Unintended pregnancy influences racial disparity in tubal sterilization rates

Association between pregnancy planning or intention and early child development: A systematic scoping review

The Sustainable Development Goals have a specific target to "ensure that all girls and boys have access to quality early childhood development" by 2030. There is sparse literature regarding the impact of pregnancy intention (wantedness and timing) or planning on child development. We aimed to summarize the evidence measuring the association between unintended or unplanned pregnancy and child development for children aged 3 to 5. We included studies that compared developmental outcomes of children from unwanted, unplanned, or mistimed pregnancies to those of children from wanted or planned pregnancies. In April 2022, we searched Ovid MEDLINE (from 1946), EMBASE (from 1974), and SCOPUS (from inception) without language restrictions. One reviewer tabulated data on country and year of study, population, sample and sampling method, age of participants, exposure, date of exposure retrieval, developmental outcome(s), assessment (direct or through third parties), statistical methods (including covariate selection methods), and effect estimates into bespoken data tables. Our scoping review identified 12 published studies reporting on 8 "cohorts" (range: 1963-2016) with information on approximately 39,000 children born mostly in developed countries. Overall, unwanted/unplanned pregnancies seemed to be associated with poorer child development when compared with wanted/planned pregnancies. Mistimed or delayed pregnancies correlated with weaker effects in the same direction. We concluded that achieving the target for SDG 4, related to child development, might entail policies that create environments supportive of wanted conception and access to safe abortion.

Emergency Contraception: Access and Challenges at Times of Uncertainty

BACKGROUND

The UN Commission on Life-Saving Commodities for Women's and Children's Health identified emergency contraceptive pills as 1 of the 13 essential underused, low-cost, and high-impact commodities that could save the lives of millions of women and children worldwide. In the US, 2 emergency contraceptive regimens are currently approved, and their most plausible mechanism of action involves delaying and/or inhibiting ovulation.

AREAS OF UNCERTAINTY

Abortion and contraception are recognized as essential components of reproductive health care. In the US, in the wake of the Dobbs v. Jackson Women's Health Organization Supreme Court decision on June 24, 2022, 26 states began to or are expected to severely restrict abortion. It is anticipated that these restrictions will increase the demand for emergency contraception (EC). Several obstacles to EC access have been described, and these include cost, hurdles to over-the-counter purchase, low awareness, myths about their mechanisms of action, widespread misinformation, and barriers that special populations face in accessing them. The politicization of EC is a major factor limiting access. Improving sex education and health literacy, along with eHealth literacy, are important initiatives to improve EC uptake and access.

DATA SOURCES

PubMed, The Guttmacher Institute, Society of Family Planning, American College of Obstetrician and Gynecologists, the World Health Organization, The United Nations.

THERAPEUTIC ADVANCES

A randomized noninferiority trial showed that the 52 mg levonorgestrel intrauterine device was noninferior to the copper intrauterine device when used as an EC method in the first 5 days after unprotected intercourse. This is a promising and highly effective emergency contraceptive option, particularly for overweight and obese patients, and a contraceptive option with a different bleeding profile than the copper intrauterine device.

CONCLUSIONS

EC represents an important facet of medicine and public health. The 2 medical regimens currently approved in the US are very effective, have virtually no medical contraindications, and novel formulations are actively being investigated to make them more convenient and effective for all patient populations. Barriers to accessing EC, including the widespread presence of contraception deserts, threaten to broaden and accentuate the already existing inequities and disparities in society, at a time when they have reached the dimensions of a public health crisis.

Disparities in postpartum contraceptive use among immigrant women with restricted Medicaid benefits

BACKGROUND

The Emergency Medicaid program offers restricted Medicaid benefits for people who meet the same financial eligibility criteria as Traditional Medicaid recipients but do not meet the citizenship requirements for enrollment in Traditional Medicaid. By federal law, Emergency Medicaid covers care for life-threatening emergencies or a hospital admission for childbirth. No prenatal or postpartum care is covered. Most of the women enrolled in Emergency Medicaid are Latina.

OBJECTIVE

We assessed postpartum visits and receipt of postpartum contraception and compared the outcomes for Emergency (restricted benefit) Medicaid recipients with those of Traditional (full-benefit) Medicaid recipients in Oregon and South Carolina, 2 states with similar-sized immigrant populations.

