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POST PARTUM CONTRACEPTION Postpartum period: traditionally 6 weeks after birth
Extended postpartum period: extend the postpartum period to include 1st year after birth to increase programmatic opportunities to reach families
Postpartum Family Planning: The initiation and use of FP during the first year after delivery
Considerations with Postpartum Family Planning
Through the first year postpartum
Timing of return to fertility
Return to sexual activity
Breastfeeding and use of various methods
Timing of various methods
LAM, concurrent use and transition to other methods
Underlying factors
Healthy spacing of the next pregnancy
Integration of FP into other service opportunities
Return to Fertility
Non breastfeeding:
As early as 3 weeks postpartum – 21 days postpartum
Breastfeeding
Using LAM accurately:
― sometime after 6 months – variable
Breastfeeding without using LAM:
― possibly even before 6 months, but again, variable.
― average is 45 days
― 5 – 10% of breastfeeding women get pregnant in first year PP
Remember: fertility returns before menses returns!
Factors Affecting Method Choice
Reproductive goals of woman or couple (spacing or limiting births)
Personal factors including client preference, time, travel costs, discomfort associated withFP method
Accessibility and availability of products that are necessary to use method
Medical factors
Timing of Initiating FP Methods Postpartum
LAM – with breastfeeding
Condoms – when intercourse resumes
Progestin-only methods –
― BF: when good milk supply and BF going well – 6 weeks
― Non-BF – right away
Combined Oral Pills (Estrogen + Progestin)
― BF: when there is no risk if quantity of milk decreases – 6 months
― Non-BF: when risk of thrombosis is reduced – 3 weeks
IUCD – when risk of infection and perforation is low
― First 48 hours or after 4-6 weeks
Tubectomy – when tubal inflammation and risk of infection low:
― First 7 days or after 6 weeks
LACTATIONAL AMENORRHOEA METHOD
Temporary Breast feeding related
Criteria: 1. 85% of feeding as breast milk 2. Feeds day and night 3. No menstruation 4. Less than 6 months old.
No medical contradictions No side effects
Mechanism of action: Excessive secretion of prolactin inhibition of pituitary inhibits LH, no effect of FSH + partial inhibition of ovarian response to gonadotrophins decreased production of progesterone and oestrogen no ovulation.Impaired luteal phaseSuckling induced oxytocin release interference with implantation
Use effectiveness: LAM is 99.5% effective with consistent and correct use and more than 98% effective as typically used
Advantages: 1. Immediately after delivery 2. No interference with sexual intercourse 3. No extra cost 4. No procedures 5. No hormonal side effects 6. Benefits of breast feeding
Disadvantages: 1. No certain effectiveness2. Difficult for working mothers3. No protection against STDs4. HIV with AFASS fulfilled
Absolute contraindications: 1. > 6 months old 2. Irregular Breast feeding 3. AFASS fulfilled HIV 4. Menstruation starts 5. Mother on drugs contraindicated during breastfeeding 6. Viral hepatitis of mother
Drawbacks: Prolonged lactation Superinvolution of the uterus, persistent hyperprolactenemia Prolonged amenorrhoea, oligomenorrhoea
Problems: - Deficient milk supply- Cracked nipples- Breast engorgement- Breast abscess
Progestin-Only Pills (POPs)
Pills that contain a very low dose of a progestin like the natural hormone progesterone in a woman’s body
Does not contain estrogen Also called “mini-pills” Work primarily by:
Thickening the cervical mucus (this blocks sperm from meeting egg) Disrupting the menstrual cycle, including preventing ovulation
Progestin-Only Pills: Key Benefits
Safe for breastfeeding women—No effect on breastfeeding, milk production or infant growth and development after infant is six weeks old
Adds to the contraceptive effect of breastfeeding—Together, if taken correctly, failure rate less than 1% during first year of use
Does not interfere with sex
Progestin-Only Pills: Limitations
Less effective for non-breastfeeding mother—If taken correctly, 3–10 women/100 will become pregnant first year
Pill must be taken every day Bleeding changes (more frequent, irregular) are common but not harmful A few women may have headaches, dizziness or breast tenderness
Progestin-only Contraceptives & Breastfeeding Women
No proven effect on breastfeeding, breast milk production or infant growth and development WHO recommends a delay of 6 weeks after childbirth before starting progestin-only methods as
infants may be at some small unknown risk from exposure to the progestin excreted in breastmilkMEC Category 3 – risks outweigh the benefits
After 6 weeks of age, safe to initiate progestin-only methodsMEC Category 1 – safe to use under any situation
Not appropriate for women who: 1. Have cirrhosis or active liver disease. 2. Take medications for TB or seizures.3. Have a blood clot in legs or lungs now.4. Have a history of breast cancer.
Progestin-Only Injectables
The injectable contraceptive DMPA (depot medroxyprogesterone acetate) contains a progestin similar to the progesterone naturally in a woman’s body
Does not contain estrogen Also known as “the shot” or the injection Given by injection into the muscle Works primarily by preventing ovulation No effect on breastfeeding, milk production or infant growth and development; safe for use after
infant is 6 weeks When women have injections on time, failure rate less than 1% during first year of use Does not require daily action, Do not interfere with sex
Helps protect against:endometrial cancerUterine fibroidsIron-deficiency anemia
Progestin-Only Injectables: Limitations
Bleeding irregularities for first two to three months (usually no bleeding at one year) Some women may have weight gain, headaches, dizziness, mood changes Should wait until six weeks to give first injection to the breastfeeding woman (who is not using
LAM)
Progestin-Only Injectables: Counseling Considerations
Discuss limitations (side effects) Agree on date for next injection in three months (can give injection even if woman is four weeks
early or late, but do not regularly extend DMPA injection interval by four weeks) She should come back no matter how late she is for her next injection; if reasonably sure she is
not pregnant, can give injection any time Assure her that she is welcome to return any time she has questions, concerns or problems