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. Author manuscript; available in PMC: 2021 Jul 1.
Published in final edited form as: Perspect Sex Reprod Health. 2020 May 28;52(2):117–127. doi: 10.1363/psrh.12137

Changing Educational Differentials in Female Sterilization

Sarah R Hayford 1, Alexandra Kissling 1, Karen Benjamin Guzzo 2
PMCID: PMC7669611  NIHMSID: NIHMS1602335  PMID: 32462730

Abstract

Context

Female surgical sterilization is widely used in the U.S., but utilization varies across sociodemographic groups. Educational differentials are particularly poorly understood.

Methods

We analyzed women aged 40–44 from the National Surveys of Family Growth (1973–2015), (n=9,277). We estimated descriptive statistics to show trends in sterilization prevalence by completed education and changes in use of other contraceptive methods. We applied demographic standardization, which breaks down change into compositional change and groupspecific rates, to explore the contributions of changes in marriage and delayed childbearing to sterilization trends.

Results

In 1982, high-school educated women and college-educated women had similar levels of sterilization (38% and 32%). By 2011–15, the prevalence declined to 19% among college-educated women, but increased to 44% for women with a high school degree. Trends among highly educated women were largely attributable to delayed fertility; all other things equal, if age at first birth had not increased, sterilization rates would have declined much less. Increased sterilization among women with a high school degree was only weakly related to changes in birth timing or marriage. The proportion of women in this group who relied on partner vasectomy declined over the period of study.

Conclusions

Declining sterilization among college-educated women seems to be due to declining demand linked to changes in childbearing timing. These demand-side factors contributed less to change in sterilization among high-school educated women, suggesting that other factors (such as contraceptive preferences and access, or provider interactions) may drive their behavior. Sterilization differentials may reflect or exacerbate other disparities.

Keywords: female sterilization, education, disparities

Female sterilization1 is one of the most common forms of contraception in the United States. Nearly 19% of women of reproductive age have undergone some sort of sterilization procedure (including hysterectomy and other procedures for medical reasons), higher than usage of the pill (12.6%) (Daniels & Abma, 2018). Sterilization is a highly effective and safe method of contraception, but it is both more invasive and less safe than other highly effective forms of contraception such as long-acting reversible contraceptives (LARCs) and male surgical sterilization (vasectomy) (Harris, 2017). In addition, female sterilization is designed to be permanent and is difficult (if not impossible) to reverse. Sterilization marks the end of the reproductive life course and is adopted by women who do not want any (more) children. However, fertility desires may change, and up to a quarter of sterilized women desire sterilization reversal (Eeckhaut & Sweeney, 2018; Eeckhaut, Sweeney, & Feng, 2018; Shreffler, McQuillan, Greil, & Johnson, 2015). Because of the greater risk of complications and potential for fertility desires to change, the high prevalence of female sterilization compared to other highly effective contraceptive methods is cause for concern.

These concerns are exacerbated by longstanding socioeconomic and race-ethnic differentials in sterilization, such that the most disadvantaged women are most likely to be sterilized (Bumpass, 1987; Bumpass & Presser, 1972; Eeckhaut & Sweeney, 2016). In the early 20th century, programs of coerced sterilization intensified racial and socioeconomic differences in sterilization rates (Schoen, 2005). Although these explicit programs have been abolished, differentials persist. It is not clear whether current disparities in sterilization are growing or shrinking relative to past differentials. Changes in the distribution of sterilization may reflect contemporary inequality in access to reproductive health care, in childbearing and marriage behaviors, or in other drivers of contraceptive method choice. In this paper, we draw on nationally-representative data from the National Surveys of Family Growth to describe education-specific trends in female sterilization over four decades and explore population-level changes that may have contributed to these trends.

Contraceptive sterilization in the 20th century

Sterilizing operations were largely concentrated among the least advantaged women during the early and mid-20th century due to systematic programs of involuntary sterilization among race-ethnic minorities and the mentally disabled (Schoen, 2005). During this time period, doctors discouraged well-educated White women in the U.S. from undergoing surgical sterilization (Kluchin, 2011). The development of laparoscopic methods of surgery in the 1960s reduced the severity of sterilizing operations and the duration of recovery time, making sterilization more accessible (Kluchin, 2011). In addition, the invention of hormonal contraception in the early 1960s increased women’s expectations for highly effective methods of limiting childbearing (Bumpass, 1987). The creation and expansion of Medicaid, as well as federally funded family planning programs, reduced the cost of surgical sterilization and made it more widely available (Borrero, Zite, Potter, & Trussell, 2014).

