Postpartum Contraception Anita L Nelson MD HarborUCLA Medical

Postpartum Contraception Anita L. Nelson, MD Harbor-UCLA Medical Center Contemporary Forums

Conflict of Interest Disclosure Anita L. Nelson, MD Grants/ Research Bayer, Merck, Pfizer, Teva Honoraria/ Speakers Bureau Bayer, Merck, Pfizer, Teva, Watson Consultant/ Advisory Board Agile, Bayer, Merck, Anita L. Nelson, MD - 11/9/2020 9: 36 PM Teva, Watson CU 2013 Contemporary Forms 2

Learning Objectives l At the end of the presentation, the participant will be able to: Describe the need for contraception in the postpartum period. l Estimate the risk of VTE in immediate postpartum period and impact estrogen containing methods might have on those risks. l Counsel women on the risks that use of progestin-only methods might have on breastfeeding success. l l Outline the procedures for immediate postpartum IUD placement and estimate the rates of complications. Anita L. Nelson, MD - 11/9/2020 9: 36 PM CU 2013 Contemporary Forms 3

Postpartum Contraception: Healthy People 2010 Goals l Increase percent of pregnancies that are intended pregnancies to 70% l Reduce the percent of births occurring within 24 months of a previous birth to 67% Whiteman M et al. MMWR 2009; 58(30): 821 -26 Anita L. Nelson, MD - 11/9/2020 9: 36 PM CU 2013 Contemporary Forms 4

Optimal Pregnancy Spacing Utah 1989 to 1996: 173, 205 birth certificates Odds Ratios Outcomes < 6 Months > 120 Months Low birth weight 1. 4 (1. 3 - 1. 6) 2. 0 (1. 7 – 2. 4) Preterm birth 1. 4 (1. 3 - 1. 5) 1. 5 (1. 3 - 1. 7) Small for gestational age 1. 3 (1. 2 - 1. 4) 1. 8 (1. 6 - 2. 0) Optimal interpregnancy interval is 18 to 23 months Zhu BP et al. N Engl J Med. 1999(6): 589 -94 Anita L. Nelson, MD - 11/9/2020 9: 36 PM CU 2013 Contemporary Forms 5

Short Interpregnancy Interval Other Findings l Risk of preterm delivery attenuates with advanced maternal age 1 l Risk of preterm delivery greatest for early <34 weeks (OR = 3. 9) rather than late preterm deliveries (34 -37 weeks)(OR = 0. 8)2 l Interval < 6 months and 6 – 12 months increased risk of extreme preterm birthing and recurrent preterm birth 3 1. De Weger FJ, et al. Am J Obstet Gynecol. 2011; (5): 421 2. Rodrigues T, et al. Eur J Obstet Gynecol Reprod Biol. 2008; 136(2): 184 -8 3. De. Franco EA et al. Am J Obstet Gynecol 2007; 197(3): 264 Anita L. Nelson, MD - 11/9/2020 9: 36 PM CU 2013 Contemporary Forms 6

Recent Preterm Delivery: Risk Factor for Poor Contraceptive Practices l Philadelphia Collaborative Preterm Prevention Project l Women who delivered ≤ 35 weeks u 566 followed 6 months and were sexually active l 90. 1% said no desire for another pregnancy within 12 months of PTB infant u 54. 6% of these using low or moderately effective method l 16. 3% withdrawal Bloch JR et al. J Obstet Gynecol Neonatal Nurs. 2012; 41(3): 389 -97. Anita L. Nelson, MD - 11/9/2020 9: 36 PM CU 2013 Contemporary Forms 7

Optimal Birth Spacing l In low resource populations, an interval of less than 2 years results in u 1 st l child: Higher rates of malnutrition and infection u 2 nd child: l Low birthweight l Preterm delivery l Infant death Speroff L et al. Contraception. 2008; 78(2): 90 -8 Anita L. Nelson, MD - 11/9/2020 9: 36 PM CU 2013 Contemporary Forms 8

