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  • Title: Use of hormonal contraceptives in an institutional setting: reasons for use, consent and safety in women with psychiatric and intellectual disabilities.
    Author: Egan TM, Siegert RJ, Fairley NA.
    Journal: N Z Med J; 1993 Aug 11; 106(961):338-41. PubMed ID: 8341476.
    Abstract:
    AIM: To describe the use of hormonal contraceptives in institutionalised women with psychiatric and/or intellectual disabilities. METHODS: Women who had been disability or mental health service inpatients for six months or more and were prescribed hormonal contraceptives were included. Data were collected from their clinical files and from structured interviews of the women and of their primary care givers. RESULTS: Forty two women were prescribed contraceptives, of whom 23 were intellectually disabled and 28 had mental illnesses. Most women had no children; four had had one child and two, two children. Thirteen were not sexually active. Depot medroxyprogesterone acetate (Depo Provera) was prescribed for 69%, combined oral contraceptive agents for 14% and progestin-only oral contraceptives for 17%. Contraceptives were initially prescribed by hospital staff for all but 1 woman, and were administered without consent for over half the group, including 11 women for whom this administration was not legally authorized. Less than half the group had blood pressure measured within the previous 12 months and only a third had a cervical smear within the previous 3 years. Of the women who were sexually active, less than half knew how to protect themselves from sexually transmitted diseases and less than 10% regularly used condoms. CONCLUSIONS: Improvements in reproductive health care for these women are needed, in particular attention to education and client participation in decisions about contraceptive treatment. It is suggested that gynaecological and family planning services be provided separately from psychiatric services. A study was made of all women who had been inpatients of the mental health or disability units of Porirua Hospital in New Zealand for at least 6 months who were prescribed oral or injectable hormonal contraceptives during January 1992. The aim was to describe the use of hormonal contraceptives in this population and assess the appropriateness and safety of this method as well as the patient consent process and patient satisfaction. Data were collected from medical records and from interviews with the patients (when possible) and their nurses. 42 women were prescribed contraceptives (60% of those under 50). 3 were married, 3 separated or divorced, and 36 never married. 32 were nulliparous, none had more than 2 children. 11 were Maoir, 1 Pacific Islander, and 29 New Zealand pakeha. 23 women were intellectually disabled, 28 had mental disorders, 9 had both. 29 of the women received Depo Provera, 7 progesterone-only oral contraceptives (OCs), and 6 combined OCs. 25 had been using their current contraceptive for more than 3 years. Treatment was prescribed by psychiatric staff in 16 cases, other staff in 25, and outside practitioners in 1. The reason for treatment was contraception in 32 women and menstruation prevention in 9. 27 women were smokers (21 heavy). 7, including 6 of the heavy smokers, had other contraindications to the use of estrogens. Of the 26 women interviewed, 12 complained of side effects, 8 of weight gain, 2 of depression, and 5 of other effects (the nurses identified only 2 of 42 women as suffering side effects). Of the 22 interviewees who were treated for contraception, 15 stated they were sexually active. The nurses thought that 29 of the 42 were or might be sexually active. Therefore, 13 women considered definitely not sexually active were prescribed contraceptives. Very few of the women used condoms, although 38% knew how to practice safe sex. 14 of the women interviewed stated they chose contraception. The nurses said 8 had given consent, the families of 2 gave consent, consent information was unknown for 10, and a unilateral staff decision was made for 22. 17 of the 28 women definitely treated without consent were mentally retarded. The women were given very little information about their contraceptive method and knew of very few other methods. These results indicate that contraceptives have been used to manage menstrual hygiene and address staff concerns. In some cases, their administration without consent was illegal. The patients received inadequate medical care and some of the prescriptions were inappropriate. Ethically correct ways in which to address the problem of contraception in this population exist through educationally-focused family planning services for both in- and out-patients.
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