Social gradients in surgical sterilization rates: opposing patterns for males and females

OBJECTIVE

The purpose of this study was to analyze population-based rates of surgical sterilization by sex, income, age group, and location of residence (urban, rural, or remote) among a universally insured population.

METHODS

The study included all 1.2 million residents of Manitoba. Data from comprehensive hospital and medical visit records were used to calculate rates of vasectomy and tubal ligation among the population aged 20 to 55 years. Analyses were carried out with generalized linear modelling, using administrative data housed at the Manitoba Centre for Health Policy.

RESULTS

There were significant income-related gradients in sterilization rates for both sexes (P < 0.001), but the trends were in opposite directions for males and females. Tubal ligation rates were highest in low-income areas, and decreased with income, whereas vasectomy rates were lowest in low-income areas and increased with income. Rates also varied considerably by age and area of residence (urban, rural, or remote).

CONCLUSION

These results are potentially worrying because tubal ligation is more invasive, associated with higher risks, and more costly than vasectomy. It would therefore be expected to be less common than vasectomy among all groups, not just those in higher income areas. The results contribute unique population-based procedure rates, which are not subject to biases that can affect survey-based studies. The findings may reflect underlying differences across income groups in decision-making regarding reproductive health issues.

Efficacy of Essure hysteroscopic sterilization--5 years follow up of 1200 women

OBJECTIVE

To assess the efficacy of the Essure hysteroscopic birth control device after 5 years follow up.

STUDY DESIGN

Retrospective analysis of case series.

SETTING

Outpatient hysteroscopy facility in a large teaching hospital.

SUBJECTS

One-thousand three-hundred and twenty-one women who underwent hysteroscopic sterilization with Essure device (Conceptus, Inc., Mountain View, CA) between January 2003 and May 2005.

INTERVENTION(S)

Hysteroscopic tubal sterilization using Essure system.

MAIN OUTCOME MEASURE

Efficacy/effectiveness, failure rate.

RESULTS

Satisfactory insertion was accomplished in the first attempt in 1166 women (97.16%). After the second attempt, successful insertion rate rise to 98.6%. (n = 31, 2.6%). Three pregnancies had been reported after 5 years follow up, which implies an overall absolute rate of 0.25%. This represents a Pearl index of 0.05 after 72,000 months of surveillance. All of them occurred in the first year of use of the microinsert. There has been no unintended pregnancy in the next 4 years.

CONCLUSION(S)

Essure has the lowest Pearl index never published being the most effective permanent birth control system to date. Unintended pregnancies tend to occur in the first year after the insertion, and can be avoided encouraging women to accomplish the protocol.

Unfavorable lipid profile and higher frequency of hot flashes during perimenopausal years after fallopian tube ligation

AIM

We sought to study the effect of tubal ligation on lipid profile, ovarian reserve and hot flashes during perimenopausal years.

METHODS

A total of 210 perimenopausal women complaining of abnormal vaginal bleeding were enrolled for the study. Subjects' menstrual, reproductive and medical histories were recorded. Serum FSH, LH and estradiol levels were screened in all women to determine menopausal status. In order to rule out any gynecologic pathology, all subjects underwent transvaginal sonography. Women were divided into two groups according to presence (study group, n = 68) or absence (control group, n = 142) of tubal ligation history. Lipid profiles and ovarian reserve tests were compared between groups.

RESULTS

Mean age, parity, serum hemoglobin (Hb), high density lipoprotein (HDL-C), triglyceride, estradiol levels, endometrial thickness and frequency of hot flashes were significantly different between groups (p < 0.05). Mean age was 42.8 ± 1.9 years in women with tubal ligation and 45.9 ± 3.5 years in control group. Mean serum estradiol level was lower in group with tubal ligation (41.4 versus 92.5 pg/ml). Mean endometrial thickness was higher in control group (10.2 versus 7.5 mm). Age-adjusted serum Hb, HDL-C, triglyceride, estradiol, FSH level, endometrial thickness and frequency of hot flashes remained significantly different between groups (p < 0.05).

CONCLUSION

Tubal ligation is associated with unfavorable lipid profile and higher frequency of hot flashes during perimenopausal years.