Unique Aspects of Postpartum Contraception l May be only time women have access to medical care u Not true in California with Family PACT l Women vulnerable to infection, hemorrhage thrombosis l Other considerations for postpartum contraception u Impact on lactation u Insurance coverage l US MEC provides medical guidance u Financial Anita L. Nelson, MD - 11/9/2020 9: 36 PM consideration may have veto power CU 2013 Contemporary Forms 9

Return to Fertility and Menstruation Outcome Mean 1 st day ovulation Mean day 1 st menses % menses preceded by ovulation % ovulation potentially Urinary LH ± Pregnanediol 45 – 94 45 ± 10. 1 BBTs 74 59 20 – 71% 33% 0 – 60% 70% 25% of women ovulated between 25 - 39 days postpartum. Jackson E, Glasier A. Obstet Gynecol. 2011; (117): 657 -62 Anita L. Nelson, MD - 11/9/2020 9: 36 PM CU 2013 Contemporary Forms 10

Return to Fertility l Women who are “partially” breastfeeding u Up to ½ will ovulate before the 6 th week postpartum 1 l In women who are formula feeding or partially breastfeeding u Contraception should be started no later than third week postpartum 1, 2 l Many women loose insurance coverage before 6 th week 3 1. Speroff L et al. Contraception. 2008; 78(2): 90 -8 2. Halderman LD et al. Am J Obstet Gynecol. 2002; 186: 1250 -6 3. Culwell KR et al. Obstet Gynecol. 2007; 110(6): 1371 -8 Anita L. Nelson, MD - 11/9/2020 9: 36 PM CU 2013 Contemporary Forms 11

Other Considerations in Postpartum Contraception l 20% of women resume sexual activity before 4 weeks 1 l Younger women have return to fertility more quickly postpartum than older women 2 l More than 50% of first menses after delivery procedure by ovulation u 50% of ovulators have active luteal phase 3 1. Byrd JE. J Fam Pract. 1998(4): 305 -8 2. Moran C et al. Contraception. 1994; (5): 401 -7 3. Campbell OM et al. Am J Obstet Gynecol. 1993; (1): 55 -60 Anita L. Nelson, MD - 11/9/2020 9: 36 PM CU 2013 Contemporary Forms 12

Lack of Patient Preparation for Postpartum Period Telephone survey 274 women within 2 weeks of delivery l Asked about their perceptions about antepartum preparation for: l Symptom Vaginal bleeding Breastfeeding problems Hemorrhoids Prevalence % 97 60 35 Prepared % 86 37 49 Urinary incontinence Mood swings Bothered by appearance 32 69 61 24 45 18 Howell A et al. Obstet Gynecol. 2012; 115: 284 -9. Anita L. Nelson, MD - 11/9/2020 9: 36 PM CU 2013 Contemporary Forms 13

Postpartum Sterilization ACOG Opinion 530 l Not all women who request postpartum sterilization get procedure done. Women who do not have procedure done: repeat pregnancy rate within 12 months about 51% l Postpartum sterilization should be considered urgent surgical procedures l Need to simplify and standardize consents needed for sterilization l Other thoughts (ALN): Reimburse for IUD and implants l Committee opinion 530. Obstet Gynecol. 2012; 120(1): 212 -5. Anita L. Nelson, MD - 11/9/2020 9: 36 PM CU 2013 Contemporary Forms 14

Need Postpartum Contraception l University of Texas, San Antonio, Dec. 2007 - May 2008 l 1460 deliveries tracked u 296 requested and got tubal ligation (BTL) u 133 requested but did not get BTLs Postpartum: BCM Postpartum Appointment % pregnant at 12 months Control No BTL 41. 1% 20. 3% 22. 3% 42. 8% 18. 8% 46. 7% Thurman AR et al. Obstet Gynecol. 2010(116): 1071 -77. Anita L. Nelson, MD - 11/9/2020 9: 36 PM CU 2013 Contemporary Forms 15

