Surgical sterilization, regret, and race: contemporary patterns

Occupational Therapists' Perspectives and Role With Illness-Induced Trauma From Medical Conditions

Illness-induced trauma (IIT) might cause a disruption in an individual's occupational performance. To examine occupational therapy practitioners' (OTPs) perspectives and role in addressing IIT. In this descriptive mixed-methods design, 24 OTPs completed an online survey and 10 OTPs participated in a semi-structured 1:1 interview. Survey questions asked about knowledge regarding IIT. Interviews addressed incorporation of IIT knowledge and trauma-informed care (TIC) into practice. Quantitative results showed most OTPs (64%) did not receive TIC training and believed training was inadequate. Qualitative results indicated three major themes: "Impact on Rehabilitation," "Variety of OT Approaches for IIT," and "Barriers to Providing Trauma-Informed Care." Although OTPs report inconsistencies with incorporating TIC into practice, there are similarities with foundational OT skills and TIC. Findings suggest OTPs utilize a TIC approach to support clients with IIT to process and re-engage in meaningful occupations.

Uncertainty in Postpartum Permanent Contraception Decision-Making: Physician and Patient Perspectives

PURPOSE

We sought to understand how patients and physicians conceptualize uncertainty in the permanent contraception decision-making process.

BASIC PROCEDURES

In 2022-2023, we interviewed postpartum patients with a documented desire for permanent contraception (n = 81) and their delivering physicians (n = 67). Eligible patients gave birth at one of our four study hospitals in California, Ohio, Illinois, and Alabama. We used rapid content analysis and thematic content analysis to develop and refine themes related to uncertainty in permanent contraceptive decision-making.

MAIN FINDINGS

Most patients reported full certainty in their decision regarding permanent contraception, although some expressed doubts. After receiving permanent contraception, some patients discussed grief but overall affirmed their decision. One patient said they wished they had considered other contraceptive options. Physicians reported using a range of strategies to safeguard from patient regret, including ensuring patients were 100% certain with their decision, inferring certainty based on their characteristics, asking patients to think through all scenarios that could affect decision-making, and repeat counseling during multiple interactions.

PRINCIPAL CONCLUSIONS

Patient experiences reveal the depth, fluidity, and nuance of patients' contraceptive decision-making processes. Physicians sometimes failed to grapple with this nuance by centering potential regret in their counseling. Personalized and supportive contraceptive counseling that acknowledges the complexity of contraceptive decision-making is imperative. Shared decision-making can help ensure patients can make informed and autonomous decisions about their reproductive lives.

Racial Disparities in Sterilization Procedure Performed at Time of Cesarean Section

OBJECTIVES

While bilateral tubal ligation has historically been performed for sterilization at cesarean delivery (CD), recent data supports the use and safety of opportunistic bilateral salpingectomy during CD to decrease lifetime ovarian cancer risk. Prior studies have described racial disparities in sterilization rates, but there is a paucity of data regarding racial disparities in type of sterilization procedure. Our objective was to determine differences in sterilization procedure type performed at CD by race (Black vs. non-Black) to evaluate for equity in bilateral salpingectomy utilization.

STUDY DESIGN

We performed a retrospective cohort study of patients included in the American College of Surgeons National Surgical Quality Improvement Program database who underwent sterilization at time of CD from January 2019, to December 2020, identified using Current Procedural Terminology codes. Patients without documented race were excluded. Multivariable logistic regression was used to determine odds of undergoing bilateral salpingectomy compared with bilateral tubal ligation by race while controlling for confounders.

RESULTS

Of 28,147 patients who underwent CD, 3,087 underwent concurrent sterilization procedure, and 2,161 met inclusion criteria (Black: n = 279; non-Black: n = 1,882). Black patients were significantly more likely to have hypertension (10.8 vs. 5.3%, p < 0.01), bleeding disorders (3.9 vs. 1.3%, p < 0.01), preoperative anemia (hemoglobin < 11 g/dL; 36.9 vs. 21.3%, p < 0.01), and be of American Society of Anesthesiologist class 3 or higher (29.4 vs. 22.5%, p = 0.01) than non-Black patients. After adjusting for differences, Black patients were almost 50% less likely than non-Black patients to undergo bilateral salpingectomy compared with bilateral tubal ligation for sterilization at CD (adjusted odds ratio = 0.52, 95% confidence interval: 0.36-0.75).

