Family planning and female sterilization in the United States

"They don't care to study it": Trust, race, and health care experiences among patient-caregiver dyads with multiple myeloma

BACKGROUND

Medical mistrust, rooted in unethical research, is a barrier to cancer-related health care for Black/African American (AA) persons. Understanding trust, mistrust, and health care experiences is crucial, especially in multiple myeloma (MM), which disproportionately burdens Black/AA persons in incidence and survival.

STUDY PURPOSE

This study qualitatively examines the experiences of Black/AA and White dyads (patient with MM and adult caregiver) to gain insights into these phenomena.

METHODS

From November 2021 to April 2022, we recruited 21 dyads from the UNC Lineberger Comprehensive Cancer Center. Participants completed a sociodemographic survey and a 60-90 min semi-structured interview. We used ATLAS.ti v9 for project management and to facilitate data analysis using the Sort and Sift, Think and Shift approach (ResearchTalk Inc).

RESULTS

We interviewed 21 racially concordant dyads (11 Black/AA, 10 White) with mean patient ages of 70 (Black/AA) and 72 (White) at enrollment. Both Black/AA and White caregivers had a mean enrollment age of 68. The mean duration from MM diagnosis to enrollment for all patients was 5.5 years. Four key themes emerged: (1) knowledge and trust, (2) heightened emotions and discomfort, (3) differing mental constructs of health care experiences, and (4) mitigating mistrust, which varied by self-identified race. Black/AA participants had greater knowledge of historical events like the U.S. Public Health Service Untreated Syphilis Study at Tuskegee and carried the emotional burden longer. They also emphasized self-learning and self-guided research about MM for informed medical decision-making. Both Black/AA and White dyads emphasized the pivotal role of patient-provider relationships and effective communication in fostering trust and addressing concerns.

CONCLUSION

Our study offers contextual insights into the enduring challenges of medical mistrust, particularly within the Black/AA community, and its implications for patients and caregivers accessing and receiving MM-related care. Future studies should leverage these insights to guide the development of multilevel interventions addressing medical mistrust within the Black/AA community.

Development of My Decision/Mi Decisión, a web-based decision aid to support permanent contraception decision making

Objective

To develop a patient-centered, web-based decision aid to support informed and value-concordant decision making among Medicaid enrollees considering tubal sterilization.

Methods

We used the Ottawa Decision Support Framework and the International Patient Decision Aids Standards (IPDAS) to guide systematic development of our decision aid. We interviewed 15 obstetrician-gynecologists and 40 women, who had considered or were considering tubal sterilization. A Steering Committee-comprising healthcare providers, social scientists, reproductive health and justice advocates, and people with lived experience-provided feedback and direction. We developed English and Spanish prototypes, which were beta tested with 24 women.

Results

The resulting web-based My Decision/Mi Decisión tool (English/Spanish) includes written and video information about tubal sterilization procedures; an interactive table of contraception options; values clarification exercises; reflection and deliberation; knowledge checks; and a summary report to share with one's provider. Users found the decision aid to be informative, engaging, easy to use, and helpful in informing contraception decision making.

Conclusion

My Decision/Mi Decisión is a scalable tool that could be implemented widely to support informed decision making about tubal sterilization.

Innovation

This is a novel and timely web-based decision tool for tubal sterilization, when demand for permanent contraception is rapidly increasing post-Dobbs. While designed for Medicaid enrollees, further investigation will explore more generalized use.

Provider and Patient Perspectives on a New Tangible Decision Aid Tool to Support Patient-Centered Contraceptive Counseling with Adolescents and Young Adults

STUDY OBJECTIVE

Despite the benefits of patient-centered contraceptive care, many adolescents and young adults do not receive such care. The objective of this study was to develop and evaluate Hello Options, a tangible decision aid to support patient-centered contraceptive counseling with adolescents and young adults in a clinic setting. DESIGN, SETTING, PARTICIPANTS, INTERVENTION, AND MAIN OUTCOME MEASURES: Hello Options is a contraceptive counseling decision aid tool (hereafter referred to as "the Tool") that allows patients to see and feel life-size "tangible" models of the range of contraceptive methods. The Tool was developed by a team of designers, adolescents, clinicians, and researchers using human-centered design. From December 2019 to March 2020, we conducted a pilot study to evaluate the usability, feasibility, and acceptability of the Tool with 10 contraceptive care providers and 40 adolescent and young adult patients (aged 12-29 years) at two Chicago clinics. We calculated descriptive statistics for patient survey data, and qualitatively analyzed provider interview transcripts for salient themes using recursive abstraction.

RESULTS

Patients had positive reactions to the Tool, reporting that it allowed them to better understand how contraceptive methods work in their body and that it allowed them to make more informed decisions. Furthermore, providers commented that the Tool facilitated conversations with their patients, helped dispel myths about particular methods, and eased patients' anxieties. Limitations mentioned included storage and portability concerns, and time constraints for counseling.

