INTRODUCTION — The postpartum period is an ideal time to access contraception services, as women are known to not be pregnant, they are likely motivated to initiate contraception, and are under the care of medical providers with the appropriate expertise. Counseling involves understanding a patient's wishes regarding future pregnancy, her preferences regarding contraceptive options, and the characteristics and attributes of the contraceptive methods themselves. Additional medical considerations include timing of contraceptive start after delivery, medical comorbidities, and breastfeeding status.

This topic will review the available data and guidelines surrounding counseling women about contraceptive selection and initiation in the postpartum period. Related information on contraceptive counseling and selection in general is presented separately. (See "Contraception: Counseling and selection".)

RESUMPTION OF OVULATION — In a systematic review of studies estimating the time to return to fertility in nonlactating postpartum women, the average time to first ovulation varied from 45 to 94 days postpartum, with the earliest reported ovulations at 25 and 27 days postpartum [1]. Although many first ovulations will be subfertile, some of the reported ovulations were estimated to be fertile, which highlights the importance of timely initiation of contraception postpartum. To address contraception and other acute postpartum needs in a timely way, postpartum follow-up within two to three weeks is advised [2]. Studies have documented wide variation in the percentage of women who attend the six-week postpartum visit (65 to 90 percent) [3]. In addition, a significant proportion of women, up to 51 percent in one study, will resume sexual activity before the six-week postpartum visit [1,4,5].

INTERPREGNANCY INTERVAL AND ROLE OF CONTRACEPTION ACCESS — Based on studies reporting adverse maternal, perinatal, and infant outcomes with shorter interpregnancy intervals (IPI; the interval between a live birth and conception of another pregnancy), the World Health Organization advises an interval of at least 24 months [6-9]. Similarly, the American College of Obstetricians and Gynecologists advises that women should be counseled to avoid IPIs shorter than six months and be counseled about the risks and benefits of repeat pregnancy sooner than 18 months [2]. Adverse outcomes with short IPIs have been reported in both low- and high-resource settings, although data from studies in higher resource settings reported weaker associations between adverse outcomes and IPIs greater than six months as compared with intervals less than six months [7]. Despite these recommendations, international estimates of the unmet need for postpartum contraception are as high as 62 percent in the first year following childbirth [10-12]. (See "Interpregnancy interval: Optimizing time between pregnancies".)

From a public health perspective, IPI is clearly associated with the effectiveness of the postpartum contraceptive method; women who use less effective methods are more likely to have shorter IPIs [13-15]. Conversely, initiation of one of the most effective contraceptives after delivery, including sterilization and long-acting reversible contraception (LARC), is associated with an 80 percent lower hazard of having a repeat delivery within 27 months compared with women who did not initiate contraception [13]. Further, health policies that mandate insurance coverage of postpartum LARC are associated with increased rates of LARC usage and a subsequent decrease in short-interval births among adult and adolescent women [16,17].

However, intent alone is ineffective if the contraceptive method is not available to the patient because of issues related to cost, staff education and training, or logistics. For example, women who are unable to receive a desired postpartum sterilization during their birth hospitalization are at higher risk of pregnancy within one year compared with women who do not request postpartum tubal sterilization at all [18]. Internationally, the lactational amenorrhea method of contraception is often emphasized given its high initial efficacy and low risk [19] (see 'Other' below). However, this method is temporary, and women may not visit a care provider during a time when a transition to another method is indicated. Thus, we advise that clinicians prioritize educating women about birth spacing and patient-appropriate postpartum contraceptive options, ensuring method access prior to discharge, and arranging timely postpartum follow-up.

OUR APPROACH TO COUNSELING — For counseling women about contraception, we use a patient-centered, shared decision-making model. Shared decision making is "a collaborative process that allows patients and their providers to make health care decisions together, taking into account the best scientific evidence available, as well as the patient's values and preferences… this process provides patients with the support they need to make the best individualized care decisions" [20]. Decisions about birth spacing are informed by multiple factors, including desired family size, beliefs about and access to contraception, and maternal age. Furthermore, the postpartum period is a clinically dynamic time, in which method eligibility may change based on venous thromboembolism (VTE) risk, breastfeeding status, and medical comorbidities. Women often have a clear plan for postpartum contraception if counseling is done during the prenatal period, which then allows clinicians to ensure the desired method is available after delivery. Helping providers comprehensively, meaningfully, and accurately counsel postpartum women regarding family planning is an important step in decreasing unmet need for postpartum family planning. Keeping system factors in mind during counseling is also important. For example, some women may be insured for a limited time after delivery, and certain hospital systems may restrict access to contraceptive methods due to religious restrictions [21]. As patients do not necessarily fully understand system barriers, providers may need to advocate on their behalf and bridge gaps for women who desire access to postpartum contraception [21,22].

We take the following approach, ideally starting during prenatal care, with portions repeated as needed (algorithm 1):

●Discuss her reproductive life plan – Eliciting a discussion of a woman's reproductive life plan is a natural start to counseling regarding postpartum contraception. This conversation should include questions about desire for, and timing of, any future pregnancies and should begin during prenatal care. We start a discussion about postpartum contraception broadly by first asking women what their ideal family size might be. More specifically, providers can ask, "After you deliver, are you interested in having more children?" If a woman would like to have additional children, a follow-up question can be, "When do you think that might be?" [23]. This moment in the conversation may be appropriate for discussing health benefits of birth spacing, taking into account individual circumstances such as desired family size, personal values about birth spacing, and maternal age to guide creation of a reproductive health plan that is based on patient values as well as evidence-based recommendations (table 1) [6-9,24]. This can then lead to a discussion about whether a woman would like to actively prevent pregnancy after delivery. (See "Interpregnancy interval: Optimizing time between pregnancies".)

