Dr Michelle Cooper (pictured) and Dr Sharon Cameron discuss the importance of post-pregnancy contraception and summarise FSRH recommendations

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Read this article to learn more about:

  • the need for prompt introduction of contraception after pregnancy to avoid unintended conception, and provision of contraception by maternity services
  • particular issues relating to contraception after childbirth, abortion, ectopic pregnancy or miscarriage, and gestational trophoblastic disease
  • UK medical eligibility criteria for contraception in the post-pregnancy setting.

Key points

GP commissioning messages

Interpregnancy intervals (i.e. an interval between a birth and subsequent conception) of less than 12 months are associated with an increased risk of obstetric and neonatal complications, including preterm birth, stillbirth, and neonatal death.1,2 A UK study found that almost 1 in 13 women giving birth conceived within 12 months of a previous pregnancy, and that a similar proportion of women presenting for abortion had become pregnant within a year of a delivery. This suggests that healthcare practitioners may be failing to meet the contraceptive needs of women in the postpartum period.3

During pregnancy women come into contact with a range of healthcare practitioners, providing important opportunities for discussion about, and/or provision of, contraception. Access to effective contraception following pregnancy allows women to plan and space subsequent pregnancies and improve outcomes for themselves and their babies.

FSRH guidance

In January 2017, the Faculty of Sexual and Reproductive Healthcare (FSRH) Clinical Effectiveness Unit (CEU) published the guideline Contraception after pregnancy4 in response to the growing recognition that a woman’s need for effective contraception after pregnancy has previously been underestimated.

In addition to general recommendations about contraception after childbirth, the guidance also provides advice for contraception after:

  • abortion
  • ectopic pregnancy or miscarriage
  • gestational trophoblastic disease.

The FSRH guideline4 recommends that contraceptive prescribing following pregnancy should be in accordance with the FSRH UK medical eligibility criteria for contraceptive use (UKMEC).5 The guideline also recommends that women should be informed during pregnancy about the effectiveness of different contraceptives and, in particular, the superior effectiveness of long-acting reversible contraception (LARC).4 The UKMEC guidance also defines categories for contraceptive methods based on risk (see Table 1, below).

UKMECDefinition of category
Table 1: Definition of UK medical eligibility criteria for contraceptive use categories5
Category 1 A condition for which there is no restriction for the use of the method
Category 2 A condition where the advantages of using the method generally outweigh the theoretical or proven risks
Category 3 A condition where the theoretical or proven risks usually outweigh the advantages of using the method. The provision of a method requires expert clinical judgment and/or referral to a specialist contraceptive provider, since use of the method is not usually recommended unless other more appropriate methods are not available or not acceptable
Category 4 A condition which represents an unacceptable health risk if the method is used

Faculty of Sexual & Reproductive Healthcare (FSRH). UK Medical eligibility criteria for contraceptive use (UKMEC 2016). FSRH, 2016. Available at: www.fsrh.org/ukmec

Reproduced with permission

The FSRH guideline4 emphasises that whenever contraception is discussed, care should be taken to make sure that the woman does not feel under pressure to choose a method of contraception.4 It advises that services should be able to offer all appropriate methods (including LARC) to women before discharge from the service. However, the guideline also recognises that this may not always be possible and, in such circumstances, services should point out to women where their preferred method of contraception can be accessed and offer a temporary ‘bridging’ method until the preferred method can be initiated.4

Contraception after childbirth

Sexual activity and ovulation can resume soon after childbirth, therefore effective contraception should be initiated by day 21 postpartum to reduce the risk of unintended pregnancy and short interpregnancy intervals.4

When to initiate discussion?

During the postpartum period women face additional barriers to accessing contraceptive services, as they have competing demands of recovery from childbirth, infant feeding, and providing care to a newborn. The guideline focuses on increasing the provision of contraception from maternity services. It also highlights that discussion around contraception should be made available to all women during the antenatal period, to enable them to commence their chosen method following birth.

