Issues relating to the control of fertility are widely related to women’s health needs on a global scale. Midwives are in a strong position to promote and educate women and their partners. It has been shown that increased education of women about contraception in the postnatal period will lead to increased use (Gebreselassie et al 2008). Contraceptive use is higher in more developed countries (DESA 2003), where 69% of women aged 15–49 in relationships take precautions. According to the World Health Organization, about 80 million women every year have unintended or unwanted pregnancies (Department for International Development (DFID) 2004), and some of these are due to contraceptive failure.

The activities of a midwife include providing ‘sound family planning information and advice’ (NMC 2004). This means that students should have an opportunity to learn about contraception and how to give advice to women and their partners during their programmes. In order to understand the principles of fertility control, midwives should have knowledge of the menstrual cycle and a thorough understanding of the physiology applied to the postnatal period.

The provision of fertility control advice has often been limited to a few moments prior to transfer from hospital to community or from community midwife to health visitor, or left until the postnatal examination by the general practitioner (GP) at six weeks. There is little evidence available to identify which timing is best (Hiller et al 2002). Presenting advice during the antenatal period does not appear to have a long-term effect (Smith et al 2002), though it has been recommended that discussion is started in the antenatal period to prevent causing offence in relation to religious or cultural beliefs (Schott & Henley 1996), or to ensure that the information given is retained and discussed effectively (Glasier et al 1996). However, it appears that the majority of advice is given by midwives on postnatal wards (Glasier et al 1996), with the suggestion that, as many births are unplanned, midwives should use every opportunity for health promotion purposes (Towse 2004). Current research indicates that the average time for the return of menstruation is 69 days (9 weeks), but a significant number of women will have started to menstruate before this time (Moran et al 1994).

Ovulation can return around 25 days following birth (Queenan 2004), which suggests that the current practice of giving advice early may be beneficial in preventing some unwanted pregnancies. The National Collaborating Centre for Primary Care (2006) state that fertility control advice should be given within the first seven days following birth. However, principles of woman-centred care suggest that women should be asked if they wish to discuss the provision of contraception, and their wishes should be respected if they decline at any time.

Clearly, privacy is required when giving such advice, and it should be remembered that this is not provided by curtains around beds in wards! The discussion should not be rushed as the woman should have the opportunity to assimilate and understand the information that is being given. She should also be offered the chance to ask questions and discuss any anxieties she may have. The use of information leaflets to support the advice given will assist the woman in making the decision that is right for her and her circumstances.

Recognition should be given to sensitivity surrounding the discussion of contraception after childbirth. There is evidence to suggest that the resumption of sexual behaviour following the birth of the baby may be influenced by a number of factors. For example, pain of any kind may have a negative effect on the woman’s sexual desires; and the experience of birth may have resulted in tears, stitches or grazes in the vagina or perineum that will be painful (Bancroft 1995:348, Demyttenaere et al 1995). Caesarean section wounds will also be uncomfortable for a while, and the woman may not want to consider full penetrative intercourse for some time. Women may also dislike having their breasts touched due to their soreness and sensitivity (Hall 1997). In addition, some men may be put off by the production of milk for the baby, which may leak during foreplay (Bear & Tigges 1993).

Increased fatigue in the postnatal period and getting used to having a new baby in a bedroom may have an effect on parents’ desires for sex. Further, there is evidence to suggest that some men have been traumatized by watching their partner in labour, and this can give them concerns about making their partner pregnant again (O’Driscoll 1994, Kitzinger 2001). Depressive illness in the woman or partner will also have a negative effect on the sexual relationship.

Some of these issues may be raised during postnatal discussion, and the midwife should be prepared to answer any questions the woman or couple may have regarding sex following birth. Advice may be given about finding alternatives to penetrative intercourse or positions where the woman may feel more comfortable. Discussion regarding timing of sex after birth will be helpful to reassure women that it is safe to resume sex when they are ready. At no time should they feel pressured into resuming sex within a certain period of time.

It is important that issues regarding sex and contraception should be raised with all women, regardless of whether they are in a stable relationship or not or whether the infant had been planned or not. Fertility control methods should be discussed with all groups of women, including teenagers (Department of Health 2003, NICE 2008). (For further information on discussing contraceptive methods with teenagers, also see Department of Health 2004.)

In order for a woman to make the right choice regarding contraception after birth, she needs to have an understanding of all the methods available. Box 9.1 indicates the ideal characteristics of a method of contraception.

Currently available methods do not fit all these characteristics. There is evidence to suggest that a woman will often change her method of contraception after childbirth (Cwiak et al 2004). It is likely that a midwife or student may be asked about the different methods, and should give advice accordingly. The different methods fall into the categories of barrier methods, non-barrier methods and physiologic. For a comparison between the different methods and their use following birth, see Table 9.1.