Seeking Synchrony Between Family Planning and Immunization: A Week-10 DMPA Start Option for Breastfeeding Mothers

The singlemost popular moment in Africa (andmany other regions) to initiate family planning may well be the 6-week postpartum clinic visit, when mothers also bring infants to begin the crucial primary immunization series. A 6-week start does indeed work well for mothers accepting long-acting, reversible contraceptives (LARCs) such as implants and intrauterine devices (IUDs), because thesemethods have no negative impacts on breastfeeding and, once inserted, remain effective for years. However, although there are no medical restrictions on starting injectables at 6 weeks, the 6-week postpartum visit may not be the optimal timing for initiating injectables, the most popular method in sub-Saharan Africa, comprising nearly half of modern method use in the region. What is the potential downside of initiating depotmedroxyprogesterone acetate (DMPA) injectables at 6 weeks? Beyond the redundant use of contraceptives during lactational infertility is the problem of high discontinuation. In a review of Demographic and Health Survey (DHS) data from 19 countries, Ali et al. noted that more than 40% of new injectable clients discontinued within the first year of use. When such early discontinuation occurs among postpartum women— during the time infants are weaned and fertility is reestablished—the stakes are even higher, because these mothers need effective contraception for optimal birth spacing. Although high injectable discontinuation has proven a particularly challenging problem to solve, several partial solutions present themselves for better protection during the first postpartum year. For example, more intensive counseling, particularly on the side effects that users can expect, has been shown to increase continuation rates among injectable users. Also, for the many women who use DMPA because more effective methods are not available, programs must continue to improve access to LARCs, particularly in rural areas where the poorest and most vulnerable live. Finally, we should do a better job promoting exclusive breastfeeding during the first 6 months postpartum and ensuring that those using the Lactational Amenorrhea Method (LAM) can smoothly transition to another effective method when desired. There is another option that merits investigation. Fully or nearly fully breastfeeding mothers desiring the most popular injectable, DMPA, at 6 weeks could be offered the option of delaying their injection for 1 month, until the second visit of the scheduled 6-, 10-, and 14-week primary immunization series. Week-10 DMPA initiation has much to recommend it. For example, given existing discontinuation patterns, the delayed start time will translate into a delayed discontinuation time, meaning that mothers will have an extra month of contraceptive protection, more likely to fall at a time without redundant protection from lactational infertility. Furthermore, well-counseled clients who want to limit births or who want a highly effective spacing methodwill have an extramonth to consider their family planning options and to discuss these options with their providers and partners. Upon return, they may be more likely to accept a more effective method and/or one with less chance of early discontinuation. Finally, when DMPA initiation is delayed until the second well-baby visit at 10 weeks, mothers benefit from better synchronization of clinic visits during the first year postpartum.