Mrs R. presented complaining that she felt slightly sick when taking her Pills, which she had been on for several years with no problems. She thought that now she was 40 she and her husband would use sheaths. The doctor agreed with what she wanted to do, saying the sheath was a good method, but not as efficient as the Pill, and how would she feel if she did get pregnant? Mrs R. then confided that this was really what she wanted. Her children were now at school and growing up, she had often wondered if she wanted a fourth child and now at 41 she felt she had to make that decision. Using a sheath would give her some chance of getting pregnant. Her ambivalence was shown by her inability to stop all contraception, and such a non-verbal clue may suggest that she is not altogether happy with her decision.
For the doctor there are the additional difficulties of weighing up the medical risks of a pregnancy in a woman of this age. It has been shown that in the years 1976 to 1987 in the UK, the risk of death in pregnancy for a woman over 40 was 10 times that of a woman between 20 and 24 years; 5 in 10 000 against 0.5 in 10 000 according to the report on Confidential Enquiries into Maternal Deaths (1991). However, there is some evidence that this risk is decreasing in the UK, as figures for 1985 to 1987 show a rate of only 2 in 10 000 deaths of women over 40 (Drife, 1992). In the end it is the couple who must be allowed to make the choice with the help of up-to-date information from their doctor. It is a delicate balance for the doctor to share the patient’s joy while providing her with realistic facts.