Association between history of abdominopelvic surgery and tubal pathology

BACKGROUND

Pelvic infection, unsafe abortion and previous laparatomy are risk factors for tubal infertility among Nigerian women. Reports on the relationship between these factors and tubal pathology seen on hysterosalpingography (HSG) from our environment have been few.

OBJECTIVE

To assess the prevalence of tubal occlusions among patients referred for HSG and examine the association between previous history of abdominopelvic surgery (including dilatation and curettage for abortion) and tubal occlusion.

METHODS

We studied one hundred and thirty women referred to the Radiology department for HSG because of infertility. HSG was performed during the early proliferative phase of the menstrual cycle. Information about type and duration of infertility, history of abdomino -pelvic surgery and history suggestive of previous pelvic infection, were obtained from the patients. The data obtained were analyzed using SPSS version 11. Test of association using the chi-square test was done where appropriate and differences were considered at p= 0.05.

RESULTS

Sixty one women had bilaterally patent tubes; tubal pathology was seen in sixty nine women. Significant association exits between tubal pathology and history of pelvic surgery p=0.01, pelvic infection p=0.02 and duration of infertility p=0.04.

CONCLUSION

Previous surgery especially dilation and curettage, PID duration and type of infertility are associated with tubal pathology among Nigerian women. Creative methods of lowering the cost of diagnosis and management of tubal occlusion need to be instituted.

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.

Barriers to completion of desired postpartum sterilization

Tubal sterilization is a highly effective, permanent, and safe method of contraception. Many women who desire postpartum sterilization do not obtain the procedure due to barriers. We performed a retrospective cohort study examining patients from a single obstetrics practice who delivered between 1/1/07 and 6/30/07 at Women and Infants Hospital in Providence, RI. During the study period, 626 women in the practice delivered. Of these subjects, 87 (14%) desired postpartum sterilization. Of these 87, 45 (51.7%) underwent sterilization as planned. In multivariable analysis controlling for age, BMI, delivery mode and marital status, older age (OR 2.15, 95% CI 1.12, 4.12, p=0.02) and cesarean delivery (OR 19.65, 95% CI 3.75, 103.1, p < 0.001) were associated with completion of postpartum sterilization and being married (OR 0.10, 95% CI 0.02, 0.56, p=0.009) and having a higher BMI (OR 0.60, 95% CI 0.39, 0.91, p=0.02) were associated with incompletion. Only half of women who request postpartum sterilization antenatally end up obtaining the procedure.

Frustrated demand for sterilization among low-income Latinas in El Paso, Texas

CONTEXT

Sterilization is the most commonly used contraceptive in the United States, yet access to this method is limited for some.

METHODS

A 2006-2008 prospective study of low-income pill users in El Paso, Texas, assessed unmet demand for sterilization among 801 women with at least one child. Multivariable logistic regression analysis identified characteristics associated with wanting sterilization. In 2010, at an 18-month follow-up, women who had wanted sterilization were recontacted; 120 semistructured and seven in-depth interviews were conducted to assess motivations for undergoing the procedure and the barriers faced in trying to obtain it.

RESULTS

At baseline, 56% of women wanted no more children; at nine months, 65% wanted no more children, and of these, 72% wanted sterilization. Only five of the women interviewed at 18 months had undergone sterilization; two said their partners had obtained a vasectomy. Women who had not undergone sterilization were still strongly motivated to do so, mainly because they wanted no more children and were concerned about long-term pill use. Among women's reasons for not having undergone sterilization after their last pregnancy were not having signed the Medicaid consent form in time and having been told that they were too young or there was no funding for the procedure.

CONCLUSIONS

Because access to a full range of contraceptive methods is limited for low-income women, researchers and providers should not assume a woman's current method is her method of choice.

Demand for long acting and permanent methods of contraceptives and factors for non-use among married women of Goba Town, Bale Zone, South East Ethiopia

BACKGROUND

Contraceptive use including short acting, long acting and permanent methods positively influence the socio-economic development of a nation by allowing families to space and limit their family size to their economic capacity. Demand for LAPMs of contraception as detrmined by utilization and unmet need for LAPMs of contraception can provide realiable information for providers.

