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

2. 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

3. 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):
Byrd JE. J Fam Pract. 1998(4):305-8

4. 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?

5. Breastfeeding Should be encouraged for all women
Lactational amenorrhea method (LAM)
Theoretical concern about hormonal contraception decreasing milk supply
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

6. 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):

7. 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

8. 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
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

9. 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

10. 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
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

11. 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.

12. 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

13. Thank you!
Questions?