Audio LecturePro Feature Postpartum Contraception 0:00 / 0:00 1x 0.25x 0.5x 0.75x 1x 1.25x 1.5x 1.75x 2x Key Points Women and pregnant people can become fertile 21 days after delivery. All progestogen-only methods, as well as the copper intrauterine device, are safe for use immediately postpartum and during breastfeeding. The appropriate timing for postpartum initiation varies by contraceptive method, and factors such as breastfeeding and VTE risk can affect eligibility of certain contraceptive methods such as combined hormonal contraception. The lactational amenorrhoea method can be up to 98% effective if a woman or pregnant person is less than 6 months postpartum, amenorrhoeic, and fully or nearly fully breastfeeding day and night, with no long intervals between feeds. Regardless of the method chosen, early counselling and shared decision-making are key components of postpartum contraceptive care. Women and pregnant people can regain fertility as early as 21 days after delivery, making contraception an important topic for healthcare providers to discuss before discharge from maternity services. An individual’s chosen method of contraception should be initiated immediately, as long as it is medically appropriate, ideally within the first 21 days postpartum.1 Discussing contraception before discharge is important for two reasons. Firstly, the immediate postpartum period may limit opportunities for individuals to seek contraception counselling after discharge. Secondly, a birth-to-conception interval of less than 12 months is associated with an increased risk of: Premature delivery Low birth weight Small-for-gestational age babies Fetal mortality1 A recent UK study of women who had previously given birth found that almost 1 in 8 conceived within a year of a previous birth, highlighting the importance of effective postpartum contraception counselling.2 Aims of Care Promote timely access to safe and effective contraception. Support informed reproductive choices and patient autonomy. Prevent unintended and closely spaced pregnancies. Support safe contraceptive use during breastfeeding and after pregnancy complications. Deliver equitable, patient-centred, non-coercive contraceptive care. Schedule of Care Different contraceptive options can be started at different times postpartum for a variety of reasons. Below is a timeline showing when each form of contraceptive is safe to be initiated: By TeachMeSeries Ltd (2026) Postpartum contraception initiation timeline by method and UKMEC category UKMEC Classification The UK Medical Eligibility Criteria for Contraceptive Use (UKMEC) provides a risk stratification framework for specific clinical contexts, classifying contraceptive methods into four categories based on the balance between their advantages and risks: Category 1 = no restriction Category 2 = advantages generally outweigh risks Category 3 = risks usually outweigh advantages Category 4 = unacceptable risk1 Combined Hormonal Contraception (CHC) CHC eligibility is primarily time and risk-factor dependent, with the main factors being breastfeeding status, time since delivery, and postpartum VTE risk. Patient group <3 weeks postpartum 3-6 weeks postpartum >6 weeks postpartum Breastfeeding UKMEC 4 UKMEC 4 UKMEC 2 (6 weeks-6 months); UKMEC 1 (>6 months) Non-breastfeeding with additional VTE risk factors UKMEC 4 UKMEC 3 UKMEC 1 Non-breastfeeding without additional VTE risk factors UKMEC 3 UKMEC 2 UKMEC 1 The risk of venous thromboembolism (VTE) is further increased by factors such as reduced mobility, transfusion at the time of delivery, a BMI of 30kg/m² or above, postpartum haemorrhage, delivery by caesarean section, pre-eclampsia, and smoking.1 Progestogen-Only Contraception Progestogen-only contraception, including the POP, implant, and POI (e.g. DMPA), is consistently UKMEC 1 for breastfeeding and non-breastfeeding individuals across the majority of postpartum scenarios. Depot medroxyprogesterone acetate (DMPA) is one of the only exceptions to this, as it is rated UKMEC 2 for the first six weeks postpartum for most individuals, reflecting the increased risk of VTE in the early postnatal period.1 Intrauterine Contraception Both the copper intrauterine device (Cu-IUD) and the levonorgestrel-releasing intrauterine system (LNG-IUS) can be safely inserted immediately after birth or up to the first 48 hours after delivery, classified as UKMEC 1 in this time period. The next safe UKMEC 1 window to have either method inserted is from 4 weeks after delivery onwards. The time between 48 hours and 4 weeks is classified as UKMEC 3, meaning the risks outweigh the benefits. The