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Postpartum contraception

Andrew M Kaunitz, MD
Section Editor
Courtney A Schreiber, MD, MPH
Deputy Editor
Kristen Eckler, MD, FACOG


Contraceptive selection requires consideration of patient preferences and medical factors unique to this period. For postpartum women, additional issues include the timing of contraceptive initiation, risk of venous thromboembolism, resumption of ovulation, and impact on lactation. Prompt initiation of postpartum contraception increases utilization and continuation and thus reduces the risk of unintended pregnancy. The woman's preferences and the risks and benefits of various contraceptive options are ideally discussed during prenatal care so the woman has adequate time to consider her options and have her questions answered.

This topic will review contraception issues specific to postpartum women. Discussions on contraceptive counseling and selection and postabortion contraception are presented separately. (See "Contraceptive counseling and selection" and "Postabortion contraception".)


In postpartum women who do not breastfeed, ovulation returns at a mean of 39 days postpartum (earliest ovulation reported 25 days after delivery) [1,2]. As many as 60 percent of these ovulations are potentially fertile [1]. Since the first ovulation often occurs before the first menses, we educate women that return of menses cannot be used as a reliable marker for when to initiate contraception.

For breastfeeding women, the resumption of ovulation appears to be influenced by the frequency and duration of breastfeeding. In an observational study of 200 postpartum women, the women who breastfed less had a quicker resumption of ovulation compared with women who breastfed exclusively [3]. In addition, exclusively breastfeeding women typically ovulated after the first menses as compared with non-breastfeeding women, who typically ovulated prior to the resumption of menses. In a different study of 101 breastfeeding women (60 women in Baltimore, Maryland, United States and 41 women in Manila, Philippines), the resumption of ovulation occurred at a mean of 27 and 38 weeks, respectively [4]. In this study, the women in Baltimore tended to breastfeed less frequently, but for a longer duration at each episode, compared with the women in the Philippines. During the first six months postpartum, approximately 10 percent of all amenorrheic women ovulated. Among women who were exclusively breastfeeding, 1 to 5 percent of amenorrheic women ovulated.

Impact of lactation — Women who exclusively breastfeed typically have a delay in resumption of ovulation postpartum due to prolactin-induced inhibition of pulsatile gonadotropin-releasing hormone release from the hypothalamus. The degree to which breastfeeding suppresses ovulation is modulated by the intensity of the breastfeeding, the basal nutritional status of the mother, and the body mass index of the mother. While breastfeeding is associated with subfertility, anovulation is likely only when all of the following specific conditions are met [5]:


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Literature review current through: Mar 2017. | This topic last updated: Apr 13, 2017.
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  1. Gray RH, Campbell OM, Zacur HA, et al. Postpartum return of ovarian activity in nonbreastfeeding women monitored by urinary assays. J Clin Endocrinol Metab 1987; 64:645.
  2. Jackson E, Glasier A. Return of ovulation and menses in postpartum nonlactating women: a systematic review. Obstet Gynecol 2011; 117:657.
  3. Perez A, Vela P, Masnick GS, Potter RG. First ovulation after childbirth: the effect of breast-feeding. Am J Obstet Gynecol 1972; 114:1041.
  4. Gray RH, Campbell OM, Apelo R, et al. Risk of ovulation during lactation. Lancet 1990; 335:25.
  5. Curtis KM, Tepper NK, Jatlaoui TC, et al. U.S. Medical Eligibility Criteria for Contraceptive Use, 2016. MMWR Recomm Rep 2016; 65:1.
  6. Kennedy KI, Rivera R, McNeilly AS. Consensus statement on the use of breastfeeding as a family planning method. Contraception 1989; 39:477.
  7. The World Health Organization multinational study of breast-feeding and lactational amenorrhea. III. Pregnancy during breast-feeding. World Health Organization Task Force on Methods for the Natural Regulation of Fertility. Fertil Steril 1999; 72:431.
  8. Shaaban OM, Glasier AF. Pregnancy during breastfeeding in rural Egypt. Contraception 2008; 77:350.
  9. Israngkura B, Kennedy KI, Leelapatana B, Cohen HS. Breastfeeding and return to ovulation in Bangkok. Int J Gynaecol Obstet 1989; 30:335.
  10. Van der Wijden C, Kleijnen J, Van den Berk T. Lactational amenorrhea for family planning. Cochrane Database Syst Rev 2003; :CD001329.
  11. Valeggia C, Ellison PT. Lactational amenorrhoea in well-nourished Toba women of Formosa, Argentina. J Biosoc Sci 2004; 36:573.
