|Home | About | Journals | Submit | Contact Us | Français|
Male sterilization is a highly effective contraceptive method that is underused especially among minorities. This analysis examined the association between race/ethnicity and receipt of sterilization counseling. This study used data collected by the 2002 National Survey of Family Growth. The analysis included men 15 to 44 years old who had not undergone sterilization. The outcome was receipt of sterilization counseling in the 12 months prior to interview, and the primary predictor was race/ethnicity. Sociodemographic characteristics, history of fathering an unintended birth, intention for more children, and access to health care were examined as confounders. Sixty-one (1.7%) men reported receiving sterilization counseling. Although counseling was reported more commonly by Black and Hispanic men compared with White men, the rates were not significantly different (odds ratio [OR] = 2.4, 95% confidence interval [CI] = 0.8–7.1 and OR = 1.9, 95% CI = 0.9–4.1, respectively). In this nationally representative sample of men aged 15 to 44 years, there were exceedingly low rates of sterilization counseling for all men regardless of race/ethnicity.
Unintended pregnancy remains a substantial problem in the United States, and racial and ethnic minorities are at particularly high risk of having an unintended pregnancy (Finer & Henshaw, 2006). There has been a growing recognition of the importance of male involvement in contraceptive decisions in improving reproductive health outcomes (Alan Guttmacher Institute, 2002; Pearson, 2003; Raine, Marcell, Rocca, & Harper, 2003; Sonfield, 2002). However, male sterilization (vasectomy), the only highly effective male-controlled method of contraception, is underused in the United States, especially among minorities (Barone, Johnson, Luick, Teutonico, & Magnani, 2004; Bumpass, Thomson, & Godecker, 2000; Dassow & Bennett, 2006). According to the 2002 National Survey of Family Growth (NSFG), nearly 17% of women have undergone sterilization compared with 6% of men (Chandra, Martinez, Mosher, Abma, & Jones, 2005; Martinez, Chandra, Abma, Jones, & Mosher, 2006). Furthermore, the proportion of African American and Hispanic men who have undergone sterilization is exceedingly low at 1.9% and 2.3%, respectively, compared with 8.0% of White men (Barone et al., 2004; Martinez et al., 2006).
The reasons underlying racial and ethnic disparities in vasectomy are likely multifactorial. Possible explanations include cultural differences in patient-level factors such as preferences and union stability (Barone et al., 2004; Borrero et al., in press; Bumpass et al., 2000). Even among continuously married couples, however, minority men are far less likely to undergo sterilization than their White counterparts (Bumpass et al., 2000). Another possible factor is differential contact with the health care system. There are very little data on racial/ethnic variations in access to or receipt of reproductive health counseling and sterilization counseling in particular. Therefore, the 2002 NSFG was used to examine the relationship between race/ethnicity and receipt of sterilization counseling among men aged 15 to 44 years.
This study is a secondary data analysis of cross-sectional data collected by Cycle 6 (2002) of the NSFG, a publicly available data set (www.cdc.gov/nchs/nsfg.htm). The NSFG is conducted by the National Center for Health Statistics, Centers for Disease Control and Prevention, to provide national estimates of factors affecting pregnancy and birth outcomes, including sexual activity, contraceptive use, marital status, infertility, and use of medical services for family planning. Interviews for Cycle 6 were performed between March 2002 and March 2003. The NSFG uses a stratified, multistage sample design to represent women and men aged 15 to 44 years in the civilian, noninstitutionalized household population of the United States. Sampling weights are applied to respondent data allowing adjustment for different sampling rates, response rates, and coverage rates.
The 2002 NSFG sample included 7,643 women and 4,928 men. This analysis focuses on data gathered from male participants. To determine likelihood of receiving sterilization counseling from a health care provider in the preceding 12 months, men who reported a history of a sterilization operation (n = 149) were excluded. The sample was further limited to men who were non-Hispanic White, non-Hispanic Black, and Hispanic as the “other” race category (n = 274) was too heterogeneous (included Asians, Pacific Islanders, Alaskan natives, and American Indians) to draw any meaningful conclusions.
The primary outcome was receipt of sterilization counseling or advice within the 12 months prior to interview. The primary predictor of interest in our analysis was self-reported race/ethnicity. Age, insurance status, income, education level, parity, marital status, history of fathering an unintended birth within the 5 years prior to interview, receipt of a physical or testicular exam in the 12 months prior to interview, and intention for more children were examined as potential confounders in the relationship between race/ethnicity and receipt of sterilization counseling.
