The provision of family planning is important for women in the postpartum and post-abortion periods because fertility can return surprisingly quickly after giving birth if not breastfeeding, or after having an abortion. In some cases, women have become pregnant before having their first menstruation following a delivery or abortion, and often the pregnancy is unwanted and may end up with a further abortion. Unfortunately, a large number of women who wish to delay or prevent future pregnancies receive little or no information on effective family planning methods during the postpartum or post-abortion period, including how or where to obtain family planning methods, and how soon they should be started. The majority of women receiving abortion or post-abortion care do not want to become pregnant again in the near future. It is because of these issues that it is important for you to know the family planning needs of women during this critical period.
In this study session, you will learn about the provision of family planning following abortion and childbirth. You will discuss the reasons for giving post-abortion/postpartum family planning, and you will cover the definitions, essential components, advantages and family planning options for women.
When you have studied this session, you should be able to:
11.1 Define and use correctly all of the key words printed in bold. (SAQ 11.1)
11.2 Define postpartum and post-abortion family planning. (SAQ 11.4)
11.3 Explain the essential components of postpartum and post-abortion family planning. (SAQs 11.2 and 11.4)
11.4 Discuss the advantages of postpartum and post-abortion family planning. (SAQs 11.3 and 11.4)
11.5 Describe the contraceptive options during postpartum and post-abortion family planning. (SAQ 11.4)
Postpartum family planning is the initiation and use of family planning methods in the first six weeks following delivery (Figure 11.1). The aim is to prevent unintended pregnancy, particularly soon after childbirth, when another pregnancy could be harmful to the health of the mother or breastfeeding baby.
In Study Session 3 of the Labour and Delivery Care Module you learnt that after the delivery of the placenta, the inhibiting effects of oestrogen and progesterone are removed. So the levels of follicle-stimulating hormone and luteinizing hormone gradually rise, and ovarian functions begin again. Due to these effects, the menstrual cycle in non-breastfeeding mothers will start within four to six weeks of delivery (on average 45 days). However, if the mother is exclusively breastfeeding, the menstrual cycle may not return until six months after delivery.
Why is family planning important during the postpartum period?
When the menstrual cycle returns, there is a risk of pregnancy that could influence the health of the mother and infant.
Post-abortion family planning is the initiation and use of family planning methods immediately after, and within 48 hours of an abortion, before fertility returns. In most women fertility returns on average about two weeks after an abortion; however, ovulation can occur as early as 11 days post-abortion. Part of your role is to help prevent unintended pregnancies in women who do not want to be pregnant again, or for whom pregnancy may be dangerous.
You can begin post-abortion family planning immediately after post-abortion care for those women who wish to prevent pregnancy. Be aware that following an abortion in the first trimester, or first three months of pregnancy, a woman’s fertility usually resumes within two weeks. However, following an abortion in the second trimester, a woman’s fertility usually returns more slowly, within four weeks.
Based on the above descriptions of the postpartum and post-abortion periods, are the principles and guidelines of family planning the same for both?
Some health providers incorrectly think that the guidelines for postpartum family planning also apply to post-abortion family planning. There are differences though. For example, special concerns for postpartum family planning related to breastfeeding do not apply to post-abortion women. As a result, women are often not offered family planning methods after an abortion that would be both appropriate and acceptable to them.
You will be involved in a variety of activities when you help women or mothers in their post-abortion or postpartum period (see Box 11.1). Your primary activity is to discuss family planning needs and to ensure protection against sexually transmitted diseases. You can also give information and counselling about short- and long-term method choices, their effectiveness, and side effects. Once a woman has reached an informed choice, you should give her, or refer her for the relevant family planning method. Do not forget to make a follow-up appointment.
It should include the following:
There are a number of potential advantages in providing postpartum and post-abortion family planning services. You will have several opportunities to contact your clients during antenatal care and the postpartum period, so introducing family planning services can be more efficient and effective.
When a woman comes to you for prenatal care, you will have an opportunity to discuss infant healthcare, breastfeeding, and family planning as well. You can also introduce these ideas at early prenatal visits, and discuss them in greater detail as the delivery date approaches.
When you assist a mother during delivery, it presents another opportunity to offer information about breastfeeding and family planning. In some cases, this may be the only contact the woman will have with you. You can also integrate family planning with postnatal or child healthcare, for example when giving vaccinations.
The period following the treatment of abortion is also an opportunity for you to help women look at family planning needs. During this time, the assessment of each woman should include her personal characteristics, her clinical condition, and the service delivery capabilities in the community where she lives and where the services will be provided.
