Female Permanent Contraception Research Articles

Patterns in Female Permanent Contraception After the Dobbs v. Jackson Ruling [ID 2683406

INTRODUCTION: On June 24, 2022, the Supreme Court reversed the constitutional right to abortion in Dobbs v. Jackson. We aimed to explore changes in interval female permanent contraception procedures before and after the Dobbs ruling. METHODS: We performed a retrospective chart review of interval female permanent contraception procedures at a large academic center between June 24, 2019, and May 25, 2023, using relevant CPT codes. Procedure counts pre- and post-ruling were compared. Chi-squared and difference-in-mean-proportions tests were used to explore differences across periods by patient characteristics. Institutional review board approval was waived for this study. RESULTS: There were 913 procedures performed during the observation period: 611 in the 3 years pre-ruling (June 24, 2019 to June 23, 2022) and 302 in the 11 months post-ruling (June 24, 2022 to May 25, 2023). There was a 49.5% increase in procedures between the pre-ruling and post-ruling timeframes. A higher proportion of patients who identify as White underwent procedures post-ruling compared to non-White counterparts (P<.001). Chi-squared testing indicated a relationship between insurance status and post-ruling procedures (P<.001). The largest proportion of patients who had procedures post-ruling were privately insured. Patients who had procedures post-ruling had lower gravidity compared to those who had procedures pre-ruling (P<.001). CONCLUSION: There was a significant increase in interval female permanent contraception procedures post-Dobbs ruling with significant differences found by race, insurance, and gravidity—notably, in a state without restrictive contraception or abortion legislation. As state abortion and contraception laws evolve, both state and national trends in female permanent contraception should be monitored.

Efficacy of Tubal Surgery for Permanent Contraception: Considerations for the Clinician.

Permanent contraception meets the needs of many people certain in their decision to never become pregnant in the future. Female permanent contraception procedures became more common than male procedures during the 1970s and 1980s, when laparoscopic surgery became widely available. To better understand the efficacy of these new procedures, the US Centers for Disease Control and Prevention conducted a prospective cohort study, known as the Collaborative Review of Sterilization (CREST). For decades, results of this study have defined perioperative counseling around failure risks of such surgeries. However, laparoscopic technology and techniques have changed significantly in recent decades and evidence has emerged supporting noncontraceptive benefits of tubal excision. Therefore, we present here a review of updated information regarding permanent contraception failure in the modern context and implications for clinical practice and future research directions.

Nonfulfillment of desired postpartum permanent contraception and resultant maternal and pregnancy health outcomes

Up to half of the patients requesting postpartum permanent contraception do not undergo the desired procedure. Although nonfulfillment of desired postpartum permanent contraception is associated with increased risk of pregnancy within 12 months of delivery, its long-term reproductive and maternal health outcomes are less clear. This study aimed to determine the association of fulfillment of postpartum permanent contraception with number and timing of subsequent pregnancies and maternal health outcomes. This was a retrospective single-center cohort chart review study of health outcomes in the 4 years following delivery (2016-2018) for 1331 patients with a documented contraceptive plan of female permanent contraception at time of postpartum discharge from 2012 to 2014. Rates of permanent contraception fulfillment within 90 days of delivery and clinical and demographic characteristics associated with permanent contraception were calculated. We determined number of and time to subsequent pregnancies, and diagnoses of medical comorbidities (hypertension, diabetes mellitus, depression, anxiety, asthma, anemia), sexually transmitted infection, and pregnancy comorbidities (preterm birth, gestational diabetes mellitus, gestational hypertension, preeclampsia, postpartum hemorrhage, low birthweight, intrauterine fetal demise) in the 4 years following delivery. Of the 1331 patients desiring permanent contraception postpartum, 588 (44.1%) had their requests fulfilled within 90 days of delivery and 743 (55.8%) did not. Patients who achieved permanent contraception fulfillment tended to have attended more outpatient prenatal visits, delivered via cesarean delivery, and were older, married, college-educated, and privately insured. Patients who received their desired postpartum permanent contraception were less likely to have subsequent intrauterine pregnancies (P<.001). In those who did not achieve permanent contraception, 22 (9.0%) subsequent pregnancies occurred within 6 months of previous deliveries, and 223 (91.0%) occurred after short interpregnancy intervals (within 18 months). Of 178 continued pregnancies, 26 (14.6%) were delivered preterm. There were no differences between the 2 groups in terms of ever attending an outpatient, preventive, or emergency room visit, or in most nonreproductive health outcomes investigated. Nonfulfillment of desired postpartum permanent contraception is associated with subsequent maternal reproductive and nonreproductive health ramifications. Given the barriers to permanent contraception, alternative plans for contraception should be discussed proactively if permanent contraception is not provided.

