Regret after decision to have a tubal sterilization

Transcription

1 FERTILITY AND STERILITY Copyright c 1985 The American Fertility Society Vol. 44, No.2, August 1985 Printed in U.SA. Regret after decision to have a tubal sterilization Gary S. Grubb, M.D., M.P.H.*t Herbert B. Peterson, M.D.** Peter M. Layde, M.D. George L. Rubin, M.B., F.R.A.C.P.* Centers for Disease Control, Atlanta, Georgia To determine characteristics associated with regretting sterilization that can be determined preoperatively, we analyzed data from the Collaborative Review of Sterilization (CREST), a multicenter, prospective, observational study. Of 5022 women, 2.0% regretted having had a tubal sterilization at 1 year after the procedure and 2.7% did so after 2 years. Using a multivariate analysis to identify risk factors for regret, we found that almost all characteristics were more closely associated with regret at 1 year than at 2 years postoperatively. Of the characteristics we examined that could be objectively determined preoperatively, we considered only age less than 30 years and (for whites) a concurrent cesarean section to be risk factors for regret at 2 years after sterilization. However, in absolute terms, < 10% of women with both those risk factors regretted having the procedure. Fertil Steril 44:248, 1985 Over the past decade, tubal sterilization has become the most prevalent method of fertility control for American women. However, for various reasons some women regret having had the procedure. Studies with high follow-up or response rates have estimated that the prevalence of women who express regret ranges from 3% to 5%.1-7 Each year approximately 650,000 American women have a tubal sterilization,8 so a large number of women are potentially affected. Therefore, it is important to better characterize women who regret having had a sterilization so that efforts to reduce the likelihood of regretting the procedure can be made more effective. Using data from the Collaborative Review of Sterilization (CREST), we determined the likelihood of regret after tubal sterilization and the risk factors for regret that can be objectively determined preoperatively. CREST is a multicenter, prospective, observational study conducted by the Division of Reproductive Health of the Cen ~rs for Disease Control (CDC). Received December 7, 1984; revised and accepted April 29, *Epidemiologic Studies Branch, Division of Reproductive Health Center for Health Promotion and Education, Centers for Disease Control. tpresent address: Family Health International, Research Triangle Park, North Carolina. treprint requests: Herbert B. Peterson, M.D., Deputy Chief, Epidemiologic Studies Branch, Department of Health and Human Services, Centers for Disease Control, Atlanta, Georgia Chronic Diseases Division, Center for Environmental Health, Centers for Disease Control. 248 Grubb et ai. Regret after sterilization MATERIALS AND METHODS ENROLLMENT AND FOLLOW-UP Between September 1978 and December 1980, three university hospitals and six university-affiliated community hospitals attempted to enroll all women scheduled for a tubal sterilization procedure. Of the 5283 women scheduled for sterilization, all were eligible for the study and 5022 (95%) were enrolled. CDC-trained interviewers administered a standard questionnaire to each Fertility and Sterili,.

