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Family Planning Module: 11. Postpartum and Post-Abortion Family Planning

Study Session 11  Postpartum and Post-Abortion Family Planning

Introduction

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.

Learning Outcomes for Study Session 11

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)

11.1  What is postpartum and post-abortion family planning?

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.

A health worker talks to a mother about immunization and family planning at her postnatal checkup.
Figure 11.1 A postnatal checkup is a good time to counsel mothers about immunization and family planning. (Photo: UNICEF Ethiopia/Indrias Getachew)

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.

11.2  Postpartum and post-abortion family planning services

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.

Box 11.1  Important points about postpartum and post-abortion family planning

It should include the following:

  • Discussion about contraceptive needs, taking into account reproductive goals and protection against sexually transmitted infections.
  • Information and counselling about methods, their effectiveness, and side effects.
  • Short- and long-term contraceptive method choices.
  • Assurance of contraceptive re-supply.
  • Access to follow-up care.

11.3  Advantages of postpartum and post-abortion family planning

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.

11.4  Postpartum and post-abortion counselling

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.

Box 11.2  Issues for clients to consider before postpartum counselling

Before you provide postpartum counselling, encourage your clients to consider the following key issues:

  • Whether they want more children, or whether they are happy with their current family size.
  • If they want more children, how long would they like to wait before having another child?
  • Their satisfaction, successes and failures with contraceptive methods used previously.
  • Their plans regarding breastfeeding.

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.

11.5  Postpartum and post-abortion family planning options

11.5.1  Family planning options postpartum

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.

  • Encourage women to exclusively breastfeed for the first six months.
  • Ensure their chosen contraceptive method will not adversely affect breastfeeding or the health of the infant.
  • Be certain that breastfeeding is not discontinued in order to start a contraceptive method.

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.

Table 11.1  Summary of family planning options for breastfeeding women.
Best choice: non-hormonal methodsAlternative choice: progestin-only methodsLess preferable: combined oestrogen-progestin methods
  • Lactation menorrhea method (LAM)
  • Diaphragm
  • Male and female condoms
  • Spermicides
  • IUCD
  • Male and female sterilisation
  • Natural Family Planning (NFP).
  • Progestin-only pills
  • Injectables (DMPA, NET-EN)
  • Implants (Jadelle, Implanon).
  • Combined oral contraceptive pills (COCs)
  • Monthly injectables (Mesigyna, Cyclofem).

11.5.2  Family planning options post-abortion

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:

  • there are no severe complications requiring further treatment
  • the provider screens for any precautions before using a particular contraceptive method
  • the woman receives adequate counselling.

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.

Box 11.3  Summary of post-abortion family planning
  • Post-abortion family planning should be started immediately:
    • Ovulation can occur as early as eleven days post-abortion.
    • 75% of women will have ovulated within four to six weeks post-abortion.
  • All modern family planning methods are appropriate for post-abortion women:
    • Condoms (which also prevent STIs and HIV)
    • Oral contraceptives
    • IUCDs
    • Injectables
    • Implants
    • Spermicides.

Summary of Study Session 11

In Study Session 11, you have learned that:

  1. Postpartum family planning is the initiation and use of family planning methods in the first six weeks following delivery. The aim is to prevent unintended pregnancy, too soon after childbirth, when another pregnancy could be harmful to the health of the mother or breastfeeding baby.
  2. Post-abortion family planning is the initiation of family planning methods immediately after, or (preferably) within 48 hours of an abortion, before fertility returns. Fertility returns on average about two weeks post-abortion.
  3. One of the advantages of postpartum and post-abortion family planning is that it creates opportunities for you to contact your clients during the prenatal, postpartum, or post-abortion period.
  4. The goal of postpartum and post-abortion family planning is to help a woman decide if she wants to use a family planning method, to help her choose an appropriate method, taking into consideration whether or not she is breastfeeding, and to prepare her to use the method effectively.
  5. The best choice of family planning postpartum is a non-hormonal method. Progestin-only methods are the next choice, and combined oral contraceptives are the last choice for a non-breastfeeding mother.
  6. All modern family planning methods are appropriate for post-abortion women.

Self-Assessment Questions (SAQs) for Study Session 11

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.

SAQ 11.1 (tests Learning Outcomes 11.1 and 11.2)

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?

Answer

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.

SAQ 11.2 (tests Learning Outcome 11.3)

What are the essential components of postpartum and post-abortion family planning?

Answer

The essential components of postpartum and post-abortion family planning are:

  • Discussing family planning needs, and protection against sexually transmitted infections (STIs).
  • Counselling about short- and long-term family planning method choices, their effectiveness, and side effects.
  • Provision of appropriate and available family planning methods or contraceptives.
  • Appointment for a follow-up meeting.

SAQ 11.3 (tests Learning Outcome 11.4)

Briefly explain the potential advantages of postpartum and post-abortion family planning services.

Answer

The potential advantages of postpartum and post-abortion family planning services are:

  • Opportunities to contact clients in order to introduce family planning services.
  • Subsequent opportunities to offer information about breastfeeding and family planning.

SAQ 11.4 (tests Learning Outcomes 11.2, 11.3, 11.4 and 11.5)

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?

Answer
  • Explain to W/ro Bekelech that her current pill, Microgynon, could affect her breastmilk and is not the best contraceptive choice.
  • Discuss with W/ro Bekelech the effectiveness of using the LAM method, and mention to her the importance of maintaining a full breastfeeding pattern over the next six months if she does.
  • Inform W/ro Bekelech about the effect of oestrogen on breastmilk production.
  • If W/ro Bekelech wants to use LAM, provide detailed instructions, and the criteria for starting a complementary method.
  • If W/ro Bekelech does not want to use LAM, and wants to use contraceptive pills, counsel her on the progestin-only methods. If she accepts progestin-only pills, provide her with a supply.
  • Discuss with W/ro Bekelech any risks concerning STIs, and provide her with condoms if needed.