The role of female permanent contraception in meeting the demand for family planning in low- and middle-income countries,

ObjectiveOur aim was to describe the reliance on female permanent contraception among women with demand for family planning satisfied with modern methods (mDFPS) in low- and middle-income countries (LMICs) and to describe socio-economic and demographic patterns of permanent contraception in countries with high use. Study DesignUsing data from the latest national health survey carried out in LMICs, we estimated mDFPS and the share of each contraceptive method used. Countries with a share of more than 25% of female permanent contraception were further explored for differences by wealth, number of living children, woman's age, and by the intersection of woman's age and number of living children. ResultsIn the 20 countries studied, between 6% and 94% of the contracepting population used modern methods. Female permanent contraception accounted for more than half of women using modern contraceptives in India, Dominican Republic, El Salvador, Mexico, and Colombia. In India and Tonga, more than 20% of women using contraceptives with fewer than 2 living children were using female permanent contraception. Among women with 2 living children, countries with the highest reliance on permanent contraception were India (79%), El Salvador (61%), Cuba (55%), Colombia (52%), and Thailand (51%). Dominican Republic, El Salvador, India, and Mexico presented high levels of permanent contraception among younger women, with reliance higher than 30% among women aged 25 to 29 and 50% or more among women aged 30 to 34. ConclusionsReliance on permanent contraception was high in several countries and among women aged less than 35 years. ImplicationsOur results may help policymakers and health managers improve family planning services in low- and middle-income settings. We identified high use of female permanent contraception among modern contraceptive users in several countries, even among young women with fewer children.

The demand for family planning to limit childbearing satisfied with female permanent contraception in Sub-Saharan Africa: a meta-analysis of demographic and health surveys

Objective To assess the percentage of the demand for family planning to limit childbearing satisfied with female permanent contraception (FPC) in sub-Saharan Africa (SSA) and the disparities by sociodemographic characteristics (educational status, wealth, religion, and area of residence). Study design This study was a secondary data analysis of Demographic and Health Surveys conducted in SSA. Countries with a standard DHS conducted between 2010 and 2019 were eligible for inclusion. We performed a meta-analysis with a random-effects model to estimate the percentage of the demand for family planning to limit childbearing satisfied with FPC and differences by sociodemographic characteristics. Results Demographic and Health Surveys (2010–2018) of 33 countries, with a total of 67,476 women with a demand for family planning to limit childbearing were included in this study. The pooled percentage of the demand for family planning to limit childbearing satisfied with FPC was 4.13% (95%CI = 2.43–6.23%, I = 99.36%, p = 0.001). The percentage ranged from 0.26% (95%CI = 0.10–0.67) in Angola to 26.85% (95%CI = 25.86–27.85%) in Malawi. The demand for family planning to limit childbearing satisfied with FPC was significantly higher in women from rich households (PR = 1.41, 95%CI = 1.21–1.65, p < 0.001). However, the differences by educational status, religion, or area of residence were not statistically significant. Conclusions The uptake of FPC among women with a demand for family planning to limit childbearing is low in many countries in SSA. Multilevel interventions are needed to address the barriers that may be limiting informed and voluntary uptake of FPC in SSA.

A retrospective cohort study of tubal occlusion or salpingectomy for permanent contraception in Australia

