Contraception & Sexual and Reproductive Health after Birth
Key Takeaways
FSRH guidance states that contraception is not needed before day 21 after birth, but fertility can return before the first period, so methods should be discussed antenatally.
Progestogen-only pills and implants can be started at any time after birth, including while breastfeeding, because they do not affect milk supply or raise VTE risk.
Intrauterine contraception can be inserted within 48 hours of birth or from 4 weeks; insertion between 48 hours and 4 weeks is not recommended.
Combined hormonal contraception is UKMEC 4 if breastfeeding in the first 6 weeks, because of VTE risk and possible effects on milk supply.
The lactational amenorrhoea method is over 98% effective only if the woman is fully breastfeeding, has no periods and is less than 6 months postpartum.
Contraception & Sexual and Reproductive Health after Birth
The Future Midwife standards require midwives to offer information and access to resources and services for sexual and reproductive health and contraception (3.4). Discussing contraception before discharge from maternity care helps women plan future pregnancies and reduces unintended pregnancy soon after birth. Guidance comes from the Faculty of Sexual and Reproductive Healthcare (FSRH), including its guidance on contraception after pregnancy and the UK Medical Eligibility Criteria (UKMEC).
Return of Fertility and Birth Spacing
- Ovulation can return before the first period, so women can become pregnant again before they realise fertility has returned. In women who are not breastfeeding, ovulation can occur from about 3 to 4 weeks after birth.
- The FSRH advises that contraception is not required before day 21 after childbirth, so the aim is to have effective contraception in place by then if a woman does not want another pregnancy.
- Short intervals between pregnancies (less than 12 months between birth and the next conception) are associated with higher risks of preterm birth, low birth weight and small for gestational age babies. The World Health Organization recommends waiting at least 24 months after a live birth before trying for another pregnancy.
- Women who have had a caesarean birth are often advised to allow time for recovery before another pregnancy, and those with conditions such as diabetes or epilepsy benefit from preconception planning.
Ideally, contraception is discussed antenatally so that a woman can make an informed choice in advance, and methods such as intrauterine contraception or an implant can be provided soon after birth if she wishes.
UK Medical Eligibility Criteria (UKMEC)
UKMEC grades the safety of each method for women with particular conditions:
| UKMEC Category | Meaning |
|---|---|
| 1 | No restriction on use. |
| 2 | Advantages generally outweigh theoretical or proven risks. |
| 3 | Theoretical or proven risks usually outweigh the advantages; use only with specialist advice when other methods are not acceptable. |
| 4 | Unacceptable health risk; the method should not be used. |
Methods and Timing after Birth
| Method | When It Can Be Started after Birth | Key Points |
|---|---|---|
| Progestogen-only pill (POP) | Any time, including immediately | Safe while breastfeeding. Desogestrel pills have a 12-hour missed-pill window; traditional POPs have a 3-hour window. |
| Progestogen-only implant | Any time, including immediately | Lasts 3 years; very effective; may cause irregular bleeding. |
| Progestogen-only injectable (DMPA) | Any time | Given every 13 weeks; may delay return of fertility after stopping; can reduce bone density with long-term use. |
| Copper IUD or levonorgestrel IUS | Within 48 hours of birth (including at caesarean) or from 4 weeks | Insertion between 48 hours and 4 weeks is UKMEC 3, because of the higher risk of expulsion and perforation. Highly effective and long-acting. |
| Combined hormonal contraception (pill, patch, ring) | Breastfeeding: avoid in the first 6 weeks (UKMEC 4); UKMEC 2 from 6 weeks to 6 months. Not breastfeeding: from day 21 if there are no other VTE risk factors, or from 6 weeks if there are | Oestrogen increases the already raised postnatal risk of venous thromboembolism and may reduce milk supply. |
| Condoms | Any time | The only methods that also protect against sexually transmitted infections. |
| Female sterilisation or vasectomy | Usually delayed rather than performed at birth | Permanent methods; counselling is needed because regret is more likely if decisions are made under pressure. Vasectomy is simpler and has fewer risks than female sterilisation. |
The Lactational Amenorrhoea Method (LAM)
LAM is more than 98% effective only when all three conditions are met:
- The woman is fully (or nearly fully) breastfeeding, day and night, with no long gaps between feeds.
