Contraception guidance for postpartum period

Get ready to revise your practice: the U.S. Medical Eligibility Criteria for Contraceptive Use has been updated regarding postpartum contraception.1

The new guidance states that postpartum women should not use combined hormonal contraceptives during the first 21 days after delivery because of the high risk for venous thromboembolism (VTE) during this period. During 21-42 days postpartum, women without risk factors for VTE generally can initiate combined hormonal contraceptives, but women with VTE risk factors generally should not use these methods, the new guidance states. After 42 days postpartum, no restrictions on the use of combined hormonal contraceptives based on postpartum status apply.1

While this new guidance from the Centers for Disease Control and Prevention (CDC) emphasizes the higher than previously appreciated risk of thrombosis in the first six weeks following childbirth (which is the rationale for avoiding estrogen-progestin contraceptives during this time interval), it also reminds clinicians that it is safe to initiate progestin-only methods immediately postpartum, regardless of lactation status, says Andrew Kaunitz, MD, professor and associate chair in the Obstetrics and Gynecology Department at the University of Florida College of Medicine — Jacksonville. Kaunitz served on the review team that led to the revised guidance.

In 2010, the World Health Organization updated its guidance on the safety of combined hormonal contraceptives among postpartum nonbreastfeeding women to be more restrictive regarding the use of combined hormonal contraceptives during the first 42 days postpartum, particularly among women with other risk factors for VTE, based on findings from new evidence.2,3 Because of the international update, CDC initiated a process to assess whether its guidance similarly should be changed.

Get the word out

Clinicians who have signed up for updates to the U.S. guidance should have received an e-mail alert through the CDC regarding the change, says Naomi Tepper, MD, obstetrician/gynecologist with the Division of Reproductive Health at CDC. Tepper served as lead author for the new guidance. [To sign up for e-mail updates, go to the U.S. Medical Eligibility Criteria for Contraceptive Use web site, www.cdc.gov/reproductivehealth/UnintendedPregnancy/USMEC. Select "Sign up to receive U.S. Medical Eligibility Criteria (USMEC) e-mail updates."]

The CDC also is developing new provider tools that will include the updated guidance, including a contraceptive choice wheel, similar to pregnancy/gestation calendar wheels used by many reproductive health providers, says Tepper. Software developers also are creating a smartphone application to allow providers to access the criteria on their portable devices, says Tepper.

News of the revised guidance is being disseminated through professional organizations that have been involved in developing the criteria, says Tepper. "We are relying on their help in getting the word out to their memberships," she says.

Check the options

Recommendations for other contraceptives, including progestin-only contraceptives and intrauterine devices, remain unchanged in the new guidance. Such methods are safe for postpartum women, including women who are breastfeeding, and can be initiated immediately postpartum.

Why is contraception so important for postpartum women? Results from the most recent cycle of the National Survey of Family Growth indicate that 49% of all pregnancies were unintended, and 21% of women gave birth within 24 months of a previous birth.4 Ovulation can occur as early as 25 days postpartum among nonbreastfeeding women, so time is of the essence when initiating contraception in the postpartum period.5

A 2009 review of the types of contraception being used by women 2-9 months postpartum shows that 88.0% of postpartum women report current use of at least one birth control method; 61.7% report using a method defined as highly effective, 20.0% use a method defined as moderately effective, and 6.4% use less effective methods.6 Rates of using highly effective contraceptive methods postpartum were lowest among women who had no prenatal care (54.5%).6

References

  1. Tepper NK, Curtis KM, Jamieson DJ, et al. Update to CDC's U.S. Medical Eligibility Criteria for Contraceptive Use, 2010: Revised recommendations for the use of contraceptive methods during the postpartum period. MMWR 2011; 60:878-883.
  2. Jackson E, Curtis K, Gaffield M. Risk of venous thromboembolism during the postpartum period: a systematic review. Obstet Gynecol 2011; 117:691-703.
  3. World Health Organization. Combined Hormonal Contraceptive Use During the Postpartum Period. Geneva, Switzerland: World Health Organization; 2010. Accessed at http://whqlibdoc.who.int/hq/2010/WHO_RHR_10.15_eng.pdf.
  4. Chandra A, Martinez GM, Mosher WD, et al. Fertility, family planning, and reproductive health of U.S. women: data from the 2002 National Survey of Family Growth. Vital Health Stat 2005; 23:1-160.
  5. Jackson E, Glasier A. Return of ovulation and menses in postpartum, non-lactating women: a systematic review. Obstet Gynecol 2011;117:657-662.
  6. Centers for Disease Control and Prevention (CDC). Contraceptive use among postpartum women — 12 states and New York City, 2004-2006. MMWR 2009; 58:821-826.