Enhancing Postpartum Contraception Bhavik Kumar, MD Jennifer Amico, MD Marji Gold, MD Family Medicine Education Consortium November 1st, 2013

Objectives By the end of the presentation, participants should be able to: Summarize the evidence about VTE (venous thromboembolism) risk and breastfeeding during the postpartum period Use the MEC to help decide safe contraceptive options for postpartum women Counsel women about contraception during the postpartum period

Why is this important? Women may not want to be pregnant soon after delivery Ovulation can occur within 4wks after delivery Women often resume sexual activity before 4wks Birth spacing may reduce subsequent preterm delivery and low birth weight Women have enhanced access to care postpartum Repro coercion Ovulation: often preceeds menses, avg 25-39d in 25% of women, shorter interval in non-bf women Birth spacing: interval of <6mo and 6-12mo assoc/ with increased risk of preterm birth In low resource settings: An interval of <2yrs, higher malnutrition in first child and 2nd child higher risk low birth weight, preterm and death Access to care: can vary by state, for some insurance coverage ends at 6wks, big issue in other states outside NE DeFranco EA et al. Am J Obstet Gynecol 2007; 197(3): 264 Speroff L et al. Contraception. 2008; 78(2):90- Jackson E, Glasier A. Obstet Gynecol. 2011;(117):657-628 Byrd JE. J Fam Pract. 1998(4):305-8

What’s happening at your institution? Counseling Provision Training Counseling: what are we telling women about options, risks for contraceptive and risks of pregnancy during PP period? When are we counseling (antenatal, postpartum inpt, outpt)? What are current provision practices? What is available at discharge (OCPs, implants, IUD)? How is MS and resident training w/ PP contraception? Any specific training experiences from group?

Breastfeeding Should be encouraged for all women Lactational amenorrhea method (LAM) Theoretical concern about hormonal contraception decreasing milk supply http://mymillsbaby.co.uk/2013/08/midwives-and-breastfeeding-sensitivity-training/ BF benefits: bonding, cancer protection for mom (ovarian and breast), free, immunity to newborn, nutrition, reduced allergies, incr intelligence LAM: unpredictable in some, women not exclusively bf or formula feeding Must be exclusively bf – no solids, no pumping q4 hour during day, q6hour at night some recommend no separation of mother-baby also, no nonbreast sucking for baby Lactation raises prolactin levels Suppresses hypothalamic-pituitary-ovarian axis <2% in first 6mo postpartum w/ perfect use Research in 70s-80s: showed decrease milk production (COCP>POP>none) Systematic review in 2010 which included research since then showed no evidence of adverse effects w/ progestin-only methods w/ infant health or w/ bf Kapp N, et al. Contraception. 2010;(82):17-37

Postpartum period and VTE Increase in coagulation factors and fibrinogen Postpartum VTE risk increased compared to nonpregnant, non-postpartum women of reproductive age who are not using hormonal contraception Risk factors increase risk of VTE Immediate Postpartum 22-84 fold increase 21d (3wks) Postpartum 5-7 fold increase 42d (6wks) Postpartum Baseline risk Using CHC 3-7 fold increase Risk factors: Age >35, Smoking, Obesity, Thrombophilia, surgery (C/S), PPHemmorhage Jackson E, etal. Obstet Gynecol. 2011117):691-703 http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6026a3.htm#tab1

United States Medical Eligibility Criteria (US MEC) for Contraceptive Use, 2010 How to access MEC, what is MEC, screenshots at end of PP if link does not work

US MEC for Postpartum Non-breastfeeding Women COC/P/R POP DMPA Implant <21 days 4 1 21-42 days w/ VTE risk factors 3 w/o VTE risk factors 2 >42 days http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6026a3.htm#tab1 1= no restriction 2 = advantages of using method outweigh the theoretical or proven risks 3 = theoretical or proven risks usually outweigh the advantages of method 4 – unacceptable health risk http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6026a3.htm#tab1

US MEC for Postpartum Breastfeeding Women COC/P/R POP DMPA Implant <21 days 4 2 21-30 days w/ VTE risk factors 3* w/o VTE risk factors 3 30-42 days 1 >42 days *women w/ VTE risk factors might increase to 4 http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6026a3.htm#tab1

IUD Use in Breastfeeding and Non-breastfeeding Women LNG-IUD Cu-IUD <10min post-placenta 2 1 ≥10min after placenta to <4wks ≥4wks Puerperal sepsis 4 http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6026a3.htm#tab1 Includes post c/s Higher expulsion rates (slightly) but comparable continuation rates Other methods: male condoms (vaginal dryness w/ bf), diaphragm (needs refitting), sponge (can use once bleeding stops), abstinence Safe to use EC during this period based on current evidence Sterilization has no effect on VTE risk or BF but evidence shows many who desire do not get (access, cost, etc.) – BTL, Essure, Vasectomy 1= no restriction 2 = advantages of using method outweigh the theoretical or proven risks 3 = theoretical or proven risks usually outweigh the advantages of method 4 – unacceptable health risk http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6026a3.htm#tab1

Case discussion – small groups What factors are important to consider? How would you counsel in these scenarios? What would you ultimately do and why? Case 1: You are discharging a postpartum 36yo woman from the hospital. She had a NSVD 2d prior and has done well since and has been breastfeeding without any issues. She asks you for a prescription for her preferred method of contraception, COCPs. Case 2: During a continuity session, a resident precepts a 24yo prenatal patient who presents for her 32wk visit. She has had a normal pregnancy so far. Last visit, contraceptive options were discussed with her. She has chosen an intrauterine device (IUD) and asks if she can have it placed immediately after birth. Case 3: A patient you followed during her prenatal care presents postpartum with baby. You are happy to observe that she is breastfeeding well and plans to continue for at least 6mo. When the topic of contraception comes up, she plans to use LAM.

Take home points Risk of VTE is highest immediately postpartum Evidence shows most contraceptive methods do not affect breastfeeding The CDC MEC is easily accessible The MEC should be used to make evidence-based decisions about contraception http://www.learningradiology.com/graphics/takehomepoint.gif

Thank you! Questions?