The choice of contraception is ultimately made by the woman. Detailed discussions of contraceptive efficacy and the general approach to method selection are presented separately. (See "Contraception: Counseling and selection".)

●Discuss contraceptive characteristics – Once the woman's desire for additional children and subsequent birth spacing has been established, we determine the contraceptive characteristics that she values most at that time. We ask, "What is most important to you in a contraceptive method?" [20]. Attributes that women may value in contraceptive methods include efficacy (figure 1), convenience (both in obtaining and using the method), cost, the ability to control whether to use the method, effect on uterine bleeding [25], and compatibility with breastfeeding. The ensuing conversation then starts with a discussion of the methods with the patient's most valued characteristic(s). For example, if a patient does not desire more children and values efficacy, then highly effective methods (ie, permanent or long-acting) would be discussed first and in detail. Even for women with a clear contraceptive preference, all methods should be mentioned at least briefly to ensure the patient is fully aware of her options.

●Review medical issues or comorbidities – In the first six weeks postpartum, multiple dynamic medical factors inform contraceptive method selection, particularly the elevated risk of VTE. With the exception of estrogen-containing methods, the Centers for Disease Control and Prevention (CDC) US Medical Eligibility Criteria (MEC) table classifies all methods immediately after delivery as either a category 1 or 2 [26,27]. The categories are defined as either no restriction (category 1) or the advantages of using the method generally outweigh the theoretical or proven risks (category 2). Due to the importance of breastfeeding in low-resource settings and the scarcity of high-quality data on the effect of hormonal contraception on breastfeeding outcomes [28,29], the World Health Organization (WHO) contraceptive eligibility criteria advise delaying progestin-only injectable methods to six weeks postpartum and estrogen-progestin combined methods to six months postpartum for breastfeeding women [27]. The WHO guidelines, which are meant to apply to a wide range of settings and resources, are interpreted below. (See 'Impact of contraception on breastfeeding' below.)

●Discuss plans for breastfeeding – When counseling women regarding the interaction of contraception, particularly hormonal contraception, and lactation, it is paramount to develop a collaborative model with obstetric providers, pediatricians, and lactation consultants, as data are sparse in this area and messaging to patients should be consistent. Furthermore, given that high-quality data are limited, it is important to avoid "bedside advocacy," in which public health messages are conveyed that primarily reflect the priorities of the provider [30]. Instead, we advise adopting a patient-centered, shared decision-making model, in which providers elicit patient priorities and tailor their recommendations to those priorities (table 1). All contraceptives are considered compatible with breastfeeding. (See 'Impact of contraception on breastfeeding' below.)

METHODS

Sterilization — Permanent sterilization of either the female or male partner is an option for patients who do not desire future pregnancy. Efficacy rates are greater than 99 percent (figure 1).

●Female – Postpartum sterilization may be performed via bilateral partial salpingectomy or bilateral complete salpingectomy. After vaginal delivery, partial salpingectomy can be performed via infraumbilical mini-laparotomy, preferably within 24 to 48 hours but up to six days postpartum, or at the time of cesarean delivery. At cesarean delivery, sterilization may be performed via bilateral complete salpingectomy (to reduce the risk of high-grade serous ovarian cancer) or by partial salpingectomy. However, studies report that one-third to one-half of women who desire a postpartum sterilization do not receive their desired procedure; risk factors for unfulfilled sterilization include elevated body mass index, time of delivery, and vaginal rather than cesarean delivery [18,31,32]. Deferral of desired sterilization after this time period results in high rates of unwanted pregnancy, up to 47 percent, within the first postpartum year, which is an issue for women who deliver at hospitals with restrictive contraception policies [18,33,34]. For women whose desired sterilization is unable to be performed during the birth admission, we offer other highly effective contraceptive methods and schedule the patient for subsequent interval laparoscopic sterilization. (See "Postpartum permanent contraception: Procedures".)

Counseling regarding postpartum female sterilization should ideally begin during the antenatal period. Shared decision making and patient-centered counseling is particularly important in preparation for sterilization; nonconsensual sterilization has been documented in the United States and other countries and has involved patients who are intellectually disabled, insured through federal funding, incarcerated, members of minority groups, with chronic disease, or disenfranchised in some way [35-39]. Cases in the United States resulted in court-mandated waiting periods for sterilization in women with public insurance, although these restrictions have since been criticized for creating unnecessary barriers to permanent contraception access for this population [40].

Given these restrictions, a discussion about sterilization should not be deferred to the end of pregnancy. Consent for sterilization should be considered as a process of delivering information, confirming voluntariness, and confirming understanding of information and, as such, should be delivered in comprehensible language with the use of an interpreter if needed [41]. A woman's decision regarding whether to proceed with sterilization should be reaffirmed during the delivery admission prior to surgery, as her wishes may have changed during the course of her pregnancy. (See "Overview of female permanent contraception", section on 'Counseling'.)

General information on female sterilization, United States mandated waiting periods, and techniques of postpartum sterilization are reviewed elsewhere.

•(See "Overview of female permanent contraception".)

•(See "Overview of female permanent contraception", section on 'United States regulatory issues'.)

•(See "Postpartum permanent contraception: Procedures".)

●Male – Vasectomy is a surgical procedure that provides permanent contraception for men. Advantages include that it is highly effective (less than 1 percent failure rate), a minimally invasive outpatient procedure, and widely available. Vasectomy is presented in detail separately. (See "Vasectomy".)