CONCLUSION

Hello Options is a useful, feasible, and acceptable decision aid that can support the provision of patient-centered contraceptive care for young people.

Perceptions and practice of state Medicaid officials regarding informed consent for female sterilization

OBJECTIVE

To explore the attitudes, beliefs, and interpretations of individual state Medicaid office employees regarding their state's postpartum sterilization policy and its impact on patient care.

STUDY DESIGN

We invited employees in all 50 state Medicaid director's offices who self- or peer-identified as best informed about the sterilization policy to participate in semi-structured qualitative interviews. Using a pilot-tested interview guide, we transcribed, coded, and analyzed each interview. We attempted to obtain supplemental data, including relevant policy details and instructions for physicians in the state, from all 50 state Medicaid office websites.

RESULTS

We collected data from 15 telephone interviews, four written responses, and 48 states' websites for analysis. Participants had varying responses regarding the impact of the Medicaid-mandated sterilization consent form in terms of informed consent as well as the utility and ramifications of the waiting period. State policies varied in terms of the age of consent, complexity of the form, availability of translations, use of unclear terminology, and the consent-obtaining process.

CONCLUSION

State Medicaid employees have differences in opinions regarding the intent of the Medicaid-mandated sterilization consent form and policies. Better understanding of the variation in individual state policies that may contribute to inequitable access to sterilization is necessary.

IMPLICATIONS

Provision of consistent guidelines and widespread coordination of the Medicaid sterilization policies in identified areas impacting informed consent may reduce existing obstacles and provide more equitable access to contraceptive care.

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.

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.

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.

What Women Want: A Qualitative Study of Contraception in Jail

OBJECTIVES

We undertook this study to understand women's perceptions of receiving contraception at Rikers Island Jail.

METHODS

We conducted semi-structured in-depth interviews in 2011 to 2012 with 32 women incarcerated at Rikers Island Jail. We analyzed the data using standard qualitative techniques.

RESULTS

Almost all participants believed that contraception should be provided at the jail. However, many said they would hesitate to use these services themselves. Reservations were caused in part by women's negative views of health care services at the jail. Fears about the safety of birth control, difficulties associated with follow-up in the community, and desire for pregnancy were other factors that influenced interest in accepting contraception.

CONCLUSIONS

Contraception at the jail must be provided by trusted medical providers delivering high quality care with the goal of allowing women to control their own fertility; this would ensure that women could access birth control and cease using birth control when desired.

Addressing reproductive health disparities as a healthcare management priority: pursuing equity in the era of the Affordable Care Act

PURPOSE OF REVIEW

To summarize the newest available evidence on maternal and reproductive health disparities, and to describe elements of the Affordable Care Act most likely to impact these disparities.

RECENT FINDINGS

Significant racial and ethnic disparities in maternal and reproductive health outcomes have persisted in recent years, contributing to poor outcomes and increasing costs. Pregnancy-related mortality ratios are up to three times higher in Black women compared with non-Hispanic White women, with the risk of severe maternal morbidity also significantly higher in Black and Hispanic women. Unintended pregnancy is twice as likely in minority women. Insurance status, socioeconomic status, and broader social determinants of health are implicated in these disparities. Coverage changes associated with the Affordable Care Act may provide some opportunities to reach communities most at risk. Delivery innovation, payment reform, and further public financing of key services are examples of further management approaches that can be used to address reproductive health disparities.

SUMMARY

The Affordable Care Act offers important opportunities to address persistent reproductive health disparities, but significant gaps remain. Efforts must be made to reduce the negative outcomes and high financial and human costs associated with disparities in reproductive health.

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.

Control and constraint for low-income women choosing outpatient sterilization

Little is known about Hispanics and their contraceptive choices in general, with some past studies detailing nonconsensual sterilization. This article is based on interviews with a mostly Hispanic sample of 44 women being sterilized at a public clinic in southeast Texas with the Essure device, which entails a new outpatient sterilization procedure. The women cited relationship factors, wanting to better their and their children's lives, and past reproductive histories as reasons for deciding on sterilization. They specifically chose Essure as a result of an apprehension of surgery and potential side effects from tubal ligation. Their choices, however, were limited by larger structural factors of work, family, the political economy, and the health care system. We concluded that this new sterilization technique provided more contraceptive choices for these women, yet more contraceptive decision-making autonomy and more equitable social structures are still needed.

Federally funded sterilization: time to rethink policy?

