When you’re pregnant you’re making a lot of plans—plans for where you’ll give birth, plans for where baby will sleep, plans for pumping if you’re breastfeeding and returning to work. In the midst of it all, it’s also important to plan what birth control method(s) you’ll use postpartum.
How soon can you get pregnant? Many people may not know that after giving birth ovulation can return before any signs of menstruation, ie. period blood. Six months is the average, but the potential for pregnancy can be as early as 25 days postpartum for moms who are not breastfeeding.
If you plan to continue with your pre-pregnancy contraception method then you’re all set. But maybe you’re interested in making a change. Maybe your old method is not recommended if you’re breastfeeding, or maybe it failed to prevent your recent pregnancy, or maybe you were unhappy with your old method and you feel like now is a good time to research other options. Whatever your reason for choosing a new birth control method, pregnancy is a good time to look into your options.
You’ve probably heard the recommendation that a woman wait until six weeks after giving birth before she resumes having sex. Some women may be ready earlier than six weeks and some women may not be interested in sex for months—everyone is different! The reasoning behind the six week recommendation is that by this point, postpartum bleeding (lochia) should have ended, any tear, episiotomy, or c-section incision should be healed, and the uterus should be back to its pre-pregnancy size. The uterus has healing of its own to do: when the placenta detaches from the uterine wall it essentially leaves behind an open wound that is vulnerable to infection (which is why it is inadvisable to insert anything into the vagina immediately following birth).
So what are your options for birth control once you do start having sex again?
Well if you’re breastfeeding you may be able to use what’s known as the Lactation Amenorrhea Method (LAM) to prevent pregnancy. For most women there is a period of menstrual suppression when they are breastfeeding, although every woman is different and you will still need to monitor your fertility signs if using LAM. For more information, check out the Cycledork article “Breastfeeding and Your Cycle.”
You can use fertility awareness as your birth control method after baby whether you are breastfeeding or not. Starting at six weeks postpartum you can begin charting your fertility signs (basal body temperature, cervical fluid and cervical position), or you can use a fertility monitor like Daysy.
Barrier methods, like condoms, diaphragms and sponges, are another birth control option (and these methods can also be used on your fertile days if you are using fertility awareness). One thing to keep in mind with many barrier methods, as well as the sponge, is that they often must be used with spermicide (or in the case of male condoms they may have added spermicide). Spermicide can be irritating to vaginal tissue, especially if it is already dry or irritated. Breastfeeding decreases estrogen levels, which can make the vagina dryer and more easily irritated, so you’ll want to consider this if you are breastfeeding and are thinking of using a contraception method with spermicide.
What about hormonal methods? It is recommended that breastfeeding women avoid using estrogen-containing hormonal contraceptives (the combination pill, patch, and ring). Breastfeeding support site KellyMom notes that, “Estrogen-containing contraceptives have been linked to low milk supply and a shorter duration of breastfeeding even when started when baby is older, after milk supply is well established.” The medical consensus is that progestin-only containing contraceptive methods (the mini-pill, hormonal IUD, implant and shot) are safe to use with breastfeeding as long as it is not started earlier than six-eight weeks postpartum and is given at normal doses.
Anecdotal evidence does, however, reveal that some women do experience supply issues while using these methods. There are also reports of fussiness in breastfed babies whose mothers are using a hormonal contraceptive, which may be due to the hormones “causing a minimal decrease in the protein/nitrogen/lactose content of the milk.” Anecdotal evidence also indicates that for some of these babies this fussiness improves if their mother switches to a non-hormonal method of birth control.
If you’re breastfeeding and thinking of using the hormonal IUD, implant, or shot, KellyMom recommends that you consider doing a month long trial with the mini-pill to see if the progestin has any effect on your milk supply: “If you find that you are among the women whose supply drops significantly due to progestin-only birth control, you can simply discontinue the pills, rather than struggling with low milk supply for several months until the injection wears off or you get the implant or IUD removed.”
The American Congress of Obstetricians and Gynecologists (ACOG) now recommends that women be offered the option of having long-acting reversible contraception or LARC devices (IUD or implant) inserted immediately after birth. The idea is that it is more convenient to have a device inserted immediately after birth than at the six week postpartum appointment, and that a woman will have contraception coverage should she resume having sex before six weeks postpartum.
There are risks however with this decision, particularly with the IUD (hormonal and copper). Studies show that there is a significantly higher rate of expulsion in IUDs inserted immediately postpartum—as much as 10-27%. Strangely enough, the website for Mirena (a hormonal IUD) says right out that, “Mirena should not be inserted until six weeks postpartum or until involution of the uterus is complete due to the increased risk of perforation and expulsion. Postpone insertion until involution is complete. The risk of perforation is higher if inserted in lactating women and may be higher if inserted in women who are postpartum or the [sic] when the uterus is fixed retroverted.” (Involution is the process by which the uterus returns to its pre-pregnancy size).
ACOG does acknowledge that inserting Mirena immediately postpartum is an off -label use of the device, but they claim “that the advantages of immediate placement outweigh the disadvantages.”
Many women also choose tubal ligation (“getting your tubes tied”) immediately after birth as their postpartum contraception method. If a woman has a cesarean the same incision can be used to perform the procedure, but if a woman has a vaginal birth a small abdominal incision will be made so that the tubal ligation can be performed. Check out this Cycledork article all about tubal ligation for more specifics on the benefits and risks of this method of contraception.
One final thought on choosing a contraception method after pregnancy. A recent study reveals that there is a definite connection between hormonal birth control and depression (even if some doctors choose to minimize this study, the results are significant and should not be ignored). Women who have recently given birth are a population already at risk for developing depression and other mood disorders. Each year postpartum depression affects an average of 11-20% of women who give birth (although this is probably an underestimate as many cases go unreported). We cannot deny that women who give birth are at risk for depression, and we also cannot deny that taking hormonal contraception puts women at risk for depression. It is important that both you and your care provider keep these risks in mind when discussing options for birth control postpartum.
Whatever birth control method you decide to use post-baby, you never have to feel stuck with it if it’s not working out. If anything hurts, or if you’re worried about milk supply, or if something just doesn’t feel right you can always make an appointment with your care provider if you need their assistance to switch to a new method. A post-pregnancy body is doing lots of new things and it may feel kind of alien at times, but it’s still your body which means it’s still the best guide to help you decide what’s right for you!
Brigid Taylor is a women’s healing arts teacher, childbirth educator, and the creator of Taweret’s Wisdom, a business dedicated to helping women reclaim their power and live their best lives. Read her full bio here.