CONCLUSION

Despite evidence that bilateral salpingectomy decreases ovarian cancer risk and is safe at CD, there is a racial disparity in bilateral salpingectomy utilization. While the cause of this disparity is unclear, further research is warranted to determine root causes and equitable solutions.

KEY POINTS

· Opportunistic salpingectomy is recommended for primary prevention of ovarian cancer in patients undergoing pelvic surgery who have completed childbearing.. · Black patients were almost 50% less likely to undergo bilateral salpingectomy compared with bilateral tubal ligation than non-Black patients even after controlling for possible confounders.. · Further research is needed to determine root cause of the racial disparity in bilateral salpingectomy utilization rate..

Changes in Permanent Contraception Procedures Among Young Adults Following the Dobbs Decision

This cross-sectional study evaluates changes in tubal ligation and vasectomy procedures among younger adults following the Dobbs v Jackson Women’s Health Organization decision.

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.

Judgment, shame, and coercion: the criminal legal system and reproductive autonomy

BACKGROUND

A growing body of research has called attention to limitations to reproductive autonomy in both women who are socially disadvantaged and in those who have had contact with the criminal legal (CL) system. However, it is unclear whether CL system contact influences contraceptive use patterns and how these processes unfold. We utilize a mixed-methods approach to investigate whether history of arrest is associated with receipt of contraceptive counseling, use of long-term contraception, sterilization, and subsequent desire for reversal of sterilization. We further consider how agents in and around the CL system may influence women's reproductive decisions and outcomes (856 survey respondents; 10 interviewees).

RESULTS

We observe that women who have been arrested more commonly report receipt of contraceptive counseling and sterilization. They are also significantly more likely to want their sterilization reversed. Our in-depth interviews suggest that women with CL contact experience considerable shame, and in some cases, coercion to limit fertility from various agents in and outside the criminal legal system including medical providers, Parole/Probation Officers (POs), guards, and family members.

CONCLUSIONS

Our findings suggest the need for ongoing attention to how exposure to this system may promote uneven use of certain forms of contraception and dissatisfaction, i.e., desire for reversal of sterilization, among these women. Findings further suggest that de-emphasizing the CL system as a means through which to address reproductive needs should be considered.

Permanent Contraception: Ethical Issues and Considerations: ACOG Committee Statement No. 8

Permanent contraception is the most used method of contraception among women aged 15-49 years and is one of the most straightforward surgical procedures an obstetrician-gynecologist can perform. At the same time, this therapeutic option is enormously complex when considered from a historical, sociological, or ethical perspective. This Committee Statement reviews ethical issues related to permanent contraception using a reproductive justice framework. Ethical counseling and shared decision making for permanent contraception should adopt a nonjudgmental, patient-centered approach, using up-to-date information about permanent contraception procedures and alternatives. Obstetrician-gynecologists should strive to avoid bringing into the clinical encounter biases around gender, race, age, and class that affect thoughts on who should or should not become a parent. Obstetrician-gynecologists should also ensure that permanent contraception requests reflect each patient's wishes, come from a desire to permanently end childbearing, and come from a preference for permanent contraception over all reversible methods as well as permanent contraception for the male partner. When difficulties in meeting a postpartum permanent contraception request are anticipated and permanent contraception is desired by the patient, transfer of care for the remainder of pregnancy should be offered. ACOG recognizes the right of all patients to unimpeded access to permanent contraception as a way of ensuring health equity, but it is unclear how to craft policies that protect from coercion but also do not create barriers to autonomously desired care. Determining the ethical balance between access and safeguards will require a collaborative interdisciplinary approach that involves a variety of stakeholders with varying perspectives.

