Dr Amy Berry and Dr Kayleigh Lawrence

Sexual and Reproductive Health Registrar, Liverpool, MBChB, DFSRH, PG Cert Med Ed

GP Registrar, Doncaster MBChB, DFRSH, DRCOG, PG Cert Psychology in the workplace

Co-founders of #day21

@postnatalcontraception and www.day21.org

Summary

The weeks after having a baby can be joyful, exhausting and overwhelming. Thinking about birth control may understandably be low on your list of priorities. However, fertility can return surprisingly quickly and navigating lots of appointments with a newborn can be tricky.

The #Day21 team share clear and honest information about contraception after having a baby.

Our message is simple: Fertility returns at day 21 after childbirth.

We help people understand their choices so they can decide what is best for themselves and their families. Our goal is to support planning for healthier and safer pregnancies by making important information easy to understand, and by standing up for fair access to postnatal contraception services for all.

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After having a baby, fertility can return before periods

It is possible to become pregnant from day 21 after giving birth, even if your periods have not returned and even if you are breastfeeding. This is well before the routine 6-8 week check with your GP where most postnatal contraception conversations first start.

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Closely spaced pregnancies may carry additional risks

UK guidance generally recommends spacing pregnancies by at least 12-18 months^1,2,3. This is to allow a woman’s body to properly recover, to replenish nutrient stores and to bond with her new baby. Research has found links between very short intervals between pregnancies (particularly less than six months) and poor outcomes such as premature birth and low birth weight.⁴ For women who have had a caesarean birth, time is needed for the scar on the womb to fully heal. A short interval between a caesarean and the next pregnancy is associated with risks including the need for a blood transfusion and possible uterine rupture (the scar on the womb opening up).^3,5,6 Making an informed plan for your postnatal contraception will help you plan for a safer and healthier future pregnancy.

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What are my options?

Most contraceptive methods can be started straight after birth and are suitable while breastfeeding.¹^,7

Method	When can it usually be started?	Pros	Cons
Progestogen-only pill	Immediately after birth	Effective if taken consistently Easy to start and stop May stop periods or make them lighter Safe while breastfeeding.	Bleeding may become irregular May get some hormone side effects User dependent
Contraceptive injection	Immediately after birth unless additional risk of a blood clot.	Very effective method Lasts for 13 weeks. May stop periods or make them lighter Safe while breastfeeding.	Bleeding may become irregular May get some hormone side effects Delayed fertility return of up to 1 year after stopping May impact bone health
Contraceptive implant	Immediately after birth	Most effective method of contraception. Lasts for five years but can be removed at any time. May stop periods or make them lighter Safe while breastfeeding	Bleeding may become irregular May get some hormone side effects
Hormonal coil/IUS	During a caesarean birth, within 48 hours of birth where available, or from four weeks afterwards	More than 99% effective. Lasts for 3-8 years, depending on the coil fitted Often makes periods lighter and less painful  Can help with conditions like endometriosis and adenomyosis Safe while breastfeeding	A coil fitted immediately after birth is more likely to come out. A coil fitted later has some procedure-associated risks May get some hormone side effects Bleeding may become irregular
Copper coil/IUD	During a caesarean birth, within 48 hours of birth where available, or from four weeks afterwards	More than 99% effective No hormones Lasts 5-10 years depending on the coil fitted. Regular periods Safe while breastfeeding	A coil fitted immediately after birth is more likely to come out. A coil fitted later has some procedure-associated risks. Periods may become heavier and more painful.
Combined pill, patch or vaginal ring	Timing depends on breastfeeding and individual blood-clot risks; usually 3 or 6 weeks	Contains oestrogen, so it cannot usually be started immediately after birth. Effective if taken consistently Easy to start and stop Good control over periods	May get some hormone side effects Small increased risk of blood clot, heart attack and stroke.
Condoms	Whenever you resume sexual activity	Reduce the risk of sexually transmitted infections. None hormonal	Effectiveness depends on correct use every time.
Diaphragm	Usually from six weeks after birth	Non-hormonal method	Effectiveness depends on correct use every time.
Fertility awareness methods	Not recommended in the initial postpartum period. Track 3 normal periods before starting	None hormonal Can be effective if rules are followed.	Relies on monitoring 3 factors, including daily morning temperature, cervical mucus, and cycle very strictly. High failure rate when rules are not followed or only using 1 factor. Affected by external factors like alcohol and illness

Long-acting methods are very effective

The implant, hormonal coil and copper coil are all more than 99% effective.⁸ Once fitted, you can forget about them, something many people appreciate when caring for a new baby. Depending on which method is fitted, they last between 3-10 years, and you can get pregnant again as soon as they are removed. We recommend long-acting methods as it supports the healthy spacing of pregnancies (at least 12-18 months) as this is associated with better outcomes. ⁹

Coils can be fitted at the time of a C-section

Having a coil fitted during a caesarean section can be convenient, provides contraception before leaving hospital and means you can avoid the fitting procedure.

However, a coil fitted immediately after birth has a slightly higher chance of falling out than one fitted later.^10,11 Women should be told how follow-up will be arranged and what to do if they feel the device, notice unexpectedly long threads or think it may have come out.

