USE OF VOLUNTARY sterilization as a means of regulating family size has been increasing over the past two decades. By 1988, tubal sterilization had become the most prevalent method of contraception among married and formerly married women and those older than 30 years of age in the United States1 and is used by 28% of women aged 15 to 44 years.2 By 1990, more U.S. women had undergone tubal sterilization than were using oral contraceptives or any other single method of contraception.3 It is estimated that in the United States alone, more than 1 million tubal sterilization procedures are preformed annually.4 Tubal sterilization is a highly effective method of preventing pregnancy5 and has the highest user satisfaction rate of any currently available method.6
Despite the efficacy of tubal sterilization in preventing pregnancy, it fails to provide protection against sexually transmitted diseases (STDs), including human immunodeficiency virus (HIV). Therefore, many women who are undergoing tubal sterilization are at risk for HIV and other STDs if they do not use a barrier form of contraception. At present, the only available method for preventing HIV transmission among sexually active persons is the correct and consistent use of condoms.7 The issue of consistent condom use is particularly important because although a woman is able to conceive a child only during a rather limited time each month, the risk of disease transmission is more evenly distributed.
Although condoms are one of the most commonly used contraceptive methods by American women,8 they are used to a lesser extent in conjunction with other methods,9,10 in particular methods that are more effective in preventing pregnancy.11 Two available studies conducted in 1980s, one among women in drug-treatment clinics12 and the other among inner-city minority women in Baltimore,13 reported condom use to be low among sterilized women compared with those not sterilized. This finding is disturbing in light of the current evidence about the growing prevalence of tubal sterilization among sexually active women2 and in particular among specific subgroups at high risk for transmitting HIV infection, such as women already infected with the acquired immunodeficiency syndrome virus.14
In the past decade, consistent condom use has been the primary focus of various disease-preventative educational programs. Whether, through these efforts, use of condom by surgically sterilized women has been enhanced is not known, because there are no recent data on the frequency of condom use among these women. The objectives of the present study were to estimate the proportion of women who discontinue using condoms after sterilization, to examine changes in reports of planned condom use with surgical sterilization from 1991 to present, and to examine factors that may be associated with condom use among sterilized women.
Materials and Methods
To examine the aforementioned objectives, we used data collected from women attending the family planning clinic at Baylor College of Medicine in Houston from January 1991 through July 1996. This clinic provides services to women for various types of contraception, including female sterilization. Approximately 400 tubal ligations are performed annually at this clinic.
Women undergoing sterilization at this clinic undergo a standard counseling and educational session, at which time method contraindications are explained to the patient and she is told about the importance of condom use for disease prevention. This session is followed by a complete physical examination, including a pelvic examination and a Pap smear if indicated. At this session, the patient is also asked to complete a questionnaire. To ensure accuracy of the information provided in the questionnaire, a bilingual clinic staff member reviews the information provided in the questionnaire with the patient. All patients are supplied with several condoms before leaving the clinic.
The questionnaire asked for information regarding medical, reproductive, menstrual, sexual, and contraceptive histories; risk status for STDs and HIV; planned condom use; partner's influences on contraceptive decision making; and patient's reasons for and concerns about selecting this method. Reason for selecting tubal sterilization was measured through patients' responses to questions about the method's comfort, convenience, expense, effect on health, and partners'/others' influences. Answers to these questions could range from 1 to 4. On this scale, a value of 1 indicated not important and 4 meant very important. To obtain information on planned condom use, the patients were asked the following question: “Do you plan to use condoms during intercourse in the future to protect yourself and/or others from HIV infection and other sexually transmitted diseases?” The response to this question was coded as a dichotomous variable. Both English and Spanish versions of the questionnaire were available.