Oops! She Didn’t Get Her BTL Postpartum! l Retrospective cohort study – women and infants in Providence, RI l 626 women delivered u 87 wanted postpartum sterilization u 45 (57. /77%) got planned procedure l Older age and c/section: �chance of BTL l Married and high BMI: � chance of BTL Boardman LA, et al. R I Med J. 2013; 96(1): 32 -4. Anita L. Nelson, MD - 11/9/2020 9: 36 PM CU 2013 Contemporary Forms 16

Rapid Repeat Teen Pregnancy l Risk of repeat pregnancy within 2 years: 35% u After delivery most young women intend to avoid pregnancy l Many u Lack become ambivalent within months of contraceptive use more likely l Early resumption of coitus l Living with male partners l Prior preterm delivery l Prior unintended teen pregnancy l No LARC users – 35 fold higher risk of RPP Baldwin MK, et al. J Adolesc Health. 2013; 52(4 Suppl): S 47 -53. Anita L. Nelson, MD - 11/9/2020 9: 36 PM CU 2013 Contemporary Forms 17

Lactogenesis l During pregnancy, hormonal changes induce breast development and differentiation u Prolactin and human placental lactogen levels rise u Only colostrum produced because progesterone interferes with prolactin l After delivery E 2 and P levels fall: u Prolactin levels rise with suckling u Full lactation ensues Rodriguez MI et al. Contraception. 2009; 80(1): 4 -6 Anita L. Nelson, MD - 11/9/2020 9: 36 PM CU 2013 Contemporary Forms 20

Lactation Benefits l Benefits to mother u u u l Bonding with newborn Protection against ovarian, premenopausal breast cancer Lower cost than formula Benefits to newborn u u u Perfectly balanced nutrition Bonding with mother Reduction in newborn allergies and infections Anita L. Nelson, MD - 11/9/2020 9: 36 PM CU 2013 Contemporary Forms 21

Lactational Amenorrhea l First 6 months, amenorrhea induced by breastfeeding u 6 month failure rate 2% u Menses generally precedes ovulation u Bleeding in first 56 days does not count l After 6 months, ovulation precedes menses u Women Anita L. Nelson, MD - 11/9/2020 9: 36 PM at risk without notice CU 2013 Contemporary Forms 23

Relative Risks of Thrombosis Postpartum l Postpartum period: time of greatest VTE risk 1 u 21. 5 – 84 fold greater than nonpregnant, non postpartum reproductive-age women u Declines rapidly during first 3 weeks l Between 4 – 6 weeks VTE risk 5 – 7 times that of nonpregnant non postpartum women l Use of estrogen-containing methods increases VTE rates by 3 – 7 fold 2 Jackson E, et al. Obstet Gynecol. 2011; (117): 691 -703 Lidegaard O. et al. BMJ. 2009; (13): 2890 Anita L. Nelson, MD - 11/9/2020 9: 36 PM CU 2013 Contemporary Forms 24

Risk Factors for VTE l. Age >35 l. Prior VTE l. Thrombophilia l. Immobility l. Transfusion at delivery l. BMI ≥ 30 l. Postpartum hemorrhage l. C-section delivery l. Preeclampsia l. Smoking Whiteman M et al. MMWR 2009; 58(30): 821 -26 Anita L. Nelson, MD - 11/9/2020 9: 36 PM CU 2013 Contemporary Forms 27

US MEC Postpartum Recommendations Non-breastfeeding Women COC/P/R POP DMPA Implants < 21 Days to 42 Days 4 1 1 1 With other risk factors for VTE 3 1 1 1 Without other risk factors for VTE 2 1 1 1 1 > 42 Days Whiteman M et al. MMWR 2009; 58(30): 821 -26 Anita L. Nelson, MD - 11/9/2020 9: 36 PM CU 2013 Contemporary Forms 28

US MEC Postpartum Recommendations Breastfeeding Women 0 - 30 Days < 21 days to < 30 days With other risk factors for VTE Without other risk factors for VTE COC/P/R POP DMPA Implants 4 2 2 2 3† 2 2 2 3 2 2 2 Whiteman M et al. MMWR 2009; 58(30): 821 -26 Anita L. Nelson, MD - 11/9/2020 9: 36 PM CU 2013 Contemporary Forms 29