2 subject preoperatively to obtain information on demographic characteristics and reproductive and medical histories. At least three attempts were made to contact each woman by phone 1 and 2 years after the sterilization procedure. After 1 year, 88.4% of those enrolled were reinterviewed; 10.1% were lost to follow-up; and 1.5%, who had a hysterectomy, pregnancy, or repeat sterilization, were no:!; asked about regret of the procedure. After 2 years, 84.8% of the enrolled subjects were rein-. terviewed; 13.8% were lost to follow-up; and 1.4%, who had a hysterectomy, pregnancy, or repeat sterilization, were not asked about regret. In the follow-up interviews, women were asked, "Do you still think tubal sterilization as a permanentmethod of birth control was a good choice for you?" Women who answered "no" to this question were defined as regretting having had a tubal sterilization. Underlying disease was defined as a history of a disease that increased a woman's risk of pregnancy complications and predisposed her to sterilization for medical reasons (e.g., diabetes, cancer, heart, or thromboembolic disease). Each woman who expressed regret was asked what was the most important reason for changing her mind. The reasons for regret were grouped into three categories: menstruation-related, fertility-related, and other reasons. Examples of menstruation-related reasons include menstrual pain or heavy menstrual bleeding. Similarly, examples of fertility-related regret include wanting more children and getting divorced or remarried. DATA ANALYSIS Two types of characteristics that can be determined preoperatively, patient characteristics and timing of sterilization, were analyzed for all patients and also separately for those with fertilityrelated and menstruation-related reasons for regret. To compute the relative risk (RR) of regret for each characteristic while simultaneously controlling for the potentially confounding effects of other characteristics, we used linear logistic regression analysis. 9 On the basis of risk factors for regret cited in the literature and a screening of potentially confounding variables, we included eight characteristics in our analysis: age, race, education, marital status, parity, underlying medical conditions, history of abortion, and timing of the sterilization. Some variables were not associated with the risk of regret in the initial Vol. 44, No.2, AUgUst 1985 analysis and therefore were not included in the regression analysis. These variables included the contraceptive used in the month before sterilization, age at last birth, time since last birth or abortion, method of tubal occlusion, and data collection institution. In the results of the regression analysis, the RR is significant at a P value of < 0.05 if the 95% confidence interval does not include 1.0. The rate of regret for those with a particular characteristic was adjusted for the confounding effects of the other characteristics. We tested the significance of differences in the number of women giving one category of a reason for regret between 1 and 2 years after sterilization by using the Mantel-Haenszel procedure. lo To analyze the association between regret and time from vaginal delivery to sterilization, we used the Mantel extension of the Mantel-Haenszel procedurey Table 1. Demographic and Medical Characteristics of Women Having Tubal Sterilization, CREST, (n = 5022) Characteristic Age (yr) Race White Black and other Education (yr) < > 12 Married Currently Never Formerly Parity o 1-2 ;;.3 Previous induced abortion Yes No Medical conditiona Yes No Timing of tubal sterilization Interval b Postvaginal delivery Concurrent with cesarean section Postabortion % achronic disease that could cause a tubal sterilization to be medically indicated. bnot associated with a pregnancy. Grubb et ai. Regret after sterilization 249

3 RESULTS Most study participants were white, 30 to 44 years of age, currently married, and had one or two children (Table 1). About 80% had at least a high school education, no history of abortion, and a nonpregnancy-associated (interval) sterilization. Ninety (2.0%) of the women interviewed 1 year after sterilization and 116 (2.7%) of those interviewed 2 years after sterilization regretted having the procedure (Table 2). After the first and second years of follow-up, 0.8% and 1.5%, respectively, said they did not know if they regretted having a tubal sterilization. Some women who expressed regret 1 year after sterilization did not continue to regret it 2 years after sterilization. This occurred more often for those with menstruation-related regret (42%) than for those with fertility-related regret (25%). A desire for more children and menstrual complaints after sterilization were most frequently given as reasons for regret (Table 3). The percentage of women regretting the procedure for menstruation-related reasons dropped