In this survey of 191 AA and white women of reproductive age, we found important racial differences in attitudes and knowledge regarding sterilization that may potentially contribute to observed racial differences in sterilization rates. We identified specific patient-level factors that may steer AA women toward sterilization over other contraceptive methods. These factors included a higher prevalence of previous unintended pregnancy, higher numbers of family members who have undergone sterilization coupled with greater family influence in sterilization decisions, greater preference to avoid a method that required insertion of a foreign object or that decreased sexual pleasure, greater misinformation about sterilization, and less awareness of IUDs among AA women compared to white women.
Previous research has indicated that a history of unintended pregnancy, which is experienced more often by AA women, may mediate the relationship between race and unintended pregnancy.(22
) Our results are consistent with this prior research in that AA women in our sample, 80% of whom reported an unintended pregnancy, were more likely than white women to report that this experience motivated them to seek out sterilization. Women who have experienced an unintended pregnancy may develop a heightened sense of perceived fertility and/or diminished locus of control and perceive sterilization to be an effective way to gain control over their fertility. Once we adjusted for sociodemographic confounders, the racial difference was somewhat attenuated and no longer statistically significant. While the drop in level of significance may be related to sample size issues, it may also suggest that factors related to socioeconomic status (SES) play a larger role than race in shaping women’s responses to unintended pregnancy and whether or not she turns to sterilization versus considering other highly-effective methods. That is, a woman’s awareness of and access to contraceptive options other than sterilization and confidence in her ability to obtain and use such methods (i.e., self-efficacy) may be more related to SES than to race.
Another interesting finding is the racial variation in the role of family in contraceptive decision making. AA women in our sample reported higher numbers of family members who had undergone the procedure and also more often reported that their mothers influenced their decisions. These findings are consistent with our focus group study in which many AA women explained that they had been familiar with tubal ligations since an early age because family members had had the procedure, and that it, therefore seemed a natural choice.(14
) This familiarity coupled with direct familial input in contraceptive decision making may perpetuate higher rates of sterilization among AA women.
Some of the attitudinal factors that may steer AA toward sterilization are not necessarily concerning or even modifiable (e.g., greater familiarity and family influence and less desire to have insertion of a foreign object); what is concerning is that such attitudes may be paired with erroneous contraceptive information. AA women in our sample seemed to have overly positive perceptions of female sterilization, overly negative perceptions of male sterilization, and less awareness about other long-acting, highly-effective reversible methods. Ironically, some of the characteristics that AA women incorrectly attributed to sterilization (high effectiveness for 5 years with easy return to fertility upon discontinuation/reversal) are actually more consistent with the characteristics of the IUD. AA women who have experienced unintended pregnancy, in particular, may be motivated to seek out a highly-effective method of contraception and because of familiarity with sterilization, belief that the procedure is 100% effective and easily reversible, and lack of awareness of IUDs, may turn to sterilization. Although there was no statistically significant racial difference with regard to percentage of women who believed that sterilization was 100% effective, 45% of women overall thought this to be the case (54% of AAs and 40% of whites). This is particularly concerning in light of recent data that sterilization failure rates may be higher than previously believed, approaching 7.5% over 10 years.(23
) Such misunderstandings of the procedure may help to explain why the prevalence of sterilization regret is so high, especially among AA women.(9
) Because sterilization is a provider-dependent method that requires informed consent, it is critical that providers assess the underlying attitudes and knowledge that govern a woman’s preference for sterilization. Given the number and potential complexity of factors that may shape women’s sterilization decisions, providing effective counseling may be challenging. As a starting point, Zite et. al have developed a validated questionnaire to assess patients’ understanding of tubal sterilization in an effort to help providers tailor pre-sterilization counseling and guide the informed consent process.
Several limitations need to be considered when interpreting our results. First, the generalizability of these findings may be limited by the fact that participants were recruited from a single hospital research registry. However, this hospital serves women from a large catchment area. Second, our survey asked women to recall events surrounding a procedure that may have occurred several years before and is, therefore, subject to recall bias. However, we are most interested in racial differences in the factors surrounding sterilization decisions and have no reason to suspect that recall differs by race. Third, the knowledge items that we used were created de novo and their psychometric properties were not formally assessed. Lastly, many of the attitudinal items which demonstrated significant racial differences in unadjusted analysis were not statistically significant in adjusted analysis. Given that point estimates remained large, this could suggest issues related to our sample size as we had only 61 participants in the AA group. Alternatively, the drop in level of significance could indicate that certain contraceptive attitudes were shaped more by SES factors (such as access to information and or resources) than cultural factors. Given that contraceptive attitudes and knowledge are shaped by the surrounding socioeconomic and cultural environment,(24
) and that AAs in the US are disproportionately poor,(19
) it may not be critical to try to tease out the independent effects of these factors when trying to understand how community attributes may impact psychosocial determinants of contraceptive behavior. Therefore, we feel that our unadjusted results are informative and can promote respectful contraceptive care by helping providers be aware of how attitudes may vary in diverse populations.
In summary, we identified specific patient-level factors that may steer AA women toward sterilization over other contraceptive methods and contribute to observed racial variation in sterilization utilization. Greater misinformation about sterilization and less awareness of contraceptive alternatives among AA women was a particularly concerning finding that should be addressed. It is important that providers assess women’s understanding of tubal sterilization including alternative contraceptive options so that all women, regardless of race/ethnicity, can make informed and satisfactory reproductive decisions.