Chapter 9 248 visualized in a jar61. Moreover, patients specifically addressed the importance of discussing (grief after) childlessness (Chapter 3, Chapter 6, Chapter 8). From studies on failed fertility treatment, we learned that grief reactions are a common reaction in couples who experience involuntary childlessness62. Although studies on childlessness amongst women with psychiatric vulnerability are currently lacking, our results imply that similar reactions occur in this group as compared to women who experience unwanted childlessness (Chapter 6). Although the findings were derived from two surveys populated by the MIND panel, the use of panel data is limited by some factors. Most panel members are elderly, higher educated and native Dutch (Chapter 3, Chapter 8). Our findings might represent this group of persons with (past) psychiatric vulnerability, but do not give insight in the experiences of those younger, with lower education, unemployment and other backgrounds than native Dutch. This is important as the MIND panel may not adequately represent the patients in general Dutch psychiatric healthcare. Our knowledge on the impact of psychiatric vulnerability on reproductive health matters as family planning and childlessness should thus be gathered from other samples, too. Finally, efforts should be made to understand the contradiction between the high prevalence of UPs amongst women with psychiatric vulnerability on the one hand (Chapter 2,3,4), and the reluctance to discuss contraceptive care on the other hand (86.6 % did not want to discuss contraception use) (Chapter 8). Although most survey respondents used contraceptives when at risk for a pregnancy (75.3%,), they also provided reasons to not use contraceptives. Diminished reproductive control (having an involuntary sexual relationship or being influenced by a partner to not use contraceptive methods), problems with using contraceptives (lacking therapeutic alliance, not tolerating hormonal contraceptives, interaction between other medication and contraceptives) and perceptions about being infertile due to psychiatric vulnerability made participants abstain from using contraceptives (Chapter 3). These reasons suggest that patients lack information about effectiveness of contraceptives, (in)fertility and psychiatric vulnerability, while simultaneously raising concerns about the presence of reproductive control in this group of patients. As aforementioned aspects of contraceptive use like therapeutic alliance, medication interactions and perceptions about fertility due to psychiatric disorders could fit the expertise of MHPs, it is unfortunate that patients with psychiatric vulnerability (both men and women) were reluctant to discuss contraceptive methods with MHPs (Chapter 8). We hypothesize this topic may be sensitive, as previous generations of (in)patients with psychiatric vulnerability received contraceptives against their will63. Future efforts should be made to understand the reluctance of patients to discuss contraceptive methods, given the risk of UPs in women with psychiatric vulnerability.
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