significantly between 1 and 2 years after the procedure. PATIENT CHARACTERISTICS Four characteristics were significantly associated with approximately a twofold risk of regret at 1 year after tubal sterilization: age less than 30 years at time of sterilization, white race, less than a high school education, and never having been married (Table 4). A history of abortion was associated with regret among women of black and other races, but was not associated with regret among whites. RR of regret for almost all the characteristics were lower at 2 years than at 1 year after sterilization. Only age less than 30 years and a history of abortion among women of black and other races remained significantly associated with regret at 2 years after sterilization. The only risk factor associated with regret in both Table 2. Percentage of Women with Regret After Tubal Sterilization, CREST, Year of follow-up Response First Second No. % No. % Regret Uncertain No regret Total Grubb et al. Regret after sterilization Table 3. Frequency of Reasons Given for Regret of Tubal Sterilization, CREST, Year of follow-up Reason given for First Second regret No. % No. % Menstruation-related Fertility-related Wants more children Divorced, remarried Loss of childa Bad ideab Other Total Other Surgical complicationse Other Loss of sexuality Nonspecific Unknown Total Total aloss of child by death or divorce. blncludes immature decision and perception of outside pressure to have a tubal sterilization. ecomplication perceived by women to be related to surgery. years of follow-up, which also applied to a substantial percentage of women (43.7%), was age less than 30 years. Two years after sterilization, 4% of these women regretted undergoing sterilization. TIMING OF STERILIZATION Among whites, the risk factor most significantly associated with regret was a concurrent cesarean section. However, 2 years after sterilization, only 6% of women with this risk factor regretted having the procedure. For whites, a sterilization performed after vaginal delivery was associated with a 1.5% to 1.7% greater risk of regret at 1 and 2 years, respectively, compared with the risk associated with an interval sterilization. Because the 95% confidence intervals for these RR overlap 1.0, however, this increased risk may be due to chance alone. The probability of regret decreased significantly with each 12-hour period from vaginal delivery to sterilization; the shorter the time period, the greater the risk of regret. To give an example of this relationship, all 17 women who regretted their postvliginal_ delivery sterilization and 65% of Fertility and Sterility

4 Table 4. RR of Regret of a Tubal Sterilization by Selected Characteristics Characteristic" Patient characteristic Age < 30 e White Education < 12 yr Never married e Formerly married e Medical conditionf Parity < 2 History of abortion WhiteD Black and other races h Timing of sterilizationi Postabortion sterilization Postvaginal delivery sterilization First b RR (95% CI d ) 2.2 ( ) 2.3 ( ) 2.2 ( ) 1.9 ( ) 1.4 ( ) 1.5 ( ) 0.7 ( ) 1.0 ( ) 2.3 ( ) 1.8 (0.(h5.2) WhiteD 1.5 ( ) Black and other 1.2 ( ) races h Concurrent cesarean section Whit# 5.8 ( ) Black and other 1.5 ( ) races h Year of follow-up Secondc RR (95% CI d ) 1.8 ( ) 1.3 ( ) 1.6 ( ) 1.3 ( ) 1.4 ( ) 1.2 ( ) 1.3 ( ) 0.8 ( ) 2.3 ( ) 1.0 ( ) 1.7 ( ) 0.5 ( ) 3.3 ( ) 1.0 ( ) areference group for each characteristic is that group of women without the characteristics specified (e.g., age ;;" 30, black or other race, education;;., 12 years, currently married, no underlying medical condition, parity;;., 2, no history of abortion, and having an interval sterilization). bof 4441 completed first year interviews, 78 with unknown variables excluded from analysis. cof 4259 completed second year interviews, 111 with unknown variables excluded from analysis. dconfidence interval. eat time of sterilization. fchronic disease that could cause a tubal sterilization to be medically indicated. greference group is white women only. hreference group is women of black and other races only. ireference group is interval tubal sterilization. those without regret were sterilized within 36 hours of delivery. RISK FACTORS AND REASONS FOR REGRET We also analyzed the risk factors separately for each category of reason for regret at 1 year after sterilization. Three risk factors were associated with markedly higher RR among women who regretted sterilization for fertility-related rather than for menstruation-related reasons: age less than 30 years (RR = 4.6 and 0.9, respectively), having formerly been married (RR = 2.7 and 0.3), and for whites having a concurrent cesarean sec~ tion (RR = 8,7 and 1.4). DISCUSSION This study avoids several of the methodologic limitations of previous studies of regret after tubal sterilization by the use of a large study-population size and the use of multivariate analysis to adjust for confounding variables. Our prospective study design minimizes bias from retrospectively collected data and standardizes the time of followup. These methodologic strengths permit a detailed analysis of characteristics of women who regret sterilization. We found that 2.7% of our study population regretted having a tubal sterilization at 2 years after the procedure. This finding is consistent with other studies that had high response or follow-up rates.1-7 As in the three other studies that followed up women more than once, the percentage of women who expressed regret increased between the first and second years after sterilization. 