Maternity services should be able to offer the full range of contraceptives, including LARC, after childbirth.4 However, there will be situations where immediate initiation of a woman’s chosen method is not possible or desired, and women will continue to attend primary care services for contraceptive advice and supplies in the postpartum period.4 For example, women choosing to commence combined hormonal contraception (CHC) postnatally, where a bridging method would be initially advised until medical eligibility criteria are met (see Table 2, below);5 or for women who wish to have an implant or intrauterine contraception (IUC) but for whom no trained fitter is available at the time.

ConditionCu-IUDLNG-IUSIMPDMPAPOPCHC
Table 2: Summary of UK medical eligibility criteria for contraceptive use categories applicable to women after childbirth5
Postpartum—breastfeeding
a) 0 to <6 weeks Use independent of breastfeeding status (see below) 1 2 1 4*
b) ≥6 weeks to <6 months 1 1 1 2
c) ≥6 months 1 1 1 1
Postpartum—non-breastfeeding
a) 0 to <3 weeks Use independent of breastfeeding status (see below)  
With other risk factors for VTE 1 2 1 4*
Without other risk factors 1 2 1 3*
b) 3 to <6 weeks  
With other risk factors for VTE 1 2 1 3*
Without other risk factors 1 1 1 2
c) ≥6 weeks 1 1 1 1
Postpartum—breastfeeding/non-breastfeeding, including post-caesarean section
a) 0 to <48 hours 1 1 Use dependent on breastfeeding status
b) 48 hours to <4 weeks 3 3
c) ≥4 weeks 1 1
d) Postpartum sepsis 4* 4*
* restricted method
Cu-IUD=copper intrauterine device; LNG-IUS=levonorgestrel intrauterine system; IMP=progestogen-only implant; DMPA=progestogenonly injectable; POP=progestogen-only pill; CHC=combined hormonal contraception; VTE=venous thromboembolism.

Adapted from: Faculty of Sexual & Reproductive Healthcare (FSRH). UK Medical eligibility criteria for contraceptive use (UKMEC 2016). FSRH, 2016. Available at: www.fsrh.org/ukmec

Reproduced with permission

 

When contraception is initiated within the first 21 days, no additional contraceptive precautions are required. When started after day 21, additional contraceptive cover is required for hormonal methods of contraception.4

Which methods can be used?

Table 2 (see above) summarises the UKMEC during the postpartum period. As can be seen in Table 2, the only hormonal methods that are restricted (marked with an asterisk [*]) during this period are the CHC methods.

Intrauterine contraception

The levonorgestrel intrauterine system (LNG-IUS) or copper intrauterine device (Cu-IUD) can be inserted within the first 48 hours following either a vaginal birth or caesarean section (see Table 2, above). The only contraindication is the presence of sepsis (UK Medical Eligibility Criteria for Contraceptive Use [UKMEC] Category 4).5 Immediate insertion of IUC (i.e. after expulsion of the placenta—post-placental) is not yet universally available across UK maternity units. However, there is ongoing work to offer this in the UK as in many other countries. Insertion after a vaginal birth is generally easy as the cervix is fully dilated.

Insertion at the time of a caesarean section is also straightforward, as the obstetrician is able to place the IUC under direct vision at the fundus via the uterine incision. The myometrium is thick after delivery and perforation is extremely unlikely. Post-placental insertion is convenient for women and is not associated with any higher risk of complications than at any other time.7

In cases when a device cannot be inserted within the first 48 hours after delivery, current advice is that insertion should be delayed until after 4 weeks postpartum (see Table 2, above).4

Combined hormonal methods

The decision to commence CHC (e.g. pill, patch, vaginal ring) in the immediate postpartum period in women without contraindications, is influenced by several factors including:

  • breastfeeding status
  • venous thromboembolism (VTE) risk assessment
  • weeks since delivery.

While the pro-coagulant effects of pregnancy usually normalise by 6 weeks postpartum, there may be concurrent risk factors that could increase the risk of VTE in the presence of CHC. Specific risk factors to consider in this setting include:4

  • immobility
  • transfusion at delivery
  • body mass index (BMI) ≥30 kg/m2
  • postpartum haemorrhage
  • post-caesarean delivery
  • pre-eclampsia or smoking.

