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The Best Birth Control After the Baby

Sex is probably the last thing on your mind when you're getting up several times a night with a newborn. But according to Contraceptive Technology, the definitive medical textbook on birth control, most women have already resumed having intercourse within several weeks of their baby's birth -- even though health experts recommend women refrain from it until their first postpartum checkup, typically at four to six weeks, to allow their bodies time to heal.

Since your ability to conceive can return as soon as a few weeks after birth, don't wait until after the baby is born to decide what contraception to use. "Ideally, you should start thinking about postpartum birth control months before you have your baby," says Sharon Schnare, a certified nurse-midwife and family nurse-practitioner in Seattle. Discuss options with your doctor, midwife, or nurse-practitioner during one of your prenatal visits or at least during the hospital stay following the birth. The important thing is to have a plan before you go home.

Nearly every method of contraception is available to new mothers, although some factors, such as a change in the size of your cervix following childbirth and whether you're nursing, must be considered. Whether you're newly pregnant, about to deliver, or have brought your infant home, read on to decide which method will be right for you. 

Barrier Methods

Condoms

Pluses: Condoms don't have to be fitted and they don't contain hormones that can interfere with nursing, so they're ideal for new parents (even before the first postpartum checkup).

Effectiveness: 86%*

What You Should Know: If you breastfeed, your body's balance of estrogen and progesterone will be thrown off for a few months following childbirth. If you don't nurse your baby, it can be off for a few weeks. During this time, you may experience vaginal dryness. You can ease some of the discomfort with a lubricated condom and by using an additional lubricant, such as K-Y Jelly.

Diaphragm, Cervical Cap

Pluses: They contain no hormones, so they won't interfere with nursing.

Effectiveness: Diaphragm, 80%; cervical cap, 60% (for women who've had a child).

What You Should Know: You need to be refitted -- or fitted for the first time -- at your first postpartum checkup whether you used a diaphragm or cervical cap before pregnancy or have never used either. By the time of the checkup, the vagina, cervix, and uterus will have recovered and reached the size and shape at which they will remain (usually a bit larger than they were before pregnancy).

You should be refitted even if you delivered by cesarean section. "An exception would be a woman who had a cesarean section but didn't labor long, have much cervical dilation, or have the baby's head come into the pelvis," says Gary Stewart, M.D., a family-planning consultant based in Boston. Ask your doctor if you fit into such a category.

One drawback with the cervical cap is its higher failure rate -- even when it's refitted -- when used after giving birth. Doctors aren't exactly clear on why the caps don't work as well after childbirth, but think it may be related to the changed shape of the cervix after delivery. Talk to your ob-gyn about whether you should switch to another birth-control method.

Hormonal Methods

Oral Contraceptives

Pluses: Most women who are not breast-feeding can return to -- or begin taking -- the Pill when they go for their first postpartum checkup.

Effectiveness: 95%

What You Should Know: The vast majority of birth-control pills prescribed in this country contain a combination of estrogen and progestin. Some clinicians will give nonnursing women a prescription while they're still in the hospital, but advise them not to begin taking the Pill until three to four weeks after they've given birth. The delay is to ensure that any additional risk of blood clotting after delivery will have passed. Other doctors sometimes prefer that nonnursing women wait to take the Pill until after their first postpartum menstrual period, at around six to ten weeks.

If you're breastfeeding, the estrogen released from the Pill can lower your milk's mineral content and also decrease the amount of milk produced. And although there is no evidence so far to suggest estrogen is bad for the baby, the hormone can enter the breast milk and be passed on to your baby. While some doctors do prescribe combination estrogen and progestin pills to nursing mothers, most now believe these women should consider other alternatives until their baby has been weaned.

There is a pill that contains only progestin, which won't affect the quantity or quality of breast milk. Dubbed the "minipill," it must be taken at the same time every day (which can be difficult for new moms) and has a slightly lower effectiveness rate than pills containing estrogen. To be on the safe side, doctors should wait six weeks before putting nursing mothers on this pill, too. Although the evidence is slim, some have voiced concern about progestin's effect on the newborn's liver and kidneys, which may not be able to process the hormone that gets into the breast milk.

Norplant Implant and Depo-Provera Injections

Pluses: If you're not nursing, before you leave the hospital you can arrange to have Norplant, a time-released progestin device that works for up to five years, surgically implanted in your arm. Or you can get an initial Depo-Provera injection, a progestin contraceptive that's administered four times a year by your doctor, in your arm or buttocks.

Effectiveness: Norplant, 99.95%; Depo-Provera, 99.7%

What You Should Know: As with the Pill, you may want to wait to use these two methods until after your first postpartum menstrual period, to be sure your cycle has returned to normal before you alter it. Nursing mothers may want to wait at least six weeks after delivery, for extra peace of mind.

The most common side effects associated with Norplant are irregular bleeding, headaches, and nausea. You should also make sure that the doctor inserting the device is experienced or it could be difficult to remove.

One potential side effect of Depo-Provera is that fertility may not return for up to a year after the injections are stopped. Some women also experience increased weight gain with each year of use (about 5 pounds the first year, and 3 to 5 pounds each year after). Although the injection shouldn't prevent loss of the pounds gained during pregnancy, women who have had weight problems in the past should discuss this with their clinician.

