I’m 39 weeks pregnant this week. As you would expect, for the past few weeks my nights and weekends have been focused on birth and babies: learning how to breathe properly during contractions, figuring out what an episiotomy is and how to avoid having one, setting up the nursery, and eating more Ben and Jerry’s than I ever have in my entire life.
What hadn’t occurred to me, until my midwife mentioned it at my last appointment, is that I’m also going to have to think about contraception again. It feels strange after being so focused on getting and staying pregnant for so long.
My midwife said I should get sorted now, before the baby arrives, because in theory I could get pregnant again as quickly as 3 weeks after giving birth.
So unless I want another child in a hurry—and one is definitely enough for now!—I need to get sorted out.
Now also seems like a good time to reassess what kind of contraception my husband and I use. I was on the pill before, but I was rubbish at remembering to take it every day. It’ll be even harder when I’m sleep-deprived with a newborn. I’m wondering if there are better options for me, but they’d have to be safe to combine with breastfeeding.
Luckily, I work in an office with lots of friendly GPs, so I asked them for advice. Here’s how our conversation went:
Is breastfeeding really an effective contraceptive?
I’ve heard breastfeeding has a contraceptive effect since it delays the return of your periods. Can I really rely on it, though? Or do I need to have another method as well?
It’s true that breastfeeding is a natural contraceptive and can be used immediately after childbirth. In fact it can be about 98 percent effective—that’s about the same as condoms.
However, this is only true under certain conditions:
- You have to be exclusively (or almost exclusively) breastfeeding – that is, no other liquids, no formula milk and no solids. In practice this means the baby can only be up to six months old, since she’ll start on solids after that.
- Your periods must not have re-started yet.
- Even during those first six months, you need to be breastfeeding frequently to get the full contraceptive effect. That means not going longer than 4 hours during the day or 6 hours at night without breastfeeding.
- If you combine formula feeding and breastfeeding – for example, you give one bottle of formula a day and the rest is breast milk – you could be fertile again. Although the return of menstruation is often the first sign of fertility, women can still fall pregnant before the first period if not fully breastfeeding.
- Expressing milk by pumping doesn’t generate the same contraceptive hormonal effect as your baby nursing directly. To be safe, you should think about another form of contraception if you are pumping milk.
- Babies using a dummy may not suckle properly at the breast – this means you might not get the full contraceptive effect with nursing, and this may lead to problems with your milk supply.
It’s worth remembering that you’re fertile about two weeks before your periods return, which complicates things as obviously you can’t know in advance when that’s going to happen. If you’re not ready to fall pregnant again then relying on breastfeeding as your only method of contraception may not be enough – there are other contraceptive methods which are more effective.
Do you recommend any specific contraceptives after pregnancy?
Okay… Since I’m definitely going to be expressing, and might not be breastfeeding often enough, it sounds like I should think about another method of contraception. Are there any forms of contraception that are better or worse for women who’ve recently given birth?
Contraception is only required from 3 weeks after giving birth. If you’re formula feeding, you can use any method. But some popular forms of contraception, including the combined contraceptive pill and the patch, shouldn’t be used if you’re breastfeeding as they can affect your milk supply.
The mini-pill, also known as the progestogen-only pill, is the only pill you should consider if you’re intending to breastfeed (at least for the first six months). You’ll have a bit of hormone in your breast milk, but it won’t do your baby any harm.
The problem for you, though, is that you need to take this pill at the same time every day, which sounds like it doesn’t suit your lifestyle!
So you might want to consider other options, like the implant, IUD, IUS, injection or condoms.
What are LARCs (long-acting reversible contraceptives)
My husband and I are definitely not in vasectomy territory. And if I’m bad at taking a pill every day, I’d be even worse at charting my temperature for ‘natural methods’…. So can you tell me more about the injection, implant, IUD and IUS?
The injection might be a good option for you, although it’s best to wait six weeks after the birth before starting on this otherwise it could worsen post-birth bleeding. Some women find it increases their appetite so you have to be extra careful if you do not want to put on weight. Depo provera needs to be given every 12 weeks. It’s fine to breastfeed while on it – but usually we would advise waiting until baby is 6 weeks old if you are breast feeding, as a small amount of progestogen will pass to your baby, but won’t affect her. Your practice nurse at your GP surgery can give you the injection. Also, although baby number 2 is probably the last thing on your mind right now, it’s worth considering that it can take a few months or even up to 1 year for your fertility to return to normal after you come off the injection, which might make it harder to plan your next conception.