By the 1970s, surgical sterilization emerged as the most commonly-used form of contraception, with rates increasing at all education levels. Still, socioeconomic differences persisted. A longstanding body of research documents higher levels of sterilization among less educated women, with educational differences persisting up to the present day (Anderson et al., 2012; Bertotti, 2013; Borrero et al., 2009; Bumpass & Presser, 1972; Bumpass, Thomson, & Godecker, 2000; Chan & Westhoff, 2010; Chandra, 1998; Eeckhaut & Sweeney, 2016; Godecker, Thomson, & Bumpass, 2001; Philliber & Philliber, 1985; Presser & Bumpass, 1972; Shapiro, Fisher, & Diana, 1983). Although racial disparities in female sterilization procedures remain, these are now dwarfed by educational disparities. Among women of reproductive age in 2015–17, 18% of non-Hispanic White women had undergone some form of sterilizing procedure, including those for non-contraceptive reasons, compared to 19% of Hispanic women and 23% of non-Hispanic Black women (Daniels et al., 2014). Looking at variation by education level, 42% of reproductive-age women without a high school degree have undergone some form of sterilization procedure compared to only 11% of college-educated women (Daniels et al., 2014).

Potential drivers of education difference

Previous research has identified multiple individual-level predictors of surgical sterilization, such as larger family sizes and older ages (Anderson et al., 2012), relationship dynamics and couple characteristics (Eeckhaut, 2015), previous experience of unintended childbearing (Borrero et al., 2010), and access to health insurance (White & Potter, 2014). In this article, we attempt to understand population-level disparities and change over time in these patterns. We therefore focus on predictors of sterilization that have changed over time, and changed differently for women at different education levels, as the most likely determinants of changing trends. Specifically, we consider changing levels of sterilization in the context of increasing educational divergence in marriage and the timing of the entrance into parenthood (Bailey, Guldi, & Hershbein, 2014; Martin, 2016). We focus on marriage and first birth timing because in many ways, these demographic behaviors drive the demand for sterilization – age at first birth affects the length of time between reaching desired family size and the end of the fertile years, as discussed below, and marital status can affect the extent to which women are sexually active but can rely upon a partner to be responsible for contraception (including vasectomy). Because sterilization decisions are made in the context of past and current childbearing and relationship experiences, we look to these characteristics as potential contributors to changes in sterilization.

Changes in available contraceptive methods have also altered the set of choices available to women wanting to limit childbearing. New contraceptive technologies may have shifted the relative advantages or disadvantages of surgical sterilization, again affecting demand for sterilization vis-à-vis other choices. Further, there is some evidence of differences in contraceptive preferences across groups, often related to variation in pregnancy acceptability and childbearing norms (Higgins, 2017; James-Hawkins & Sennott, 2015). We do not consider changes or differentials in other factors, such as health insurance coverage or access to family planning services, as the wide variation over time and across geography often reflect legal and policy barriers and changes that do not reflect demand for sterilization.

First birth timing and marriage

Age at first birth and marriage are particularly relevant for aggregate trends in sterilization. All other things equal, an earlier age at first birth increases the length of time women are at risk of having an unwanted birth at the end of the childbearing years, since women who start childbearing earlier likely reach their desired family size at an earlier age. (Desired family size does not vary substantially by socioeconomic status or educational attainment [Morgan & Rackin, 2010; Musick, England, Edgington, & Kangas, 2009]). As a result, women with a later age at first birth are less likely to be sterilized (Chandra, 1998). Since the 1970s, age at first birth has increased substantially for women with a four-year college degree or more, whereas women with lower levels of education exhibited only small increases in the age at first birth (Livingston, 2018). Thus, divergence in age at first birth by education level may have contributed to divergence in sterilization rates because demand for sterilization would have declined more substantially for college-educated women than their less-educated counterparts.

Marriage rates and timing have also diverged by education. In the 1970s and 80s, marriage rates were high across all education groups (Goldstein & Kenney, 2001). Over the last few decades of the 20th century, marriage rates declined, and these declines were concentrated among less educated women. By 2000, there were large differentials, with considerably more college-educated women married compared to those with less than a college degree (Allred, 2018). Overall, married women are more likely to be sterilized than unmarried women (Daniels et al., 2014; Eeckhaut, 2015; Godecker et al., 2001). Much, but not all, of this difference, is explained by the fact that married women have more children than unmarried women – when statistically controlling for parity, differences in sterilization by marital status are reduced (Eeckhaut, 2015). However, among married women, those with a bachelor’s degree or more education are less likely to be sterilized themselves and more likely to have a partner who has had a vasectomy (Eeckhaut, 2019). High levels of educational homogamy also mean that the spouses of college-educated women more often have a college degree (Mare, 2016); unlike women, men with a college degree are more likely to be sterilized than their less educated counterparts (Anderson et al., 2012; Sharma et al., 2013). Thus, college-educated women may have less demand for female sterilization because they can rely upon their partners to undergo vasectomies or otherwise be responsible for contraception. As such, changing education patterns in marriage may also contribute to changing trends in sterilization. These impacts may be complex, with both marriage prevalence and the association of sterilization with marriage changing differentially across education levels.

