How to Be Reasonably Sure The
Woman Is Not Pregnant
You can be reasonably sure the woman is not pregnant if she has no symptoms (see "History,"
below) or signs (see "Physical Exam," below) of pregnancy and she:
- Has not had intercourse since last normal menses, or
- Has been correctly and consistently using another reliable method, or
- Is within the first 7 days after normal menses, or
- Is within 4 weeks postpartum (for nonlactating women), or
- Is within the first 7 days postabortion, or
- Is fully breastfeeding, amenorrheic, and less than 6 months postpartum (see "Relying on Lactational Amenorrhea,"
below).
History or symptoms of pregnancy:
- Absent (or altered) menses,
- Nausea (with or without vomiting),
- Fatigue (persistent),
- Breast tenderness (and breast enlargement),
- Increased frequency of urination,
- Maternal perception of fetal movements (late symptom: at 16 to 20 weeks gestation).
Physical exam. Physical exam is seldom necessary except to rule out pregnancy of greater
than 6 weeks, when uterine enlargement begins to be noticeable. Later (around 18 weeks), the fetal heartbeat can be
heard with a stethoscope, and fetal movements can be perceived by the examiner.
Laboratory tests. In certain settings, pregnancy tests are not very helpful or practical because
highly sensitive tests (positive about 10 days after conception) are not usually affordable. However, in cases where the
possibility of pregnancy is difficult to rule out, a highly sensitive pregnancy test may be helpful, if it is readily
available and not too expensive and if it is part of routine clinic practice.
Relying on lactational amenorrhea method. The lactational
amenorrhea method (LAM) is a highly effective method of contraception
(98% protection during the first 6 months postpartum in women who are
fully or nearly fully breastfeeding* and amenorrheic) (156, 157, 159).
The effectiveness of LAM in the second 6 months postpartum is under study
(159). (See Question 2, Lactational
Amenorrhea Method.)
A service provider can be reasonably sure that a woman is not pregnant if she is still amenorrheic, within the first 6
months postpartum, fully or nearly fully breastfeeding,* and has no clinical symptoms of pregnancy. When an accurate
pregnancy test is not easily available or affordable, and a woman more than 6 months postpartum requests an IUD,** or
Norplant implants, or injectables, you can still be reasonably sure she is not pregnant if the woman has kept her
breastfeeding frequency high,*** and she is still amenorrheic.
It should be noted that bleeding in the first 8 weeks (56 days) postpartum is not considered "menstrual" bleeding in
breastfeeding women (22, 156, 157, 159).
* "Fully" breastfeeding includes exclusive or almost exclusive breastfeeding (only occasional tastes of foods or water)
day and night. "Nearly fully" breastfeeding means that supplemental feedings are given but comprise a minimal part
of the infant's diet.
** It is more important to rule out pregnancy before inserting an IUD than before starting hormonal methods because of
the risk of septic miscarriage with the IUD.
*** A woman who breastfeeds 10 times per day or more or who gives more than 80% of her infant's meals as
breastfeeds is at less risk of being fertile. Breastfeeding before giving each supplement is optimal.
