INTRODUCTION

Family planning is a highly effective public health intervention that saves lives. Globally 214 million women would like to prevent or delay pregnancy but have no access to contraception.¹ Postnatal family planning is an important strategy for meeting unmet need for contraception, and reducing child and maternal morbidity and mortality. Short inter-pregnancy intervals increase the risk of preterm birth, low birth weight, stillbirth, and neonatal death.^2,3 Meeting the global unmet need for contraception would prevent one third of maternal deaths from obstetric complications or unsafe abortion and prevent 1 in 10 child deaths if pregnancies are spread more than 2 years apart.^4,5 Globally 40% of pregnancies are unplanned.

The World Health Organization recommends a 24 month inter-pregnancy interval after delivery.⁶ Worldwide more than 9 out of 10 women want to avoid pregnancy for 2 years after having had a baby, but 1 in 7 of them are not using contraception. This means that pregnancies soon after childbirth are not uncommon and many of these are unplanned. Provision of postnatal family planning is therefore vitally important but is often ignored and a number of biases and misconceptions limit its availability.

Childbirth presents an opportunity for providing contraception, as women have contact with healthcare providers with the skills to offer a full range of methods, and are often highly motivated to start using an effective method. There is a window of opportunity in the first 48 hoursours postpartum when most methods can be used effectively, followed by a “wait” period for some methods, until 4–6 weeks postpartum (see Figure 2).

RETURN OF FERTILITY IN NON-BREASTFEEDING WOMEN

Following the delivery of the placenta, levels of oestrogenestrogen and progesterone fall and follicle-stimulating hormone (FSH) and luteinising hormone (LH) gradually rise, allowing ovulation to recommence. Ovulation in a non-breastfeeding woman occurs around 4–7 weeks (average 45 days) after delivery. The woman’s first menses will then occur 2two weeks after this. Many women start to become sexually active following birth before this time; a UK study found that 32% of women had resumed sexual activity by 6 weeks postpartum.⁷ It is therefore possible to become pregnant again before menstruation occurs. In order to prevent this from happening, contraception needs to be started by 3 weeks after delivery (see Figure 1).

It is important to note that ovulation can occur as early as 8 days after first- or second- trimester miscarriage, abortion or ectopic pregnancy. Therefore, if these women wish to delay or prevent future pregnancies, contraception should be started within 5 days.

Exclusive breastfeeding suppresses LH secretion, meaning that the menstrual cycle may not resume until 6 months, or even later, after delivery. Some women may choose to rely on breastfeeding initially for contraception. They can be advised that this is around 98% effective contraception in the first 6 months after delivery, as long as conditions for the lLactational aAmenorrhea mMethod (LAM) are met (see below).

It is important to discuss and plan contraception options with the woman before this 6 month period is over (or earlier if any of the above criteria are no longer fulfilled.

Family planning can be integrated with other sSexual rReproductive hHealth services, e.g. childbirth, infant and child immunization, HIV/STI testing and treatment, cervical screening, and assessment for gender-based violence.

TIMING OF CONTRACEPTION PROVISION

Immediate postpartum contraception is beneficial in terms of convenience for the woman and is particularly important in situations where women may have difficulties accessing healthcare providers and facilities. Immediate postpartum contraception ensures that the woman can start the method before her first ovulation. When contraception provision is delayed, women are less likely to access it⁹ and may then be at risk of unplanned pregnancy and short inter-pregnancy intervals.

Whilst the majority of contraceptive methods can be started immediately postpartum, some can not and some women may decline immediate provision, but decide to commence contraception at a later date. Furthermore, advice varies for some methods according to whether the woman is breastfeeding or not. The chart below depicts the timings for initiating different methods.

