Exploring Experiences with Sterilization among Nulliparous Women

Abstract

Although nulliparous women who are sterilized appear voluntarily “childfree,” the majority report non-contraceptive reasons for their surgical procedure. Using an analytical subsample of the National Survey of Fertility Barriers, we examined 105 women’s closed- and open-ended responses about the reasons for their sterilization surgeries and whether their sterilization occurred before their childbearing desires were met. We found considerable heterogeneity in the experiences and attitudes of participants. We highlight important implications of women’s experiences for fertility and reproductive health research and practice, particularly by drawing a distinction between voluntarily childfree and involuntarily childless women.

By age 44, nearly one-third of women in the U.S. have undergone a sterilizing surgery (Daniels, Daugherty, & Jones, 2014); the majority (90%) had children before the surgery (Shreffler, McQuillan, Greil, & Johnson, 2015). Women who are nulliparous (i.e., have not given birth to a child) who report a sterilization surgery are often classified as “voluntarily childless” (e.g., Abma & Martinez, 2006). Yet there are reasons to suspect that some, or even many, nulliparous women undergo a surgical procedure that results in sterilization even though they want children. Although sterilization is often assumed to be primarily a method of contraception, women report a variety of contraceptive and non-contraceptive reasons for their surgeries; about one-half are due to non-contraceptive reasons (Shreffler et al., 2015). For example, some women have sterilization surgery to treat a health condition that could make pregnancy or childbearing difficult or impossible. Moreover, among women who have been surgically sterilized, nulliparous women are significantly more likely than mothers to report that their surgeries occurred before their childbearing desires were met (Shreffler et al., 2015). Involuntary childlessness has long-term implications for psychological well-being, including depressive symptoms and decreased life satisfaction (Lechner, Bolman, & Van Dalen, 2007; Schwerdtfeger & Shreffler, 2009). Therefore, it is important to more fully understand the experiences of women who are sterilized and nulliparous from their perspectives.

Childfree vs. Childless

A key weakness of many studies that compare women with children to women without is failure to take the reason for childlessness into account (McQuillan et al., 2012). Ireland (1993) defined “childfree” women as those who made a conscious decision not to have children and are strongly committed to childlessness. Bulcroft and Teachman (2004) emphasized the inadequacy of the term “childless” because it implies a problematic lack of a child, when some women consider themselves “childfree.’ Women who are involuntarily “childless” often have less choice about their childlessness, particularly in the case of biomedical fertility barriers (McQuillan et al., 2012). Women without children are therefore a diverse group (Umberson, Pudrovska, & Reczek, 2010). A national survey of women in the United States found that, of those who were aged 25 to 45 in 2004–2006, 12% were voluntarily childfree, 38% reported a biomedical barrier (e.g., sterilization, infertility), and 49% reported a situational barrier (e.g., lack of partner) or no barrier (McQuillan et al., 2012). Few studies of nulliparous women include measures of women’s childbearing expectations and their ability to bear children (Abma & Martinez, 2006). Umberson et al. (2010, p. 614) specifically urged researchers to focus on the “reasons for childlessness as well as the consequences for well-being.”

Yet survey questions with fixed response categories (e.g., reason for sterilization surgery, type of surgery) can hide some of the complexity of women’s experiences with sterilization surgeries. For example, nearly one-half of women who had had a tubal ligation (46%) reported a reason other than solely for contraceptive purposes (Shreffler, McQuillan, Greil, & Gallus, 2016). Further, simply asking women if the surgery prevented them from having children that they had wanted might hide conflict and uncertainty. For example, the health conditions that can lead to surgical sterilization (e.g., endometriosis, tumors, cysts) are often painful. Therefore, women might elect sterilization to relieve pain yet might also want a child.

The Present Study

In the present study, we used data from the National Survey of Fertility Barriers (NSFB)—a nationally representative, population-based, random-digit-dial telephone survey conducted in 2004–2006 that was designed to assess social and health factors related to reproductive choices and fertility among U.S. women (Johnson et al., 2009)—to examine the reasons for and feelings about sterilization among nulliparous women. The NSFB provides a unique opportunity for studying this topic because it overcomes some of the limitations of previous studies. First, although the sample is small (N = 105), NSFB participants were selected at random, which provided us with a unique opportunity to examine the subset of nulliparous sterilized women within this nationally representative sample. Second, we know of no other random sample studies that include open-ended questions about reproductive choices, barriers, and regrets.

