Contraception Confusion: What's Right for You?
If you just had a baby, you may be rethinking your birth control. Find out what the options are.
As a new mom, you're dealing with sleep deprivation and learning to care for a newborn, so birth control may not be on your mind. But fertility can return as quickly as two weeks after delivery, particularly if you're not breastfeeding. Discuss the options with your partner and doctor during pregnancy, or after childbirth, before diaper duty takes over. Our mom-friendly guide will make it easy.
Because the cervix is stretched during labor, some of your favorite barrier methods of birth control will need to be refitted after childbirth. Your tissues are healing, and devices that work by keeping spermicide near the cervix for an extended period may cause irritation. So it's probably best to wait to have sex until you've discussed all available methods with your ob-gyn at your six-week postpartum checkup.
- How it works: A sheath made from latex, synthetic materials, or natural membranes covers the penis, preventing sperm from entering the vagina.
- Advantages: Condoms (except for those made from natural membranes) are the most effective method for preventing sexually transmitted diseases (STDs).
- Risks: Two percent of women will become pregnant in the first year of use, if condoms are used perfectly; but people make mistakes when using them, so the typical failure rate is 15 percent.
- Postpartum issues: Lubricated condoms may help alleviate bothersome vaginal dryness.
Female Condom (i.e., Reality)
- How it works: A polyurethane sheath is inserted into the vagina. Flexible rings hold it in place inside and outside the vagina.
- Advantages: Female condoms protect against contracting STDs and can be inserted up to eight hours before sex.
- Risks: Vaginal irritation or allergic reactions. Twenty-one percent of women will get pregnant during the first year of typical use; with perfect use, the failure rate is 5 percent.
- Postpartum issues: Doesn't need to be refitted after childbirth.
- How it works: Spermicides come in jellies, films, creams, foams, and suppositories. They all contain nonoxynol-9, a chemical that destroys the sperm-cell membrane.
- Advantages: Offers lubrication to counteract vaginal dryness.
- Risks: Irritation, allergic reactions, urinary tract infections. Some research indicates that frequent spermicide use may create microscopic lesions that make it easier for the human immunodeficiency virus (HIV) to enter tissue. Twenty-nine percent of women will get pregnant during the first year of typical use; with perfect use, the failure rate is 18 percent.
- Postpartum issues: Possible irritation following childbirth.
- How it works: A prescribed, reusable dome-shaped rubber cup is filled with spermicide and inserted into the vagina to cover the cervix. It provides protection for at least six hours, and must be left in place at least six hours after intercourse.
- Advantages: Some studies show use lowers cancer risk.
- Risks: Irritation, allergic reactions to spermicide, urinary tract infections, and toxic shock syndrome -- a rare but serious bacterial infection -- may occur if a diaphragm is worn for more than 24 hours. Six percent failure with perfect use in the first year; 16 percent for typical use. Replace after one or two years.
- Postpartum issues: Must be refitted by your gynecologist.
More Barrier Methods
- How it works: A prescribed, one-size, reusable silicone rubber device is inserted into the vagina to cover the cervix. It must be used with spermicide, left in place eight hours after intercourse, and removed within 48 hours. You should replace it every six months.
- Advantages: Secretions and air pass out of a central valve to create a tight suction; a loop makes the device easy to remove.
- Risks: Irritation, urinary tract infection, and possible risk of toxic shock syndrome if used too long. Data on its failure rates is limited, but the FDA says 15 percent of women will get pregnant per year with perfect use.
- Postpartum issues: Because this device was only recently approved by the FDA in March 2002, studies have not yet established that the shield is safe and effective after having a baby.
Cervical Cap (i.e., FemCap)
- How it works: A prescribed, silicone rubber cup fits snugly over the cervix to keep sperm out. It must be used with spermicide, left in place at least six hours after intercourse, and removed within 48 hours. Replace it after one year.
- Advantages: Spermicide can be placed on the inside and outside of the cap for added protection.
- Risks: Irritation and allergic reactions, abnormal Pap test results, and toxic shock syndrome if worn too long.
- Postpartum issues: Your gynecologist will need to prescribe a new size. The cap is less effective for women who have given birth vaginally: The typical failure rate doubles for women who have had children: 32 percent versus 16 percent in the first year.
- How it works: The spermicide-saturated sponge covers the cervix. Leave it in place for six hours after intercourse. (After being off the market since 1995, the Today Sponge is again available, but by mail order only.)
- Advantages: You can have protected sex for 24 hours, no matter how many times you have intercourse.
- Risks: Irritation, allergic reactions, and toxic shock syndrome if worn too long.
- Postpartum issues: The typical failure rate doubles for women who have had children: 32 percent versus 16 percent in the first year of use.
