1. Introduction (premise and organization of the chapter)

In the United States, approximately 30% of all repeat pregnancies are conceived within 18 months of the previous birth, and approximately 40% of these pregnancies are unintended [1]. In regions of the world with the highest burden of unmet family planning need, the proportions are higher. Robust epidemiologic evidence demonstrates that interconception intervals less than 18 months, and most notably less than 6 months, are associated with adverse perinatal outcomes. Based on this the World Health Organization recommends an interpregnancy interval of 24 months [2]. An estimated 35% of adolescent mothers in the United States experience rapid repeat pregnancy within 2 years. These young women are more likely to experience adverse perinatal outcomes, are unable to attain an educational degree, and depend on public assistance programs [3]. Some women are not offered immediate postpartum contraception planning in many countries around the world. This may be due to the fact that women are absorbed with the range of emotions and adjustments that precede and follow having a baby. However, despite such hesitations or barriers from providers and patients to discuss contraception and sexual behaviors, it is very valuable to explore birth spacing prior to and following a delivery, even in the immediate peripartum time.

Serum steroid hormones, such as estrogens and progesterone, decrease to prepregnancy levels after approximately 2–3 days following delivery. It is at this time that most women experience milk letdown with lactogenesis. If a woman does not breastfeed, her prolactin levels fall to baseline 7 days following delivery. Gonadotropin-releasing hormone (GnRH) pulsatility will then resume after 2–4 weeks. Non-nursing mothers may ovulate 26 days postpartum, and 78% of women will ovulate prior to menses. Approximately 40% will ovulate by 6 weeks postpartum [4]. Among women who breastfeed elevated prolactin levels inhibit GnRH, preventing the pituitary from secreting follicular-stimulating hormone and luteinizing hormone, which in turn maintain ovarian suppression and prevent ovulation. Prolactin levels rise 10–20-fold in response to latch and suckling of an infant to the breast and will remain elevated with regular breastfeeding for months. Some research has demonstrated that supplemental feeding of an

Postpartum Family Planning: Methods to Decrease Unintended Pregnancies

http://dx.doi.org/10.5772/intechopen.73534

245

Exclusive and on-infant-demand breastfeeding postpartum is an effective method of contraception, called lactation amenorrhea, for up to 6 months postpartum. However, regular, day, and night breastfeeding of an infant is required. This method requires that the infant's total suckling experience be at the breast, without pacifiers or bottles, and that the mother is amenorrheic [9]. We do not know the impact of using a breast pump on the efficacy of ovulatory suppression.

Barrier methods, including the female condom and the male condom, have no impact on breastfeeding and also have the benefit of preventing sexually transmitted infections (Figure 1). Male condoms are 98% effective with perfect use and 85% effective with actual use. Female condoms are 95% effective with perfect use and 79% effective with actual use. Spermicides, and natural family planning or fertility-based contraceptive methods, have no impact on breastfeeding. However, irregular vaginal bleeding Patterns postpartum as well as the risk of ovulation prior to menstruation places couples at high risk for unintended pregnancy if they choose to use natural family planning methods (such as cervical mucus assessment, Billing method, or 2 day methods) during the immediate postpartum period. It is unknown that the failure rates of these methods are in the postpartum setting; however, they are likely much higher than the projected 20–30% rates observed with typical use (Figure 2). There is a single-size diaphragm available on

infant is associated with decreased suckling and ovulation within 6 weeks.

1.2. Barrier methods

Figure 1. Female condom.

Women often rely on physicians and medical visits to access contraception. However, the antiquated and traditional western model of postpartum care delays counseling and initiation of contraception until a 6-week postpartum visit. Prior to the advent of implantable and hormonal contraceptive devices, this 6-week postpartum visit would have been an appropriate time to fit a woman for a diaphragm after involution of the uterus [4]. However, a large percentage of women, many of who are without stable insurance, transportation, housing, or support, are unable to present for their 6-week postpartum visit [5]. This chapter will review the range of contraceptive resources and technologies available to couples for postpartum contraception, with attention to considerations such as risk of venous thromboembolism and impact on lactation. Women have a range of contraceptive choices they can use to prevent pregnancy or to space their pregnancies.