Third, we converted the survey responses for each woman into narratives based on structured answers to questions as well as open-ended responses and analyzed the resulting narratives for themes. This analytical strategy, referred to as “survey-driven narrative construction” (see Kazyak, Park, McQuillan, & Greil, 2014), provides a more coherent sense of the sterilization stories of nulliparous women than the variable-based approach often used in statistical analyses of survey data.

We focused on the following questions: Among nulliparous women who have undergone surgical sterilization, did more report seeking sterilization for a medical issue (e.g., being childless) or for contraceptive purposes (e.g., being childfree)? Which themes emerged from open-ended comments and survey responses regarding choices, barriers, and psychosocial consequences of sterilization among nulliparous women?

Method

Sample

To explore variations in sterilization patterns, meanings, and reasons among childless women, we drew on the first wave (2004–2006) of the National Survey of Fertility Barriers (NSFB; Johnson et al., 2009), which some of the authors of this article helped to create. The NSFB is a nationally representative, population-based, random-digit-dial telephone survey designed to assess the social and behavioral consequences of infertility and reproductive experiences among U.S. women. The NSFB complied with established survey research ethical standards and was approved by the Institutional Review Boards at the Pennsylvania State University and the University of Nebraska-Lincoln. Of the 4,794 women interviewed, 105 indicated that they had not had a pregnancy that resulted in a live birth and had undergone a surgery that made it difficult or impossible for them to become pregnant.

The women in the sample were on average 30 years old when they had a sterilizing surgery (SD= 7.86, Range= 15–44 years old). White women comprised 60% of the sample; the other women were Black (22%), Hispanic/Latina (12%), American Indian (4%), and other race/ethnicity (2%). The participants were fairly highly educated, with an average educational attainment of some college (M= 14.96, SD= 2.48). The average level of family income fell in the $40,000-$49,000 range (M= 8.03, SD= 2.74). More than one-half of the women reported being in a relationship at the time of interview (62%). Catholics comprised the largest group in our sample (47%), followed by “other” religious affiliation (23%), no religious affiliation (19%), and Protestants (11%).

Concepts and Measures

Sterilization and reproductive-related measures.

Our determination of sterilization came from the question: “Have you ever had a surgery that makes it difficult or impossible to have a baby?”, where 1 = yes and 0 = no. The wording of this question allowed for a broader measure of surgical sterilization than the numerous studies restricted to tubal ligation surgeries only. The more inclusive language provides a means to examine the full range of reasons for different types of sterilizing surgeries and whether the reasons for and types of surgeries were associated with unmet childbearing desires. Unmet childbearing desires was assessed with a question that asked whether the surgery prevented participants from having children that they had wanted to have (1 = yes; 0 = no). Participants were also asked an open-ended question about reasons for being sterilized.

Interviewers also asked whether participants had had any prior pregnancies and their outcomes (e.g., abortion, miscarriage, stillbirth, live birth). Those who reported a live birth were excluded from the present study. Although it would be useful to classify women as voluntarily childfree versus involuntarily childless, doing so is complex (Wager, 2000). Situational reasons, health reasons, and pressure from others are associated with something less than full “voluntariness,” but they may represent various degrees of “involuntariness.” Those who felt pressured by others into surgical sterilization might feel more regret due to perceived lack of control (Elson, 2008), yet they might feel less regret because they could not have acted otherwise. We followed Shreffler and colleagues’ (2015) suggestion to collapse the various responses into more general categories than voluntary/involuntary. These categories are similar to those used in the National Survey of Family Growth (see Groves, Mosher, Lepkowski, & Kirgis, 2009), but they include an additional category of “suggestion/pressure from others.” The final scheme consisted of voluntary (e.g., contraceptive) sterilization (N = 9), non-contraceptive sterilization including situational (e.g., financial, age, and relationship) factors and health problems (N = 72), suggestion/pressure from others (N = 14), and other reasons (N = 9). Age at sterilization was calculated based on the date provided for the sterilization and the respondent’s age at the time of the interview. A measure of the type of sterilization allowed us to discern if the surgery was a tubal ligation, hysterectomy, or other type of surgery. Two additional open-ended questions were used in the analyses to help us to understand the meaning for the participants of not having given birth. The first questions asked participants: “We have asked you many questions. If you could change anything about the decisions you have made about pregnancy and childbearing, what would you change?” and “What would you say are the most important reasons you have not had biological children yet?”

Sociodemographic measures.

