At this stage the family planning adviser is often seen as an intruder and rarely as the one with whom the patient can share her anxieties about the delivery or her concerns for the future. Nevertheless, some information about when it is considered safe to resume sexual intercourse, where to obtain contraception and how to use it is obviously desirable, if only to be referred to when the woman herself feels ready to consider sexual matters. Verbal information will need to be backed up by written information in the form of leaflets, and supplies of condoms may be given. If contraceptive pills are prescribed then written instructions on when and how to begin must be included, as much that is said during those first few days is probably not taken in or not remembered, and the woman’s preoccupation with other matters needs to be respected.
*163/197/1*
Mrs S. was desperate for a second child when she first arrived at the clinic. Her first child was conceived easily and was now about to start school. She had developed polycystic ovarian disease and was grossly overweight. A regime of ovulation induction was carried out successfully for six months but no pregnancy was achieved. The doctor was wondering how she could manage the next visit because she knew that Mrs S. could not afford an assisted conception programme. She need not have worried. Mrs S. hurried into the clinic saying that she had made up her own mind. ‘I’ve finished grieving for the baby that has not happened,’ she said. ‘I want to live my own life for a while. I’m starting a job next week.’ She had been through a lot of heartache, seeing friends and relatives with babies, but she had managed to lose some weight and with the help of the clinic staff she had been able to make her own choices.
Mrs S. had continuous support throughout her treatment in an environment where she had been encouraged to make her own decisions, including whether or not to have treatment, and when to stop. Others need more than this, especially when there is the added problem of mental or physical disability in the first baby. It is not just the obvious problem of managing to cope with another child at home, but consideration of whether there is a likelihood of the next baby having the same problem. Genetic advice must be sought, and discussions with a counsellor and perhaps self-help groups should be offered. Much of the personal assessment for the two individuals concerned is to do with how much fault they attribute to themselves for the disability in the child.
*126/197/1*
Miss F. was a West Indian aged 25. The decision for abortion had initially seemed straightforward. She intended to go to college later that year and a baby would prevent this. On the pre-operative round the doctor usually asks the patient if she is still sure about going ahead with the procedure. To her surprise this patient replied, ‘No, I’m not.’ It was suggested that she should not go ahead that day but make another appointment to see the doctor in the outpatient clinic. The nursing staff seemed pleased – a baby saved and a woman rescued in the nick of time (Potts er a/., 1977). Miss F. came back the next week. She had changed her mind because she had talked to her boyfriend who wanted her to have the baby and had made her feel guilty about having an abortion. However, he was unreliable, beat her up sometimes and was unlikely to modify his own life on the arrival of a baby. College was her chance to get away and make something of herself. She had her abortion the following week.
This woman changed her mind about abortion out of guilt rather than desire to have a baby. The guilt came from her boyfriend who seemed keen to keep her dependent on him. There were also cultural pressures as in her community it was more usual for girls to have babies than to go to college. She wanted to do something for herself and having a baby might have jeopardized her chances. Yet it would have been easy to believe at first that continuing the pregnancy would have been a good outcome.
*89/197/1*
Despite the wide variation in sexual and emotional maturity mentioned above, the majority of young people, who are in the throes of separation from parental dependence and embarking on a sexual life of their own, are doing so at a chronological age that lies within the normal limits for the society in which they live. Contact with doctors at this age is rare, so that even without its sexual connotation, the appointment with the doctor is special to the patient. Confidentiality is of paramount importance. Whoever is the first contact, be it a nurse, doctor or social worker (in those few clinics where one is available), a tone needs to be set which will allow the individual time to express needs and wishes. Each patient should be able to sense that this very important step in their life is being treated in confidence, as well as with respect and understanding.
*52/197/1*
Mrs D. aged 21 years had produced four children in as many years. She was a loving mother but exhausted. She seemed set to follow her mother’s pattern of having 14 children. Several of these children, including herself, had been in the care of the local authority from time to time, a fact that Mrs D. sometimes remembered and sometimes seemed to choose to forget. She decided to try the intrauterine device but it became increasingly evident with each meeting that a tremendous struggle was going on inside her as shown by her complaints about contraception and her feelings about the doctor (female) which were sometimes hostile and sometimes friendly. On the latter occasions she would express great interest and curiosity in family planning work. The doctor then felt like a warm supportive mother. When Mrs D. was hostile, the doctor felt like a baby-hater out to prevent Mrs D. and all other women from having all the babies she and they longed to have.
At one visit, Mrs D. yet again voiced her anxiety about the harm that the intrauterine device was doing to her insides. The doctor decided to take the bull by the horns and told her about the way she made her feel and wondered if this reflected the way she was feeling. Mrs D. then began talking about her mother who made her feel that having babies was a normal, natural thing to do and that they should not be prevented. However, she also knew that her mother had found it very difficult to look after all her children (though this was usually blamed on their father). Admitting all this made her feel she was being critical of her mother and she hated doing it. The doctor said she did not have to be like or unlike her mother, she could be herself. They agreed that it was obvious that she loved her children but knew she did not have endless patience or energy, and that what could be managed with four children could not be with 14. This seemed to free her in some way and there were no further complaints with the coil.
*15/197/1*