Laparoscopic permanent contraception was previously accomplished most commonly using tubal occlusion procedures. Bilateral salpingectomy (BS) has recently been introduced as an alternative due to possibly superior contraception and greater protection against ovarian cancer. The aim of this study is to assess uptake, feasibility and perioperative outcomes of laparoscopic BS as an alternative to tubal occlusion in Australia. A retrospective review of permanent female contraception at two Australian hospitals from January 2014 through December 2020 was performed. The primary outcome was the uptake of BS. Secondary outcomes were feasibility, procedure length, number of ports, perioperative complications and admission length. A total of 414 women were included; 92 (22.2%) underwent BS and 322 (77.8%) underwent tubal occlusion. There was a slow uptake of BS from 2014 to 2016 (0-3.2%), with a steep uptake from 2017 to 2020 (30-72%) (P=0.001). Procedure feasibility was 96.8% (62/64) and 99.3% (282/284) for BS and tubal occlusion group, respectively (P=0.64). BS procedure time was longer by 23min (P<0.001). Three or more surgical ports were used in all cases of BS compared to 4.5% of the tubal occlusion group (P<0.001). There were no intraoperative complications. There were nine and six postoperative complications in the tubal occlusion versus BS group, respectively (P=0.10). The median admission length was 7.1 (tubal occlusion) versus 7.3 (BS) h (P=0.10), with five unintended overnight admissions. BS is an increasing choice for permanent contraception. It appears equally feasible as tubal occlusion but typically requires a longer procedure time and a minimum of three surgical ports.

Female permanent contraception policies and occurrence at a sample of U.S. prisons and jails

Incarcerated individuals have an unmet need for contraception, yet have also been subject to coercive permanent contraception practices. Data do not exist on prison and jail policies around access to permanent contraception or how often it occurs among women in custody. We sought to describe permanent and reversible contraception policies at U.S carceral institutions and the frequency of these procedures. We surveyed a convenience sample of 22 state prison systems and 6 county jails from 2016 to 2017 about female permanent contraception and reversible contraception policies. In addition, 10 prisons and 4 jails reported 6 months of monthly data on the number of postpartum permanent contraception procedures performed on women who gave birth in custody. We analyzed results for descriptive statistics. Eleven prisons (50%) and 5 jails (83%) permitted female permanent contraception; 7 of these prisons and 3 of these jails allowing permanent contraception did not have a written policy about it. Six prisons and no jails provided access to permanent but not reversible contraception. Over 6 months, 3 women from 2 prisons and 4 women at 2 jails received postpartum permanent contraception. The majority of prisons and jails in our study allowed incarcerated women to have permanent contraception in custody, often without formalized policies in place. Postpartum permanent contraception occurred during the study period. Given the inherent lack of autonomy of incarceration and history of sterilization abuses in this marginalized group, policy-makers should advance policies that avoid coercive permanent contraception and increase access to reversible contraception in carceral settings. Many carceral institutions permit women to undergo permanent contraception but provide no access to reversible contraception; this practice raises concern for compromised autonomy and further reproductive marginalization of a group with limited access to quality reproductive health care.

Variation by state in Medicaid sterilization policies for physician reimbursement

ObjectiveTo evaluate state-level variation in Medicaid sterilization reimbursement policies for physicians in terms of policy details, flexibility, and review process. Study DesignWe reviewed state Medicaid websites and interviewed state employees to better understand reimbursement policies and implementation. We attempted to obtain policy details and instructions for physicians from all 50 state Medicaid office websites. We invited employees in all 50 state Medicaid director's offices to participate in semi-structured qualitative interviews. ResultsWe were able to collect data from 48 states’ websites for analysis, conducted 15 telephone interviews, and received 4 written responses from state Medicaid employees. State policies varied greatly in terms of degree of instruction available online to clinicians, number of content-related and logistical changes made compared to the federal policy, type of procedures included, corrections permitted, flexibility in terms of surgeon and procedure changes, review process, reasons for and ramifications of denial, and date of last policy revision. ConclusionThere is need for increased transparency and instruction by state Medicaid offices as well as revision of the Medicaid policy to account for the contemporary clinical practice of female permanent contraception. Clinicians should communicate with state Medicaid employees in order to clarify important policy details and obtain greater understanding of their state's review process and ramifications to ensure their clinical practice is both correct and reimbursable. ImplicationsGreater consistency between states in terms of Medicaid policy and implementation is crucial to ensuring physicians are fairly reimbursed for their work, and female permanent contraception remains an accessible contraceptive method for women.