2 3,7 Although the percentage of women who regret sterilization seems to keep rising even after 1 year after sterilization, there is no information to suggest how long this trend continues to rise. ENROLLMENT AND FOLLOW-UP RATE Although the high enrollment and follow-up rates in our study reduced the likelihood of selection biases in enrollment or follow-up, there was such a bias in follow-up: those who expressed regret at 1 year after sterilization were about 1. 7 times more likely to be lost to follow-up at 2 years than those who expressed no regret after 1 year. Among those with regret at 1 year, women subsequently lost to follow-up had similar characteristics to those completing follow-up at 2 years. To estimate the potential effect of this bias in follow-up rates, we assumed women who did not participate in the study or were lost to follow-up had a rate of regret of 10%. This is the highest rate of regret previously reported in a sizable study population. 12 We also assumed that all women who had later become pregnant or who had a repeat sterilization and 50% of those who had a hysterectomy regretted having the sterilization. With these assumptions, the rate of regret for all women was 4.9% at 1 year and 5.8% at 2 years after the procedure. Vol. 44, No.2, August 1985 Grubb et al. Regret after sterilization 251

5 PATIENT CHARACTERISTICS All of the characteristics significantly associated with regret at 1 year after sterilization were less closely associated with regret at 2 years after the procedure. Risk factors for regret that can be determined preoperatively may become less closely associated with regret over time, because, with increasing time after sterilization, postoperative life changes (e.g., divorce and remarriage) become stronger factors influencing regret. We were not able to assess these postoperative life changes or other preoperative factors that are subjective, e.g., reasons for sterilization and persons involved in the decision to undergo sterilization. This study confirms the finding of other studies. that young age is associated with an increased likelihood of regret after a patient's having a tubal sterilization Because young age is usually associated with low parity, our analysis controlled for one while calculating the risk of the other. This analysis revealed that parity < 2 is not an important risk factor for regret in our study population. In retrospective studies in which subjects were interviewed a longer time after sterilization than in our study, marriage and remarriage were the reasons most commonly cited for a woman's regretting a tubal sterilization.16, 17 In this study, the women most likely to marry or remarry (never married or formerly married women) did not have more than a twofold risk of regret, compared with currently married women. However, if women in this study were followed for a longer period, change in marital status might have a greater effect on the likelihood of regret, because marital status tends to change over time. Thus, our estimated risk of regret for unmarried women may increase with longer follow-up. In this study, an unknown portion of the women with an underlying medical condition had a medically indicated tubal sterilization. These women may regret having the procedure, partly because they regret having a condition that necessitated sterilization. Inclusion of these women in the study had little effect on our results, because their exclusion from the multivariate analysis resulted in no substantial change in the risks associated with the other factors. In both years of follow-up, about 3% of women with an underlying condition regretted having a sterilization. TIMING OF STERILIZATION Other studies have suggested that postpartum sterilizations, particularly those performed con- 252 Grubb et al. Regret after sterilization currently with cesarean sections,3, 12, 14 are associated with an increased risk of regret. Women who have a cesarean section may have a sterilization concurrently with a first or a repeat cesarean section or have an interval sterilization 6 or more weeks after a cesarean section. In this study, women having their first cesarean section were no more likely than women having a repeat cesarean section to regret