Race, insurance status, and desire for tubal sterilization reversal

A Decision Aid to Support Tubal Sterilization Decision-Making Among Pregnant Women: The MyDecision/MiDecisión Randomized Clinical Trial

Importance

Tubal sterilization is common, especially among individuals with low income. There is substantial misunderstanding about sterilization among those who have undergone the procedure, suggesting suboptimal decision-making about a method that permanently ends reproductive capacity.

Objective

To test the efficacy of a web-based decision aid for improving tubal sterilization decision quality.

Design, Setting, and Participants

This randomized clinical trial conducted between March 2020 and November 2023 included English- or Spanish-speaking pregnant cisgender women aged 21 to 45 years who had Medicaid insurance and were contemplating tubal sterilization after delivery. Participants were recruited from outpatient obstetric clinics in 3 US cities.

Intervention

Participants were randomized 1:1 to usual care (control arm) or to usual care plus a web-based decision aid (MyDecision/MiDecisión) (intervention arm). The aid includes written, audio, and video information about tubal sterilization procedures; an interactive table comparing contraceptive options; values-clarifying exercises; knowledge checks; and a summary report.

Main Outcomes and Measures

The co-primary outcomes were tubal sterilization knowledge and decisional conflict regarding the contraceptive decision. Knowledge was measured as the percentage of correct responses to 10 true-false items. Decisional conflict was measured using the low-literacy Decision Conflict Scale, with lower scores on a range from 0 to 100 indicating less conflict.

Results

Among the 350 participants, mean (SD) age was 29.7 (5.1) years. Compared with the usual care group, participants randomized to the decision aid had significantly higher tubal sterilization knowledge (mean [SD] proportion of questions answered correctly, 76.5% [16.9%] vs 55.6% [22.6%]; P < .001) and lower decisional conflict scores (mean [SD], 12.7 [16.6] vs 18.7 [20.8] points; P = .002). The greatest knowledge differences between the 2 groups were for items about permanence, with more participants in the intervention arm answering correctly that tubal sterilization is not easily reversible (90.1% vs 39.3%; odds ratio [OR], 14.2 [95% CI, 7.9-25.4]; P < .001) and that the tubes do not spontaneously "come untied" (86.6% vs 33.7%; OR, 13.0 [95% CI, 7.6-22.4]; P < .001).

Conclusions and Relevance

MyDecision/MiDecisión significantly improved tubal sterilization decision-making quality compared with usual care only. This scalable decision aid can be implemented into clinical practice to supplement practitioner counseling. These results are particularly important given the recent increase in demand for permanent contraception after the US Supreme Court decision overturning federal abortion protections.

Trial Registration

ClinicalTrials.gov Identifier: NCT04097717.

U.S. physicians' perspectives on the complexities and challenges of permanent contraception provision

OBJECTIVES

Evidence shows many misconceptions exist around permanent contraception, and there are numerous barriers to accessing the procedure. This qualitative study explored physician perspectives regarding patients' informational and decision-support needs, the complexities and challenges of counseling and access, and how these factors may differ for people living on lower incomes.

STUDY DESIGN

We conducted 15 semistructured, telephone interviews with obstetrician-gynecologists in three geographic regions of the United States to explore their perspectives on providing permanent contraception counseling and care. We analyzed the interviews using content analysis.

RESULTS

Physicians discussed a tension between respecting individual reproductive autonomy and concern for future regret; they wanted to support patients' desire for permanent contraception but were frequently concerned patients did not have the information they needed or the foresight to make high-quality decisions. Physicians also identified barriers to counseling including lack of time, lack of continuity over the course of prenatal care, and baseline misinformation among patients. Physicians identified additional barriers in providing a postpartum procedure even after thedecision was made including lack of personnel and operating room availability. Finally, physicians felt that people living on lower incomes faced more challenges in access primarily due to the sterilization consent regulations required by Medicaid.

CONCLUSIONS

Physicians report numerous challenges surrounding permanent contraception provision and access. Strategies are needed to support physicians and patients to enhance high-quality, patient-centered sterilization decision making and ensure that patients are able to access a permanent contraceptive procedure when desired.

IMPLICATIONS

This qualitative study demonstrates the various challenges faced by physicians to support permanent contraception decision making. These challenges may limit patients' access to the care they desire. This study supports the need to transform care delivery models and improve the federal sterilization policy to ensure equitable patient-centered access to desired permanent contraception.

DISCLAIMER

Although the term permanent contraception has increasingly replaced the word sterilization in clinical settings, we use sterilization in some places throughout this paper as that was the standard terminology at the time the interviews were conducted and the language the interviewed physicians used.

