Weight loss and diet plan for a healthy lifestyle.

Among the socially deprived, poor attendance at postnatal examinations is frequent. Such default is often attributed to fecklessness but this is not often the case and may be for purely logistical reasons such as difficulties with transport, especially where there are other children who cannot be left at home. Equally it may be a deliberate rebellion against authority where the doctor is seen as someone imposing her view on how many children the woman should have or how they should be spaced. Sometimes such rebellion is not recognized as such by the patient, who will blame the practical difficulties for her non-attendance. Even if domiciliary help is offered she is likely to be out when the doctor calls.

Those with poor self-esteem also tend to be among the patients who find it difficult to attend for routine postnatal and other medical appointments. It is as if they do not feel they have the right to the attention implicit in such routine care. At the same time it is difficult for them to believe that planning is possible in view of their chaotic lifestyle so far. They find it difficult to believe that professional people will heed their views and they can make a choice only when they feel their choice will be listened to.

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There is no doubt that dislike for the condom is common. The clearest description met was, ‘Once you have gone bareback, there is nothing like it!’ Men dislike having to pause, and may find losing their erection at this stage a problem, even after years of use.

On the other hand some men can be very fond of condoms. They are old friends and remind us of exciting times. One man told me their loving was dull until one family camping holiday when she asked him to get some to save messing their sleeping bag. Now when they can at last afford hotels they still take condoms with them on holiday to add a spice of excitement.

Conversely, as a means of slowing down excitement the use of the sheath is not always helpful.

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Counselling in the case of the unplanned pregnancy has to be brief and to the point. Psychosexual counselling is usually more open ended, allowing patients time to understand their unconscious feelings which may block their fulfilment and allowing a gradual move towards change in attitude. However, psychosexual doctors are trained to listen not only to what is said but what is not said, and to understand what is going on in the consulting room. The specific techniques associated with understanding the doctor-patient relationship and the genital examination can give rapid insight to the patient’s feelings which may have nothing to do with a detailed history of her circumstances, as in the case of Miss D. (p. 53) who had enormous financial problems but who still wanted a baby. The genital examination can give the trained doctor an insight into how the woman feels about her sexuality, as in the case of Mrs H. (p. 58), which was important in helping her to understand her feelings about her pregnancy and her contraception. This ability to perform a genital examination in a psychotherapeutic way is a skill which nonmedical counsellors may find difficult to accept or understand.

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If the history is taken thoughtfully, the younger patient perceives that care is being offered and that her needs are respected. In this context, patients in this group may be keen to find out their rubella status, and to discuss their weight and smoking habits vis-a-vis the Pill. The problem of weight gain may be the over-riding anxiety for the patient, and this is an area where her agenda may differ markedly from that of the doctor, who is concerned with the possible presence of pre-existing obesity as a risk factor. As regards diabetes and heart disease, the patients normally understand the need for their consultant physician to be involved in the final decision. If there is any family history suggestive of increased risks, they usually co-operate readily with any blood test thought advisable. With today’s focus on prevention and health checks, such patients do not find this alarming. The breast cancer issue is still awaiting clarification but must be discussed, and an informed choice made, to be reviewed in the light of any future evidence.

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Pregnancy itself compensates for feelings of inner emptiness, literally filling the woman with new life. Women who experience this emptiness often feel depleted after childbirth and may be anxious to get pregnant again soon afterwards, resenting any discussion of contraception. The baby can also represent one’s own baby self to love in a way that one was not loved. Being a mother enhances status and although mothers are not necessarily treated well, they are regarded as good. Children can counteract boredom and loneliness, providing interest and entertainment, and can satisfy the need to be needed. They can compensate for a lack of material possessions and give a sense of potency: ‘Something new created in a material world,’ as one unemployed and destitute young man put it when he was asked how he felt about the pregnancy of his girlfriend.

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