If any method is started later than 3 weeks postpartum, the practitioner should be reasonably certain that the woman is not pregnant or at risk of pregnancy due to recent unprotected sex. If there is a recent risk of pregnancy, emergency contraception should be considered, in the form of either oral hormonal emergency contraception (levonorgestrel or ulipristal acetate) or the Copper intrauterine contraceptive device (Cu-IUC). However, ulipristal acetate is excreted in breastmilk and there is uncertainty about the safety for neonates. Women are therefore advised not to breastfeed for 1 week after use, or to express and discard milk for this time.⁸ In situations where women are currently breastfeeding it therefore may be more appropriate to avoid ulipristal acetate and rather offer levonorgestrel emergency contraception when an oral method is desired.

COUNSELLINGCOUNSELING A WOMAN ABOUT CONTRACEPTION

Discussions about postnatal family planning and contraceptive options should ideally start in the antenatal period. Firstly, because many methods can be provided at the time of delivery (particularly the intrauterine contraceptive methods) or in the immediate postpartum period while the women is still in the birthing facility. Secondly, prior to delivery, women may have more time to consider their options.

Contraceptive counsellingcounseling should be non-judgmental and promote informed decision-making for the woman to decide on her preferred contraceptive options.

Information and postnatal family planning can be provided during one-to-one appointments, group counsellingcounseling sessions, and through posters and leaflets.

How to ensure opportunities for postnatal family planning counseling are not missed

Postnatal family planning should be discussed at every opportunity and if possible the discussion should start while the woman is still pregnant so that she is able to start her chosen method as soon as possible after delivery.

In the antenatal clinic

• Women should be given verbal and written information about all contraceptive options and told about the particular benefits of postnatal family planning, particularly of intrauterine contraceptives (IUC) and implants, as the most effective methods.
• For women who are considering limiting their family size, it may be appropriate to discuss vasectomy or female sterilisationsterilizationsterilization with the woman and her partner at this time.
• For women who are considering limiting their family size and undergoing a planned caesareancesarean section, the possibility of concurrent tubal ligation should be discussed.
• Women should be given the opportunity to ask questions about contraception every time they are seen in the antenatal clinic.
• The method that the woman has chosen should be documented in the appropriate case record so that it can be provided as soon as possible after childbirth.
• If hormonal pills or barrier methods are chosen, these could be provided during late pregnancy so that women have a supply at home to start at the appropriate time after childbirth.

In the labourlabor ward

• Women should be asked whether they have received contraceptive advice antenatally and, if so, the method they have chosen should be confirmed and then provided unless complications during pregnancy or delivery indicate the need for review.
• If the chosen method is not available in the labourlabor ward, the method should be provided before the woman leaves the hospital or she should be referred to the most convenient place where the contraceptive method can be provided.
• Contraception should not be discussed with a woman who is in active labourlabor.
• In women having a caesareancesarean section, intrauterine contraceptives can be fitted as soon as the placenta has been delivered. Insertion is simple and expulsion rates are low.

In the postnatal ward

• If a woman has not had the chance to discuss contraception before she arrives on the postnatal ward, it should be discussed with her before she leaves the hospital and her chosen method (including an implant, or an intrauterine contraceptive if within 48 hours of delivery) should be provided.

In the postpartum care clinic

• Women attending for postpartum care should be asked whether they are using, or have a supply of, contraception.
• It should be confirmed with women who have chosen their method that they are happy with their choice, are knowledgeable about the method, have sufficient supplies and know where they can get more (if appropriate).
• If a woman has not chosen a contraceptive method, she should be told about all methods, particularly the most effective methods, and arrangements made to provide her with the method she has chosen.

In the baby immunisationimmunizationimmunization clinic

• Women bringing their babies for immunisationimmunizationimmunization should be asked whether they are using contraception.
• It should be confirmed with women who have chosen their method that they are happy with their choice, are knowledgeable about the method, have sufficient supplies and know where they can get more (if appropriate).
• If a woman is not using contraception, she should be told about all methods, particularly the most effective methods, and arrangements made to provide her with the method she has chosen.

WHAT DO WOMEN NEED TO KNOW ABOUT POSTNATAL CONTRACEPTION?