The implant might also be a good option. You can have it inserted just 21 days after your baby is born, it’s 99 percent effective, and you can breastfeed at the same time. It needs to be fitted by either a nurse or a doctor and can be removed any time under local anaesthetic. It lasts for up to 3 years and your normal fertility will return very quickly once it’s removed.
The coil is a small plastic and copper device which is inserted into the uterus. It’s 99 percent effective, can be fitted 4-6 weeks after giving birth, is no problem to breastfeed with, and lasts for 5-10 years. It doesn’t contain hormones so it is a good choice if you are worried about the hormonal side effects with other contraceptive methods. However, some women find their periods can be heavier, longer and more painful for a few months afterwards. Once it’s removed, your normal fertility will come back quickly.
The IUS (intra-uterine system) is a plastic device which works by releasing the hormone progestogen. It’s similar to an IUD in that it’s 99 percent effective, it’s no problem to breastfeed with one in, and it’s usually fitted about 4-6 weeks after birth. However, it has the opposite effect on periods to the IUD: they usually become much lighter and shorter, and may even stop completely. It lasts for five years. Your normal fertility will return as soon as it is removed.
Start thinking about the pros and cons of these now, and you’ll be ready for a good conversation with your midwife after you have your baby. You’ll have a postnatal check up with the GP about six weeks after the birth and you can talk more about it then, as well.
Resuming sex after childbirth
Women should not feel pressurised to resume having sex straight after giving birth. Most women wait at least six weeks (possibly with less enthusiasm on the woman’s part) but often much longer. Sleepless nights, exhaustion and limited time together can affect both partners. Compounded by a reduced sex drive, feeling less attractive and physical problems such as nipple tenderness, vaginal dryness and pain from the perineal wound. And let’s not forget all these can be worse if there is postpartum depression. The main thing is to not delay speaking to your doctor and midwife as there is lots of help and support at hand.
Studies are conflicting as to whether the mode of delivery has any impact on resumption of sexual activity. If you have pain around the perineal wound it is important to check there are no signs of infection which can be treated and that it is healing properly. It is also important to keep the perineum clean after birth with daily bathing or showering, and by changing sanitary pads frequently. Water-based lubricants can also help ease discomfort during sex.
Contraception after childbirth: stories from other mothers
What do other mums do about contraception after giving birth? We asked for stories…
- “I tried various methods before having my first baby (pill, patch, ring, injection) and finally found the copper coil. After my son was born I had no doubts that the coil was what I wanted. I had it fitted 6 or 7 weeks after birth. This time I think I will use the coil again before deciding on more permanent methods.”
- “I can’t recommend the coil enough. No remembering and can be up to 10 years! You just have to be careful if you lose a lot of weight to get the position checked. I had the coil for five years before we had our first baby. It was pretty awesome not to have to think about it for that long.”
- “We always used natural methods before our first baby. After that I got the non-hormonal coil. I don’t like the idea of hormones so have never used them. The coil was great. Slightly heavier periods, although much worse in the beginning.”
- “I chose the copper coil as previous hormonal contraceptives were making me crazy! But my periods were so heavy and painful that I got rid of it. I might give it a go after baby arrives as my insides will have had a good mix up, and it might be different this time.”
- “My periods were heavy for about 6 months on the copper coil but then they settled to only a bit heavier.”
- “I was on the pill before and will go back on it once I’ve had my baby. I tried injections in the past and didn’t get on with them. Coil and condoms just don’t appeal to me.”
- “The hormonal contraceptive pill mainly worked for me by making me repulsed by sex and depressed! It was like having constant PMT. I just thought that was how I was until I stopped hormones and it was like the sun came out and I discovered sex and happiness again!”
- “We decided to just use condoms in-between pregnancies as we were not planning a large gap. I am not planning any more babies after this one, so I think we’ll use condoms at first and then review options when we finally have time and energy for regular sex.”
“I was on the pill for over ten years before trying for my first baby and when I came off it I realised how much it had been interfering with my body. So we used condoms until ready to try for this baby.”