Racial and ethnic disparities in long-term contraception use among the birthing population at an academic hospital in the Southeastern United States

Ensuring women and birthing people have access to the contraceptive of their choice is essential for patient-centered care, health equity, and reproductive justice. While trends in national data in the United States reveal racial disparities in long-term contraceptive use, health-system and hospital-level investigations are essential to understand disparities and encourage interventions. We used data from 5011 patients who delivered at a large academic hospital to determine the effect of race/ethnicity and social vulnerability index (SVI) on the odds of undergoing a long-term contraceptive procedure. Results indicate that SVI substantially affects the odds of long-term contraception for non-Hispanic White women and birthing people. In contrast, Hispanic and non-Hispanic Black women and birthing people have significantly higher odds of undergoing a long-term contraceptive procedure due to race/ethnicity. Contributions to these disparities may be based on factors including healthcare providers, organizational and external policies. Interventions at all levels of care are essential to address disparities in contraceptive care, outcomes, and patient experience.

Tubal Sterilization Requests at a Single Institution Following the Supreme Court Decision to Overturn the Constitutional Right to Abortion

This study uses data from electronic health records to examine the rate of tubal sterilization requests in 3 periods before and after the US Supreme Court’s 2022 Dobbs v Jackson Women’s Health Organization decision, compared with the same periods in 2019 and 2021, at a single institution in Michigan.

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.

Sterilized and Satisfied: Outcomes of Childfree Sterilization Obtainment and Denials

As more women choose to forgo motherhood, childfree women and people assigned female at birth (AFAB) are important to study, particularly given pronatalist ideals that can make the choice not to have children difficult to exercise. Although temporary contraception prevents motherhood, physicians sometimes discourage or deny women access to more permanent options, including sterilization, due to their belief that childfree women and those AFAB will regret their decision. From a reproductive justice framework, we examined psychological outcomes of sterilization approval and denials among a sample of 154 childfree women and nonbinary people AFAB who sought and either obtained or were denied sterilization. Participants completed measures of psychological well-being, self-esteem, and sexual quality of life. Childfree participants who obtained sterilization reported higher self-esteem, better sexual quality, and higher well-being than childfree individuals who were denied the procedure. Neither age nor time since making the sterilization request accounted for the differences between the groups in terms of sexual quality of life and psychological well-being. Collectively, these findings offer the first empirical evidence of the potential outcomes among childfree women seeking sterilization.

Permanent Sterilization in Nulliparous Patients: Is Legislative Anxiety an Indication for Surgery?

AbstractThe Supreme Court's Dobbs v. Jackson Women's Health Organization decision, first leaked to the public on 2 May 2022 and officially released on 24 June 2022, overturned Roe v. Wade and thereby determined that abortion is no longer a federally protected right under the Constitution. Instead, the decision gives individual states the right to regulate abortion. Since the Dobbs decision first leaked, our institution has received numerous requests for permanent contraception from individuals stating that their motivation to pursue permanent contraception was influenced by the Dobbs decision and concerns about their reproductive autonomy. Discussions with patients seeking permanent contraception since the Supreme Court's leaked decision have led us to ask ourselves, is legislative anxiety an indication for surgery? This article presents a case series consisting of a convenience sample of 17 young, nulliparous individuals who sought out permanent contraception in the six months following the leak of the Dobbs decision. Healthcare professionals often feel discomfort in offering permanent contraception to young and nulliparous individuals. Accordingly, we discuss pertinent legal issues, review relevant ethical considerations, and offer a framework for these discussions intended to empower the consulting healthcare professional to center the bodily autonomy of every patient regardless of age, parity, or indication for permanent contraception.

Professionalism in Family Planning Care Workshop

INTRODUCTION

When clinicians feel negative emotions toward patients, providinge patient-centered care can be difficult. This can occur in family planning scenarios, such as when a provider is uncomfortable with a patient choosing abortion. The Professionalism in Family Planning Care Workshop (PFPCW), framed around professionalism values, used guided reflection to foster self-awareness and empathy in order to teach future providers to provide patient-centered care.

METHODS

In the PFPCW, learners discussed challenging patient interactions and family planning scenarios to develop self-awareness and identify strategies for maintaining therapeutic relationships with patients when they experience negative feelings toward them. We implemented the workshop across the United States and Canada and collected pre- and postsurvey data to evaluate program outcomes at Kirkpatrick evaluation levels of participant reaction and effects on learners' attitudes.

