What are the recommendations for contraception pills for a postpartum woman, considering her breastfeeding status and medical history?

Postpartum Contraceptive Pill Recommendations

For non-breastfeeding women, start progestin-only pills immediately postpartum or combined oral contraceptives at 21 days; for breastfeeding women, start progestin-only pills immediately but delay combined oral contraceptives until at least 6 weeks postpartum. 1

Non-Breastfeeding Women

Progestin-Only Pills (POPs)

• Can be started at any time postpartum, including immediately after delivery (U.S. MEC Category 1), with no restrictions 1, 2
• Require only 2 days of backup contraception if started ≥21 days postpartum when menses has not returned 1
• If started within 5 days of menstrual bleeding onset, no additional contraceptive protection is needed 3
• Have a typical-use failure rate of approximately 5% (perfect use 0.5%) 2

Combined Oral Contraceptives (COCs)

• Absolutely contraindicated during the first 3 weeks (21 days) postpartum due to significantly elevated venous thromboembolism risk (U.S. MEC Category 4) 1, 4
• Can be started at 21 days postpartum in women without additional VTE risk factors (U.S. MEC Category 2) 1
• Require 7 days of backup contraception if started when menses has not returned or >5 days since menstrual bleeding started 1, 3
• Women with VTE risk factors (age ≥35, previous VTE, BMI ≥30, smoking, thrombophilia) generally should not use COCs until after 6 weeks postpartum (U.S. MEC Category 3) 1, 5

Critical pitfall to avoid: Waiting until the 6-week postpartum visit to initiate contraception in low-risk women is a common error—COCs can safely be started at 3 weeks in women without VTE risk factors 1

Breastfeeding Women

Progestin-Only Pills (POPs)

• Preferred oral contraceptive option for breastfeeding women as they do not affect milk production or infant development 1, 3, 6
• Can be started immediately postpartum (U.S. MEC Category 2 if <1 month postpartum; Category 1 if ≥1 month postpartum) 1, 3
• Require only 2 days of backup contraception if started ≥21 days postpartum when menses has not returned 1
• No backup contraception needed if woman is <6 months postpartum, amenorrheic, and exclusively/nearly exclusively breastfeeding (≥85% of feeds) 1, 3

Combined Oral Contraceptives (COCs)

• Absolutely contraindicated during the first 3 weeks postpartum (U.S. MEC Category 4) due to VTE risk 1
• Generally should not be used during the 4th week postpartum (U.S. MEC Category 3) due to concerns about negative effects on breastfeeding performance and milk production 1
• Should not be used until at least 6 weeks (42 days) postpartum when both VTE risk has normalized and concerns about establishing lactation are minimized 1, 4
• May decrease milk volume, though no detrimental effects on infant growth have been shown 6
• Require 7 days of backup contraception if started >5 days after menstrual bleeding onset 3

Important consideration: The return of menses indicates that the contraceptive protection of exclusive breastfeeding is no longer reliable, and effective contraception is needed 3

Alternative Long-Acting Options (Superior to Pills)

Etonogestrel Implant

• Can be inserted at any time postpartum, including immediately after delivery 7, 1
• Failure rate <0.05% with typical use, making it more effective than oral contraceptives 5, 2
• U.S. MEC Category 1 for non-breastfeeding women; Category 2 if <1 month postpartum for breastfeeding women (Category 1 if ≥1 month) 1
• Requires 7 days of backup contraception if inserted ≥21 days postpartum when amenorrheic 7, 1
• No negative effects on breastfeeding performance or infant health 1

Intrauterine Devices (IUDs)

• Can be inserted immediately postpartum or at any time thereafter 1
• Levonorgestrel IUD: 0.2% failure rate; Copper IUD: 0.8% failure rate 5
• No backup contraception needed at insertion 5
• U.S. MEC Category 1 for non-breastfeeding women; Category 2 if <1 month postpartum for breastfeeding women 1

Clinical recommendation: Long-acting reversible contraception (LARC) methods—specifically the etonogestrel implant or levonorgestrel IUD—are optimal first-line choices for postpartum women, particularly those over 35, due to their superior effectiveness and lack of restrictions regardless of breastfeeding status or VTE risk factors 5