Progestin-only implants — Etonogestrel (commercial name Nexplanon) and levonorgestrel (LNG) implants (commercial names Jadelle and Sino-implant [II]) can be safely inserted at any time after delivery, as the advantages generally outweigh the theoretical or proven risks [26,27].

Details regarding the contraceptive implant in general, insertion, and the effect of the implant on lactation are described separately.

●(See "Etonogestrel contraceptive implant".)

●(See "Etonogestrel contraceptive implant", section on 'Insertion procedure'.)

Intrauterine devices — Both copper and LNG-releasing intrauterine devices (IUDs) can be inserted after delivery.

Options for timing of insertion after delivery — For women who desire an IUD after delivery, explicit counseling should center on timing of IUD insertion. Although nomenclature to describe timing of IUD insertion in the postpartum period can vary, we use the Society of Family Planning definitions to describe IUD insertion after delivery including [42]:

●Postplacental (immediate postpartum) – Defined as within 10 minutes of delivery of the placenta

●Early postpartum insertion – Defined as IUD insertion >10 minutes to one week postpartum

●Delayed postpartum – IUD insertion one week through six to eight weeks after delivery

●Interval – IUD insertion unrelated to timing of delivery (ie, beyond the postpartum period)

Risks (eg, expulsion and perforation) and benefits (eg, effectiveness) vary by timing of IUD placement after delivery. Although some outcome variables differ by timing of insertion, overall, IUD insertion at all time points after delivery is safe [42-44], with very low incidence of perforation [45], infection [46-49], and/or heavy vaginal bleeding [50,51]. Postplacental IUD placement is contraindicated in women with chorioamnionitis, endometritis, or active postpartum hemorrhage [42].

Our approach to postpartum IUD insertion — In our practice, we use an electronic medical record-based script to guide counseling regarding postpartum IUD placement, in which providers are prompted to review the differential risks of postplacental and delayed postpartum IUD placement including expulsion, malposition, and missing strings; that follow-up is recommended after postplacental insertion to assess for positional abnormalities; and that the advantage of postplacental IUD insertion is maximized for women who may not be able to return for delayed postpartum insertion or who wish to avoid a separate procedure. Although predictors for nonattendance to follow-up have been described [52], these predictors cannot be used on an individual level to prioritize access to postplacental IUDs, particularly because follow-up after postplacental IUD placement is important in the recognition of complications of this contraceptive method.

We advise removing potential barriers to a two- to three-week postpartum visit [2,53] and early ultrasound evaluation for women who receive a postplacental IUD, enabling sufficient time for confirmation of IUD position and correction if needed, prior to the potential for return to fertility. Furthermore, in settings in which women have insurance coverage for a finite number of weeks after delivery, early recognition of IUD positional abnormalities allows for clinical management during the time of coverage.

Given the public health benefit of access to immediate postpartum long-acting reversible contraceptives (LARC), health systems should work to provide this service to patients. However, logistical, financial, and educational barriers may restrict the development of these programs at a departmental level. The American College of Obstetricians and Gynecologists publishes and collates a variety of resources to aid in the development and sustainability of immediate postpartum LARC programs.

IUD device types, candidates and device selection, techniques for insertion and removal, and management of side effects and complications are described separately.

●(See "Intrauterine contraception: Background and device types".)

●(See "Intrauterine contraception: Candidates and device selection".)

●(See "Intrauterine contraception: Insertion and removal".)

●(See "Intrauterine contraception: Management of side effects and complications".)

Issues related to postpartum IUD insertion

Expulsion — Expulsion rates appear to differ by timing of IUD placement, mode of delivery, and device type. Absolute expulsion rates for postpartum IUD insertion range from 10 to 40 percent, compared with 3 to 10 percent for non-postpartum women [46,54-60]. Two different meta-analyses of 48 studies that pooled counts of postpartum IUD placements and expulsions and adjusted for IUD type, delivery method, study region, study quality, and length of follow-up reported [54,61]:

●Risk of expulsion was six to seven times higher for immediate and delayed insertion compared with interval insertion (adjusted risk ratio [RR] 7.63, 95% CI 4.30-13.51 and RR 6.17, 95% CI 3.19-11.93, respectively).

●Vaginal delivery conferred a fivefold increased risk of expulsion compared with cesarean delivery (adjusted RR 5.19, 95% CI 3.85-6.99).

●Risk of expulsion at less than four weeks postpartum was nearly double for the LNG-releasing IUD compared with the copper IUD (adjusted RR 1.91, 95% CI 1.50-2.43).

●Among immediate postplacental placements following vaginal delivery, LNG-releasing IUDs have nearly twice the risk of expulsion of copper IUDs (adjusted RR 1.90, 95% CI 1.36-2.65).

At least one study has reported that use of ultrasound guidance at the time of IUD placement does not appear to lower IUD expulsion rates [46]. In our practice, we advise women who have had postplacental insertion of an IUD to undergo ultrasound evaluation of IUD position at four to six weeks postpartum.

Uterine perforation — Observational studies suggest that perforation after postplacental insertion of an IUD is rare. Cases of perforation have been reported in the literature and suggest rates that are no greater than the risk of insertion more than six months after delivery [42,45,62].

Rates of uterine perforation for women who have delayed IUD insertion are similar to women who have interval IUD insertion. In a trial of 201 women randomly assigned to IUD placement at three or six weeks postpartum (ie, delayed postpartum insertion), no complete expulsions or perforations occurred [63]. Although there are very limited data on perforation risks following early postpartum IUD insertion, perforation is likely to be low in this population as well [63]. It is unknown if breastfeeding modulates perforation risk in the time period up to six weeks postpartum; 90 percent of women in this trial were breastfeeding. Beyond six weeks postpartum, IUD perforation rates appear to be somewhat higher in breastfeeding as compared with nonbreastfeeding women, although overall perforation rates in both populations are exceedingly low (less than 1 percent in both groups) [64,65]. Risk of perforation is not considered a reason to defer IUD insertion in breastfeeding women.