Effectiveness and correct use

It is important that women are advised about the range of contraceptive options available to them. Provided the options are medically safe and suitable, the woman should be free to choose the method she wishes. Many factors influence a woman’s choice of contraceptive method; effectiveness is often one of the most important factors. The World Health Organization (WHO) therefore recommends providing information about different methods using a tiered effectiveness model, which gives information about methods in terms of the effectiveness of each method.¹¹ With no method of contraception, approximately 85% of women who are regularly sexually active will become pregnant within 1 year. Figure 3 depicts the effectiveness of different methods, comparing the percentage of women who will become pregnant by the end of 1 year with typical and perfect use. Perfect use refers to what happens when the method is used correctly 100% of the time, whereas typical use refers to what happens in reality when the method may be used incorrectly or inconsistently by some women. The top line of Figure 3 shows that for these methods, the typical and perfect use is either the same or very similar; this is because these methods do not rely on the user to remember something, e.g. taking a pill each day or using a condom every time they have sex. WHO have a pictorial version of this chart, which can be useful for discussions with patients.¹¹

Safety of different contraceptive methods (mMedical eligibility)

When thinking and talking about family planning methods, it is important to remember that you are advising someone to use a method in order to avoid pregnancy. While many people worry about the theoretical risks of contraception, it is always the case that the risks of pregnancy and childbirth are greater than those associated with contraception. So, for example, the most common serious risk among all the methods of family planning is the risk of blood clots [(venous thromboembolism (VTE)]) among women taking the combined oral contraceptive pill (COCP). It is true that women who take the COCP have double or triple the risk of getting a VTE compared with women who are not taking the pill, but the risk of VTE in pregnancy is five times higher and in the postpartum period it is 60 times higher than in a woman who is not pregnant. It is also important to remember that, while it sounds serious to say that the risk of something is doubled or tripled, if the risk is only 1 in 1,000 then doubling or tripling it only makes it 2 or 3 in 1,000, so 997 women are not at risk. Quite apart from the medical risks associated with unintended pregnancy, whether the pregnancy is continued or not, it also carries profound social, economic, and emotional consequences.

All methods of contraception are associated with side effects: most of them are simply a nuisance but they often result in the woman stopping the method unless you can reassure her that the side effects are not dangerous and putting up with them is better and safer than being pregnant when she does not want to be.

Very rarely, the theoretical or known risks of a method will outweigh the benefits of that method for a particular woman.

The World Health Organization’s Medical Eligibility Criteria for contraceptive use (MEC)¹² provides guidance to practitioners regarding the use of various contraceptive methods in the context of a variety of health conditions and characteristics. It primarily considers whether the contraceptive method could worsen the health condition or create additional risks, and secondarily whether the health condition may make the contraceptive method less effective. The contraceptive method is then given a category according to that health condition (see below).

The WHO have produced MEC tables and wheels that which can be used to work out the category for a particular contraceptive method for a woman but it should be remembered that, even if a woman has a condition that is categorisedcategorized as 3 for a particular method, if there is no other method available or acceptable thean she can still use it. For example, if a woman has breast cancer, she should not take the combined pill but actually pregnancy would be a far greater risk for her.

A medical history should be taken from all women and their medical eligibility checked. This will need to be checked again if labourlabor or delivery is complicated (e.g. puerperal sepsis). There should be no restrictions on provision of any method based on age, parity, or the number of children a woman has had, unless there is a medical reason.