- She has no periods (amenorrhoea).
- The baby is less than 6 months old.
If any condition is no longer met, she needs another method.
Emergency Contraception
- Emergency contraception is not needed before day 21 after childbirth.
- The copper IUD is the most effective emergency contraception and can be used from 28 days after birth.
- Levonorgestrel 1.5 mg (licensed within 72 hours of unprotected sex) is compatible with breastfeeding.
- Ulipristal acetate 30 mg (licensed within 120 hours) is effective, but the FSRH advises women to avoid breastfeeding for one week afterwards, expressing and discarding milk in that time.
Sexual Health, Wellbeing and Relationships
- Resuming sex: there is no set time; women can resume when they feel physically and emotionally ready. Perineal pain, vaginal dryness during breastfeeding (low oestrogen), tiredness and body image changes are common. Water-based lubricants and pelvic floor exercises can help, and persistent pain (dyspareunia) should be assessed.
- Sexually transmitted infections: chlamydia is the most commonly diagnosed bacterial STI in England. Women at risk can be signposted to sexual health services, and partners should be tested and treated when an STI is diagnosed in pregnancy.
- Cervical screening: the NHS programme invites women aged 25 to 64. Screening that is due during pregnancy is usually postponed until at least 12 weeks after the birth.
- Reproductive coercion and domestic abuse: a partner who controls contraception, sabotages pills or condoms, or forces pregnancy or its ending is showing coercive behaviour. Midwives ask about this in private and follow domestic abuse pathways.
- Young parents and women with additional needs: services should be accessible, confidential and non-judgemental. For under-16s, the Fraser guidelines apply to contraceptive advice without parental involvement.
The Midwife's Role
Before transfer to community or health visiting care, the midwife should:
- Discuss the woman's plans for future pregnancies and her preferred method.
- Explain the effectiveness of each method, including that long-acting reversible contraception (LARC: implants, IUDs, IUS and injections) is the most effective because it does not depend on daily use.
- Provide or arrange the chosen method, including immediate postnatal provision where services allow (for example, an implant before discharge or an IUD at caesarean).
- Give information about local sexual health services and emergency contraception.
- Document the discussion and the plan, and share it with the GP and health visitor.
A woman who is exclusively breastfeeding her 2-week-old baby asks to start the combined oral contraceptive pill. What should the midwife advise?
She can start immediately because combined pills are UKMEC 1 at any time after birth
She should wait until 4 weeks after birth, when combined pills become UKMEC 1
She should not start it now because combined hormonal contraception is UKMEC 4 in the first 6 weeks while breastfeeding; a progestogen-only method can be started instead
She does not need contraception while breastfeeding, whatever her baby's age or feeding pattern
A woman who had a vaginal birth 10 days ago asks to have a copper intrauterine device fitted at her postnatal visit. What advice is correct?
It can be fitted now because there is no restriction on timing after a vaginal birth
Insertion between 48 hours and 4 weeks after birth is not recommended, so it should be fitted from 4 weeks, using another method if needed in the meantime
It can only be fitted after her first period has returned
An intrauterine device cannot be used by women who have recently given birth
Which set of conditions must all be met for the lactational amenorrhoea method (LAM) to be more than 98% effective?
Breastfeeding at least once a day, periods returned and the baby is under 12 months old
Mixed feeding with formula at night, no periods and the baby is under 9 months old
Expressing breast milk for bottle feeds, irregular periods and the baby is under 3 months old
Fully or nearly fully breastfeeding, no periods since the birth, and the baby is less than 6 months old
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