Choosing your post-partum birth control

By Jessica Douthit, MD, PhD

Your midwife or doctor comes to see you the day after your delivery and asks you what your plans are for birth control. You may be thinking (on less than 2 hours of sleep), “But I just had a baby! I’m not thinking about having sex right now! Or ever again!” Since this discussion can be overwhelming, it can be helpful to think about this before you deliver. This is especially true because there are options that can be implemented before you leave the hospital with your newborn or even just minutes after you deliver.  Your provider is interested in making sure you have a plan whether or not you are planning a future pregnancy. The American College of Obstetrics and Gynecology (ACOG) recommends 18 months between pregnancies and a minimum interpregnancy interval of 6 months to reduce adverse maternal and child outcomes. This recommendation comes from observational studies completed in the United States. The World Health Organization actually recommends at least 2-3 years between births to reduce risks of adverse outcomes. Regardless of the decision you make for yourself and your family, choosing a reliable and safe form of birth control can be important for your overall health. 

There are plenty of considerations to make when deciding between methods and ways to think about the different categories. There are methods with and without hormones, pills that you have to take every day, methods that can work for several years, and methods that are permanent. Each of these involves more or less work to be effective (think about remembering to take a pill every day with a new baby!), may require a clinic visit and small procedure when you are done using them, may require a surgery or procedure, or rely on a male or sperm-producing partner. Their effectiveness and risks are also slightly different in a postpartum body. It is important to know what your priorities are and what questions you can ask your provider in order to make the best decision for you.

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Options for family planning and preventing pregnancy

• Long-acting reversible methods (hormonal and non-hormonal)
  • Intrauterine device (IUD): The IUD can be inserted immediately after a vaginal delivery or during a C-section (called postplacental insertion), but there are higher rates of it falling out (expulsion)-- ~10%. It can also be inserted at your postpartum visit, anywhere from 2-6 weeks postpartum). Most providers would recommend either postplacental placement or waiting close to 6 weeks. Risks of insertion at any time can include uterine perforation and pain. Your provider may recommend taking ibuprofen before your appointment and can talk to you about using a paracervical block to make it more comfortable. After 1-2 days of cramping, you should not notice that you have an IUD.
    • Levonorgestrel IUD: Brand names include Mirena, Liletta, Skyla, and Kyleena. They contain a progesterone hormone which acts in the uterus to prevent pregnancy, so many side effects can be avoided. Many people do not have periods or have very light spotting. They last from 3-7 years to prevent pregnancy depending on the brand.
    • Paragard (Copper) IUD: This type of IUD does not secrete hormone, so you will continue to have periods and they can be heavier. They last for 10-12 years to prevent pregnancy depending on how old you are when it is inserted. 
    • Nexplanon (Implant): This implant can be inserted into your arm before you leave the hospital or at your postpartum appointment any time. It delivers a progesterone hormone throughout the body, so some people experience side effects like headache, weight gain, acne, or breast tenderness. It can lead to changes in your bleeding pattern as well. They last for 5 years to prevent pregnancy. 

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• Pills: It can be hard to remember to take a pill at the same time every day, which is why with typical use, rates of prengnacy are between 4 to 7 per 100 people in 1 year. 
  • Combined oral contraceptives (COCs): These pills contain estrogen and progestins. Due to the estrogen content, we recommend starting them 3 to 6 weeks after delivery to avoid the increased risk of blood clots that can happen postpartum. You can take them continuously to avoid having a period or take the inactive pills for a week per month to have a period (both options are safe). Side effects include nausea, bloating, headache, and breast tenderness, which often decrease over time.
  • Progesterone only pill (POPs): These are a good option for people who may have contraindications to using estrogen or side-effects from other methods. Generally they have to be taken at exactly the same time every day, but there is a new formulation called Slynd (drosperinone), that is still effective if you miss taking a pill for 24 hours. There is now a version of POPs available over-the-counter (without a prescription) called Opill, which luckily increases access to reliable birth control. POP users can expect some irregular bleeding or no period at all, and may see increased acne, but do not usually experience headaches or weight gain like other methods.

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• Tubal ligation (sterilization): This procedure is considered permanent birth control (not reversible) and is extremely effective. The typical technique involves removing a portion or all of the fallopian tube. Removing the tube (rather than clipping or burning it) is more effective to prevent pregnancy or pregnancies outside of the uterus (ectopic) and can reduce your overall risk for ovarian cancer. Your doctor can perform this at the time of C-section, meaning there is no additional procedure or incision needed. It can be done 1-2 days postpartum through a small incision near your belly button (using an epidural or pain control) or 6+ weeks postpartum with laparoscopic surgery. Laparoscopic surgery requires general anesthsia, there are small incsions/scars on your belly, and patients can go home the same day, but overall recovery can take a little bit longer. 

• Depo-provera (injectable): This method requires an injection every 12-15 weeks. It is highly effective, but can come with undesired side effects, like headache, mood changes, weight gain, and irregular bleeding. This method is often used for people with very heavy periods, since after a few injections, many people experience amenorrhea (no periods or no bleeding). 