Changing contraceptive methods

Shifting sterilization patterns may also reflect the changing availability and acceptability of alternative forms of contraception (Kavanaugh & Jerman, 2018), including differential preferences for method type (He, Dalton, Zochowski, & Hall, 2017). Over the past two decades, multiple new forms of hormonal contraception have been introduced (injectable contraception, contraceptive implants, vaginal ring, etc.), and new hormonal intrauterine devices (IUDs) have gained in popularity. Long-acting reversible contraceptive (LARC) methods (IUDs and implants), in particular, can serve as an alternative to permanent sterilization. However, method choice varies by education; accounting for differences in parity, LARC use is more common among the highly educated (Kavanaugh & Jerman, 2018), perhaps because less advantaged women are more concerned about the potential harms of LARCs and so have little demand for such methods (Alfred & Holmes, 2019). As mentioned above, women’s reliance on vasectomy also varies by education. In 2011–13, 15% of college-educated women relied on male sterilization as their primary contraceptive method compared to 1% of women with less than a high school degree; ten years earlier, the gap was only ten percentage points (Daniels et al., 2014). It is also worth noting that the delays in childbearing discussed above may be linked to changes in contraceptive use, as more women, especially the college-educated, approach the end of their fertile years and continue to desire (additional) children and thus have little demand for a permanent contraceptive method (Guzzo, 2018). As such, among women at the end of the reproductive years, use of reversible methods and non-use of contraception could be attributable to plans for childbearing. Examining changes and differentials in the use of other contraceptive methods (or no methods) likely provides insight into educational variation in demand for sterilization.

The present study

We address two primary research questions. First, have education differences in sterilization increased, decreased, or stayed the same over the past four decades? Second, if education differences have changed, can compositional changes in first birth timing, marriage, and/or use of other contraceptive methods account for these changes? By answering these questions, we can either identify or eliminate the role of compositional characteristics and variation in method choices in sterilization disparities. Understanding the contribution of aggregate changes to sterilization differentials can shed light on the degree to which these differentials could be addressed by interventions and policies related to health care delivery and funding.

Most work on sterilization to date has adopted an individual-level approach, using regression models to identify key characteristics of individuals and couples. We adopt a different, and complementary, macro approach to this well-established body of research. We draw on demographic techniques and descriptive statistics to understand the primary contributors to changing trends in sterilization. We begin with a descriptive presentation of levels of sterilization among women age 40–44, overall and by level of completed education, between the 1970s and the early 21st century. We then use two approaches to shed light on possible contributing factors to these trends. First, we use demographic standardization to understand the contribution of changes in the distribution of age at first birth and marital status to observed trends and gaps by education. Second, we show the distribution of contraceptive methods used by women at the end of their reproductive years to understand how fertility desires, contraceptive preferences, and other factors may play a role in sterilization behavior and differentials. Both approaches rely on aggregate data to focus on population-level trends rather than causal mechanisms; in doing so, our primary goal is to identify key associations for further exploration via more micro-level approaches.

Methods

Data and sample

We use data from the National Surveys of Family Growth (NSFG), a series of cross-sectional surveys of reproductive behavior that are nationally representative of women of reproductive age (15–44). The NSFG began in 1973, and surveys have been carried out at approximately five-year intervals thereafter. Starting in 2006, surveys switched to continuous interviewing, with sampling based on a four-year cycle.2 We use data from the 1973, 1976, 1982, 1988, 1995 and 2002 surveys and the 2006–2010 and 2011–15 releases of the continuous data. For the 1973–2002 surveys, we use data from the Integrated Fertility Survey Series (Smock, Granda, & Hoelter, 2014), a harmonized data repository that compiles and prepares comparable versions of variables and survey weights and design variables.

In the 1973 and 1976 surveys, only ever-married women and women with own children in the household were included in the sample frame. Marriage rates were high in the cohorts of women eligible to be included in these surveys,3 but these surveys may still produce distorted estimates of sterilization. We include the 1973 and 1976 surveys to document overall trends but focus our discussion of standardized trends and contraceptive use from 1982 onwards. Details of the complex sample design vary slightly across surveys; see Appendix Table 1 for details. All descriptive and multivariate statistics are weighted; survey weights are designed to adjust for differential sampling procedures and response rates in order to produce nationally-representative estimates. Sample sizes by survey, as well as the distribution of completed education by survey, are presented in Table 1.

Table 1.

Sample sizes of component surveys and educational distribution

NSFG survey year Total N Analytic sample Proportion with no high school diploma Proportion with high school diploma Proportion with some college Proportion with bachelor’s degree or higher
1973 9797 1,064 0.33 0.43 0.14 0.10
1976 8611 894 0.31 0.43 0.16 0.11
1982 7969 493 0.19 0.43 0.24 0.15
1988 8450 813 0.14 0.37 0.25 0.23
1995 10847 1,453 0.11 0.38 0.24 0.27
2002 7643 917 0.12 0.34 0.29 0.25
2006–2010 12279 1,307 0.09 0.35 0.27 0.29
2011–2015 11300 1,159 0.11 0.22 0.26 0.40
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Data: National Surveys of Family Growth. Unweighted counts, weighted proportions. Analytic sample includes women age 40–44 without missing data on tubal sterilization, education, first birth timing, marital status, or contraceptive use. Sample excludes women with other sterilizing operations (hysterectomy, oophorectomy, and other non-contraceptive sterilizing operations).