Diagnosis and management of uterine perforation are presented elsewhere. (See "Intrauterine contraception: Management of side effects and complications".)

Abnormal IUD position — Postplacental IUD placement appears to be associated with more positional abnormalities compared with delayed or interval placement. In a prospective cohort study of 200 women receiving the Copper T380A IUD immediately after vaginal delivery, 15 percent were malpositioned (defined as rotated or away from the fundus but not partially expelled) [62]. Data on proportion of IUDs that are malpositioned after delayed postpartum or interval placement are scant, although "device-related" reasons for discontinuation (most of which were not malpositions) occurred in only 0.12 to 0.24 per 1000 women by one year in a large randomized controlled trial of the LNG versus copper IUD [66]. In a case-control study, malpositioning after interval IUD placement was more likely to be identified in women with suspected adenomyosis and less likely to be reported in women with a prior vaginal delivery and with private insurance [67]. Physiologic reasons for these risk factors are unclear.

However, the clinical significance of abnormal IUD position is unknown. Prior research shows that greater distance of copper from the cornua decreases effectiveness of a copper IUD, suggesting that IUD malposition may decrease effectiveness as well [68,69]. The proportion of women who experience pain or bleeding abnormalities with IUD malposition is not known [68,69]. Given the paucity of data in this area, we recommend offering IUD replacement to patients experiencing this outcome, especially those patients experiencing discomfort.

IUD strings — IUD strings are folded into the uterus and are unable to be visualized on speculum examination in nearly one-quarter of patients who have postplacental placement after vaginal delivery [62,70]. Presence of IUD strings is a poor test to assess correct position of an IUD placed after placental delivery; conversely, absence of IUD strings is a poor test to predict abnormal IUD positioning. The sensitivity and specificity of a string check as a test for IUD position are 36.2 and 84.5 percent in women who have a postplacental IUD after vaginal delivery [62].

Patients who desire postplacental IUD insertion should be counseled regarding the potential increased risk of absent strings. In addition, patients may be bothered by long strings resulting from uterine involution after postplacental IUD placement. One study comparing postplacental with delayed LNG IUD insertion reported that 17 percent of women with a postplacental IUD had an unscheduled clinic visit for IUD string trimming; unscheduled visits for string trimming were not reported for women in the delayed insertion group [46]. Given the lower risk of expulsion of an IUD after cesarean delivery but the higher risk of nonvisible strings, string check is likely an even poorer test to assess IUD position after cesarean delivery [71].

IUD continuation rate — Despite the increased risk of expulsion, perforation, and positional abnormalities after postplacental IUD insertion, the odds of using an IUD six months after delivery is twice as high for women who receive a postplacental IUD as compared with interval insertion (odds ratio 2.04, 95% CI 1.01-4.09) [3]. A different study reported 81 percent of women who received a postplacental copper IUD were still using it six months after delivery despite the complications [62]. This relatively high retention rate appears to translate into higher contraceptive efficacy of intended postplacental IUD placement compared with intended delayed postpartum IUD placement, as indicated by a decision analysis study [3]. Despite higher rates of expulsion, intended postplacental IUD insertion is more effective in preventing pregnancy at one year than intended delayed insertion.

The primary factor influencing variation in estimates of intended IUD effectiveness is the proportion of women who return for a postpartum visit. A practice would need to have postpartum follow-up rates of 90 percent or greater in order for intended delayed postpartum IUD insertion to be a more effective method of contraception than intended postplacental IUD placement. On the other hand, once the IUD is placed, a delayed postpartum IUD is more effective than a postplacental IUD, due to the lower expulsion rate. Thus, public health and individual-level benefits of postplacental IUD placement may be in conflict, and it is essential to clearly educate women on the risks and benefits of both timings of IUD placement [3].

Short-acting hormonal contraception — Short-acting reversible hormonal contraception includes progestin injections and oral pills as well as combined estrogen-progestin products (oral pills, patch, vaginal ring). These are considered highly effective methods of contraception (figure 1). While progestin-only methods can be started any time in the postpartum period, combined hormonal contraception (CHC) should not be initiated earlier than 21 days postpartum for any woman because of the increased risk of venous thromboembolism (VTE) [26].

Advantages of these methods include relative ease of use, wide access, relatively low upfront cost, and noncontraceptive benefits. As discussed in detail below, the World Health Organization's (WHO) contraceptive eligibility criteria advise waiting longer before starting hormonal contraceptives in lactating women compared with the Centers for Disease Control and Prevention (CDC) table. In our practice, we counsel women that the advantages of immediate initiation of progestin-only methods are believed to outweigh the theoretical risks. We delay initiation of CHC for at least 21 days postpartum for all women because of the increased risk of VTE. (See 'Impact of contraception on breastfeeding' below and 'Counseling regarding venous thromboembolism risk and hormonal contraception in the postpartum period' below.)

●Progestin-only injectable – This method, which can be administered during the birth admission, has the advantage of being a single injection that lasts 12 weeks. Postpartum depot medroxyprogesterone acetate (DMPA) can therefore bridge a woman to an outpatient postpartum visit, at which time she may initiate a long-acting reversible method or continue DMPA, as she desires. Some clinicians and practitioners have raised concerns about a link between DMPA and postpartum depression, but studies have reported conflicting results. A clear link between DMPA and postpartum depression has not been proven or excluded [72,73]. While immediate use of DMPA has been associated with a small increased risk of VTE, the overall incidence remains low [74]. (See 'Counseling regarding venous thromboembolism risk and hormonal contraception in the postpartum period' below.)

