PARTI CULARI TI ES OF FAMI LY PLANNI NG I N W OMEN W I TH MENTAL DI SORDERS
Tat ian e Gom es Gu edes1 Escolást ica Rej ane Fer r eir a Mour a2 Paulo César de Alm eida3
Guedes TG, Moura ERF, Alm eida PC. Part icularit ies of fam ily planning in w om en w it h m ent al disorders. Rev Lat ino- am Enferm agem 2009 set em bro- out ubro; 17( 5) : 639- 44.
The st udy aim ed t o ident ify t he gy necological and obst et r ic pr ofile of w om en w it h m ent al disor der s; t o v er ify t he associat ion bet ween m edical diagnosis of m ent al disorder and correct / incorrect use of cont racept ive m et hods, an d v er ify diagn oses, fr equ en cy of h ospit alizat ion s an d v ar iet ies of m edicat ion con su m ed. Par t icipan t s w er e 2 5 5 w om en w h o r eceiv ed car e in a Psy ch osocial Car e Ser v ice. Dat a w er e collect ed t h r ou gh m edical r ecor d r ev iew and st r uct ur ed int er v iew . The inher it ance of som e m ent al disor der s, psy chiat r ic hospit alizat ion as t he cause t o int errupt cont racept ion, use of cont racept ives t hat do not depend on personal cont rol, drug int eract ions b et w een p sy ch ot r op ic d r u g s an d or al con t r acep t iv es; p ar t icip at ion of t h e p ar t n er an d / or r elat iv es in t h e r epr oduct iv e choice and cont r acept iv e pr act ice w er e par t icular it ies of t his t ar get audience in fam ily planning. Ther e w as no st at ist ical associat ion bet w een m edical diagnoses and cor r ect or incor r ect use of cont r acept ives. Wom en suffer ing fr om m ent al disor der s need specific and com pr ehensiv e fam ily planning car e.
DESCRI PTORS: w om en; m ent al disor der s; fam ily planning
PARTI CULARI DADES DE LA PLANI FI CACI ÓN FAMI LI AR DE MUJERES
PORTADORAS DE TRASTORNO MENTAL
Se t uvo com o obj et ivo ident ificar el perfil ginecológico y obst ét rico de m uj eres port adoras de t rast orno m ent al, v er ificar la asociación ent r e diagnóst ico m édico de t r ast or no m ent al y uso cor r ect o/ incor r ect o de los m ét odos ant iconcept ivos y verificar diagnóst icos, frecuencia de int ernaciones y variedades de m edicam ent os consum idos. Par t icipar on 255 m uj er es at endidas en un Cent r o de At ención Psicosocial. Los dat os fuer on r ecolect ados por m edio de r ev isión de fichas y ent r ev ist a est r uct ur ada. La her edit ar iedad de algunos t r ast or nos m ent ales, la int ernación psiquiát rica com o causa de int errupción de la ant iconcepción, el uso de ant iconcept ivos que independen del cont role personal, la int eracción m edicam ent osa ent re psicot rópicos y ant iconcept ivos orales, la part icipación d el com p añ er o y / o d e f am iliar es en la elección r ep r od u ct iv a y la p r áct ica an t icon cep t iv a, con st it u y er on part icularidades en el planificación fam iliar de ese público. No hubo asociación est adíst ica ent re los diagnóst icos m édicos y el uso cor r ect o o incor r ect o de los m ét odos ant iconcept iv os. Las m uj er es por t ador as de t r ast or no m ent al pr esent an una dem anda par a la at ención de la planificación fam iliar específica e int egr al.