We limit analysis to women at the end of the reproductive years (age 40–44), and the primary outcome is whether women have undergone a tubal sterilization by the time of the interview (some women may undergo sterilization at older ages, but the age restrictions of the data preclude observing such events). All of the NSFG surveys ask about tubal ligation. In the continuous NSFGs conducted since 2006, women are also asked specifically about Essure inserts (a form of permanent birth control); we include these women as having received a tubal sterilization. In some of the NSFGs, women who had had a sterilizing operation were asked if the operation had been reversed. In other surveys, questions about sterilizing operations were asked only for women who were surgically sterile at the time of the survey. Thus, for some survey years, it is not possible to distinguish women with reversed operations from other non-sterile women. For consistency, we treat all women with reversed tubal sterilizations as unsterilized in all analyses. In surveys where it is possible to identify this group, women with reversed operations constitute less than 1% of all women who have ever had a tubal sterilization, and so including these women is unlikely to substantially alter the results. Women were also asked about other operations that make it impossible for them to have a child (hysterectomy, bilateral oophorectomy (ovary removal), and other sterilizing operations). Because we are primarily interested in sterilization as a contraceptive method, we exclude women who have had non-tubal sterilizing operations from the analysis, since such operations are driven by medical needs. Among women age 40–44, the proportion who reported either a hysterectomy or oophorectomy ranged from about 20% in the 1970s and 1980s to about 7% in recent surveys. Note that because we do not include women who had sterilizing procedures for non-contraceptive reasons, our estimates do not perfectly align with those from other sources, such as the National Center for Health Statistics, that use a more expansive definition.

Measures

Our main independent variable is educational attainment: less than high school, high school only, some college, and bachelor’s degree or more. In the earliest NSFG surveys (1973, 1976, and 1982), attainment is based on completed years of education. We assume that women with 12 or more years of completed education had a high school diploma and women with 16 or more years of completed education had a bachelor’s degree and refer to them as such; these measures do not account for women who earned a GED or women who attended college without completing a degree, and thus may slightly misrepresent true education credentials. In the 1988 NSFG, women were directly asked whether they had earned a GED or high school diploma in addition to being asked about completed years of education, and in the 1995 and later surveys women were also asked about college degrees earned. The slightly different measures of education used in the different surveys may introduce some inconsistency; we also conducted analyses using completed years of education for all surveys, and results were largely the same as those presented here.

As our results will show, the largest differences in sterilization are between women with at least a bachelor’s degree and women with lower levels of education. For clarity, in presenting results, we occasionally show only two groups: women with a bachelor’s degree or higher and women with a high school diploma (the largest group among women with less than a bachelor’s degree). Results for other education groups are available on request.

All NSFG surveys collected marriage and fertility histories. We use the fertility histories to construct measures of age at first birth (categorized as before age 20, age 20–24, age 25–29, age 30 and up, and childless) in order to assess the contribution of changes fertility timing to changes in sterilization. To assess the contribution of changes in marriage to changes in sterilization, we ideally would want to measure marital status at the time women were deciding whether to undergo tubal sterilization. However, for women who were not sterilized by the time of the survey, there is no discernable point to benchmark when the decision against sterilization was made or, in the case of women who never considered this option, when a ‘non-decision’ about sterilization occurs. Thus, there is no clear age at which to measure marital status in order to compare women who are sterilized with women who are not sterilized. We conducted exploratory analyses using marital status at time of the survey, marital status at first birth (with a separate category for childless women), and marital status at age 30 (average age at sterilization for sterilized women was around age 33). Results were substantively similar using all of these measures. We present models using marital status at age 30 because this measure most closely approximates a stage when many women have become mothers and begin contemplating sterilization and other long-term reproductive decisions.

Standardization analyses

To investigate how changes in marriage and birth timing are linked to shifts in sterilization by education, we use demographic standardization, a method for understanding how compositional changes in a population have contributed to aggregate changes (Preston, Heuveline, & Guillot, 2001). Mathematically, overall levels of a given event or behavior of interest are the product of levels in particular subgroups and the size of those subgroups. Standardization draws on these arithmetic relationships to identify the specific subgroups or behaviors that contribute most to population-level changes or differences. Standardization simulates a counterfactual trend by combining observed levels with hypothetical group sizes fixed at a selected “standard” – in this case, a specific year. That is, we conduct a mathematical exercise in which we approximate what trends would have looked like if group sizes (e.g., the proportion of women married at age 30) had changed while sterilization behavior (e.g., proportion of married and unmarried women who were sterilized) had not. We then compare these artificial trends with observed trends. When the two levels differ dramatically, it suggests that the shifts in the size of the population subgroups, rather than changes in behavior among groups, are driving trends and gaps in overall levels. As used in this paper, standardization demonstrates what sterilization levels would look like if differential change by education in the timing of first births and in marital status had not occurred.

