Session Objectives
Define postpartum contraception Explain the benefits of birth-spacing Postpartum Contraception: For both breastfeeding and non- Family Planning Methods and breastfeeding women, discuss: Birth Spacing After Childbirth Postpartum return of fertility Timing and initiation of method types Use of key contraception methods Overview of WHO Medical Eligibility Criteria for Contraceptive Use
JHPIEGO in partnership with Save the Children, Constella Futures, The Academy for Educational Development, The American College of Nurse-Midwives and Interchurch Medical Assistance 2
Unmet Need: Fertility Preferences Definitions of Postpartum Women
Postpartum contraception is the initiation According to many DHS surveys: and use of family planning methods during the 92-97% of women do not want another child first year after delivery within 2 years after giving birth Post-placental – within 10 minutes after placenta But 35% of women had their children spaced at delivery 2 years apart or less Immediate postpartum – within 48 hours after 40% of women who intend to use a FP method delivery (e.g., voluntary sterilization) in the first year postpartum are not using one Early postpartum – 48 hours up to 6 weeks Extended postpartum – 48 hours up to one year after birth *Ross JA and Winfrey WL, 2001
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Birth Spacing
Time interval from one child’s birth date until the next child’s birth date Healthy timing and spacing of pregnancy Both infants and mothers are more likely to survive if couples space their births 3 to 5 years apart This means that couples should wait 2 years after the birth of their last baby before trying to conceive Source: FHI 2000
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1 Contraception after Childbirth: Birth Spacing Saves Mothers’ Lives Basic Care and Services
Healthy timing and spacing of Basic care should include: pregnancies has positive effects on Discussion of contraceptive needs maternal health and newborn outcomes Considering client’s reproductive goals Women who have their babies at 27 to 32 Information and counseling about month intervals are methods, their effectiveness rates, and More likely to avoid anemia side effects More likely to avoid 3rd trimester bleeding More likely to survive childbirth Short- and long-term method choices
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Contraception after Childbirth: Basic Counseling Care and Services (cont’d)
Assurance of contraceptive re-supply with Encourage breastfeeding for all access to follow-up care postpartum women Integration with other maternal-infant child care Do not discontinue breastfeeding to begin ANC and postpartum visits Newborn care use of a contraceptive method Immunizations There are many contraceptive choices for HIV/STI prevention breastfeeding women To help clients assess their risk and make necessary These methods do not have negative effects on changes in behavior and choose appropriate FP method breast milk or breastfeeding
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Counseling (cont’d) Return to Fertility
Main goals of FP counseling: To help women (and couples) decide if they want to use a During pregnancy, the cyclic function of contraceptive method. the ovaries is suspended due to presence With the client’s permission, include partner of placental hormones Birth spacing/limiting If she does not want contraception, to help her choose an During early postpartum: appropriate method, taking into consideration whether or Inhibiting effects of estrogen and progesterone not she is breastfeeding. are removed To prepare her to use the method effectively. Levels of Follicle Stimulating Hormone (FSH) To help the woman develop a transition plan from LAM to and Luteinizing Hormone (LH) gradually rise another method Ovarian function begins again To discuss return to fertility Source: Pathfinder 1998.