Female sterilisation at the time of C section

If your family is complete, you may want to consider a sterilisation at the time of your C section. This often needs deciding in advance to confirm you are sure of your decision, but you can speak to your obstetrician about this. ¹

Male sterilisation

This is a procedure done under local anaesthetic to cut or seal the male tubes that carry sperm. It is not considered reversible; it has less risk than female sterilisation and is more effective. It requires an alternative contraceptive method to cover until a sperm sample is completed at 16 weeks to confirm the procedure was successful. ¹

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Breastfeeding and contraception

The implant, injection, hormonal coil and progestogen-only pill can be used while breastfeeding. All non-hormonal options are also safe. It is recommended that the combined pill is not started until 3- 6 weeks after birth as there is an increased risk of a blood clot in the leg or lung; after this, it is safe with breastfeeding. ¹

Breastfeeding as contraception

Breastfeeding can be used as contraception through the lactational amenorrhoea method (LAM) and is 98% effective if done properly. It is only considered reliable when all three of the following apply:

1. Your baby is under six months old.
2. Your periods have not returned.
3. Your baby is fully or almost fully breastfed, feeding frequently during the day and night without long gaps. (4-hourly during the day and 6-hourly overnight)

Expressing milk, introducing formula or solid food, longer gaps between feeds, night weaning, or the return of bleeding may mean LAM is no longer reliable. If you are unsure, use another method and ask a healthcare professional for advice.¹

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What we don’t know

There is no single “best” method of postnatal contraception. Studies can compare effectiveness and side effects, but they cannot decide which features matter most to an individual woman.

Some hospitals offer this service before women are discharged but many don’t as there are complex problems surrounding funding and commissioning.

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How to use the evidence

We aim to provide accurate, evidence-based information so you can make an informed decision that is best for you. This will support you to adequately space your pregnancies and avoid an unintended pregnancy.

We want to make it as easy as possible for you to access your preferred method of contraception. Where available, you can receive it before leaving hospital, reducing the need for additional appointments while you recover and adjust to life with your new baby.

You may find it helpful to ask your midwife:

• Which methods can I start before leaving hospital?
• Can I have an implant or coil fitted as part of my maternity care?
• Is my preferred method suitable with my medical history and feeding plans?
• What bleeding changes or side effects might occur?
• Where can I get help if I change my mind?
• How quickly can an implant or coil be removed?
• What should I do if I have sex after day 21 without contraception?

You can record your preference in your maternity notes or birth plan, while remembering that you can change your mind at any time.

Consider what is most important to you:

• A method you do not need to remember?
• A very effective method?
• A hormone-free method?
• Lighter or fewer periods?
• A method you can stop yourself?
• Protection lasting months or years?
• Contraception that can be started before you leave hospital?
• A permanent method if you are certain your family is complete?

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Midwives and birth workers: how to use the evidence

Begin conversations antenatally

Contraceptive counselling should not be left until discharge or the six-to-eight-week postnatal review. NICE recommends providing information as soon as possible after birth and within the first postnatal week, but earlier antenatal discussion gives women more time to consider their preferences.²

A simple opener is:

“You can become pregnant again from 21 days after birth, before your periods return. Would it be helpful to talk through the methods that can be started after birth? If you’ve decided on a preferred method, we might be able to help arrange it for you, so you have fewer appointments to attend with your baby”

Provide balanced information about:

• All suitable methods and how they work
• Effectiveness with typical use
• Positive things about the method
• Bleeding changes and other common side effects
• Timing of initiation
• Breastfeeding
• Reversibility and return to fertility
• Access to review and removal

Turn the #Day21 message into a routine safety check. Before discharge, check that the woman understands:

“Fertility can return from day 21 after birth, before your first period and even if you are breastfeeding. Most contraception can be started immediately. You do not have to decide now, but would you like information or help arranging a method?”

Discuss:

• how and where her preferred method will be obtained and provide it if possible
• where to seek emergency contraception or advice following discharge

Reduce service barriers

Many services across the UK are offering postnatal contraception services; however, there are large gaps in delivery and a postcode lottery still exists.

If you would like to make an impactful change and improve services in your local hospital, consider:

• endorsing the #day21 campaign to inspire informed discussions on options – this might be by displaying our poster, digital slide or using our stickers on discharge condom packets or patient information leaflets – all available on our website day21.org
• training midwives and obstetric staff to discuss and provide postnatal contraception – see courses below
• using written information or QR codes linked to accessible resources
• recording contraceptive preferences in electronic maternity notes in antenatal appointments
• including a prompt in discharge documentation
• establishing direct referral pathways to community sexual health services
• supplying the progestogen-only pill before discharge either by doctor’s prescription or via PGD
• offering implant insertion on postnatal wards
• developing pathways for coils at caesarean and after vaginal birth
• auditing informed choice, access, satisfaction, continuation and removal

This factsheet is for general information and does not replace individual clinical advice. If you are concerned about your baby’s health, seek advice from an appropriate healthcare professional.

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