Clinical overview
The puerperium is one of the most consequential — and most missed — opportunities in a woman's reproductive life. A woman who leaves the postnatal ward without a contraceptive plan is at real risk of a short inter-pregnancy interval, and the data are unforgiving: pregnancies conceived within six months of a birth carry higher rates of preterm birth, low birthweight, uterine rupture in those with a previous caesarean (relevant to VBAC), and maternal anaemia. The World Health Organization recommends spacing of at least 24 months from a live birth to the next conception. In South Africa, where the maternal mortality burden is driven by obstetric haemorrhage, hypertension and non-pregnancy-related infection (predominantly HIV) as documented in successive Saving Mothers reports, every avoided unintended pregnancy is a directly preventable risk exposure.
To evaluate postpartum contraceptive options is to weigh four variables simultaneously for each individual woman: (1) the timing since delivery and its effect on venous thromboembolism (VTE) and lactation; (2) breastfeeding status, because oestrogen-containing methods interact with both VTE risk and milk supply; (3) comorbidity, especially the obstetric complication that brought her to a high-risk delivery (pre-eclampsia, peripartum cardiomyopathy, prior VTE, previous caesarean); and (4) HIV status and antiretroviral therapy, which in the South African context is near-universal to consider. The single most effective intervention is to provide the chosen method before discharge — immediate postpartum long-acting reversible contraception (LARC) removes the access barrier that otherwise leaves women unprotected through the fertile window that reopens at around three weeks in the non-breastfeeding woman.
Core knowledge
Return of fertility and the lactational window
Ovulation can resume from approximately day 21–28 postpartum in a woman who is not breastfeeding; the first ovulation may precede the first menses, so a woman is fertile before she has any warning. Contraception is therefore advised from day 21 in the non-breastfeeder. In the fully breastfeeding woman, lactational amenorrhoea suppresses ovulation through prolactin-mediated inhibition of GnRH pulsatility.
The Lactational Amenorrhoea Method (LAM) is a legitimate, evidence-based method but is only reliable when all three conditions hold: the woman is fully or nearly fully breastfeeding, she remains amenorrhoeic, and the infant is under six months old. When all three are met, efficacy is high (standard teaching ~98% in the first six months). The moment any one condition fails — supplementary feeds begin, menses return, or six months pass — protection is lost and a transition method must already be in place. LAM should be taught as a bridge, never a destination.
Method classes
| Class | Examples (SA EML/national availability) | Oestrogen? | LARC? |
|---|---|---|---|
| Progestogen-only pill (POP) | Levonorgestrel/norethisterone POP; desogestrel POP | No | No |
| Injectable progestogen | DMPA (depot medroxyprogesterone acetate) IM; NET-EN | No | No |
| Implant | Etonogestrel subdermal implant | No | Yes |
| Levonorgestrel IUS | LNG-IUS | No | Yes |
| Copper IUD (Cu-IUD) | Copper intrauterine device | No | Yes |
| Combined hormonal contraception (CHC) | Combined oral pill, patch, ring | Yes | No |
| Permanent | Tubal ligation/occlusion; vasectomy (partner) | No | Permanent |
The conceptual division that matters most for postpartum evaluation is oestrogen-containing (CHC) versus progestogen-only/non-hormonal. Oestrogen is the problematic ingredient in the puerperium: it independently raises VTE risk during the already-prothrombotic postpartum period and can theoretically reduce milk volume in early lactation.
The two eligibility frameworks
Evaluation is anchored to medical eligibility criteria, which classify a method–condition pairing as Category 1 (no restriction), 2 (benefits generally outweigh risks), 3 (risks generally outweigh benefits — use only if better options unavailable, with expert judgement) or 4 (unacceptable health risk).
- The WHO Medical Eligibility Criteria for Contraceptive Use, 6th edition (2025) is the current international standard.
- South Africa's own National Contraception Clinical Guidelines (2019) and the Handbook for Contraceptive Method Provision (2019) remain the national documents, but they are aligned to the older WHO MEC 5th edition (2015). Where the SA guidance and WHO MEC 6th diverge — most importantly around HIV risk and antiretroviral interactions, which WHO has liberalised — flag the discrepancy and default to the more current evidence while remaining mindful of the operative national policy.