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2 Return to Fertility: Effect of Lactation Return to Fertility: Effect of Lactation (cont’d)
Non-lactating women: Breastfeeding women: Will menstruate within 12 weeks Period of infertility longer for exclusive or On average first ovulation 45 days after nearly exclusive breastfeeding delivery − Risk of pregnancy On demand feeding blocks ovulation Return to fertility not predictable Likelihood of menses and ovulation is low during first 6 months Ovulation may occur prior to menses
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When to Introduce Methods in Breastfeeding Women Breastfeeding Women
Protected for at least 6 months if using LAM LAM COC POC IUD BTL Con- Fully or nearly fully breastfeeding doms Less than 6 months postpartum At delivery OK NO NO OK OK NO Menses has not returned Protected up to 6 weeks if not using LAM 3 weeks OK NO NO NO NO OK At 6 weeks can use combined methods At 6 weeks can use progestin only methods safely or TL 6 weeks OK NO OK OK** OK OK
All non-hormonal methods are safe for mother 6 months OK OK OK OK OK OK and baby Can use IUD >6 months NA OK OK OK OK OK
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Non-Breastfeeding Women When to Start Contraception
Contraception should be started at the time Timing depends on of or before first intercourse Breastfeeding status Combined hormonal methods should not Method of choice be used until after 3 weeks postpartum Reproductive goals
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3 Medical Eligibility Criteria for Purpose of the Medical Eligibility Contraceptive Use (MEC) Criteria (MEC)
Covers 17 contraceptive methods, 120 medical To guide family planning practices based conditions on the best available evidence Addresses who can use contraceptive method To address and change misconceptions based on medical about who can and cannot safely use methods contraceptive methods Gives guidance to To reduce medical policy and practice providers for clients with medical problems or other barriers (i.e., not supported by evidence) special conditions To improve quality, access, and use of http://www.who.int/reproductive-health/ publications/mec/mec.pdf family planning services
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What Is Answered by MEC? WHO Medical Eligibility Criteria Classification Categories
With clinical With limited Classification Identifies which contraceptive or FP judgment clinical judgment Use method in any Yes 1 method can be safely used in the circumstances Use the method
Generally use: Yes presence of a given individual 2 characteristic or medical condition advantages outweigh risks Use the method Generally do not use: No 3 risks outweigh advantages Do not use the method
No 4 Method not to be used Do not use the method
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Postpartum Contraception for Summary– HIV-Positive Women Contraception and HIV Acquisition
Important information for HIV+ women: Male condoms proven effective; female condoms effectiveness may be similar to Correct and consistent use of male and male condoms female condoms can reduce risk of STI/HIV transmission Spermicides (N-9) not effective against HIV N-9 in WHO MEC is category 4 for HIV-positive Using another contraception in addition to people a condom (dual method use) reduces the IUDs and hormonals do not increase HIV chance of pregnancy, this avoiding mother acquisition from findings of observational to child transmission studies
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4 Integration of HIV with FP Postpartum FP and HIV
HIV prevention should be an integral part HIV-positive women who are not breastfeeding need a of FP services to help clients assess their family planning method immediately risk and make necessary changes in HIV-positive women who are breastfeeding may practice LAM, but will need to choose another method behavior. at 6 months when they stop breastfeeding FP providers should encourage clients to Counsel all women (even when status is unknown) about the importance of postpartum FP: seek VCT to prevent HIV transmission to Significance of safer sex and dual protection partners, to improve quality of life if HIV- Available contraceptive choices positive, and to prevent HIV transmission Healthy timing and spacing if future pregnancy desired to future children. Surgical contraception if no future pregnancy desired
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What is Non-Hormonal Methods Lactational Amenorrhea Method (LAM)?
Non-hormonal methods Exclusively or nearly exclusively breastfeeding LAM On demand around the clock feeding (every 2-3 hours) No supplemental infant feeding Barrier methods Menses has not returned Periodic abstinence (fertility awareness, SDM) Less than 6 months postpartum Male and female sterilization If any of these three factors change, FP is IUDs (Copper) needed to prevent pregnancy All non-hormonal contraceptive methods can Begin planning for FP method to transition at be used safely by breastfeeding women 6 months
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Lactational Amenorrhea Method Transition from LAM… (cont’d)
Before 6 months: For women who exclusively breastfeed: Assist the woman in planning for transition to Fertility is delayed during the first 6 months postpartum another FP method post LAM More than 98% protection from pregnancy At 6 months women will need to begin Effective, safe contraception suitable for most women Non-hormonal another FP method: Non-invasive Weaning from exclusive breastfeeding often Can be used as a transitional method until couple starts decides on or meets criteria for another method Less suckling/less prolactin—ovulation no longer Can be used by HIV+ mothers in addition to condoms, inhibited LAM is consistent with WHO guidelines for HIV+ women Menses and ovulation more likely