  12. American College of Obstetricians and Gynecologists’ Committee on Obstetric Practice. Committee Opinion No. 670: Immediate Postpartum Long-Acting Reversible Contraception. Obstet Gynecol 2016; 128:e32.
  13. Sénat MV, Sentilhes L, Battut A, et al. Postpartum practice: guidelines for clinical practice from the French College of Gynaecologists and Obstetricians (CNGOF). Eur J Obstet Gynecol Reprod Biol 2016; 202:1.
  14. American College of Obstetricians and Gynecologists’ Committee on Obstetric Practice, Association of Women’s Health, Obstetric and Neonatal Nurses. Committee Opinion No. 666: Optimizing Postpartum Care. Obstet Gynecol 2016; 127:e187.
  15. Thiel De Bocanegra H, Braughton M, Bradsberry M, et al. Racial and ethnic disparities in postpartum care and contraception in California's Medicaid program. Am J Obstet Gynecol 2017.
  16. Speroff L, Mishell DR Jr. The postpartum visit: it's time for a change in order to optimally initiate contraception. Contraception 2008; 78:90.
  17. Brito MB, Ferriani RA, Quintana SM, et al. Safety of the etonogestrel-releasing implant during the immediate postpartum period: a pilot study. Contraception 2009; 80:519.
  18. Connolly A, Thorp J, Pahel L. Effects of pregnancy and childbirth on postpartum sexual function: a longitudinal prospective study. Int Urogynecol J Pelvic Floor Dysfunct 2005; 16:263.
  19. White K, Teal SB, Potter JE. Contraception after delivery and short interpregnancy intervals among women in the United States. Obstet Gynecol 2015; 125:1471.
  20. Harney C, Dude A, Haider S. Factors associated with short interpregnancy interval in women who plan postpartum LARC: a retrospective study. Contraception 2017; 95:245.
  21. Brunson MR, Klein DA, Olsen CH, et al. Postpartum contraception: initiation and effectiveness in a large universal healthcare system. Am J Obstet Gynecol 2017.
  22. Conde-Agudelo A, Rosas-Bermúdez A, Kafury-Goeta AC. Birth spacing and risk of adverse perinatal outcomes: a meta-analysis. JAMA 2006; 295:1809.
  23. Hatcher RA, Trussel RA, Nelson AL, et al. Contraceptive Technology, 20th ed, Ardent Media, New York 2011.
  24. Bahamondes L, Brache V, Meirik O, et al. A 3-year multicentre randomized controlled trial of etonogestrel- and levonorgestrel-releasing contraceptive implants, with non-randomized matched copper-intrauterine device controls. Hum Reprod 2015; 30:2527.
  25. Birgisson NE, Zhao Q, Secura GM, et al. Preventing Unintended Pregnancy: The Contraceptive CHOICE Project in Review. J Womens Health (Larchmt) 2015; 24:349.
  26. Tocce KM, Sheeder JL, Teal SB. Rapid repeat pregnancy in adolescents: do immediate postpartum contraceptive implants make a difference? Am J Obstet Gynecol 2012; 206:481.e1.
  27. Kamel H, Navi BB, Sriram N, et al. Risk of a thrombotic event after the 6-week postpartum period. N Engl J Med 2014; 370:1307.
  28. Cohen R, Sheeder J, Arango N, et al. Twelve-month contraceptive continuation and repeat pregnancy among young mothers choosing postdelivery contraceptive implants or postplacental intrauterine devices. Contraception 2016; 93:178.
  29. Crockett AH, Pickell LB, Heberlein EC, et al. Six- and twelve-month documented removal rates among women electing postpartum inpatient compared to delayed or interval contraceptive implant insertions after Medicaid payment reform. Contraception 2017; 95:71.
  30. Aiken AR, Creinin MD, Kaunitz AM, et al. Global fee prohibits postpartum provision of the most effective reversible contraceptives. Contraception 2014; 90:466.
  31. World Health Organization. Medical eligibility criteria for contraceptive use, 5th ed, 2015. http://apps.who.int/iris/bitstream/10665/181468/1/9789241549158_eng.pdf (Accessed on August 04, 2016).
  32. Nexplanon. US Food and Drug Administration (FDA) approved product information. Revised March 14, 2016. US National Library of Medicine. (Available online at www.dailymed.nlm.nih.gov.)
  33. Baldwin MK, Edelman AB, Lim JY, et al. Intrauterine device placement at 3 versus 6 weeks postpartum: a randomized trial. Contraception 2016; 93:356.