RESULTS

A total of 403 participants participated in 27 workshops in which pre- and postworkshop surveys (70% and 46% response rates, respectively) were administered. Sixty-five percent of the participants were residents, and 36% had previously participated in a similar workshop. The majority (92%) rated the PFPCWs as worthwhile. Participants valued the discussion and self-reflection components. Afterward, 23% reported that their attitudes toward caring for people with unintended pregnancy changed to feeling more comfortable. Participants said they would employ self-reflection and empathy in future challenging interactions.

DISCUSSION

In this pilot implementation study, our workshop provided learners with strategies for patient-centered care in challenging family planning patient interactions. We are currently modifying the workshop and evaluation program based on feedback.

Knowledge and Attitudes About Sterilization and Long-Acting Reversible Contraception

OBJECTIVES

To describe understanding of the irreversible nature of permanent contraception and knowledge and attitudes about long-acting reversible contraception (LARC) among individuals seeking and not seeking permanent contraception.

METHODS

We performed a cross-sectional survey among patients with Medicaid insurance attending an obstetrics and gynecology clinic in [location]. The survey consisted of 20 true/false and Likert questions assessing knowledge and perceptions about permanent contraception and LARC. Sixty-seven participants were needed to detect a small-to-medium Cohen's effect size f² = 0.20, with 95% power and alpha = 0.05.

RESULTS

Ninety potential participants were contacted and 67 were recruited. Forty-three participants desired permanent contraception and 24 did not. Approximately half of all participants were not aware that permanent contraception is irreversible. Participants who desired permanent contraception had lower LARC knowledge scores (62% correct versus 70%, p = 0.042) and more negative perceptions about LARC (54% versus 38%, p = 0.048). Fewer participants desiring permanent contraception identified LARC efficacy as equal to permanent contraception (32% versus 83%, p < 0.01), and fewer would consider using LARC (intrauterine device: 23% versus 58%, p < 0.01; implant: 16% versus 46%, p < 0.01). These differences persisted in multivariable models adjusting for age, gravidity, and parity.

CONCLUSIONS FOR PRACTICE

Individuals who desire permanent contraception may not be aware of its permanence, or of equally effective alternatives. They were also found to have more negative perceptions of LARC in our sample. Additional research is needed to understand factors underlying these differences. Counseling practices should be tailored to ensure accurate knowledge about permanent contraception and LARC for all people seeking to avoid pregnancy.

Integrating Surveillance Data to Estimate Race/Ethnicity-specific Hysterectomy Inequalities Among Reproductive-aged Women: Who's at Risk?

BACKGROUND

Inequalities by race and ethnicity in hysterectomy for noncancerous conditions suggest that some subgroups may be shouldering an unfair burden of procedure-associated negative health impacts. We aimed to estimate race- and ethnicity-specific rates in contemporary hysterectomy incidence that address three challenges in the literature: exclusion of outpatient procedures, no hysterectomy prevalence adjustment, and paucity of non-White and non-Black estimates.

METHODS

We used surveillance data capturing all inpatient and outpatient hysterectomy procedures performed in North Carolina from 2011 to 2014 (N = 30,429). Integrating data from the Behavior Risk Factor Surveillance System and US Census population estimates, we calculated prevalence-corrected hysterectomy incidence rates and differences by race and ethnicity.

RESULTS

Prevalence-corrected estimates show that non-Hispanic (nH) Blacks (62, 95% confidence interval [CI] = 61, 63) and nH American Indians (85, 95% CI = 79, 93) per 10,000 person-years (PY) had higher rates, compared with nH Whites (45 [95% CI = 45, 46] per 10,000 PY), while Hispanic (20, 95% CI = 20, 21) and nH Asian/Pacific Islander rates (8, 95% CI = 8.0, 8.2) per 10,000 PY were lower than nH Whites.

CONCLUSION

Through strategic surveillance data use and application of bias correction methods, we demonstrate wide differences in hysterectomy incidence by race and ethnicity. See video abstract at, http://links.lww.com/EDE/B657.

Socioeconomic differences persist in use of permanent vs long-acting reversible contraception: An analysis of the National Survey of Family Growth, 2006 to 2010 vs 2015 to 2017

OBJECTIVE

Permanent contraception has historically been more prevalent among non-White women with lower education and income. Given increasing popularity of long-acting reversible contraception (LARC), we examine changing sociodemographic patterns of permanent contraception and LARC.