Statistical evaluation comparing groups of interest was performed using analysis of variance, Student's t test, and the chi-square categorical procedure. We investigated the association between condom use and various reproductive, psychosocial, and HIV risk behaviors, using a logistic regression model. Odds ratios (OR) and 95% confidence intervals were calculated to test for significant relationships. In the initial analysis, the relationship between study variables and condom use was investigated. For each study variable, the crude ORs (univariable analysis) and the corresponding 95% confidence intervals are presented. The final multivariable models included all statistically significant variables and those whose removal changed the effect of other factors. Relation between various reasons for selecting tubal sterilization and planned condom use was measured using Wilcoxon rank sum test, a nonparametric method for ordinal scales (15). Furthermore, changes in reports of condom use over time were examined using Mantel-Haenszel chi-square test for linear association (15). P ≤ 0.05 was considered significant. All analyses were performed using SAS System statistical software (SAS, Cary, NC).
A total of 2,782 women underwent laparoscopic tubal sterilization at the participating clinic during the 6-year study period. These women ranged in age from 18 to 50 years with a mean of 30.3 years. Sixty-two percent were Hispanics, 20% were black, 17% were white, and 1% belonged to other ethnic backgrounds. About 31% of the women reported to be unmarried, and most had low educational attainment (mean, 9.8 years). The mean number of previous pregnancies and births were 3.8 and 3.1, respectively. Also, one fifth (20%) of the women requesting tubal sterilization at the study clinic had a known risk factor for HIV, including previous STD, history of intravenous drug use or exchanging sex for drugs/money, exposure to multiple partners (at least three) in the previous year, or exposure to a high-risk sex partner defined as a male partner who has had a history of intravenous drug use. There were no significant differences in various demographic and reproductive characteristics, including age, race, marital status, number of previous pregnancies, births, and abortions between patients by year of the study.
Among the sterilized patients, 646 (23%) reported regular condom use as a method for contraception or for protection from disease during the 3 months before sterilization. Of these women, 45% (n = 291) reported no intention to use condoms in the future. Thus, 11% of the total sample planned to stop using condoms once sterilized. Condom use discontinuation varied significantly by ethnic background and marital status. Among Hispanic, white, and black women, respectively, 55%, 36%, and 18% planned to stop condom use once sterilized (P = 0.001). This pattern continued after adjustment for potential influence of marital status; black women were less likely and Hispanics were more likely to discontinue condoms use as compared with whites, independent of marital status. Also, within former condom users, married women were more likely than the unmarried ones to plan to abandon use of condoms once sterilized (54% versus 21%, P < 0.001). The difference in condom discontinuation between married and unmarried women persisted after control for ethnicity.
Table 1 details the changes in frequency of planned condom use over the 6-year study period by age, ethnicity, and marital status among sterilized patients. Information on future use of condoms was not available on 287 women undergoing sterilization. Overall, 42% of the sterilized women had intentions to use condoms in the future. Planned condom use appeared to be higher among the younger women (≤30 years old), African-Americans, and those unmarried. Also, reports of future condom use appeared to significantly increase over time among both the younger and older women, Hispanics, and both married and nonmarried women (P ≤ 0.001). Overall, among sterilized patients, planned condom use increased steadily from 32% in 1991 to 51% in 1996, a significant increase in trend (P ≤ 0.001).
Table 2 displays the relationship between future condom use and various characteristics of women undergoing sterilization. Sterilized women who were planning to use condoms were significantly younger and had more years of schooling than those who did not plan to use condoms (P < 0.001). Black women were over twice as likely and Hispanics were less likely than whites to indicate future condom use (P < 0.001). Furthermore, married women were less likely to plan to use condoms than unmarried women (OR = 0.3).
Certain reproductive characteristics were also related to future condom use. Odds for future condom use was significantly lower among women who had more than one pregnancies and births, whereas it was higher among those who had a previous history of abortion. With respect to sexual behavior, probability of future condom use was significantly lower among women who reported a greater frequency of sexual intercourse per week. Other factors that were related to increased odds for future condom use among sterilized women were having had a sexual partner who injected drugs, having been treated for an STD, and having a greater number of sexual partners in their lifetime or during the previous year (P < 0.01).