US MEC Postpartum Recommendations Breastfeeding Women 0 - 30 Days COC/P/R POP DMPA Implants 30 – 42 days With other risk factors for VTE Without other risk factors for VTE > 42 days 3† 1 1 1 2 1 1 1 Whiteman M et al. MMWR 2009; 58(30): 821 -26 Anita L. Nelson, MD - 11/9/2020 9: 36 PM CU 2013 Contemporary Forms 30

Summary of Recommendations IUD Use LNG-IUD Cu-IUD < 10 minutes after delivery of the placenta ≥ 10 minutes after delivery of the placenta to < 4 weeks ≥ 4 weeks Puerperal sepsis 2 1 2 2 1 4 Whiteman M et al. MMWR 2009; 58(30): 821 -26 Anita L. Nelson, MD - 11/9/2020 9: 36 PM CU 2013 Contemporary Forms 31

Progestogen-only Contraceptive Use Among Breastfeeding Women l Systematic review of all studies of progestinonly methods in breastfeeding women with reports about contraceptive outcomes of either women or their infants l 43 articles: 5 randomized: 38 observational l No adverse effects of various progestin-only methods on multiple measures of breastfeeding performance through 12 months Kapp N, et al. Contraception. 2010; (82): 17 -37 Anita L. Nelson, MD - 11/9/2020 9: 36 PM CU 2013 Contemporary Forms 32

Progestogen-only Contraceptive Use Among Breastfeeding Women: Infant Impacts l No adverse effects demonstrated in infant growth, health or development from 6 months to 6 years of age l No effects on infant immunoglobulins l No effect on sex hormones of exposed male infants Kapp N, et al. Contraception. 2010; (82): 17 -37 Anita L. Nelson, MD - 11/9/2020 9: 36 PM CU 2013 Contemporary Forms 33

DMPA and Lactogenesis l Theoretical concern: progestin could block prolactin l Evidence shows progestin-only contraceptives do not impair lactation 1 u Progestin-only contraceptives may actually increase the quality and duration of lactation 1, 2, 3, 4 1. Halderman LD et al. Am J Obstet Gynecol. 2002; 186: 1250 -6 2. Queenan JT. Clin Obstet Gynecol. 2004; 47(3): 734 -9 3. Koetsawang S. Int J Gynaecol Obstet. 1987; 25: 115 -27 4. Baheiraei A et al. Int J Gynaecol Obstet. 2001; 74(2): 203 -5 Anita L. Nelson, MD - 11/9/2020 9: 36 PM CU 2013 Contemporary Forms 34

Remember Progestin-Only Pill The Go-To Pill! l US MEC: only one category 4 condition u Recent breast cancer (in last 5 years) l Efficacy in typical use rated equivalent to estrogen containing OCs u No studies of efficacy of US POPs since 1960 s l Remaining perceptions of POPs (no data) u Higher rates of unscheduled bleeding or spotting u Higher rates of discontinuation Anita L. Nelson, MD - 11/9/2020 9: 36 PM CU 2013 Contemporary Forms 35

DMPA Issues in the Immediate Postpartum Period l Product labeling recommends initiation 4 -6 weeks postpartum l Concerns l Possible about newborn safety adverse impact on lactogenesis l Possible adverse impact on quality and quantity of breast milk l VTE Risk Anita L. Nelson, MD - 11/9/2020 9: 36 PM CU 2013 Contemporary Forms 36

DMPA: Newborn Safety Facts l Newborns are not able to absorb progestins from breast milk until about 3 months of age u Same age as they are able to metabolize them hepatically 1 l Amount transferred to breastfeeding neonate over 3 months is 0. 05% of maternal dose 2 l Urine of neonates breastfeeding from moms using DMPA found to have 2 u No detectable metabolites of DMPA u No changes in gonadotropins or hormones 1. Patel SB et al. Adv Contracept. 1994; 10(4): 249 -55 2. Virutamasen P et al. Contraception. 2096; 54(3): 153 -7 Anita L. Nelson, MD - 11/9/2020 9: 36 PM CU 2013 Contemporary Forms 38