STUDY DESIGN

We conducted a retrospective cohort study using linked Medicaid claims and birth certificate data of live births covered by Medicaid (Traditional and Emergency) between January 1, 2010 and September 30, 2017, in Oregon and South Carolina. Our analysis was at the individual level. Primary outcomes were postpartum visit attendance and receipt of postpartum contraception within 2 months. We examined differences in demographic and delivery characteristics by Medicaid type. If women received postpartum contraception, we compared the timing of receipt (immediate postpartum, ≤1 month, 1–2 months, and 2–6 months after delivery) by the type of Medicaid. Among women using contraception, we described the type of contraceptive received at each time point, stratified by Medicaid type. Associations between Medicaid type (Traditional vs Emergency) and postpartum visit attendance and contraception use were assessed using adjusted absolute predicted probabilities from logistic regression models. We ran models for the entire cohort and conducted a subanalysis restricted to only Latina women.

RESULTS

Our study included 375,544 live births to 288,234 women, with 12.7% of births among Emergency Medicaid recipients. Women enrolled in Emergency Medicaid tended to be older (age >35 years; 18.1% vs 7.2%; P<.001) and were more likely to be multiparous (76.8% vs 60.8%; P<.001) and Latina (80.3% vs 9.5%; P<.001) than their Traditional Medicaid peers. Among women enrolled in Emergency Medicaid, the probability of having a postpartum visit was 6.1% (95% confidence interval, 5.9–6.4) compared with 58.8% (95% confidence interval, 58.6–58.9) for women covered by Traditional Medicaid. After 6 months following delivery, 97.6% of Emergency Medicaid recipients had no evidence of contraceptive use compared with 55.6% of Traditional Medicaid enrollees (P<.001). In our adjusted model, Emergency Medicaid recipients were also significantly less likely to receive postpartum contraception than Traditional Medicaid enrollees (1.9% vs 35.5%; 95% confidence interval, [1.8–2.1] vs [35.4–35.7]). We examined the role that race may play in postpartum contraceptive use by conducting a subanalysis restricted to Latina women only.

Latinas with births covered by Emergency Medicaid had a 1.9% (95% confidence interval, 1.8–2.0) adjusted probability of postpartum contraception use within 2 months compared with 39.8% (95% confidence interval, 38.7–39.9) among Latinas enrolled in Traditional Medicaid.

CONCLUSION

Women enrolled in Emergency Medicaid experience large disparities in postpartum care and contraceptive use. Policies that restrict Medicaid coverage following delivery exacerbate inequities in postpartum care, potentially leading to worse health outcomes for low-income immigrants and their children.

The process of opting for female permanent contraception: A qualitative study of women's experiences in Sweden

OBJECTIVES

We aimed to explore Swedish women's decision-making experiences regarding permanent contraception.

STUDY DESIGN

In this study, we included 17 women aged 30-48 who were scheduled to undergo female permanent contraceptive procedures. We conducted semistructured interviews using two broad open-ended questions. We analyzed these data using systematic text condensation based on the principles of psychological phenomenological analysis.

RESULTS

The interviewees experienced no counseling or support from health care workers regarding permanent contraception until they specifically asked for it. Participants reported that they themselves place the responsibility of permanent contraception solely on women. Consequently, our participants described feeling hesitancy and ambivalence in the process of deciding to have the procedure. Once the decision was made and the women were on the waiting lists for surgery, they experienced relief and empowerment.

CONCLUSIONS

Our findings suggest that health care providers in Sweden miss opportunities to support patient-centered decision-making regarding permanent contraception. This study indicates that women make deliberate and considered decisions regarding permanent contraception and are best positioned to know when the procedure should take place in their reproductive lives.

IMPLICATION STATEMENTS

Health care professionals should discuss permanent contraception as an option with all women desiring contraception to allow them to decide if that method is right for them.

Changing Educational Differentials in Female Sterilization

CONTEXT

Female surgical sterilization is widely used in the United States. Educational differentials in sterilization are large, but poorly understood. Improved understanding of these differences is important to ensure that all women have access to the full range of contraceptive methods.

METHODS

Data from the National Survey of Family Growth (1973-2015) from 8,100 women aged 40-44 were used to describe trends in sterilization and other contraceptive methods by educational attainment. Demographic standardization was employed to examine how compositional changes in marital status and age at first birth contribute to aggregate changes in sterilization prevalence.

RESULTS

In 1982, women with a high school diploma and those with at least a bachelor's degree reported similar levels of sterilization use (38% and 32%, respectively), but by 2011-2015, prevalence had declined to 19% among college-educated women and had increased to 44% among those with a diploma. The trend among college graduates was largely attributable to delayed fertility; all other things being equal, if their age at first birth had not increased, the prevalence of sterilization would have declined by approximately 3% instead of 14% between 1982 and 2002. Increased use of sterilization among women with a high school diploma was only weakly related to changes in birth timing and marital status.