Comparative Effectiveness and Safety of Intrauterine Contraception and Tubal Ligation

BACKGROUND

Tubal ligation remains common in the USA, especially among low-income patients.

OBJECTIVE

To compare the effectiveness and safety of intrauterine contraceptives (IUC) to laparoscopic tubal ligation for Medicaid clients.

DESIGN

We partnered with patient and clinician stakeholders to conduct a retrospective cohort study using California Medicaid claims for patients who had an IUC placed or laparoscopic tubal ligation performed in 2008-2014, excluding procedures performed within 42 days of a birth. We applied log-linear (Poisson) event-history regression models for clustered person-period data to adjust for sociodemographic variables and pre-procedure health status when examining associations between these contraceptive procedures and claims related to contraceptive failure, complications, and pain in the first year post-procedure.

KEY RESULTS

We identified 35,705 patients who had a levonorgestrel IUC placed, 23,628 patients who had a copper IUC placed, and 23,965 patients who underwent laparoscopic tubal ligation. In unadjusted analyses, rates of pregnancy within 1 year were similar following levonorgestrel IUC (2.40%) or copper IUC placement (2.99%) or tubal ligation (2.64%). In adjusted analyses, compared to tubal ligation, pregnancy was less common following placement of a levonorgestrel IUC (adj IRR 0.72, 95% CI 0.64-0.82) and similar with placement of a copper IUC (adj IRR 0.92, 95% CI 0.82-1.05). Procedural complications such as infection (0.35% vs. 2.91%) were significantly less common with IUC placement than tubal ligation. Claims for pelvic and abdominal pain decreased in frequency with time since all procedures; 6 to 12 months post-procedure, pelvic pain claims were less common after levonorgestrel IUC (adj IRR 0.69, 95% CI 0.65-0.73) or copper IUC placement (adj IRR 0.70, 95% CI 0.66-0.75) than tubal ligation.

CONCLUSIONS

IUC appears at least as effective as laparoscopic tubal ligation at 1-year post-procedure with lower rates of infection and pelvic pain 6 to 12 months post-procedure.

CLINICAL TRIAL REGISTRATION

NCT03438682.

Robot-Assisted Tubal Reanastomosis after Sterilization: A Choice for Family Planning

A variety of procedures have been used for family planning. One of these is sterilization surgery, which can be reversed by a tubal reanastomosis. In the present report, we compare Robot-assisted tubal reanastomosis sterilization with other methods of family planning and discuss factors related to the choice of the approach. The keywords used for the electronic search in PubMed were family planning, sterilization, Robot-assisted, tubal reanastomosis, depression, and regret. The decision in favor of or against sterilization surgery has been a sensitive issue for several years. Robot-assisted technology is a modern and precise approach. It has contributed to the flexibility of the decision between sterilization and its reversal through tubal reanastomosis, as well as enhanced the success rate of the surgery. Based on our analysis of the published literature, we believe that Robot-assisted tubal anastomosis is the optimum approach. However, to ensure the quality of health care, the surgeon must be well trained, well versed with the anatomy of the fallopian tubes, and thoroughly informed on the psychological impact of family planning.

FSFI score and timing of tubal ligation in patients: preliminary results of an online survey

Introduction

Tubal ligation is the most common contraceptive method worldwide. Apart from a very low pearl index and anxiety relief, other benefits are not commonly recognised. In young patients, there is the post-operative risk of regretting the decision with the need for In-Vitro-Fertilisation or refertilising surgery. Positive side effects have not been widely published. In our study we investigated the change in the female sexual function index score after tubal ligation.

Material and method

In this survey the FSFI score of participants around the time of the tubal ligation was compared with the FSFI score of intermediate and long-term time distance to the ligation.

Results

The data indicate an increase in younger women seeking information on permanent contraception and whilst the FSFI score of the early group indicates a risk of female sexual dysfunction, the intermediate and long-term FSFI scores are comparable to published control groups.

Discussion

Besides the obvious benefit of a low pearl index, tubal ligation may contribute to reduce the risk of female sexual dysfunction in the mid and long term. Informed consent is essential for the surgeon and patient to weigh up the risks and benefits individually including possible future perspectives on family planning.