DMPA Within 1 Week of Delivery l No 5, 6, 7 adverse impact on lactation patterns 1, 2, 3, 4, l No adverse impacts on neonatal outcomes 1, 2, 3, 4, 5, 6, 7 1. Kennedy KJ et al. Med J Aust. 2008; 188(4): 209 -13 2. Guiloff E et al. Am J Obstet Gynecol. 1974; 118(1): 42 -5 3. Karim M et al. Br Med J. 1971; 1: 200 -3 4. Halderman LD et al. Am J Obstet Gynecol. 2002; 186: 1250 -6 5. Virutamasen P et al. Contraception. 1996; 54: 153 -7 6. Xiang AH et al. Diabetes Care. 2006; 29: 613 -7 7. Truitt ST et al. Cochran Database Syst Rev. 2003: CD 003988 Anita L. Nelson, MD - 11/9/2020 9: 36 PM CU 2013 Contemporary Forms 40

DMPA and Postpartum Depression l l Retrospective chart review: 404 charts postpartum Edinburgh Depression Scale (EPDS) routinely given at 6 -week visit EPDS Score % With PPD 55 - immediate DMPA 5. 02 10. 9 192 - no hormones 6. 17 14. 1 p Score 0. 16 0. 88 l Conclusion: immediate postpartum administration of DMPA does not predispose to postpartum depression Tsai R, et al. Contraception. 2010; (82): 174 -77 Anita L. Nelson, MD - 11/9/2020 9: 36 PM CU 2013 Contemporary Forms 41

DMPA and Weight Gain Postpartum l DMPA users vs. women with BTL l Several anthropometric measures taken 1 year postpartum u DMPA users did not differ from BTL group in weight or percent body fat changes u½ DMPA users returned to prepregnancy weight u½ DMPA users gained weight l Overweight, obese women gained weight Nyirati CM, et al. Contraception. 2012; 7824(12): Epub ahead of print. Anita L. Nelson, MD - 11/9/2020 9: 36 PM CU 2013 Contemporary Forms 42

ENG Implant Immediately Postpartum l 40 breast feeding women randomized u 20 ETG implant 24 – 48 hours postpartum u 20 DMPA at 6 weeks l 50% had intercourse before 6 week visit despite instructions for abstinence l Headaches were more common among implant users u 45% vs 10% Brito MB et al. Contraception. 2009(80): 519 -526 Anita L. Nelson, MD - 11/9/2020 9: 36 PM CU 2013 Contemporary Forms 43

ENG Implant Immediately Postpartum l Lochia: 13 ± 3 days implant vs 12 ± 4 days other l No significant adverse impacts on women's weight, BP, lipids, hemoglobin l No significant adverse impacts on infant weight gain l No significant adverse impact on breastfeeding continuation Brito MB et al. Contraception. 2009(80): 519 -526 Anita L. Nelson, MD - 11/9/2020 9: 36 PM CU 2013 Contemporary Forms 44

Implants and Lactogenesis l 69 women randomly assigned Early: 1 – 3 days u Standard: 4 – 8 weeks u Implant COC/DMPA Other % Repeat pregnancy by 24 months Mean time (months) l l 27 40 50 23. 8 18. 1 17. 6 6 week milk composition not different 6 month followup: u Use of formula not different between Gurtcheff SE et al. Obstet Gynecol. 2011(5): 1114 -21 Anita L. Nelson, MD - 11/9/2020 9: 36 PM groups CU 2013 Contemporary Forms 45

Immediate Postpartum Implants (IPI) l Prospective observational study of adolescent postpartum women n 6 month data: % continuation % pregnant 12 months: % continuation % pregnant LNG-EC 171 Copper IUD 225 96. 9 0. 0 86. 3 2. 6* 18. 6* 38. 5 * None in current users Turok DK, et al. Contraception. 2010; 82(6): 520 -5. Anita L. Nelson, MD - 11/9/2020 9: 36 PM CU 2013 Contemporary Forms 46

