What are the recommended contraception methods for postpartum (puerperal) women?

Postpartum Contraception Recommendations

Immediate Postpartum Options (All Women)

Progestin-only methods and IUDs can be initiated immediately after delivery and are the preferred first-line options for postpartum contraception, while combined hormonal contraceptives must be delayed based on breastfeeding status and VTE risk. 1, 2

Long-Acting Reversible Contraception (LARC) - Highest Efficacy

• Etonogestrel implant (Nexplanon) can be inserted immediately postpartum, including before hospital discharge, with no restrictions (U.S. MEC Category 1 for non-breastfeeding women; Category 2 if <21 days postpartum for breastfeeding women). 1, 2

  • Requires 7 days of backup contraception if inserted ≥21 days postpartum when menses has not returned. 2
  • Failure rate <0.05% with typical use. 1

• Levonorgestrel IUD (Mirena) can be inserted immediately postpartum (Category 1 if inserted <10 minutes after placental delivery; Category 2 if inserted later in first 21 days). 1, 2

  • After 30 days postpartum, becomes Category 1 for all women. 1
  • Failure rate 0.2% with typical use. 1

• Copper IUD (Paragard) follows same timing guidelines as levonorgestrel IUD and provides 10 years of protection. 1

  • Can also serve as emergency contraception if inserted within 5 days of unprotected intercourse. 1
  • Failure rate 0.8% with typical use. 1

Progestin-Only Pills

• Can be started immediately postpartum in both breastfeeding and non-breastfeeding women (U.S. MEC Category 1 for non-breastfeeding; Category 2 if <21 days for breastfeeding). 1, 2
• Require only 2 days of backup contraception if started ≥21 days postpartum when menses has not returned. 2, 3
• Do not affect milk volume or composition. 3, 4

Depot Medroxyprogesterone Acetate (DMPA/Depo-Provera)

• Can be initiated immediately postpartum (U.S. MEC Category 1 for non-breastfeeding; Category 2 if <21 days for breastfeeding). 1
• Failure rate 6% with typical use. 1

Combined Hormonal Contraceptives - Timing Algorithm

Non-Breastfeeding Women

Combined hormonal contraceptives (pills, patch, ring) are absolutely contraindicated for the first 21 days postpartum due to elevated VTE risk (U.S. MEC Category 4). 1, 2

• Days 0-20: Contraindicated (Category 4) - unacceptable health risk. 1, 2

• Days 21-29:

  • Without VTE risk factors: Can initiate (Category 2) - advantages generally outweigh risks. 1, 2
  • With VTE risk factors: Generally should not use (Category 3) - risks usually outweigh advantages. 1, 2

• Days 30-42:

  • Without VTE risk factors: Can initiate (Category 2). 1
  • With VTE risk factors: Generally should not use (Category 3). 1, 2

• After 42 days: No restrictions (Category 1) for otherwise healthy women. 1, 5

Common VTE risk factors include: age ≥35 years, previous VTE, thrombophilia, immobility, transfusion at delivery, BMI ≥30 kg/m², postpartum hemorrhage, post-cesarean delivery, preeclampsia, or smoking. 1

Breastfeeding Women

Breastfeeding women should avoid combined hormonal contraceptives until at least 6 weeks postpartum, preferably waiting until after 6 months. 2, 3, 6

• Days 0-20: Contraindicated (Category 4) due to VTE risk. 2, 6

• Days 21-29: Generally should not use (Category 3) due to potential negative effects on breastfeeding performance and milk production. 1, 2, 6

• Days 30-42:

  • Without VTE risk factors: Generally should not use (Category 3) due to lactation concerns. 1, 2
  • With VTE risk factors: Generally should not use (Category 3). 1, 2

• After 42 days to 6 months: Advantages generally outweigh risks (Category 2), but progestin-only methods remain preferred. 2, 6

• After 6 months: Combined hormonal contraceptives become fully appropriate (Category 2) as concerns about milk production and infant hormone exposure are resolved. 6

Backup Contraception Requirements

When Starting Combined Hormonal Contraceptives

• Use backup contraception or abstain for 7 days if starting when menses has not returned or if >5 days since menstrual bleeding started. 1, 2, 3
• No backup needed if starting within 5 days of menstrual bleeding onset. 2

When Starting Progestin-Only Methods

• Progestin-only pills: 2 days of backup if started ≥21 days postpartum when menses has not returned. 2, 3
• Etonogestrel implant: 7 days of backup if inserted ≥21 days postpartum when menses has not returned. 2
• IUDs and DMPA: No backup contraception needed. 1

Critical Clinical Pitfalls to Avoid

Waiting until the 6-week postpartum visit to initiate contraception in low-risk, non-breastfeeding women is a common error. 2

• Combined hormonal contraceptives can safely be started at 3 weeks (21 days) in non-breastfeeding women without VTE risk factors. 2
• Progestin-only methods and IUDs can be initiated immediately, removing barriers to care and preventing unintended pregnancy during the early postpartum period. 1, 2
• Immediate postpartum insertion of implants or IUDs (before hospital discharge) is safe, effective, and strongly supported by ACOG and CDC. 1