CONCLUSIONS

Among women with a high school diploma, elements other than childbearing and marital status-such as contraceptive preferences and access-appeared to influence their contraceptive behavior. Sterilization differentials between high school and college graduates may reflect or exacerbate other socioeconomic disparities that affect women's health and well-being.

Racial and ethnic differences in patterns of long-acting reversible contraceptive use in the United States, 2011-2015

OBJECTIVE

To investigate whether demographic, socioeconomic, and reproductive health characteristics affect long-acting reversible contraceptive (LARC) use differently by race-ethnicity. Results may inform the dialogue on racial pressure and bias in LARC promotion.

STUDY DESIGN

Data derived from the 2011-2013 and 2013-2015 National Surveys of Family Growth (NSFG). Our study sample included 9321 women aged 15-44. Logistic regression analyses predicted current LARC use (yes vs. no). We tested interaction terms between race-ethnicity (non-Hispanic White, non-Hispanic Black, Hispanic) and covariates (for example, education, parity, poverty level) to explore whether their effects on LARC use vary by race-ethnicity.

RESULTS

In the race-interactions model, data did not show that low income and education predict LARC use more strongly among Black and Hispanic women than among White women. There was just one statistically significant race-interaction: experience of unintended pregnancy (p=.014). Among Whites and Hispanics, women who reported ever experiencing an unintended pregnancy had a higher predicted probability of LARC use than those who did not. On the other hand, among Black women, the experience of unintended pregnancy was not associated with a higher predicted probability of LARC use.

CONCLUSIONS

With the exception of the experience of unintended pregnancy, findings from this large, nationally representative sample of women suggest similar patterns in LARC use by race-ethnicity.

IMPLICATIONS

Results from this analysis of NSFG data do not provide evidence that observed differences in LARC use by race-ethnicity represent socioeconomic disparities, and may assuage some concerns about reproductive coercion among women of color. Nevertheless, it is absolutely critical that providers use patient-centered approaches for contraceptive counseling that promote women's autonomy in their reproductive health care decision-making.

Recommendations for Contraception: Examining the Role of Patients' Age and Race

The literature suggests that women of different races are more or less likely to use certain contraceptive methods and patient race can influence which contraceptive recommendations a provider makes. To explore whether health care providers treat individuals of different races differently, we conducted a preliminary investigation on whether medical students recommended different contraceptive methods for hypothetical patients presenting with the same clinical features who only varied by race. Third- and fourth-year medical students (n=103) at the University of Hawai'i completed an online survey. Students read case studies about a 23-year-old and 36-year-old patient and then made contraceptive recommendations. All students reviewed the same scenarios, with the exception of the patient's name which was randomly assigned to represent one of five racial/ethnic groups (White, Chinese, Filipina, Native Hawaiian, and Micronesian). Recommendations were analyzed using χ² tests and bivariate logistic regressions. For the younger patient, students were most likely to recommend intrauterine devices (IUDs), followed by the contraceptive pill and Etonogestrel implant; recommendations did not differ by race/ethnicity (P = .91). For the older patient, students were most likely to recommend IUDs or sterilization, and Micronesian women were more likely to receive sterilization recommendations compared to White women (60% versus 27%, P = .04). In summary, contraceptive recommendations, specifically the frequency of recommending sterilization varied by race. Our findings add to the literature exploring the role of a patient's race/ethnicity on recommendations for contraception and highlights the need for more studies exploring the etiology of health care disparities.

HIGH PREVALENCE OF VOLUNTARY STERILIZATION AMONG AMERICAN WOMEN EXPLAINED BY TRADE-OFFS RESULTING FROM MALE PARENTAL COMMITMENT

Tubal ligation is the modal form of family planning among American women aged 30 and older. As the preference for tubal ligation over cheaper, lower risk and more reliable methods, such as vasectomy, has puzzled experts, a theoretical approach that explains this preference would be useful. The present study investigates the high prevalence of voluntary sterilization among American women from the perspective of life history theory, arguing that the trade-offs between investing in current and future offspring will favour tubal ligation when women cannot obtain reliable male commitment to future parental investment. Data came from the National Survey of Fertility Barriers (NSFB), a nationally representative survey of 4712 American women aged 25-45 conducted between 2004 and 2007. Four novel predictions of the prevalence of tubal ligation, drawn from life history theory, were developed and tested: 1) it is most common among unpartnered women with children, and least common among married women with children; 2) it is negatively correlated with age at first birth; 3) it is least common among highly educated women without children, and most common among less educated women with children; and 4) among women with two or more children, it is positively correlated with lifetime number of long-term partners. These predictions were tested using multivariate regression analysis. The first prediction was not supported: women with children were more likely to be sterilized, regardless of their marital status. The other three predictions were all supported by the data. The results suggest that trade-offs influence women's decisions to undergo voluntary sterilization. Women are most likely to opt for tubal ligation when the costs of an additional child will impinge on their ability to invest in existing offspring, especially in the context of reduced male commitment.