Etonogestrel Implant Postpartum: Brazilian Teens l ENG implant placed mean: 102 days postpartum u 65% breastfeeding u Followed 12 months l No women requested implant removal l No pregnancies u 20% of COC users got pregnant Guazzelli CAF et al. Contraception. 2010(3): 256 -9 Anita L. Nelson, MD - 11/9/2020 9: 36 PM CU 2013 Contemporary Forms 49

IUD Placement Postpartum: Cochrane Review Summary Findings l Immediate placement within 10 minutes of delivery of placenta Safe when compared to delayed postpartum placement u Lower expulsion than later postpartum u Higher expulsion than interval u l Immediate placement at C-section u Lower expulsion than following vaginal deliveries Grimes DA et al. Cochran Database Syst Rev. 2010; (5): CD 003036 Anita L. Nelson, MD - 11/9/2020 9: 36 PM CU 2013 Contemporary Forms 52

Postpartum IUD Placement l IUD expulsion rates following placement at C -section lower than following vaginal delivery 1 Suturing IUD to uterine wall does not reduce risk of expulsion 1 u Placement with cervical dilation < 2 cm lowers risk of expulsion 1 u l Women who receive immediate postpartum placement 10 times more likely to get IUDs placed than women who were asked to wait for uterine involution 2 1. Grimes DA et al. Cochran Database Syst Rev. 2010; (5): CD 003036 2. Mohamed S et al. Med Princ Pract. 2005; (12): 120 -5 Anita L. Nelson, MD - 11/9/2020 9: 36 PM CU 2013 Contemporary Forms 53

Immediate vs 6 Weeks Placement Mexico Study ≤ 10 min. ≥ 6 Weeks 3 month expulsion rates Total Nulliparous Parous 16. 0% 14. 3% 25. 9% 2. 1% 3. 2% 4. 0% Kapp N et al. Contraception. 2009(4): 327 -336 Anita L. Nelson, MD - 11/9/2020 9: 36 PM CU 2013 Contemporary Forms 56

Things That Do Not Increase Use of IUDs/Implants Postpartum l Randomized, controlled trial u 50 low-income postpartum women desiring LARC u Telephone contact to provide contraception education, facilitation of insurance coverage, appointment scheduling and assistance with childcare and transportation l No difference in percentage women who got top tier methods 67% vs. 72% Simmons KB, et al. Contraception. 2012; 784(12): Epub ahead of print. Edelman AB, CU 2013 Contemporary Forms Anita L. Nelson, MD - 11/9/2020 9: 36 PM 57

2 Visit IUD Placement Protocols Create Barriers l Retrospective database review: medicaidinsured women u 708 women requested IUDs at first visit l 385 (54. 4%) had IUD placed Single women less likely: (52. 4% vs. 70. 3%) u IUD ordered at GYN vs. OB office: (60% vs. 50. 2% u Bergin A et al. Contraception. 2012; 86(6): 694 -7. Anita L. Nelson, MD - 11/9/2020 9: 36 PM CU 2013 Contemporary Forms 58

POPs vs COCs Started Postpartum in Breastfeeding Women l Randomized, blinded study of breastfeeding women 2 weeks postpartum visit u Given 8 week supply u Contacted weekly, weeks 4 -7 u Returned to office week 8 u Anita L. Nelson, MD - 11/9/2020 9: 36 PM CU 2013 Contemporary Forms 59

POPs vs COCs Started Postpartum in Breastfeeding Women l Randomized, blinded study of breastfeeding women 2 weeks postpartum visit u Given 8 week supply u Contacted weekly, weeks 4 -7 u Returned to office week 8 u Breastfeeding Randomized (n) At 8 Weeks At 6 months POP 64 41/48 28/29 COC 63 40/40 26/30 Espey E et al. Obstet Gynecol. 2012(1): 5 -13. Anita L. Nelson, MD - 11/9/2020 9: 36 PM CU 2013 Contemporary Forms 60