DESCRI PTORES: m uj er es; t r ast or nos m ent ales; planificación fam iliar
PARTI CULARI DADES DO PLANEJAMENTO FAMI LI AR DE MULHERES
PORTADORAS DE TRANSTORNO MENTAL
Obj et iv ou - se iden t if icar o per f il gin eco- obst ét r ico de m u lh er es por t ador as de t r an st or n o m en t al, v er if icar a associação ent re diagnóst ico m édico de t ranst orno m ent al e uso corret o/ incorret o dos m ét odos ant iconcepcionais e v er ificar diagn óst icos, fr equ ên cia de in t er n ações e v ar iedades de m edicam en t os con su m idos. Par t icipar am 255 m ulheres at endidas em um Cent ro de At enção Psicossocial. Os dados foram colet ados por m eio de revisão de pront uário e ent revist a est rut urada. A heredit ariedade de alguns t ranst ornos m ent ais, int ernação psiquiát rica com o causa de int er r upção da ant iconcepção, uso de ant iconcepcionais que independem do cont r ole pessoal, int eração m edicam ent osa ent re psicot rópicos e ant iconcepcionais orais, part icipação do parceiro e/ ou de fam iliares na escolha r epr odut iv a e pr át ica ant iconcept iv a const it uír am par t icular idades no planej am ent o fam iliar desse público- alv o. Não houv e associação est at íst ica ent r e os diagnóst icos m édicos e uso cor r et o ou incor r et o dos m ét odos an t icon cepcion ais. Mu lh er es por t ador as de t r an st or n o m en t al possu em dem an da par a at en dim en t o de planej am ent o fam iliar específico e int egr al.
DESCRI TORES: m ulher es; t r anst or nos m ent ais; planej am ent o fam iliar
1RN, Doct oral St udent in Nursing, Universidade Federal do Ceará, Brazil, e- m ail: t [email protected] .br; 2RN, Ph.D. in Nursing, Adj unct Professor,
Universidade Federal do Ceará, Brazil, e- m ail: [email protected] .br; 3St at ist ician, Ph.D. in Public Healt h, Faculty, Cent ro de Ciências da Saúde,
Universidade Est adual do Ceará, Brazil, e- m ail: pc49alm eida@gm ail.com .
I NTRODUCTI ON
F
am ily plan n in g ( FP) car e sh ou ld pr ov ide w om en , m en an d / or cou p l es w i t h t h e n ecessar y inform at ion for t he free choice and effect ive use of con t r acep t iv e m et h od s t h at b et t er ad ap t t o t h eir in div idu al con dit ion s( 1 ). Pu blic policies en f or ced inrecent years have focused on t he search for equit y, f r eed om an d social j u st ice in f em ale sex u al an d r e p r o d u ct i v e h e a l t h , o v e r co m i n g p r e j u d i ce s, discrim inat ion and st ruct ural problem s.
The interface between public wom en’s health an d m en t al h ealt h p olicies n eed t o m ov e b ey on d official discourse and becom e practice in care delivery t o wom en wit h m ent al disorders. FP of wom en wit h these problem s, focus of this study, is an exam ple of t h e n e e d f o r e f f e ct i v e i n t e r a ct i o n b e t w e e n t h e m entioned policies. Wom en with m ental disorders are pr ot ect ed by Law n . 9 . 2 6 3 , issu ed on Jan u ar y 1 2 1 9 9 6( 2 ), w h i ch i n d i scr i m i n at el y u n i v er sal i zes t h e
par t icipat ion of m en and w om en in FP act ions and specific m ent al healt h policies t o recover cit izenship, r espect differ ences, aut onom y and social inclusion, based on Law n.10.216, from April 6 2001( 3).
Th e cu r r e n t Co m p r e h e n si v e Na t i o n a l Wom en ’s Healt h Car e Policy ( PNAI SM) in t r od u ces act ion s t ar g et in g sp ecif ic social sect or s, su ch as wom en wit h m ent al disorders, int o t he public healt h n et w or k . I n it s p olicies, com p r eh en siv e w om en ’s health care should be guided by respect for differences, w i t h o u t d i s- cr i m i n at i o n o f an y k i n d an d w i t h o u t im posit ion of values and personal beliefs( 4).
Deliv er in g car e t o w om en in t h e FP ar ea should be a pr ior it y in pr im ar y car e. Nev er t heless, t hese act ions should ensure t he equit y of sexual and reproduct ive right s of wom en wit h m ent al disorders. On t he ot her hand, t he Psy chosocial Car e Ser v ices ( CAPS) , also in t h e per spect iv e of com pr eh en siv e act ions, should offer biopsychosocial care t o wom en w it h m ent al disor der s, ser v ing as t echnical suppor t for prim ary care t eam s and vice versa.
