Having trained in obstetrics and gynaecology, I made the decision to move into sexual health around 18 years ago. My boss in sexual health at the time (a formidable force of nature who thought nothing of asking me if my fourth pregnancy had been planned!) was also a woman who had no tolerance of fools but advocated for those who she felt had no voice. At one of our first clinics, we were discussing contraceptive options. She gave me a phrase which I have stolen and used repeatedly when teaching others. “If she doesn’t choose it, she won’t use it”.
Whilst my approach to managing patients (and my trainees) is very different from hers, the mantra of patient choice remains paramount to good practice and central to healthcare today. Clinicians are not the experts on what is best for women. Women know what is best for them. As professionals we may feel that long-acting contraception (LARC) is best for a woman who has had unplanned pregnancies, terminations, had children removed or is at risk of any or all of these. As professionals, we have the evidence of the efficacy of these methods which work better because they do not rely on humans remembering to use them. The woman in front of us, however, is the one who will be using the method. We can support her in her decision making by discussing what is available and the pros and cons of each method. At the end of this information-giving however, it must be her choice.
Although highly effective, LARC have side effects, most commonly unpredictable bleeding. Whilst this may be acceptable to some women in exchange for the removal of anxiety over risk of pregnancy and worry about having to remember to use contraception, for others it is not acceptable. ‘Control freaks’, like myself, want to know when bleeding is to be expected and are happy to swallow a pill daily for years to manage this. We also need to remember that use of LARC involves needles or examinations for insertion which may be traumatic to some women especially those who have injected substances in the past or have been sexually assaulted or raped.
In order to even try to achieve gender equality, women must be able to control their fertility. They need to be empowered to do that. Doctors and nurses pushing one method or another to the extent that the woman feels pressured to accept it in order to ‘please’ the healthcare staff are doing themselves and their patients an injustice. The decision as to which method of contraception to use is not for the clinical staff to make, except to advise against a method which is medically unsafe for the woman. Even if staff feel one method is not ideal and that others would be better, they must not be judgemental.
Worse still, and appalling that it should even be countenanced, is conditional healthcare where women are required to use a LARC method of contraception in order to receive support and care. Women, who have complex needs, who have suffered traumas, abuse, adverse childhood experiences and/or violence deserve to be cared for and not coerced (again). They need to be respected, allowed to move at their own pace and to state what their needs are. Empowerment comes through giving that decision-making to the woman, and then sitting alongside her on a journey to a better place. It may be a slow journey - stopping first at housing, benefits rights, access to children, harm reduction in relation to alcohol, substances or prostitution, safety planning in situations of violence. Throughout the journey, the woman keeps control of where it is going. Not the doctor or nurse or social worker but the woman who is living her life. All women are worthy of this type of holistic care. Health cannot provide for all needs, so joint working with third sector agencies who specialise in this is essential. Clinical staff need to reach beyond health and communicate with those who can help with social issues. Supporting and empowering women in this way ultimately leads to positive choices, which includes planning pregnancies and contraceptive use.
For the past 12 years, I have managed a service for women who have complex needs and have to cope daily with the stuff of other women’s nightmares. The ethos of this service (WISHES – women inclusive sexual health extended service) is to keep the woman at the centre of everything we do. We work jointly with the ‘Another Way’ project from SACRO, Salvation Army and several other organisations to provide a harm reduction model of care to keep women as safe as possible. Small acts of kindness such as empowering women to have choices mean a huge amount. One woman giving feedback on the service said
This was a huge turning point for her. She had a choice and she was given permission to make it. She was valued. It is her body and she is entitled to own it. We must not abuse this by forcing contraception on her, in order to make ourselves feel better!
Contraception is not just about effective use and efficiently avoiding pregnancy. It is not just about ‘choosing and using’ so that target figures for terminations or children taken into care are reached. It is an emotive issue related to choices, equality and empowerment. Doctors and nurses don’t always know what is best but they can learn, if they listen to the woman, how to use the skills they have to help her move to a safer, empowered life.
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