What are the guidelines for oral contraception in the postpartum (post-partum) period?

From the Guidelines

Oral contraception can be safely initiated in the postpartum period, but timing depends on breastfeeding status and risk factors, with progestin-only pills (POPs) being the preferred choice for breastfeeding women, and combined hormonal contraceptives (CHCs) being avoided until at least 6 weeks postpartum in breastfeeding women, as recommended by the CDC 1.

Key Considerations

• For non-breastfeeding women, CHCs can be started 3 weeks after delivery when the risk of thromboembolism has decreased, as stated in the U.S. Selected Practice Recommendations for Contraceptive Use, 2013 1.
• For breastfeeding women, POPs like norethindrone 0.35mg or drospirenone 4mg are preferred and can be started immediately after delivery, as they don't affect milk production, according to the CDC guidelines 1.
• Women with additional risk factors for thromboembolism (such as cesarean delivery, obesity, or history of thrombosis) should delay CHCs until 6 weeks postpartum, as indicated in Table 4 of the CDC guidelines 1.

Important Recommendations

• Postpartum women who are breastfeeding should not use combined hormonal contraceptives during the first 3 weeks after delivery, due to concerns about increased risk for venous thromboembolism, as stated in the U.S. Selected Practice Recommendations for Contraceptive Use, 2013 1.
• If the woman is <6 months postpartum, amenorrheic, and fully or nearly fully breastfeeding, no additional contraceptive protection is needed, as recommended by the U.S. Selected Practice Recommendations for Contraceptive Use, 2013 1.
• Patients should be counseled that fertility can return as early as 4 weeks postpartum in non-breastfeeding women, so contraception should be initiated before resuming sexual activity, as advised by the CDC guidelines 1.

Additional Guidance

• Postpartum women should also be informed about potential side effects including irregular bleeding with POPs and the importance of backup contraception if pills are missed, as stated in the CDC guidelines 1.
• The CDC specifies time frames for postpregnancy contraception, with estrogen-containing methods being deferred until at least three or up to six weeks postpartum, partly because of the risk of venous thromboembolism, as indicated in Table 4 of the CDC guidelines 1.

From the Research

Guidelines for Oral Contraception in the Postpartum Period

• In breastfeeding women, combined hormonal pills are not recommended prior to 6 weeks postpartum due to effects on milk production 2.
• Progestogen-only pills do not adversely affect milk production, but the lack of data regarding possible effects on infants exposed to progestogens in breastmilk renders the timing of initiation of this method controversial 2.
• In non-breastfeeding women, the elevated risk of venous thromboembolism restricts the use of combined hormonal pills prior to 21 days postpartum 2.
• From 21 to 42 days postpartum, the use of combined hormonal pills should be assessed based on a woman's personal venous thromboembolism risk profile; after 42 days postpartum, there is no restriction on the use of combined hormonal pills for otherwise healthy women 2.
• Non-breastfeeding women may safely use progestogen-only pills at any time during the postpartum period 2.

Recommendations for Postpartum Contraception

• A contraceptive counseling is ideally recommended after delivery to avoid unplanned pregnancies 3.
• Starting effective contraception later than 21 days after delivery in women who do not want closely spaced pregnancies is recommended 3.
• In breastfeeding women, the recovery of ovarian activity is dependent on breastfeeding characteristics, and only exclusive breastfeeding with very specific conditions can be used for contraception over a six-month period 3.
• According to the postpartum risk of venous thromboembolism, the combined hormonal contraceptive use before six postpartum weeks is not recommended 3.
• Progestin-only contraceptives with low doses are allowed in the early postpartum period, except in the acute phase of severe thromboembolic events 3.

Considerations for Breastfeeding Women

• Preparations containing estrogen should be avoided altogether during lactation because they have been associated with a reduction in milk production 4.
• Progestin-only methods comprise a viable option for breastfeeding women, and nonhormonal methods of contraception are the preferred choice 5.
• Combined hormonal methods of contraception containing estrogen and progestin may be considered as a third option for birth control in breastfeeding women 5.

Timing of Contraception Initiation

• The World Health Organization guidelines contraindicate combined hormonal contraceptives postpartum in breastfeeding patients between 6 weeks and 6 months after delivery 6.
• The Faculty of Sexual and Reproductive Healthcare and the Centers for Disease Control and Prevention guidelines do not contraindicate the use of combined hormonal contraceptives in women who breastfeed from 6 weeks to 6 months postpartum 6.
• Progestin-only pills can be administered immediately postpartum in non-breastfeeding women, but should ideally be postponed for 6 weeks in breastfeeding women 4.