I ncidence lev els of unplanned pr egnancies ar e h ig h am on g p sy ch iat r ic p at ien t s, d u e t o t h e frequent lack of insight caused by m ent al disorders, lack of p lan n in g an d b eh av ior al con t r ol, b esid es pot ent ial m edicat ion int er act ion bet w een hor m onal contraceptives and som e psychotropic drugs, reducing co n t r a ce p t i v e e f f e ct i v e n e ss( 5 ). Mo r e o v e r, t h e se
wom en’s m at ernit y perform ance can be j eopardized by r ecu r r en t psy ch iat r ic h ospit alizat ion s, im pair ed
autonom y and lim itations of their self and fam ily care funct ions. I n t his perspect ive, it is relevant t o know t he par t icular it ies of t his populat ion’s FP, aim ing t o contribute to a fairer and m ore hum an care, com plying wit h legal inst rum ent s’ det erm inat ions on sexual and r epr oduct ive r ight s.
Th u s, t h i s st u d y a i m e d t o i d e n t i f y t h e gy n ecological an d obst et r ic pr of ile of w om en w it h m ent al disorders; t o verify t he associat ion bet w een m edical diagn osis of m en t al disor der an d cor r ect / in cor r ect u se of con t r acept iv e m et h ods an d v er ify diagnoses, frequency of hospit alizat ions and variet ies of m ed icat ion con su m ed , t h u s ch ar act er izin g t h e particularities of FP in this target public.
METHODS
This is a cross- sect ional st udy wit h a m ixed approach. The cross- sect ional design perm it t ed dat a collection at one m om ent, so as to obtain a m om entary an d sh or t - t er m p ict u r e of f am ily p lan n in g am on g w o m e n w i t h m e n t a l d i so r d e r s. Th e m i x e d d a t a collection m ethod involves qualitative and quantitative collect ion and analy sis, int egr at ing t he infor m at ion w hen int er pr et ing t he gener al r esult s( 6). Qualit at iv e
d a t a r e f e r r e d t o p a r t i ci p a n t s’ st a t e m e n t s, w e r e organized by the categorical analysis technique( 7) and
then processed using the Statistical Package for Social Science ( SPSS) .
The study was carried out at a Psychosocial Care Service ( CAPS) in Fort aleza, st at e of Ceara, bet ween May and August 2007. Part of the data was surveyed in patient files and the rem ainder was collected through st at em en t s d u r in g st r u ct u r ed in t er v iew s. Sev er al statem ents were included in the discussion section for the sake of illustration, followed by participants’ age and m edical diagnosis of m ental disorder.
t h e Fi sh e r - Fr e e m a n - Ha l t o n t e st w a s u se d , w i t h significance level at 5% .
The st udy followed t he Resolut ion 196/ 1996 of t h e Nat ion al Healt h Cou n cil r egar din g r esear ch involving hum an subjects. I t was approved by the Ethics and Research Com m it t ee of t he Federal Universit y of Cear a - COMEPE ( Pr ot ocol n . 8 1 / 0 7 ) . Af t er bein g infor m ed about t he st udy ’s obj ect iv es and gener al aspect s, part icipant s volunt arily signed t he free and in f or m ed con sen t ag r eem en t . Th ey w er e en su r ed anonym it y and access t o research inform at ion.
RESULTS AND DI SCUSSI ON
Alm ost half of the wom en, that is, 119 ( 46.6% ) were at the extrem es of reproductive age, represented by 2 ( 0.8% ) up t o 19- year- old and 117 ( 45.9% ) over 3 5 - y ear - old . Ed u cat ion al lev el w as p r ed om in an t ly bet w een 8 and 10 y ear s and fr om 4 t o 7 y ear s of st udy, corresponding t o 67 ( 26.3% ) and 79 ( 31% ) , r e sp e ct i v e l y. On l y 3 5 ( 1 3 . 7 % ) h a d co m p l e t e d secondary school ( 11 years or m ore of st udy) ; 114 ( 44.7% ) did not have incom e or earned less than one m i n i m u m w a g e p e r m o n t h . Mo st w o m e n w e r e housem aids, 179 ( 70.2% ) . Only 14 ( 5.5% ) w om en had a form al j ob and perform ed occupational activities. Th e u n i v e r se o f m a r r i e d w o m e n , 1 1 9 ( 4 6 . 7 % ) , prevailed over ot her m arit al st at us.