only scenario in which either of these methods is classified as UKMEC 4 is in the case of postpartum sepsis.1 Non-UKMEC Classification There are other options available for contraceptive purposes that are not classified under the UKMEC categories, including barrier methods, lactational amenorrhoea and female sterilisation. Lactational Amenorrhoea (LAM) The lactational amenorrhoea method (LAM) can provide effective contraception during the first 6 months postpartum when a woman or pregnant person has not yet resumed menstruation and is exclusively breastfeeding. However, its reliability declines if breastfeeding becomes less frequent, menstruation returns, or the individual is over 6 months postpartum.1 Barrier Methods Both male and female condoms may be used safely immediately after childbirth, although their effectiveness is relatively low compared with other methods when used typically. Diaphragms should not be fitted until at least 6 weeks postpartum, allowing time for postpartum anatomical changes to resolve. Anyone wishing to use a diaphragm should therefore consider an alternative contraceptive method from 21 days postpartum until an appropriate fitting can be carried out.1 Female Sterilisation Female sterilisation is a safe and highly effective permanent contraceptive method. During counselling, women and pregnant people should be made aware that some LARC methods may offer comparable or greater contraceptive effectiveness, as well as other benefits. Nevertheless, the decision should remain patient-centred, and individuals should be supported in whichever method they choose.1 Fertility Awareness Methods Fertility awareness methods remain an option postpartum; however, women and pregnant people should be advised that the postpartum period and breastfeeding-related changes can make fertility signs more difficult to recognise and interpret, potentially reducing the effectiveness of these methods.1 Additional Contraception If hormonal contraception is not initiated within 21 days of childbirth, individuals should be advised to use additional contraceptive methods, e.g. barrier methods or abstinence. These additional methods should be used for 2 days after initiation for the POP, and 7 days after initiation for all other forms of contraception.1 Emergency Contraception If an individual has had unprotected sexual intercourse (UPSI) from 21 days postpartum, they should be offered emergency contraception (EC). If they have had UPSI prior to 21 days postpartum, this is not required. Oral levonorgestrel and ulipristal acetate are safe to use from 21 days postpartum, and the copper intrauterine device is safe to use as EC only from 28 days postpartum. Individuals who breastfeed should be advised to avoid breastfeeding and to express and discard milk for a week after taking ulipristal acetate, but these precautions are not recommended if they have taken levonorgestrel as EC instead.1 Early Pregnancy Loss: Abortion, Ectopic Pregnancy and Miscarriage According to UKMEC, all contraceptive options are safe to use by individuals who have had an uncomplicated abortion, ectopic pregnancy, or miscarriage. Intrauterine contraception should not be inserted in the presence of sepsis after abortion, ectopic pregnancy or miscarriage. Although it is safe to start DMPA following an abortion, patients should be informed that giving it concurrently with mifepristone may slightly increase the risk of an ongoing pregnancy due to failed abortion. Due to concerns about increased failure rate and future decision regret, tubal occlusion is ideally scheduled after a post-abortion interval rather than performed immediately. Where immediate female sterilisation is requested as a form of contraception post-abortion, counselling should include discussion of these risks. After use of methotrexate in cases of ectopic pregnancy, patients should be advised that contraception is recommended for at least 3 months after treatment due to the teratogenic effects of this medication. If an individual has experienced recurrent early miscarriages, this should be investigated. However, investigations should not delay initiation of a contraceptive method if the individual does not wish to become pregnant. The only contraception that should be avoided during this period of investigation is CHC, until antiphospholipid syndrome has been excluded. If hormonal contraception is initiated 5 or more days after an abortion, ectopic pregnancy, or miscarriage, additional contraceptive precautions will be required. These additional methods, such as barrier methods or abstinence, should be used for 2 days after initiation