Race/ethnicity, and indicator of degree of vulnerability to bias and discrimination, was assessed using standard questions and coding schemes based on U.S. Census recommendations, which resulted in constructed indicator variables for White, Black, Hispanic, American Indian, and “Other.” Education, an indicator of resources, was a continuous variable measured in years. Household income, also an indicator of resources, was an ordinal variable that ranged from 1 (lowest) to 12 (highest). Intimate partner union status included indicator variables for currently in a union or single, and we also examined ever-married status. Employment status included indicator variables for full time, part time, and not employed.

Attitudinal measures.

Importance of motherhood is a scale with five items about the importance of having children or giving birth (McQuillan, Greil, Shreffler, & Tichenor, 2008), where higher values indicate greater importance (α = .77 in the full sample). Importance of successful career and importance of leisure are continuous variables (1 = low importance and 4 = high importance). Religiosity is a 4-item scale that includes questions about the importance of religious beliefs and behaviors (α =.78 for the total sample). Because the Catholic religion has specific teachings about contraception, we included an indicator for Protestant, Catholic, Other, and None.

Analytic strategy

We took advantage of the uniqueness of this data set (e.g., closed and open-ended survey responses, nationally representative sample) by employing a survey-driven narrative construction technique (Kazyak et al., 2014). This approach entailed converting the survey responses for each woman into narratives based on structured answers to questions as well as any open-ended responses. To understand better the reasons and experiences women had regarding their sterilization surgeries, we first read their comments on survey questions in an effort to identify emergent themes, similar to the method used by qualitative researchers to code interview transcripts (Emerson, Fretz, & Shaw, 1995). Reading responses in this way provided a more coherent sense of the sterilization experiences and stories for each respondent than statistical (variable-centered) analysis could reveal. For example, combinations of responses to several survey questions provided insightful information about respondents’ health and other issues that resulted in sterilization surgeries for many women. Similar to Kazyak et al. (2014), we amplified the qualitative findings with frequencies using classifications of women by their reasons for sterilization based on criteria used in past research. Rather than dichotomizing categories into voluntary vs. involuntary, we used the following categories: voluntary, non-contraceptive, suggested/pressured, and other reasons (Shreffler et al., 2015). Once patterns were identified by frequencies, we returned to the qualitative summaries to see what similarities and differences existed within the groups we had identified. We ascribed pseudonyms to the women in order to facilitate descriptions of women’s experiences while maintaining confidentiality.

Results

Table 1 presents descriptive statistics for the 105 women in our sample by reason for sterilization. Differences in unmet childbearing desires are particularly striking: 11% of women in the voluntary group reported unmet desires, as compared to 22% in the “other” group, 48% in the non-contraceptive group, and 83% in the suggested/pressured by others group. There are also some differences in type of surgery; none of the women in the voluntary group reported having had a hysterectomy, and only 6% of women in the non-contraceptive group reported having had a tubal ligation. Women in the voluntary group, on average, had higher educational attainment, were less religious, and reported a lower value of parenthood and higher values of career and leisure than women in the other sterilization groups. Yet across the different groups, there are some similarities in addition to differences. Age at sterilization was about 30 across the groups, and some women in all groups had experienced pregnancy, miscarriage, and abortion.

Table 1.

Descriptive Statistics for Women who are Nulliparous and Sterilized by Reason for Sterilization