Table 1 – Dist ribut ion of t he num ber of wom en wit h m e n t a l d i so r d e r, a cco r d i n g t o o b st e t r i c a n d g y n ecolog ical p r of ile. Psy ch osocial Car e Ser v ice. Fort aleza, CE, May- August 2007
As shown in Table 1, m ore t han half of t he wom en had at least one pregnancy ( n= 144) , of whom 125 ( 86.8% ) had bet ween one and four pregnancies and 19 ( 13.2% ) had m ore t han four. The age of t he fir st deliv er y v ar ied bet w een 13 and m or e t han 35 y ea r s o f a g e, a n d t h e l o n g est i n t er v a l b et w een deliveries was of 20 to 35 years, corresponding to 70 ( 51.4% ) of the sam ple. Fifty- four ( 59.3% ) reported a pregnancy interval longer than two years, 38 ( 14.9% ) suffer ed spont aneous or pr ov ok ed abor t ion, as 1 3 ( 34.2% ) and 25 ( 65.8% ) of the participants indicated, r espect iv ely.
Th e g y n e co l o g i ca l a n d o b st e t r i c p r o f i l e confirm s t hat t he pregnancy of w om en w it h m ent al disorders is a realit y. Taking int o considerat ion t hat t hese w om en hav e pr oblem s t hat can com pr om ise t heir aut onom y, it is essent ial t o pr ov ide indiv idual care in fam ily planning, involving part ners and ot her r elat iv es im p lied in d ecision - m ak in g . Hen ce, t h e pr egnancy / m ent al disor der r elat ionship, w hich is a delicat e r elat ionship, w ould be t r eat ed as a sex ual and reproduct ive right of t his populat ion.
Pa r t n e r s h a v e a r e p r i v i l e g e d i n t h e d ei n st i t u t i o n al i zat i o n p r o p o sal o f t h e Psy ch i at r i c Reform . Thus, m en perform an im portant role in their part ner’s rehabilit at ion and, as FP is a choice of t he couple, CAPS and pr im ar y car e ser vice st aff should m ore closely involve t hem in FP and m ake t hem co-responsible for cont racept ive pract ices.
Table 2 – Dist ribut ion of t he num ber of wom en wit h m ental disorder regarding the planning of pregnancies a n d co n t r a ce p t i v e p r a ct i ce s. Psy ch o so ci a l Ca r e Service. Fort aleza, CE, May- August 2007
s e l b a i r a
V N %
) 4 4 1 = n ( s e i c n a n g e r p f o g n i n n a l P s e
Y 34 23.6
o
N 47 32.6
s e m it e m o
S 63 43.8
h c r a e s e r e h t g n i r u d e r a c g n i n n a l p y li m a F s e
Y 15 5.9
o
N 240 94.2
) 5 3 = n ( s d o h t e m e v it p e c a r t n o c g n i s U e v it p e c a r t n o c l a r
O 22 62.9
m o d n o
C 11 31.4
e v it p e c a r t n o c e l b a t c e j n
I 2 5.7
) 5 3 = n ( d o h t e m e h t f o e s u t c e r r o C s e
Y 8 22.8
o
N 27 77.2
) 5 5 2 = n ( n o it a z il i r e t s l a b u T s e
Y 40 15.7
o
N 215 84.3
s e l b a i r a
V n %
) 4 4 1 = n ( s e i c n a n g e r P 4
-1 125 86.8
4
> 19 13.2
) 6 3 1 = n ( y r e v il e d t s r if t a e g A 5 1 -3
1 9 6.6
9 1 -6
1 56 41.1
5 3 -0
2 70 51.4
5 3
> 1 0.9
) 1 9 = n ( s e i c n a n g e r p n e e w t e b l a v r e t n I s r a e y 2
> 54 59.3
s r a e y 2
< 37 40.7
) 8 3 = n ( n o it r o b A
1 33 86.8
2 4 10.5
3 1 2,7
s u o e n a t n o p
s 13 34,2
d e s u a
According to Table 2, 34 ( 23.6% ) participants r ep or t ed h av in g p lan n ed all p r eg n an cies. Men t al d isor d er in f lu en ces t h is sit u at ion , w h ich r eq u ir es part ners’ and/ or responsible relat ives’ support , w ho should have access t o cont racept ive inform at ion and m ethods. These were used by only 35 ( 13.7% ) of the w om en , w h ile t h e ot h er s w er e at t h e r isk of an u n p l a n n e d p r e g n a n cy. Su p p o r t i n g t h i s i ssu e , p ar t icip an t 1 8 9 , 4 7 y ear s, w it h b ip olar d isor d er, affirm ed: I only st art ed t o t ake cont racept ive drugs aft er t he
fort h pregnancy.
