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

Non breastfeeding:

As early as 3 weeks postpartum – 21 days postpartum

Breastfeeding

Using LAM accurately:

― sometime after 6 months – variable

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 withFP method

Accessibility and availability of products that are necessary to use method

Medical factors

Timing of Initiating FP Methods Postpartum

LAM – with breastfeeding

Condoms – when intercourse resumes

Progestin-only methods –

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

― Non-BF – right away

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

IUCD – when risk of infection and perforation is low

― First 48 hours or after 4-6 weeks

Tubectomy – when tubal inflammation and risk of infection low:

― First 7 days or after 6 weeks

LACTATIONAL AMENORRHOEA METHOD

Temporary Breast feeding related

Criteria: 1. 85% of feeding as breast milk 2. Feeds day and night 3. No menstruation 4. Less than 6 months old.

No medical contradictions No side effects

Mechanism of action: Excessive secretion of prolactin inhibition of pituitary inhibits LH, no effect of FSH + partial inhibition of ovarian response to gonadotrophins decreased production of progesterone and oestrogen no ovulation.Impaired luteal phaseSuckling induced oxytocin release interference with implantation

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

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

Disadvantages: 1. No certain effectiveness2. Difficult for working mothers3. No protection against STDs4. HIV with AFASS fulfilled

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

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

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

No proven effect on breastfeeding, breast milk production or infant growth and development 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 breastmilkMEC Category 3 – risks outweigh the benefits

After 6 weeks of age, safe to initiate progestin-only methodsMEC 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 cancerUterine fibroidsIron-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