Patient selection, risks and benefits, and administration of DMPA are presented in separate discussions.

•(See "Depot medroxyprogesterone acetate (DMPA): Formulations, patient selection and drug administration".)

•(See "Depot medroxyprogesterone acetate (DMPA): Efficacy, side effects, metabolic impact, and benefits".)

●Progestin-only pills – Progestin-only pills (POPs) can be initiated at any time after delivery, but their efficacy is likely lower than CHCs due to the need to take them at nearly the same time every day [75-77]. In a retrospective cohort study, women who had a short interpregnancy interval were most likely (fivefold increased risk) to have been prescribed a progestin-only pill compared with any other reversible method, including no method at all [78]. The reason for this finding is unclear, but it may be indicative of low continuation rates for POPs in the postpartum period. Women who prefer oral contraceptive pills may use POPs until three to six weeks after delivery and then switch to combined oral contraception if desired [26]. As discussed below, the WHO and CDC have differing recommendations regarding the timing of initiation for both progestin-only and estrogen-containing methods [26,27]. (See 'Impact of contraception on breastfeeding' below.)

Information on candidates, use, and side effects of progestin-only pills is reviewed in detail elsewhere. (See "Progestin-only pills (POPs) for contraception".)

●Combined hormonal contraception (pills, patch, and vaginal ring) – CHCs include both an estrogen and a progestin. Formulations include pills, patch, and vaginal rings. CHC is not recommended until three to six weeks postpartum due to the effect of estrogen on VTE risk. (See 'Counseling regarding venous thromboembolism risk and hormonal contraception in the postpartum period' below.)

Detailed discussions of candidate selection, efficacy, and risks and benefits of each of the CHC methods are available separately.

•(See "Combined estrogen-progestin oral contraceptives: Patient selection, counseling, and use".)

•(See "Combined estrogen-progestin contraception: Side effects and health concerns".)

•(See "Contraception: Transdermal contraceptive patches".)

•(See "Contraception: Hormonal contraceptive vaginal rings".)

Other

●Lactational amenorrhea method – The lactational amenorrhea method (LAM) is defined as the educated use of breastfeeding as a contraceptive method by a woman who is amenorrheic and is not using supplementary feeding or breast pumps for up to six months after delivery. It is thought that infant suckling results in a reduction of pulsatile secretion of gonadotropin-releasing hormone (GnRH) and luteinizing hormone (LH), which in turn suppresses ovarian activity. The exact mechanism by which the suckling stimulus affects GnRH pulsatile secretion remains unknown [19,79].

Life table pregnancy rates for LAM at six months range from 0.45 to 7.5 percent (ie, 4.5 to 75 unintended pregnancies per 1000 women exclusively using this method) in controlled and uncontrolled studies [19]. Studies have not found clear differences in pregnancy rates between women using LAM specifically as a contraceptive method and those who are fully breastfeeding and amenorrheic but not reporting use of any method. Thus, there is no evidence that LAM as a contraceptive method delays the recurrence of menstruation any more than exclusive breastfeeding.

Promotional and training materials for LAM often advise transitioning to other contraceptive methods as soon as the woman is adding supplemental feedings, is menstruating, or has a baby older than six months. However, 20 to 56 percent of fully nursing women are not amenorrheic at six months, and many women will stop exclusively breastfeeding prior to six months [19]. Given the variable rates of patient follow-up after delivery, it seems prudent to use the first months following delivery to promote and support women in exclusive breastfeeding for infant health, while also providing highly effective contraceptive methods as desired within the first few weeks postpartum.

●Pericoital methods – Pericoital methods of contraception, including diaphragms and cervical caps, are not to be used for the first six weeks postpartum, as the uterus is still undergoing involution at this time. Spermicides and the contraceptive sponge may be used without restriction in the first weeks postpartum, although vaginal irritation is common with these methods. (See "Pericoital contraception: Diaphragm, cervical cap, spermicides, and sponge".)

●Barrier methods – In the first six weeks after delivery, both female and male condoms can be used for pregnancy prevention without restriction. (See "Internal (formerly female) condoms" and "External (formerly male) condoms".)

Emergency contraception — All women who wish to avoid pregnancy should be aware of emergency contraceptive (EC) methods and when and how to access them. The copper IUD, oral LNG, and oral ulipristal acetate (UPA) are safe for use in postpartum and breastfeeding women [80]. However, breastfeeding is not advised for 24 hours after taking UPA. Women who are breastfeeding and require UPA are counseled to pump or express, and then discard, their breastmilk for 24 hours after taking UPA. Ethinyl estradiol plus LNG (Yuzpe method) should be avoided in the first three to six weeks postpartum due to possible increased risks of VTE with this method. Use of a copper IUD for EC is safe for postpartum women [80].

EC options, risks and benefits, and use are presented in detail separately. (See "Emergency contraception".)

IMPACT OF CONTRACEPTION ON BREASTFEEDING

Copper intrauterine device — The copper intrauterine device (IUD) does not affect milk supply or breastfeeding [64].

Issues surrounding hormonal contraception during breastfeeding

Concerns — Concerns have been raised that exogenous hormones could impact lactogenesis and thereby affect breastfeeding performance (eg, breastfeeding frequency, proportion of women breastfeeding at different time periods), infant milk intake, or infant health outcomes (such as weight and height). Progesterone withdrawal after delivery initiates production of copious milk. The action of infant suckling and removal of milk increases prolactin levels, which causes alveolar cells to produce milk. This combination of suckling and elevated prolactin then prompts oxytocin levels to increase and causes alveolar contractions to release milk into the ductal system.