• Ring (Nuvaring) or birth control patch: These methods contain both estrogen and progestin-based hormones, so also should be started at least 3 to 6 weeks after delivery to avoid the risk of blood clots. They have similar effectiveness rates and side effects as birth control pills (COCs). They are typically changed after 3 weeks (ring) or every week (patch) and generally users will opt to have a monthly period by skipping one week. 

• Condoms: If you are using lubricant, remember to get one that is water-based!

• Natural cycles: This method can be harder when patients are breast feeding and not having regular menstrual cycles.
  
  
• Vasectomy: Male partners may opt to have a vasectomy, which is an outpatient/same-day procedure. It is more likely to be reversible than the surgery on fallopian tubes. It takes about 3 months for it to be completely effective, so use a backup method until the doctor has verified that your partner is not making sperm.
  
  
• Emergency contraception: Methods include IUDs and progesterone-based pills. These are all still effective postpartum when used within 1-3 days of intercourse. If you end up needing to use ullipristal acetate, then you should not breastfeed or pump and dump for 24 hours. 

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What are the most effective methods?

With rates of fewer than 1 pregnancy per 100 people, the most effective methods include the Nexplanon implant, IUD, tubal ligation, and vasectomy. People should be reminded that breast feeding does not always completely stop ovulation and that you can ovulate (i.e. get pregnant) before having your period return. 

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Which methods can be started right away?

Most methods can be started either right after delivery or soon after, like before you leave the hospital. Only methods that include estrogen (combined oral contraceptives and Nuvaring), require waiting 3 to 6 weeks after delivery due to the higher risk of blood clots.

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Which methods affect breast feeding or milk production?

There is no consistent data to suggest that any of the methods affect milk production or have an adverse effect on breastfeeding or breastfeeding infants, especially when initiated at the recommended times. 

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What are the risks associated with closely spaced pregnancies?

A worldwide study with 692,000 pregnancies showed that risk of perinatal death (fetal death occurring after 28 weeks gestation) was 2.72 times higher for an interpregnancy interval of less than 6 months compared to when the interval was 18-23 months. Short intervals after an abortion or miscarriage did not have the same risks. 

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A study done in North America with 148,000 pregnancies found that the risks of needing a blood transfusion, admission to the intensive care unit, organ failure, or death were increased when the interpregnancy interval was less than 6 months in women over age 35. Women 20-34 years old did not have the same increased risks to their health. Outcomes measured for babies included stillbirth, death after delivery, low birth weight, and preterm delivery. These risks were increased for women aged 20-34 when their pregnancies were spaced closer together, compared to an 18-month interpregnancy interval or when moms were over 35. 

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What should I know about resuming intercourse with my partner?

Your healthcare provider will want to see you between 2-6 weeks after delivery to check-in about many different things. The method of delivery or any medical problems you may have can change when these follow-up appointments will take place. After 6 weeks, most women will be cleared to have intercourse. If you are breastfeeding, this can lower your estrogen levels. Along with having a laceration from a vaginal delivery, this can make vaginal intercourse more uncomfortable. Ensuring you have a good lubricant (water-based if using condoms) can help. Your provider may even prescribe an estrogen cream to help moisturize the tissue and help with healing. Listen to your body and keep in mind that things can feel different or even painful. Communicating with your partner about how you feel (emotionally and physially) can be really helpful. Check in with your provider if you have more questions or concerns. 

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Where else can I get more information?

For easy to understand information or when people just need more time to digest all of the options,  I often refer people to the website Bedsider (bedsider.org). This website is also available in Spanish. 

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Resources: 

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Ali, M. M., Bellizzi, S., & Shah, I. H. (2023). The risk of perinatal mortality following short inter-pregnancy intervals—insights from 692 402 pregnancies in 113 demographic and health surveys from 46 countries: A population-based analysis. The Lancet Global Health, 11(10). https://doi.org/10.1016/s2214-109x(23)00359-5 

The American College of Obstetricians and Gynecologists, & Society for Meternal-Fetal Medicine. (2019). Obstetric Care Consensus No. 8: Interpregnancy care. Obstetrics & Gynecology, 133(1). https://doi.org/10.1097/aog.0000000000003025 

Conde-Agudelo A, Belizán, JM, Breman R, Brockman SC, Rosas-Bermúdez A. Effect of the interpregnancy interval after an abortion on maternal and perinatal health in Latin America. International Journal of Gynaecology and Obstetrics, 2005, 89: S34–S40 (supplement). https://iris.who.int/bitstream/handle/10665/73710/RHR_policybrief_birthspacing_eng.pdf

Curtis KM, Jatlaoui TC, Tepper NK, et al. U.S. Selected Practice Recommendations for Contraceptive Use, 2016. MMWR Recomm Rep 2016;65(No. RR-4):1–66. DOI: http://dx.doi.org/10.15585/mmwr.rr6504a1.

Schummers L, Hutcheon JA, Hernandez-Diaz S, et al. Association of Short Interpregnancy Interval With Pregnancy Outcomes According to Maternal Age. JAMA Intern Med. 2018;178(12):1661–1670. doi:10.1001/jamainternmed.2018.4696

Sonalkar, S., & Mody, S. K. (24AD). Contraception: Postpartum counseling and methods. UpToDate.https://www.uptodate.com/contents/contraception-postpartum-counseling-and-methods?search=postpartum+birth+control

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