- “I was on the pill which caused all sorts of issues. I stopped and got pregnant with my son immediately. We have talked about it loosely as I don’t want to be on the pill again, and don’t like the idea of hormones so will probably be using condoms until ready for no. 2.”
- “I was on the combined pill from 16 till approx. 30. Came off despite trying lots of different brands throughout that time – it screwed with my hormones and I never found one that properly suited. Moved to condoms. Will go back to condoms until baby number 2. Not thought longer term yet.”
- “Having a baby was contraception enough! No time, energy or inclination for sex for ages, then it was few and far apart so we just used condoms. Got pregnant with second baby first month of trying, after first cycle!”
- “Condoms only, as before. I’ve not been on the pill in nearly a decade as I didn’t get on with it, and like other mums I’ve spoken to, I couldn’t be trusted to take it religiously.”
- “I’m allergic to latex. There are latex-free condoms but they are hideous, like carrier bags.”
- “I struggled to conceive after coming off depo provera and then was diagnosed with polycystic ovaries. Because of this I will not be going back onto the depo provera. I did conceive naturally although it took over 2 years so will be going on something. Undecided what yet.”
- “I was on the pill and then Depo from about 16 years old so had never really got to know my body before it was filled with hormones. It wasn’t until about 10 years later I finally came off hormone contraceptives and realised how much they altered my mood and sex drive! It’s insane. They never tell you about that when they’re handing them out like sweets!”
- “I was technically on the pill when I got pregnant! But I was notoriously rubbish at remembering to take it so although I haven’t given it all that much thought, I suspect I won’t go back on the pill but will get something more permanent & less reliant on me, like the implant.”
- “Last time I went back on Cerazette after six week check. We’re not planning on any more children so have discussed longer-term methods such as implant or even the snip.”
- “I suppose I never considered that the option I was using was the ‘natural method’. Maybe a bit naive of us but we always just found other places to… er.. deposit the goods?”
- “We use natural methods. Charting and temperature, that is. It worked for us for eight years until we decided we wanted a baby. Couldn’t imagine using withdrawal, what’s the fun in that? You do have to be fairly sure of what you are doing – it isn’t just hope for the best! You chart your ovulation, avoid high risk days and withdrawal in addition, to try to avoid pregnancy. It is nowhere near as effective as pretty much any other type of contraception but the third world use it heavily with some degree of success (often a baby after 3/4 years instead of annually) & Catholics often do – well did – many more are relaxed about contraception now. It’s not a complete hope for the best type method but it is fairly risky. Good. Or I wouldn’t exist. You have to know when you ovulate to use the natural method.”
Vasectomy or tubes tied
- “I got the contraceptive implant at my 6 weeks check up after my 1st baby. This time I’ll go on the pill till hubby’s appointment for the snip comes through!!”
- “Not sure yet – limited to the mini pill due to migraines, but had near-continous bleeding with that so then had years on depo (including a trial self-administering it), switched to the implant a year before wanting to ttc and loved both at the time as I had no periods at all on either. I wouldn’t touch hormonal stuff again though – I fell pregnant immediately (within a week) after implant came out, resulting in MMC, then took another year with cycles up to 70 days long to conceive again. Also my mum has since had breast cancer so that puts me off using the hormonal stuff. Considering the copper coil as not a fan of condoms ether, but will probably use them short term until I can face having the coil fitted! DH planning to have the snip when we have decided no more sprogs as he reckons he’ll be well overdue his turn with the contraceptives by then!”
- “This time my husband will be getting the snip!”
- “My husband and I know we want a more permanent method, but we haven’t decided who does it yet. My husband is very happy to have the snip but I am also happy to block my fallopian tubes. For some reason I do not think it’s fair for him to do it, because I am the one who does not want to get pregnant again. We decided that if we want another child we will adopt, because that is something we always wanted.”
- “Condoms in short term then I’m going to get my tubes sorted as 100% no more babies.”
- “We only want one child and my husband is keen for the snip ASAP which was sweet. I was the one who pointed out that maybe in a few years he can, but no need to rush.”
- “After my last baby, my periods didn’t come back for two years thanks to breastfeeding, at which point we were ready to try for number two, and it wouldn’t have been the end of the world if I had got pregnant before that so we didn’t use anything.”