OBJECTIVE

To determine the utilization of long acting and permanent contraception and its associated factors among married women of Goba town, South East Ethiopia.

METHODS

A cross sectional community based study was conducted among 734 systematically selected married women of reproductive age in Goba town in September/ 2009. A structured and pretested, interview questionaire was used to collect data on socio-demographic, behavioral factors and data related to demand for LAPMs of contraception. Data were analyzed using EPI INFO and SPSS version 16.

RESULT

The demand for Long Acting and Permanent Methods (LAPMs) of contraception was 18.1%. Utilization of LAPMs of contraception in the town was 64 (8.7%) and the unmet need for LAPMs was 69 (9.4%). Information on LAPMs in the town was 636 (86.6%). Media (radio and television) was the major sources of information 641 (87.3%). The use of LAPMs was significatly associated with ever use AOR[17.43, 95% CI:9.19, 33.03], number of times discussions made on methods AOR[4.6, 95% CI: 1.72,12.17] and main decider of using methods AOR[ 2.2, 95% CI:1.03, 4.65]. It was not associated with socio-demographic variables.

CONCLUSION AND RECOMMENDATION

The utilization of LAPMs in the town was less although higher than the Ethiopian demographic and health survey 2005 result. Moreover, there was a considerable unmet need. Increase the method mix of LAPMs by incorporating varaies of implnats in order to increase utilization. Proper counseling of client and partners discussion were some of the recommendation forwarded.

Current and future role of voluntary surgical contraception in increasing access to and utilization of family planning services in Africa

BACKGROUND

Voluntary surgical contraception is the most widely utilized method of contraception in the world. High effectiveness, low complication rates and reduced cost in the long term make them the ideal contraceptive choice to diverse group of clients including clients from low resource settings.

OBJECTIVE

To assess the current status of utilization and effectiveness of voluntary surgical contraception in Africa and suggest possible future roles in contraceptive method choice.

METHODS

A review of available literature on voluntary surgical contraception and synthesis of information under relevant headings.

RESULTS

Despite very high total fertility rates in most countries of Africa, surgical contraceptives still contribute to a very small proportion ofcontraceptive method choice in the continent. Client profile and acceptability studies indicate a large unmet need for permanent contraception in the continent. Lack of information, misconceptions and weak health systems (particularly surgical care) are the major impediments to increasing availability of surgical contraception. Lack of knowledge and low levels of motivation among health care providers may also be significant barriers to access.

CONCLUSIONS

Ihcreasing availability of information on the safety and effectiveness of these methods to both health care providers and the general population can increase demand and acceptability. Delegating service provision to appropriately trained non-physician providers at primary care settings can assist in increasing accessibility of these important family planning methods.

Reproductive healthcare needs and desires in a cohort of HIV-positive women

BACKGROUND

The aim of this study was to determine current contraceptive use, contraceptive desires and knowledge, future fertility desires, and sterilization regret in a cohort of HIV-positive women.

STUDY DESIGN

127 HIV-positive women receiving care at an urban infectious disease clinic completed a survey addressing their contraceptive and reproductive histories as well as their future contraceptive and fertility desires.

RESULTS

The most common forms of contraception used were sterilization (44.4%) and condoms (41.3%). Less than 1% used a long-term reversible method of contraception (LARC) despite these being the methods that best fit their desired attributes of a contraceptive method. Overall, 29.4% desired future fertility. Only 50.6% of those sexually active had spoken with a provider within the last year regarding their contraceptive plans. There was a high degree of sterilization regret (36.4%), and 18.2% of sterilized women desired future fertility. Multivariate analysis found women in a monogamous relationship had a statistically increased rate of regret compared to women who were not sexually active (OR 13.8, 95% CI 1.6-119, P = 0.17).

CONCLUSION

Given the diversity in contraceptive and fertility desires, coupled with a higher rate of sterilization regret than is seen in the general population, integration of comprehensive family planning services into HIV care via increased contraceptive education and access is imperative.