Sociodemographic characteristics of the study sample were compared by race/ethnicity using chi-square tests for all categorical variables. Bivariate associations between all covariates and receipt of sterilization counseling, the primary outcome, were then examined. Because there were so few outcome events, a multivariable model was not constructed. Instead, each important covariate (p < .10 in bivariate analysis) was examined one at a time in a logistic regression model to determine which of these had the highest confounding effect on the relationship between race/ethnicity and receipt of sterilization counseling. The covariate that changed the odds ratio the most was determined to have the highest confounding effect.
In an attempt to focus the analyses on men who may have been in greater need of sterilization counseling, two subgroup analyses were performed including only men who reported that they did not intend to have more children and men who were married at the time of interview. A secondary analysis was conducted in which the main analysis was repeated but included any men who reported both having a sterilization procedure and receiving sterilization counseling in the past 12 months because we could not determine if they had received the procedure after (and, potentially, in response to) receiving sterilization counseling.
Analyses were conducted using STATA software, Version 9.0 (StataCorp, College Station, TX) with appropriate adjustment for the NSFG's complex sample design. As such, all percentages shown have been weighted to reflect national estimates, and “design-based” estimates of sampling errors were calculated to account for the stratified and clustered sampling. This study was approved by the University of Pittsburgh Institutional Review Board.
The sociodemographic characteristics of the 4,504 men included in the study sample are shown in Table 1. In general, Hispanic and Black men had lower levels of education, lower income, and were less likely to have private insurance. Fewer Black men were married at the time of interview (30% compared with 40% of White men and 42% of Hispanic men; p < .01). Black men were more likely to have received a physical or testicular exam in the past 12 months compared with White and Hispanic men (66% vs. 49% and 48%, respectively; p < .01). Hispanic and Black men were more likely than White men to report fathering an unintended birth within the 5 years prior to interview (14% and 12% vs. 7%, respectively; p < .01).
Overall, only 61 (1.7%) men reported receiving sterilization counseling in the 12 months prior to interview (Table 2). Among men who received either a physical or testicular exam within the year, only 2.7% (n = 51) reported having received sterilization counseling. Furthermore, only 2.5% (n = 37) of men who reported that they had no intention for additional children received sterilization counseling. Receipt of sterilization counseling was infrequent but equivalent across the racial and ethnic groups. Although sterilization counseling was reported more commonly by Black and Hispanic men compared with White men, the rates were not significantly different (unadjusted odds ratio [OR] = 2.4, 95% confidence interval [CI] = 0.8–7.1 and unadjusted OR = 1.9, 95% CI = 0.9–4.1, respectively). Characteristics associated (p < .10) with receipt of sterilization counseling were education, income, parity, marital status, having had a physical or testicular exam in the past year, history of fathering an unintended birth, and reporting no intention for additional children. ORs adjusted for each of these covariates are presented in Table 3. History of a physical or testicular exam was the strongest confounder for Black men whereas income was the strongest confounder for Hispanic men. There was no significant association between receipt of sterilization counseling and age or insurance status.
Results from subgroup analyses, which included only men who reported that they did not intend to have more children (n = 1,516) and men who were married (n = 1,058), were similar in that there were no statistically significant racial differences in receipt of sterilization counseling. Among men who reported that they did not intend to have more children, Black men had higher odds whereas Hispanic men had lower odds of receiving counseling, though neither estimate achieved statistical significance (unadjusted OR = 1.4, 95% CI = 0.4–5.3 and unadjusted OR = 0.7, 95% CI = 0.2–2.2, respectively). Among married men, both Black and Hispanic men had higher, though statistically insignificant, odds of receiving counseling in the year prior to interview (unadjusted OR = 2.8, 95% CI = 0.7–11.0 and unadjusted OR = 1.2, 95% CI = 0.4–3.8, respectively). There were only 13 men who reported receiving both a sterilization procedure and sterilization counseling in the 12 months prior to interview. Including this small cohort of men did not significantly alter the relationship between race and the outcome (unadjusted OR = 1.7, 95% CI = 0.7–4.4 for Black men and unadjusted OR = 1.2, 95% CI = 0.6–2.4 for Hispanic men).
In this analysis of 4,504 men aged 15 to 44 years, no racial/ethnic differences in receipt of sterilization counseling were identified. In addition, the proportion of men receiving sterilization counseling in the 12 months prior to interview was exceedingly low even among those who had accessed the health care system within that time frame.
These results indicate that the low rates of sterilization among minority men do not appear to be related simply to differences in contact with the medical system or access to sterilization counseling. Black men were significantly more likely to have had a physical or testicular exam in the past year and were more likely to have reported receiving sterilization counseling in the past year, although this higher OR did not reach statistical significance. These findings are congruent with those from a recent study by Kalmuss and Tatum (2007) that used the 2002 NSFG and reported that minority men were more likely than White men to use sexual or reproductive health services.