Som e of t he wom en in t he st udy are aware o f m e d i ca t i o n i n t e r a ct i o n b e t w e e n h o r m o n a l contraceptives and psychotropic drugs. Participant 79, 29 years, with anxiety disorder, reported: I never t ook
pills t o avoid pregnancy, because of t he m edicat ion I already t ook
for m y t reat m ent. Oral horm onal contraceptives interact
wit h ant iconvulsant s( barbit urat es, diphenylhydant oin,
prim idone and carbam azepine) reducing their efficacy, as t hey induce hepat ic enzym es( 1).
Al t h o u g h 2 3 3 ( 9 1 . 4 % ) o f t h e w o m e n , according t o t he report ed m arit al st at us ( m arried or wit h casual part ners) , had an act ive sexual life, t he n u m b e r o f p a r t i ci p a n t s w h o u se d co n t r a ce p t i v e m ethods and those who received fam ily planning care was significantly low, corresponding to 15 ( 5.9% ) and 3 5 ( 1 3 . 7 % ) , r e sp e ct i v e l y. Am o n g t h o se u si n g m e t h o d s, 2 2 ( 6 2 . 9 % ) u se d o r a l h o r m o n a l contraceptives, 11 ( 31.4% ) used condom and 2 ( 5.7% ) used inj ect able cont r acept iv es. The analy sis of t his results, from the perspective of the num ber of wom en w h o r ecei v ed FP- t a r g et ed ca r e, r ev ea l s t h a t 2 0 ( 57.1% ) used the m ethods without form al care, which could be relat ed t o t he incorrect use by 27 ( 77.2% ) of t hese wom en.
Tubal st er ilizat ion, r epor t ed by 40 ( 15.7% ) of t h e r esear ch ed w om en , is an im por t an t aspect for an aly sis. I n people’s im agin at ion , an d ev en in t he v iew of m any healt h pr ofessionals, t he sur gical m et h od is t h e on ly on e in dicat ed f or w om en w it h m ent al disor der, w hich is pr ej udiced and unet hical. Con t r acep t iv e m et h od s t h at d o n ot n eed p at ien t con t r ol ar e, in deed, t h e m ost ef f icien t f or w om en w it h sever e m ent al disor der s. How ev er, appr opr iat e e t h i c a l b e h a v i o r t o w a r d s t h e s e p a t i e n t s p r e s u p p o s e s r e s p e c t f o r t h e i r s e x u a l a n d r e p r o d u c t i v e r i g h t s , w h i c h i m p l i e s i n d i v i d u a l t r eat m ent t o each per son w it h m ent al disor der. Of t h e p a r t i c i p a n t s w h o h a d u n d e r g o n e t u b a l
st er ilizat ion, 6 ( 15% ) r epor t ed it w as not a per sonal choice. I nst ead, ot her people ( ph y sicians, m ot her, s i s t e r a n d p a r t n e r ) m a d e t h i s d e c i s i o n , a s d em o n st r at ed i n so m e w o m en ’ s st at em en t s: m y
m ot h er t h ou g h t it w as b et t er . Som et im es I t h in k I g ot w or se
r egar d in g m y d isease b ecau se of t h at . Sh e p aid t h e p h y sician
an d h e d id it ( par t icipant 6, 30 y ear s, w it h schizophr enic
disor der ) . Wh en I w ok e u p I w as t old I h ad b een st er ilized .
Du r in g deliv er y t h e doct or ask ed m e h ow m an y ch ildr en I h ad
an d p er f o r m ed t h e t u b al st er i l i zat i o n ( par t icipan t 9 9 , 3 6
y ear s, w it h bipolar disor der ). Du r in g t h e n in e m on t h s of t h e
last p r eg n an cy I w as m en t ally ill, t h en m y h u sb an d sig n ed
t h e paper s an d t h e ph y sician per f or m ed t h e t u balst er ilizat ion
( p a r t i ci p a n t 1 6 , 4 3 y e a r s, w i t h b i p o l a r d i so r d e r ) . Fo r p eop le ab solu t ely in cap ab le, t h e FP Law en su r es t h e per f or m an ce of t u bal st er ilizat ion , pr ov ided it is au t h or ized in cou r t , at t h e r isk of ar r est if n ot follow ed( 2). I n t he st udied gr oup, t he char act er ist ic
of com plet e in capabilit y w as n ot obser v ed, w h ich show s t he w ay s in w hich t hese pr ocedur es occur r ed in t h e r esear ch ed gr ou p.