  34. Zerden ML, Stuart GS, Charm S, et al. Two-week postpartum intrauterine contraception insertion: a study of feasibility, patient acceptability and short-term outcomes. Contraception 2017; 95:65.
  35. Kapp N, Curtis KM. Intrauterine device insertion during the postpartum period: a systematic review. Contraception 2009; 80:327.
  36. Grimes D, Schulz K, van Vliet H, Stanwood N. Immediate post-partum insertion of intrauterine devices: a Cochrane review. Hum Reprod 2002; 17:549.
  37. Ogburn JA, Espey E, Stonehocker J. Barriers to intrauterine device insertion in postpartum women. Contraception 2005; 72:426.
  38. ParaGard TCu380A copper intrauterine device. US Food and Drug Administration (FDA) approved product information. Revised August, 2015. US National Library of Medicine. (Available online at www.dailymed.nlm.nih.gov.)
  39. Hayes JL, Cwiak C, Goedken P, Zieman M. A pilot clinical trial of ultrasound-guided postplacental insertion of a levonorgestrel intrauterine device. Contraception 2007; 76:292.
  40. Chen BA, Reeves MF, Hayes JL, et al. Postplacental or delayed insertion of the levonorgestrel intrauterine device after vaginal delivery: a randomized controlled trial. Obstet Gynecol 2010; 116:1079.
  41. Dahlke JD, Terpstra ER, Ramseyer AM, et al. Postpartum insertion of levonorgestrel--intrauterine system at three time periods: a prospective randomized pilot study. Contraception 2011; 84:244.
  42. Stuart GS, Bryant AG, O'Neill E, Doherty IA. Feasibility of postpartum placement of the levonorgestrel intrauterine system more than 6 h after vaginal birth. Contraception 2012; 85:359.
  43. Mirena levonorgestrel intrauterine device. US Food and Drug Administration (FDA) approved product information. Revised May, 2014. US National Library of Medicine. (Available online at www.dailymed.nlm.nih.gov.)
  44. Liletta levonorgestrel intrauterine device. US Food and Drug Administration (FDA) approved product information. Revised May, 2014. US National Library of Medicine. (Available online at www.dailymed.nlm.nih.gov.)
  45. Skyla levonorgestrel intrauterine device. US Food and Drug Administration (FDA) approved product information. Revised May, 2014. US National Library of Medicine. (Available online at www.dailymed.nlm.nih.gov.)
  46. Curtis KM, Jatlaoui TC, Tepper NK, et al. U.S. Selected Practice Recommendations for Contraceptive Use, 2016. MMWR Recomm Rep 2016; 65:1.
  47. Black A, Guilbert E, Costescu D, et al. Canadian Contraception Consensus (Part 3 of 4): Chapter 7--Intrauterine Contraception. J Obstet Gynaecol Can 2016; 38:182.
  48. Lopez LM, Bernholc A, Hubacher D, et al. Immediate postpartum insertion of intrauterine device for contraception. Cochrane Database Syst Rev 2015; :CD003036.
  49. Grimes DA, Lopez LM, Schulz KF, et al. Immediate post-partum insertion of intrauterine devices. Cochrane Database Syst Rev 2010; :CD003036.
  50. Lara R, Sánchez RA, Aznar R. [Application of intrauterine device through the incision of the cesarean section]. Ginecol Obstet Mex 1989; 57:23.
  51. Chi IC, Zhou SW, Balogh S, NG K. Post-cesarean section insertion of intrauterine devices. Am J Public Health 1984; 74:1281.
  52. Eggebroten JL, Sanders JN, Turok DK. Immediate postpartum intrauterine device and implant program outcomes: a prospective analysis. Am J Obstet Gynecol 2017.
  53. Chi IC, Wilkens L, Rogers S. Expulsions in immediate postpartum insertions of Lippes Loop D and Copper T IUDs and their counterpart Delta devices--an epidemiological analysis. Contraception 1985; 32:119.
  54. Stuart GS, Lesko CR, Stuebe AM, et al. A randomized trial of levonorgestrel intrauterine system insertion 6 to 48 h compared to 6 weeks after vaginal delivery; lessons learned. Contraception 2015; 91:284.
  55. Aoun J, Dines VA, Stovall DW, et al. Effects of age, parity, and device type on complications and discontinuation of intrauterine devices. Obstet Gynecol 2014; 123:585.
  56. Rivera R, Chen-Mok M, McMullen S. Analysis of client characteristics that may affect early discontinuation of the TCu-380A IUD. Contraception 1999; 60:155.