What constitutes a good healthcare experience for unintended pregnancy? A qualitative study among young people in California

Little is known about young people's experiences accessing healthcare for unintended pregnancy in the USA. To address this gap, we conducted in-depth interviews with 25 young people in California who had experienced at least one unintended pregnancy at or before 25 years of age. Participants were asked about their interactions with healthcare providers during the pregnancy, their thoughts on the determinants of their perceived quality of care, and the ways in which their healthcare experience could have been improved. Thematic analysis was used to organise information within and across interview transcripts. Two important determinants of participants' satisfaction with their healthcare experience were identified during analysis: (1) receiving comprehensive information about their pregnancy options and what to expect from each, and (2) having an empathetic, non-judgemental provider. Regarding abortion, participants described an unmet need for accurate information and frequent stigmatising experiences with dismissive and judgemental care providers. These findings highlight the importance of providing comprehensive, non-judgemental pregnancy options counselling to all pregnant people, regardless of age and desired pregnancy outcome; and reinforce the need for providers to consider ways in which their own bias may influence the quality of care they provide.

Racial and Ethnic Disparities in Obliterative Procedures for the Treatment of Vaginal Prolapse

OBJECTIVES

Although racial disparities are well documented for common gynecologic surgical procedures, few studies have assessed racial disparities in the surgical treatment of vaginal prolapse. This study aimed to compare the use of obliterative procedures for the treatment of vaginal prolapse across racial and ethnic groups.

STUDY DESIGN

This is a retrospective cohort study of surgical cases from 2010 to 2018 from the American College of Surgeons National Surgical Quality Improvement Program, a nationally validated database. Cases were identified by Current Procedural Terminology codes. Modified Poisson regression was used to calculate risk ratios and 95% confidence intervals, adjusting for potential confounders selected a priori.

RESULTS

We identified 45,865 surgical cases, of which 10% involved an obliterative procedure. In the unadjusted model, non-Hispanic Asian and non-Hispanic Black patients were more likely to undergo an obliterative procedure compared with non-Hispanic White patients (risk ratio [95% confidence interval], 2.4 [2.1-2.7] and 1.2 [1.03-1.3], respectively). These relative risks were largely unchanged when controlling for age, body mass index, diabetes, American Society of Anesthesiologists classification, and concurrent hysterectomy.

CONCLUSIONS

Although both obliterative and reconstructive procedures have their respective risks and benefits, the proportion of patients undergoing each procedure differs by race and ethnicity. It is unclear whether such disparities may be attributable to differences in preference or inequity in care.

Role of tubal surgery in the era of assisted reproductive technology: a committee opinion

This document reviews surgical options for reparative tubal surgery and the factors that must be considered when deciding between surgical repair and in vitro fertilization. This document replaces the document of the same name, last published in 2012 (Fertil Steril 2015;103:e37-43). This document reviews surgical options for reparative tubal surgery and the factors that must be considered when deciding between surgical repair and in vitro fertilization.

Understanding Sterilization Regret in the United States: The Role of Relationship Context

Although one fourth of sterilized reproductive-aged women in the U.S. express a desire to have their sterilization procedures reversed, the pathways leading to sterilization regret remain insufficiently understood. Particularly little is known about how cohabitation affects the likelihood of sterilization regret. This study used data from the 2006-2010 National Survey of Family Growth to investigate how relationship context shapes women's risk of sterilization regret. Our findings point to higher levels of regret among women who were cohabiting, rather than married or single at the time of sterilization. Experiencing post-sterilization union dissolution or post-sterilization union formation was also associated with an elevated risk of regret. Together, post-sterilization union instability and selected background characteristics largely explained elevated levels of regret observed among women who were cohabiting at the time of sterilization. An association between regret and post-sterilization union instability persisted, however, even when socioeconomic and reproductive background factors were controlled.

Desire for Sterilization Reversal Among U.S. Females: Increasing Inequalities by Educational Level

CONTEXT

For decades, high reliance on female sterilization in the United States has been accompanied by a high level of desire for sterilization reversal, and less-educated women have been more likely than better educated women to use the method and desire a reversal. Little is known about how levels of and educational differentials in such desire have changed in recent decades.

METHODS

Data from 4,147 women who reported being sterile from a tubal sterilization in the 1995, 2002 and 2006-2010 waves of the National Survey of Family Growth were analyzed using chi-square and Wald tests and binary logistic regression analyses. Predicted probabilities were calculated to determine the likelihood of desire for procedure reversal by wave and educational level.

RESULTS

The prevalence of desire for sterilization reversal rose by 41%, from 18% in 1995 to 23% in 2002 and 25% in 2006-2010. Overall, women with a bachelor's degree were less likely than those who had not finished high school to desire a reversal (odds ratio, 0.2), and this educational differential was larger in 2006-2010 than in earlier waves. Predicted probabilities indicate that 9% of sterilized women with less than a high school education and 8% of those with a bachelor's degree expressed a desire for procedure reversal in 1995, as did 15% and 3%, respectively, in 2006-2010.