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5 Advantages of LAM Disadvantages of LAM
Breastfeeding practices required by LAM have other health benefits for mother No protection against STIs and baby Effectiveness after 6 months uncertain Bonding, protects baby from diseases, healthiest food for baby, etc. Exclusive breastfeeding may not be Universally available convenient for some women Can be used immediately after childbirth Small chance of MTCT during No supplies or procedures needed breastfeeding if mother is HIV-positive Bridge to other contraceptives No hormonal side effects
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Barrier Methods: Condoms Advantages of Condoms
Prevent STIs, including HIV/AIDS as well as When used consistently and correctly, pregnancy when used correctly and with each male condoms are highly effective against act of intercourse pregnancy and STIs/HIV Can be used soon after childbirth A latex sheath or covering made to fit over No hormonal side effects erect penis Can be stopped anytime 97% effective in preventing pregnancy No need for health provider or clinic visit when used correctly every time Usually easy to obtain and sold in many places Anyone can use if not allergic to latex
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Disadvantages of Condoms Fertility Awareness Methods
A man’s cooperation is needed Based on awareness of or ability to May decrease sensation determine fertile time of menstrual cycle Poor reputation—associated with immoral sex, extra-marital sex or prostitution Includes: May be embarrassing/uncomfortable to Basal body temperature/cervical secretions purchase or ask partner to use Calendar calculations Can be weakened if stored too long, in too Standard Days Method − much heat or humidity or if used with oil- Cycle beads based lubricants—may break during use Periodic abstinence during fertile period Some men or women may be allergic to latex
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6 Fertility Awareness Methods/SDM Male Sterilization: Vasectomy
Advantages: A safe, convenient, highly effective and Inexpensive simple form of contraception for men that Not necessary to acquire supplies at is provided under local anesthesia in an clinic/dispensary out-patient setting Disadvantages: Vasectomy is safer, simpler, less Most methods unreliable in postpartum women expensive and equally effective as FS Postpartum women, especially when breastfeeding, need to have 4 menstrual cycles, (tubal ligation) the most recent cycle is 26 to 32 days long Vasectomy is popular in the US and UK Partner’s cooperation needed in periodic abstinence www.maqweb.org Technical briefs 37 38
Male Sterilization: Vasectomy Male Sterilization: Vasectomy (cont’d) (cont’d)
Not effective until after 3 months Highly effective in preventing pregnancy Can be timed to coincide with the (99.6 to 99.8% effective) postpartum period when fertility is reduced Comparable to FS, Implants, IUDs in Ideal with LAM If not using LAM, couple will need to use another preventing pregnancy contraceptive method during the first 12 weeks Not effective immediately—WHO Follow local protocols for counseling recommends use of backup contraception couples in advance and obtaining informed for 3 months after the procedure consent
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Vasectomy: Vasectomy: Safety Crucial Programmatic Facts
Very safe, with few medical restrictions Men in every region, cultural, religious and SE Major morbidity and mortality rare setting show interest in vasectomy, despite Adverse long-term effects not been found common assumptions about negative male attitudes or societal prohibitions (MAQ) Minor complications (e.g., infection, bleeding, post-operative and/or chronic pain 5-10%) However, men often lack full access to information and services, especially male- No-scalpel (NSV) technique has lower incidence centered programming, which has been shown of bleeding and pain than incisional technique to result in greater uptake of vasectomy Morbidity and mortality rare
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7 Postpartum Female Sterilization Female Sterilization: Effectiveness
Ideally done within 48 hours after delivery Highly effective, 99.5% comparable to May be performed immediately following vasectomy, implants, IUDs delivery or during C/section Risk of failure (pregnancy), while low: If not performed within 1 week of delivery, continues for years after the procedure delay for 4-6 weeks does not diminish with time Follow local protocols for counseling is higher in younger women clients and obtaining informed consent in No medical condition absolutely restricts advance a person's eligibility for FS Discuss during ANC
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IUD IUDs (Cu-T)
IUDs are among the most reliable and cost- IUDs can be inserted: effective long-acting method of contraception Immediately after delivery of the placenta available to women today. IUD offers a level of During C/Section protection comparable to female sterilization with Within 48 hours of childbirth the added advantage of easy and rapid If not inserted within 48 hours, insertions should reversibility. be delayed for 4-6 weeks IUD prevents pregnancy by preventing Expulsion rates can be higher than with interval fertilization; the mechanism of action of copper insertions IUDs is spermicidal. Copper causes a sterile body Some studies show that insertion within 10 minutes of inflammatory reaction resulting in biochemical and placenta delivery is better than other times before hospital cellular changes that are toxic to sperm in the discharge uterine cavity rendering the sperm incapable of High fundal placement has lower expulsion rates fertilization.