STUDY DESIGN

We performed a descriptive analysis of the National Survey of Family Growth (NSFG) from 2006 to 2017, with multivariable analyses of the 2006 to 2010 and 2015 to 2017 cohorts. Using multinomial logistic regression, we investigate predictors of contraceptive category (permanent contraception vs LARC, lower-efficacy contraception vs LARC) in reproductive-aged women.

RESULTS

Total 8161 respondents were included in 2 distinct but analogous regression analyses: (1) the most recent survey cohort, 2015 to 2017 and (2) the cohort a decade prior, 2006 to 2010. Over this period, the prevalence of LARC increased nearly 3-fold (6.2%-16.7%), while permanent contraception use trended downwards (22%-18.6%). Yet, in adjusted models, we observed little change in the sociodemographic predictors of permanent contraception: from the early to recent cohort, use of permanent contraception (vs LARC) remained less likely among college graduates (multinomial odds ratio (OR) 0.45 [95% confidence interval 0.21, 0.97]) and Hispanic women (OR 0.41 [0.21, 0.82]). In addition, high income (>$74,999) and metropolitan residence came to predict less use (OR 0.33 [0.13, 0.84] and 0.47 [0.23, 0.97]). Multiparity, advanced age (over ≥35), and marital status remained strong predictors of permanent contraception.

CONCLUSION

Although use of LARC nearly equals that of permanent contraception in the most recent NSFG survey, socioeconomic differences persist. Continued effort is needed to detect and address structural barriers to accessing the most effective forms of contraception for women.

IMPLICATIONS

Comparing 2006-2010 to 2015-2017, reliance on female permanent contraception decreased while LARC use increased, making prevalence more similar. However, significant socioeconomic differences persist in who chooses permanent contraception, with urban, educated, higher income women more likely to use LARC. Ongoing efforts are needed to understand and reduce economic barriers to LARC.

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.

CE: An Evidence-Based Update on Contraception

Contraception is widely used in the United States, and nurses in all settings may encounter patients who are using or want to use contraceptives. Nurses may be called on to anticipate how family planning intersects with other health care services and provide patients with information based on the most current evidence. This article describes key characteristics of nonpermanent contraceptive methods, including mechanism of action, correct use, failure rates with perfect and typical use, contraindications, benefits, side effects, discontinuation procedures, and innovations in the field. We also discuss how contraceptive care is related to nursing ethics and health inequities.

Pathways to Parenthood in Social and Family Context: Decade in Review, 2020

OBJECTIVE

This article reviews research from the past decade on patterns, trends, and differentials in the pathway to parenthood.

BACKGROUND

Whether, and under what circumstances, people become parents has implications for individual identity, family relationships, the well-being of adults and children, and population growth and age structure. Understanding the factors that influence pathways to parenthood is central to the study of families and can inform policies aimed at changing childbearing behaviors.

METHOD

This review summarizes recent trends in fertility as well as research on the predictors and correlates of childbearing, with a focus on the United States and on research most relevant to family scholars. We document fertility differentials and prevailing explanations for variation across sub-groups and discuss alternative pathways to parenthood, such as adoption. The article suggests avenues for future research, outlines emerging theoretical developments, and concludes with a discussion of fertility policy.

RESULTS

U.S. fertility has declined in recent years; whether fertility rates will increase is unclear. Elements of the broader social context such as the Great Recession and increasing economic inequality have impacted pathways to parenthood, and there is growing divergence in behaviors across social class. Scholars of childbearing have developed theories to better understand how childbearing is shaped by life course processes and social context.

CONCLUSION

Future research on the pathways to parenthood should continue to study group differentials, refine measurement and theories, and better integrate men and couples. Childbearing research is relevant for social policy, but ideological factors impact the application of research to policy.

Exploring Experiences with Sterilization among Nulliparous Women

Although nulliparous women who are sterilized appear voluntarily "childfree," the majority report non-contraceptive reasons for their surgical procedure. Using an analytical subsample of the National Survey of Fertility Barriers, we examined 105 women's closed- and open-ended responses about the reasons for their sterilization surgeries and whether their sterilization occurred before their childbearing desires were met. We found considerable heterogeneity in the experiences and attitudes of participants. We highlight important implications of women's experiences for fertility and reproductive health research and practice, particularly by drawing a distinction between voluntarily childfree and involuntarily childless women.