However, concerns about the impact of hormonal contraception on lactation and breastfeeding must be balanced against the method benefits (both contraceptive and noncontraceptive) and the potential harms to the infant if breastfeeding is interrupted. As an example, for women in low-resource regions, the World Health Organization (WHO) advises exclusive breastfeeding for the first six months of life to reduce the risk of infant diarrheal illness and respiratory infection [81]. In response to these variables and in recognition of the medical importance of breastfeeding (particularly in low-resource regions), the paucity of high-quality evidence on the effects of hormonal contraception on breastfeeding outcomes [28,29], and the varying populations, the WHO and the Centers for Disease Control and Prevention (CDC) have published differing opinions on the timing of initiation of hormonal contraception in postpartum women [26,27]. The WHO contraceptive eligibility criteria advise delaying progestin-only injectable methods to six weeks postpartum and estrogen-progestin combined methods to six months postpartum, while the CDC table does not advise against any hormonal contraceptive method while breastfeeding, although use of combined hormonal contraception (CHC) is delayed for at least the first three weeks after delivery because of elevated risk of venous thromboembolism (VTE) [26,27]. (See 'Counseling regarding venous thromboembolism risk and hormonal contraception in the postpartum period' below.)

The data informing the WHO and CDC statements are presented in detail below for each method. In general, the available evidence does not support a significant or consistent effect of hormonal contraception on breastfeeding outcomes. Only small amounts of estrogen and progestins are transferred to the infant through breastmilk, and data have not suggested adverse health effects of these hormones on infants [29]. However, high-quality data are lacking, and most studies on hormonal contraception and breastfeeding have included low-risk women and those who have had success with breastfeeding prior children, or have not controlled for prior success with breastfeeding. Further research is needed on the effect of hormonal contraception on women with preterm infants for whom breastfeeding provides additional benefits, or in women who are primarily using breast pumps to express milk.

Progestin-only methods

●Progestin-only implants – Neither the etonogestrel or levonorgestrel (LNG) contraceptive implants appear to have a negative effect on breastfeeding outcomes, although the available data are limited to observational studies or small trials [82]. In a trial including 24 women who received either the contraceptive implant immediately after delivery or no contraceptive method, infant milk intake, rates of exclusive breastfeeding, and newborn weights were similar between the groups at six weeks postpartum [83]. Milk consumption was determined by having the women ingest the stable isotope deuterium (D₂O) on postpartum days 0 and 29, and then determining infant milk intake by measuring infant salivary D₂O levels. A systematic review of cohort studies comparing postpartum women using etonogestrel implants or the copper IUD did not show differences in infant growth or other infant health outcomes [28]. In a trial comparing immediate (within five days) or delayed (six to eight weeks postpartum) insertion of the LNG implant, change in infant weight from birth to six months, time to lactogenesis, and proportion of women who were breastfeeding exclusively did not differ between groups [84].

In response to these data, both the WHO contraceptive eligibility criteria and CDC table agree that the advantages of progestin-only implants generally outweigh theoretical or proven risk and support immediate use of progestin-only implants in breastfeeding women (although the timing of this label varies slightly between the groups) [26,27]. In our practice, we routinely offer contraceptive implants to women prior to discharge from the hospital after delivery in order to ensure access to the method.

●Progestin-releasing IUDs – Studies of the LNG IUD in breastfeeding women have generally reported minimal to no effect on breastfeeding outcomes, and the advantages of the LNG IUD are considered by the CDC's medical eligibility criteria and WHO to outweigh any theoretical or proven risks in breastfeeding women [26,82]. In a trial of 259 women randomly assigned to immediate (postplacental) or delayed (4 to 12 weeks postpartum) insertion of an LNG IUD, no differences were reported for any breastfeeding, time to lactogenesis, exclusive breastfeeding at eight weeks, or any breastfeeding at six months postpartum [85]. While one study limitation may have been a noninferiority margin that could have masked a true difference in the primary outcome, exploratory outcomes of breastfeeding at six months were reassuring. Due to the paucity of data on expulsion of an IUD when inserted from 48 hours to four weeks after delivery, WHO contraceptive eligibility criteria, but not the CDC table, state that the theoretical or proven risks usually outweigh the advantages of using the method during this period; this restriction is unrelated to any potential effect on breastfeeding. In our practice, we offer LNG IUDs at any time in the postpartum period in accordance with CDC guidance and counsel regarding signs and symptoms of IUD expulsion. (See 'Expulsion' above.)

●Progestin-only injectable – The effect of progestin-only injectable contraception on breastfeeding has been examined in clinical trials and observational studies, and most have reported either no change or improved breastfeeding outcomes for depot medroxyprogesterone acetate (DMPA) users and generally demonstrated no harmful effects on infant growth, health, or development [28]. However, citing a concern from animal studies that reported a possible effect of DMPA on the developing rat brain, the WHO contraceptive eligibility criteria advise delaying initiation of DMPA in lactating women until six weeks postpartum [27]. The WHO also includes a caveat in their guidance that recognizes the importance of DMPA in the immediate postpartum period in many settings where other methods are less accessible and thus supports DMPA use when that is the best option. By contrast, the CDC table states that immediate use of DMPA generally outweighs any proven or theoretical concerns and that it can be used without restriction in breastfeeding women more than 30 days postpartum [26]. In our practice, we offer DMPA at any time in the postpartum period, including immediately after delivery, in accordance with CDC guidance as we believe the benefits outweigh any theoretical risks.