We standardize education-specific sterilization trends by age at first birth and marital status distributions at age 30 in 1982, the first year of the period of analysis. More specifically, to standardize by marital status distributions in 1982, we use the retrospective histories of women’s marital behaviors to identify the proportion of women who were married at age 30 from the 1982 survey (drawn from the NSFG data for women age 40–44 with a high school diploma and women with a bachelor’s degree, our populations of interest). For each subsequent year, we multiply these proportions by the observed sterilization levels in that year by education and marital status. The sum of these products simulates what sterilization levels would have been if distributions of marital status had not changed, but sterilization rates had. Similarly, to standardize by age at first birth distributions in 1982, we calculate this distribution based on the 1982 NSFG and multiply this distribution by observed sterilization levels by education and age at first birth in subsequent years. This exercise produces two sets of standardized (simulated) levels of sterilization over time: age at first birth standardization and marital status standardization. For each set, we produce standardized trends for women with a high school diploma and women with a bachelor’s degree or higher. We graph the standardized trends over time along with the observed trends in sterilization for these two education groups on one figure to allow direct comparisons. Although standardization is only a simulation and does not attempt to identify causal processes at the individual level, this exercise identifies important contributors to macro change.

Contraceptive method shifts

To consider whether shifts in sterilization are linked to shifts in the use of other contraceptive methods, we present tabulations of contraceptive use at the time of the survey for different education groups and for different survey years. For visual clarity, we show only two education groups (high school diploma and bachelor’s degree or more, corresponding with our populations of interest) and two time points (1982 and 2011–15, to illuminate long-term trends). Because of sampling variability and short-term conditions, individual surveys reflect point-to-point fluctuation; the end points of the series capture broad patterns of change over the long term. We categorize contraceptive use into four categories: female sterilization (tubal ligation, and tubal implants in later years), male sterilization, effective/highly effective methods, and less effective methods. Effectiveness classifications are based on the Center for Disease Control’s efficacy tiers (Centers for Disease Control and Prevention, n.d.). Tier 1 or highly effective methods include tubal sterilization, vasectomy, hormonal implant, and IUD; Tier 2 or effective methods include injectable, pill, patch, ring, and diaphragm; and Tier 3 or less effective methods include male and female condoms, withdrawal, sponge, and calendar methods. We separate contraceptive sterilization from other highly effective and effective methods because of our research focus on sterilization. For women reporting multiple methods, we prioritized methods in this order: female sterilization, male sterilization, highly effective/effective, and less effective. For example, women using both the pill and condoms were classified as using an effective method (pill). Among women not using contraception, we use a question on whether the woman intends to have a(nother) child to distinguish between women not using contraception because they intend a child and women not using contraception for other reasons. This distinction allows us to identify, to some extent, whether any shifts in non-use of contraception may be linked to delayed fertility and plans for continued childbearing.

Results

Figure 1 shows change over time in the proportion of women age 40–44 who report having had a sterilization procedure for contraceptive purposes, separately by educational attainment. This figure answers our first research question: starting in the early 1980s, education differences in female sterilization increased substantially4. Overall, the proportion of women using surgical sterilization increased in the 1970s and 1980s and leveled off after 1988. The figure also shows point-to-point fluctuation, attributable to some combination of sampling variation and short-term conditions; we focus discussion of results on the long-term trends. In all time periods, women with less than a high school education had the highest levels of tubal sterilization, but the magnitude of education differences varied over time. The prevalence of sterilization among the least educated women increased monotonically through most of the time period under study, rising from about 18% in 1973 to around 65% at the peak in 2006–2011. Among those with high school diplomas and those with some college education, the proportion leveled off during the 1990s and 2000s. In contrast, among women with a bachelor’s degree or more education, rates of female sterilization dropped substantially after 1982. The sharpest decline occurred between 1982 and 2006–2011, when rates fell from about 30% to about 15%.

Figure 1.

Figure 1.

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Proportion of women age 40–44 with unreversed tubal sterilizations, overall and by educational attainment

Data: National Surveys of Family Growth. Weighted proportions. Sample excludes women with other sterilizing operations (hysterectomy, oophorectomy, and other non-contraceptive sterilizing operations).

Before presenting results from the demographic standardization, we first show basic patterns of change over time in marriage and childbearing by education level (Table 2). Both mean age at first birth and proportion of respondents who were married at age 30 have changed over time. However, the extent to which these outcomes have changed differ by education. Changes in mean age at first birth were greatest among those with at least a bachelor’s degree, with an increase of about four years. When looking at the proportion married at age 30, there were substantial declines across all education groups.5

Table 2.

Changes in fertility and family formation behavior by education level

Mean age at first birth (years)
1982 1988 1995 2002 2006–10 2011–15
No high school diploma 20.8 19.6 20.2 19.9 21.6 21.5
High school diploma 21.9 22.4 22.6 23.5 23.3 22.8
Some college 23.3 23.5 24.8 24.9 24.7 24.3
Bachelor’s degree or higher 25.2 27.0 28.6 29.3 30.2 29.6
Proportion of women married at age 30
1982 1988 1995 2002 2006–10 2011–15
No high school diploma 0.73 0.73 0.62 0.60 0.56 0.44
High school diploma 0.86 0.76 0.70 0.50 0.58 0.53
Some college 0.86 0.76 0.69 0.72 0.60 0.52
Bachelor’s degree or higher 0.80 0.72 0.62 0.60 0.59 0.54
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Data: National Surveys of Family Growth. Weighted means and percentages. Women age 40–44 without missing data on tubal sterilization, education, first birth timing, marital status, or contraceptive use. Sample excludes women with other sterilizing operations (hysterectomy, oophorectomy, and other non-contraceptive sterilizing operations). Mean age at first birth includes only women with children.

