Proceedings in Obstetrics and Gynecology, 2013; 3(2):1

A select issue in the : contraception

The importance of providing postpartum contraception counseling

Whitney Cowman, MD,1 Abbey Hardy-Fairbanks, MD,1 Jill Endres, MD,2 Colleen K. Stockdale, MS, MD1

Keywords: postpartum, contraception, guidelines, counseling

Abstract Data from the United States reveals that of the approximately 6.6 million One half of in the United States are pregnancies per year, one-half are unintended and associated with adverse unintended.1-3 Of the approximately 61 outcomes. The postpartum period is million women of reproductive age in an important, yet underutilized, time to initiate 2006-2010, 62% were using some form contraception. The U.S. Medical Eligibility 4 Criteria for Contraceptive Use, 2010 provides of contraception. 7.7% of those not evidence-based guidelines for choosing a using contraception had intercourse in contraceptive method and an update in 2011 the previous 3 months, and represent specifically addresses contraceptive method use those at highest risk for unintended in the puerperium. The variety of contraceptive pregnancy.5 Unintended pregnancies methods include hormonal contraception, lactational , barrier contraception, are associated with adverse pregnancy natural family planning, and sterilization. Ideally, outcomes and behaviors, including late counseling about contraceptive choice should entry into prenatal care, decreased begin early in pregnancy care and continue breastfeeding, and low birth weight.6 postpartum; it should also include a variety of Also, short interval pregnancies are at teaching modalities. Specifically we recommend LARC options such as intrauterine devices and increased risk for obstetric etonorgestrel implants, postpartum tubal complications, including low birth sterilization, and progestin-only pills for those weight, preterm birth and neonatal desiring an oral method. mortality.7-9 The optimal interval 1Department of Obstetrics and Gynecology, between pregnancies is debated, but Carver College of Medicine, University of Iowa greater than 11-18 months has been Hospitals and Clinics, Iowa City, IA, 522422 suggested as reducing complications in 7,8 2 the subsequent pregnancy. Department of Family Medicine, University of Postpartum contraception is vital to the Iowa Hospitals and Clinics, Iowa City, IA, 52242 reduction of short interval pregnancies,

which is a significant source of neonatal

Please cite this paper as: Cowman W, Hardy-Fairbanks A , Endres J. Stockdale CK. A select issue in the postpartum period: contraception. Proc Obstet Gynecol. 2013;3(2):Article 1 [15 p.]. Available from: http://ir.uiowa.edu/pog/. Free full text article.

Corresponding author: Whitney Cowman, Department of Obstetrics and Gynecology, University of Iowa, 200 Hawkins Drive, Iowa City, IA 42242. [email protected]

This is an Open Access article distributed under the terms of the Creative Commons Attribution 3.0 Unported License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. 1

Proceedings in Obstetrics and Gynecology, 2013; 3(2):1 morbidity and medical care costs. criteria can be used to evaluate options for women in the postpartum period with The immediate puerperium is an and without chronic medical conditions. important period to initiate Updates to the CDC-MEC 10 contraception. Women are often recommendations specific for motivated to prevent or delay another postpartum women were released in pregnancy, they have immediate access 2011 and will be reviewed here. to health care providers, and they are known not be pregnant.10,11 Because Hormonal contraception ovulation may occur as early as 25 days postpartum among women not Combined and progestin breastfeeding, providing an effective hormonal contraceptive agents (oral contraceptive method during the combined hormonal contraceptive puerperium is vitally important in pills, transdermal patch, ) reducing unintended pregnancy.12 Hormonal contraceptives are among the The puerperium is a unique time period most used methods of contraception in in a woman’s life, resulting in unique the United States. In fact, according to contraception needs. Understanding the most recent data from the National and communicating the risks and Center for Health Statistics, the oral benefits of the various contraceptive contraceptive pill is used by 17.1% of all methods is vital, as some contraceptive reproductive age women (28% of forms are better suited than others for women using some form of use during this time period. contraception), 1.3% use the contraceptive ring, and 0.9%, the In 2010, the Centers for Disease Control implant or transdermal patch.5 These (CDC) published U.S. Medical Eligibility methods prevent ovulation by Criteria for Contraceptive Use, 2010 (US suppressing hypothalamic 13 MEC), providing evidence-based gonadotropin-releasing factors, which guidelines for choosing a contraceptive then prevents pituitary secretion of FSH method based on the relative safety for and LH. prevent ovulation by women with certain suppressing FSH release, and also characteristics/conditions, including stabilize the . Progestins those who are postpartum. A category suppress LH, thicken cervical mucus, 1 distinction indicates that there are no and render the endometrium restrictions for the use of a particular unfavorable for implantation.14 Oral contraceptive method. Category 2 progestin-only options can provide designates that the method may be contraceptive efficacy, although the used but that individualization and estrogen component improves cycle careful follow-up may be required. control, unfortunately at the expense of Category 3 indicates that a certain estrogenic side effects such as nausea, method is generally not recommended breast tenderness and thromboembolic unless other methods are unavailable or events.15 Progestins produce unacceptable. Category 4 notes an androgenic side effects such as acne, unacceptable health risk may be hirsutism and lipid changes.15 The 13 conferred with use. The CDC-MEC overall side effect profile, therefore, is

