Authors' response to comment on ‘Postpartum contraception: a missed opportunity to prevent unintended pregnancy and short inter-pregnancy intervals’
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* Rebecca Heller
* Sharon Cameron
* Rosie Briggs
* Norma Forson
* Anna Glasier

*   postpartum contraception
*   long-acting reversible contraception
*   family planning service provision

We welcome Tvarozkova *et al.*'s1 investigation of their patient population's knowledge about postnatal contraception, and we agree that postnatal care currently represents a missed opportunity. However we would question the plan for a dedicated postnatal contraception service, in the absence of antenatal contraceptive counselling. The difficulty with a postpartum-only service is that discussing contraception immediately postpartum is a low priority for women2 and the need for an extra visit for long-acting reversible contraception (LARC) methods such as the intrauterine device (IUD) represents a significant barrier to uptake. Ogburn *et al.* 3 found the DNA (did not attend) rate for postpartum IUD insertion to be as high as 35%. In addition, breastfeeding women may ovulate as early as 3 weeks postpartum,4 meaning that a dedicated service after this period may be too late for some.

When so few women in the study had discussed contraception during their pregnancy it is perhaps unsurprising that they were unlikely to accept immediate fitting of these devices, particularly as some had never heard of the IUD or intrauterine system. We would suggest that a more effective response to these findings would therefore be to offer comprehensive contraception counselling (perhaps by the designated nurse or midwife that Tvarozkova *et al.* suggest) in the antenatal period, followed by offering all methods of contraception immediately postpartum. Women can therefore take time to consider their chosen method while not at risk of pregnancy, and avoid the need for further burdensome visits to services. This practice would be in line with the recommendation of the *Contraception After Pregnancy* guideline published in January 2017 by the Faculty of Sexual & Reproductive Healthcare.5 

## Footnotes

*   Competing interests None declared.

## References

1.   Tvarozkova K , Killicoat K , Munro H , et al . Comment on ‘Postpartum contraception: a missed opportunity to prevent unintended pregnancy and short inter-pregnancy intervals’. J Fam Plann Reprod Health Care 2017;43:164.
    
    [FREE Full Text](http://jfprhc.bmj.com/lookup/ijlink/YTozOntzOjQ6InBhdGgiO3M6MTQ6Ii9sb29rdXAvaWpsaW5rIjtzOjU6InF1ZXJ5IjthOjQ6e3M6ODoibGlua1R5cGUiO3M6NDoiRlVMTCI7czoxMToiam91cm5hbENvZGUiO3M6MTQ6ImZhbWlseXBsYW5uaW5nIjtzOjU6InJlc2lkIjtzOjg6IjQzLzIvMTY0IjtzOjQ6ImF0b20iO3M6MzE6Ii9mYW1pbHlwbGFubmluZy80My8yLzE2NC4yLmF0b20iO31zOjg6ImZyYWdtZW50IjtzOjA6IiI7fQ==) 

2.   McCance K , Cameron S . Midwives’ experiences and views of giving postpartum contraceptive advice and providing long-acting reversible contraception: a qualitative study. J Fam Plann Reprod Health Care 2014;40:177–183. [doi:10.1136/jfprhc-2013-100770](http://dx.doi.org/10.1136/jfprhc-2013-100770) 
    
    [Abstract/FREE Full Text](http://jfprhc.bmj.com/lookup/ijlink/YTozOntzOjQ6InBhdGgiO3M6MTQ6Ii9sb29rdXAvaWpsaW5rIjtzOjU6InF1ZXJ5IjthOjQ6e3M6ODoibGlua1R5cGUiO3M6NDoiQUJTVCI7czoxMToiam91cm5hbENvZGUiO3M6MTQ6ImZhbWlseXBsYW5uaW5nIjtzOjU6InJlc2lkIjtzOjg6IjQwLzMvMTc3IjtzOjQ6ImF0b20iO3M6MzE6Ii9mYW1pbHlwbGFubmluZy80My8yLzE2NC4yLmF0b20iO31zOjg6ImZyYWdtZW50IjtzOjA6IiI7fQ==) 

3.   Ogburn JA , Espey E , Stonehocker J . Barriers to intrauterine device insertion in postpartum women. Contraception 2005;72:426–429. [doi:10.1016/j.contraception.2005.05.016](http://dx.doi.org/10.1016/j.contraception.2005.05.016) 
    
    [PubMed](http://jfprhc.bmj.com/lookup/external-ref?access_num=16307964&link_type=MED&atom=%2Ffamilyplanning%2F43%2F2%2F164.2.atom) 

4.   Jackson E , Glasier A . Return of ovulation and menses in postpartum nonlactating women: a systematic review. Obstet Gynecol 2011;117:657–662. [doi:10.1097/AOG.0b013e31820ce18c](http://dx.doi.org/10.1097/AOG.0b013e31820ce18c) 
    
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5.  Faculty of Sexual & Reproductive Health. Contraception After Pregnancy. 2017. http://www.fsrh.org/standards-and-guidance/documents/contraception-after-pregnancy-guideline-january-2017/ [accessed 10 February 2017].