Racial and Ethnic Disparities in Health and Health Care

A health disparity is defined as an increased burden of an adverse health outcome or health determinant within a specific subset of the population. There are well-documented racial and ethnic disparities throughout health care at the patient, provider, and health care system levels. As the minority populations within the United States grow to record numbers, it is increasingly important to invest in efforts to characterize, understand, and end racial and ethnic disparities in health care. Inequities in health outcomes and care pose real threats to the entire nation's well-being. Eliminating health disparities is fundamental to the well-being, productivity, and viability of the entire nation.

Racial and Ethnic Health Care Disparities Among Women in the Veterans Affairs Healthcare System: A Systematic Review

BACKGROUND

Women are a rapidly growing segment of patients who seek care in the Veterans Affairs (VA) Healthcare System, yet many questions regarding their health care experiences and outcomes remain unanswered. Racial and ethnic disparities have been well-documented in the general population and among veterans; however, prior disparities research conducted in the VA focused primarily on male veterans. We sought to characterize the findings and gaps in the literature on racial and ethnic disparities among women using the VA.

METHODS

We systematically reviewed the literature on racial and ethnic health care disparities exclusively among women using the VA Healthcare System. We included studies that examined health care use, satisfaction, and/or quality, and stratified data by race or ethnicity.

RESULTS

Nine studies of the 2,591 searched met our inclusion criteria. The included studies examined contraception provision/access (n = 3), treatment of low bone mass (n = 1), hormone therapy (n = 1), use of mental health or substance abuse-related services (n = 2), trauma exposure and use of various services (n = 1), and satisfaction with primary care (n = 1). Five of nine studies showed evidence of a significant racial or ethnic difference.

CONCLUSION

In contrast with the wealth of literature examining disparities both among the male veterans and women in non-VA settings, only nine studies examine racial and ethnic disparities specifically among women in the VA Healthcare System. These results demonstrate that there is an unmet need to further assess health care disparities among female VA users.

The perplexing links between contraceptive sterilization and (dis)advantage in ten low-fertility countries

This study investigated the association between contraceptive sterilization and socio-economic status (measured by educational attainment) in ten countries, using data from the 2006-10 National Survey of Family Growth and the 2004-10 Generations and Gender Surveys. The findings confirm that a long-standing association between socio-economic status and sterilization persists in the contemporary United States: female sterilization is associated with economic disadvantage, whereas male sterilization is associated with economic advantage. The latter association is found to be unique to the United States, but female sterilization is associated with disadvantage in most of the other countries studied. While basic demographic background factors such as early childbearing and parity can explain the observed associations in most of the countries, a strong gendered association between sterilization and socio-economic status remains in the United States and Belgium even after adjusting for these factors.

Perceived Interest in Vasectomy among Latina Women and their Partners in a Community with Limited Access to Female Sterilization

The low prevalence of vasectomy among Latino men in the United States is often attributed to cultural characteristics despite limited evidence supporting this hypothesis. We assessed male partners' perceived willingness to undergo vasectomy through surveys with 470 Mexican-origin women who did not want more children in El Paso, Texas. Overall, 32% of women reported that their partner would be interested in getting a vasectomy. In multivariable analysis, completing high school (OR=2.03 [1.05, 3.95]), having some college education (OR=2.97 [1.36, 6.48]) or receiving US government assistance (OR=1.95 [1.1, 3.45]) was associated with partners' perceived interest. Additionally, we conducted two focus groups on men's knowledge and attitudes about vasectomy with partners of a subsample of these women. Despite some misperceptions, male partners were willing to get a vasectomy, but were concerned about cost and taking time off work to recover. Health education and affordable vasectomy services could increase vasectomy use among Mexican-origin men.

Contraceptive continuation in Hispanic women

OBJECTIVE

The purpose of this study was to examine the effect of Hispanic ethnicity on the continuation and satisfaction of reversible contraceptive methods.

STUDY DESIGN

We analyzed 12 months of data that were collected from 7913 participants in the Contraceptive CHOICE Project. Kaplan-Meier survival curves were used to estimate continuation, and Cox proportional hazard models were used to estimate the risk of discontinuation.