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dependent upon the concentration of suppressive effect on lactation. Those each hormone and specific type of with 35 mcg or less, still have some progestin.15 suppressive effects, and low-dose combination oral contraceptives Combined hormonal contraceptive pills containing 0.03 mg ethinyl estradiol and have many benefits, including familiarity 0.15 mg levonorgestrel in women who with the method, effectiveness, safety, had been nursing for one month, had a reversibility, cycle control, decrease in small but significant decrease in , decrease in days of lactation performance and in weight gain bleeding and amount of blood loss and of their infants17 or cause maternal 16 other, non-contraceptive benefits. anxiety about milk supply. This slight Non-oral delivery methods such as the inhibition of lactation induced by transdermal patch or vaginal ring have combined oral contraceptive agents may the additional advantage of eliminating be sufficient enough to discourage the need for daily compliance, as well as women from continuing breastfeeding, offering a different pharmacokinetic particularly in those whose desire to 15 profile. Daily intake of oral combined nurse is marginal.17 On the other hand, hormonal contraceptives creates peaks a 2003 Cochrane review concluded that and troughs in ethinyl estradiol there was insufficient evidence to concentrations, whereas the ring and establish the effect of combined patch deliver more constant levels. hormonal contraceptives, if any, on milk Exposure is lowest with the ring, while quality or quantity18 and a systematic the patch is associated with the greatest review confirmed an inconsistent effect 15 overall exposure. Intermenstrual of combined oral contraceptives on bleeding, amenorrhea, breast breastfeeding duration and success, tenderness, abdominal bloating, and found that infant outcomes were not headache and nausea are a few of the affected.19 common side effects of combined oral contraceptives. The transdermal patch An update to the US MEC, specifically has similar side effects, though breast regarding use of contraceptive methods discomfort and dysmenorrhea are during the postpartum period, was significantly more common. The most published in 2011.11 These updated frequent side effects associated with the recommendations describe specific vaginal ring are headache, leukorrhea, guidelines stating that all postpartum , weight gain and nausea.15 women should not use combined hormonal contraceptives during the first Despite the advantages, there are 21 days postpartum due to significant several reasons why combined increased risk of venous hormonal contraceptives are not thromboembolism (VTE) (category 4). typically used in the puerperium. The During days 21-42, non-breastfeeding safety and timing of contraceptive women with risk factors for VTE (e.g. initiation during lactation are subject to prior VTE, recent cesarean delivery, or debate. Studies of hormonal smoking), should not use these methods contraceptive agents with doses of for the same reason of increased VTE ethinyl estradiol or mestranol of 50 mcg risk (category 3). Without additional risk or more have demonstrated a factors for VTE, use of combined