In the 1970s, concern about coercive sterilization of low-income and minority women in the United States led the US Department of Health, Education, and Welfare to create strict regulations for federally funded sterilization procedures. Although these policies were instituted to secure informed consent and protect women from involuntary sterilization, there are significant data indicating that these policies may not, in fact, ensure that consent is truly informed and, further, may prevent many low-income women from getting a desired sterilization procedure. Given the alarmingly high rates of unintended pregnancy in the United States, especially among low-income populations, we feel that restrictive federal sterilization policies should be reexamined and modified to simultaneously ensure informed decision-making and honor women's reproductive choices.

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.

Disparities in family planning

Prominent racial/ethnic and socioeconomic disparities in rates of unintended pregnancy, abortion, and unintended births exist in the United States. These disparities can contribute to the cycle of disadvantage experienced by specific demographic groups when women are unable to control their fertility as desired. In this review we consider 3 factors that contribute to disparities in family planning outcomes: patient preferences and behaviors, health care system factors, and provider-related factors. Through addressing barriers to access to family planning services, including abortion and contraception, and working to ensure that all women receive patient-centered reproductive health care, health care providers and policy makers can substantially improve the ability of women from all racial/ethnic and socioeconomic backgrounds to make informed decisions about their fertility.

Unintended pregnancy influences racial disparity in tubal sterilization rates

BACKGROUND

Minority women are more likely than white women to choose tubal sterilization as a contraceptive method. Disparities in rates of unintended pregnancy may help explain observed racial/ethnic differences in sterilization, but this association has not been investigated.

OBJECTIVE

To examine the associations among race/ethnicity, unintended pregnancy, and tubal sterilization.

DESIGN AND PARTICIPANTS

Cross-sectional analysis of data from a nationally representative sample of women aged 15-44 years [65.7% white, 14.8% Hispanic, and 13.9% African American (AA)] who participated in the 2002 National Survey of Family Growth.

MAIN MEASURES

Race/ethnicity, history of unintended pregnancy, and tubal sterilization. A logistic regression model was used to estimate the effect of race/ethnicity on unintended pregnancy while adjusting for socio-demographic variables. A series of logistic regression models was then used to examine the role of unintended pregnancy as a confounder for the relationship between race/ethnicity and sterilization.

KEY RESULTS

Overall, 40% of white, 48% of Hispanic, and 59% of AA women reported a history of unintended pregnancy. After adjusting for socio-demographic variables, AA women were more likely (OR: 2.0; 95% CI: 1.6-2.4) and Hispanic women as likely (OR: 1.0; 95% CI: 0.80-1.2) as white women to report unintended pregnancy. Sterilization was reported by 29% of women who had ever had an unintended pregnancy compared to 7% of women who reported never having an unintended pregnancy. In unadjusted analysis, AA and Hispanic women had significantly higher odds of undergoing sterilization (OR: 1.5; 95% CI: 1.3-1.9 and OR: 1.4; 95% CI: 1.2-1.7, respectively). After adjusting for unintended pregnancy, this relationship was attenuated and no longer significant (OR: 1.2; 95% CI: 0.95-1.4 for AA women and OR: 1.3; 95% CI: 1.0-1.6 for Hispanic women).

CONCLUSION

Minority women, who more frequently experience unintended pregnancy, may choose tubal sterilization in response to prior experiences with an unintended pregnancy.

The impact of race and ethnicity on receipt of family planning services in the United States

OBJECTIVE

This study sought to examine the independent effect of patient race or ethnicity on the use of family planning services and on the likelihood of receiving counseling for sterilization and other birth control methods.

METHODS

This study used national, cross-sectional data collected by the 2002 National Survey of Family Growth (NSFG). Our analysis included women aged 18-44 years who had heterosexual intercourse within the past 12 months, who were not actively seeking to get pregnant, and who had not undergone surgical sterilization. The primary outcome was receipt of family planning services within the past 12 months. Specific services we examined were (1) provision of or prescription for a method of birth control, (2) checkup related to using birth control, (3) counseling about sterilization, and (4) counseling about birth control.

RESULTS

Although we found no racial/ethnic differences in the overall use of family planning services, there were racial/ethnic differences in the specific type of service received. Hispanic and black women were more likely than white women to receive counseling for birth control (adjusted OR 1.5, 95% confidence interval [CI] 1.2, 1.8, and adjusted OR 1.3, 95% CI 1.1, 1.7, respectively). Hispanic women were more likely than white women to report having been counseled about sterilization (adjusted OR 1.5, 95% CI 1.0, 2.3).

CONCLUSIONS

Minority women were more likely to receive counseling about sterilization and other birth control methods. However, there were no differences in access to family planning services by race or ethnicity. Future studies are needed to examine the quality and content of contraceptive counseling received by minority compared with nonminority women.

"Everything I know I learned from my mother...Or not": perspectives of African-American and white women on decisions about tubal sterilization

BACKGROUND

African-American women have had higher rates of female sterilization compared to white women since its emergence as a contraceptive method. The reasons underlying this observed racial difference are unknown.