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.

Female Sterilization and Cognitive Disability in the United States, 2011-2015

OBJECTIVE

To compare female sterilization among three mutually exclusive groups of females: 1) those without any self-reported disability, 2) those with noncognitive disabilities (sensory or physical disabilities), and 3) those with cognitive disabilities.

METHODS

We conducted a secondary analysis of nationally representative data from the National Survey of Family Growth 2011-2015, which surveyed individuals aged 15-44 years in the U.S. civilian population. Disability status (self-reported) was ascertained using a standard set of questions about hearing, vision, cognitive, ambulatory, self-care, and independent living difficulties. Regression models were used to calculate odds of female sterilization, hysterectomies, and age of sterilization while accounting for sociodemographic differences.

RESULTS

Female sterilization rates were higher among females with cognitive (22.1% [n=272]) and noncognitive disabilities (24.7% [n=150]) than among those without disabilities (14.8% [n=1,132]). After adjusting for sociodemographic covariates, females with cognitive disabilities had significantly higher odds of female sterilization (adjusted odds ratio [OR] 1.54, 95% CI 1.19-1.98, P<.01) and hysterectomy (adjusted OR 2.64, 95% CI 1.53-4.56, P<.001) than those without cognitive disabilities. Females with cognitive disabilities also underwent sterilization at significantly younger ages (27.3 years, 95% CI 27.0-27.6) than those with noncognitive disabilities (28.3 years, 95% CI 27.9-28.8) and those without any disability (29.8 years, 95% CI 29.5-30.0).

CONCLUSION

U.S. females with cognitive disabilities were more likely to have undergone female sterilizations and hysterectomies and at younger ages than those with other disabilities or without disabilities. Drivers of these disability-related differences in female sterilization patterns must be explored.

The use of a low-literacy version of the Medicaid sterilization consent form to assess sterilization-related knowledge in Spanish-speaking women: results from a randomized controlled trial

OBJECTIVE

To learn whether a version of the Medicaid Sterilization Consent Form (SCF) adapted for populations of low-literacy can help Spanish-speaking women better understand the process and consequences of tubal sterilization.

STUDY DESIGN

We randomly assigned Spanish-speaking women, ages 21-45 years, to review either a "standard" or "low-literacy" version of the Medicaid SCF. We assessed sterilization-related knowledge using items from the Postpartum Tubal Sterilization Knowledge questionnaire, using as the primary outcome correct identification of least four or more knowledge items and as secondary outcome participants' preferred version of the SCF.

RESULTS

Overall sterilization-related knowledge was low in both groups, with 33% of women (n=100) who reviewed the standard SCF form and 42% of those who reviewed the low-literacy form (n=100) correctly identifying four or more knowledge-related items (p=.19). Regarding specific items, women in the low-literacy SCF group were more likely than those in the standard SCF group to understand the permanence of sterilization (69% versus 49%, p<.01) and the time requirement between signing the consent document and undergoing sterilization (79% versus 59%, p<.01). The groups were similar in appreciating availability of equally effective nonpermanent contraceptive options (71% versus 64%, p=.29), time from signing to expiration (33% versus 38%, p=.46), or non-binding nature of sterilization consent (55% versus 62%, p=.32). Overall, 71% of participants from both groups preferred the low-literacy form.

CONCLUSION

In our patient population, characterized by low educational attainment and inadequate health literacy skills, a low-literacy SCF did not improve overall sterilization-related knowledge when compared to the standard SCF. The low-literacy version did improve understanding of the permanence of sterilization and time requirements to undergo the procedure.

IMPLICATIONS

Neither form conveyed an adequate level of knowledge to this vulnerable Spanish-speaking population. Therefore, a considerable need persists for detailed education regarding availability of equally effective reversible contraceptive options, procedure-related risks, and permanence of sterilization throughout the process of informed consent.