a concurrent sterilization. Therefore it is unlikely that women regretted having a post-cesarean section tubal sterilization, primarily because it followed an unexpected cesarean section. Women having a history of cesarean section with a subsequent interval sterilization were no more likely to regret the procedure than women without prior cesarean section who had an interval sterilization. This suggests that a concurrent cesarean section, rather than a history of cesarean section, is associated with an increased risk of regret. The decision to undergo a sterilization concurrently with a cesarean section must be made before the outcome of the delivery is known. In making this decision, the possibility of cesarean section in connection with future pregnancies must be considered, as well as the option of avoiding the separate operation necessary for the performance of an interval sterilization. These concerns may cause a woman to be sterilized at a time in her life when she would not otherwise have chosen to be sterilized and may later lead to her having feelings of regret. Our finding of an increased risk of regret associated with sterilization performed shortly after vaginal delivery suggests that the timing of sterilization with respect to pregnancy termination may be an important consideration. There are many obstetric and anesthetic considerations that determine the interval from vaginal delivery to sterilization, and our finding, if substantiated by further studies, could add the potential risk of regret to those many considerations. RISK FACTORS AND. REASONS FOR REGRET Our data show that some risk factors are closely associated with fertility-related regret but not with regret for other reasons. Risk factors specific to women with fertility-related regret should be identified, because our data suggest that these women may regret the procedure longer after sterilization than women who regret the procedure for other reasons. In addition, these women Fertility and Sterility

6 may be more likely to regret the procedure enough to request a reversal of the sterilization, an expensive and frequently unsuccessful operation. Follow-up for longer than 2 years will be required to clarify these concerns. Acknowledgments. We thank the individual contributors of this report and their institutional affiliations. Design, coordination, and analysis center: Epidemiologic Studies Branch, Division of Reproductive Health, Centers for Disease Control, Atlanta, GA. Data collection institutions: Barnes Hospital, Washington University Center for Outpatient Gynecologic Surgery, Ernst Friedrich, M.D.; Children's Hospital of Buffalo, Buffalo General Hospital, Erie County Medical Center, Millard Fillmore Hospitals, Norman Courey, M.D.; North Carolina Memorial Hospital, J. F. Hulka, M.D.; Johns Hopkins Hospital, Lucas Blanco, M.D. and Howard Zacur, M.D.; and Sutter Memorial Hospital, Gary Stewart, M.D. REFERENCES 1. Cooper P, Gath D, Fieldsend R, Rose N: Psychological and physical outcome after elective tubal sterilization. J Psychosom Res 25:357, Cooper P, Gath D, Rose N, Fieldsend R: Psychological sequelae to elective sterilisation: a prospective study. Br Med J 284:462, Campanbella R, Wolff JR: Emotional reaction to sterilization. Obstet Gynecol 45:331, Cheng MCE, Cheong J, Khew KS, Ratnam SS: Psychological sequelae of sterilization in women. Singapore Int J Gynaecol Obstet 15:44, Watkins RA, Correy JF, Wise DA, Perkin GJ: Social and psychological changes after tubal sterilization: a reevaluation study on 425 women. Med J Aust 2:251, Whitelaw RG: Ten-year survey of 485 sterilisations. II. Patients' view of their sterilisation. Br Med J 1:34, Smith AHW: Psychiatric aspects of sterilization: a prospective survey. Br J Psychiatry 135:304, Centers for Disease Control: Tubal sterilization among women of reproductive age, United States, update for CDC Surveillance Summaries 32:9, Schlesselman JJ: Case-Control Studies: Design, Conduct, Analysis. New York, Oxford University Press, 1982, p Miettinen OS: Estimability and estimation in case referent studies. Am J Epidemiol 103:226, Mantel N: Chi-square tests with one degree of freedom, extensions of the Mantel-Haenszel procedure. J Am Stat Assoc 58:690, Olive JE: Timing offemale sterilization. Br Med J 2:1126, Leader A, Galan N, George R, Taylor PJ: A comparison of definable traits in women requesting reversal of sterilization and women satisfied with sterilization. Am J Obstet Gynecol 145:198, Murray J: A review of women requesting reversal of tubal sterilization. Aust NZ J Obstet Gynaecol 20:211, Alderman B: Women who regret sterilisation. (Letter) Br Med J 2:766, Gomel V: Profile of women requesting reversal of sterilization. Fertil Steril 30:39, Winston RML: Why 103 women asked for reversal of sterilisation. Br Med J 2:305, 1977 Vol. 44, No.2, August 1985 Grubb et ai. Regret after sterilization 253