OBJECTIVES

The goals of this study were to (1) explore what factors shape black and white women's decisions about tubal sterilization as a contraceptive method and (2) generate hypotheses about the relationship of race to the decision-making process.

DESIGN

We conducted six focus groups stratified by tubal sterilization status and race. During each of the audio-recorded sessions, participants were asked to discuss reasons that women choose sterilization as a contraceptive method.

PARTICIPANTS

The participants of the study were 24 African-American women and 14 white women.

APPROACH

Transcripts of the sessions were qualitatively analyzed with particular attention to factors that might be unique to each of the two racial groups.

RESULTS

Personal factors shaped black and white women's decisions regarding tubal sterilization. Preference for a convenient, highly effective contraceptive method was the main reason to get a tubal sterilization for women of both racial groups. We also identified socio-cultural differences that might explain why black women are more likely than white women to choose tubal sterilization over other contraceptive methods. An unanticipated, but clinically important, finding was that women often reported feeling that their doctors and the health-care system served as barriers to obtaining the desired procedure.

CONCLUSION

Socio-cultural differences may help explain why black and white women choose different contraceptive methods.

Race, Insurance Status, and Tubal Sterilization

OBJECTIVE

To examine the independent effects of race or ethnicity and insurance status on use of tubal sterilization rates.

METHODS

This study used cross-sectional data collected by the 2002 National Survey of Family Growth. The survey is designed to represent women and men aged 15-44 years in the household population of the United States. Our main outcome measure was tubal sterilization at any time before interview. A multivariable logistic regression model was used to estimate the effects of race or ethnicity and insurance status on rates of tubal sterilization after adjusting for important confounders.

RESULTS

The sample consisted of 7,643 women: 66% were white, 15% were Hispanic, and 14% were African American; 68% had private insurance and 32% had public or no insurance. After adjusting for age, insurance status, parity, income, education, marital status, and religion, African-American women were more likely than white women to undergo tubal sterilization (adjusted odds ratio 1.43, 95% confidence interval 1.08-1.88). After adjusting for age, race or ethnicity, parity, income, education, marital status, and religion, women with public or no insurance were more likely to undergo sterilization compared with women with private insurance (adjusted odds ratio 1.38, 95% confidence interval 1.09-1.74).

CONCLUSION

African-American women and women with no or public insurance were more likely to have undergone tubal sterilization compared with white women and women with private insurance, respectively. Additional research to identify factors that influence women's decision to undergo sterilization is warranted.

LEVEL OF EVIDENCE

II.

Sterilization in Finland: from eugenics to contraception

The purpose of this paper was to describe the transition of sterilization in Finland from an eugenic tool to a contraceptive. Historical data were drawn from earlier reports in Finnish. Numbers of and reasons for sterilizations since 1950 were collected from nationwide sterilization statistics. Prevalence, characteristics of sterilized women, and women's satisfaction with sterilizations were studied from a 1994 nationwide survey (74% response rate). Logistic regression was used for adjustments. In the first half of the 20th century, eugenic ideology had influence in Finland as in other parts of Europe, and the 1935 and 1950 sterilization laws had an eugenic spirit. Regardless of this, the numbers of eugenic sterilizations remained low, and in practice, family planning was the main reason for sterilization. Nonetheless, prior to 1970 not all sterilizations were freely chosen, because sterilizations were sometimes used as a precondition for abortion. Female sterilizations showed remarkable fluctuation over time. Male sterilizations have been rare. The reasons stipulated by the law did not explain the numbers of sterilizations. In a 1994 survey, 9% of Finnish women reported they were using sterilization as their current contraceptive method (n = 189). Compared to women using other contraceptive methods, sterilized women were older, had had more births and pregnancies, and came from lower social classes. Sterilized women were satisfied with their sterilization, but there were women (8.5%) who regretted it. In conclusion, sterilizations have been and are likely to continue to be an important family planning method in Finland. The extreme gender ratio suggests a need for promoting male sterilizations, and women's expressed regrets suggest consideration of a higher age limit.

Incidence of hysterectomy and tubal ligation in public hospitals in south Australia, 1980-82

This paper presents information on the incidence of hysterectomy and tubal ligation in South Australia in the period 1980–82, and on the age, marital status and ethnicity of women undergoing these procedures in public hospitals during the period. A typical woman undergoing one of these procedures was married or previously married and in her mid-40s for hysterectomy or mid-30s for tubal ligation. South Australian women had a lifetime chance of one in six of undergoing hysterectomy and of one in five of undergoing tubal ligation. The findings are consonant with the suggestion that increasing numbers of women are choosing forms of sterilization as means of contraception.