	Total (n=105)		Voluntary (n=9%)		Non-contraceptive (n=69%)		Suggested/ Pressure (n=13%)		Other (n=9%)
	M/%	SD	M/%	SD	M/%	SD	M/%	SD	M/%	SD
Unmet childbearing desires	50%		11%		48%		83%		22%
Age at sterilization	29.99	7.86	30.50	6.19	31.15	7.31	29.64	9.01	28.00	8.17
Type of sterilization
Hysterectomy	30%		0%		37%		25%		17%
Tubal ligation	15%		63%		6%		17%		50%
Ovaries removed	8%		0%		7%		25%		0%
Other surgery/treatment	47%		38%		49%		33%		33%
Pregnancy history*
At least 1 pregnancy	47%		22%		47%		54%		44%
At least 1 miscarriage	28%		22%		32%		15%		22%
At least 1 stillbirth	4%		0%		6%		0%		0%
At least 1 abortion	21%		22%		15%		38%		22%
Race/Ethnicity
White	60%		78%		54%		69%		67%
Black	22%		22%		24%		8%		33%
Hispanic/Latina	12%		0%		13%		23%		0%
American Indian	4%		0%		6%		0%		0%
Other	2%		0%		3%		0%		0%
Education	14.96	2.48	16.89	2.67	15.22	2.25	14.00	3.24	13.22	1.30
Family income	8.03	2.74	10.00	2.14	8.20	2.75	7.08	2.54	7.14	2.67
Relationship status
Single	38%		25%		38%		41%		22%
Union	62%		75%		62%		59%		78%
Ever married	68%		78%		65%		62%		67%
Employment
Full-time	74%		89%		74%		77%		78%
Part-time	9%		11%		6%		15%		11%
Other	17%		0%		21%		08%		11%
Importance of motherhood	2.66	.75	1.89	.40	2.71	.73	2.73	.63	2.50	.88
Importance of career	3.50	.76	3.89	.33	3.37	.84	3.77	.44	3.44	.73
Importance of leisure	3.48	.74	3.89	.33	3.49	.70	3.38	.87	3.11	.93
Religiosity	−.93	3.04	−2.37	3.37	−.61	3.02	−1.47	2.74	.08	2.59
Religion
Protestant	11%		33%		8%		8%		13%
Catholic	47%		44%		46%		38%		63%
Other	23%		11%		25%		38%		1%
None	19%		11%		21%		15%		22%

Note: National Survey of Fertility Barriers, 2004–2006, women who are nulliparous and have had surgical sterilization.

^*Does not total to 100%; it is possible to have multiple pregnancy events.

Is Voluntary Sterilization the Same as “Childfree”?

About 9% of the women had had a sterilizing surgery voluntarily, or for contraceptive reasons. Eight of nine had had a tubal ligation, and three had had some other type of surgery. The desire not to have children influenced most of these women’s decision to have surgery. Five of the women in this group described their desires in explicit terms. For example, Suzy, a 38-year-old White woman who had had a tubal ligation, said her reason was rooted in her desire not to have children. She said: “I did not want to have children. I begged the doctor to get my tubes tied, and at age 25 I was referred to a specialist and went through with the tubal ligation.” When asked whether she would change anything about the decisions she had made about childbearing, Suzy said that she would change “absolutely nothing.”

For some women, children clearly were not part of the life that they had envisioned for themselves. Tabitha, a 44-year-old White woman who had had a tubal ligation elaborated: “I had no interest in childrearing, baby rearing, no interest in conceiving, having, or raising a child. More than anything else, I did not want the responsibility.”

Even though all nine women in the voluntarily sterilized group stated that they would not change anything about their childbearing decisions, four of them responded to other questions in a way that suggests some incongruence in their narratives. For instance, Mary, a 35-year-old White woman, had had a tubal ligation surgery when she was 21 years old because she did not want children at the time. Although she did not report that the surgery had prevented her from meeting her childbearing desires, when asked if she would change anything about her childbearing decisions she said: “I didn’t want them until recently.” For other women, the combination of desires and health concerns influenced their decisions. For example, Brenda, a 33-year-old Black woman, had surgery to help control her menstrual periods, but said that she and her husband had made the conscious decision not to have children.

How Do Outside Influences of Pressure or Suggestion Play a Role in Sterilization Surgery Decisions?

Fourteen women were coded as sterilized due to coercion or suggestion for medical reasons or other circumstances. For some of them, the reason for the surgery is not entirely clear. Georgia, a 27-year-old Black woman, had had a tubal ligation surgery at the age of 23 because it was requested by her doctor, but she said that she was unsure why - other than that she was having problems with her fallopian tubes at the time. Angela, a 43-year-old White woman, reported having had both a miscarriage and an abortion. Angela explained that she had “had an abortion and that [sterilization] is how they carried out the abortion,” and she said that she wished she had not had the abortion. Yet Georgia and Angela were the only women in this group who did not say the surgery had prevented them from having a child that they wanted.

The other 12 women in the suggested/coerced group said that the surgery had prevented them from having a child that they wanted. Some suggestions to have sterilizing surgery came from family members. Emily, a 44-year-old White woman, said that she had had a hysterectomy at the age of 15 because it was something that her family “decided was the right choice,” and she also said that she would have liked to have had a child. Another woman described her hysterectomy as malpractice. Frances, a 39-year-old White woman, stated: “The surgeon didn’t have permission to remove any organs, and it was supposed to be a laparoscopy.” She said that, although she had never felt her “biological clock ticking,” as a single woman, she might have tried to have a child on her own. She was taking care of her nephew at the time of the interview, and said that she could see herself adopting someday.