●Progestin-only pills – Both trial and observational data generally support the use of progestin-only pills (POPs) in the postpartum period [28,86,87]. One trial of nearly 130 women reported no differences in breastfeeding continuation or supplementation at six months postpartum for women using POPs compared with combined oral contraceptive pills [87]. In a systematic review of eight observational studies including women who started POPs in the first six weeks postpartum, POP users had either no difference or improved breastfeeding outcomes compared with nonusers; study outcomes included breastfeeding initiation, breastfeeding duration, or use of supplementation [28]. Both the WHO and the CDC agree that breastfeeding women who are less than six weeks postpartum can use POPs, as the benefits appear to outweigh the risks. Beyond six weeks, there are no restrictions [26,27]. In our practice, we offer POPs at any time during the postpartum period in accordance with CDC and WHO guidance.

Combined estrogen-progestin methods — In general, studies assessing the impact of CHCs (pills, patch, vaginal ring) on breastfeeding duration and success have reported inconsistent data. In a 2015 meta-analysis that included four trials of combined oral contraceptive pills, one trial reported a negative effect on breastfeeding duration while the other three trials did not assess this outcome [88]. Two trials reported lower breast milk volume for oral CHC users compared with placebo; one trial did not quantify results, and the other reported lower mean volumes that were unlikely to be clinically meaningful. In a trial performed after the meta-analysis that assessed women who initiated their desired contraceptive method on postpartum day 42, infant breast milk intake and growth were similar between women using hormonal and nonhormonal contraception [89].

●The WHO contraceptive eligibility criteria advise delaying use of estrogen-containing methods until six months postpartum for women who are primarily breastfeeding because of the importance of breastfeeding on infant health in low-resource settings [27]. They advise women who desire CHCs to begin other progestin-only or nonhormonal methods until CHC is initiated. (See 'Impact of contraception on breastfeeding' above.)

●As presented in the CDC contraceptive table, women are advised to avoid CHC until at least 30 days postpartum due to the increased risk of VTE [26]. Breastfeeding women who do not have additional VTE risk factors may reasonably begin CHC at 30 days postpartum. However, breastfeeding women with additional VTE risk factors should delay CHC initiation until at least 42 days (six weeks) postpartum.

Consistent with CDC guidance, we avoid prescribing CHCs for the first three to six weeks postpartum due to increased risk of VTE in the postpartum period (timing of initiation varies based on VTE risk factors). After three to six weeks postpartum, breastfeeding is generally established, and we offer CHC to postpartum women who are appropriate medical candidates consistent with the CDC medical eligibility criteria [26]. (See 'Counseling regarding venous thromboembolism risk and hormonal contraception in the postpartum period' below.)

Other — Pericoital and barrier methods of contraception do not impact milk supply or breastfeeding.

COUNSELING REGARDING VENOUS THROMBOEMBOLISM RISK AND HORMONAL CONTRACEPTION IN THE POSTPARTUM PERIOD — There are few studies evaluating the incidence of venous thromboembolism (VTE) in postpartum women using combined hormonal contraceptives (CHCs) or progestin-only contraceptives. However, the risk of VTE associated with CHC use in healthy nonpregnant women is three to seven times higher than in nonusers, and thus, use of CHCs for the initial three to six weeks postpartum is generally contraindicated [26,27,90]. Most evidence does not suggest an increase in odds for venous or arterial thromboembolic events with the use of progestin-only oral or implantable contraceptives. A database study comparing over 8300 individuals who received an etonogestrel implant during the delivery admission with unexposed postpartum individuals reported similar 30-day readmission rates for VTE for both groups (adjusted odds ratio 1.81, 95% CI 0.44-7.45) [91]. While several studies have reported an increased risk of VTE with the use of progestin-only injections, the absolute incidence remains low [74,92,93]. Both the World Health Organization and the Centers for Disease Control and Prevention advise that the data supporting immediate use of progestin-only contraception generally outweigh the risks, either established or theoretical [26,27].

Women in the postpartum period have a higher risk of VTE compared with both nonpregnant, non-postpartum women and pregnant women. Normal hematologic changes in the postpartum period include increasing coagulation factors and fibrinogen, and decreasing natural anticoagulants protein S and adenomatous polyposis coli, which likely occur to prevent hemorrhage after delivery. A systematic review estimated that the risk of VTE is as much as five times higher during the postpartum period compared with pregnancy itself, and during the first six weeks postpartum, women's risk of VTE increases 21- to 84-fold from baseline [90]. The systematic review further reported the incidence rate of VTE was 357.3 in week 1, decreased weekly through the first six postpartum weeks to 31.5, and then plateaued at 3.2 in postpartum weeks 7 to 12. (See "Maternal adaptations to pregnancy: Hematologic changes", section on 'Coagulation and fibrinolysis'.)

SPECIAL POPULATIONS

●Adolescents – Selection of contraception for postpartum teens and young adults does not differ from that of older women. Issues specific to adolescents are discussed separately. Access to long-acting reversible contraceptives, including implants and intrauterine devices, immediately after delivery has been shown to increase time to next pregnancy in adolescents and is an important public health intervention in this age group [55]. (See "Contraception: Issues specific to adolescents".)

●Women with depression and related disorders – Hormonal contraception, both estrogen-progestin and progestin-only methods, can be used by women with depressive disorders (either preexisting or postpartum) [26,27]. There are no restrictions for this use of hormonal contraception in this population in both the Centers for Disease Control and Prevention (CDC) table and World Health Organization (WHO) contraceptive eligibility criteria.