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

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

Responding to Infertility: Lessons From a Growing Body of Research and Suggested Guidelines for Practice

Infertility is a common, yet often misunderstood, experience. Infertility is an important topic for family scientists because of its effects on families; its relevance to research in related areas, such as fertility trends and reproductive health; and its implications for practitioners who work with individuals and couples experiencing infertility. In this review, we focus on common misperceptions in knowledge and treatment of infertility and highlight insights from recent research that includes men, couples, and people with infertility who are not in treatment. The meaning of parenthood, childlessness, awareness of a fertility problem, and access to resources are particularly relevant for treatment seeking and psychosocial outcomes. On the basis of insights from family science research, we provide specific guidelines for infertility practice within broader social contexts such as trends in health care, education, employment, and relationships. Guidelines are presented across three areas of application: infertility education for individuals, families, and practitioners; steps to support the emotional well-being of those affected by infertility; and understanding of treatment approaches and their implications for individuals and couples.

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.

Tubal Sterilization in Women Under 30: Case Series and Ethical Implications

OBJECTIVE

According to the SOGC Contraception Consensus, it is recommended that permanent contraception be offered to women regardless of age or parity. Many women who desire sterilization at a young age experience barriers from physicians who decline to facilitate the request.

METHODS

As part of a quality assurance project, we performed a review of cases where tubal sterilization was performed in women under 30 over a 42-month period (September 2013-March 2017). We also performed a literature review on the ethical and clinical considerations with respect to young women requesting permanent contraception.

RESULTS

We identified 29 women under 30 who had consented for tubal sterilization; 27.5% of women were nulliparous, and 27.5% had a medical condition for which unintended pregnancy is associated with an increased risk of adverse event. As documented in the patients' records, many women expressed prior difficulty in obtaining the procedure. Despite being informed of the risk of regret, most women proceed with the surgical procedure. Three additional women had consented and subsequently cancelled their surgical procedure.

CONCLUSION

Women who are well-informed and desire permanent contraception should be offered the procedure, regardless of age or parity. Declining such requests is a form of conscientious refusal and is not a clinical decision.

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.

Factors associated with sterilization among HIV-positive US women in an urban outpatient clinic

This cross-sectional study sought to determine factors associated with sterilization among HIV-positive US women. HIV-positive women aged 18-45 completed an Audio Computer Assisted Self Interview (ACASI) questionnaire. Chi-square tests and multivariable logistic regression evaluated factors associated with sterilization. The median age of the 187 participants was 37, the majority had at least a high school education, and 88% were African American. Nearly a quarter (22%) of women had undergone sterilization at an average age of 25; of these women, 71% cited their HIV-positive status as an important factor in deciding to have a tubal ligation, 22% expressed desire for future children, 32% reported sterilization regret, and 20% reported feeling pressure to undergo sterilization. In multivariable analysis, factors significantly associated with sterilization included non-African American race, no desire for future pregnancy, having heard of any birth control methods making it harder to get pregnant in the future, belief that women should take a break from hormonal methods every few years, and having had a child born with HIV. While almost a quarter of this HIV-positive group was sterilized, many during the height of the early HIV epidemic, a large proportion of sterilized women expressed sterilization regret. Counseling messages for sterilized HIV-positive women should be sensitive to the fact that women may have regret regarding a decision that, in some cases, may historically have been part of provider recommendations to prevent vertical transmission of HIV. Improved knowledge about contraceptive options such as the IUD and implant is needed among HIV-positive women.

A Multilevel Test of Constrained Choices Theory: The Case of Tobacco Clean Air Restrictions

According to Bird and Rieker's sociology of constrained choices, decisions and priorities concerning health are shaped by the contexts-including policy, community, and work/family-in which they are formulated. While each level received attention in the original and subsequent research, we contend their constrained choices theory provides a powerful multilevel framework for modeling health outcomes. We apply this framework to tobacco clean air restrictions, combining a comprehensive database of tobacco policies with the National Longitudinal Survey of Youth 1997 from ages 19 to 31. Using multilevel panel models, we find that clean air policies lower the odds of past 30 day smoking and dependence while controlling for other policy-, city-, and individual-level constraints. We also find unique between- and within-person effects, as well as gender effects, for the constraint levied by smoking bans. We argue for the theory's broad applicability beyond commonly cited findings regarding gender and biological influences.

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.