When the delivery is known to have been traumatic in physical terms, when the baby is not thriving or has died, or when an abnormal baby has been born, a particularly sensitive approach to discussion of contraception will be needed. The woman’s pain and distress or anger at what has happened may be hard for the family planning adviser to bear, and it may be tempting to avoid counselling such a woman with the excuse that she needs help in coping with her misfortune rather than consideration of her sexual activity in the future. And yet, these are often the women who need the most help, for to treat them differently may only increase their feelings of isolation and abnormality. They may have considerable anxieties about when to embark on a pregnancy again, and even at the height of their grief they may be looking forward in their mind. Time needs to be spent in allowing the woman to share her grief, while acknowledging with her that her need for comfort and closeness with her partner could lead to sexual activity. She may need encouragement to allow herself to consider sexual pleasure, especially where there are feelings of guilt or blame. Time spent exploring her anxieties at this stage may allow natural healing to begin to take place.
*164/197/1*
Mrs P. was seen initially in a psychosexual clinic following the birth of her first child who suffered from osteogenesis imperfecta (brittle bone disease). Intercourse was extremely painful. She was unable to gain any insight into how angry she was with the doctors for not diagnosing the problem correctly so that some fractures occurred during the baby’s delivery, but she was also angry with her husband for possibly causing some fractures when he lay on her having intercourse.
The previous fun of lovemaking had led to a wanted pregnancy, but it had caused so much pain now for her and her baby. How could she possibly enjoy it again? She did not want any more children and therefore there was no need for intercourse. She decided not to attend for further help with the psychosexual problem because of lack of progress.
Three years later she appeared at the infertility clinic having decided herself, a year before, that the time was right for another baby. She looked surprised when the doctor asked if she was enjoying lovemaking again, as though that painful time had not existed.
The power of time to heal both pain and anger can sometimes be surprising, and doctors have to accept that they will often never know if the work they have done with a patient has played any part in the healing process.
*127/197/1*
Bearing in mind all the above difficulties, there are three major components to be considered in counselling a woman with an unplanned pregnancy, not necessarily in this order.
Giving accurate information about the options, procedures and relative risks so that the woman can make an informed decision. Despite the fact that abortion is a commonly carried out surgical procedure, it is often not openly discussed. A woman with an unplanned pregnancy may set out with very little accurate knowledge of her options. Much of the information available may be produced by radical pro- or anti-abortion groups carrying strongly emotional overtones. It is important that the woman receives accurate information before making a decision.
Allowing the woman the opportunity to explore her feelings about this pregnancy in particular and her fertility in general.
Helping the woman reach an understanding as to why she fell pregnant at this particular time. Sometimes this is related to a simple contraceptive failure or mistake (Hutchinson, 1992). She may need help in finding a suitable method of contraception and be given proper instructions as to how to use it. Sometimes the reason for the present pregnancy is more complex, to do with the woman’s emotional problems and attitudes to her sexuality. These may need to be understood before she can make use of any contraception offered. She may occasionally need further help from other agencies such as Social Services or psychotherapy.
*90/197/1*
An 18-year-old girl attended a clinic two hours away from her home. A new doctor expressed surprise at the distance she had travelled, noting that she had been attending for four years. ‘I like coming here,’ the girl said. ‘I know I could go to a nearer clinic, but I first came here in a state, needing the ‘morning-after’ pill.’
Her first experience was good, and she found the staff kind and friendly. At that time she had been worried on two counts, the risk of pregnancy and the risks of the Pill. Her mother had frightened her with myths about the Pill causing breast and cervical cancer. She felt that at the clinic her anxieties had been given credence and replaced by information. Four years on she is a happy Pill user who prefers to return for her contraceptive care to the clinic where her first experience, in a crisis, was good. This girl, only 14 years at the time of her first attendance, had achieved a considerable degree of emotional maturity, being able to take responsibility into her own hands and finding the first contraceptive consultation all that she had hoped for.
*53/197/1*
The case of Mrs D. shows how inevitable and necessary it is for the doctor to become ‘entangled’ in the patient’s problem, allowing herself to feel in response to the patient, as this provides valuable clues to what is really going on in the patient’s mind. The doctor must be aware of what she herself feels in order to be able to use the feelings to help the patient to understand herself. In this case the contradictory feelings in the doctor, of being a warm supportive mother and yet also a destructive baby-hater, accurately mirrored the patient’s conflict in relation to her mother and babies.
*16/197/1*