In women who are not breastfeeding, CHC should generally be avoided in the first 3 weeks4 postpartum as this is the time period when risk of VTE is greatest. Where additional risk factors for VTE exist, CHC should not be used at all for the first 6 weeks.4,5

In breastfeeding women, CHC should not be used prior to 6 weeks (see Table 2, above). This is due to the theoretical concerns about the effect of CHC on the production and composition of breast milk, and the growth and development of the infant. Evidence on CHC and breastfeeding is extremely limited; however, evidence suggests that when commenced 6 weeks postpartum in breastfeeding mothers, CHC use results in no significant difference in breastfeeding duration, breast milk composition, or infant growth when compared with non-hormonal contraception and progestogen-only contraception.8

Progestogen-only contraception

All of the progestogen-only methods (the progestogen-only pill [POP], implant, or injection) can be used in the postpartum period and can be initiated immediately following childbirth (see Table 2, above).4 Breastfeeding women can be reassured that the evidence indicates that progestogen-only methods have no detrimental effects on lactation, infant growth, or development.4,9

Lactational amenorrhoea method

The lactational amenorrhoea method (LAM) may be a suitable means of contraception provided the following criteria are met. The woman should be:4

  • less than 6 months postpartum
  • amenorrhoeic
  • fully breastfeeding.

In these circumstances, the method is around 98% effective. However, women should be advised that pregnancy risk increases if they are more than 6 months postpartum, if menstruation resumes, or if the frequency of absolute breastfeeding declines. This includes the additional use of pacifiers, milk expressing, discontinuation of night feeds or addition of supplementary feeds.4

Emergency contraception

Emergency contraception is indicated if unprotected sex has taken place after 21 days following childbirth. The Cu-IUD is the most effective form of emergency contraception and can be safely fitted from 28 days after childbirth.4

Both oral methods (levonorgestrel and ulipristal acetate [UPA]) can be used within the standard time frames (i.e. 72 hours post-unprotected sexual intercourse [UPSI] for levonorgestrel and 120 hours post-UPSI for UPA). However, breastfeeding women should be advised not to breastfeed and to express milk for 1 week following use of UPA due to lack of safety data on effects of UPA in breast milk.4

Pregnancy-specific conditions: medical eligibility

There are some pregnancy-specific conditions that can affect medical eligibility for certain contraceptive methods thereafter, as summarised in Table 3 (below). Generally, progestogen-only methods may be used in most circumstances, as discussed above.5

Contraception after abortion

Evidence shows that women value the opportunity to discuss contraception before abortion and appreciate being supplied with their chosen method after the procedure.10 The FSRH guideline recommends that abortion services should be able to provide all forms of contraception prior to discharge, including LARC.4

Most women ovulate in the month after an abortion.11 As summarised in Table 4 (below), most methods of contraception can be started immediately after uncomplicated medical or surgical abortion. When commenced within the first 5 days following an abortion, no additional contraceptive precautions are required.

Post-abortion or miscarriage (<24 weeks)Cu-IUDLNG-IUSIMPDMPAPOPCHC
Table 4: UK medical eligibility criteria for contraceptive use categories applicable to a woman following an abortion, miscarriage, or ectopic pregnancy5
a) First trimester 1 1 1 1 1 1
b) Second trimester 2 2 1 1 1 1
c) Post-abortion/postpartum sepsis 4 4 1 1 1 1
Past ectopic pregnancy 1 1 1 1 1 1
Cu-IUD=copper intrauterine device; LNG-IUS=levonorgestrel intrauterine system; IMP=progestogen-only implant; DMPA=progestogen-only injectable; POP=progestogen-only pill; CHC=combined hormonal contraception.