s i s o n g a i d l a c i d e M
e h t g n i r u d s d o h t e m f o e s U
) 5 3 = n ( h c r a e s e r
t c e r r o
C Incorrect
N % N %
s r e d r o s i d d o o
M 5 14.2 19 54.4
c it o h c y s p r e h t o d n a a i n e r h p o z i h c S
s r e d r o s i
d 1 2.8 3 8.6
s r e d r o s i d c it o r u e
N 1 2.8 3 8.6
s r e d r o s i d y t il a n o s r e
P 1 2.8 2 5.8
Table 3 – Dist ribut ion of m edical diagnosis of m ent al d i so r d e r r e g a r d i n g co r r e ct o r i n co r r e ct u se o f cont r acept iv e m et hods. Psy chosocial Car e Ser v ice. Fort aleza, CE, May- August 2007
Fisher’s p = 0.685
For these people, m ethods that do not depend on personal cont rol should be preferred, due t o t he p ossib ilit y of u ser s’ alt er ed b eh av ior. Th u s, m ale condom , inj ect able cont r acept iv e, I UD and sur ger y are the m ost appropriate m ethods. Moreover, partners sh o u l d b e i n v o l v e d i n f o l l o w i n g t h e u se o f t h e contraceptive m ethod, as this is a unique opportunity for m en t o assum e t he responsibilit y for FP and opt for t he m ale m et hods.
Ob st a cl es t h a t p r ev en t a ccess t o h ea l t h services m ake the insertion of these wom en in fam ily p lan n in g act ion s m or e com p licat ed , as st at ed b y participant 3, 36 years, with psychotic disorder: I w ent
t here t o regist er, but on t hat day t hey w ere not regist ering.
Aim in g t o m it ig at e t h ese ob st acles, CAPS n u r ses sh ou ld n ot on ly f or w ar d w om en t o p r im ar y car e services for FP care, but also follow and guide t hem in t his respect , prom ot ing com prehensive care.
Table 4 – Dist ribut ion of t he num ber of wom en wit h m en t al d isor d er, accor d in g t o m ed ical d iag n osis, n u m b er o f p sy ch o t r o p i c m ed i ca t i o n s i n u se a n d p sy ch i a t r i c h o sp i t a l i za t i o n s. Psy ch o so ci a l Ca r e Service. Fort aleza, CE, May- August 2007
s e l b a i r a
V N %
) 5 5 2 = n ( s i s o n g a i d l a c i d e M s r e d r o s i d d o o
M 125 49
s r e d r o s i d d i o n a r a p d n a l a p y t o z i h c s , a i n e r h p o z i h c
S 60 23.6
s r e d r o s i d d e t a l e r -m r o f o t a m o s d n a s s e r t s , c it o r u e
N 48 18.8
r e d r o s i d r o i v a h e b tl u d a d n a y t il a n o s r e
P 11 4.3
s r e h t
O 11 4.3
) 6 4 2 = n ( e s u n i s n o it a c i d e m c i p o r t o h c y s p f o r e b m u N
1 23 9.3
3 o t
2 168 68.3
e r o m d n a
4 48 19.5
t n e m e t a t s o
N 7 2.8
n o it a z il a t i p s o h c i r t a i h c y s P s e
Y 128 50.2
o
N 127 49.8
Mood disorders are m ore frequent , affect ing alm ost half of t he wom en in t he st udy, followed by schizophrenia and neurotic disorders. Prevalence rates of t hese disorders are high in t he world populat ion, and are the cause of significant patient losses. I t is a d isease w it h an im p or t an t g en et ic f act or, w h ose inherit ance is charact erized by com plex t ransm ission m echanism s, involving m ult iple genes influenced by countless environm ental factors( 8). The heredity of the m ent ioned disor der w as a concer n t he par t icipant s m en t ion ed as a f act or ag ain st t h e d esir e t o g et
pregnant. Participant 4, 32 years, with m ood disorder em phasized: I ’m afraid t o have a child like m e. How will I t ake
care of him / her?Professionals who work in m ental health
and FP should inform the wom an and/ or couple about t he her edit y bur den of t his pat hology, so t hat t he d e ci si o n t o h a v e ch i l d r e n o r n o t ca n b e t a k e n conscient iously.