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hormonal contraceptive during days 21- In a recent review on the topic, studies 42 is category 2, thus acceptable. After examining the initiation of progestogen- 42 days postpartum, no exceptions only methods among postpartum apply and use of combined hormonal women consistently concluded that contraceptives for all non-breastfeeding there were no overall, adverse effects women is category 1. In breastfeeding on measures of breastfeeding success, postpartum women, from 21 days to < such as duration of breastfeeding or 30, regardless of the presence of time to supplementation.21 Studies also, additional risk factors for VTE, use is importantly, showed no consistent category 3. Without additional risk adverse effects on infant health factors for VTE, use of combined outcomes such as growth, gross hormonal contraceptive from day 30 development, psychomotor forward, is category 2.11 (see table 1) development, milestones, and general Since ovulation is unlikely in the first health.21 DMPA is commonly month after delivery, women can be administered to US women before they provided with a prescription for are discharged from the hospital and combined hormonal contraception to has been recommended immediately begin at one month (30 days from postpartum by some experts.22 There delivery). are limited studies specifically examining administration of DMPA prior Progestogen-only contraceptives to hospital discharge in breastfeeding (progestin-only oral contraceptive women, although existing studies have pills, injectables) not shown detrimental effects on breastfeeding, infant growth, or development.21 Progestogen-only hormonal methods, including progestin-only pills and depot Some of the disadvantages of medroxyprogesterone acetate (DMPA) progestogen-only methods include the injections have long been recommended strict regimen of compliance required by as an alternative to combined hormonal progestin-only pills, prolonged and contraceptives in the postpartum period. frequent bleeding in the etonorgestrel They are safe for postpartum women, implant (Nexplanon), irregular menstrual including women who are breastfeeding, bleeding and prolonged and can be initiated immediately after discontinuation of DMPA, as well postpartum (categories 1 and 2)11 (see as weight gain and loss of bone mineral table 1). Because progesterone density (most relevant for withdrawal may be the stimulus that adolescents).14,23 Progestin-only pills initiates lactogenesis, administration of should be avoided in Hispanic women progestin-only methods shortly after with gestational diabetes who are delivery could theoretically inhibit or breastfeeding, because of an increased alter lactation, so some authors risk for subsequent development of type recommend waiting at least 3 days II diabetes.17 Contraindications include postpartum for administration,20 women with unexplained uterine however data for this is lacking and the bleeding, known breast cancer, benign risk of repeat pregnancy may outweigh or malignant liver tumors, or acute liver the theoretical risk of altered lactation. disease.14

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Table 1. US MEC guidelines for contraceptive use

Condition COC/Ring/Patch Progestin- DMPA Implants LNG- Copper- only pill releasing containing IUC IUC Postpartum (non-breast-feeding) <21 days 4 1 1 1 21 – 42 days Risk factors 3 1 1 1 None 2 1 1 1 >42 days 1 1 1 1

Postpartum (breast-feeding} <21 days 4 2 2 2 21 to <30 Risk factors 3 2 2 2 None 3 2 2 2 30 - 42 Risk factors 3 1 1 1 None 2 1 1 1 >42 days 2 1 1 1

Postpartum (breast-feeding, non- breastfeeding, cesarean delivery) <10 min after 2 1 placental delivery 10 min to <4 weeks 2 2 after placental delivery ≥4 weeks 1 1 Peurperal sepsis 4 4

Abbreviations: COC (combined oral contraceptive), DMPA (depot medroxyprogesterone acetate injection), LNG (levonorgestrel), IUC (intrauterine contraceptive.

Key: 1 - no restriction; 2 - advantages generally outweigh theoretical risks; 3 - theoretical or proven risks usually outweigh the advantages; 4 - unacceptable health risk

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Long-acting reversible contraceptive progesterone-releasing. Some of the methods (progestogen-only methods pertinent contraindications in the including subdermal implants and puerperium include postpartum intrauterine contraceptives) and uterine anomalies.14,17 With appropriate counseling, the IUC may be used in women with a history of Intrauterine contraception (IUC) in the ectopic pregnancy or with risk factors for postpartum period warrants special ectopic pregnancy.13 consideration, especially given the push for long-acting reversible contraceptives. While traditionally inserted 4-8 weeks According to a recent American College postpartum,14,26,27 there is much interest of Obstetricians and Gynecologists in the option of immediate post-placental committee opinion, the United States’ insertion. Insertion of an IUC high unintended pregnancy rate may be immediately after delivery is appealing in part, due to a relatively low use of for many reasons; the woman is known long-acting reversible contraceptive not to be pregnant, her motivation for (LARC) methods.24 Despite an increase contraception may be high, and for in use since 1995 (when 0.8% of US those women with limited access to women chose intrauterine medical care, hospitalization related to contraceptive), only 3.5% of all the delivery affords a unique opportunity reproductive age women and 5.6% of to address the need for contraception.28 contraceptive-using women use an One US study showed that of 193 intrauterine contraceptive device.3 women who desired a postpartum IUC, 35% did not return for a postpartum visit IUCs, including the levonorgestrel- and only 60% actually received an IUC. releasing IUC and copper-containing Seven (3.6%) of these women actually IUC, are highly effective in preventing became pregnant before they were able pregnancy, with pregnancy rates less to receive an IUC.29 Other studies have than 1 per 100 woman-years.25 described similar findings.28 Therefore, Excellent candidates include women immediate postpartum insertion would who desire inter-pregnancy interval of certainly seem to improve utilization more than 2 to 3 years, desire long-term rates. In a small study investigating contraception but prefer to avoid postpartum insertion immediately (within sterilization, breastfeeding women, 10 minutes of delivery), early women with side effects from hormonal (10 min to 48 hours postpartum), or contraception, and women with prior interval (≥6 weeks postpartum), there birth control failures,17 though all women was no difference in utilization rates who desire highly effective between groups at 3 and 6 months contraception should be considered postpartum.26 Another study echoed candidates. In general, disadvantages these results, finding that use of the include the uncommon side effects of levonorgestrel-releasing IUC at 6 uterine perforation, expulsion and months postpartum was not different discontinuation secondary to side between women who received post- effects, such as increased vaginal placental or delayed insertion.30 These bleeding in copper-containing devices findings come despite the higher and decreased in expulsion rates with post-placental

