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Contraception after pregnancy

  • This Guidelines  summary focuses specifically on those recommendations relating to the discussion and provision of contraception after pregnancy and childbirth. Please refer to the original guideline for a full list of recommendations, including those relating to contraception after abortion, ectopic pregnancy, miscarriage, or gestational trophoblastic disease: www.fsrh.org

Discussion and provision of contraception after pregnancy

What methods of contraception are available in the UK? 

  • Clinicians should refer to the relevant current FSRH guidelines, including the UK Medical Eligibility Criteria for Contraceptive Use (UKMEC), when making a clinical judgement on safe and appropriate methods of contraception for a woman after pregnancy

Effectiveness of contraceptive method

  • Women should be informed during pregnancy about the effectiveness of different contraceptives, including the superior effectiveness of long-acting reversible contraception (LARC), when choosing an appropriate method to use after pregnancy

Information giving and counselling

  • All clinicians involved in the care of pregnant women should provide the opportunity to discuss contraception

  • Whenever contraceptive counselling is provided, care should be taken to ensure women do not feel under pressure to choose a method of contraception

  • Clinicians should adopt a person-centred approach when providing contraceptive counselling 

  • Clinicians who are giving advice to women about contraception after pregnancy should ensure that this information is timely, up to date, and accurate

  • Comprehensive, unbiased, and accurate information on contraceptive methods after pregnancy should be made available in different languages and formats including audio-visual

Provision of contraception

  • Services providing care to pregnant women should be able to offer all appropriate methods of contraception, including LARC, to women before they are discharged from the service 

  • Services should ensure that there are sufficient numbers of staff able to provide intrauterine contraception (IUC) or progestogen-only implants (IMP) so that women who choose these methods and are medically eligible can initiate them immediately after pregnancy

  • Women who are unable to be provided with their chosen method of contraception should be informed about services where their chosen method can be accessed. A temporary (bridging) method should be offered until the chosen method can be initiated 

Discussing women’s contraceptive needs 

  • Clinicians should discuss with the woman any medical or social factors that may be relevant to her choice of contraceptive method after pregnancy

  • Clinicians should clearly document the discussion and provision of contraception. Valid consent must be obtained before providing women with their chosen method

Provision of continuing care and support

  • Clinicians should facilitate opportunities to discuss issues with the woman in private without a partner, friend or relative being present

  • Clinicians should know how to enquire about gender-based violence (GBV) and how to support women affected by GBV and abuse, including providing access to information and referral to specialist support

  • Services involved in the care of pregnant women should have agreed pathways of care to local community sexual and reproductive health (SRH) services for women with complex medical conditions or needs which may require specialist contraceptive advice 

  • Services should have agreed pathways of care to local services for women who may require additional non-medical care and support

Discussion and provision of contraception after childbirth

When should contraception after childbirth be discussed/provided?

  • Maternity services (including services providing antenatal, intrapartum, and postpartum care) should give women opportunities to discuss their fertility intentions, contraception and preconception planning

  • Whenever contraceptive counselling is provided, care should be taken to ensure women do not feel under pressure to choose a method of contraception

  • Effective contraception after childbirth should be initiated by both breastfeeding and non-breastfeeding women as soon as possible, as sexual activity and ovulation may resume very soon afterwards

  • Maternity service providers should ensure that all women after pregnancy have access to the full range of contraceptives, including the most effective LARC methods, to start immediately after childbirth. This should not be limited to those women with conditions that may pose a significant health risk during pregnancy and vulnerable groups (including young people) at risk of a short interpregnancy interval (IPI) or an unintended pregnancy

  • Women should be informed about the effectiveness of the different contraceptive methods, including the superior effectiveness of LARC, when choosing an appropriate method to use after childbirth

  • Clinicians should adopt a person-centred approach when providing women with contraceptive counselling

  • Clinicians who are giving advice to women about contraception after childbirth should ensure that this information is timely, up-to-date and accurate 

  • Comprehensive, unbiased, and accurate information on contraceptive methods postpartum should be made available in different languages and in a range of formats including audio-visual

  • Contraceptive counselling should be made available to women in the antenatal period to enable them to choose the method they wish to use after childbirth

  • Any contraceptive counselling (general or specialist) needs to be given in conjunction with easy access to contraception in the immediate postpartum period

When can contraception after childbirth be initiated? 

  • The choice of contraceptive method should be initiated by 21 days after childbirth 

  • A woman’s chosen method of contraception can be initiated immediately after childbirth if desired and she is medically eligible

  • Women should be advised that IUC and IMP can be inserted immediately after delivery

  • Clinicians should be aware that insertion of IMP soon after childbirth is convenient and highly acceptable to women. This has been associated with high continuation rates and a reduced risk of unintended pregnancy

  • Clinicians should be aware that insertion of IUC at the time of either vaginal or caesarean delivery is convenient and highly acceptable to women. This has been associated with high continuation rates and a reduced risk of unintended pregnancy

How long should a woman wait before trying to conceive again? 

  • Women should be advised that an IPI of less than 12 months between childbirth and conceiving again is associated with an increased risk of preterm birth, low birthweight, and small for gestational age (SGA) babies

Who should provide contraception to women after childbirth?