The lack of association between insurance status and receipt of sterilization counseling is also interesting. Although insurance status often plays a dominant role in disparities for many health services, this factor may be less prominent with regard to disparities in reproductive health services because of publicly funded Title X programs implemented specifically to improve access to these services for socioeconomically disadvantaged populations (Kaeser, 1997). It is possible that the type of insurance men have may be a proxy for the clinical setting in which they received care. Men with private insurance generally receive care from private physicians and those with public or no insurance often receive clinic-based care. There is evidence suggesting that publicly funded clinics may actually provide more comprehensive reproductive services (Frost, Darroch, & Remez, 2008; Landry, Wei, & Frost, 2008), which may account for the higher, though statistically nonsignificant, proportions of men with public or no insurance that received sterilization counseling as compared with those with private insurance.
Given our findings that minority men do not, in fact, receive sterilization counseling less often than White men, other potential explanations for the low rates of sterilization among minority men should be considered. For example, cultural differences in patient-level factors such as union stability (fewer Black couples were married than White couples) or in knowledge of or attitudes toward male sterilization may play a dominant role. There is no recent literature examining knowledge and attitudes toward sterilization among American men, although older data indicate that there may be cultural differences (Arevalo, Wollitzer, & Arana, 1987; Huether, Howe, & Kelaghan, 1984; Philliber & Philliber, 1985). Two survey studies from the 1980s reported that Black and Hispanic men were less knowledgeable about vasectomy and had more negative attitudes toward the procedure compared with their White counterparts (Arevalo et al., 1987; Huether et al., 1984). Potential system-level factors that may contribute to observed lower vasectomy use among minorities include payment issues and/or regional differences in clinical practice. Minority men are less likely to have private insurance, and vasectomy services may not be offered where uninsured or publicly insured men seek health care (Barone et al., 2004). Previous research has noted that vasectomy rates are highest in the western United States (Bumpass et al., 2000), where the concentration of African Americans is lower (U.S. Census Bureau, n.d.). This, however, does not explain the low rate of sterilization observed in Hispanic men who are more concentrated in western United States (U.S. Census Bureau, n.d.).
Although vasectomy is certainly not appropriate for all men, the low incidence of counseling reported by men in our sample is surprising. This is especially remarkable given the effectiveness of this form of contraception and the high incidence of unintended pregnancy. Even among men who reported that they did not intend to have more children, less than 3% of men received sterilization counseling. Part of the explanation for these low rates of counseling may stem from the fact that it is unclear who should be providing reproductive health services, including contraceptive education, and in which health care settings (Kalmuss & Tatum, 2007; Sonfield, 2002). Furthermore, there are no guidelines for providing such services for adult men. These issues may contribute to tremendous missed opportunities to educate and counsel men even when they access health care. For example, of the 52% of men that accessed the health care system in the NSFG, only 18% of them reported receiving counseling about any birth control method (NSFG, Cycle 6, 2002). Moreover, health care providers can play a pivotal role in contraceptive decisions: In one survey study of men undergoing vasectomy, doctors and nurses were the most commonly reported source of information that helped men decide to undergo the procedure (Barone et al., 2004).
There are important limitations to consider in interpreting our results. First, there may not have been adequate power to detect significant racial/ethnic differences in receipt of sterilization counseling because only 61 men reported this outcome. Point estimates indicate that minority men were more likely to have received counseling, but these odds did not reach statistical significance. Even if these estimates had been significant, the odds are in the opposite direction than would be expected if receipt of counseling was a mediating factor in the relationship between race/ethnicity and vasectomy. Second, in this self-report, men's recall of having received sterilization counseling may not be accurate. Third, the NSFG only samples men aged 15 to 44 years. Because a man's fertility often goes beyond 44 years of age, he may be a candidate for vasectomy beyond this age range. However, data indicate that more than 90% of men who receive a vasectomy are younger than 45 years of age (Barone et al., 2004).
In summary, in this nationally representative sample of men aged 15 to 44 years, we report exceedingly low rates of sterilization counseling for all men regardless of race/ethnicity. This finding does not explain the observed underuse of vasectomy among minority men. Future research should explore other factors, such as cultural differences in knowledge of and attitudes toward the procedure, which could explain racial/ethnic differences in vasectomy, a highly effective method of contraception.
This publication was made possible by Dr. Borrero's grant (1 KL2 RR02415403) from the National Center for Research Resources (NCRR), a component of the National Institutes of Health (NIH), and NIH Roadmap for Medical Research. The content of this publication is solely the responsibility of the authors and do not necessarily represent the official view of NCRR or NIH.