Adapted from: Faculty of Sexual & Reproductive Healthcare (FSRH). UK Medical eligibility criteria for contraceptive use (UKMEC 2016). FSRH, 2016. Available at: www.fsrh.org/ukmec

Reproduced with permission

Contraception after miscarriage and ectopic pregnancy

The FSRH guideline advises that fertility intentions and need for contraception should be discussed with women experiencing an early pregnancy loss.4 If a woman wishes to delay or prevent a further pregnancy, contraception should be initiated as soon as possible.4 For those wishing to conceive, recent evidence supports a higher chance of successful pregnancy outcome in the initial 6 months following a miscarriage and, as such, there is no need to delay attempts to conceive.1,4

Most contraceptive methods can be safely commenced after an early miscarriage or ectopic pregnancy. The method-specific guidance following abortion, as summarised in Table 4 (see above), can also be applied in these settings. Contrary to popular myth, a previous ectopic pregnancy does not preclude the use of IUC. Indeed, IUC is a good option, as it is one of the most effective methods of preventing further pregnancy and can be inserted at the time of medical or surgical management of an ectopic pregnancy.4

Special circumstances

If a woman has experienced recurrent miscarriage (three or more consecutive pregnancy losses), referral and investigation by specialist services is advised. The use of CHC should be avoided until antiphospholipid syndrome has been excluded.4

For women treated medically with methotrexate for ectopic pregnancy, effective contraception should be continued for 3 months after treatment due to the teratogenic potential of this drug.4

Contraception after gestational trophoblastic disease

Following diagnosis of gestational trophoblastic disease (GTD), women are followed up by specialist services until serum levels of human chorionic gonadotrophin (hCG) return to normal after treatment. Further pregnancy should be avoided until hCG monitoring is complete, and the woman’s chosen method of contraception should therefore be started as soon as possible.4 The risk of disease recurrence is related to the degree of previous GTD and therefore the recommended duration to avoid pregnancy after treatment varies (see Table 5, below)

Most contraceptive methods can be started immediately after initial surgical management, except for IUC, which should be avoided in confirmed GTD until hCG levels have returned to normal. Insertion should then be carried out in a specialist setting.4 Recent evidence shows that use of oral contraceptives immediately after GTD is safe and does not have any adverse effect on risk of disease progression (UKMEC Category 1).5,12

Contraception in primary care

Advising on contraception remains an important role for primary care physicians throughout a woman’s life course and many women will continue to seek advice from their GP. It is important that GPs are kept up to date with the rapid developments in this area.

Women may also seek assistance from primary care clinicians in relation to a contraceptive method already commenced within a hospital setting. This may be of particular importance for IUC inserted after childbirth in a hospital setting; the woman may present for an IUC thread check and be found to have non-visible threads (ultrasound will be needed to confirm if the IUC is still in situ). Clear communication and referral pathways should exist between primary care, hospital, and community sexual health services to ensure appropriate management in such cases.

Summary

The FSRH guideline on Contraception after pregnancy aims to provide a consistent approach to contraceptive care from the wide range of healthcare providers that a woman encounters before, during, and after a pregnancy. By equipping healthcare professionals with the most up-to-date guidance on post-pregnancy contraception, they can support women to make an individual and informed choice.

 

Key points

  • Adequate birth spacing (minimum 1 year) is recommended to reduce the risk of preterm birth, low birthweight babies, and perinatal mortality
  • Intrauterine contraception (LNG-IUS and Cu-IUD) can be safely inserted immediately after birth, or within the first 48 hours after uncomplicated Caesarean section or vaginal birth. Beyond 48 hours, insertion should be delayed until 4 weeks following birth
  • All women should undergo a risk assessment for VTE during the postnatal period—CHC should be avoided for the first 6 weeks after childbirth by women who have additional risk factors for VTE
  • Women who are not breastfeeding and are without additional risk factors for VTE can commence a CHC method from 21 days after childbirth
  • Progestogen-only methods of contraception (pill, implant, or injection) can be safely started at any time after childbirth, including immediately following birth
  • The lactational amenorrhoea method (LAM) is an effective method of contraception provided the woman is less than 6 months postpartum, amenorrhoeic, and fully breastfeeding
  • Emergency contraception is indicated for women who have unprotected sexual intercourse in the following post-pregnancy situations:
    • after 21 days following childbirth
    • after 5 days following abortion/miscarriage
    • after 5 days following medical or surgical treatment for ectopic pregnancy
  • A woman’s chosen contraception method should ideally be initiated at the time of abortion or soon after, as sexual activity and ovulation can resume very soon after abortion
  • Women who wish to conceive after miscarriage can be advised there is no need to delay, as successful pregnancy outcomes after miscarriage are more favourable when conception occurs within the subsequent 6 months
  • Following treatment with methotrexate for ectopic pregnancy, women should be advised that effective contraception is recommended for at least 3 months due to potential teratogenic effects.