Postpartum intrauterine device insertion and postpartum tubal sterilization in the United States

OBJECTIVE

The purpose of this study was to estimate US rates of postpartum intrauterine device (IUD) insertion and postpartum tubal sterilization.

STUDY DESIGN

Data from the 2001-2008 Nationwide Inpatient Sample were used to identify delivery hospitalizations with IUD insertion or tubal sterilization procedure codes.

RESULTS

Estimated rates of postpartum IUD insertion and postpartum tubal sterilization were 0.27 and 770.67 per 10,000 deliveries, respectively. Although the rate of IUD insertion was similar across age groups, the rate of tubal sterilization increased with age. Nonetheless, 15% of tubal sterilizations occurred among women who were ≤ 24 years old. IUD insertion was more likely among women who delivered at teaching hospitals (odds ratio, 3.02; 95% confidence interval, 1.43-6.37); tubal sterilization was more likely among women without private insurance (odds ratio, 2.04; 95% confidence interval, 1.97-2.11).

CONCLUSION

Among US postpartum women, IUD insertion occurs considerably less frequently than tubal sterilization, even among younger women for whom poststerilization regret is a concern.

[Cesarean birth: justifying indication or justified concern?]

BACKGROUND

Caesarean section is the most common surgery performed in all hospitals of second level of care in the health sector and more frequently in private hospitals in Mexico.

OBJECTIVE

To determine the behavior that caesarean section in different hospitals in the health sector in the city of Aguascalientes and analyze the indications during the same period.

MATERIAL AND METHOD

A descriptive and cross in the top four secondary hospitals in the health sector of the state of Aguascalientes, which together account for 81% of obstetric care in the state, from 1 September to 31 October 2008. Were analyzed: indication of cesarean section and their classification, previous pregnancies, marital status, gestational age, weight and minute Apgar newborn and given birth control during the event.

RESULTS

were recorded during the study period, 2.964 pregnancies after 29 weeks, of whom 1.195 were resolved by Caesarean section with an overall rate of 40.3%. We found 45 different indications, which undoubtedly reflect the great diversity of views on the institutional medical staff to schedule a cesarean section.

CONCLUSIONS

Although each institution has different resources and a population with different characteristics, treatment protocols should be developed by staff of each hospital to have the test as a cornerstone of labor, also request a second opinion before a caesarean section, all try to reduce the frequency of cesarean section.

Breast cancer risk and ovariectomy, hysterectomy, and tubal sterilization in the women's contraceptive and reproductive experiences study

Removal or impairment of ovaries before menopause may affect a woman's breast cancer risk by altering her cumulative exposure to ovarian hormones. The Women's Contraceptive and Reproductive Experiences Study, a population-based, multicenter case-control study of incident invasive breast cancer, recruited women aged 35-64 years (4,490 cases and 4,611 controls) who provided data on ovariectomy, hysterectomy, and tubal sterilization during in-person interviews. Controls were frequency-matched to cases by age, race, and study site. Unconditional logistic regression analysis was used. Women who had not undergone premenopausal reproductive surgery were the referent group. Bilateral ovariectomy was associated with reduced breast cancer risk overall (odds ratio (OR) = 0.59, 95% confidence interval (CI): 0.50, 0.69) and among women <45 years of age (ORs ranged from 0.31 to 0.52), but not among those who were older at surgery. It was also associated with a reduced risk for estrogen and progesterone receptor-positive tumors (OR = 0.63, 95% CI: 0.52, 0.75) but not receptor-negative tumors. Hysterectomy with ovarian conservation (OR = 0.83, 95% CI: 0.72, 0.96) and hysterectomy with partial ovary removal (OR = 0.73, 95% CI: 0.59, 0.91) were also associated with lower risk. No association with breast cancer risk was observed with tubal sterilization only or partial ovariectomy without hysterectomy. Reproductive organ surgeries may alter ovarian hormone levels, thereby affecting breast cancer risk.

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.

