Postpartum Period: Traditionally 6 Weeks After Birth

POST PARTUM CONTRACEPTION

§  Postpartum period: traditionally 6 weeks after birth

§  Extended postpartum period: extend the postpartum period to include 1st year after birth to increase programmatic opportunities to reach families

§  Postpartum Family Planning: The initiation and use of FP during the first year after delivery

Considerations with Postpartum Family Planning

§  Through the first year postpartum

§  Timing of return to fertility

§  Return to sexual activity

§  Breastfeeding and use of various methods

§  Timing of various methods

§  LAM, concurrent use and transition to other methods

§  Underlying factors

§  Healthy spacing of the next pregnancy

§  Integration of FP into other service opportunities

Return to Fertility

l  Non breastfeeding:

l  As early as 3 weeks postpartum – 21 days postpartum

l  Breastfeeding

l  Using LAM accurately:

―  sometime after 6 months – variable

l  Breastfeeding without using LAM:

―  possibly even before 6 months, but again, variable.

―  average is 45 days

―  5 – 10% of breastfeeding women get pregnant in first year PP

Remember: fertility returns before menses returns!

Factors Affecting Method Choice

§  Reproductive goals of woman or couple (spacing or limiting births)

§  Personal factors including client preference, time, travel costs, discomfort associated with
FP method

§  Accessibility and availability of products that are necessary to use method

§  Medical factors

Timing of Initiating FP Methods Postpartum

l  LAM – with breastfeeding

l  Condoms – when intercourse resumes

l  Progestin-only methods –

―  BF: when good milk supply and BF going well – 6 weeks

―  Non-BF – right away

l  Combined Oral Pills (Estrogen + Progestin)

―  BF: when there is no risk if quantity of milk decreases – 6 months

―  Non-BF: when risk of thrombosis is reduced – 3 weeks

l  IUCD – when risk of infection and perforation is low

―  First 48 hours or after 4-6 weeks

l  Tubectomy – when tubal inflammation and risk of infection low:

―  First 7 days or after 6 weeks

LACTATIONAL AMENORRHOEA METHOD

Ø  Temporary

Ø  Breast feeding related

Ø  Criteria: 1. 85% of feeding as breast milk

2. Feeds day and night

3. No menstruation

4. Less than 6 months old.

Ø  No medical contradictions

Ø  No side effects

Ø  Mechanism of action: Excessive secretion of prolactinà inhibition of pituitaryà inhibits LH, no effect of FSH + partial inhibition of ovarian response to gonadotrophinsà decreased production of progesterone and oestrogenà no ovulation.

Impaired luteal phase

Suckling induced oxytocin releaseà interference with implantation

Ø  Use effectiveness: LAM is 99.5% effective with consistent and correct use and more than 98% effective as typically used

Ø  Advantages: 1. Immediately after delivery

2. No interference with sexual intercourse

3. No extra cost

4. No procedures

5. No hormonal side effects

6. Benefits of breast feeding

Ø  Disadvantages: 1. No certain effectiveness

2. Difficult for working mothers

3. No protection against STDs

4. HIV with AFASS fulfilled

Ø  Absolute contraindications: 1. > 6 months old

2. Irregular Breast feeding

3. AFASS fulfilled HIV

4. Menstruation starts

5. Mother on drugs contraindicated during breastfeeding

6. Viral hepatitis of mother

Ø  Drawbacks: Prolonged lactation à Superinvolution of the uterus, persistent hyperprolactenemia à Prolonged amenorrhoea, oligomenorrhoea

Ø  Problems:

- Deficient milk supply

- Cracked nipples

- Breast engorgement

- Breast abscess

Progestin-Only Pills (POPs)

§  Pills that contain a very low dose of a progestin like the natural hormone progesterone in a woman’s body

§  Does not contain estrogen

§  Also called “mini-pills”

§  Work primarily by:

§  Thickening the cervical mucus (this blocks sperm from meeting egg)

§  Disrupting the menstrual cycle, including preventing ovulation

Progestin-Only Pills: Key Benefits

§  Safe for breastfeeding women—No effect on breastfeeding, milk production or infant growth and development after infant is six weeks old

§  Adds to the contraceptive effect of breastfeeding—Together, if taken correctly, failure rate less than 1% during first year of use

§  Does not interfere with sex

Progestin-Only Pills: Limitations

§  Less effective for non-breastfeeding mother—If taken correctly, 3–10 women/100 will become pregnant first year

§  Pill must be taken every day

§  Bleeding changes (more frequent, irregular) are common but not harmful

§  A few women may have headaches, dizziness or breast tenderness

Progestin-only Contraceptives & Breastfeeding Women

l  No proven effect on breastfeeding, breast milk production or infant growth and development

l  WHO recommends a delay of 6 weeks after childbirth before starting progestin-only methods as infants may be at some small unknown risk from exposure to the progestin excreted in breastmilk

MEC Category 3 – risks outweigh the benefits

l  After 6 weeks of age, safe to initiate progestin-only methods

MEC Category 1 – safe to use under any situation

Not appropriate for women who:

1.  Have cirrhosis or active liver disease.

2.  Take medications for TB or seizures.

3.  Have a blood clot in legs or lungs now.

4.  Have a history of breast cancer.

Progestin-Only Injectables

§  The injectable contraceptive DMPA (depot medroxyprogesterone acetate) contains a progestin similar to the progesterone naturally in a woman’s body

§  Does not contain estrogen

§  Also known as “the shot” or the injection

§  Given by injection into the muscle

§  Works primarily by preventing ovulation

§  No effect on breastfeeding, milk production or infant growth and development; safe for use after infant is 6 weeks

§  When women have injections on time, failure rate less than 1% during first year of use

§  Does not require daily action, Do not interfere with sex

§  Helps protect against:

endometrial cancer

Uterine fibroids

Iron-deficiency anemia

Progestin-Only Injectables: Limitations

§  Bleeding irregularities for first two to three months (usually no bleeding at one year)

§  Some women may have weight gain, headaches, dizziness, mood changes

§  Should wait until six weeks to give first injection to the breastfeeding woman (who is not using LAM)

Progestin-Only Injectables: Counseling Considerations

§  Discuss limitations (side effects)

§  Agree on date for next injection in three months (can give injection even if woman is four weeks early or late, but do not regularly extend DMPA injection interval by four weeks)

§  She should come back no matter how late she is for her next injection; if reasonably sure she is not pregnant, can give injection any time

§  Assure her that she is welcome to return any time she has questions, concerns or problems