Combined hormonal versus nonhormonal versus progestin-only contraception in lactation
RHL practical aspects by Levy DP
FIRST CONTACT (PRIMARY CARE) LEVEL
In many settings, the most important contribution that health services can make at the primary care level (or the community health care level) is to inform women that they have many options for contraception in the postpartum period. Timing is critical for effective use of contraception post partum, since, for example in China, more than 10% of women conceive in the first year after delivery. Information and advice can be provided to women at the primary care level, after their discharge from maternity and while they are still breastfeeding.
The WHO gives lactation a category 3 rating for combined oral contraceptives use among lactating women between six weeks and six months post partum, indicating that the risks usually outweigh the advantages of using the method. Progestin-only methods should be started only after 6 weeks post partum. Finally, non-hormonal methods (LAM, barrier methods and the IUD) should be presented as the best options in the post partum period. For Chinese women, non-hormonal methods are already the number one choice for contraception in the post partum period. Couples rely essentially on condoms, IUDs and sterilization for effective contraception after the first birth. Progesterone implants and vaginal rings are used very rarely. Thus, the issue is more to promote IUD insertion post partum, or condom use despite amenorrhoea, than to avoid combined contraceptive pills in lactating women. Family planning providers still would have a long way to go to dispel fears surrounding the use of hormonal methods, and promote progestin implants or vaginal rings for the women who cannot use an IUD.
REFERRAL HOSPITAL (SECONDARY CARE) LEVEL
The referral hospital has a major role at the time of delivery for immediate postpartum IUD insertion in women who have delivered vaginally. Currently, this issue is very rarely discussed with pregnant women prior to delivery, and as a consequence, the number of IUDs inserted immediately after placental delivery is extremely low in China.
Family planning programmes in referral hospitals should offer a wide range of services for postpartum contraception, including implant insertion. Contraceptive options should be discussed with each mother in the postnatal ward by a dedicated member of staff. Formal and regular evaluation of the provided contraceptive education should be built into any education programme at this level of health care.
AT HOME OR IN THE COMMUNITY
In most settings, fear of side-effects with hormonal methods is probably the single most important reason for their non-use. On the other hand many women have misconceptions about the protection against pregnancy during the period of lactation. Health education campaigns, including those targeting adolescents in schools, should continue to emphasize the need for contraction post partum and the range of options available to women.
This document should be cited as: Levy DP. Combined hormonal versus nonhormonal versus progestin-only contraception in lactation: RHL practical aspects (last revised: 2 March 2009). The WHO Reproductive Health Library; Geneva: World Health Organization.