RESULTS

Hispanic women were more likely to choose a long-acting reversible contraceptive (LARC) method compared with non-Hispanic black and non-Hispanic white women (80%, 73%, and 75%, respectively; P < .05). The 12-month continuation rates were higher for LARC methods than combined hormonal methods for all race/ethnicity (Hispanic women, 87% vs 40%; non-Hispanic black women, 85% vs 46%; non-Hispanic white women, 87% vs 56%). There was no statistical difference in discontinuation of LARC methods at 12 months. Eighty percent of LARC users reported high satisfaction levels at 12 months, regardless of race/ethnicity.

CONCLUSION

Hispanic women in the Contraceptive CHOICE Project experienced high continuation and satisfaction for LARC methods, similar to women of other ethnicities.

Surgical sterilization, regret, and race: contemporary patterns

Surgical sterilization is a relatively permanent form of contraception that has been disproportionately used by Black, Hispanic, and Native American women in the United States in the past. We use a nationally representative sample of 4592 women ages 25-45 to determine whether sterilization continues to be more common and consequential by race for reproductive-age women. Results indicate that Native American and Black women are more likely to be sterilized than non-Hispanic White women, and Hispanic and Native American women are more likely than non-Hispanic White women to report that their sterilization surgeries prevent them from conceiving children they want. Reasons for sterilization differ significantly by race. These findings suggest that stratified reproduction has not ended in the United States and that the patterns and consequences of sterilization continue to vary by race.

Factors associated with sterilization use among women leaving a U.S. jail: a mixed methods study

Background

Despite the high rates of reported sterilization use among women who have spent time in correctional facilities, little is known about the context in which women in this population choose this option. The objective of our study was to use both quantitative and qualitative methods to understand factors associated with sterilization use among women leaving a U.S. jail.

Methods

We administered a cross-sectional survey with 102 jailed women who were participating in a study about contraceptive use after release from jail, and then conducted semi-structured interviews with 29 of those women after their release from jail. We used logistic regression and analytic induction to assess factors associated with self-reported sterilization use.

Results

In our cross-sectional survey, one-third of our sample reported a history of sterilization use. Controlling for age and past pregnancies, the only factor associated with sterilization use was physical abuse history before age 16. In semi-structured interviews, we found that women’s primary motivation for sterilization was the desire to limit childbearing permanently, in some cases where other contraceptive methods had failed them. The decision for sterilization was generally supported by family, partners, and providers. Many women who opted for sterilization expressed financial concern about supporting children and/or reported family histories of sterilization.

Conclusions

The decision to use the permanent method of sterilization as a contraceptive method is a complex one. Results from this study suggest that while explicit coercion may not be a factor in women’s choice for sterilization, interpersonal relationship histories, negative experiences with contraceptives, and structural constraints, such as financial concerns and ongoing criminal justice involvement, seem to influence sterilization use among the vulnerable group of women with criminal justice histories. Public health programs that connect women to reproductive health services should acknowledge constraints on contraceptive decision-making in vulnerable populations.

Racial/ethnic disparities in contraceptive use: variation by age and women's reproductive experiences

OBJECTIVE

Disparities in unintended pregnancy in the United States are related, in part, to black and Hispanic women being overall less likely to use effective contraceptive methods. However, the fact that these same groups are more likely to use female sterilization, a highly effective method, suggests there may be variability in disparities in contraceptive use across a woman's life course. We sought to assess the relationship between race/ethnicity and contraceptive use in a nationally representative sample and to approximate a life course perspective by examining effect modification on these disparities by women's age, parity, and history of unintended pregnancy.

STUDY DESIGN

We conducted an analysis of the 2006 through 2010 National Survey of Family Growth to determine the association between race/ethnicity and: (1) use of any method; (2) use of a highly or moderately effective method among women using contraception; and (3) use of a highly effective method among women using contraception. We then performed analyses to assess interactions between race/ethnicity and age, parity, and history of unintended pregnancy.

RESULTS

Our sample included 7214 females aged 15-44 years. Compared to whites, blacks were less likely to use any contraceptive method (adjusted odds ratio, 0.65); and blacks and Hispanics were less likely to use a highly or moderately effective method (adjusted odds ratio, 0.49 and 0.57, respectively). Interaction analyses revealed that racial/ethnic disparities in contraceptive use varied by women's age, with younger women having more prominent disparities.

CONCLUSION

Interventions designed to address disparities in unintended pregnancy should focus on improving contraceptive use among younger women.

Sterilization of rural and urban women in the United States

OBJECTIVE

To examine the prevalence of sterilization among women aged 20-34 years in rural and urban areas in the United States.