The Intrauterine Device (IUD)

Pluses: Today's IUDs are considered safe and effective by health experts and can be used by most women, although manufacturers, looking to prevent legal problems (memories of multimillion-dollar claims against the Dalkon Shield are still with them, years after it was taken off the market), recommend using their products only after having had a child.

Effectiveness: Progestasert, 98%; ParaGard, 99.2%

What You Should Know: Health experts recommend that any woman choosing an IUD be in a mutually monogamous relationship, where the risk of sexually transmitted infections is low. The device is linked to a slight increase in pelvic infections in women who have multiple partners. Most doctors prefer to insert the device at the four- to six-week postpartum checkup, when the uterus has returned to its normal size. Depending on the advice of her doctor, a woman who has had repeat cesarean sections can have an IUD safely inserted.

There are two IUDs available today. The first is ParaGard, a T-shaped device that is made of plastic wrapped with copper wire. ParaGard can be kept in place for up to ten years. It works by killing the sperm before they come in contact with an egg; the copper does not affect the quantity or quality of breast milk in nursing mothers.

The other type of IUD is Progestasert, also a T-shaped device, which releases the hormone progestin. Progestasert works by thickening the cervical mucus, so a fertilized egg can't implant itself in the uterus. It needs to be changed annually.

Side effects of IUDs include uterine cramping and increased menstrual bleeding, the main reasons some women have had them removed.

Fertility Awareness Method

Pluses: Women who prefer not to use hormonal or mechanical contraception can use this method.

Effectiveness: 75%

What You Should Know: Because the female body's indicators of fertility -- cervical mucus changes and basal body temperature -- are not reliable in the first two to three months after delivery, it can be difficult to learn and use this method. Cervical mucus doesn't return to normal until ovulation resumes, and basal body temperature can't be accurately measured unless a woman has had six hours of uninterrupted sleep, a rarity for most mothers in the first months of their baby's life.

Until regular cycles return, couples should use another method of contraception or -- if religious beliefs forbid other means -- withdrawal. According to Contraceptive Technology, withdrawal is 81% effective.

If you do decide to use a fertility awareness method (there are several), make sure you receive complete training in it to be certain you're doing it correctly.

Lactational Amenorrhea Method

Pluses: Some women who are nursing their infants have the choice of using this form of birth control. Proven effective in studies worldwide, the lactational amenorrhea method (LAM) has been endorsed by the World Health Organization and Georgetown University's Institute for Reproductive Health, among others.

Effectiveness: 98%, if you meet the criteria and perform it perfectly.

What You Should Know: LAM is very simple, but you should only consider using it if you fit all of the following criteria:

1. You've had no periods since the delivery.

2. All or most of the baby's nutrition is coming from your breast milk (meaning you nurse on demand at least every 4 hours during the day, and every 6 hours at night).

3. Your baby is younger than 6 months old.

"When any one of these conditions changes, a woman should use another family-planning method," says Kristin Cooney, a reproductive health expert at the U.S. Agency for International Development.

LAM works because the stimulation of the infant's suckling sends a signal to the mother's hypothalamus gland, which responds by decreasing the secretion of the pituitary hormones needed for ovulation. Once menstruation resumes, another contraceptive method must be used.

Sterilization

Tubal Ligation

Couples who have completed their families may opt for one partner to be sterilized. Tubal ligation is the most popular method of birth control in the country, and the most common method of sterilization for women.

Pluses: Women can have the surgery -- to cut and tie the fallopian tubes -- performed immediately following a C-section or vaginal birth, or they can have it done laparascopically once the uterus has returned to its normal size (two to three months later), says Charles Debrovner, M.D., associate clinical professor of obstetrics and gynecology at New York University. The surgery usually won't require a longer stay, and will not interfere with your ability to care for your new baby. Some women prefer to wait several months after delivery before deciding on sterilization. "One reason is that they want to be absolutely sure their baby is healthy before they end their fertility," says Dr. Debrovner.

Effectiveness: 99.5%

What You Should Know: Tubal ligation -- whether done right after birth or several months later -- may interrupt breastfeeding, especially if performed under general anesthesia. Nursing mothers can minimize the problem by making sure the surgery is done with a local or regional anesthetic, and that they won't be away from the baby for more than a few hours.

Vasectomy

Pluses: The procedure, which involves cutting the tubes that carry sperm from the testes, is easier, cheaper, and safer than female sterilization. It's done in a urologist's office, takes about 20 minutes, and requires only a local anesthetic.

Effectiveness: 99.85 %

What You Should Know: Other forms of contraception should be used following the surgery; since sperm remain in the tubes, it takes about 15 to 20 ejaculations and a mandatory semen analysis before a man is considered sterile. Although rare and usually not serious, there may be some bleeding and an infection following the procedure.

Whatever method you decide on, a careful choice is worth the effort. As difficult as it might be to think of anything else but your newborn, it pays off in family-health dividends for all new parents to practice safe and effective after-baby birth control.

*Effectiveness rates reflect a typical user and account for people who don't use the method correctly as well as for product or procedure failure.

Beth Weinhouse is the coauthor of Outrageous Practices: How Gender Bias Threatens Women's Health.

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