#### 1.1. Ovulation, sexual activity, lactation & sterilization

Many women resume sexual activity before their 6-week postpartum visit and are not using any form of contraception [6]. Women surveyed in the following countries reported sexual activity within 6 weeks postpartum: 57% in the United States, 60% in England, 71% in Scotland, 35% in Thailand, and 32% in Nigeria. Teens are also likely to have resumed sexual intercourse if they are living with their partner, and women who delivered by cesarean are more likely to be sexually active than women who had a vaginal delivery [7]. Sterilization is an effective and reliable method of contraception, which has no impact on breastfeeding or risk for venous thromboembolism. At the time of cesarean delivery, tubal ligation is an effective method, with minimal added morbidity or risk. Postpartum minilaparotomy is another excellent option and is typically completed during the same hospital admission as the delivery. Unfortunately, due to difficulty in mobilizing resources, a large percentage of women in the United States who deliver vaginall are discharged without receiving their requested sterilization. Forty-seven percent of these women with unfulfilled sterilization requests will become pregnant within a year of delivery [8].

Serum steroid hormones, such as estrogens and progesterone, decrease to prepregnancy levels after approximately 2–3 days following delivery. It is at this time that most women experience milk letdown with lactogenesis. If a woman does not breastfeed, her prolactin levels fall to baseline 7 days following delivery. Gonadotropin-releasing hormone (GnRH) pulsatility will then resume after 2–4 weeks. Non-nursing mothers may ovulate 26 days postpartum, and 78% of women will ovulate prior to menses. Approximately 40% will ovulate by 6 weeks postpartum [4]. Among women who breastfeed elevated prolactin levels inhibit GnRH, preventing the pituitary from secreting follicular-stimulating hormone and luteinizing hormone, which in turn maintain ovarian suppression and prevent ovulation. Prolactin levels rise 10–20-fold in response to latch and suckling of an infant to the breast and will remain elevated with regular breastfeeding for months. Some research has demonstrated that supplemental feeding of an infant is associated with decreased suckling and ovulation within 6 weeks.

Exclusive and on-infant-demand breastfeeding postpartum is an effective method of contraception, called lactation amenorrhea, for up to 6 months postpartum. However, regular, day, and night breastfeeding of an infant is required. This method requires that the infant's total suckling experience be at the breast, without pacifiers or bottles, and that the mother is amenorrheic [9]. We do not know the impact of using a breast pump on the efficacy of ovulatory suppression.

#### 1.2. Barrier methods

1. Introduction (premise and organization of the chapter)

244 Family Planning

pregnancy or to space their pregnancies.

pregnant within a year of delivery [8].

1.1. Ovulation, sexual activity, lactation & sterilization

In the United States, approximately 30% of all repeat pregnancies are conceived within 18 months of the previous birth, and approximately 40% of these pregnancies are unintended [1]. In regions of the world with the highest burden of unmet family planning need, the proportions are higher. Robust epidemiologic evidence demonstrates that interconception intervals less than 18 months, and most notably less than 6 months, are associated with adverse perinatal outcomes. Based on this the World Health Organization recommends an interpregnancy interval of 24 months [2]. An estimated 35% of adolescent mothers in the United States experience rapid repeat pregnancy within 2 years. These young women are more likely to experience adverse perinatal outcomes, are unable to attain an educational degree, and depend on public assistance programs [3]. Some women are not offered immediate postpartum contraception planning in many countries around the world. This may be due to the fact that women are absorbed with the range of emotions and adjustments that precede and follow having a baby. However, despite such hesitations or barriers from providers and patients to discuss contraception and sexual behaviors, it is very valuable to explore birth spacing prior to and following a delivery, even in the immediate peripartum time. Women often rely on physicians and medical visits to access contraception. However, the antiquated and traditional western model of postpartum care delays counseling and initiation of contraception until a 6-week postpartum visit. Prior to the advent of implantable and hormonal contraceptive devices, this 6-week postpartum visit would have been an appropriate time to fit a woman for a diaphragm after involution of the uterus [4]. However, a large percentage of women, many of who are without stable insurance, transportation, housing, or support, are unable to present for their 6-week postpartum visit [5]. This chapter will review the range of contraceptive resources and technologies available to couples for postpartum contraception, with attention to considerations such as risk of venous thromboembolism and impact on lactation. Women have a range of contraceptive choices they can use to prevent