A wide variety of prescribed contraceptives deliver small doses of hormones in different combinations. One of four kinds of synthetic progestin provides most of the birth control. To foil conception it thickens cervical mucus to prevent sperm from getting into the uterus, inhibits ovulation, and seems to limit the sperm's ability to move and fertilize the egg. Many products also have one of two types of estrogen, which may help suppress the hormone surge that triggers ovulation and reduce some side effects. (Warning for breastfeeding moms: Estrogen can depress, or dry up, your milk supply.)
Hormonal contraceptives have health benefits, including decreased menstrual cramps and pain and lower risk of endometrial and ovarian cancer, but they may also cause heart attacks, strokes, and blood clots. If a woman takes them exactly as directed, there's a less than 1 percent chance of pregnancy in the first year of use, but the risk with typical usage is 8 percent.
Combined Birth Control Pill
- How it works: With two kinds of formulations, some brands contain the same dose of progestin and estrogen in each pill, while others vary the doses throughout the cycle. Most packs have 21 active pills and 7 placebo, or nonactive pills.
- Advantages: Users experience a quick return to fertility after discontinuing.
- Risks: Nausea, moodiness, heart attacks, strokes, and blood clots. For women with no risk factors, some formulations can double heart disease risk. The risk for smokers can increase 13 times, and smokers over 35 shouldn't take birth control pills.
- Postpartum issues: Wait for six-week checkup.
Extended-Cycle (i.e., Seasonale)
- How it works: Combined pills taken in three-month cycles, 12 weeks of active pills, followed by one week of placebos, causing women to have only four periods a year.
- Advantages: Reduces menstrual-related problems, such as migraines and mood swings.
- Risks: The same as for 21-day-cycle pills. Some women experience spotting and breakthrough bleeding, but this abates over time.
- Postpartum issues: Theoretically the same as the pill; wait for six-week checkup.
- How it works: Contains only progestin, a formula thought to decrease menstrual bleeding, cramping, and anemia. The low-dose pills must be taken at exactly the same time each day. If the interval between pills is longer than 24 hours, cervical mucus thins and lets more sperm through.
- Advantages: Similar to the combined pill.
- Risks: Because it's not widely used, large-scale studies on risks and effectiveness don't exist; the mini-pill has been associated with more spotting and breakthrough bleeding; and other medications can interfere with its contraceptive effect.
- Postpartum issues: If you're nursing, the mini-pill doesn't seem to affect milk supply. Wait until the six-week checkup before taking progestin-only contraception; some experts feel that early exposure to external hormones may interfere with a newborn's own natural hormones.
More Hormonal Contraceptives
The Patch (i.e., Ortho Evra)
- How it works: Gradually delivers contraceptive progestin and estrogen through the skin; each patch must be replaced every seven days for three weeks (nothing is worn in the fourth week).
- Advantages: Once-a-week application.
- Risks: Similar to the combined pill. A recent Associated Press investigation found that wearing the patch may carry a higher risk of blood clots and stroke than using the pill, but more research is needed.
- Postpartum issues: Same as combined hormonal methods.
Vaginal Ring (i.e., NuvaRing)
- How it works: A plastic ring, inserted near the cervix, gradually releases progestin and estrogen in lower doses than the pill or patch. Stays in place for 21 days, then is removed for 7 days.
- Advantages: You only have to think about it once a month.
- Risks: Similar to combination pills; may cause discomfort.
- Postpartum issues: Wait until the six-week checkup.
Injection (i.e., Depo-Provera)
- How it works: Administered every three months.
- Advantages: Long intervals between treatments.
- Risks: Decrease in bone density, allergic reactions, possible increase in cholesterol. Although women sometimes miss their scheduled visits for follow-up injections, the failure rate for typical use in the first year is still a low 3 percent.
- Postpartum issues: Wait until your six-week checkup. Depo-Provera is safe for breastfeeding moms.
Intrauterine Devices, Natural Planning, and Sterilization
Fewer than 1 percent of American women use intrauterine devices (IUDs), due in large part to the disastrous Dalkon Shield, an IUD that was pulled from the market in the 1970s for causing pelvic inflammatory disease, miscarriage, and death. Today's IUDs have been redesigned and are considered safe.
Copper IUD (i.e., ParaGard)
- How it works: A small plastic device coated with copper is inserted into the uterus and left for up to 10 years. It's not completely understood how IUDs prevent pregnancy, but scientists believe that the copper ion from the device kills sperm. New studies indicate that IUDs may impair how sperm functions to prevent fertilization.
- Advantages: Long-term contraception that will fail in fewer than 1 percent of women in the first year because there's no user error. Doctors should be trained in IUD insertion.