  57. Long-term reversible contraception. Twelve years of experience with the TCu380A and TCu220C. Contraception 1997; 56:341.
  58. Sivin I, Schmidt F. Effectiveness of IUDs: a review. Contraception 1987; 36:55.
  59. Mechanism of action, safety and efficacy of intrauterine devices. Report of a WHO Scientific Group. World Health Organ Tech Rep Ser 1987; 753:1.
  60. Madden T, McNicholas C, Zhao Q, et al. Association of age and parity with intrauterine device expulsion. Obstet Gynecol 2014; 124:718.
  61. Levi EE, Stuart GS, Zerden ML, et al. Intrauterine Device Placement During Cesarean Delivery and Continued Use 6 Months Postpartum: A Randomized Controlled Trial. Obstet Gynecol 2015; 126:5.
  62. Jatlaoui TC, Marcus M, Jamieson DJ, et al. Postplacental intrauterine device insertion at a teaching hospital. Contraception 2014; 89:528.
  63. Smaill FM, Gyte GM. Antibiotic prophylaxis versus no prophylaxis for preventing infection after cesarean section. Cochrane Database Syst Rev 2010; :CD007482.
  64. Burrows LJ, Meyn LA, Weber AM. Maternal morbidity associated with vaginal versus cesarean delivery. Obstet Gynecol 2004; 103:907.
  65. Fernandez H, Gagnepain A, Bourget P, et al. Antibiotic prophylaxis against postpartum endometritis after vaginal delivery: a prospective randomized comparison between Amox-CA (Augmentin) and abstention. Eur J Obstet Gynecol Reprod Biol 1993; 50:169.
  66. Farley TM, Rosenberg MJ, Rowe PJ, et al. Intrauterine devices and pelvic inflammatory disease: an international perspective. Lancet 1992; 339:785.
  67. Walsh T, Grimes D, Frezieres R, et al. Randomised controlled trial of prophylactic antibiotics before insertion of intrauterine devices. IUD Study Group. Lancet 1998; 351:1005.
  68. Heinemann K, Reed S, Moehner S, Minh TD. Comparative contraceptive effectiveness of levonorgestrel-releasing and copper intrauterine devices: the European Active Surveillance Study for Intrauterine Devices. Contraception 2015; 91:280.
  69. Heinemann K, Reed S, Moehner S, Minh TD. Risk of uterine perforation with levonorgestrel-releasing and copper intrauterine devices in the European Active Surveillance Study on Intrauterine Devices. Contraception 2015; 91:274.
  70. Caliskan E, Oztürk N, Dilbaz BO, Dilbaz S. Analysis of risk factors associated with uterine perforation by intrauterine devices. Eur J Contracept Reprod Health Care 2003; 8:150.
  71. Van Houdenhoven K, van Kaam KJ, van Grootheest AC, et al. Uterine perforation in women using a levonorgestrel-releasing intrauterine system. Contraception 2006; 73:257.
  72. Kaislasuo J, Suhonen S, Gissler M, et al. Intrauterine contraception: incidence and factors associated with uterine perforation--a population-based study. Hum Reprod 2012; 27:2658.
  73. Berry-Bibee EN, Tepper NK, Jatlaoui TC, et al. The safety of intrauterine devices in breastfeeding women: a systematic review. Contraception 2016; 94:725.
  74. WHITACRE FE, LOEB WM, LOEB L. The time for postpartum sterilization; report of 150 cases; bacteriologic studies on the postpartum uterus. Am J Obstet Gynecol 1946; 52:1041.
  75. Rozier JR. Immediate postpartum tubal ligation. An intraumbilical approach. Am J Obstet Gynecol 1973; 117:226.
  76. Lu T, Chun D. A long term follow-up study of 1,055 cases of postpartum tubal ligation. J Obstet Gynaecol Br Emp 1967; 74:875.
  77. Black WP, Sclare AB. Sterilization by tubal ligation--a follow-up study. J Obstet Gynaecol Br Commonw 1968; 75:219.
  78. Green LR, Laros RK Jr. Postpartum sterilization. Clin Obstet Gynecol 1980; 23:647.
  79. Peterson HB, Xia Z, Hughes JM, et al. The risk of pregnancy after tubal sterilization: findings from the U.S. Collaborative Review of Sterilization. Am J Obstet Gynecol 1996; 174:1161.
  80. Rodriguez MI, Edelman AB, Kapp N. Postpartum sterilization with the titanium clip: a systematic review. Obstet Gynecol 2011; 118:143.
