Clinical Question

Does providing women with contraceptive education within the first month postpartum reduce subsequent unintended pregnancies?

Evidence-Based Answer

Postpartum education may increase contraceptive use and reduce unplanned repeat pregnancies, although the evidence is mixed. The optimal timing and content of educational programs are not known. (Strength of Recommendation: B, based on inconsistent or limited-quality patient-oriented evidence.)

Practice Pointers

Repeat unintended pregnancy in the first year postpartum is common. This is especially true in adolescents, up to 35% of whom will become pregnant again within one year after delivery.¹ Although not all repeat pregnancies are unintended, two-thirds of postpartum women use no, or ineffective, contraception,² even though several effective methods are available.³ Providing contraceptive counseling in the postpartum period is generally considered to be the standard of care. Still, it is unclear what the optimal timing and content of such counseling should be.² A previous Cochrane review was unable to determine which communication methods were most effective.⁴

Of the 10 trials included in this review, six were conducted in the United States; the others were from Pakistan, Nepal, Australia, and Syria. Meta-analysis was not performed because of the varied types of interventions and outcomes across studies. It is not clear what proportion of the repeat pregnancies in these studies were truly unintended. Use of contraception was a primary outcome measure of this analysis; however, no specific definition of contraceptive use or criteria for effectiveness were used.

Three studies involved one session focused on contraception only. A fourth study included contraception among a wider range of topics in either one or two sessions. Two of the four studies showed a positive effect on rates of contraceptive use. In one study, women who received counseling were more likely than those without counseling to be using contraception at eight to 12 weeks postpartum (odds ratio [OR] = 19.6; 95% confidence interval [CI], 11.7 to 32.8).⁵ In the second study, women who received counseling immediately after birth were more likely than those who received no counseling, or counseling only at three months postpartum, to be using contraception at six months (OR = 1.6; 95% CI, 1.1 to 2.5).⁶

The six other studies involved interventions consisting of multiple patient contacts. Three of these studies showed positive effects on pregnancy or contraceptive use. Among the studies with positive results, observed benefits included an increased use of effective contraception at six months and fewer repeat pregnancies at 18 to 24 months.^7,8 The other three studies with multiple patient contacts failed to show a benefit.

Four studies reported pregnancy outcomes in adolescents. One study found that the education group was less likely than the control group to have a repeat pregnancy at 18 months (15% vs. 32%).⁷ Another found less than half the rate of second births by two years among participants in an in-home mentoring program.⁸ The other two studies found no difference in repeat births at two years.

Although the evidence is mixed, providing women with postpartum contraceptive education may increase contraceptive use and reduce repeat unintended pregnancies. Because the optimal content of that education is unclear, physicians should tailor their own practices to meet the needs of their particular patient populations.