 weeks (U.S. MEC 4) due to increased risk of venous thromboembolism 1, 2, 3
3-6 Weeks Postpartum
- Combined hormonal contraceptives can be initiated at 4 weeks postpartum in women who elect not to breastfeed 3
- Women with additional risk factors for venous thromboembolism generally should not use combined hormonal contraceptives 3-6 weeks after delivery (U.S. MEC 3) 1
- If starting contraception at 4 weeks postpartum and has not yet had a period, use another method of contraception until hormonal pills have been taken daily for 7 days 3
After 6 Weeks Postpartum
Special Considerations
Need for Backup Contraception
- For combined hormonal methods: Use backup for 7 days if started >5 days since menstrual bleeding began 1
- For progestin-only methods: Use backup for 2 days if started >5 days since menstrual bleeding began 1
Timing Considerations
- Ovulation can resume as early as 21 days postpartum in non-fully breastfeeding women 5
- Traditional 6-week postpartum visit is often too late for contraception initiation 5, 6
- Ideally, contraception should be discussed during pregnancy so the method of choice can be offered immediately postpartum 5
Thromboembolism Risk
- The postpartum period carries an inherently increased risk of thromboembolism 3, 4
- Combined hormonal contraceptives further increase this risk, necessitating the waiting period 1, 3
Clinical Pitfalls to Avoid
- Don't wait until the 6-week postpartum visit to discuss contraception, as this is often too late 5, 6
- Don't assume breastfeeding alone provides reliable contraception unless all LAM criteria are met (exclusive breastfeeding, amenorrhea, <6 months postpartum) 7
- Don't start combined hormonal contraceptives too early in any postpartum woman due to thromboembolism risk 1, 3, 4
- Don't overlook the opportunity to discuss long-acting reversible contraceptives (implants, IUDs) which can be safely inserted in the immediate postpartum period 5
By following these evidence-based guidelines for postpartum contraception initiation, providers can help women effectively prevent unintended pregnancies while minimizing health risks.