Socioeconomic differences persist in use of permanent vs long-acting reversible contraception: An analysis of the National Survey of Family Growth, 2006 to 2010 vs 2015 to 2017

ObjectivePermanent contraception has historically been more prevalent among non-White women with lower education and income. Given increasing popularity of long-acting reversible contraception (LARC), we examine changing sociodemographic patterns of permanent contraception and LARC. Study designWe performed a descriptive analysis of the National Survey of Family Growth (NSFG) from 2006 to 2017, with multivariable analyses of the 2006 to 2010 and 2015 to 2017 cohorts. Using multinomial logistic regression, we investigate predictors of contraceptive category (permanent contraception vs LARC, lower-efficacy contraception vs LARC) in reproductive-aged women. ResultsTotal 8161 respondents were included in 2 distinct but analogous regression analyses: (1) the most recent survey cohort, 2015 to 2017 and (2) the cohort a decade prior, 2006 to 2010. Over this period, the prevalence of LARC increased nearly 3-fold (6.2%–16.7%), while permanent contraception use trended downwards (22%–18.6%). Yet, in adjusted models, we observed little change in the sociodemographic predictors of permanent contraception: from the early to recent cohort, use of permanent contraception (vs LARC) remained less likely among college graduates (multinomial odds ratio (OR) 0.45 [95% confidence interval 0.21, 0.97]) and Hispanic women (OR 0.41 [0.21, 0.82]). In addition, high income (>$74,999) and metropolitan residence came to predict less use (OR 0.33 [0.13, 0.84] and 0.47 [0.23, 0.97]). Multiparity, advanced age (over ≥35), and marital status remained strong predictors of permanent contraception. ConclusionAlthough use of LARC nearly equals that of permanent contraception in the most recent NSFG survey, socioeconomic differences persist. Continued effort is needed to detect and address structural barriers to accessing the most effective forms of contraception for women. ImplicationsComparing 2006–2010 to 2015–2017, reliance on female permanent contraception decreased while LARC use increased, making prevalence more similar. However, significant socioeconomic differences persist in who chooses permanent contraception, with urban, educated, higher income women more likely to use LARC. Ongoing efforts are needed to understand and reduce economic barriers to LARC.

Individual- and country-level correlates of female permanent contraception use in sub-Saharan Africa.

BackgroundFemale permanent contraception is a cost-effective contraceptive method that can help clients with the desire to limit childbearing achieve their reproductive intention. However, despite its benefits, the use of FPC remains low in sub-Saharan Africa (SSA), and limited studies have examined the correlates of its uptake. In this study, we assessed the individual- and country-level factors associated with the use of FPC among married or in-union women using modern contraceptive methods to limit childbearing in SSA.MethodsThis study was a secondary data analysis of individual- and country-level data obtained from the Demographic and Health Surveys (DHS) Program and three open data repositories. The study included 29,777 married or in-union women aged 15–49 years using modern contraceptive methods to limit childbearing from DHS conducted in 33 sub-Sahara African countries between 2010 and 2018. We performed descriptive statistics and fitted multilevel logistic regression models to determine the predisposing, enabling, and need factors associated with the use of FPC.ResultsApproximately 13% of the women used FPC. About 20% of the variance in the odds of using FPC was attributable to between-country differences. In the full model, the significant individual-level factors associated with the use of FPC compared with other modern contraceptive methods were: age (odds ratio [OR] = 1.10; 95%CI = 1.08–1.12), living children (OR = 1.11, 95%CI = 1.04–1.16), high household wealth (OR = 1.39, 95%CI = 1.18–1.64), rural residence (OR = 0.83, 95% CI = 0.71–0.97), joint contraceptive decision with partner (OR = 1.68, 95% = 1.43–1.99), contraceptive decision by partner and others (OR = 2.46, 95% = 1.97–3.07), and the number of living children less than the ideal number of children (OR = 1.40, 95%CI = 1.21–1.62). The significantly associated country-level factors were births attended by skilled health providers (OR = 1.03, 95%CI = 1.00–1.05) and density of medical doctors (OR = 1.37, 95%CI = 1.01–1.85).ConclusionsOur results suggest that both individual- and country-level factors affect uptake of FPC in SSA. Increasing geographic, economic, and psychosocial access to FPC may improve its uptake in SSA.