Do Non-contraceptive Sterilization Surgeries Prevent Women from Meeting their Childbearing Desires?

The majority of women in our sample had had sterilizing surgeries for reasons that we coded as non-contraceptive (69%). Roughly one-half of them reported that the surgery had prevented them from having a child that they wanted. Only six of the women coded as non-contraceptive had had a tubal ligation; about one-half had had a hysterectomy. Fibroids, cancer, and endometriosis were the most common reasons reported for these sterilization surgeries.

Among those for whom sterilization surgery was coded as non-contraceptive, there was considerable variation in the narratives that emerged in their responses to both close-ended and open-ended questions. Some of the women gave responses similar to the voluntarily childfree women. Tina, a 43-year-old Black woman, had had a hysterectomy at the age of 36 because of fibroids, but she would not change anything about her reproductive decisions and clearly stated that she did not want children. Other women discussed the difficulty of raising children and related that to their own childhood experiences. For example, Erica, a 42-year-old White woman, had had a hysterectomy at the age of 29 because of endometriosis and a tumor, but said that she had known since puberty that she did not want children and enjoys being the “fun aunt.” These women were consistent across their responses: They did not regret their surgeries, nor did they want to have children.

On the other hand, some women we coded as non-contraceptive had wanted children, but seemed less interested in the biological connection than in the identity of mother. For example, Jessica, a 42-year-old Black woman, identified fibroids as the reason for her hysterectomy. She did not think that the surgery had prevented her from having a child, however, and elaborated on this by saying: “Just because you feel the need to have a child doesn’t mean you have to actually give birth to a child. Adoption is just as important.”

The women who reported unmet childbearing desires (i.e., the surgery had prevented them from having a child that they wanted) and for whom we coded the reason for their sterilization as non-contraceptive had a range of responses as well. Carrie, a 38-year-old Latina, had had treatment for leukemia at the age of 36. Although she reported that the treatment had prevented her from meeting her childbearing desires, she also reported that she “wouldn’t change a thing” about her reproduction. Another participant, Rita, a 42-year old Black woman, had a hysterectomy because of fibroids and said that she “would have not had the hysterectomy until after I had a baby.”

Discussion

Childbearing decisions rarely occur at a single point in time, but rather unfold in parallel time as life course transitions (or lack of transitions) in domains of life such as education, work, and relationships (Elder, Johnson, & Crosnoe, 2003). In addition, reproductive potential and health may become more salient with transitions and/or time. There is a strong assumption in the United States that motherhood is highly important to all women, yet there is evidence of variation in attitudes toward motherhood (McQuillan et al., 2008). Still, some health care providers might assume that any health crisis that threatens future reproductive capacity must be devastating if a woman has not had the opportunity to bear children (American College of Obstetricians and Gynecologists, 2017). Conversely, some women may experience ambivalence regarding sterilizing surgeries and desire to have children. Therefore, in our survey-driven narrative construction analysis, we focused on the reasons that women reported having had sterilizing surgeries, their feelings about whether their surgeries prevented them from meeting their childbearing desires, and whether they would change anything about their childbearing if they could. Findings highlight the complexity of the choices women face regarding health and childbearing and the meanings that women assigned to their surgeries.

In particular, this approach proved useful in our investigation into how sterilization experiences are associated with the meaning of voluntarily childfree vs. involuntarily childless. We found considerable variation among women who were nulliparous and had had sterilizing surgery. Some women in our sample had wanted to become mothers and were prevented from meeting that goal due to non-contraceptive surgical sterilization procedures, which included mostly hysterectomies but also some tubal ligation surgeries and treatments for cancer. Although some voluntarily childfree women opted for sterilization to prevent pregnancy, others were sterilized for reasons other than contraception, such as health problems.

Limitations and Strengths

The NSFB dataset used for this study has some limitations as well as strengths. First, we had not anticipated developing the survey-driven narrative construction method employed here. Had we imagined that we could convert the survey responses into narratives that reflect the “conversation” between the interviewer and the participant (Kazyak et al., 2014), we would have focused more on encouraging open-ended comments and making sure that they were recorded.