METHODS

Data were obtained from the 2006-2010 National Survey of Family Growth, a cross-sectional survey conducted by the Centers for Disease Control and Prevention. The study population included the 4,685 female respondents who did not want to become pregnant at the time of the survey. Women who were not sexually active with men or were infertile for reasons other than contraception were excluded. We performed bivariate and stratified analysis and multivariable logistic regression modeling to determine the associations between place of residence and sterilization after considering other demographic characteristics.

RESULTS

Rural women were at increased odds of undergoing sterilization compared with urban and suburban women (22.75% compared with 12.69%, respectively; crude odds ratio [OR] 2.03, 95% confidence interval [CI] 1.44-2.86; risk difference 0.10, 95% CI 0.05-0.16). Education level was found to be a significant effect modifier of the relationship between location of residence and sterilization. In adjusted analysis, controlling for age, parity, race and ethnicity, income, insurance status, history of unintended pregnancy, and relationship status, rural women without a high school degree were more likely to have undergone sterilization compared with urban and rural women with greater than a high school education (OR 8.34, 95% CI 4.45-15.61).

CONCLUSIONS

Rural women with low education levels have a high prevalence of sterilization. Future studies need to address the reasons for this interaction between education and geography and its influence on contraceptive method choice.

LEVEL OF EVIDENCE

II.

Racial and ethnic differences in U.S. women's choice of reversible contraceptives, 1995-2010

CONTEXT

In the United States, unintended pregnancies disproportionately affect minority populations. Persistent disparities in contraceptive use between black and Hispanic women and white women have been identified, but it is unclear whether racial and ethnic differences in use of the most effective methods have changed.

METHODS

Data on 4,727 women from the 1995 National Survey of Family Growth and 5,775 women from the 2006-2010 cycle were used to examine the association between race and ethnicity and women's choice of reversible contraceptives according to level of method effectiveness. Stepwise multinomial logistic regressions were used to identify changes in this association between cycles. Analyses controlled for demographic, socioeconomic, family, religious, behavioral and geographic characteristics.

RESULTS

The proportion of women using the most effective reversible contraceptive methods increased from 46% in 1995 to 53% in 2006-2010. In 1995, black and Hispanic women's use of the most effective reversible contraceptives did not differ from that of white women. By 2006-2010, however, black women were substantially less likely than white women to use highly effective reversible contraceptive methods rather than no method (relative risk ratio, 0.6). An analysis that combined the two data sets and included a term for the interaction between survey year and race and ethnicity found that relative to white women, black women were less likely in 2006-2010 than in 1995 to use more effective methods rather than no method (0.6).

CONCLUSIONS

Further research is needed to identify factors that may be causing racial and ethnic disparities in contraceptive decisions to widen.

Does a history of unintended pregnancy lessen the likelihood of desire for sterilization reversal?

BACKGROUND

Unintended pregnancy has been significantly associated with subsequent female sterilization. Whether women who are sterilized after experiencing an unintended pregnancy are less likely to express desire for sterilization reversal is unknown.

METHODS

This study used national, cross-sectional data collected by the 2006-2010 National Survey of Family Growth. The study sample included women ages 15-44 who were surgically sterile from a tubal sterilization at the time of interview. Multivariable logistic regression was used to examine the relationship between a history of unintended pregnancy and desire for sterilization reversal while controlling for potential confounders.

RESULTS

In this nationally representative sample of 1,418 women who were sterile from a tubal sterilization, 78% had a history of at least one unintended pregnancy and 28% expressed a desire to have their sterilization reversed. In unadjusted analysis, having a prior unintended pregnancy was associated with higher odds of expressing desire for sterilization reversal (odds ratio [OR]: 1.80; 95% confidence interval [CI]: 1.15-2.79). In adjusted analysis controlling for sociodemographic factors, unintended pregnancy was no longer significantly associated with desire for reversal (OR: 1.46; 95% CI: 0.91-2.34).

CONCLUSION

Among women who had undergone tubal sterilization, a prior history of unintended pregnancy did not decrease desire for sterilization reversal.

Hormonal contraceptive use and discontinuation because of dissatisfaction: differences by race and education

The unintended pregnancy rate in the United States remains high, and there are large race and education differences in unintended pregnancy and fertility. These differences make it important to study race and education differences in contraceptive behavior. Using nationally representative data from the 2002 National Survey of Family Growth, this study examines the effects of race and education on the likelihood that women have ever used particular types of hormonal contraception and have ever discontinued hormonal contraception because of dissatisfaction. The results show that blacks and Latinas were more likely to have used injectable contraceptives ("the shot") and less likely to have used oral contraceptives ("the pill") than were white women. Women with less education were more likely than college-educated women to have used the shot but there were no significant education differences in use of the pill. Among women who had ever used hormonal birth control, those with less than a college degree were more likely than college-educated women to discontinue the birth control because of dissatisfaction. However, net of education, this study found no significant racial/ethnic differences in discontinuation. The most commonly stated reason for discontinuation because of dissatisfaction was side effects.

