CDC revises recommendations for postpartum contraception

The US Centers for Disease Control and Prevention (CDC) has released revised recommendations for postpartum contraceptive use based on an assessment of new evidence, according to an article published in the July 8 issue of Morbidity and Mortality Weekly Report.

The guidelines update the CDC's U.S. Medical Eligibility Criteria for Contraceptive Use, 2010, and recommend that postpartum women should not use combined hormonal contraceptives during the first 21 days after delivery because of the high risk for venous thromboembolism (VTE).

“Use of combined hormonal contraceptives (during this time) represents an unacceptable health risk and should not be used (category 4),” the statement said.

Women without risk factors for VTE, such as previous VTE or recent cesarean delivery, generally can initiate combined hormonal contraceptives among postpartum days 21 to 42; women with risk factors should not use combined hormonal contraceptives during this time as the risks usually outweigh the advantages (category 3). After 42 days, there are no recommended restrictions on contraceptive use, the report said.

Category 3 is characterized as a condition for which the theoretical or proven risks usually outweigh the advantages of using the method. Category 4 is a condition that represents an unacceptable health risk if the contraceptive method is used.

The CDC’s original guidelines, published in 2010, which were adapted from World Health Organization (WHO) guidelines, recommended that combined hormonal contraceptives generally should not be used in women less than 21 days postpartum, but after that time, they could be used without restriction.

The CDC initiated an assessment to evaluate whether its guidelines should be updated in line with WHO’s recently updated guidelines, which was based on a review of evidence from 13 studies that found:

• The risk for VTE among women within the first 42 days postpartum is 22-fold to 84-fold greater than the risk among nonpregnant, nonpostpartum reproductive age women.
• The highest risk is immediately after delivery and declines during the first 21 days.
• Risk returned to baseline 42 days postpartum in most studies.

Separate recommendations for the use of combined hormonal contraceptives among women who are breastfeeding remain unchanged, as do the recommendations for use of other contraceptives, including progestin-only hormonal contraceptives.

“Healthcare providers assessing a woman's individual risk also should consider any other characteristics or medical conditions that might impact the classification,” the authors wrote. “For postpartum women, this might include examining the recommendations for other risk factors for VTE, such as known thrombogenic mutations (category 4) or history of VTE with risk factors for recurrence (category 4), both of which pose an unacceptable health risk for combined hormonal contraceptive use, whether or not women are postpartum.”