Figure 2 shows actual and standardized trends in sterilization for women with a high school diploma and women with a four-year college degree or more. The solid lines represent observed trends (identical to those depicted in Figure 1); the dotted lines represent trends standardized by age at first birth distribution (i.e., trends if age at first birth had not increased); and the dashed lines represent trends standardized by marital status distribution (i.e., trends if the proportion of women married at age 30 had not decreased). For both education groups, the standardized lines are above the observed lines. That is, sterilization would have been more common if first birth timing and marriage rates had not changed. For women with a high school diploma, that counterfactual reflects an intensification of trends. Sterilization would have increased even more in the absence of demographic changes that reduced demand; rather than driving trends, demographic changes if anything reduced the impact of increases in sterilization rates. For women with a bachelor’s degree or higher, there is less change in the counterfactual scenario than in the observed trends. In particular, the age at first birth standardized trend (dotted line) is relatively flat between 1982 and 2002. That is, if the average age at first birth for women with a four-year college degree had not increased between 1982 and 2002, sterilization rates would have declined much less over this time period – about 3% instead of about 14%. Based on these decomposition results, a substantial proportion of the decline in sterilization for women with a four-year college degree after 1982 is attributable to increasing age at first birth in this group of women. The marital status standardized trend (dashed line) is closed to the observed trend than the age at first birth standardized trend, suggesting that changes in marriage contributed less to change in sterilization than changes in first birth timing. Overall, these standardization results suggest that decreasing demand for sterilization related to changing marriage and childbearing contributed to the declines in sterilization for women with a college degree, but did not drive increases for women with a high school diploma.

Figure 2.

Figure 2.

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Education-specific trends in tubal sterilization, observed and standardized

Data: National Surveys of Family Growth. Standardization based on weighted proportions, calculated for women age 40–44 without missing data on tubal sterilization, education, first birth timing, marital status, or contraceptive use. Sample excludes women with other sterilizing operations (hysterectomy, oophorectomy, and other non-contraceptive sterilizing operations).

Change over time in contraceptive method mix can also help us understand changes in sterilization. Figure 3 shows the distribution of women age 40–44 across the four categories of contraceptive use and two categories of non-use. As above, we focus on women with a high school diploma and women with a four-year college degree or more and show only the earliest and latest years of the time period for visual clarity. Over this time period, for women with a high school diploma, there was a slight increase in surgical sterilization. At the same time, there was a decline in the proportion of women with a high school diploma reporting that they have a partner who has been sterilized. (This question is only asked for married and cohabiting women; changes in the proportion of women who rely on partner’s vasectomy potentially reflect both changes in partnership and changes in sterilization behavior of male partners.) The decline in male sterilization (vasectomy) is slightly larger than the corresponding increases in female sterilization. Thus, over time, there was a net decline in permanent methods of contraception in this education group, although this net decline was small. The proportion of women with a high school diploma using effective/highly effective methods increased, while the proportion using less effective methods declined, although again these changes were small. The proportion using no method increased slightly for women with a high school diploma, both among those not intending another child and among those intending another child. Overall, this figure shows relative stability in the distribution of women with a high school diploma across contraceptive method categories, compared with the larger changes see among women with a bachelor’s degree.

Figure 3.

Figure 3.

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Trends in contraceptive method mix, women age 40–44

Data: National Surveys of Family Growth. Weighted proportions. Women age 40–44 with no missing data on tubal sterilization, education, first birth timing, marital status, or contraceptive use. Most effective/effective methods include IUD, hormonal methods (implant, injectable, pill, patch, ring), and diaphragm (CDC Tiers 1 and 2). Least effective methods include male and female condoms, withdrawal, sponge, and calendar methods (CDC Tier 3). Sample excludes women with other sterilizing operations (hysterectomy, oophorectomy, and other non-contraceptive sterilizing operations).

For women with a bachelor’s degree or more, the decline in female sterilization is apparent. Over the period of study, there was very little change in reliance upon male sterilization but an increase in the use of effective/highly effective methods. The proportion of women who intended another child also increased, from about 3% in 1982 to about 8% in 2011–15. This increase is consistent with the idea that rising ages at first birth among the most educated women correspond to rising numbers of women in the 40–44 age group who have not yet completed their desired childbearing.

The top three categories in the figure together comprise highly effective and effective methods. Looking at these methods together, there was little educational difference in the use of highly effective/effective contraception by the end of the period. However, there was a substantial difference in the distribution of women across these categories. A much greater proportion of women with a bachelor’s degree are using reversible methods (24% vs. 7%), while more women with a high school diploma are using tubal sterilization (44% vs. 19%). This difference increased over the period of study.

