Data Highlights | References | Tables

Background

In the postpartum period, use of contraception may contribute to improved birth outcomes by lengthening the interval between pregnancies. The interpregnancy interval is the number of months between the end date of a woman's last pregnancy and the beginning of a subsequent pregnancy.¹

Numerous studies have found that short interpregnancy intervals, ranging from less than 3 months to less than 18 months, are associated with an increased risk of adverse birth outcomes, including low birthweight,^2–6 preterm births,^2,3,5–10 small for gestational age,^2,3,5,7 neonatal death,⁹ and infant mortality.¹¹ Proposed causal mechanisms for the relationship between short interpregnancy intervals and poor birth outcomes include postpartum stress and maternal nutrient depletion.^5,12–14

Few studies have addressed the prevalence of postpartum contraceptive use or its determinants. Analysis of 2000 PRAMS data for 19 states found that state-level prevalence of contraceptive use in the postpartum period ranged from 77.9% to 89.9%.¹⁵ Factors associated with postpartum contraceptive use varied across the states. For example, postpartum contraceptive use was associated with maternal education in six states, race in five states, and Medicaid status in three states.¹⁵ Among adolescent mothers for whom preventing a repeat pregnancy is critical, one study found that 87% of postpartum adolescents were using hormonal contraceptives 6 months postpartum, but that at 12 months only 70% were still using a hormonal method.¹⁶ Other studies found similar declines in adolescent postpartum contraceptive use.^17,18

There are a number of safe and effective contraceptive methods that women can begin at various points after delivery, including immediately postpartum. A mother's breastfeeding plans are an important consideration in selecting and initiating a postpartum contraceptive method. Breastfeeding women have a choice of several nonhormonal and hormonal methods that do not interfere with breast-milk composition or quantity, including the lactational amenorrhea method (LAM), copper-bearing intrauterine devices (IUDs), progestin-only methods (pills, injectables, implants, and IUDs), condoms, and other barrier methods (diaphragms and cervical caps), and sterilization.¹⁹ Women who are not breastfeeding may safely use any contraceptive method, with some restrictions on the timing for initiating certain methods. Combined hormonal contraception, for example, should not begin until approximately 3 weeks after childbirth, when the risk of venous thromboembolic disease is reduced.¹⁹ The American College of Obstetricians and Gynecologists (ACOG) and the World Health Organization (WHO) agree that women who are breastfeeding should not use combined hormonal contraception before 6 weeks' postpartum, after breastfeeding skills and patterns are established.^19,20 WHO also recommends that, if possible, breastfeeding women further delay use of combined hormonal contraceptives until 6 months' postpartum, because of concerns about their impact on milk quantity and composition.²⁰

PRAMS provides data on the prevalence of postpartum contraceptive use, the prevalence of prenatal counseling on use of postpartum contraception, and mothers' reasons for not using contraception postpartum. Selected states also capture information on the types of contraceptive methods that postpartum women adopt. States can use these data to understand the characteristics and contraceptive behaviors of women who are at risk of experiencing short interpregnancy intervals, and to develop service delivery strategies that minimize access barriers and promote and support effective postpartum contraceptive use. These data can also guide development of informational strategies that increase awareness and understanding of the health benefits of longer interpregnancy intervals and the role of contraception in helping women to achieve the desired spacing interval. States can also use these data to develop policies and programs that are working towards the Healthy People 2010 objective (Objective 9–2) of reducing the number of births occurring within 24 months of a previous birth from 11% (1995) to 6%.²¹

Data Highlights

• In 2002, use of postpartum contraception (any method) ranged from 76.1% (Hawaii) to 88.9% (Arkansas).
  
  
• During 2000–2002, the prevalence of postpartum contraceptive use decreased in 1 state (Washington).

References

1. Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Division of Nutrition and Physical Activity (Web site). Pregnancy Nutrition Surveillance System (PNSS) Indicators. November 15, 2004. Available at http://www.cdc.gov/pednss/what_is/pnss_health_indicators.htm#Maternal Health Indicators.
   
   
2. Zhu BP, Rolfs RT, Nangle BE, Horan JM. Effect of the interval between pregnancies on perinatal outcomes. The New England Journal of Medicine 1999;340(8):589–594.
   
   
3. Zhu BP, Haines KM, Le T, McGrath-Miller K, Boulton ML. Effect of the interval between pregnancies on perinatal outcomes among white and black women. American Journal of Obstetrics and Gynecology 2001;185(6):1403–1410.
   