CONCLUSION

Future research should consider how insurance coverage of all methods under the Affordable Care Act may affect use of sterilization and desire for reversal.

Postpartum care and contraception provided to women with gestational and preconception diabetes in California's Medicaid program

OBJECTIVES

To compare rates of postpartum care and contraception provided to women with gestational or preconception diabetes mellitus to women with no known diabetes mellitus.

METHODS

A retrospective cohort study of 199,860 women aged 15-44 years who were continuously enrolled in California's Medicaid program, Medi-Cal, from 43 days prior to 99 days after delivering in 2012. Claims for postpartum clinic visits and contraceptive supplies were compared for 11,494 mothers with preconception diabetes, 17,970 mothers with gestational diabetes, and 170,396 mothers without diabetes. Multivariable logistic regression was used to control for maternal age, race/ethnicity, primary language, residence in a primary care shortage area, state-funded healthcare program and Cesarean delivery, when examining the effects of diabetes on postpartum care and contraception.

RESULTS

Although postpartum clinic visits were more common with diabetes (55% preconception, 55% gestational, 48% no diabetes, p=<.0001), almost half did not receive any postpartum care within 99 days of delivery. Women with pregnancies complicated by diabetes were more likely to receive permanent contraception than women without diabetes (preconception diabetes, aOR: 1.39, 95% CI: 1.31-1.47; gestational diabetes, aOR: 1.20, 95% CI: 1.14-1.27). However, among women without permanent contraception, less than half received any reversible contraception within 99 days of delivery (44% preconception, 43% gestational, 43% no diabetes) and less effective, barrier contraceptives were more commonly provided to women with preconception diabetes than women without diabetes (aOR: 1.24, 95% CI:1.16-1.33).

CONCLUSIONS

Low-income Californian women with pregnancies complicated by diabetes do not consistently receive postpartum care or contraception that may prevent complication of future pregnancies.

IMPLICATIONS

Efforts are needed to improve rates of provision of postpartum care and high quality contraceptive services to low income women in California, particularly following pregnancies complicated by diabetes.

Robotic-assisted laparoscopy in reproductive surgery: a contemporary review

Robotic surgery is a conceptual fusion of the conventional open surgery and the minimally invasive laparoscopic surgery. We reviewed the current role of robotic-assisted laparoscopy in the field of reproductive surgery by a literature search in PubMed database. We analyzed the reported advantages and limitations of the use of robotics in reproductive surgeries like myomectomy, tubal reanastomosis, endometriosis, ovarian tissue cryopreservation, and ovarian transposition. Overall, robotic assistance in reproductive surgery resulted in decreased blood loss, less post-operative pain, shorter hospital stay, and faster convalescence, whereas reproductive outcomes were similar to open/laparoscopic approaches. The main drawbacks of robotic surgery were higher cost and longer operating times. It is as safe and effective as the conventional laparoscopy and represents a reasonable alternate to abdominal approach. Procedures that are technically challenging with the conventional laparoscopy can be performed with robotic assistance. It has advantages of improved visualization and Endowrist™ movements allowing precise suturing. This helps to overcome the limitations of laparoscopy, especially in complicated procedures, and may shorten the steep learning curve in minimal invasive surgery. Randomized controlled trials looking at both short- and long-term outcomes are warranted to strengthen the role of robotic surgery in the field of reproductive surgery.

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.

Reasons for tubal sterilisation, regret and depressive symptoms

OBJECTIVE

To examine the associations between sterilisation reasons, regret, and depressive symptoms.

STUDY DESIGN

Black, Hispanic, and non-Hispanic White US women ages 25-45 who participated in the National Survey of Fertility Barriers (NSFB) and reported a tubal sterilisation surgery were included in the sample for this study (n=837). Logistic regression was used to examine how characteristics of the sterilisation surgery (reasons for sterilisation, time since sterilisation, and new relationship since sterilisation) are associated with the odds of sterilisation regret, and linear regression was used to examine associations between sterilisation regret, sociodemographic factors, and depressive symptoms.

RESULTS

Findings revealed that 28 percent of U.S. women who have undergone tubal sterilisation report regret. Time since sterilisation and having a reason for sterilisation other than simply not wanting (more) children (e.g., situational factors, health problems, encouragement by others, and other reasons) are associated with significantly higher odds of sterilisation regret. Finally, sterilisation regret is significantly associated with depressive symptoms after controlling for sociodemographic characteristics.

CONCLUSION

Sterilisation regret is relatively common among women who have undergone tubal sterilisation, and regret is linked to elevated, but not necessarily clinical depressive symptoms. The reasons for sterilisation can have important implications for women's sterilisation regret and associated depressive symptoms.