MOST EFFECTIVE CONTRACEPTIVE METHODS

Long-acting rReversible mMethods

Progestogen-only subdermal implants and intrauterine contraceptives (IUC) are highly effective reversible methods of contraception and are referred to together as long- acting reversible contraceptives (LARCs). The provision of LARC immediately after childbirth has been shown to be associated with a reduced risk of unintended pregnancy.¹³

Implants

The progestogen-only subdermal implant works primarily by inhibiting ovulation and can be started any time following childbirth (Figure 4). Subdermal implants are effective for 3–5 years, depending on the implant. They are usually inserted in the upper arm. There are a range of different implants, the two of the most commonly used worldwide are an implant containing etonorgestrel that lasts 3 years and comes as one rod (e.g. Nexplanon) and an implant containing levonorgestrel that lasts 5 years and comes as two rods (e.g. Jadelle). The insertion procedure for Nexplanon is summarisedsummarized below. The most common side effect is an irregular bleeding pattern. Fertility returns immediately after removal.

Checklist for implant insertion

Below is a checklist of the steps involved in inserting the implant Nexplanon according to the manufacturer’s guidance. Steps for insertion of other devices will differ. This checklist should only be used in conjunction with practical training.

Intrauterine contraceptives (IUC)

Intrauterine contraceptive methods, both the Copper-releasing IUC (Cu-IUC) and the levonorgestrel-releasing IUC (Lng-IUC) (e.g. Mirena®, Levosert®, Kyleena®, Jaydess® etc.), can be inserted immediately after delivery of the placenta (0–48 hours) (Figure 5). This can either be at the time of CaesareancCesarean section or following vaginal delivery. Due to a lack of evidence for the safety of insertion between 48 h and 4 weeks, it is recommended insertion is avoided during this time. The insertion of IUC within the first 48 hours after childbirth is associated with an increased risk of expulsion of the device, but also higher continuation rates at 6–12 months postpartum.^13,14 The insertion technique within 48 hours of delivery differs from insertion in the non-postnatal period. See table below for a step-by-step checklist for insertion of IUC within the first 48 hours after delivery. Insertion at the time of CaesareancCesarean section can be performed by placing the device with the sterile gloved hand at the uterine fundus prior to closure. Insertion following vaginal delivery requires different equipment and training for insertion due to the enlarged uterus, compared to interval insertion (after 4–6 weeks). Insertion is most effective when performed using long placental forceps.¹⁴

IUC work through a mixture of both pre- and post-fertilisationfertilizationfertilization effects. Cu-IUC are effective for 5–10 years, depending on the device. The most common side effect is heavier or more painful menstruation. Return of fertility is immediate following removal. Lng-IUC are effective for 3–5 years, depending on the device. The most common side effect is lightened, or no bleeding, occasionally the bleeding may be heavier or more frequent in the first few months following insertion.

Checklist for insertion of intrauterine contraception

Below is a checklist of the steps involved in inserting intrauterine contraception within the first 48 hoursours after delivery. This checklist should only be used in conjunction with practical training.

Permanent methods

Both female sterilisationsterilizationsterilization and vasectomy can be safely performed at any time postnatally. However, there is an increased risk of regret when sterilisationsterilizationsterilization is requested in association with pregnancy. This is particularly the case when female sterilisationsterilizationsterilization is performed at the time of CaesareancCesarean section and the women has felt pressurized into it by their healthcare provider.^15,16 If sterilization is considered during the antenatal period, newborn survival rates should be discussed.

EFFECTIVE CONTRACEPTIVE METHODS

The lactational amennorhea method is effective in the first six months postpartum if the woman is breastfeeding exclusively, see above.

Progestogen-only injectable contraceptives and pills

Progestogen-only injectable contraceptives are provided by either the subcutaneous or intramuscular route and work primarily by inhibiting ovulation. Depot (intramuscular) and subcutaneous medroxyprogesterone acetate both last 13 weeks and norethisterone enanthate lasts 8 weeks. The WHO recommends that the risks may outweigh the benefits of providing the progestogen-only injectable before 6 weeks postpartum in breastfeeding women due to a theoretical concern regarding exposure of the neonate to DPMA/NET-EN.¹² However, other organisationsorganizations, including the Faculty of Sexual and Reproductive Healthcare and the Royal College of Obstetricians and Gynaecologists disagree with this advice and advise provision any time following childbirth is acceptable.^8,10 The typical failure rate of 6% with injectable contraceptives is usually due to failure to get a repeat injection within the correct timescale. Amenorrhea is common with long-term use, with around 70% of women amenorrheic after 1 year of use. There may be a delay in the return of fertility with the use of this method of up to 1 year.