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insertion, which vary from 10-27%,26,28,31 use of contraceptive implants and and even 38% in one study,10 compared intrauterine contraceptives (IUCs) could with 1-6% at one year with interval reduce repeat pregnancy among insertion.26,30 With close clinical follow- adolescent mothers.24 Typical use up (2 weeks postpartum suggested by pregnancy rates are lower and one author26) and early identification of continuation rates are higher for LARCs expulsions so that reinsertion can occur, when compared to oral hormonal overall continuation/utilization rates at 3 methods. and 6 months may not be impacted.26,30 In a US study of adolescent mothers, A Cochrane review on the topic initiation of the six-rod contraceptive concluded that immediate post-partum implant (Norplant) was the factor most insertion of IUCs appears safe and strongly associated with repeat effective.28 According to guidelines by pregnancy prevention in the first 2 US MEC, IUCs, including the postpartum years.34 Despite the levonorgestrel-releasing IUD and unavailability of Norplant in the US, in a copper-containing IUD, may be inserted recent study investigating early initiation postpartum, including immediately after of the etonogestrel implant versus an delivery (categories 1 and 2) and are not intrauterine contraceptive, the implant associated with an increase in was far more likely to be received prior complications.11,13,30 The convenience to resumption of sexual activity than the of immediate postpartum insertion of a IUC.33 long-acting reversible contraception (LARC) reduces barriers to access, Lactational amenorrhea method possibly outweighing the known disadvantage of an increased expulsion Postpartum ovulation and return to rate.24 fertility is delayed for breastfeeding women, to 8-10 weeks or more.14,16,17 Studies reviewed by Truitt et al. did not Lactational amenorrhea can be used as find that IUCs interfere with lactation,18 an effective method of contraception though a more recent study investigated provided the woman is exclusively the impact on breastfeeding duration by breastfeeding (on demand, day and post-placental or delayed levonorgestrel night more than 5 times per day, total intrauterine device insertion.32 These suckling duration greater than 65 authors found that more women in the minutes, and at least 10 minutes per 35 delayed group compared with the post- feed), has not resumed menses and is 16,23,27 placental group continued to breastfeed within six months of delivery. This at 6–8 weeks, 3 months, and 6 months method, when used properly, is at least postpartum.32 The difference was only 98% effective during the first 6 months 16,36 significant at 6 months. postpartum. Lactational amenorrhea becomes less effective Approximately 14–35% of adolescent after 6 months postpartum, or when mothers become pregnant again within menstrual bleeding resumes, or one year of delivery, despite intention to supplemental feedings are introduced. use contraception.33 We know from At which point another form of emerging evidence that increasing the contraception must be initiated to