Anot her par t icular it y of fam ily planning for w om en w it h m en t al d isor d er s r eg ar d s t h e u se of psychot ropic drugs during pregnancy, used by alm ost a l l w o m e n i n t h e st u d y, a s m o st o f t h e m a r e t erat ogenic, like lit hium , one of t he m ood st abilizers used to treat bipolar disorder. Children of wom en under t r eat m en t w it h lit h iu m ar e ex p osed t o con g en it al abnor m alit ies in 4 t o 12% of cases, against a r isk fr om 2 t o 4 % in t he gener al populat ion( 9 ). Bipolar
disorder can aggravat e during pregnancy, due t o t he need t o decr ease dr ugs cont r aindicat ed for per fect fet al developm ent . Thus, t he perm anent int eract ion bet w een pr egnant w om en, fam ily, obst et r ician and psychiat rist is an im port ant resource t o support risk-benefit analysis in decisions. Nevert heless, research dat a on t he use of ant idepressive agent s is already available for pregnant and breast feeding pat ient s( 10).
From an ethical viewpoint, one cannot prohibit patients with m ental disorders from getting pregnant, due t o t heir r ight t o fr eely choose concept ion, lik e ev er y ot her w om an, for w hich t hey should r eceiv e car e in all dim ensions. Ser vices involved in care t o w om en w it h m ent al disor der s need t o under st and, regarding t heir right t o choose m ot herhood, t hat t he healt h syst em should be prepared t o respond t o t his dem and, respecting wom en who have decided in favor of concept ion, despit e t he risks, m onit oring children concer ning t he possible appear ance of t he disor der and prom ot ing proper follow- up.
The use of m edicat ion is seen as t he m ain therapeutic practice in the different levels of the public healt h syst em( 11). This is an aggravat ing fact or, as it
prevent correct ly. When I was hospit alized I did not t ake t he
p i l l s.
Psy ch i a t r i c h o sp i t a l i za t i o n h a s a d o u b l e function in care to patients, which is to treat and protect pat ient s wit h m ent al disorders, at t he risk of lim it ing their citizenship rights and contributing to sexual and reproductive risks. To decrease these possibilities, the current m ent al healt h act ions, guided by t he law on t h e p r o t ect i o n an d r i g h t s o f p eo p l e w i t h m en t al disorders, recom m end psychiat ric hospit alizat ion only w hen all ot her com m unit y r esour ces hav e alr eady been ex haust ed( 3). These r esour ces consolidat e t he
p sy ch iat r ic r ef or m an d ar e con sid er ed in n ov at iv e p r oj ect s, cap ab le of g u ar an t eein g q u alit y car e t o carriers of m ent al disorders, based on prem ises like singularity and the right to decent health and life( 12).
FI NAL CONSI DERATI ONS
Part icularit ies of fam ily planning for wom en with m ental disorders were recognized in the present
st u d y, su ch a s h e r e d i t a r i n e ss o f so m e m e n t a l disor der s, psy chiat r ic hospit alizat ion as a cause for int er r upt ing t he cont r acept ive pr act ice, m ult ivar iat e use of psychot ropic drugs t hat can have m edicat ion int er act ions w it h or al hor m onal cont r acept iv es and ca u se t e r a t o g e n i c e f f e ct s, u se o f co n t r a ce p t i v e m et h ods t h at r equ ir e per son al con t r ol, w h ich w as j eop ar d ized d u e t o t h e alt er ed b eh av ior an d t h e im por t an ce of par t icipat ion by t h e par t n er an d/ or f am ily m em b er s r esp on sib le f or r ep r od u ct iv e an d cont r acept iv e choices.
The st udied group suffers int ervent ion by a f r a g m e n t e d h e a l t h sy st e m , w h i ch d e n i e s co m p r e h e n si v e ca r e a n d w o m e n ’ s se x u a l a n d r e p r o d u ct i v e r i g h t s. Re su l t s sh o w t h e n e e d f o r interaction between public fam ily planning and m ental h ealt h policies, w h ich w ou ld per m it t h e r escu e of cit izenship, r espect for differ ences, aut onom y, and social inclusion of users. Future studies can strengthen changes in t he dynam ics of FP care t o wom en wit h m ental disorders, in which CAPS and health unit team s can bet t er respond t o t his dem and.
REFERENCES
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