  • Appropriately trained clinicians including SRH doctors and nurses, obstetricians, midwives, nurses, GPs, and health visitors should be able to provide women with contraception after childbirth

  • Maternity services should be able to provide IUC and progestogen-only methods, including IMP, injectable (POI) or pill (POP), to women before they are discharged from the service after childbirth

  • Maternity services should ensure that there are sufficient numbers of staff able to provide IUC or IMP so that women who choose these methods and are medically eligible can initiate them immediately after childbirth

  • Women who are unable to be provided with their chosen method of contraception should be informed about services where their chosen method can be accessed. A temporary (bridging) method should be offered until the chosen method can be initiated

  • Maternity services should have agreed pathways of care to local specialist contraceptive services (e.g. community SRH services) for women with complex medical conditions or needs which may require specialist contraceptive advice

  • Maternity services should have agreed pathways of care to local services for women who may require additional non-medical care and support

  • Clinicians should clearly document the discussion and provision of contraception after childbirth. Valid consent must be obtained before providing women with their chosen method

Medical eligibility

Which methods of contraception are safe to use after childbirth? 

  • Women should be advised that although contraception is not required in the first 21 days after childbirth, most methods can be safely initiated immediately, with the exception of combined hormonal contraception (CHC)

Can women who develop medical problems during pregnancy safely use contraception after childbirth?

  • Clinicians should discuss with the woman any personal characteristics or existing medical conditions, including those that have developed during pregnancy, which may affect her medical eligibility for contraceptive use

Is emergency contraception (EC) safe to use after childbirth?

  • Emergency contraception (EC) is indicated for women who have had unprotected sexual intercourse (UPSI) from 21 days after childbirth, but is not required before this

  • Oral EC levonorgestrel 1.5 mg (LNG-EC) and ulipristal acetate 30 mg (UPA-EC) are safe to use from 21 days after childbirth. The copper intrauterine device (Cu-IUD) is safe to use for EC from 28 days after childbirth

  • Women who breastfeed should be informed that available limited evidence indicates that LNG-EC has no adverse effects on breastfeeding or on their infants

  • Women who breastfeed should be advised not to breastfeed and to express and discard milk for a week after they have taken UPA-EC

Is additional contraception required after initiation of a method after childbirth?

  • Women should be advised that additional contraceptive precautions (e.g. barrier method/abstinence) are required if hormonal contraception is started 21 days or more after childbirth. Additional contraceptive precaution is not required if contraception is initiated immediately or within 21 days after childbirth

Breastfeeding and contraception

Does initiation of hormonal contraceptives affect breastfeeding outcomes or infant outcomes?

  • Women who are breastfeeding should be informed that the available evidence indicates that progestogen-only methods of contraception (LNG-IUS, IMP, POI and POP) have no adverse effects on lactation, infant growth or development

  • Women who are breastfeeding should wait until 6 weeks after childbirth before initiating a CHC method

  • Women who are breastfeeding should be informed that there is currently limited evidence regarding the effects of CHC use on breastfeeding. However, the better quality studies of early initiation of CHC found no adverse effects on either breastfeeding performance (duration of breastfeeding, exclusivity and timing of initiation of supplemental feeding) or on infant outcomes (growth, health and development)

Can women who breastfeed effectively use lactational amenorrhoea method (LAM) as contraception?

  • Women may be advised that, if they are less than 6 months postpartum, amenorrhoeic and fully breastfeeding, the lactational amenorrhoea method (LAM) is a highly effective method of contraception

  • Women using LAM should be advised that the risk of pregnancy is increased if the frequency of breastfeeding decreases (e.g. through stopping night feeds, starting or increasing supplementary feeding, use of dummies/pacifiers, expressing milk), when menstruation returns or when more than 6 months after childbirth

Method-specific considerations

Intrauterine contraception (IUC)

  • IUC can be safely inserted immediately after birth (within 10 minutes of delivery of the placenta) or within the first 48 hours after uncomplicated caesarean section or vaginal birth. After 48 hours, insertion should be delayed until 28 days after childbirth

Progestogen-only implants (IMP)

  • IMP can be safely started at any time after childbirth including immediately after delivery

Progestogen-only injectable (POI)

  • POI can be started at any time after childbirth, including immediately after delivery

Progestogen-only pills (POP)

  • POP can be started at any time after childbirth, including immediately after delivery

Combined hormonal contraception (CHC)

  • All women should undergo a risk assessment for venous thromboembolism (VTE) postnatally. CHC should not be used by women who have risk factors for VTE within 6 weeks of childbirth. These include immobility, transfusion at delivery, body mass index (BMI) ≥30 kg/m2, postpartum haemorrhage, post-caesarean delivery, pre-eclampsia, or smoking. This applies to both women who are breastfeeding and not breastfeeding

  • Women who are not breastfeeding and are without additional risk factors for VTE should wait until 21 days after childbirth before initiating a CHC method

Female sterilisation

  • Female sterilisation is a safe option for permanent contraception after childbirth

  • For sterilisation after childbirth, both Filshie clips and modified Pomeroy technique are effective. Filshie clip application is quicker to perform

  • Women should be advised that some LARC methods are as, or more, effective than female sterilisation and may confer non-contraceptive benefits. However, women should not feel pressured into choosing LARC over female sterilisation

  • Tubal occlusion should ideally be performed after some time has elapsed following childbirth. Women who request tubal occlusion to be performed at the time of a delivery should be advised of the possible increased risk of regret

  • Clinicians should ensure that written consent to be sterilised at caesarean section is obtained and documented at least 2 weeks in advance of a planned elective caesarean section

Barrier methods

  • Male and female condoms can be safely used by women after childbirth

  • Women choosing to use a diaphragm should be advised to wait at least 6 weeks after childbirth before having it fitted because the size of diaphragm required may change as the uterus returns to normal size

Fertility awareness methods (FAM)

  • Fertility awareness methods (FAM) can be used by women after childbirth. However, women should be advised that because FAM relies on the detection of the signs and symptoms of fertility and ovulation, its use may be difficult after childbirth and during breastfeeding 

full guideline available from…

Faculty of Sexual and Reproductive Healthcare

www.fsrh.org/standards-and-guidance

FSRH. Contraception after pregnancy. January 2017.

First included: February 2018.