In South Africas public sector maternity services, injectable progestogen-only contraceptives
(POCs) have been typically administered immediately after delivery to women choosing to use these methods. POCs are hormonal methods, which contain a progestogen similar to the natural hormone that a womans body makes. POCs have been approved as a safe and
effective contraceptive method by major international regulatory bodies such as the Federal Drug Administration (FDA) of USA, and the International Planned Parenthood Federation (IPPF) as well as locally, by the South African Medicine Control Council. In South Africa,
POCs are on the Essential Drug List for Primary Health Care. This has become a popular contraceptive method amongst many women all over the world, in particular in South Africa, where it comprises 49% of current method use.
A series of studies arose in response to the draft South African National Contraceptive Guidelines (1999), which recommended that women be advised to delay use of POCs until six weeks postpartum. This recommendation followed the international guidelines of the WHO and the IPPF, which were based on theoretical concerns that the early transfer of small amounts of hormones to the infant through breastmilk, may affect its growth development.
The studies sought to investigate the feasibility of recommending this delay in POC administration, taking into account both the mothers risk of pregnancy in the early postpartum
period and her ability to return to a health service at six weeks post-delivery, to initiate a method of contraception.
Studies were conducted in 2000 in Gugulethu, which is an urban area in Cape Town and in 2001, in Stellenbosch in the rural Western Cape. A further need arose to investigate and
explore these issues in an area where conditions would be different to the Western Cape.
Hence, a similar study was conducted in a rural area of the Eastern Cape. A site where the Health Systems Trust, active as the Initiative for Sub-District Support (ISDS) was chosen as a
For the purpose of this research we undertook an extensive literature review of the effects of the use of POCs on breastfed infants in the postpartum period. This literature review did not find any scientific evidence to support possible adverse effects on the infant.
In addition, a quantitative survey was conducted amongst 346 women attending the child health clinic (CHC) and amongst 346 women attending the antenatal clinic (ANC) at St
Patricks Hospital, in Bizana in the Eastern Cape. The women were interviewed to determine
contraceptive knowledge and contraceptive use, practices concerning contraceptive use pregnancy risk in the early postpartum period knowledge of the time they are likely to become pregnant, the feasibility of delaying POC initiation access to contraceptive services with regards to time, transport and costs and breastfeeding practices and patterns of sexual
activity in the postpartum period.
The results of the survey were as follows: Most women were able to access health services without difficulty. Contraceptive use was low, at 29%. Six percent of women may be at risk of
becoming pregnant, as they were not exclusively breastfeeding and were sexually active within the first six weeks, postpartum. Seventy-eight percent and 75% at the CHC and ANC
respectively, lacked good knowledge about the time they were most fertile. Most women did not regard exclusive breastfeeding as a reliable method of contraception (40% and 47%, at
the CHC and ANC respectively).
Disturbingly, nearly 20% of the women experienced difficulties if they refused sexual intercourse with their husbands or partners.
A workshop was held with stakeholders (Health Systems Trust and health service providers) in February 2003. The purpose of the workshop was to report on the findings in order to make
recommendations regarding ways in which to improve the quality of contraceptive and other reproductive health services provided. This final report has been written on the basis of the study findings as well as feedback during this workshop.
The National Contraceptive Policy Guidelines, published subsequent to this study, have been amended from the original draft and recommend that women be given a choice about the timing of post-partum POC initiation, after appropriate counselling. Arising from this study, it is further recommended that effective implementation of the guidelines require that providers
counsel women appropriately about the theoretical risks of immediate post-delivery POC initiation and assist women in their assessments of postpartum pregnancy risk (i.e. their
intentions regarding and ability to negotiate resumption of sexual relations their ability to use
barrier method contraceptives the feasibility of exclusive breastfeeding for at least six weeks post-delivery and the feasibility of visiting a clinic six weeks postpartum to initiate a contraceptive method). POCs should be available immediately after delivery for women who choose not to delay initiation of sexual activity or for those who have no choice in delaying
sexual activity. The provision of adequate information will assist women in making informed choices with respect to their reproductive health.