Cassandra’s prophecy: a psychological perspective. Why we need to do more than just tell women

The most salient psychological issue in the article ‘Cas- sandra’s Prophecy’ is the lack of fertility knowledge (Every- woman, 2013). Jane lacked knowledge in many areas, concerning reproduction (e.g. chance of pregnancy without using contraception), risk factors associated with reduced fertility (e.g. age, menstrual pain and irregularities) and medical options available if natural attempts to conceive fail (e.g. success rates of assisted reproductive technolo- gies). All these had a direct impact on her decision-making about when she should start trying to get pregnant and when she should seek medical help. Unfortunately, even when Jane did seek medical help she was met with medical pro-

fessionals who also lacked knowledge of potential signs and symptoms of disease (e.g. unpredictable menstrual cycle, severe period pains) and were clearly not adhering to current national fertility guidelines (e.g. women aged

35 years or older warrant early investigation, National Insti- tute for Health and Clinical Excellence (NICE), 2004). Together, this lack of knowledge exhibited by both Jane and the medical professionals resulted in a delay in trying to get pregnant and in seeking and receiving appropriate care, ultimately resulting in inadvertent childlessness.

Jane’s narrative highlights that better education about fertility health issues is required for everyone (laypeopleand healthcare professionals) spanning childhood through to adulthood to empower people to take control of and make informed decisions about their reproduction.

First and foremost, boys and girls need better sex educa- tion. Jane assumed that sex without contraception always resulted in pregnancy. The belief that ‘all acts of unpro- tected intercourse’ inevitably result in a live birth is more than likely formed from years of sex education focusing solely on preventing pregnancy and the spread of sexually transmitted infections (Welsh Assembly Government, 2010). Whilst it is vital to educate young people about the risks involved in engaging in unprotected sex, the probability of getting pregnant from having one completely random act of unprotected sexual intercourse is around 3% (Wilcox et al., 2001). Statutory sexual health education needs to be more informative about reproduction and the factors that impact on fertility, so that young people grow up understanding the potential limitations of their fertility (e.g. fertility declines with age, lifestyle affects fertility, fertile window during a menstrual cycle) and the ways they can optimize their chances of achieving parenthood, if desired.

A second educational initiative missing in the current education curriculum and National Health Service is the inclusion of family planning beyond the distribution of con- traception. One would assume that the term ‘family plan- ning’ would include planning to become a parent. However, as Jane experienced when visiting a family plan- ning and women’s health clinic, she was turned away as her issues were not relevant to the clinic’s mission. Family planning (education and services available at clinics) is about preventing pregnancy and not planning pregnancy. However, much could be improved if family planning ser- vices were expanded to also include periconceptional advice and planning. Therefore, as young boys and girls reach adulthood, education should promote value clarifica- tion regarding important life goals (e.g. professional career, personal realization, family building) including parenthood goals (e.g. whether to have children or not, how many, at what age) and of what will be required (over time) to achieve these. Although it was clear for Jane that starting a family was at the top of her agenda, she lacked under- standing about how to balance this with other relevant life goals. Nowadays, tools already exist (e.g. My Reproductive Life Plan, Centers for Disease Control and Prevention, to facilitate value clarification and parenthood planning.

Another critical issue to consider are the implications of the different possible plans that people envisage for them- selves. A women planning to have a child before the age of

30 can expect to achieve it through natural conception, but a women planning to have a child at the age of 40 will prob- ably need to use assisted reproduction treatment and even donated eggs (Wang et al., 2008). Women and couples need to consider if they are willing to accept how they can achieve parenthood and, if they do, they need to be informed about how they should behave so as not to com- promise their chances of success. For instance, although fertility preservation techniques allow women to prevent the loss of oocyte quantity and quality due to age, women are using it at a stage when its potential benefit is already negligible (i.e. around 38 years of age; Gold et al., 2006).

Jane’s narrative highlights that the media portraits of the efficacy of assisted reproduction treatment have been coun- terproductive and should equally be tackled in educational campaigns. Jane was given a false idea that she still had plenty of time for childbirth because in media reports numerous celebrities were getting pregnant for the first time after 40. The media could also play a role in public awareness of fertility but reporting would need to be better balanced to take into account empirical evidence about medical and non-medical fertility options (e.g. success rates, costs, availability). More effort from the media to embrace changing trends in many developed nations (e.g. single parents, working mothers, older parents) and to reduce pressure on people who may feel that they need to conform to a set of traditional values to achieve the perfect parenting scenario (e.g. heterosexual, middle-class and aged 25–35) could also be beneficial (Hadfield et al., 2007).

Third, we need public health campaigns to increase awareness of the risk factors associated with reduced fertil- ity potential and enable people to feel empowered to seek medical help (if desired) when risk factors exist and/or when they are trying to conceive without success. Forty years ago, few people would have known what the signs and symptoms of breast cancer were, yet through health promotion activities such as the introduction of mammogra- phy and the endorsement of breast self-examination, find- ing a lump in a breast for most women signals the need to seek medical advice and investigation. We need to take the same approach to fertility. According to current statis- tics, many women are not optimizing their fertility. For example, women are entering parenthood at an age where their fertility is declining and are increasingly engaging in fertility-compromising behaviours (obesity, smoking, alco- hol, sexually transmitted infections). In addition to increas- ing general awareness about lifestyle and reproductive risk factors, Jane recommended that all women be given infor- mation about age-related fertility. Despite the validity of her recommendation, knowledge of risks alone may not be sufficient to get people to attend to their fertility health. The health belief model (Rosenstock, 1990) emphasizes the need for an individual to feel personally vulnerable (i.e. perceived susceptibility) to the threat (e.g. likelihood of becoming childless) in order for any action (e.g. reduction of risk) to occur. In addition, empirical research has shown that focusing on personal risk is more effective in promoting change than a general awareness of risk (Fischhoff et al.,

1993; Greening et al., 2005). Evidence-based tools such as the FertiSTAT (Bunting and Boivin, 2010) provide a compre- hensi