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reliably prevent pregnancy.16 Indeed, a using some form of contraception),5 and recent World Health Organization protection against sexually transmitted (WHO) study on lactational amenorrhea infections. Condoms are often advised revealed that cumulative pregnancy for postpartum women who wish to rates at 12 months were as high as postpone a decision about contraceptive 7.4%.23 Even in breastfeeding women therapy or sterilization until the whose amenorrhea extends beyond 6 postpartum visit.17 With perfect and months, there is an increased tendency typical use, pregnancy rates with for the first ovulation to precede the first condoms are 2% and 15% ; thus the contraceptive respectively.25 Pregnancy rates for the reliability of breastfeeding diminishes other barrier methods are substantially with time. 12,14,27 higher.25 The diaphragm has the disadvantages of requiring fitting by a Even women planning on using physician and re-fitting is required after lactational amenorrhea for postpartum delivery due to changes in the contraception may benefit from and . Additionally, weight anticipatory guidance and/or provision of alterations and deliveries might change 16 contraceptives. One US study the vaginal diameter.23 In breastfeeding demonstrated that 8% of women who women, low estrogen levels contribute were planning on breastfeeding their to vaginal dryness and tightness, newborns at the time of discharge from making proper fitting of a diaphragm the hospital never initiated more difficult. Proper size of the breastfeeding, and another 22% diaphragm should be determined at the discontinued prior to the sixth 6-week postpartum visit.17 The only side postpartum week, putting them at risk of effects are vaginal wall irritation and an conception earlier than fully increased risk of urinary tract 36 breastfeeding women. The success of infections.23 this method is more likely to be achieved in highly motivated couples Natural family planning than among the general population.30 In women with regular cycles, for whom Barrier contraception periods of abstinence are acceptable, natural family planning may be used17 The use of barrier methods, including but is generally considered less reliable condoms, spermicides, and than combined-hormonal or progestin- diaphragm/cap, have a category 1 only methods, IUCs, condoms, or LAM. distinction from the US MEC for use in Pregnancy rates with perfect use vary all cases postpartum, with the one between 1 to 9%.25 Because regular exception of the diaphragm/cervical cap, menses are required of this method, in which cannot be used less than 6 weeks breastfeeding women less than 6 weeks postpartum due to lack of complete postpartum, both the symptom-based 13 uterine involution. For condoms in (basal body temp and cervical particular, advantages are familiarity secretions) and calendar-based with this method, as they are used for methods should not be used. Greater contraception by 10.2% of all women in than 6 weeks postpartum and with the the United States (16.4% of women resumption of menses, both methods

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should be used with caution and may helping reduce unintended pregnancy. require additional counseling to ensure the woman is using the method Postpartum contraception education correctly. When at least 3 postpartum for patients; when to start and how to menses have occurred and cycles are counsel? regular again, a calendar-based method can be used.13 In non-breastfeeding Many reasons contribute to the women, neither fertility awareness continued rate of unintended pregnancy; based method should be used less than these include lack of patient education, 4 weeks postpartum. Greater than 4 ineffective contraceptive methods, weeks postpartum, women may use inconsistent use of contraception, unplanned sexual activity, and symptom-based methods without 38 restriction or caution. Calendar-based contraceptive failure. While many of methods may be used as soon as they these factors are patient-dependent, contraceptive counseling is one in the have completed three postpartum 39 menses. Methods appropriate for the purview of clinicians. The postpartum postpartum period should be offered period represents a unique opportunity before that time.13 to provide contraception counseling. These women have close contact with Sterilization providers, allowing time to discuss the many contraceptive options. Female sterilization is used by 27% of Additionally, prenatal care visits offer contraceptive-using women or 16.5% of additional opportunities to provide all reproductive age women in the patients with information about United States,5 and the puerperium is a contraception after delivery.40 convenient time for tubal ligation. There Contraceptive counseling is particularly are no restrictions on the important for women who have recommendations for sterilization experienced an unwanted pregnancy postpartum,13 and it can be performed and those at risk for repeat unintended at the time of cesarean section or up to pregnancy.39 For some, counseling 48 hours after delivery.17 However, a during pregnancy may be the first time small proportion of women regret this having received any education on decision (1%–26% from different contraception.39 studies, with higher rates of regret reported by women who were younger A CDC report summarizing the results of at sterilization,13 which must be the 2004-2006 Pregnancy Risk considered while counseling patients Assessment Monitoring System and likely benefits from perinatal (PRAMS) survey, indicated that 88.0% counseling). Unfortunately, only 50% of of postpartum women at risk for women who desire postpartum unintended pregnancy (not pregnant sterilization actually undergo the and sexually active) reported current procedure and nearly one half of women use of at least one contraceptive with unfulfilled sterilization request method 2-9 months postpartum. 61.7% become pregnant again within one reported using a method defined as year.37 Ensuring that sterilization is highly effective (sterilization, vasectomy, available in the puerperium is vital to shot, pill, ring, patch or intrauterine