  81. US Food and Drug Administration. Premarket approval of Femcare Ltd Filshie Clip System (Mark VI), 1996. www.accessdata.fda.gov/cdrh_docs/pdf/p920046.pdf (Accessed on February 13, 2012).
  82. Braniff K, Gomez E, Muller R. A randomised clinical trial to assess satisfaction with the levonorgestrel- releasing intrauterine system inserted at caesarean section compared to postpartum placement. Aust N Z J Obstet Gynaecol 2015; 55:279.
  83. Chen BA, Reeves MF, Creinin MD, Schwarz EB. Postplacental or delayed levonorgestrel intrauterine device insertion and breast-feeding duration. Contraception 2011; 84:499.
  84. Phillips SJ, Tepper NK, Kapp N, et al. Progestogen-only contraceptive use among breastfeeding women: a systematic review. Contraception 2016; 94:226.
  85. Kapp N, Curtis K, Nanda K. Progestogen-only contraceptive use among breastfeeding women: a systematic review. Contraception 2010; 82:17.
  86. Rodriguez MI, Kaunitz AM. An evidence-based approach to postpartum use of depot medroxyprogesterone acetate in breastfeeding women. Contraception 2009; 80:4.
  87. Truitt ST, Fraser AB, Grimes DA, et al. Hormonal contraception during lactation. systematic review of randomized controlled trials. Contraception 2003; 68:233.
  88. Taneepanichskul S, Reinprayoon D, Thaithumyanon P, et al. Effects of the etonogestrel-releasing implant Implanon and a nonmedicated intrauterine device on the growth of breast-fed infants. Contraception 2006; 73:368.
  89. Kennedy KI, Short RV, Tully MR. Premature introduction of progestin-only contraceptive methods during lactation. Contraception 1997; 55:347.
  90. Gurtcheff SE, Turok DK, Stoddard G, et al. Lactogenesis after early postpartum use of the contraceptive implant: a randomized controlled trial. Obstet Gynecol 2011; 117:1114.
  91. Brownell EA, Fernandez ID, Howard CR, et al. A systematic review of early postpartum medroxyprogesterone receipt and early breastfeeding cessation: evaluating the methodological rigor of the evidence. Breastfeed Med 2012; 7:10.
  92. Brownell EA, Fernandez ID, Fisher SG, et al. The effect of immediate postpartum depot medroxyprogesterone on early breastfeeding cessation. Contraception 2013; 87:836.
  93. Halderman LD, Nelson AL. Impact of early postpartum administration of progestin-only hormonal contraceptives compared with nonhormonal contraceptives on short-term breast-feeding patterns. Am J Obstet Gynecol 2002; 186:1250.
  94. Lopez LM, Grey TW, Stuebe AM, et al. Combined hormonal versus nonhormonal versus progestin-only contraception in lactation. Cochrane Database Syst Rev 2015; :CD003988.
  95. Tepper NK, Phillips SJ, Kapp N, et al. Combined hormonal contraceptive use among breastfeeding women: an updated systematic review. Contraception 2016; 94:262.
  96. Jackson E, Curtis KM, Gaffield ME. Risk of venous thromboembolism during the postpartum period: a systematic review. Obstet Gynecol 2011; 117:691.
  97. Lidegaard Ø, Løkkegaard E, Jensen A, et al. Thrombotic stroke and myocardial infarction with hormonal contraception. N Engl J Med 2012; 366:2257.
  98. US Food and Drug Administration. Nexplanon (etonogestrel) implants: Warnings and precautions. http://www.fda.gov/safety/medwatch/safetyinformation/ucm400441.htm (Accessed on March 28, 2016).
  99. Tepper NK, Whiteman MK, Marchbanks PA, et al. Progestin-only contraception and thromboembolism: A systematic review. Contraception 2016; 94:678.
  100. Mantha S, Karp R, Raghavan V, et al. Assessing the risk of venous thromboembolic events in women taking progestin-only contraception: a meta-analysis. BMJ 2012; 345:e4944.
  101. Tsai R, Schaffir J. Effect of depot medroxyprogesterone acetate on postpartum depression. Contraception 2010; 82:174.
  102. Singata-Madliki M, Hofmeyr GJ, Lawrie TA. The effect of depot medroxyprogesterone acetate on postnatal depression: a randomised controlled trial. J Fam Plann Reprod Health Care 2016; 42:171.
  103. Goldberg AB, Grimes DA. Injectable contraceptives. In: Contraceptive Technology, 19th ed, Hatcher RA, Trussell J, Nelson AL (Eds), Ardent Media, New York 2007. p.162.