Type of relationship and partner's attitude toward tubal sterilization were also related to future condom use. Probability of future condom use was significantly lower among women who had a steady partner than among those who were not in a steady relationship (OR = 0.4). When women were asked “who feels more strongly in favor of you having tubal sterilization?,” women whose partner was in favor of this method of family planning were less likely to indicate future condom use. Furthermore, women who were planning to use condoms in the future were more likely to have relied on use of condoms for disease prevention in the past compared with women who had no future condom use plans (45% versus 6%, P = 0.001). Personal history of intravenous drug use or exchanging sex for drugs/money was very low among study women (1.5%); these variables were not related to intentions to use condoms in the future (data not shown).
For the multivariable logistic regression model, we retained variables that were independent risk factors for future condom use (Table 3). For most variables the results of the multivariable analysis were similar to the results of the univariable analysis. The odds for future condom use were higher among black women, those with a previous history of induced abortion, women who have been treated for an STD in the past, and women with a higher number of sexual partners during the past year and during their lifetime. However, being older and married, having a steady partner, or having a partner who is strongly in favor of tubal sterilization significantly lowered the likelihood of planned condom use among sterilized women. In the multivariable context, level of education, frequency of intercourse per week, ever having a partner who injected drugs, and number of previous pregnancies and births were no longer associated with future condom use.
With respect to reasons for selecting tubal sterilization, the most important reasons for selecting this procedure were wanting to terminate fertility (mean score, 3.7), cost-effectiveness of sterilization compared with other contraceptive methods (mean score, 3.3), and lack of desire to use contraceptives anymore (mean score, 2.7). We also examined the relation between reasons for selecting tubal sterilization and planned condom use. Various reasons for selecting tubal sterilization were not significantly related to future condom use.
Concerns about selecting tubal sterilization were related to future use of condoms. The most frequently cited concerns about sterilization were pain and complications associated with surgery (43%), effectiveness of the method in preventing pregnancy (31%), and the method's side effects (28%). Women who had plans to use condoms were more likely to have had concerns about the method's side effects, its effectiveness in preventing pregnancy, and problems the method may cause in their sex life (P < 0.001). Overall, an average of 1.7 concerns were cited by women who were planning to use condoms compared with 1.2 by those who indicated no desire to use condoms after being sterilized, a difference of statistical significance (P < 0.01).
There is a paucity of data regarding the extend of condom use among sterilized women, in particular among Hispanics. Although a large proportion of women undergoing sterilization at the present clinic expressed intentions to use condoms in the future, at least 11% of the total sample will experience an increased risk for exposure to HIV or other STDs. Hispanics and married women are more likely to cease condom use than either non-Hispanics or unmarried women. These women, although enhancing their protection against unintended pregnancy, place themselves at risk for disease. The higher rate of condom abandonment among Hispanics may be of concern, because of recent reports about the high frequency of Hispanic men's involvement with a secondary sexual partner and low frequency of condom use with these partners.16 Currently, HIV infection is the sixth leading cause of death among Hispanic adults.17 Condom use discontinuation observed in the present study is lower than rates reported for users of other long-term contraceptives such as Norplant18 and injectable contraceptives.19
The significant difference in condom abandonment seen among women of various ethnicities may be related to ethnic differences in perceptions and attitudes toward condom use. Compared with white women, black women are reported to worry more about acquired immunodeficiency syndrome, to be more approving of condom use (in particular with a new partner), and to feel less uncertain about initiating condom use or less embarrassment about buying condoms.20 In contrast, Hispanic women have been reported to have more negative attitudes toward condom use than non-Hispanics, such as “embarrassment to buy condoms” or “condoms are too much trouble to use,” and are less knowledgeable about correct use of condoms and about STD symptoms.21 Overall, our findings indicate that increased educational and counseling programs for STD/HIV prevention and condom use are needed for Hispanic women.