The process of opting for female permanent contraception: A qualitative study of women’s experiences in Sweden

ObjectivesWe aimed to explore Swedish women's decision-making experiences regarding permanent contraception. Study designIn this study, we included 17 women aged 30–48 who were scheduled to undergo female permanent contraceptive procedures. We conducted semistructured interviews using two broad open-ended questions. We analyzed these data using systematic text condensation based on the principles of psychological phenomenological analysis. ResultsThe interviewees experienced no counseling or support from health care workers regarding permanent contraception until they specifically asked for it. Participants reported that they themselves place the responsibility of permanent contraception solely on women. Consequently, our participants described feeling hesitancy and ambivalence in the process of deciding to have the procedure. Once the decision was made and the women were on the waiting lists for surgery, they experienced relief and empowerment. ConclusionsOur findings suggest that health care providers in Sweden miss opportunities to support patient-centered decision-making regarding permanent contraception. This study indicates that women make deliberate and considered decisions regarding permanent contraception and are best positioned to know when the procedure should take place in their reproductive lives. Implication statementsHealth care professionals should discuss permanent contraception as an option with all women desiring contraception to allow them to decide if that method is right for them.

RESOLUTION OF CHRONIC PELVIC PAIN AND ABNORMAL UTERINE BLEEDING AFTER ESSURE® SURGICAL REMOVAL AND LAPAROSCOPIC STERILIZATION: A CASE REPORT

Hysteroscopic sterilization with Essure® microinsert is a method of female permanent contraception. Complications of the procedure are malpositioning, unintended pregnancy, abnormal uterine bleeding, and chronic pelvic pain. We report the case of a 44-year-old patient presented to our hospital for chronic pelvic pain and abnormal uterine bleeding. She had 5 years before a hysteroscopic placement of an Essure® device. At hysteroscopy, both devices were removed and a laparoscopic bilateral salpingectomy was performed. The patient reported resolution of chronic pelvic pain and of abnormal uterine bleeding following surgical procedures. Pelvic pain is the main symptom described after Essure® insertion with an incidence of 4.2% regarding persistent pain. The patients should be informed about the risks and benefits of hysteroscopic and laparoscopic sterilization procedures.

Description and comparison of postpartum use of effective contraception among women with and without diabetes

ObjectiveAs diabetes is increasing among women of reproductive age in the United States, access to effective contraception is important to allow time for optimal glycemic control which may mitigate complications in future pregnancies. This study sought to describe contraceptive use and compare the effectiveness of contraceptive methods among postpartum women with and without diabetes. Study designThis study used data from the Pregnancy Risk Assessment Monitoring System and included women with recent live births during 2012–2015 (N = 93,574). Women were asked about pre-gestational or recent gestational diabetes and their postpartum contraceptive method. Chi-square and multivariate logistic regression analyses were used to compare contraceptive methods between women with and without diabetes. ResultsContraceptive prevalence was similar between women with (82%) and without (83%) diabetes; women with diabetes were more likely to use the most effective methods. This was driven by higher use of female sterilization among women with diabetes (15%) compared to women without diabetes (9%) (p < 0.001). In multivariate analysis, odds of use of female sterilization versus reversible prescription methods was higher among women with diabetes than women without diabetes (adjusted odds ratio 1.29, 95% confidence interval 1.19–1.39). ConclusionsAlthough overall postpartum contraceptive use was high, only 1/3 of women with or without diabetes were using the most effective methods. Furthermore, women with diabetes were more likely to use female sterilization than women without diabetes. It is important all postpartum women, particularly those with high risk pregnancies such as women with diabetes, receive counseling about and access to all contraceptive methods. ImplicationsIt is important for clinicians to counsel women with pregnancies affected by diabetes that reversible contraceptives such as implants and IUDs are as effective as female permanent contraception.

Women's Preferences for Permanent Contraception Method and Willingness to Be Randomized for a Hypothetical Trial

(Abstracted from Contraception 2019;99:56–60 More than 20% of women in the United States use female permanent contraception to prevent pregnancy. Surgical options for women who desire permanent contraception include tubal occlusion, partial or total salpingectomy, or transcervical sterilization.

Update on Permanent Contraception for Women

We completed this review to update readers on the current literature and controversies surrounding different approaches to permanent female contraception. Permanent contraception continues to be a popular method of pregnancy prevention. The withdrawal of the Essure® hysteroscopic approach to permanent contraception from the US market and the increased use of salpingectomy to decrease risk of ovarian cancer have changed options available to women. Current studies support allowing adult women who desire no future pregnancies to access permanent contraception regardless of age, parity, or marital status. Permanent contraception may offer particular benefit to women with complex medical issues, and those who decline hormonal contraception or intrauterine devices. We also discuss the development of new methods of permanent contraception, including the FemBloc® system and polidocanol foam. Permanent contraception remains an important option for women who have completed desired family size as it results in long-term, non-hormonal prevention of pregnancy. Women should be thoroughly counseled on the different methods of permanent contraception as well as the risks and benefits.

