What are the recommended options for postpartum birth control?

Postpartum Birth Control Options

All postpartum women can safely initiate contraception immediately after delivery with progestin-only methods (pills, implants, IUDs), while combined hormonal contraceptives must be delayed until at least 3 weeks postpartum in non-breastfeeding women and preferably until after 6 months in breastfeeding women. 1, 2

Immediate Postpartum Options (Can Start Right After Delivery)

Progestin-Only Methods

These are the safest and most versatile options for all postpartum women:

• Progestin-only pills (POPs) can be started immediately postpartum in both breastfeeding and non-breastfeeding women (U.S. MEC 1 for non-breastfeeding; U.S. MEC 2 if <1 month postpartum for breastfeeding, U.S. MEC 1 if ≥1 month) 1

  • Require only 2 days of backup contraception if started ≥21 days postpartum when menses has not returned 1
  • Do not affect milk production or infant growth 3, 4
  • If the woman is <6 months postpartum, amenorrheic, and fully/nearly fully breastfeeding (≥85% of feeds are breastfeeds), no additional contraceptive protection is needed 1

• Etonogestrel implant can be inserted at any time postpartum, including immediately after delivery (U.S. MEC 1 for non-breastfeeding; U.S. MEC 2 if <1 month postpartum for breastfeeding, U.S. MEC 1 if ≥1 month) 1

  • Requires 7 days of backup contraception if inserted ≥21 days postpartum when menses has not returned 1
  • No backup needed if woman is <6 months postpartum, amenorrheic, and fully breastfeeding 1

• Intrauterine devices (IUDs) - both copper and levonorgestrel-releasing can be inserted immediately postpartum or at any time thereafter 1, 5

  • Postplacental insertion (within 10 minutes of placenta delivery) requires special training but can reduce unintended pregnancy rates 6, 5

Delayed Initiation: Combined Hormonal Contraceptives

For Non-Breastfeeding Women

Combined oral contraceptives (COCs), patches, and rings are contraindicated for the first 3 weeks postpartum due to significantly elevated venous thromboembolism risk (U.S. MEC Category 4). 2, 7, 8

• At 3 weeks (21 days) postpartum: COCs can be started if the woman has no additional VTE risk factors (U.S. MEC Category 2) 2, 8

  • Require 7 days of backup contraception if started when menses has not returned or if >5 days since menstrual bleeding started 2
  • No backup needed if started within 5 days of menstrual bleeding onset 2

• Women with additional VTE risk factors should generally avoid COCs until after 6 weeks postpartum (U.S. MEC Category 3) 2

For Breastfeeding Women

Combined hormonal contraceptives face additional restrictions beyond VTE concerns due to potential effects on milk production:

• First 3 weeks: Contraindicated (U.S. MEC 4) due to VTE risk 2, 9
• Week 4 (3-4 weeks postpartum): Generally should not be used (U.S. MEC 3) due to potential effects on breastfeeding performance 9
• 1-6 months postpartum: Advantages generally outweigh risks (U.S. MEC 2), but progestin-only methods are preferred 9, 10
• After 6 months postpartum: COCs can be safely initiated as breastfeeding concerns are resolved 9

Critical Clinical Pitfalls to Avoid

Do not wait until the 6-week postpartum visit to initiate contraception in low-risk, non-breastfeeding women—this is a common error. COCs can safely be started at 3 weeks in women without VTE risk factors. 2

For women who desire COCs postpartum and are not breastfeeding: Provide a prescription or supply at hospital discharge with clear instructions to start at exactly 21 days postpartum, and bridge with condoms or another method until then. 2, 7

For breastfeeding women who have return of menses: This signals loss of lactational amenorrhea protection. Progestin-only pills are the preferred oral contraceptive option as they require only 2 days of backup contraception (versus 7 days for COCs) and have no negative effect on milk production. 10

When initiating any hormonal contraception postpartum in women who have not yet had a period: Use backup contraception or abstain from intercourse for the specified duration (2 days for POPs, 7 days for COCs/implants) unless the woman meets criteria for lactational amenorrhea method. 1, 2