The initiation of family planning during the immediate postpartum and post-abortion period can lead to short- and long-term cost savings for both your clients and the health services.
When you provide counselling for a postpartum mother, your goal is to help the woman decide if she wants to use a family planning method, and what the most appropriate method would be for her (see Box 11.2). You will need to take into consideration whether or not she is breastfeeding.
Ideally, you should have already provided counselling during prenatal care. However, it is also possible to provide family planning counselling and services following delivery.
Can you give counselling during labour?
You should not give counselling during labour. You can provide useful advice on family planning only after the mother has recovered from the immediate physical and emotional stress of childbirth.
Before you provide postpartum counselling, encourage your clients to consider the following key issues:
If a mother is interested in family planning, you should use your counselling skills to help her focus on which method, or combination of methods, may be most appropriate. She should be clear about the effects of family planning methods on breastfeeding, the correct use of methods, and the period before resumption of sexual relations following delivery.
In Ethiopia, more than 90% of all mothers breastfeed their infants for some period of time. In this case, the impact of contraceptive methods on breastfeeding, breastmilk, and infant health is of some concern.
Effective breastfeeding should be encouraged for the benefit of the mother, and the health of the infant. Here are three general guidelines you should follow.
For breastfeeding women, non-hormonal methods are the best choice and can safely be used. They do not interfere with a woman’s ability to breastfeed, or the quality and quantity of breastmilk and there is no adverse effect on infant growth and development. From your previous sessions in this module, you have learnt that non-hormonal methods include lactation amenorrhoea method (LAM), male or female condoms, spermicides, diaphragms, IUCDs, male or female voluntary surgical contraception (VSC), and natural family planning methods.
Progestin-only oral contraceptive methods are the next best choice, and are considered a suitable method for breastfeeding women six weeks after childbirth. This method has been shown not to affect breastmilk secretion and breastfeeding or infant growth and development. Options include progestin-only injectables, progestin-only pills, and implants put under the skin.
It is recommended that progestin-only methods be provided after the first six weeks postpartum. However, some find it more convenient to begin these methods immediately after delivery, since no adverse effects on the infant or breastfeeding have been observed.
Combined oral contraceptives are less frequently recommended for breastfeeding mothers, because they are known to decrease breastmilk secretion by inhibiting the secretion of prolactin. However, it is an option if the mother is no longer breastfeeding, or breastfeeding less frequently six months after childbirth. These methods include combined oral contraceptives and combined injectable contraceptives (Mesigyna and Cyclofem). See Table 11.1 for a summary of options for breastfeeding women.
|Best choice: non-hormonal methods||Alternative choice: progestin-only methods||Less preferable: combined oestrogen-progestin methods|
Following abortion, menstruation usually returns after between two and four weeks, depending on the trimester in which it took place (see section 11.1) so a woman will be fertile and may get pregnant again unless she starts a family planning method. All modern family planning methods can be used immediately after post-abortion care, provided that:
You should advise women not to have sexual intercourse until their bleeding stops (usually five to seven days after abortion) and any complications have been resolved. Also advise women not to use natural family planning (NFP) methods until their regular menstrual pattern returns. Moreover, all women should be advised that the only contraceptive method that provides protection against sexually transmitted infections (STIs) is the condom. Box 11.3 summarises the principal guidelines for post-abortion family planning.
In Study Session 11, you have learned that:
Now that you have completed this study session, you can assess how well you have achieved its Learning Outcomes by answering these questions. Write your answers in your Study Diary and discuss them with your Tutor at the next Study Support Meeting. You can check your answers with the Notes on the Self-Assessment Questions at the end of this Module.
Why is it recommended to use contraception immediately following an abortion in the first trimester (first three months), compared with an abortion in the second trimester?
Following an abortion in the first trimester (first three months of pregnancy), a woman’s fertility resumes almost immediately and usually within two weeks. However, following an abortion in the second trimester, a woman’s fertility usually resumes within four weeks, allowing slightly longer to begin appropriate contraception.
What are the essential components of postpartum and post-abortion family planning?
The essential components of postpartum and post-abortion family planning are:
Briefly explain the potential advantages of postpartum and post-abortion family planning services.
The potential advantages of postpartum and post-abortion family planning services are:
W/ro Bekelech gave birth in your health post and now she is six hours postpartum. Before she leaves for home, she asks you to restart her former contraceptive pills (Microgynon). W/ro Bekelech has already started breastfeeding her infant following delivery. During a previous birth she breastfed her first child exclusively for six months without problems. How would you manage W/ro Bekelech’s postpartum family planning request?