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Important Programmatic Characteristics of IUDs IUDs: Programmatic Considerations
More service cadres can provide Effectiveness is comparable to FS (because it is non-surgical) 12-13 yrs with CU-T (approved) Choice: Long-acting methods that can be Cheaper to provide than other methods used long-term, non-permanent. Providing Quickly and completely reversible a woman with a PPIUD prior to discharge is less than half as expensive as providing in Very safe for most women (including: outpatient settings immediately postpartum, postabortion, or interval; breastfeeding; young; and nulliparas) Good option for HIV+ women Most cost-effective method of all reversible methods if used for 2 or more years
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8 Common Concerns about IUDs: Dispelling Myths About IUDs New Information
IUDs... Pelvic Inflammatory Disease (PID) do not cause abortion Infertility do not cause infertility are unlikely to cause HIV/AIDS discomfort for male partner do not travel to distant parts of the body are not too large for small women May offer protection against endometrial and cervical cancer
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Medical Evidence: IUD Use and HIV: Low PID Rates and Infertility among IUD Users Three Main Questions
First 20-days: highest risk due to insertion 1. Does IUD increase risk of HIV acquisition by the woman using it? Beyond 20 days: PID risk is same as if no IUD NO 99.8% of women with IUDs have no problems with PID 2. Does use of IUD by HIV-infected women IUD use NOT associated with infertility increase their other health risks? NO The real culprit is Chlamydia Trachomatis (and GC), not the IUD! 3. Does the HIV-infected IUD user increase risk to sero-negative male partner? NO
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WHO Medical Eligibility Criteria: Cu-IUD Side Effects HIV/AIDS and Copper IUDs
3rd Ed 2004 Heavier menses in the fist few months 2nd Ed. Category HIV/AIDS Category I C Increased cramping and menstrual pattern High Risk of HIV 3 2 2 changes in the first few months
HIV-infected 3 2 2 Low expulsion rate, when occurring usually within the first 3 months AIDS 3 3 2
Clinically well on ARV therapy 2 2
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9 Summary: IUD Hormonal Methods
Comparable in safety, effectiveness to FS Progestin-only Contraceptives Can be inserted during the postpartum Implants period Injectables Progestin-only pills (POPs) Risk of PID very small , even in high STI settings Does not increase risk of infertility Combined Estrogen-Progestin Methods Combined oral contraceptives (COCs) Safe for women with no children Monthly injectables (Mesigyna, Cyclofem Safe (and a good choice) for HIV-infected women or women with AIDS doing well on ARVs who do not desire pregnancy
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Progestin-Only Contraceptives; Breastfeeding Women Implants
Norplant: (will no longer be produced after 2006) No effect on breastfeeding, breast milk 6 capsules, effective 7 years production or infant growth and 1-yr failure rate 0.05% (1 pregnancy / 2000 users) development 5-yr failure rate 1.6% WHO recommends a delay of 6 weeks after Jadelle childbirth before starting progestin-only 2 rods, effective 5 years methods as infants may be at risk of 1-yr failure rate 0.05%; 5-yr failure rate 1.1% exposure to the progestin Implanon 1 rod, effective 3 years; with failure rate 0.07/100 ♀ years (<1%)
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Combined Estrogen-Progestin Methods: Projestogen-Only Injectable Breastfeeding Women
Safe to use immediately PP if not breastfeeding Safe to use after 6th week postpartum if breastfeeding DO NOT use within the first 6 weeks Injection of: postpartum 150 mg DMPA IM every 3 mos. NOT recommended during first 6 months 104 mg DMPA subQ every 3 months postpartum due to diminished quantity of NET EN 200mg every 2 months breast milk, decreased duration of lactation Women of any age and parity can use it (MEC Cat. 1, age 18-45) and possible adverse affects on infant Start first 7 days after LMP, or can use any time growth reasonably sure woman not pregnant Source: WHO 2004 Safe to use immediately PAC
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10 Women Eligible for COCs Combined Estrogen-Progestin Methods Without Restriction