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GP commissioning messages

written by Dr David Jenner, GP, Cullompton, Devon

  • Women should be informed about the increase in adverse outcomes associated with interpregnancy intervals of less than 12 months
  • There are several options for contraception after pregnancy and some of these require discussion and decision during pregnancy, especially LARC
  • Commissioners should ensure maternity providers:
    • include discussion about contraception in their antenatal care protocols
    • can provide IUC insertion post delivery
  • GPs should receive education in the different options for immediate postnatal contraception:
    • a locally designed information leaflet for GPs and patients could be used to inform shared decision making
  • Discussion about contraception methods should be built into postnatal care pathways for midwives and health visitors so decisions can be made before the traditional GP 6-week postnatal check
  • Commissioners should ensure that patients receive prompt contraceptive advice before and immediately after an abortion or early pregnancy complication as fertility can return quickly.

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References

  1. Bigelow C, Bryant A. Short interpregnancy intervals: an evidence-based guide for clinicians. Obstet Gynecol Surv 2015; 70 (7): 458–464.
  2. Smith G, Pell J, Dobbie R. Interpregnancy interval and risk of preterm birth and neonatal death: retrospective cohort study. BMJ 2003; 327: 313–318.
  3. Heler R, Cameron S, Briggs R et al. Postpartum contraception: a missed opportunity to prevent unintended pregnancy and short inter-pregnancy intervals. J Fam Plann Reprod Health Care 2016; 42 (2): 93–98.
  4. Faculty of Sexual & Reproductive Healthcare (FSRH). Contraception after pregnancy. FSRH, 2017. Available at: www.fsrh.org/standards-and-guidance/documents/contraception-after-pregnancy-guideline-january-2017/ (accessed 7 April 2017).
  5. Faculty of Sexual & Reproductive Healthcare (FSRH). UK Medical eligibility criteria for contraceptive use (UKMEC 2016). FSRH, 2016. Available at: www.fsrh.org/ukmec (accessed 7 April 2017).
  6. Jackson E, Glasier A. Return of ovulation and menses in postpartum nonlactating women: a systematic review. Obstet Gynecol 2011; 117 (3): 657–662.
  7. Sonalkar S, Kapp N. Intrauterine device insertion in the postpartum period: a systematic review. Eur J Contracept Reprod Health Care 2015; 20 (1): 4–18.
  8. Lopez L, Grey T, Stuebe A, et al. Combined hormonal versus nonhormonal versus progestin-only contraception in lactation (review). Cochrane Database Syst Rev 2015; 3: CD003988
  9. Phillips S, Tepper N, Kapp N, et al. Progestogen-only contraceptive use among breastfeeding women: a systematic review. Contraception 2016; 94 (3): 226–252.
  10. Purcell C, Cameron S, Lawton J et al. Contraceptive care at the time of medical abortion: experiences of women and health professionals in a hospital or community sexual and reproductive health context. Contraception 2016; 93 (2): 170–177.
  11. Schreiber C, Sober S, Ratcliffe S, Creinin M. Ovulation resumption after medical abortion with mifepristone and misoprostol. Contraception 2011; 84 (3): 230–233.
  12. Braga A, Maestá I, Short D, et al. Hormonal contraceptive use before hCG remission does not increase the risk of gestational trophoblastic neoplasia following complete hydatidiform mole: a historical database review. BJOG 2016; 123 (8): 1330–1335