The progestogen-only pill can be started any time following childbirth. Traditional progestogen only pills primarily work by thinning the uterine endometrium and thickening cervical mucus, whereas newer desogestrel -containing pills also inhibit ovulation in most users. Traditional progestogen- only pills should be taken within 3 hoursours of the same time every day, whereas the desogestrel progestogen only pill should be taken within 12 hoursours of the same time every day. This requirement to remember a pill every day is the reason that both progestogen- only and combined pills have a typical failure rate of 9%. Progestogen- only pills may cause irregular bleeding patterns or amenorrhea. Fertility returns immediately once the woman ceases to take them.

Combined hormonal contraception

Combined hormonal contraception (CHC) works primarily by suppressing ovulation, due to exerting feedback on the hypothalamo-pituitary-ovarian axis resulting in suppression of LH and FSH. CHC can be administered orally (pills), transdermally (patches) or vaginally (vaginal ring). Patches are replaced weekly, vaginal rings every 3 weeks and pills are required to be taken every day. Traditionally, combined methods were designed to be taken for 3 weeks, followed by a 1 week break to allow the woman to have a regular withdrawal bleed. However, there is now guidance that allows women to take them in an extended format, which allow women to reduce the frequency of, or eliminate entirely, their withdrawal bleeds.¹⁷ Fertility returns immediately once the woman ceases to take CHC.

CHC, including the combined oral hormonal contraceptive pill (COCP) carries a risk of venous thromboembolism (VTE) and therefore should not be started prior to 3 weeks postpartum. In non-breastfeeding women, it may be started at, or after, 3 weeks postpartum as long as the woman does not have any additional risk factors for VTE, if she has additional risk factors for VTE, initiation should be delayed to 6 weeks postpartum. In breastfeeding women, initiation prior to 6 weeks is MEC 4, and between 6 weeks and 6 months MEC 3. This is due to inconsistent evidence regarding effects on breastfeeding continuation or exclusivity and a lack of evidence regarding long-term effects of oestrogenestrogen on the neonate.¹²

LESS EFFECTIVE CONTRACEPTIVE METHODS

Barrier methods

Male and female condoms can be used at any time postnatally and have the benefit of protecting against sexually transmitted infections. However, they have a high typical failure rate for pregnancy prevention due to the requirement for them to be used correctly and consistently for every episode of sexual intercourse. Women may wish to use both condoms and another, more effective contraceptive method together to give dual protection against pregnancy and sexually transmitted infections. Diaphragms also have a high typical use failure rate and do not protect against sexually transmitted infections. Their use should be delayed until 6 weeks after delivery when uterine involution is complete.

Fertility awareness methods

Fertility awareness methods include a variety of different techniques used by women to identify when in their cycle they are most and least likely to be fertile. They have a relatively high failure rate with typical use. Furthermore, they are not appropriate for use in the immediate postnatal period as the woman needs to have completed at least three3 or four4 menstrual cycles first.

FOLLOW UP FOR WOMEN USING CONTRACEPTION

Women who receive contraception should be followed up to ask about satisfaction with the method and side-effects. This is predominantly led by the women for LARCs, and COCPs can be provided in up to 1 year’s supply at a time. Follow-up for progesterone-only injectables can be at the time of the next injection. In some countries, including the UK, some women have been taught to self administer the injectable Sayana Press every 13 weeks (subcutaneous medroxyprogesterone acetate) and then a year’s supply of injectables may be provided at a time. Specific training  is needed for some methods, such as IUC string checks for women who attend with problems or concerns about their IUC.

PRACTICE RECOMMENDATIONS