for the POP, and 7 days after initiation for all other forms of contraception. Emergency contraception should be offered following UPSI 5 or more days after an abortion, ectopic pregnancy, or miscarriage. Any method of emergency contraception is safe to use.1 Equity, Safety and Professionalism Choices regarding postpartum contraception should be guided by discussion and shared decision-making. Women and pregnant people should be provided with clear information to support their decision throughout their pregnancy, allowing contraceptive methods to be planned prior to the time of birth. This allows more time for individuals to consider their options, rather than having to make decisions in the immediate postpartum period when they are recovering and caring for a baby.3 During contraceptive counselling, it is important to take a person-centred approach and consider the individual’s preferences, beliefs, and previous experiences. Women and pregnant people should not be made to feel under pressure to choose any particular form of contraception and should feel encouraged to make their own decision after obtaining and discussing as much information as they require. Although long-acting reversible contraceptives (LARCs) are highly effective, this factor alone should not determine the decision.1 Unfortunately, access to postpartum contraception in the UK is highly inconsistent. Many individuals face barriers in obtaining contraception in the postpartum period, largely due to differences in local provision. This has led to significant geographical variation in access to postpartum contraceptive services, with contraceptive counselling and options varying significantly depending on where women and pregnant people live.2 Services caring for pregnant people should be able to offer all appropriate contraceptive options prior to discharge from hospital.4 If an individual’s preferred contraceptive method cannot be delivered before discharge, they should be provided with effective bridging contraception, alongside information on how to access local services to obtain their chosen method later.3 Recent Changes and Controversies Immediate insertion of a LARC postpartum raises some debate. Although immediate insertion improves uptake and helps to reduce missed opportunities for contraception, concerns are raised regarding higher IUS/IUD expulsion rates in the immediate postpartum window, and ensuring valid consent at this time. Antenatal counselling regarding postpartum contraception is advised in order to allow decisions to be considered before labour and the immediate postpartum period, when women and pregnant people may be exhausted, overwhelmed and focused on caring for their newborn. However, discussions should not end at delivery, as individuals should have opportunities to revisit their choices and ask further questions postpartum if they wish to.1 References 1. Faculty of Sexual and Reproductive Healthcare. Contraception After Pregnancy. 2017 (amended October 2020). Available from: https://www.cosrh.org/Common/Uploaded%20files/documents/contraception-after-pregnancy-guideline-oct2020.pdf [Accessed 22 Jun 2026]. 2. CoSRH, RCOG. Beyond Barriers: Reimagining Access to Post-Pregnancy Contraception – The Case for Change. 2025. Available from: https://www.cosrh.org/Common/Uploaded%20files/documents/The%20Case%20for%20Change%20%E2%80%93%20Beyond%20Barriers%20%E2%80%93%20CoSRH%20RCOG.pdf [Accessed 22 Jun 2026]. 3. RCOG. Guidance on the Provision of Contraception by Maternity Services after Childbirth during the COVID-19 Pandemic. 2021. Available from: https://www.rcog.org.uk/media/cqql4p0b/2021-02-guidance-on-the-provision-of-contraception-by-maternity-service.pdf [Accessed 22 Jun 2026]. 4. Knight M, Bunch K, Felker A, Patel R, Kotnis R, Kenyon S, Kurinczuk JJ (Eds.) on behalf of MBRRACE-UK. Saving Lives, Improving Mothers’ Care: Lessons Learned to Inform Maternity Care from the UK and Ireland Confidential Enquiries into Maternal Deaths and Morbidity 2019-21. Oxford: National Perinatal Epidemiology Unit, University of Oxford; 2023. Available from: https://www.npeu.ox.ac.uk/assets/downloads/mbrrace-uk/reports/maternal-report-2023/MBRRACE-UK_Maternal_Compiled_Report_2023.pdf [Accessed 22 Jun 2026]. Recommended Reading NICE NG194 – Postnatal Care NICE CG30 – Long-Acting Reversible Contraception NICE CKS – Postnatal Care Management MBRRACE-UK – Saving Lives, Improving Mothers’ Care GIRFT – Maternity and Gynaecology National Report 2024 FSRH – UK Medical Eligibility Criteria for Contraceptive Use (UKMEC) 2025 RCOG Best Practice Paper No. 1 – Postpartum Family Planning Rate This Article