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device), 20.0% used a method defined based on a limited number of studies.43 as moderately effective (condoms), and There is evidence to suggest that 6.4% used less effective methods prenatal counseling may be especially (including diaphragm, cervical cap, beneficial in increasing contraceptive sponge, rhythm or withdrawal). Women use among women with lower levels of with no prenatal care had the lowest education45 or low-income women at rate of use, at 76.4%.41 Yet other reports high risk for repeat unintended from demographic and health surveys in pregnancy.47 Given that women with no 27 countries indicate that as many as prenatal care had the lowest rate of 2/3 of postpartum women had an unmet postpartum contraception use, at 76.4%, need for contraception.42 these women might benefit from more consultation about postpartum Contraceptive education is considered contraceptive options.41 by many to be a standard component of postpartum care.43 Indeed, various Several small studies have investigated studies have indicated that between 77- the way in which postpartum 82% of women receive antenatal contraception is approached in an counseling regarding postpartum attempt to determine which method may contraception,38-40 though one small be most effective.38,46-48,50 For example, study showed that contraception was women who watched a video were less discussed antenatally with only 4% of satisfied than those who had received women.44 Postpartum discussions are counseling from a physician, though the initiated in 68-87% of women.38,40 The video watchers were as likely to be effectiveness of counseling interventions satisfied as those who received a in reducing unintended pregnancy and pamphlet.43 In a paper investigating increasing postpartum contraceptive patient satisfaction and the impact of use, however, has been seldom written material about postpartum examined.39,43 contraceptive decisions in 109 women, women in the intervention group were Of those studies investigating the topic, more likely to state that written material several have concluded that focused contributed to their ultimate choice in contraceptive counseling in the birth control.38 Additionally, those postpartum or antepartum period is women receiving multi-component 45-47 effective, yet others report no impact antepartum contraceptive counseling on contraceptive use following (consisting of counseling, a videotape 48 contraception counseling alone, versus and written material) about oral 49 educational leaflets, or a short-term contraception as well as usual care 40 increase in contraceptive use only. A were more likely to remain not pregnant systematic review (2010) of at their 12 month follow-up, compared to contraceptive counseling interventions those who received usual care only.47 A taking place in the postpartum period, 2008 randomized investigation found including both short-term and multiple- that women who were received contact interventions, concluded that postpartum contraception educational postpartum contraceptive education led leaflets and 20 minute verbal counseling to more contraception use and fewer sessions were more likely to have unplanned pregnancies, though, was started contraception (56.9% versus

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6.3%) by the time of the postpartum Combined hormonal methods such as follow-up visit, and were more likely to the vaginal ring, patch or OCPs should have chosen an effective method (i.e. not be used less than 21 days oral hormonal contraceptive), compared postpartum. However, prescriptions can to those who had not received the be given prior to discharge for initiation educational intervention.46 of these methods after 30 days postpartum. Others have attempted to identify the ideal timing for postpartum Progestin-only pills are a good option for contraception counseling, with one women desiring an oral method and are qualitative study concluding that appropriate for breastfeeding women. counseling should take place throughout the antenatal care process via thorough, References frequent and provider-initiated discussions using multiple teaching 1. Mosher WD, Jones J. Use of contraception in the United States: modalities. Clearly, more work is 1982-2008. Vital Health Stat 23. 2010 needed to identify the optimal timing, Aug;(29):1-44. PubMed PMID: method and content of effective 20939159. perinatal contraceptive counseling that results in reduced unintended 2. Mishell Jr. DR. Chapter 14. Family Planning: Contraception, Sterilization, pregnancy rates, sustainable knowledge 39 and Pregnancy Termination. In: Katz and pregnancy prevention behaviors. VL, Lentz GM, Lobo RA, Gershenson DM, eds. Comprehensive Gynecology. Conclusion 5th ed. Philadelphia: Mosby; 2007.