Other Findings l At 2 week postpartum visits u 1/3 of women already supplementing with formula l At 8 Weeks u 64% were breastfeeding (any) u 28. 9% were exclusively breastfeeding Espey E et al. Obstet Gynecol. 2012(1): 5 -13 Anita L. Nelson, MD - 11/9/2020 9: 36 PM CU 2013 Contemporary Forms 61

Quick Start Method at 6 Week Visit l Retrospective study: 979 patients at 6 week postpartum visit at FQHC 2004 -6 l Standard protocols until July 2005, then Quick Start n % asking for contraception Did not get contraception Standard Protocols 516 80% 26% Quick Start Protocol 46% 26% 3% Stechna S et al. Contraception. 2012; 7824(12): Epub ahead of print. Anita L. Nelson, MD - 11/9/2020 9: 36 PM CU 2013 Contemporary Forms 62

Male Condom Use Postpartum l Excellent u But choice to reduce risk of infection does not completely eliminate it l Vaginal flora introduced through cervix l Issue: u Dry vagina, especially with breast feeding l Use Anita L. Nelson, MD - 11/9/2020 9: 36 PM of appropriate lubricant helpful CU 2013 Contemporary Forms 63

Female Barrier Use Postpartum l Female condom u Provides l Semen protection against pathogens born and some vaginal flora l Diaphragm, Fem Cap u Need to refit and wait for cervical normalization l Sponge u May l Other be used once bleeding stops spermicides u Probably l Foam Anita L. Nelson, MD - 11/9/2020 9: 36 PM suppository or film better injects air into vagina (uterus? ) CU 2013 Contemporary Forms 64

Other Methods l Coitus interruptus – always available u Prudent to wait until bleeding stops l Fertility awareness – not appropriate until cycle resumes. Anita L. Nelson, MD - 11/9/2020 9: 36 PM CU 2013 Contemporary Forms 65

What About EC? l Levonorgestrel u OK EC in breastfeeding women l Yuzpe method u Follow proscriptions outlined for estrogencontaining methods postpartum l Ulipristal u Not tested in breast feeding women l No adverse impacts anticipated l Copper u Okay Anita L. Nelson, MD - 11/9/2020 9: 36 PM acetate IUD once uterus involuted established CU 2013 Contemporary Forms 67

Contraceptive Counseling During Pregnancy: Young Minority Women l Focus group recommendations l Frequent, short episodes of contraception counseling throughout pregnancy u In order to explain contraception “step by step” l During pregnancy best time u “When you have time to decide” Yee L. J Midwifery Womens Health. 2011; 50(1): 54 -60 Anita L. Nelson, MD - 11/9/2020 9: 36 PM CU 2013 Contemporary Forms 68

Contraceptive Counseling During Pregnancy: Young Minority Women l Following delivery: u Review of options, reassurance and reinforcing instruction l Postpartum u Repeat l Multiple visit : of steps following delivery ways of teaching Yee L. J Midwifery Womens Health. 2011; 50(1): 54 -60 Anita L. Nelson, MD - 11/9/2020 9: 36 PM CU 2013 Contemporary Forms 69

Antenatal Contraceptive Counseling l Review of 528 deliveries at Brown University l Factors associated with antenatal counseling u Non-Hispanic white women (OR = 1. 5) u > 10 prenatal visits (OR = 6. 2) u Being seen by nurse practitioner vs. resident (OR = 4. 5) Day T, et al. Contraception. 2008; (4): 294 -9 Anita L. Nelson, MD - 11/9/2020 9: 36 PM CU 2013 Contemporary Forms 70

Counselling During Pregnancy Helps l Data from 198, 323 women in PRAMS u Pregnancy Risk Assessment Monitoring System l Women who received counselling vs. no counselling u Those with unintended pregnancy more likely to use postpartum contraception l 83. 6% vs. 16. 4% Krans EE, et al. Am J Obstet Gynecol. 2013; 208(2): 141. e 1 -7. Anita L. Nelson, MD - 11/9/2020 9: 36 PM CU 2013 Contemporary Forms 71