In a systematic review that included 26 studies, no clear relationship was noted between progestin contraceptives and depression scores or incident diagnoses [94]. Some studies evaluating the effect on mood of depot medroxyprogesterone acetate (DMPA) in postpartum women have suggested that injectable progestin-only contraception may increase depression scores temporarily in postpartum women; however, data are not robust [72,95], and other studies have reported conflicting results [73]. We believe that the data are conflicting enough that providers should not restrict DMPA postpartum in those women who desire it. Counseling on method risks should be comprehensive, and screening for postpartum depression should occur regardless of contraceptive method chosen.

●Medical illness – Women with comorbid medical conditions should be offered contraceptive methods in accordance with the WHO contraceptive eligibility criteria, or other relevant national guidance. Mobile applications are readily available for quick reference regarding women's eligibility for contraceptive methods based on comorbid conditions, including women with thromboembolic disease, hypertension, diabetes, headache, HIV infection, obesity, pelvic infection, and seizure disorders.

Women taking other medications should be offered contraceptive methods in accordance with CDC, WHO, or other relevant national guidance. Mobile applications are readily available for quick reference regarding women's eligibility for contraceptive methods based on concurrent use of anticonvulsants, antimicrobials, or antiretrovirals.

●Obese women – Obese women (ie, body mass index ≥30 kg/m²) may have additional medical comorbidities or higher risk of venous thromboembolism that can impact their choice of postpartum contraception. Issues specific to obese women who desire effective contraception, including method efficacy, are addressed elsewhere. (See "Contraception: Counseling for females with obesity".)

WOMEN WHO ARE UNDECIDED ABOUT CONTRACEPTION — Women who are undecided about contraception at any point during pregnancy or postpartum should be counseled regarding all of their options and given written support materials on contraceptive methods. Women can be counseled on the effect on fertility of exclusive breastfeeding, as well as the risk of ovulation within the first four to six weeks postpartum. In addition, women should be given comprehensive information on emergency contraception. Consistent with the American College of Obstetricians and Gynecologists, we believe that contact with a provider during the postpartum period should be a process rather than a discrete visit and should occur at least once in the one to three weeks postpartum, with individualization of ongoing follow-up as needed [2]. Thus, contraception can and should be addressed at more than one time point in the postpartum period if needed. However, women should not be made to feel pressured to choose a method if they are undecided or would prefer behavioral methods of pregnancy prevention such as abstinence, withdrawal, lactational amenorrhea method, or fertility awareness methods. (See "Contraception: Counseling and selection".)

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Contraception" and "Society guideline links: Postpartum care".)

INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." The Basics patient education pieces are written in plain language, at the 5^th to 6^th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10^th to 12^th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.

Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on "patient info" and the keyword(s) of interest.)

●Beyond the Basics topic (see "Patient education: Birth control; which method is right for me? (Beyond the Basics)")

SUMMARY AND RECOMMENDATIONS

●In a systematic review of studies estimating the time to return to fertility in nonlactating postpartum women, the average time to first ovulation varied from 45 to 94 days postpartum, with the earliest ovulation reported at 25 days postpartum. (See 'Resumption of ovulation' above.)

●For counseling women about contraception, we use a patient-centered, shared decision-making model. Key components to discuss include the patient's reproductive life plan, desired characteristics of contraceptives, medical issues or comorbidities, and plans for breastfeeding. (See 'Our approach to counseling' above.)

●Contraceptive methods that can be initiated immediately after delivery include female and male sterilization, progestin-only implants, intrauterine devices (IUD; copper or levonorgestrel), the progestin injection, and the progestin-only pill. (See 'Sterilization' above and 'Progestin-only implants' above and 'Intrauterine devices' above.)

●For women who desire an IUD after delivery, explicit counseling should center on timing of IUD insertion. IUD insertion timing can be postplacental, delayed, or interval. Risks (eg, expulsion and perforation) and benefits (eg, effectiveness) vary by timing of IUD placement after delivery. (See 'Options for timing of insertion after delivery' above.)

●Issues that we discuss with patients who desire a postpartum intrauterine device include the risks of IUD expulsion, perforation of the uterus, and IUD malposition. Despite these concerns, the odds of using an IUD six months after delivery is twice as high for women who receive a postplacental IUD as compared with interval insertion. (See 'Issues related to postpartum IUD insertion' above.)

●For women who desire short-acting combined estrogen-progestin contraception, the oral pill, transdermal patch, and vaginal ring should not be started earlier than 21 days postpartum for any woman because of the increased risk of venous thromboembolism (VTE). (See 'Short-acting hormonal contraception' above.)

●In general, the progestin-only methods appear to have minimal to no effect on breastfeeding outcomes. Studies assessing the impact of combined hormonal contraceptives (CHCs; pills, patch, vaginal ring) on breastfeeding duration and success have reported inconsistent data. The Centers for Disease Control and Prevention and the World Health Organization recommendations about hormonal contraceptives and breastfeeding differ. (See 'Issues surrounding hormonal contraception during breastfeeding' above.)

●No studies have evaluated the incidence of VTE in postpartum women using CHCs or progestin-only contraceptives. However, the risk of VTE associated with CHC use in healthy nonpregnant women is three to seven times higher than in nonusers, and thus use of CHC for the initial three to six weeks postpartum is generally contraindicated. (See 'Counseling regarding venous thromboembolism risk and hormonal contraception in the postpartum period' above.)

●Women who are undecided about contraception at any point during pregnancy or postpartum should be counseled regarding all of their options and given written support materials on contraceptive methods, including emergency contraception. (See 'Emergency contraception' above and 'Women who are undecided about contraception' above.)

ACKNOWLEDGMENT — The UpToDate editorial staff acknowledges Andrew M. Kaunitz, MD, who contributed to an earlier version of this topic review.