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Is the Domiciliary Service still needed?
In view of the fact that in 1974 birth control advice and supplies will be obtainable through the National Health
Service on a doctor's prescription, it may be wondered whether domiciliary visiting will still be necessary. It
seems likely that there will continue to be a group of women for whom contraception is a problem and who will
not go to get advice and even if they do will not persevere with a method. Given that there are many complex
emotional and social problems associated with the continued use of contraception then some couples will
continue to need more time than can reasonably be spent by a general practitioner. While several methods of
birth control certainly require medical aid, it is important to appreciate that this area of medicine differs in an
essential way from usual medical practice. Perhaps the most important difference is that the choice of method
(again provided there are no medical contraindications) should be left to the individual concerned. As
contraception is closely linked to attitudes towards sex and sexual relationships and since these attitudes vary
enormously (e.g. with different cultures and age groups) then acceptability to the couple is paramount—it is
not what the doctor thinks but what the couple feel would be the best methods. Thus while it may be simpler
for a doctor to write a prescription for the pill much more may be needed for couples with sexual and
emotional difficulties.
Haringey, in common with other London Boroughs, has a large immigrant population with different cultures
and differing attitudes to fertility and contraception, and this has to be taken into account when giving advice.
For instance a common view amongst West Indian women is that heavy menstruation is needed to clear our
"bad blood" and if this does not happen that this blood will go to the head and cause headaches. This might
explain why more West Indian women chose the IUD; they do not like the scanty periods that are usual with the
pill.
It also is relevant that one in seven babies born in Haringey is illegitimate. Of course the child may be the result
of a stable union. However, as seen from the report over ¼ of the women referred are single or divorced. There is
also a small but increasing number of unmarried mothers, mainly West Indian, who are in their early teens. As
noted in previous reports these girls are very vulnerable, their relationships are often tenuous and so they need
much support to persevere with contraception. This again may prove difficult for the general practitioner. Indeed,
though some women will certainly be prepared to ask their GP for advice, others, especially the unmarried may
be too embarrassed. In many cases the GP, health visitor or social worker will need to initiate discussions in a
tactful non-critical way—not as one obstetric registrar offered advice standing at the bottom of one patient's
bed by saying in front of 12 other women "As you're unmarried its about time you had birth control advice".
She left the hospital very angry..As she was known to the domiciliary service for sometime before this it was
possible to recover the situation. The registrar meant well but a tactful approach is essential.
Conclusions
1. Success is difficult to quantify in this work. Several years are needed before the overall outcome can be
assessed.
A description of two individual cases may convey this better than statistical tables—
Mrs. E. is an Irish woman (RC) in her late 20's who was referred to the service 5 years ago. She had had
severe Pre eclamptic toxinemia with her 7th child and was advised to be sterilised. Her husband afraid she
would die with an operation refused to sign the form. The couple had not previously used birth control. Just
prior to my arrival the "method" used was sleeping in separate rooms. She had an IUD fitted and she has not
become pregnant. She looks well and has been rehoused and her home is now clean and comfortable, her
children are all at school; she works part-time to help with the family's income and is taking driving lessons.
She says now that she wishes she had heard about us earlier.
Mrs. S. a 30 year old West Indian with 5 children under 7 years was referred by Homeless Families Unit
5 years ago. Her husband worked sporadically and they had many debts. He also had another woman. She
was fitted with an IUD and has not become pregnant. The marriage has been patched up though the
family still get into debt. With the children at school she is able to work part-time to help the family.
2. Social Services
Social Workers, particularly the younger ones, might perhaps be helped by occasional case discussions (with
special reference to family planning) with the domiciliary team.
3. Young people are subjected to many pressures nowadays and are urged to grow up quickly—some indeed
may speed this up by becoming pregnant in order to escape from an unhappy home situation. They need
help at school through education for sexual responsibility. Health visitors can advise mothers on preparing
their children for responsible sexual relationships; many parents do not know how to talk about sex to their
children. Health visitors attending family planning appreciation courses have often expressed a wish to help
with sex education.
4. Women should continue to have the option of obtaining birth control advice from a clinic, from a general
practitioner or where a special need exists, from a domiciliary service.
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