   
4. Zhu BP, Le T. Effect of interpregnancy interval on infant low birth weight: a retrospective cohort study using the Michigan Maternally Linked Birth Database. Maternal and Child Health Journal 2003;7(3):169–178.
   
   
5. Zhu BP. Effect of interpregnancy interval on birth outcomes: findings from three recent U.S. studies. International Journal of Gynaecology and Obstetrics 2005;89(Supplement 1):S25–S33.
   
   
6. Khoshnood B, Lee KS, Wall S, Hsieh HL, Mittendorf R. Short interpregnancy intervals and the risk of adverse birth outcomes among five racial/ethnic groups in the United States. American Journal of Epidemiology 1998;148 (8):798–805.
   
   
7. Shults RA, Arndt V, Olshan AF, Martin CF, Royce RA. Effects of short interpregnancy intervals on small-for-gestational age and preterm births. Epidemiology 1999;10(3):250–254.
   
   
8. Fuentes-Afflick E, Hessol NA. Interpregnancy interval and the risk of premature infants. Obstetrics and Gynecology 2000;95(3):383–390.
   
   
9. Smith GC, Pell JP, Dobbie R. Interpregnancy interval and risk of preterm birth and neonatal death: retrospective cohort study. BMJ (British Medical Journal) 2003;327(7410):313.
   
   
10. Klerman LV, Cliver SZ, Goldenberg RL. The impact of short interpregnancy intervals on pregnancy outcomes in a low-income population. American Journal of Public Health 1998;88(8):1182–1185.
    
    
11. Kallan JE. Reexamination of interpregnancy intervals and subsequent birth outcomes: evidence from U.S. linked birth/infant death records. Social Biology 1997;44(3–4):205–212.
    
    
12. King JC. The risk of maternal nutritional depletion and poor outcomes increases in early or closely spaced pregnancies. Journal of Nutrition 2003;133(5 Supplement 2):1732S–1736S.
    
    
13. Smits LJ, Essed GG. Short interpregnancy intervals and unfavourable pregnancy outcome: role of folate depletion. Lancet 2001;358 (9298):2074–2077.
    
    
14. Stephansson O, Dickman PW, Cnattingius S. The influence of interpregnancy interval on the subsequent risk of stillbirth and early neonatal death. Obstetrics and Gynecology 2003;102(1):101–108.
    
    
15. Williams LM, Morrow B, Lansky A, Beck LF, Barfield W, Helms K, et al. Surveillance for selected maternal behaviors and experiences before, during, and after pregnancy. Pregnancy Risk Assessment Monitoring System (PRAMS), 2000. MMWR Surveillance Summaries 2003;52(SS-11):1–14.
    
    
16. Kershaw TS, Niccolai LM, Ickovics JR, Lewis JB, Meade CS, Ethier KA. Short and long-term impact of adolescent pregnancy on postpartum contraceptive use: implications for prevention of repeat pregnancy. The Journal of Adolescent Health 2003;33(5):359–368.
    
    
17. Templeman CL, Cook V, Goldsmith LJ, Powell J, Hertweck SP. Postpartum contraceptive use among adolescent mothers. Obstetrics and Gynecology 2000;95(5):770–776.
    
    
18. Stevens-Simon C, Kelly L, Singer D. Preventing repeat adolescent pregnancies with early adoption of the contraceptive implant. Family Planning Perspectives 1999;31(2):56–63.
    
    
19. American College of Obstetricians and Gynecologists (ACOG). Breastfeeding: Maternal and Infant Aspects (ACOG educational bulletin number 258, July 2000). Compendium of Selected Publications. Washington, DC: ACOG; 2005:210–225.
    
    
20. World Health Organization (WHO). Postpartum Care of the Mother and Newborn: A Practical Guide. Geneva: WHO Division of Reproductive Health, Maternal and Newborn Health/Safe Motherhood Unit; 1998.
    
    
21. U.S. Department of Health and Human Services. Healthy People 2010: Understanding and Improving Health. 2nd Edition. Washington, DC: U.S. Government Printing Office; 2000.