Sterilization by minilaparotomy in south-eastern Nigeria

The study aimed to assess the trend in acceptance and characteristics of acceptors of female sterilization between January 1999 and December 2006 at the University of Nigeria Teaching IHospital, linugu, South-Eastern Nigeria. There were a total of 20,485 new clients, with 212 (1.0%) accepting sterilization between January 1999 and December 2006. There was an initial rise in acceptance from 0.4% in 1999 to 3.0% in 2004, then a decline. 108 (50.9%) were between 35-39 years. 169 (79.7%) had more than five living children. 69 (32.5%) and 76 (35.9%) had secondary and higher education respectively. Health workers were the main source of information. Completed family size was the reason for choosing sterilization in 185 clients (87.3%). 120 (56.6%) were in occupational social class 3.106 (50.0%) did not practice any form of family planning prior to the procedure. 184 (86.8%) had interval sterilization and the rest (13.2%) postpartum. Acceptance of tubal sterilization is still low in our community.

Does vasectomy explain the difference in tubal sterilization rates between black and white women?

OBJECTIVE

To examine whether the observed difference in tubal sterilization rates between black and white women is dependent on racial/ethnic differences in vasectomy rates.

DESIGN

Secondary analysis of national, cross-sectional survey.

SETTING

2002 National Survey of Family Growth.

PATIENT(S)

Women 15 to 44 years old with a current partner who were able to provide information about their partner's vasectomy status.

INTERVENTION(S)

None.

MAIN OUTCOME MEASURE(S)

The primary outcome was tubal sterilization. Among women with a current partner who had not undergone vasectomy, a multivariable logistic regression model was used to estimate the effects of race/ethnicity on tubal sterilization after adjusting for potential confounders.

RESULT(S)

Of the 3,391 women in the sample, 14% of white women had a current partner who had undergone vasectomy compared with 5% of Hispanic women and 4% of black women. Among the 3,064 women whose partners had not undergone vasectomy, black women were more likely to undergo tubal sterilization (odds ratio: 1.6; 95% confidence interval: 1.1, 2.2) on the basis of adjusted multivariable analysis.

CONCLUSION(S)

After controlling for partner vasectomy status, black women were still more likely to undergo tubal sterilization than white women.

Factors predictive for failure to perform postpartum tubal ligations following vaginal delivery

OBJECTIVE

To identify patients requesting postpartum sterilization and compare those who underwent the procedure with those who did not.

STUDY DESIGN

A retrospective study of requested postpartum tubal ligations was completed. Demographics and clinical characteristics were analyzed. We analyzed whether the failure to obtain postpartum sterilization resulted in an interval laparoscopic tubal ligation or future pregnancy.

RESULTS

A total of 135 women requested sterilization, but only 56% received the desired procedure. Time of delivery (OR 2.23, CI 1.08-4.58), body mass index (OR 2.38, CI 1.10-5.16) and gravidity (OR 0.80, CI 0.65-0.97) were significant variables that were different between the 2 groups. Of the women who left the hospital postpartum without a sterilization procedure, 44% received an interval laparoscopic tubal ligation and 18% later became pregnant.

CONCLUSION

Postpartum tubal ligations are often not performed despite patient request. Additional measures should be undertaken to ensure that patient requests for postpartum tubal ligation are implemented.

Race, insurance status, and desire for tubal sterilization reversal

OBJECTIVE

To examine the independent effects of race/ethnicity and insurance status on desire for tubal sterilization reversal.

DESIGN

Secondary analysis of cross-sectional data collected by the 2002 National Survey of Family Growth (NSFG).

SETTING

Interviews were conducted in person by a trained female interviewer in the participant's home.

PATIENT(S)

The NSFG is designed to represent women and men 15-44 years of age in the U.S. household population. The sample consisted of 934 women who had undergone tubal sterilization at any time before being interviewed.

INTERVENTION(S)

None.

MAIN OUTCOME MEASURE(S)

Desire for sterilization reversal.

RESULT(S)

Among women older than 30 years at time of surgery, black women were significantly more likely to desire sterilization reversal compared with white women (adjusted odds ratio, 2.6; 95% confidence interval, 1.2, 5.8). In the total cohort and in the subset of women 30 years or younger, there were no significant racial/ethnic variations in desire for sterilization reversal.