Contraceptive use at last intercourse among reproductive-aged women with disabilities: an analysis of population-based data from seven states

ObjectiveTo assess patterns of contraceptive use at last intercourse among women with physical or cognitive disabilities compared to women without disabilities. Study designWe analyzed responses to 12 reproductive health questions added by seven states to their 2013 Behavioral Risk Factor Surveillance System questionnaire. Using responses from female respondents 18–50 years of age, we performed multinomial regression to calculate estimates of contraceptive use among women at risk for unintended pregnancy by disability status and type, adjusted for age, race/ethnicity, marital status, education, health insurance status, and parity. ResultsWomen with disabilities had similar rates of sexual activity as women without disabilities (90.0% vs. 90.6%, p=.76). Of 5995 reproductive-aged women at risk for unintended pregnancy, 1025 (17.1%) reported one or more disabilities. Contraceptive use at last intercourse was reported by 744 (70.1%) of women with disabilities compared with 3805 (74.3%) of those without disabilities (p=.22). Among women using contraception, women with disabilities used male or female permanent contraception more often than women without disabilities (333 [29.6%] versus 1337 [23.1%], p<.05). Moderately effective contraceptive (injection, oral contraceptive, patch, or ring) use occurred less frequently among women with cognitive (13.1%, n=89) or independent living (13.9%, n=40) disabilities compared to women without disabilities (22.2%, n=946, p<.05). ConclusionsThe overall prevalence of sexual activity and contraceptive use was similar for women with and without physical or cognitive disabilities. Method use at last intercourse varied based on presence and type of disability, especially for use of permanent contraception. ImplicationsAlthough women with disabilities were sexually active and used contraception at similar rates as women without disabilities, contraception use varied by disability type, suggesting the importance of this factor in reproductive health decision-making among patients and providers, and the value of further research to identify reasons why this occurs.

Update on the Essure System for Permanent Birth Control

In 2002, the U.S. Food and Drug Administration approved the Essure system for permanent birth control. Implantation with this device offers a minimally invasive option for permanent female contraception that is placed during a brief office visit. Unlike laparoscopic tubal sterilization, the Essure procedure requires no hospitalization or general anesthesia, resulting in minimal recovery time. After a decade of stability in the report of adverse effects, the U.S. Food and Drug Administration noted a sharp increase in patient-reported adverse events, including chronic pelvic pain, irregular bleeding, allergic reactions, and autoimmune-like reactions. In response to this increase in complaints, the U.S. Food and Drug Administration issued updated guidelines for patient education and counseling. This article discusses those updates, as well as implications for nurses who provide health care to women seeking permanent contraception.

Perceptions of nonsurgical permanent contraception among potential users, providers, and influencers in Wardha district and New Delhi, India: Exploratory research

New permanent contraceptive methods are in development, including nonsurgical permanent contraception (NSPC). In the present study, perceptions of NSPC in India among married women, married men, mothers-in-law, providers, and health advocates in Eastern Maharashtra (Wardha district) and New Delhi were examined. We conducted semi-structured interviews with 40 married women and 20 mothers-in-law; surveys with 150 married men; and focus group discussions with obstetrics/gynecology providers and advocates. Transcripts were coded and analyzed using a grounded theory approach, where emerging themes are analyzed during the data collection period. The majority of female respondents expressed support of permanent contraception and interest in NSPC, stating the importance of avoiding surgery and minimizing recovery time. They expressed concerns about safety and efficacy; many felt that a confirmation test would be necessary regardless of the failure rate. Most male respondents were supportive of female permanent contraception (PC) and preferred NSPC to a surgical method, as long as it was safe and effective. Providers were interested in NSPC yet had specific concerns about safety, efficacy, cost, uptake, and government pressure. They also had concerns that a nonsurgical approach could undermine the inherent seriousness of choosing PC. Advocates were interested in NSPC but had concerns about safety and potential misuse in the Indian context. Although perceptions of NSPC were varied, all study populations indicated interest in NSPC. Concerns about safety, efficacy, appropriate patient counseling, and ethics emerged from the present study and should be considered as NSPC methods continue to be developed.

