This article examines the rationales for commonly advocated postpartum family planning services and challenges the behavioral and biological assumptions on which they are based. An alternative approach to service delivery is suggested. Services should be designed to incorporate breastfeeding and to increase their acceptability to postpartum women.
PIP: Postpartum is considered conceptually muddy, since the definition varies with its use, even within family planning programs; the context within this article is after childbirth. Postpartum programs to provide contraceptive information and supplies after childbirth are an accepted part of family planning service delivery. The objective of this article is to review the underpinnings of the postpartum service delivery model. Demographic implications are discussed based on empirical and simulation studies; the assumptions that women are most receptive to contraceptive programs at the time of childbirth, and that women will not generally return for services are discussed in terms of descriptions of women's contraceptive behavior in the postpartum period (survey and program information). Another objective is to discuss recent findings on the effects of breastfeeding on fertility and the implications for postpartum programs. A reexamination of women's needs is suggested. Studies discussed in the demographic implications sections pertain to postpartum ovulation and menstruation, the use of oral contraceptives during lactational amenorrhea, and studies of the duplication of protection. Various simulation models of the timing of postpartum contraceptive use are described, but none deals with whether women are more motivated to practice contraception just after childbirth, or whether women find it difficult to return for services after leaving a health facility. Attitudinal data are missing and are needed on postpartum motivation to contracept. Initiation after a recent birth may be based on her amenorrheic and breastfeeding status, the infant's developmental level, household or extra household activities, or the appropriate age at which the child may be left with others. The scarce data on the timing of contraceptive use indicates that women not menstruating were less likely to use contraception. The 1987 Thailand survey showed that 14% of women returned to nonpermanent methods prior to the return of menses, and 32% in the month immediately after the return of menses. This pattern may reflect the practices of family planning providers. Multivariate analyses support the inverse relationship between breastfeeding and use of contraception. In the returning to services issue, models do not tell whether availability of full services for well baby care and postpartum and contraceptive care would improve returns. The International Postpartum Program reveals some patterns. Future research agendas should focus on experiments to test different options for mother and baby care, and to test options and timing of their initiation.