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the social services", the poor clinic attender. For the health visitor the introduction of discussions about birth
control is comparatively easy. This is usually done at the first or second visit after a confinement. The
importance of a 'good' referral cannot be overestimated—the purpose of family planning and the domiciliary
service should be offered in a constructive way and the woman's consent is essential before referral is made, so
that the visit from the doctor is not seen as threatening or frightening. When this has not been properly done the
woman may refuse to open the door.
Health visitors have recently had the opportunity to update their knowledge about contraception through the
Health Visitors Appreciation Courses run by the Family Planning Association, sponsored by the Department of
Health and Social Security. Hospital staff may find it more difficult to recognise the woman in need as they may
only see her in her best nightdress in a hospital bed.
The task of referral is more difficult for the social worker which may perhaps account for the few referrals from
them despite the fact that many have 50 or more families to cope with—a large proportion being families with
young children. Social workers have to create an opening where contraception can be discussed—they do not
have the ready made situation of the health visitor of the visit after confinement. The social worker may feel
unsure of himself because of lack of medical knowledge about contraception and may therefore feel it is not
his place to discuss it. As there is as yet practically no information given about contraception in courses for
social studies it is perhaps not surprising that many social workers feel ill at ease with the subject and fear they
might be intruding or pushing their own views on a person who does not want it. It is unfortunate that
contraception may be seen as incidental rather than central to a family's problems—for instance, the family with
a history of a "battered child" is in urgent need of contraceptive advice; a woman who cannot cope with 4 or
5 children is unlikely to cope with 6 or 7.
Having worked in Haringey for five years doing domiciliary work and three years before that working as parttime
medical officer I am aware of and appreciate the many problems and large caseloads facing the social
services and of the turnover in staff and of junior and inexperienced staff; nevertheless, it was disconcerting to
find that two assistant social workers who attend the Haringey Health Visitors' Appreciation Course in February
1973 did not know of the existence of the domiciliary service or the times and places of the local family planning
clinics. The social worker (especially now that the importance of community medicine is increasingly recognised)
is in a vital position with regard to a family to deal with marital and sexual problems and related contraceptive
difficulties.
Once a woman has been referred, and after the consent of the GP has been obtained, the doctor usually makes
the initial visit in which the methods of birth control are discussed together with their limitations and side effects
including the risk of thrombosis with the pill. This is essential if there is to be trust between doctor and patient
because of the adverse publicity surrounding the pill. Providing there are no medical contraindications, the
choice is left with the woman and this is crucial to successful family planning. The woman has the doctor's and
nurse's home telephone number and can contact them if they are worried or have a query. It is found in
practice that only a few use this facility, and these tend to be individuals who have a variety of problems with
which they cannot get other help. The nurse follows up the initial visit by frequent regular visits if the woman
chooses the pill. Women choosing the pill will rarely transfer to clinics, perhaps because they need the
reassurance of a doctor or nurses' visits. The woman.selecting the IUD will often go for check visits to the IUD
clinic, finding confidence after making the initial visit with a nurse. G.P.'s and the referring agent are notified
about the method selected.
What is the role of the domiciliary service?
Originally this was to give contraceptive advice and supplies and to give support to the women to persevere
with the method. However, as a result of its unique position several other roles have evolved. Domiciliary family
planning is essentially social and preventive medicine combining many skills. It stands between health and social
welfare and shares much in common with public health and social services. As mentioned before it acts as a
pregnancy advisory service. Another function is to help with marital and sexual problems and also in some
cases advising about the upbringing of children. Many of the families visited have marital and sexual problems
that they have been reluctant to discuss with anyone else. One woman said just as I was leaving "You might
think I'm a sex maniac having had 6 kids but will the pill help me to enjoy it, my husband says I'm frigid".
There is often concern about the sexual development of children and what to say about sex to children. Like
the patient who regularly visits her doctor with minor ills or for repeat prescriptions, some of the women seen
by the domiciliary service seem to be "contained" by being able to "off load" their worries and anxieties at
routine regular visits, and perhaps this is why women who have managed to make such a relationship with the
doctor or nurse are reluctant to be transferred subsequently to a clinic. It could be argued that this is creating a
form ef dependence but it may well prevent the woman from troubling her GP or the social services unnecessarily.
As mentioned in previous reports there is difficulty in referring such cases to the social services which because of
the large caseloads cannot always undertake preventive work.
Another vital function of the domiciliary service is to liaise with the GP, Hospital, Social Worker etc. That this
is so often necessary may be a reflection on the lack of communication between these groups.
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