Hormonal contraceptive use and discontinuation because of dissatisfaction: differences by race and education

The unintended pregnancy rate in the United States remains high, and there are large race and education differences in unintended pregnancy and fertility. These differences make it important to study race and education differences in contraceptive behavior. Using nationally representative data from the 2002 National Survey of Family Growth, this study examines the effects of race and education on the likelihood that women have ever used particular types of hormonal contraception and have ever discontinued hormonal contraception because of dissatisfaction. The results show that blacks and Latinas were more likely to have used injectable contraceptives ("the shot") and less likely to have used oral contraceptives ("the pill") than were white women. Women with less education were more likely than college-educated women to have used the shot but there were no significant education differences in use of the pill. Among women who had ever used hormonal birth control, those with less than a college degree were more likely than college-educated women to discontinue the birth control because of dissatisfaction. However, net of education, this study found no significant racial/ethnic differences in discontinuation. The most commonly stated reason for discontinuation because of dissatisfaction was side effects.

Lack of insurance and parity influence choice between long-acting reversible contraception and sterilization in women postpregnancy

BACKGROUND

Disparities in postpregnancy contraception utilization exist, with low-income women disproportionately undergoing sterilization. We assessed the impact of increased intrauterine device (IUD) availability on rates of female sterilization.

STUDY DESIGN

Hospital billing records were used to identify women with an IUD placement or sterilization within 1 year of a pregnancy at a university hospital between Oct 2005 and Jun 2007. Demographic data were compared between women receiving either an IUD or sterilization.

RESULTS

There were 365 sterilizations and 223 IUD placements during the study period. IUD placements doubled over the study period from 6% to 12% of all deliveries, while sterilizations remained stable at 11% (p<.001). Demographic variables were examined for women with either public or private insurance who had financial access to both sterilization (n=253) and IUD (n=223). Women receiving sterilization were slightly older (mean age 31 years versus 30 years, p=.03), of higher parity (median three versus two, p<.01), more likely to have had cesarean delivery (69% versus 31%, p<.001) and more likely to have public insurance (77% versus 23%, p<.001) than women who received IUD. Approximately 45% of women delivering in Oregon in 2007 were publicly insured (2010 Maternal and Child Health Update: States Make Progress Towards Improving Systems of Care. National Governor's Association, Table 6. Available at http://www.nga.org/files/live/sites/NGA/files/pdf/MCHUPDATE2010.PDF, accessed Nov 2011). After adjusting for age, parity and type of delivery, women choosing sterilization were more likely to have public insurance than women choosing IUD (odds ratio 8.4, 95% confidence interval 4.7-14.9, p<.0001).

CONCLUSIONS

Women choosing sterilization are more likely to have public insurance than women choosing IUD and may represent a continued trend toward nonreversible contraception among women of lower socioeconomic status despite available long-acting reversible methods.

Pregnancy outcomes following use of escitalopram: a prospective comparative cohort study

Escitalopram is a serotonin reuptake inhibitor prescribed for depression and anxiety. There is a paucity of information regarding safety in pregnancy. The objective of this study was to determine whether escitalopram is associated with an increased risk for major malformations or other adverse outcomes following use in pregnancy. The authors analyzed pregnancy outcomes in women exposed to escitalopram (n = 212) versus other antidepressants (n = 212) versus nonteratogenic exposures (n = 212) and compared the outcomes. Among the escitalopram exposures were 172 (81%) live births, 32 (15%) spontaneous abortions, 6 (2.8%) therapeutic abortions, 3 stillbirths (1.7%), and 3 major malformations (1.7%). The only significant differences among groups was the rate of low birth weight (<2500 g) and overall mean birth weight (P = .225). However, spontaneous abortion rates were higher in both antidepressant groups (15% and 16%) compared with controls (8.5%; P = .066). There were lower rates of live births (P = .006), lower overall birth weight (P < .001), and increased rates of low birth weight (<2500 g; P = .009) with escitalopram. Spontaneous abortion rates were nearly double in both antidepressant groups (15% and 16%) compared with controls (8.5%) but not significant (P = .066). Escitalopram does not appear to be associated with an increased risk for major malformations but appears to increase the risk for low birth weight, which was correlated with the increase in infants weighing <2500 g. In addition, the higher rates of spontaneous abortions in both antidepressant groups confirmed previous findings.

