Chapter XII-Pregnancy Services

X. Preventing Unplanned Pregnancies

The caseworker's job is not done until every possible step is taken to ensure that the client will not be involved in another unplanned pregnancy. Helping the woman and her partner establish a pattern of responsible sexual behavior, when indicated, and educating them in the use of the most reliable forms of contraceptives that are available are two closely related tasks. Without reliable contraception, there is no pattern of responsible heterosexual behavior that is likely to be successful in avoiding pregnancy other than total abstinence. Without an educated choice and responsible use, even the most effective contraceptive could still produce failure.

A. Promoting Sexual Responsibility

In promoting greater sexual responsibility, there are several questions that the caseworker may choose to explore in an attempt to understand the client's situation and attitude.

1. Was a conscious decision for sexual involvement made? Often couples simply drift into intercourse with no conscious decision to do so. Some individuals who have sexual desires feel guilty about their thoughts. That guilt makes it impossible for them to accept personal sexual behavior. Some individuals are conditioned to feel that intercourse is wrong unless it is spontaneous. However, "being in love" is an acceptable crutch for entering into a sexual relationship. The client may need a better understanding of the meaning of both sex and love. (S)he may also need to develop self acceptance and personal responsibility for thinking about and planning for sexual relations.

2. Is there adequate knowledge of sexual psychology and physiology? Sex may need to be put in the proper perspective as one important way to express love, and not the way. Education about the facts of sexual anatomy and physiology paves the way for better use of contraception and responsible attitudes toward one's partner.

3. How much is known about contraception? Methods are important to know, but so is the fact that effective contraception is planned and consistently practiced. Is the client trying to use a method that requires more forethought than she can provide? Perhaps conditions in the home are not conducive to proper use of the chosen method (e.g., no bathroom or privacy). Difficulties in accepting contraception may result from problems in accepting the sexual relationship.

4. What is known about venereal disease? Facts about the dangers of contracting STD and HIV through sexual relations can help promote sexual responsibility. Choice of partner, failure to practice "safe sex", and delayed diagnosis are factors that can contribute to the likelihood of contracting sexually transmitted diseases.

5. Was vulnerability or exploitation an important factor in this unplanned pregnancy? Some women have a strong, or even compulsive, need to be liked and wanted. They may be trying to prove to themselves that they are desirable and sexually attractive females despite their poor self-image. Sexual expression may be used by these individuals to prove themselves. They may believe or are exploited into believing that economic security, status, and "love" can be gained through sexual surrender. Some women have been challenged to prove their love for their partner. Others wish to dominate a member of the opposite sex.

Sexual exploitation is being de-emphasized today by wider acceptance of a single standard of sexual morality. Equality in desires for sexual satisfaction and understanding and acceptance of sexuality as an integral and desirable part of one's total existence also decreases exploitation. Recognition of the dynamics of a relationship is key to responsible sexual behavior.

6. Did the unplanned pregnancy result because of differences in values and behavior? Both parents and young people are exposed to peer pressures and practices that are in conflict with values instilled by their parents.

Pressure to ignore values may result in emotional trauma and anxiety. A third alternative to either living with the anxiety or retreating from the discrepant behavior may be to look for ways to modify the values and to compromise on the behavior. Recognition of the reason for the anxiety that may have resulted in the unplanned pregnancy allows thoughtful changes to be initiated that are acceptable and less likely to produce stress.

7. What about achieving satisfaction from a sexual relationship? The conditions under which so many unplanned pregnancies come to be -- haste, secrecy, and pretense -- too often preclude the development of the happiness of sex in a meaningful personal relationship. The caseworker can help a client to recognize the value of meaningful personal relationship and to learn to expect and look for positive feelings from his/her spouse or partner.

B. Contraceptive Counseling

Knowledge of and access to reliable contraception is vital if unplanned pregnancies are to be prevented. There are three basic elements involved with contraceptive counseling: information and education, making referrals to resources for services, and counseling to assist the client to relate conception control to the unique circumstances of the client's life situation.

Effective contraceptive counseling begins with the caseworker. Not only must the caseworker be knowledgeable about birth control, sterilization, and common health problems, but (s)he must also be comfortable with his/her selfhood and sexuality. The caseworker must be willing to help the client learn that love is important, happiness is important, and children born to parents who want them is important. The caseworker also needs to be able to discuss sex and sexuality in the language the client understands. Translating neutral words for words a client understands may be a mutual learning process.

A multitude of barriers prevent successful contraception.

1. Contraceptive-related problems: these include a history of method-related side effects and complications, previous failures or discontinuation of use, ambivalence or fear of specific methods, opposition from sexual partner, and moral or religious objections. The caseworker may have the answers to the more commonly asked medical concerns, and may have to make referrals to a doctor or religious caseworker for other concerns.

2. Emotional and intellectual problems and needs: including low intelligence; a history of being exploited sexually; the need to have a child to gain status, feel more important, or have someone dependent on her; hostility toward parents; a history of hospitalization for mental illness; a desire to become pregnant or to impregnate a woman in hope that marriage will result; or an attitude of hopelessness or helplessness. A sensitive caseworker will help the client explore his or her motivations and problems in relation to his or her consistent and effective use of contraception.

3. Problems related to the lack of correct information: a lack of knowledge of contraceptive methods; confusion regarding the correct use of contraceptive methods; misconceptions regarding the menstrual cycle and the fertile period; and myths regarding the effects of various methods. Family Planning personnel at the county health department can supply factual information. When problems need more in-depth counseling, the client should be referred for Family Planning Services.

4. Overwhelming unresolved reality situations: economic crises; housing and employment problems; and severe interpersonal conflicts can overshadow an individual's concerns about birth control. Problems must be dealt with in order of priority to the client. Motivation to use contraceptive services often occurs only after the client realizes that the caseworker is helpful in resolving other more pressing problems.

Other barriers to effective contraceptive counseling include negative pressures from peers or relatives; accessibility of family planning services; communications problems; and the attitude of the agency or caseworker. The caseworker must assess these barriers and assist the client to work toward the goal of no more unplanned pregnancies.

As a final step in the counseling process, referral should be made to Family Planning resources for post-natal Family Planning services.