- Risks: Pelvic inflammatory disease, especially within the first 20 days after insertion.
- Postpartum issues: An IUD may be placed immediately after delivery. Otherwise, insertion should be delayed until the second postpartum month because of the risk that the uterus might be punctured.
Progestin IUD (i.e., Mirena)
- How it works: This IUD has a mechanism similar to that of other IUDs, with the addition of a slow-release dose of progestin. The device may be left in place for as long as five years.
- Advantages: Less than 1 percent failure risk in the first year.
- Risks: Similar to other IUDs and progestin-only methods.
- Postpartum issues: Wait until your six-week checkup. Mirena is safe for breastfeeding moms.
So you just had a baby and you're again preoccupied with your "fertile window." Want to use natural contraception? Consider this.
The successful practice of fertility awareness depends on your dedication and the combination of various methods, an integrated approach better known as the symptothermal method. It usually involves analyzing changes in cervical mucus and recording the 0.4? temperature increase that occurs around the time of ovulation. Or you can even add another method, such as calculating fertile days.
If you're not committed to this meticulous charting and your menstrual cycle does not consistently fall between 26 and 32 days, you have at least a 25 percent chance of pregnancy. Postpartum women should keep in mind that their cycles might not be regular for many months, especially if nursing, says Alison Edelman, MD, a professor at Oregon Health & Science University, in Portland.
Can I get pregnant when I'm breastfeeding?
Breastfeeding does have a contraceptive effect, but only for about six months, and only if you exclusively breastfeed your baby.
Nursing seems to release endorphins that depress the production of hormones necessary for ovulation. This temporary period of infertility is called lactational amenorrhea (LAM).
For LAM to work, your breasts must be nearly drained with each frequent feed. The goal is have as much suckling as possible to keep the ovulation hormones suppressed. If your baby drinks formula, uses a pacifier, or if you pump milk regularly, then all bets are off.
Four studies of women who used LAM exclusively for six months showed pregnancy rates that ranged from 0.5 to 1.5 percent. Most gynecologists say that LAM is 98 percent effective for a while. If you want to be absolutely sure of not conceiving, most doctors recommend using an additional contraceptive method, such as a condom, for added protection.
If you've gotten your period, don't rely on LAM. Even breastfeeding moms usually start to menstruate between four and six months after giving birth. Ovulation does not always precede the first postpartum menses, especially if it comes soon after delivery. But the longer the return of your period is delayed, the more likely ovulation, and the risk of pregnancy, will precede that first menstrual cycle.
Is it permanent?
There are complicated surgeries to reverse sterilization, but they're expensive, not usually covered by insurance, and have low success rates.
How does the technique work?
In tubal ligation, the surgeon blocks the fallopian tubes by cutting them, using electricity to burn the tissue, or by clamping off the passage with a clip or ring. Afterwards, eggs can't descend into the uterus, making pregnancy nearly impossible.
In 2002, the FDA approved a new nonsurgical method called Essure. The doctor places what looks like a metal spring into each tube. Over the course of three months, scar tissue builds up around the implant, thereby blocking the tubes.
Can it fail?
The annual failure risk is 0.5 percent. Over a decade, ob-gyns say that the risk of pregnancy is approximately 1 percent. Over two decades, it's 2 percent, and so on.
Because the tubes are blocked, either sterilization method can cause an ectopic pregnancy (when a fertilized egg implants outside the uterus, usually in a fallopian tube) if it fails.
Is menstrual suppression harmful?
"Some women say, 'If I could take something to keep me from having my period, I'd be happy.' Others say, 'My period makes me feel like I'm healthy,'" says Katherine LaGuardia, MD, director of medical affairs for Ortho Women's Health, the contraception maker. "But there's no strong health argument that advocates either position."
In fact, you may not realize that all forms of hormonal contraception -- even the 21-day combined pill -- will suppress your period. In essence, if you're on birth control, the bleeding you experience every month isn't a true menstruation because no uterine tissue is being shed. These "pill bleeds" are the body's reaction to withdrawing from the hormone progesterone.
Basically, there aren't any long-term studies of the effects of menstrual suppression. Short-term studies don't show any danger, because women become fertile again as soon as they stop taking hormones. Yet ob-gyns do point out that women today have far more periods than did their forebears just two or three generations ago. When women had eight or 10 children in a lifetime, they spent much of their fertile years pregnant or nursing -- and not menstruating. Hunters-gatherers might have had 25 to 50 periods in a lifetime. The current generation of women, who live longer and give birth far later and to far fewer children in life, will have between 450 and 500.
Heather Millar is a freelance writer in Brooklyn, New York.
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