This review highlights the importance of 3. Ventura SJ, Curtin SC, Abma JC, utilizing the postpartum period to initiate Henshaw SK. Estimated pregnancy rates and rates of pregnancy outcomes contraceptive use among reproductive for the United States, 1990-2008. Natl aged women, in order to decrease the Vital Stat Rep. 2012 Jun 20;60(7):1-21. risk of unintended pregnancy. Ideally, PubMed PMID: 22970648. counseling will begin early on in the antenatal period and include provider- 4. Mosher WD, Jones J, Abma JC. Intended and unintended births in the initiated discussions and a variety of United States: 1982-2010. Natl Health teaching modalities. With a little time Stat Report. 2012 Jul 24;(55):1-28. and effort on the part of the physician, PubMed PMID: 23115878. we can help patients decide on an effective and appropriate method of 5. Jones J, Mosher W, and Daniels K. Current Contraceptive Use in the United contraception. States, 2006-2010, and Changes in Patterns of Use since 1995. National Postpartum tubal ligation is safe and health statistics reports; no. 60. easy to perform. Hyattsville, MD: National Center for Health Statistics. 2012. LARC options such as the etonogestrel http://www.cdc.gov/nchs/data/nhsr/nhsr implant and intrauterine devices may be 060.pdf inserted prior to discharge and may be safely used in breastfeeding women.

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6. Gipson JD, Koenig MA, Hindin MJ. 11. Centers for Disease Control and The effects of unintended pregnancy on Prevention (CDC). Update to CDC's infant, child, and parental health: a U.S. Medical Eligibility Criteria for review of the literature. Stud Fam Plann. Contraceptive Use, 2010: revised 2008 Mar;39(1):18-38. Review. PubMed recommendations for the use of PMID: 18540521. DOI: 10.1111/j.1728- contraceptive methods during the 4465.2008.00148.x postpartum period. MMWR Morb Mortal Wkly Rep. 2011 Jul 8;60(26):878-83. 7. Zhu BP, Rolfs RT, Nangle BE, Horan PubMed PMID: 21734635. JM. Effect of the interval between pregnancies on perinatal outcomes. N 12. Jackson E, Glasier A. Return of Engl J Med. 1999 Feb 25;340(8):589- ovulation and menses in postpartum 94. PubMed PMID: 10029642. nonlactating women: a systematic http://dx.doi.org/10.1056/NEJM1999022 review. Obstet Gynecol. 2011 53400801 Mar;117(3):657-62. doi: 10.1097/AOG.0b013e31820ce18c. 8. Grisaru-Granovsky S, Gordon ES, PubMed Haklai Z, Samueloff A, Schimmel MM. Effect of interpregnancy interval on 13. Centers for Disease Control and adverse perinatal outcomes--a national Prevention (CDC). U S. Medical study. Contraception. 2009 Eligibility Criteria for Contraceptive Use, Dec;80(6):512-8. doi: 2010. MMWR Recomm Rep. 2010 Jun 10.1016/j.contraception.2009.06.006. 18;59(RR-4):1-86. PubMed PMID: Epub 2009 Jul 22. PubMed PMID: 20559203.PMID: 21343770. 19913144. 14. Cunningham FG, Leveno KJ, Bloom 9. Smith GC, Pell JP, Dobbie R. SL, Hauth JC, Rouse DJ, Spong CY. Interpregnancy interval and risk of Chapter 32. Contraception. In: preterm birth and neonatal death: Cunningham FG, Leveno KJ, Bloom SL, retrospective cohort study. BMJ. 2003 Hauth JC, Rouse DJ, Spong CY, eds. Aug 9;327(7410):313. Williams Obstetrics. 23rd ed. New York: http://dx.doi.org/10.1136/bmj.327.7410.3 McGraw-Hill; 2010. 13 Erratum in: BMJ. 2003 Oct 11;327(7419):851. PubMed PMID: 15. Bitzer J, Simon JA. Current issues 12907483. and available options in combined http://dx.doi.org/10.1136/bmj.327.7419.8 hormonal contraception. Contraception. 51 2011 Oct;84(4):342-56. doi: 10.1016/j.contraception.2011.02.013. 10. Stuart GS, Bryant AG, O'Neill E, Epub 2011 Apr 27. PubMed PMID: Doherty IA. Feasibility of postpartum 21920188. placement of the levonorgestrel intrauterine system more than 6 h after 16. Jackson E. Controversies in vaginal birth. Contraception. 2012 postpartum contraception: when is it Apr;85(4):359-62. doi: safe to start oral contraceptives after 10.1016/j.contraception.2011.08.005. ? Thromb Res. 2011 Feb;127 Epub 2011 Sep 28. PubMed PMID: Suppl 3:S35-9. doi: 10.1016/S0049- 22067759. 3848(11)70010-X. PubMed PMID: 21262436.

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