CONCLUSION(S)

Among women over age 30 at the time of tubal sterilization, black women were much more likely to express desire for reversal than white women.

Longitudinal association between hormonal contraceptives and bacterial vaginosis in women of reproductive age

OBJECTIVES

This study examined whether hormonal contraceptive use is associated with diagnosis of bacterial vaginosis (BV) over 1 year.

STUDY DESIGN

A total of 3,077 women of reproductive age were recruited from gynecologic and family planning clinics for a 1-year prospective longitudinal study. Data collected over 5 visits included demographics, health and hygiene behaviors, and gynecological exams. Gram stains were used to quantify vaginal flora.

RESULTS

There was a decreased risk of overall BV prevalence among oral contraceptive users (odds ratio, OR 0.76; confidence interval, CI 0.63-0.90) and among those using hormonal injection/implant (OR 0.64; CI 0.53-0.76). An increased risk for BV prevalence (OR 1.38; CI 1.11-1.71) and incidence (OR 1.43; 1.02-2.07) was observed among those subjects who had tubal ligation. Greater remission of BV was found among those using hormonal injection or implant (OR 1.67; CI 1.23-2.27) whereas less remission occurred among those subjects who had tubal ligation (OR 0.56; CI 0.39-0.80).

CONCLUSIONS

Hormonal contraceptive use is associated with a decreased risk of BV.

Copper IUD and LNG IUS compared with tubal occlusion

This article will cover current contraceptive use around the world, then examine the advantages and disadvantages of female sterilization, the hormonal intrauterine system and the copper intrauterine device. Finally, the need for contraceptive choice will be discussed along with a discussion on the cost-effectiveness of these methods.

Does the number of previous caesarean deliveries affect maternal outcome and complication rates?

We evaluated maternal complications in relation to number of previous caesarean sections in Princess Badea Teaching Hospital, Irbid, Jordan. Analysis of the medical records of 1739 patients delivered by caesarean section was conducted. It revealed a 14-fold increase in the risk of caesarean hysterectomy in patients with placenta praevia and previous caesarean section compared to patients with placenta praevia and no previous caesarean section. The risk of caesarean hysterectomy increased with increasing number of previous caesarean sections. Those with 3 or more previous caesarean sections were at significantly higher risk of blood transfusion. Post-operative pyrexia was commoner in women with 3 or more previous caesarean sections compared to those undergoing their first one.

Contraception and fertility plans in a cohort of HIV-positive women in care

OBJECTIVE

The aim of this study was to examine determinants of contraceptive use, desired future childbearing and sterilization regret among HIV-positive women.

METHODS

One hundred eighteen HIV-positive women, age 18-46, receiving care at a university HIV clinic completed a survey on their reproductive history in 2004. We reviewed their medical records for contraception, antiretroviral medications and HIV/AIDS disease markers. We performed descriptive analysis of population characteristics and logistic regression to assess predictors of their desire to have future children.

RESULTS

Subjects had a median age of 37 years and had been diagnosed with HIV for a mean of 9.2 years; 55% had AIDS. Most (68%) subjects were currently monogamous and 29% were abstinent. Forty-seven percent had been sterilized and of those who were sexually active but not sterilized, 90% were using reversible contraception. One third of subjects desired future childbearing, including 12% of those who had been previously sterilized. In a multivariate analysis, predictors of desire for future childbearing were younger age, not being on HIV medication, higher current CD4 cell count and having a relationship duration of less than 2 years.

CONCLUSION

HIV-positive women have reproductive patterns similar to those of HIV-negative women, with most having borne children and many wanting children in the future. A substantial proportion has been sterilized and express sterilization regret. Potent antiretroviral therapy has greatly improved the outlook for HIV-infected women, even those with an AIDS diagnosis. Many HIV-positive women want to have children and would benefit from preconception counseling and counseling about reversible methods of contraception.

Características relacionadas ao primeiro e último parto por cesárea

OBJECTIVE

To study the association between first and last caesarian sections with tubal sterilization; to determine length of reproductive life after the first delivery.