Examples: BREASTFEEDING NON-BREASTFEEDING DO NOT use combined NOT recommended to Adolescents estrogen-progestin use combined estrogen- Nulliparous women methods within the first progestin methods 6 weeks postpartum during the first 3 weeks Postpartum (3 weeks, if not breastfeeding) NOT recommended postpartum during the first 6 months Safe to start after Immediately postabortion postpartum 3 weeks post-delivery Women with varicose veins Any weight (including obese)
Source: WHO, Medical Eligibility Criteria for Contraceptive Use, 3rd Ed. 2004
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Women Who Should Not Use COCs Emergency Contraception
Breastfeeding (<6 weeks postpartum) Methods of preventing pregnancy after unprotected sexual intercourse Smoke heavily AND are over age 35 Regular birth control pills used in a special higher At increased risk of cardiac valvular dosage. ECPs are a higher dosage of the same hormones disease found in daily birth control pills Have certain pre-existing conditions (e.g., within 120 hours (5 days) of unprotected sex (but as soon as possible after unprotected sex) breast cancer, liver disease, high risk of CV disease) IUDs can also be used 5days after unprotected sex Distinct from RU-486 (The Abortion Pill) Pregnant (but no proven negative effects Millions of unintended pregnancies and abortions on fetus if taken accidentally) could be averted with EC
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Types of ECPs ECP Effectiveness and Time
Progestin-only OCs: Levonorgestrel-only, in ECPs are effective up to 120 hours (5 preferred regimen one dose of 1.5 mg days), thought to be slightly more effective (or can be in 2 doses of 0.75mg, 12 hrs apart) during first 24 hours. →88% reduction in risk (1/100 will get pregnant) This offers providers and women more Combined OCs: 2 doses of pills containing ethinyl flexibility of use particularly when ECPs are estradiol (100 mcg) and levonorgestrel (0.5 mg) taken not given in advance of need. 12 hrs apart
→75% reduction in risk (2/100 will get pregnant)
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11 Possible Mechanisms Withdrawal (Coitus Interruptus) of Action of ECPs
Depending on when used during cycle, may: A traditional family planning method in which inhibit or delay the man completely removes his penis from ovulation the vagina, and away from the external affect sperm and ovum genitalia of the female partner, before he function ejaculates. Prevention of implantation is an CI prevents sperm from entering the woman's unlikely effect vagina, thereby preventing contact between spermatozoa and the ovum. EC pills do not interrupt an established pregnancy
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CI: Effectiveness CI or Withdrawal (cont’d)
This method may be appropriate for postpartum When used perfectly, effectiveness can be women and couples: as high as 95% Who are highly motivated and able to use this method With typical usage, effectiveness about 75 effectively; With religious or other reasons for not using other to 81% methods of contraception; However, CI is better than no method at Who need contraception immediately and have entered all! into a sexual act without alternative methods available; Who need a temporary method while awaiting the start of another method; and Who have intercourse infrequently.
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Advantages of CI Disadvantages of CI
If used correctly, does not affect Does not provide protection against STIs breastfeeding and is always available for primary use or use as a back-up method Requires the man’s self control Involves no economic cost or use of May reduce the pleasure of intercourse chemicals During withdrawal, some sperm may have No health risks associated directly with CI already entered into the women’s vagina Men and women who are at high risk of STI/HIV infection should use a condom with each act of intercourse.
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12 To save lives, parents should wait until their baby Helpful Resources is 2 years old before they try to get pregnant again
http://www.fhi.org/en/RH/Pubs/servdelivery/index.htm http://www.who.int/reproductive- health/publications/mec/mec.pdf WHO, Rivers life of http://www.reproline.jhu.edu/ http://www.engenderhealth.org/wh/fp/index.html http://www.maqweb.org/iudtoolkit/
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