Fundamentals of Midwifery: A Textbook for Students (113 page)

discuss the meaning of family planning

explain the influences on women’s choices in relation to contraception

describe the methods of contraception available

recognise the need for sensitive and individualised information and advice.
Introduction
Midwives are in an ideal position to offer information and advice with regard to contraceptionand family planning, but often lack confidence to do so. Since ovulation can re-commence as early as 25 days post-delivery it is important that women have sound information about their contraceptive options particularly as these may be limited by the woman’s general health, breastfeeding or religious and cultural beliefs. Contraception can be a difficult topic to discuss for both women and midwives, but if it is approached with sensitivity the advice provided can empower women and allow them to make choices best suited to their individual needs.This chapter aims to provide an overview of contraception and family planning with guidance for further reading to support development of knowledge and understanding.
What is meant by ‘family planning’?
Contraception and family planning are often used by both healthcare professionals and laypeople interchangeably and are generally perceived to be used to define the prevention of
Fundamentals of Midwifery: A Textbook for Students
, First Edition. Edited by Louise Lewis.© 2015 John Wiley & Sons, Ltd. Published 2015 by John Wiley & Sons, Ltd. Companion website: www.wileyfundamentalseries.com/midwiferypregnancy or control over fertility. Whilst this perception has some truth within it, family plan- ning can have a much more literal meaning, i.e. a plan for the number and spacing of children within the family. This is an important issue when discussing contraception as some women may be put off discussing the prevention of pregnancy if they feel it is not placed in the context of future children. For some women religious or cultural beliefs may mean that contraception is not an option, but this does not mean they do not need advice about sex and fertility after childbirth. The National Institute for Health and Care Excellence (NICE) (2006) guidance on postnatal care states that contraception should be discussed within the first week following birth; however to fully meet women’s needs midwives should be responding to individual need and ensuring that women are fully informed about sex and sexuality, contraception and plans for further pregnancy.
Appropriate timing of advice
There is a strong association between transfer from hospital to community care and discussionabout contraception, but it is also provided on transfer from midwifery care to the health visitor or even left until the six week postnatal examination (Hall 2005). A review of the evidence by Hiller et al. (2002) failed to identify which timing is best. The hospital transfer appears to be the most common time, but this often means that it is rushed and women may feel overloaded with information as other health and safety advice is offered at the same time. Norris (2006) suggests that not only is information often rushed, it is also provided in an environment that offers very little privacy for such an intimate and personal discussion. She also recommends that privacy and confidentiality are of vital importance not least because some women may choose to use contraceptive measures in secret (Figure 12.1). Hall (2005) concurs with the importance of privacy and suggests that the principles of woman-centred care require that women should be asked if they want to discuss family planning and their wishes respected. This approach would give the opportunity for a discussion at a time which was best suited to the needs of the woman whether this is in the antenatal period, prior to postnatal transfer from hospital or on the com- munity. What is essential is that this is not a topic that is simply glossed over because midwives find it a difficult subject or not something that they see as a priority. Research suggests that
267Private

Topic should be raised in private as some women may not want anyone to know they are discussing it

The discussion needs to take place where it cannot be overheardIndividualised

Discussion should be woman centred

Assumptions about religion and culture should not be made

Consider issues such as perineal and casearean wound discomfortConfidential

Discussions and decisions must be confidential. However it should also be considered that they may wish their partner to be able to discuss some aspects of family planning or sexual health, as they may also have concerns or questions.

Priorities for family planning discussions.

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menstruation returns around 69 days following birth on average (Hall 2005) but some women may ovulate at around 25 days (Queenan 2004) so midwifery advice regarding contraception and family planning could be beneficial in preventing unwanted pregnancies.

Hall (2005) emphasises the need to approach any discussion about family planning and contra-

ception with sensitivity. It is important to discuss the resumption of sexual intimacy which may be affected by a range of issues. The most obvious influence is pain from any perineal or vaginal wall trauma and this is not necessarily related to the severity of the trauma; the pain from grazes and minor tears can be significant and have a lasting effect on the woman. Similarly caesarean section wounds can remain sore for some time following delivery and this, in addition to the fatigue associated with major surgery, can result in a delay in wanting to be sexually active. Simply having a new baby and the disruption in the previous routine will be both tiring and have a constraining effect on intimacy.

The impact of childbirth on sexual relationships is not only something experienced by women. Men who have witnessed the birth may feel reluctant to cause any pain or discomfort or may worry about the risk of further pregnancy particularly if there were problems during labour or the birth.

Both women and midwives need to be able to discuss these issues. It is helpful for women to know that it is safe to resume sex when they feel ready but that they should not feel pres- sured into it.

The increase in global travel and movement has resulted in most nations being culturally diverse

and it is therefore important that midwives have some understanding of the influence culture and religion can have on family planning and contraceptive choices. Equally, it is essential that assumptions are not made regarding an individual’s beliefs and as a consequence the advice and care provided not meeting an individual’s needs. Just because a woman identifies herself as being a member of a particular culture or religion does not mean that she agrees with all its associated beliefs. It is also true that many religions are sub-divided into groups that have dif- fering interpretations of the overall teachings. In relation to family planning and contraceptive advice there is a need to be sensitive to potential cultural and religious beliefs whilst at the same time treating each woman as a unique individual. Table 12.1 provides a generalised and brief overview of the mainstream religious attitudes to contraception based on a Canadian study by Srikanthan and Reid (2008). The key to providing culturally competent care is avoiding stereo- typical assumptions; recognising that all women do not necessarily share the same values and beliefs as their peers whether or not they describe themselves as having a particular cultural or religious background. For example, it may be important for some women to experience regular bleeding whilst using contraception whether or not they are adherents of those religions that value the monthly cycle.

As already emphasised all information and advice provided to women should be tailored to

their individual needs. As well as accounting for their cultural and/or religious preferences it is also important to consider the health issues that may impact on their options. In order to do

Mainstream religious attitudes to contraception

Christian: Roman Catholic

Contraception goes against the purpose of marriage.

Unnatural methods of contraception are banned – this includes barrier or chemical methods (i.e. condoms, diaphragms and spermicides).

Abstinence and the rhythm method can be used for birth spacing.

Christian: Eastern Orthodox

Strict adherents permit only abstinence.

More liberal adherents allow the use of contraception that does not destroy the products of conception (some IUDs and emergency contraception) for birth spacing.

Monthly menstruation may be valued; therefore some methods may not be acceptable on this basis.