Female sterilisation in the United States

Female sterilisation is a safe and effective form of permanent birth control. In the United States (US), it is still the second most commonly used form of contraception overall and is the most frequently used method among married women and among women over 30 years of age. Although several European countries have noted a sharp decline in the number of women electing tubal sterilisation in recent years, such trends have not been as obvious in the US. While female sterilisation remains popular, there are considerable system-level barriers to getting the procedure for certain segments of the population as well as emerging concerns about appropriate utilisation of this contraceptive method in light of newer, reversible options and the knowledge that regret after permanent contraception is high. Given the complexity of this decision-making process, it is critical that providers ensure at the very least that women are aware of the potential disadvantages of tubal occlusion and are knowledgeable of other highly effective contraceptive methods that are available but vastly underutilised in the US, namely, vasectomy, intrauterine contraceptives, and implants.

Racial variation in tubal sterilization rates: role of patient-level factors

OBJECTIVE

To assess racial differences in attitudes and knowledge about sterilization.

DESIGN

Cross-sectional survey.

SETTING

Questionnaires were mailed to participants' home addresses.

PATIENT(S)

One hundred ninety-three women, aged 18-45, who had undergone tubal sterilization.

INTERVENTION(S)

None.

MAIN OUTCOME MEASURE(S)

Attitudes and knowledge about tubal sterilization and awareness of contraceptive alternatives.

RESULT(S)

We received 193 completed surveys (64% response rate). African American (AA) woman were more likely to have a family member who had undergone tubal sterilization, to report that their mothers influenced their sterilization decisions, and to report that prior unintended pregnancy and desire to avoid insertion of a foreign object were very important factors in their decision to choose sterilization over other methods. Compared with white women, AA women more often thought that sterilization reversal could easily restore fertility (62% vs. 36%); that a woman's sterilization would reverse itself after 5 years (60% vs. 23%); and that a man cannot ejaculate after vasectomy (38% vs. 13%). Fewer AA women had ever heard of intrauterine contraception (90% vs. 98%). Racial differences in knowledge remained statistically significant after adjusting for socioeconomic confounders.

CONCLUSION(S)

Misinformation about sterilization and limited awareness of contraceptive alternatives among AA women may contribute to racial disparities in tubal sterilization rates.

Vasectomy: the other (better) form of sterilization

Male sterilization (vasectomy) is the most effective form and only long-acting form of contraception available to men in the United States. Compared to female sterilization, it is more efficacious, more cost-effective, and has lower rates of complications. Despite these advantages, in the United States, vasectomy is utilized at less than half the rate of female sterilization. In addition, vasectomy is least utilized among black and Latino populations, groups with the highest rates of female sterilization. This review provides an overview of vasectomy use and techniques, and explores reasons for the disparity in vasectomy utilization in the United States.

Time-to-pregnancy and pregnancy outcomes in a South African population

BACKGROUND

Time-to-pregnancy (TTP) has never been studied in an African setting and there are no data on the rates of adverse pregnancy outcomes in South Africa. The study objectives were to measure TTP and the rates of adverse pregnancy outcomes in South Africa, and to determine the reliability of the questionnaire tool.

METHODS

The study was cross-sectional and applied systematic stratified sampling to obtain a representative sample of reproductive age women for a South African population. Data on socio-demographic, work, health and reproductive variables were collected on 1121 women using a standardized questionnaire. A small number (n = 73) of randomly selected questionnaires was repeated to determine reliability of the questionnaire. Data was described using simple summary statistics while Kappa and intra-class correlation statistics were calculated for reliability.

RESULTS

Of the 1121 women, 47 (4.2%) had never been pregnant. Mean gravidity was 2.3 while mean parity was 2.0 There were a total of 2467 pregnancies; most (87%) resulted in live births, 9.5% in spontaneous abortion and 2.2% in still births. The proportion of planned pregnancies was 39% and the median TTP was 6 months. The reliability of the questionnaire for TTP data was good; 63% for all participants and 97% when censored at 14 months. Overall reliability of reporting adverse pregnancy outcomes was very high, ranging from 90 - 98% for most outcomes.

CONCLUSION

This is the first comprehensive population-based reproductive health study in South Africa, to describe the biologic fertility of the population, and provides rates for planned pregnancies and adverse pregnancy outcomes. The reliability of the study questionnaire was substantial, with most outcomes within 70 - 100% reliability index. The study provides important public information for health practitioners and researchers in reproductive health. It also highlights the need for public health intervention programmes and epidemiological research on biologic fertility and adverse pregnancy outcomes in the population.