Many women resume sexual activity before their 6-week postpartum visit and are not using any form of contraception [6]. Women surveyed in the following countries reported sexual activity within 6 weeks postpartum: 57% in the United States, 60% in England, 71% in Scotland, 35% in Thailand, and 32% in Nigeria. Teens are also likely to have resumed sexual intercourse if they are living with their partner, and women who delivered by cesarean are more likely to be sexually active than women who had a vaginal delivery [7]. Sterilization is an effective and reliable method of contraception, which has no impact on breastfeeding or risk for venous thromboembolism. At the time of cesarean delivery, tubal ligation is an effective method, with minimal added morbidity or risk. Postpartum minilaparotomy is another excellent option and is typically completed during the same hospital admission as the delivery. Unfortunately, due to difficulty in mobilizing resources, a large percentage of women in the United States who deliver vaginall are discharged without receiving their requested sterilization. Forty-seven percent of these women with unfulfilled sterilization requests will become Barrier methods, including the female condom and the male condom, have no impact on breastfeeding and also have the benefit of preventing sexually transmitted infections (Figure 1). Male condoms are 98% effective with perfect use and 85% effective with actual use. Female condoms are 95% effective with perfect use and 79% effective with actual use. Spermicides, and natural family planning or fertility-based contraceptive methods, have no impact on breastfeeding. However, irregular vaginal bleeding Patterns postpartum as well as the risk of ovulation prior to menstruation places couples at high risk for unintended pregnancy if they choose to use natural family planning methods (such as cervical mucus assessment, Billing method, or 2 day methods) during the immediate postpartum period. It is unknown that the failure rates of these methods are in the postpartum setting; however, they are likely much higher than the projected 20–30% rates observed with typical use (Figure 2). There is a single-size diaphragm available on

Figure 1. Female condom.

1.3. Copper IUD

Figure 4. Copper IUDs.

1.4. Hormonal contraceptive methods

The copper IUD, when placed immediately after the delivery of a placenta or at a later interval, has no impact on lactation or a woman's risk for venous thromboembolism (Figure 4). The nonhormonal copper IUD is 3.6 cm with 380 mm2 of copper. It has a failure rate less than 1% and was approved in 1984 for up to 10 years of use. It interferes with sperm function and prevents fertilization. It is associated with increased menstrual blood flow. The copper IUD is one of the most effective methods of emergency contraception. The IUD can be placed immediately following a vaginal delivery by a skilled provider using a sterile technique as shown in (Figure 5) or at the time of cesarean delivery. When placed following a vaginal delivery, patients should be counseled about increased risk for expulsion. High satisfaction has been

Postpartum Family Planning: Methods to Decrease Unintended Pregnancies

http://dx.doi.org/10.5772/intechopen.73534

247

Hormonal contraceptive methods contain progestins, or progestins and estrogens, which have historically raised concerns regarding potential interactions with lactation. Limited research suggests that combined hormonal contraceptives (that contain both estrogens and progestins) such as many of the pills, patches, vaginal rings, and injectables may slightly decrease milk quantity. However, the majority of research supports that progestin-only methods, such as injections (Uniplant and Depo-Provera), levonorgestrel-releasing IUDs, progestin contraceptive implants, progestin-only pills (POP), and the progestin ring, do not adversely impact lactation, fetal growth, or development. A systematic review of 43 studies and five randomized controlled trials (RCT) that assessed the impact of progestin-only contraceptives on

noted among women who received an IUD at the time of cesarean section [10].

Figure 2. Comparing effectiveness of family planning methods.

the international market. The use of this diaphragm has no impact on lactation (Figure 3). None of these methods impact a woman's postpartum risk for venous thromboembolism.

Figure 3. Single-size diaphragm.

#### 1.3. Copper IUD

The copper IUD, when placed immediately after the delivery of a placenta or at a later interval, has no impact on lactation or a woman's risk for venous thromboembolism (Figure 4). The nonhormonal copper IUD is 3.6 cm with 380 mm2 of copper. It has a failure rate less than 1% and was approved in 1984 for up to 10 years of use. It interferes with sperm function and prevents fertilization. It is associated with increased menstrual blood flow. The copper IUD is one of the most effective methods of emergency contraception. The IUD can be placed immediately following a vaginal delivery by a skilled provider using a sterile technique as shown in (Figure 5) or at the time of cesarean delivery. When placed following a vaginal delivery, patients should be counseled about increased risk for expulsion. High satisfaction has been noted among women who received an IUD at the time of cesarean section [10].

#### 1.4. Hormonal contraceptive methods

Hormonal contraceptive methods contain progestins, or progestins and estrogens, which have historically raised concerns regarding potential interactions with lactation. Limited research suggests that combined hormonal contraceptives (that contain both estrogens and progestins) such as many of the pills, patches, vaginal rings, and injectables may slightly decrease milk quantity. However, the majority of research supports that progestin-only methods, such as injections (Uniplant and Depo-Provera), levonorgestrel-releasing IUDs, progestin contraceptive implants, progestin-only pills (POP), and the progestin ring, do not adversely impact lactation, fetal growth, or development. A systematic review of 43 studies and five randomized controlled trials (RCT) that assessed the impact of progestin-only contraceptives on

Figure 4. Copper IUDs.

the international market. The use of this diaphragm has no impact on lactation (Figure 3). None

of these methods impact a woman's postpartum risk for venous thromboembolism.