METHODS

From February to October 2001 in a university hospital, interviews were carried out with 653 women having had at least two pregnancies. Of these women, 172 had a first caesarian section; 294 had a last caesarian section. Variables were social demographic characteristics, obstetric history and characteristics of the first and last deliveries and tubal sterilization. Bivariate analysis was performed, followed by multiple regression analysis calculating the adjusted odds ratio. Women who had undergone tubal sterilization were divided into age groups of 25 to 44 and >45 years in a percentile distribution. The Wilcoxon test was used to analyze age at tubal sterilization and length of reproductive life after the last delivery. The study was approved by the Ethics Committee.

RESULTS

Of these women, 89% completed<8 years of school education and 78% were Caucasian. On multiple regression analysis, there was an association between the first and last caesarian section (OR=15.28, 95%CI 8.54 to 27.36), having a partner (OR=3.87, CI95% 1.63 to 9.17) and giving birth in the '70s, '80s or '90s (OR=4.43, 95%CI 1.37 to 14.27), (OR=6.11, 95%CI 1.47 to 25.47) and (OR=6.67, 95%CI 1.21 to 40.26), respectively. The last caesarian section was associated with intrapartum tubal sterilization (OR=14.09, 95%CI 7.37 to 26.97), giving birth in the '70s, '80s or '90s (OR=1.81, 95%CI 1.06 to 3.09), (OR=5.53, 95%CI 3.18 to 9.61) and (OR=5.90, 95%CI 3.03 to 11.48), respectively, family income of >5 minimum wages (OR=2.41, 95%CI 1.42 to 4.08) and age at first delivery>25 years (OR=1.80, 95%CI 1.01 to 3.22). Mean age at sterilization was 29.0 and 33.2 years in women aged 25 to 44 years and >45 years, respectively (p<0.001). The duration of the reproductive period after the first delivery was 9.0 and 11.4 years for the same groups (p<0.001).

CONCLUSION

The first caesarian section was associated with the last caesarian section. The last caesarian section was associated with intrapartum tubal sterilization. Age at sterilization was lower and the reproductive period was shorter among younger women.

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.

[Intrapartum and interval tubal sterilization]

BACKGROUND

Brazil is a country with a high prevalence of tubal ligation, which is frequently performed at the time of delivery. In recent years, an increase in tubal reversal has been noticed, primarily among young women.

OBJECTIVES

To study characteristics correlated with the procedure, determine frequency of intrapartum tubal ligation, measure patient satisfaction rates and tubal sterilization regret, in a sample of post-tubal patients.

METHODS

Three hundred and thirty-five women underwent tubal ligation. The variables studied were related to the procedure: age at tubal ligation, whether ligation was performed intrapartum (vaginal or cesarean section) or after an interval (other than the intrapartum and puerperal period), health service performing the sterilization, medical expenses paid for the procedure, reason stated for choosing the method and causes related to satisfaction/regret: desire to become pregnant after sterilization, search for treatment and performance of tubal ligation reversal. The women were divided into two groups, a group undergoing ligation in the intrapartum period and a second group ligated after an interval, to evaluate the association between variables by using Fisher's exact test and chi-squared calculation with Yates' correction. The study was approved by the Ethics Committee of the institution.

RESULTS

There was a predominance of Caucasian women over 35 years of age, married, and with a low level of education of which 43.5% had undergone sterilization before 30 years of age. Two hundred and forty-five women underwent intrapartum tubal ligation, 91.2% of them had cesarean delivery and 44.6% vaginal delivery. In both groups undergoing intrapartum tubal ligation and ligation after an interval, 82.0% and 80.8% reported satisfaction with the method. Although 14.6% expressed a desire to become pregnant at some time after sterilization, consultation regarding sterility occurred in 3.4% and 2.3%, respectively, and one woman underwent tubal reversal. The most frequent reasons for choosing the method were satisfaction with the number of offspring (35.5% and 46.7%) and medical indication (41.6% and 32.2%), respectively.

CONCLUSION

The incidence of intrapartum tubal ligation was higher when the last delivery had been a cesarean section. No difference was detected among the groups regarding rates of satisfaction and regret after performance of the sterilization procedure.