What is the most appropriate first‑line contraceptive method for a postpartum woman, including breastfeeding considerations?

Best Postpartum Contraceptive Method

Long-acting reversible contraception (LARC)—specifically intrauterine devices (IUDs) and the etonogestrel implant—represents the most appropriate first-line contraceptive method for postpartum women, including those who are breastfeeding, due to superior continuation rates, immediate effectiveness, and compatibility with lactation. 1

Why LARC Methods Are First-Line

• The Society for Maternal-Fetal Medicine (SMFM) explicitly recommends that obstetric care providers discuss the availability of immediate postpartum LARC with all pregnant women during prenatal care (GRADE 1C). 1

• LARC methods achieve failure rates of less than 1% with typical use, compared to 6% for depot medroxyprogesterone acetate (DMPA) and 9% for progestin-only pills. 2

• Despite higher expulsion rates with immediate postpartum insertion (24% vs. 2% at 6 months), the 6-month continuation rate is significantly superior with immediate placement (80% vs. 50%; OR 2.04,95% CI 1.01-4.09) because women who delay insertion often miss appointments and never receive contraception. 1

• Immediate postpartum LARC improves overall postpartum contraceptive rates and reduces unintended pregnancy and short interpregnancy intervals. 1

Specific LARC Options and Timing

Copper IUD (Paragard)

• Can be inserted immediately after placental delivery (within 10 minutes) following either vaginal or cesarean delivery, with U.S. MEC Category 1 (no restrictions) for both breastfeeding and non-breastfeeding women. 1, 2

• Provides 10 years of protection with a failure rate of 0.8% with typical use. 2

• Represents the only hormonal-free LARC option and is particularly valuable for women with contraindications to hormonal methods. 1

• Expulsion rates are approximately 10% when placed within 10 minutes of placental delivery. 1

Levonorgestrel IUD (Mirena, Skyla, Liletta)

• Can be inserted immediately postpartum with U.S. MEC Category 2 if less than 1 month postpartum for breastfeeding women (advantages generally outweigh theoretical risks) and Category 1 if ≥1 month postpartum. 2

• Provides 3-5 years of protection depending on the specific device, with a failure rate of 0.2% with typical use. 2

• Despite theoretical concerns about progestin effects on lactation, current evidence from SMFM suggests these methods do not negatively influence breastfeeding performance. 1

Etonogestrel Implant (Nexplanon)

• Can be inserted at any time postpartum, including immediately after delivery, with U.S. MEC Category 2 if less than 1 month postpartum for breastfeeding women and Category 1 if ≥1 month postpartum. 2

• Provides 3 years of protection with a failure rate of less than 0.05%. 2

• Studies have generally found no effects on breastfeeding performance or infant health and growth. 3

• Requires 7 days of backup contraception if inserted 21 days or more postpartum when the woman is amenorrheic. 3

Contraindications to Immediate Postpartum LARC

Absolute Contraindications for IUDs

• Active infection (chorioamnionitis or prenatal sexually transmitted infection without test of cure). 1

• Known uterine cavity anomaly or distorted uterine cavity. 1

• Ongoing postpartum hemorrhage. 1

• Retained placenta requiring manual removal or surgical evacuation. 1

• Current breast cancer (levonorgestrel IUD is U.S. MEC Category 4; copper IUD remains Category 1). 1

• Wilson disease (copper IUD is Category 4; levonorgestrel IUD is acceptable). 1

Absolute Contraindications for Implants

• Current breast cancer (etonogestrel implant is U.S. MEC Category 4). 1

Alternative Progestin-Only Methods for Immediate Use

Progestin-Only Pills (POPs)

• Can be started immediately postpartum in both breastfeeding and non-breastfeeding women (U.S. MEC Category 1 for non-breastfeeding, Category 2 if less than 1 month postpartum for breastfeeding). 3

• Require only 2 days of backup contraception if started 21 days or more postpartum when menses has not returned. 3

• Have a 9% failure rate with typical use, significantly higher than LARC methods. 2

Depot Medroxyprogesterone Acetate (DMPA)

• Can be initiated immediately postpartum with no backup contraception needed. 2

• Has a 6% failure rate with typical use. 2

Why Combined Hormonal Contraceptives Are NOT First-Line

• Combined oral contraceptives, patches, and rings are absolutely contraindicated (U.S. MEC Category 4) during the first 3 weeks postpartum for all women due to markedly elevated venous thromboembolism risk. 3

• For breastfeeding women, combined hormonal contraceptives should be avoided until after 6 weeks postpartum (Category 3 during weeks 3-6) due to concerns about negative effects on lactation performance and milk production. 3

• Estrogen can reduce breast milk volume by interfering with both quantity and quality of milk production. 3

• For non-breastfeeding women without VTE risk factors, combined oral contraceptives become appropriate (Category 2) at 3 weeks postpartum, but this still requires waiting and offers no advantage over immediately available LARC methods. 3

Critical Clinical Pitfalls to Avoid

• Waiting until the 6-week postpartum visit to initiate contraception is a common error that creates unnecessary barriers to access and increases risk of unintended pregnancy. 3

• Failing to offer immediate postpartum LARC before hospital discharge misses a critical window when women are motivated and access is guaranteed. 1

• Concerns about expulsion rates should not deter immediate placement, as the higher continuation rates with immediate insertion outweigh the expulsion risk. 1

• Fundal placement using transabdominal ultrasound guidance decreases expulsion rates and should be utilized when available. 4

Backup Contraception Requirements

• No backup contraception is needed when IUDs or DMPA are inserted/administered. 2

• The etonogestrel implant requires 7 days of backup contraception if inserted 21 days or more postpartum when amenorrheic. 3

• Progestin-only pills require only 2 days of backup contraception when started 21 days or more postpartum without return of menses. 3

Special Consideration: Lactational Amenorrhea Method (LAM)

• LAM is highly effective for the first 6 months postpartum if the mother is exclusively or nearly exclusively breastfeeding (≥85% of feeds), remains amenorrheic, and the baby is less than 6 months old. 2

• Once any of these criteria are no longer met, another contraceptive method must be used immediately. 2

• LAM should be combined with counseling about transitioning to LARC or another method before the 6-month mark. 2