Figure 2. Comparing effectiveness of family planning methods.

Figure 3. Single-size diaphragm.

246 Family Planning

1.5. Combined hormonal methods

Category Restriction 1 No restriction

Source: Centers for Disease Control and Prevention (CDC) [14].

Table 1. US medical eligibility criteria for contraceptive use.

4 Unacceptable health risk

for reasons related to breastfeeding.

1.6. Progestin-only methods

Combined hormonal methods, which contain estrogens and progestins, are among the most commonly utilized methods among women in the United States. All hormonal contraceptives primarily prevent pregnancy by stimulating the cervix to produce thickened impenetrable mucus, which prevent sperm from entering the upper reproductive tract. Combined hormonal contraceptives often also prevent ovulation. Limited data suggests that estrogen-containing products may decrease the quantity of milk production or shorten the duration of breastfeeding [15]. An eight-year follow-up of children whose mothers took combined hormonal contraceptive pills and breastfeeding demonstrated no effect on the child's intelligence, behavior, or development of subsequent diseases [16]. The CDC MEC considers combined hormonal methods (such as pills, patches, vaginal rings, and injectables) to be category 4 until 21 days postpartum for breastfeeding and non-breastfeeding women. Among breastfeeding women it is category 3 after 42 days until 6 months postpartum. In non-breastfeeding women, it is category 2 from approximately 22 days until 42 days. After 42 days it is category 1. The American College of Obstetricians and Gynecologists and the World Health Organization recommend delaying initiation of combined hormonal methods until 6 months postpartum

2 Advantages generally outweigh theoretical or proven risks 3 Theoretical or proven risks usually outweigh advantages

Postpartum Family Planning: Methods to Decrease Unintended Pregnancies

http://dx.doi.org/10.5772/intechopen.73534

249

Progestin-only methods include pills, implants, injections, and a vaginal ring. Progestin-only pills (POP) are taken continuously and without a pill-free, withdrawal bleed cycle, and contraceptive efficacy is approximately 87% with actual use. Depot medroxyprogesterone acetate (DMPA) is a progestin-only injection given every 1 or 3 months (depending on the dose) that inhibits ovulation (Figure 6). Trace amounts are transferred in the milk to the infant; however, no adverse events have been reported after decades of widespread global use. The Centers for Disease Control and Prevention (CDC) lists POP and DMPA as category 2 for the first 30 days postpartum for breastfeeding women, predominately due to theoretic concerns regarding lactogenesis and lactation. After 30 days postpartum, both of these methods are a category 1 among postpartum women who are breastfeeding. They are both category 1 among postpartum women who are not breastfeeding immediately postpartum. There is a progestinreleasing vaginal ring, which is intended for use among breastfeeding women after 30 days

Figure 5. Post placental intrauterine device placement immediately following vaginal delivery.

breastfeeding continuation or infant outcomes saw no significant impact. However, evidence remains limited [11].

Furthermore, research supports that estrogens, but not progestins, contribute to an increased risk of venous thromboembolism (VTE) during the immediate postpartum period, approximately 30 days after delivery. At baseline women of reproductive age are at risk for VTE at a rate of 50/ 100,000 women-years. During pregnancy and postpartum, this increases fourfold to 200/ 100,000 women-years. Incidence of VTE is highest in the first week after delivery, and half of all postpartum VTE occurs during the first 2 weeks postpartum. There are increased serum concentrations of clotting factors synthesized in the liver during pregnancy and postpartum. Estrogen-containing contraceptives increase risk of VTE two- to fourfold because they further stimulate the liver to synthesize more clotting factors and serum globulins.

Guidance regarding the risks of various contraceptives in different populations is delineated in the World Health Organization's (WHO) Medical Eligibility Criteria for Contraceptive Use (MEC), as well as the US Medical Eligibility Criteria for Contraceptive Use [12, 13]. Both documents score the safety of a method in a specific population or scenario. There are four numeric categories: category 1 indicates that the method is safe and can be used without restrictions, category 2 may have some theoretic or proven risks and advantages generally outweigh the risks, category 3 indicates the theoretical or proven risks that outweigh the benefits in most scenarios, and category 4 is consistent with unacceptable health risk to women using this contraceptive method (Table 1). Due to the global burden of infant morbidity and mortality related to diarrheal illness and unclean water, the importance of lactation and the nutritional benefits for the infant heavily guide the WHO and Centers for Disease Control and Prevention (CDC) recommendations regarding contraception in the postpartum period. In the absence of data, many committees feel it prudent to ensure that lactogenesis is safely established so as to mitigate the risk of infant malnutrition.


Table 1. US medical eligibility criteria for contraceptive use.