Recent developments have made female permanent contraception an increasingly attractive option, and pregnant women in particular ought to be counselled about it.

BackgroundDespite the increased prevalence of reversible contraception, global unintended pregnancy rates are stable. Mistakes, method failures, side effects, alcohol, stock-outs, fears, costs, delays, myths, religious interference, doctors with other priorities, traditions and lack of health professionals may all factor in. Yet these unintended pregnancies ― nearly a hundred million annually ― cause much individual suffering, and in the long run, can aggravate conflicts, poverty, forced emigration and climate change. Presently, non-poor women postpone childbearing because of longer educational trajectories and careers. Sterilisations are therefore less often regretted or coerced. For poor-resourced women with a completed family, an unwanted pregnancy often has serious consequences, including crossing the (extreme) poverty line in the wrong direction, choosing an unsafe abortion, or even death. Caesarean sections (CSs), which currently stand at around 23 million annually, are increasing. On an “intention-never-to-become-pregnant-again” analysis, choosing a partial, and even more so a total bilateral tubectomy to be implemented during an ― anyway performed ― CS is by far the most reliable and safe contraceptive choice compared to meaning to start female or male sterilisation or any other contraceptive method later, and it reduces the chance of a future ovarian carcinoma substantially. CSs make subsequent pregnancies more dangerous. Simultaneously, they provide convenient, potentially cost-free opportunities for voluntary permanent contraception (PC): particularly important if there is no guaranteed future access to reliable contraception, safe abortion and well-supervised labour.Partial solutionMillions of women are within reach of attaining freedom from the “tyranny of excessive fertility” when they have a CS. Therefore, any woman who might conceivably be of the firm opinion that her family will be (over) completed after delivery should antenatally have “what if you have a CS” counselling to assess whether she would like a tubectomy/ligation. Yet many are not provided with this option: leading to frequent regret, more often than having been giving that choice would.ConclusionWithholding antenatal counselling about the option of PC for in case the delivery might become a CS is very prevalent, yet often more medically risky, and morally questionable than when, even in labour, a doctor sometimes decides in the absence of earlier counselling, considering numerous factors, to provide the choice to undergo a concurrent sterilisation if s/he is convinced that would be in the patient’s best interest.

Temporal trend in the use of hysteroscopic vs laparoscopic sterilization and the characteristics of commercially insured and Medicaid-insured females in the US who have had the procedures.

PurposeLimited research has examined the factors associated with female permanent contraception procedures. This study evaluated the temporal trend in the use of hysteroscopic sterilization (HS) vs laparoscopic sterilization (LS) and characteristics of commercially insured and Medicaid-insured women in the US who have had the procedures.MethodsWomen aged 15–49 years with claims for HS and LS procedures were identified from two MarketScan databases, one consisting of commercial claims and the other Medicaid claims, during the time period of January 1, 2003 to December 31, 2012 and January 1, 2006 to December 31, 2011, respectively. Proportions and characteristics of women who underwent HS or LS procedures were determined. Multivariable logistic regressions were used to identify characteristics associated with the use of HS vs LS.ResultsCommercially insured women who had HS (n=32,012) vs LS (n=64,725) were slightly older (37.2 years vs 36.4 years, respectively, P<0.001) but had similar Charlson Comorbidity Index scores. Among commercially insured women, those who had a sterilization procedure during 2008–2012 were more likely to undergo HS (odds ratio: 7.1, P<0.001) than those who had a sterilization procedure during 2003–2007. Medicaid-insured women who had HS (n=2,001) were also slightly older than women who had LS (n=12,523; 30.1 years vs 28.8 years, respectively, P<0.001) but had a higher mean Charlson Comorbidity Index score (0.32 vs 0.25, respectively, P<0.001). Among Medicaid-insured women, the likelihood of having HS vs LS increased 3.3-fold (P<0.001) in years 2009–2011 compared to years 2006–2008. Among both populations, older age, obesity, and the use of oral contraceptives within the previous 12 months were associated with having HS vs LS.ConclusionAmong both commercially insured and Medicaid-insured women, the likelihood of having HS vs LS increased over time.