To our knowledge, the present investigation is the first study to report on the changes in frequency of condom use among sterilized women over time. Future use of condoms among women undergoing tubal sterilization increased steadily and significantly from 1991 to 1996. This increase occurred irrespective of age, marital status, or ethnic background. The increase in dual use of condoms with sterilization is promising because increasingly more sexually active women, especially those at high risk for HIV infection, are using this contraceptive method to regulate fertility.11
Willingness and ability to combine effective contraception with disease protection may depend on partnership characteristics and dynamics. Evidence suggests that male partner's attitudes toward family planning, choice of contraception, and STD prevention significantly influences a couple's contraceptive practices.22–24 In the present study, use of condoms was lower among couples where the male partner was strongly in favor of permanent sterilization. These men may be encouraging their female partner to seek a permanent method of contraception because they want to reduce their risk of an unintended pregnancy but want to have minimal involvement in family planning.
Type of relationship has also been reported to be related to contraceptive practices. Women with only one partner or those in long-term relationships are less likely to use condoms as opposed to women with more than one partner or in casual relationships.24,25 It has been suggested that women with regular partners may feel more certain that their partner is uninfected and believe that condom use is unnecessary.26 Also, in such relationships, discussions about using a condom, something already associated with disease and misbehavior, may represent an open acknowledgment that the partner or the woman herself has multiple partners, which in either case may be viewed negatively by the male partner.27,28 Although women in mutually monogamous relationships may in fact have a lower need to use condoms, women in such relationship should consider the use of condoms unless they are certain about the disease-free status of their partner by having the partner tested, as opposed to a more subjective criteria such as “he look clean” or “he seems trustworthy” or informal conversations or assumptions about sexual histories.
Concerns about the potential side effects associated with the use of contraceptives and the actual experiences of side effects is another indicator of a couple's contraceptive practices.29 In the present study, future condom users had significantly more concerns about sterilization, in particular concerns about the effectiveness of this method in preventing pregnancy, than noncondom users. This finding is important and may suggest that aside from STD/HIV prevention, sterilized women may be using condoms to provide additional protection from pregnancy. This suggestion may be further supported by the increased condom use among sterilized women with a previous history of abortion. The tendency for dual use of condoms for pregnancy prevention rather than disease protection has been suggested by others.10 Dual use of condoms to provide additional protection from pregnancy rather than disease prevention may be problematic because it may lead to inconsistent use of condoms; women may use them at times when they perceive themselves to be at high risk of pregnancy (i.e., midcycle) or only with certain partners rather than in a more consistent manner with all partners.
Although the present study provides pertinent information concerning dual condom use with sterilization in an understudied population, it contains certain limitations that should be addressed. First, most patients in the present study were seen in a publicly funded clinic and were indigent, although there was an adequate representation of each ethnic group in our sample. Women of lower socioeconomic status may differ from their more affluent counterparts with respect to disease preventative practices and attitudes toward condom use. Therefore, broad generalization to all sterilized women may not be possible. Second, our data represent intention for future use of condom rather than actual condom use. Although research has shown close correlations between intentions and subsequent behavior,30–32 the reported condom use in the present study may be exaggerated. Furthermore, the present study does not provide information on the amount of condom use with different partners. Future studies are needed to examine the extent of condom use in various types of relationship and the underlying factors associated with such use among women of various ethnicities, in particular among Hispanics.
In conclusion, the present investigation reveals the encouraging findings that condom use intention among women undergoing sterilization appears to be on the rise, that sterilized women at most risk for contracting STDs (i.e., history of STD or exposure to high number of partners in the past) are significantly more likely than others to plan to use condoms, and only some women will experience an increased risk for exposure to disease as a result of selecting this permanent method of contraception. The issue of condom use by sterilized women is particularly important because most women undergoing tubal sterilization have limited to no future contact with family planning providers. Because in many areas these clinics are the community's main source of information and access to disease-preventive materials, there will be fewer opportunities for public health workers to remind sterilized women about the importance of consistent condom use. Therefore, family planning providers need to provide clear and convincing information on the importance of consistent and correct condom use for HIV/STD prevention to women undergoing tubal sterilization and to ensure continuous access to this prophylactic measure.
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