 

Prevalence of Postpartum Contraceptive Use, 2002

State	Respondents	Percent†	Standard Error	95% CI‡
Alabama	1,551	87.7	1.0	85.5–89.6
Alaska	1,613	80.2	1.1	77.9–82.4
Arkansas	1,961	88.9	1.0	86.8–90.6
Colorado	2,258	86.4	0.9	84.4–88.1
Florida	1,994	84.0	1.2	81.6–86.2
Hawaii	1,798	76.1	1.2	73.6–78.4
Illinois	1,913	85.3	0.9	83.5–86.9
Louisiana	1,690	84.6	1.0	82.5–86.4
Maine	1,134	87.6	1.1	85.3–89.6
Maryland	1,452	82.2	1.5	79.1–84.9
Michigan	1,532	85.4	1.0	83.2–87.3
Minnesotaa	1,132	81.6	1.5	78.5–84.2
Montana	1,037	87.6	1.0	85.4–89.5
Nebraska	1,882	84.7	1.0	82.7–86.6
New Jerseyb	941	78.6	1.6	75.4–81.5
New Mexico	1,550	88.2	0.9	86.3–89.7
New Yorkc	1,212	84.3	1.3	81.5–86.7
North Carolina	1,538	87.9	1.0	85.7–89.7
North Dakota	902	86.2	1.1	83.8–88.3
Ohio	1,364	87.7	1.2	85.2–89.8
Oklahoma	1,859	85.1	1.3	82.4–87.5
Rhode Island	1,399	83.7	1.2	81.3–85.9
South Carolina	1,375	87.6	1.4	84.5–90.2
Utah	1,561	86.1	1.1	83.7–88.2
Vermont	1,104	88.2	0.9	86.2–89.9
Washington	1,514	84.6	1.3	81.8–87.1
West Virginia	1,690	88.2	1.1	85.9–90.2
All PRAMS states§	40,956	85.2	0.3	84.7–85.8
Note: Contraceptive use is defined as using any of the following birth control methods at time of survey: not having sex at certain times (rhythm) or using such birth control methods as the pill, Norplant®, shots (Depo-Provera® ), condoms, diaphragm, foam, IUD, tubal ligation, or vasectomy. † 2002 state range is 76.1–88.9%. ‡ Confidence interval. § Aggregate of the 27 PRAMS states. a Data represent Minnesota births from May–December 2002. b Data represent New Jersey births from July–December 2002. c Data exclude New York City.

 

Prevalence of Postpartum Contraceptive Use, 2002

 

Prevalence of Postpartum Contraceptive Use, 2000–2002

State	2000 (%)	2001 (%)	2002 (%)	P value for trend#
Alabama	88.5	90.1	87.7	0.597
Alaska	80.9	83.1	80.2	0.678
Arkansas	87.9	87.9	88.9	0.537
Colorado	87.7	88.3	86.4	0.317
Florida	85.8	83.7	84.0	0.306
Hawaii	77.9	78.6	76.1	0.249
Illinois	84.6	82.6	85.3	0.591
Louisiana	85.1	84.5	84.6	0.678
Maine	88.6	87.3	87.6	0.533
Maryland	—	82.8d	82.2	# #
Michigan	—	83.1e	85.4	# #
Minnesota	—	—	81.6a	# #
Montana	—	—	87.6	# #
Nebraska	86.2	84.2	84.7	0.288
New Jersey	—	—	78.6b	# #
New Mexico	86.9	84.6	88.2	0.313
New Yorkc	84.5	83.5	84.3	0.904
North Carolina	89.9	87.9	87.9	0.130
North Dakota	—	—	86.2	# #
Ohio	84.6	83.9	87.7	0.072
Oklahoma	85.4	85.9	85.1	0.895
Rhode Island	—	—	83.7	# #
South Carolina	87.1	87.5	87.6	0.763
Utah	88.4	88.8	86.1	0.143
Vermont	—f	86.9f	88.2	# #
Washington	88.8	86.8	84.6	0.014*
West Virginia	88.6	88.1	88.2	0.777
Note: Contraceptive use is defined as using any of the following birth control methods at time of survey: not having sex at certain times (rhythm) or using such birth control methods as the pill, Norplant®, shots (Depo-Provera® ), condoms, diaphragm, foam, IUD, tubal ligation, or vasectomy. # Based on a test for linear trend using logistic regression. * p value is less than 0.05. # # < 3 years of data available; test for linear trend not applicable. a Data represent Minnesota births from May–December 2002. b Data represent New Jersey births from July–December 2002. c Data exclude New York City. d Data represent Maryland births from February–December 2001. e Data represent Michigan births from July–December 2001. f Data represent Vermont births from October 2000–December 2001.