Discussion and conclusions

Discussion

Female sterilization remains an important tool in the family planning arsenal. As we show in our analyses, nearly one in three women in the U.S. has undergone tubal sterilization by the end of the childbearing years. However, the prevalence of tubal sterilization varies widely by educational attainment, and these education differentials have grown over time. The wide difference in sterilization between college-educated women and those with less than a college degree aligns with other dramatic differences in marriage and childbearing, including delayed fertility and rising levels of nonmarriage. Over the period of study, for instance, the average age at first birth increased more than four years for women with a bachelor’s degree or more, compared to less than one year for women with a high school diploma. These changes are part of a larger pattern of increasing divergence in marriage and childbearing behaviors along socioeconomic lines, a divergence that has been attributed to growing economic inequality in the United States (Carlson & England, 2011; Martin, 2016; McLanahan, 2004). Further, contraceptive technologies have also changed over the past few decades, with the emergence of new short- and long-term reversible contraceptives that have become increasingly popular – but differentially adopted across population subgroups (Kavanaugh & Jerman, 2018). Together, these shifts in the context in which women make reproductive decisions may have altered the demand for sterilization in ways that vary across educational levels.

To better understand trends and differentials in sterilization, we first looked at the general trends and asked how educational differentials have changed over the past few decades. Overall, we found that sterilization increased during the 1970s and 80s before leveling off, perhaps even declining. However, patterns varied substantially by educational attainment. In particular, since the 1980s, sterilization generally declined for women with a bachelor’s degree or more, while prevalence continued to increase or leveled off for women with less education. In an attempt to understand how broad shifts in the context in which women make reproductive decisions contribute to these trends, we then investigated whether changes in fertility timing, marital status, and use of non-sterilization contraceptive methods – which, together, reflect different aspects of demand for sterilization – may have contributed to educational differentials in sterilization. Our results suggest that the increasing education gap in female sterilization is linked to shifts in two factors among college-educated women: (1) changes in first birth timing, such that fewer women are turning to sterilization, and (2) their growing adoption of effective and highly effective reversible methods of contraception. In essence, college-educated women appear to have declining demand for permanent contraception. Their less-educated counterparts, however, seem to continue to desire permanent methods. High levels of sterilization among women with a high school diploma have persisted, and even increased slightly, even as marriage and childbearing have shifted and new contraceptive methods have been developed.

Limitations

While informative, the present study has several limitations. First, we combine data from multiple rounds of the NSFG to examine sterilization trends over this time period. Generally, these NSFG surveys are considered comparable and are widely used to study trends. However, any sample survey contains sampling error, and the different sampling methods and survey designs used across the NSFG samples may induce idiosyncrasies into any individual time point. We attempt to minimize the influence of these idiosyncrasies by focusing on long-term trends rather than point-to-point comparisons as much as possible. Second, NSFG does not include measures of sterilization or contraceptive preferences, so we cannot determine whether women’s sterilization behavior reflects their preferences (instead of, say, a partner’s preference or pressure from health care providers). Finally, the present study does not consider how access or cost may impact sterilization use or its relationship with educational attainment. Future research should consider these important measures.

Conclusions

Our analyses document growing education gaps in sterilization. We show that education gaps in sterilization have grown because prevalence has decreased among women with a bachelor’s degree or higher while remaining stable or increasing for women with lower levels of education. The decline in sterilization rates for the most educated women is in large part attributable to changes in marriage and birth timing among these groups – later childbearing and later marriage have shortened the period in which women have completed their childbearing and want no more children, reducing the need for sterilization. These demographic changes have not been experienced in the same way by less educated women. A large literature explores the economic and social pressures that have produced uneven patterns in family change (e.g., Bailey, Guildi, & Hirschbein, 2014; Carlson & England, 2011; Martin, 2016), and our study illustrates how these pressures are embodied in contraceptive decision-making as well.

We also document continued high, and even growing, levels of sterilization among women without a bachelor’s degree. Our analyses did not identify a clear driver for this stability/increase. Future research focusing on interactions with the medical system may be useful in understanding the high reliance on sterilization of less educated women in the United States. Some research suggests that women with higher levels of education have greater health literacy on average and greater ease in interactions with health professionals (Bell, 2014; Verlinde, De Laender, De Maesschalck, Deveugele, & Willems, 2012). This may, in turn, better enable them to research and understand reproductive physiology and negotiate with doctors, feel comfortable with – and have access to – new methods of contraception that are nearly as effective as sterilization but less invasive and easily reversible (e.g., injectable hormonal methods, hormonal implants, new types of intrauterine devices). In addition, education is associated with an increased sense of personal control and associated improvements in health-related behaviors (Mirowsky & Ross, 1998, 2007). Greater perceived control, in turn, may make women more confident about using methods that require some planning and action (taking a pill, getting an injection) and reduce the perceived benefits of sterilization.

