OCs lead reversible choices, but sterilization is top contraceptive
New finding: One-third of women unmarried at time of sterilization
As the Pill turns 40, it remains the most popular reversible contraceptive method in the United States. But as it reaches middle age, the oral contraceptive (OC) has yet to unseat tubal sterilization as the top family planning choice among American women. And now a new sterilization study has surprised researchers with this finding: One-third of all women in the study population were unmarried at the time of sterilization.1
In reviewing the social and behavior contexts of sterilization in the United States, researchers at the Center for Demography and Ecology at the University of Wisconsin-Madison found that about one-fifth of the sterilizations of Caucasian women were performed while they were unmarried, with as many as 31% performed on unmarried African-American women.
"While we were quite surprised by the finding on the high proportions of sterilizations that are to unmarried women, in retrospect, we should not have been," says Larry Bumpass, PhD, professor in the department of sociology at the University of Wisconsin-Madison and lead author of the study. "We know that a) a third of all births are to unmarried women; b) about two-thirds of these are to women who are out of their teens; c) about half of these unmarried births are to women who have already had at least one child; d) marriage has been delayed dramatically; and e) a family size of two is preferred by a majority of women."
Given those factors, many women will be living out their reproductive lives without having married, and others will prefer to avoid having more children while they are divorced and sexually active, says Bumpass.
Between 1965 and 1988, the prevalence of surgical sterilization increased dramatically among U.S. married women ages 15 to 44, growing from 16% to 42%.2 In 1995, the prevalence remained about the same at 41%. Since 1982, tubal ligation has become more prevalent than vasectomy; among married women in 1995, 24% reported a tubal ligation, compared with 15% reporting their husbands had a vasectomy.2
Female sterilization, the Pill, and the male condom were the most widely used methods in the United States in 1995.3 Between 1988 and 1995, the proportion of users relying on the pill decreased from 31% to 27%, while condom use increased from 15% to 20%.3
Why sterilization?
Why is sterilization so widely used? "When you take into account that almost half of the pregnancies in the U.S. are unintended, and the fact that women in the U.S. tend to be less effective users of contraception than those in similarly developed countries, I think it makes intuitive sense that sterilization would be very popular just because it is such an effective form of contraception," notes Vanessa Cullins, MD, MPH, MBA, vice president and medical director of the New York City-based AVSC International.
While there are no definitive answers, the popularity of sterilization might be influenced by unfounded safety concerns about OCs, which arose in the early 1970s, and the demise of the intrauterine device (IUD) in the 1980s, notes Anne R. Davis, MD, assistant professor of obstetrics and gynecology at Columbia University in New York City. Davis served as co-author of a paper examining the U.S. experience with tubal sterilization.4 The paper was presented at a 1998 conference convened by the contraception and reproductive health branch of the National Institute of Child Health and Human Development in Bethesda to examine female and male sterilization.
While women are now more comfortable with OCs, they still are hesitant about using IUDs, due in part to the continued fallout from the Dalkon Shield. The Dalkon Shield’s manufacturer, A.H. Robins Co. of Richmond, VA, declared bankruptcy in 1985 after more than 4,000 product liability cases had been filed against it. (Contraceptive Technology Update examined the use of IUDs in February 1998, p. 17.)
Although the push is on for more inclusive coverage of all reproductive health choices, insurance payment in the public and private sectors remains very good for sterilization and not as good for other contraceptive methods, notes Cullins. In a recent national poll conducted for the Washington, DC-based American College of Obstetricians and Gynecologists, nearly two-thirds of women surveyed said their contraception was not covered by insurance or they did not know the status of coverage.5
Ease of use also might play a factor in choosing sterilization as a contraceptive method, Cullins says. "Sterilization is a method that is not coitally related, so once you have the procedure done, you really don’t have to think about doing something immediately before or after intercourse in order to prevent pregnancy. You do have to remember about prevention of sexually transmitted diseases, but in terms of pregnancy, you’re well-covered."
Overall, 71% of women who have had a tubal ligation say that they underwent sterilization because they did not want to have another child.6 Just over 10% of women with children said their husband or partner did not want more children; 21% cited medical problems that would make pregnancy dangerous for them or their babies; and 8% reported problems with their previous contraceptive method.
About half of the women with no children chose the procedure due to medical problems, with 35% noting problems with their contraceptive method and 6% stating they or their husband did not want any children.
Women who are seeking sterilization primarily due to its effectiveness need to know that failures do occur, notes Davis. The U.S. Collaborative Review of Sterilization (CREST), which followed more than 10,000 U.S. women poststerilization, shed new light on cumulative failure rates.7 (CTU covered findings from the CREST study in August 1996, p. 93.) Findings indicated a 10-year failure rate of 18.5 pregnancies for every 1,000 procedures, a risk higher than previously reported.
"Many physicians are still not aware of the CREST data," says Davis. "They need to know the failure rates for sterilization and know that other long-term methods offer comparable efficacy so that women can understand there are other choices."
The factors surrounding an individual’s decision about tubal sterilization varies from woman to woman, according to Contraceptive Technology.8 Prior to her decision, each woman needs to weigh the risks, benefits, effectiveness, and side effects of the various contraceptive options. Providers need to facilitate the decision-making process so the patient may make the best choice for her life situation.
"It is important for the health care team to assess where [the woman] is in her decision making, tailor the information that is conveyed to her, and tailor their approach to her in terms of when to schedule the procedure and how many more additional meetings and sessions need to be held in order to be assured that this woman has thoughtfully considered this permanent decision," says Cullins.
(Brush up on your sterilization counseling strategy with provider tips offered in the article at right.)
References
1. Bumpass LL, Thomson E, Godecker AL. Women, men, and sterilization. Fertil Steril 2000; 73:937-946.
2. Chandra A. Surgical sterilization in the United States: Prevalence and characteristics, 19651995. National Center for Health Statistics. Vital Health Stat 1998; 20:23.
3. Piccinino LJ, Mosher WD. Trends in contraceptive use in the United States: 1982-1995. Fam Plann Perspect 1998; 30:4-10, 46.
4. Westhoff CS, Davis AR. Tubal sterilization: Focus on the U.S. experience. Fertil Steril 2000; 73:913-922.
5. Gallup Organization Survey conducted for The American College of Obstetricians and Gynecologists. April 2000.
6. Moore M. Most U.S. couples who seek surgical sterilization do so for contraception; fewer than 25% desire reversal. Fam Plann Perspect 1999; 31:102-103.
7. Peterson HB, Xia Z, Hughes JM, et al. The risk of pregnancy after tubal sterilization: Findings from the U.S. Collaborative Review of Sterilization. Am J Obstet Gynecol 1996; 174:1,161-1,168; discussion 1,168-1,170.
8. Hatcher RA, Trussell J, Stewart F, et al. Contraceptive Technology. 17th ed. New York City: Ardent Media; 1998.
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