Female Sterilization and Poor Mental Health: Rates and Relatedness among American Indian and Alaska Native Women

OBJECTIVE

To describe the reproductive and mental health of American Indian and Alaska Native (AI/AN) women, an understudied population.

METHODS

Data from the 2004 Behavioral Risk Factor Surveillance System survey were analyzed to determine the 1) prevalence of female sterilization among a nationally representative sample of reproductive age AI/AN women and 2) the association of female sterilization and poor mental health among AI/AN women compared with non-Hispanic White, non-Hispanic Black, and Hispanic women.

RESULTS

Nearly 25% of AI/AN women reported female sterilization, a prevalence higher than the comparison racial/ethnic groups (p < .005). Adjusting for sociodemographic characteristics, AI/AN women reporting female sterilization had nearly 2.5 times the odds of poor mental health compared with AI/AN women not reporting female sterilization (p = .001). The same magnitude of relationship between female sterilization and poor mental health was not found for non-Hispanic White, non-Hispanic Black, and Hispanic women.

CONCLUSIONS

The prevalence of female sterilization is greater among AI/AN women compared with non-Hispanic White, non-Hispanic Black, and Hispanic women, and AI/AN women reporting female sterilization have higher odds of reporting poor mental health. Common cultural experiences, such as a shared ancestral history of forced sterilizations, may be relevant, and could be considered when providing reproductive and mental health services to AI/AN women.

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.

Who is using long-acting reversible contraceptive methods? Findings from nine low-fertility countries

CONTEXT

Long-acting reversible contraceptive (LARC) methods-IUDs and implants-are more effective than other reversible methods, yet are little used in the United States. Examining which U.S. women use LARC methods and how they differ from users in other low-fertility countries may help point the way toward increasing use.

METHODS

Data from married or cohabiting women participating in the National Survey of Family Growth (2008-2010) and in eight countries' Generations and Gender Programme surveys (2004-2010) were used in bivariate and multinomial logistic regression analyses examining LARC use within each setting.

RESULTS

The proportion of contraceptive use accounted for by LARC methods was generally greater in Europe (10-32%) than in the United States (10%) and Australia (7%). Compared with LARC use among comparable groups in other countries, use was particularly low among U.S. women who were married, were aged 40-44 or had had three or more children, yet was comparatively high among 18-24-year-olds. Among U.S. women, those aged 35-39 or 40-44 were more likely than 18-29-year-olds to rely on sterilization rather than on LARC methods (odds ratios, 3.0 and 10.7, respectively), those who had had three or more children were more likely to do so than were those who had had none or one (4.9), and women who had completed college were less likely than those who had not finished high school to do so (0.4).

CONCLUSIONS

Certain subgroups of U.S. women may benefit from the reversibility and effectiveness of LARC methods.

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.

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.

Preprocedure patient preferences and attitudes toward permanent contraceptive options

OBJECTIVE

To determine patient preference for laparoscopic tubal occlusion or hysteroscopic tubal occlusion, two common sterilization interventions, and the acceptability of a postprocedure confirmation test for a hysteroscopic approach.

PARTICIPANTS AND METHODS

A total of 100 patients were offered two procedures. A description of each procedure was developed and read to each patient by a research nurse on site. Patients were then asked to respond to a questionnaire concerning options. Final informed consent, procedure review, and procedural date determination were provided by a physician upon completion of the questionnaire. Patients were not allowed to change their questionnaire responses after completion. No interviewer or physician input was allowed during the questionnaire. The study was completed in English or Spanish, as per patient request, by a bilingual/fluent speaker. Physicians completing informed consent were unaware of the questionnaire responses. Patients were not financially incentivized.

RESULTS

Of 100 participants, 93 (93%) preferred hysteroscopic sterilization to laparoscopy. The reasons were as follows: fear of general anesthesia (24/93 [26%]), fear of incision (25/93 [27%]), cost (32/93 [34%]), and time (12/93 [13%]) to return to routine activity. All 93 viewed "office-based location" as the main advantage over laparoscopy; 88/93 (94.6%) considered a confirmation test to be a benefit of the procedure. After informed consent was obtained, one additional patient switched from a laparoscopic decision to hysteroscopy (total = 94/100); 89/94 (95%) hysteroscopic decisions underwent hysteroscopic sterilization; 4/6 (67%) laparoscopic decisions proceeded to that surgery. The remainder (N = 7) cancelled due to lack of financial resources.

CONCLUSION

A nonincisional, office-based approach to sterilization has high patient acceptability. Patients viewed a confirmatory test for tubal occlusion as a benefit after sterilization.

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.

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.