Conversely, some evidence suggests less educated women may be less comfortable using hormonal methods, have less access to contraceptive counseling and LARCs, or misunderstand the permanence of sterilization (James-Hawkins & Sennott, 2015; Zite & Wallace, 2011). Although explicit attempts to forcibly sterilize those deemed unfit to parent (the poor, the physically and mentally disabled, persons of color) have generally disappeared, it is remains possible that health care providers continue to steer less advantaged women towards sterilization and away from other effective but less invasive and permanent forms of contraception (Dehlendorf, Rodriguez, Levy, Borrero, & Steinauer, 2010; Roberts, 1999). Women with lower levels of education may also lack the agency to negotiate with their male partners or spouses to get a vasectomy, or they, or their partners, may have less egalitarian views about contraceptive responsibilities (Leyser-Whalen & Berenson, 2019). It is important to recognize, though, that the choice to undergo sterilization could be a way for poor women to gain control and agency over their own bodies (Leyser-Whalen & Berenson, 2019). Our macro-level analysis has identified important long-term trends, but more micro-level exploration is necessary in order to fully contextualize these trends. In particular, more work that specifically considers educational attainment as a key factor stratifying reproductive behaviors could help illuminate the processes driving the observed differentials. For instance, while there is substantial research on race-ethnic differences in contraceptive and reproductive decision-making, there is far less literature that explores – using survey data or qualitative approaches such as focus groups and interviews – the ways that education affects preferences, interactions with health care providers, communications and negotiations with partners, and the like.

Some sterilized women would like to reverse their procedures (Eeckhaut & Sweeney, 2018; Eeckhaut et al., 2018; Shreffler et al., 2015), and there are greater chances of medical complications associated with sterilization relative to other forms of contraception (Harris, 2017). Thus, education gaps in sterilization may contribute to socioeconomic disparities in health and well-being in the United States. Documenting these gaps also provides additional evidence for the large body of work on the ways that less advantaged women lack full reproductive autonomy and choices (Gubrium et al., 2016; Luna & Luker, 2013). Indeed, that there are growing educational disparities not just in sterilization itself but desire for reversal (Eeckhaut et al., 2018) as well in unintended childbearing (Hayford & Guzzo, 2016) suggests that less educated women face greater obstacles in managing reproductive behaviors compared to their counterparts with a college degree. As such, identifying the individual, interpersonal, and institutional barriers to reproductive autonomy for less advantaged individuals remains an important goal.

Acknowledgments

While this research was conducted, the authors were supported in part by center grants from the Eunice Kennedy Shriver National Institutes of Child Health and Human Development to Ohio State University’s Institute for Population Research (P2C-HD058484) and Bowling Green State University’s Center for Family and Demographic Research (P2C-HD050959).

Appendix table 1: Sample size and design for National Surveys of Family Growth

Survey Sample frame N (women)
1973 Ever-married women and single women with children in household, age 15–44; black women oversampled 9,797
1976 Ever-married women and single women with children in household, age 15–44; black women oversampled 8,611
1982 Women, age 15–44; black and teenage women oversampled 7,969
1988 Women, age 15–44; black women oversampled 8,450
1995 Women, age 15–44; black and Hispanic women oversampled 10,847
2002 Women, age 15–44; black, Hispanic, and teenage women oversampled 7,643
2006–10a Women, age 15–44; black, Hispanic, and teenage women oversampled 12,279
2011—15a Women, age 15–44; black, Hispanic, and teenage women oversampled 11,300
Open in a new tab
a

Data collected continuously starting in 2006.

Footnotes

1

We use the term “female sterilization,” or sometimes just “sterilization,” to refer to any voluntary permanent birth control procedure undertaken by women. Surgical procedures done primarily for medical reasons, such as hysterectomies (removal of the uterus) and oophorectomies (removal of the ovaries), are not included unless otherwise noted. Most sterilizations are tubal ligation, a surgical procedure. In 2002, the Food and Drug Administration approved Essure, a non-surgical birth control device permanently implanted in the fallopian tubes. Essure implants are included as a form of sterilization in our analyses. In 2013–15 NSFG data release, 97% of women sterilized for contraceptive reasons had undergone tubal ligation (authors’ calculation). We use “tubal sterilization” to refer to both surgical sterilization and non-surgical tubal interventions (e.g., Essure).

2

The continuous surveys describe average behavior over the four-year period covered by each release. The survey weights for these releases are designed to produce estimates representative of the population in the middle of the time period (e.g., data from the 2006–2010 release are weighted to the 2008 U.S. population). In our figures, estimates for the continuous releases are placed at the middle of the time period. In the text, we refer to the full time period covered by the data collection.

3

During the 1970s, more than 90% of women were ever-married by age 44 (Goldstein & Kenney, 2001).

4

As described in the data and methods section, the 1973 and 1976 NSFGs are limited to ever-married women and women with children in the household. We replicated Figure 1 applying these sample restrictions to the later surveys as well in order to assess how much the changing sample frame contributed to the patterns shown for the 1970s and 1980s. The shape of the trend lines for these periods was essentially identical when the sample was limited to ever-married women with children in all surveys. This supplementary figure is available on request

5

These trends reflect shifts in the age at marriage as well as the proportion of women who ever marry. There are larger educational differences in trends when examining the proportion of women married at the time of the survey (not shown), consistent with the research cited above showing higher marriage rates among women with a bachelor’s degree than among less educated women (Allred, 2018).

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