Second, the data are now more than a decade old, and the participants’ sterilization surgeries occurred prior to the survey interview. In recent years, medical advances have resulted in new methods of sterilization surgeries (Powell et al., 2017) and increased uptake in long-acting reversible contraception (LARC) (England, 2016; Shoupe, 2016), which should expand women’s choices. Yet the majority of women do not receive contraceptive counselling in a given year, and racial/ethnic and social class disparities remain regarding contraceptive options provided and enacted (Meier, Sundstrom, DeMaria, & Delay, 2019). Also new since the data were collected is wider acceptance of the reproductive justice framework, as evidenced by the American College of Obstetricians and Gynecologists (2017) committee opinion on sterilization. The opinion, which explicitly describes the potential challenges to ethical use of sterilization (e.g. honoring the wishes of young nulliparous women, recognizing that individuals can make decisions that they later regret, highlighting the potential of implicit biases to influence provider choices), is focused primarily on contraceptive sterilization surgeries. As our findings illustrate, other types of health treatments and surgeries can result in sterilization as well. Future research on how women and their health care providers make decisions about surgical procedures that result in sterilization could support efforts to ensure ethical care.

Further, the use of retrospective data is somewhat problematic. We know, for example, that non-contraceptive sterilization is associated with greater unmet childbearing desires, but we cannot know for sure if women wanted to have children at the time of their sterilization surgeries or if they desired to have children at some point after the surgeries occurred. If future researchers could follow women from before surgery to several years after surgery, it would be possible to determine how stable or variable their perspectives are, and whether women who, at one point, thought the surgery that resulted in sterilization was a good idea might later wish that they had made a different choice, or whether they may wish now for children but still see their decision as the best overall for their health and well-being. The only dataset we know of that comes close to providing the kinds of insights that the current study cannot address is the German pairfam project that has been collecting annual surveys with individuals over a period of 12 years (Brüderl et al., 2016). We know of no similar data in the US.

Re-contacting and interviewing the women in the current study would also be informative. Learning from women who have lived over a decade with their situation could help providers and women now facing these decisions to have helpful perspectives on what matters most. For example, if there are dimensions of the surgery that are optional (e.g., removing the uterus but not the ovaries, removing ovaries but not the uterus), then women and their health care providers might make choices that do or do not preserve some dimensions of fertility (if possible). Taking women through the event history process would provides anchors for recall that could help women to recall accurately how they felt at the time of the surgery that resulted in sterilization (e.g., relief, fear, sadness, sense of loss, sense of freedom) compared to how they feel now (or how they felt when they met a new partner, or when a friend had a baby, etc.) (Connidis & McMullen, 1999).

Finally, the sample size is small; nulliparous women who had been sterilized comprised less than 3% of the full representative sample. Still, although this number prevents multivariate quantitative analysis, we believe that these women constitute an important and under-examined group. Construction of participants’ stories through the use of survey responses, particularly to open-ended questions, provides insights regarding the complex nature of the degree of voluntariness of both sterilization surgeries and childlessness that would be difficult or impossible to discover through quantitative analysis alone. The richness of the NSFB dataset, including the use of open-ended data to better explain survey responses, allows for greater understanding of this small and hard-to-reach population, which is a strength of the current study.

Implications for Research, Practice, and/or Policy

Our findings highlight themes of interest to fertility and reproductive health researchers. For example, we extended prior research on the distinction between voluntarily childfree and involuntarily childless. Researchers who categorize women into these groups must be thoughtful about the distinctions. Among women who have not been sterilized, this is relatively easy in a large, nationally representative survey through fertility intentions and desires measures. It is more difficult to categorize women who have completed their childbearing or “reproductive careers” (Johnson, Greil, Shreffler, & McQuillan, 2018), as fertility intentions questions are not relevant. Our findings also suggest that researchers should not simply separate women by type of surgery, as tubal ligations are not always used for contraceptive purposes, and some women who were sterilized for a health problem did not want to have children anyway. Researchers also cannot simply use wanting a child after having had sterilization surgery as a measure of sterilization regret or unmet childbearing desires, because some women opted to have sterilizing surgery because they viewed the procedure as medically necessary even though they stated in response to other questions that they wished they could have had children.

Although race was not the focus of this study, the descriptive statistics showed that White women were over-represented in the “voluntary” category and underrepresented in the non-contraceptive category, which suggests racial differences in reasons for and types of sterilization surgery. In part, this may be because White women have higher rates of sterilization for contraceptive purposes than other groups (Shreffler et al., 2015), and it may be because women of color are more likely to have children at younger ages, possibly before some of the reported health problems (e.g., cancer, fibroids) occur (Sullivan, 2005). Our data cannot fully tease out, however, whether differences are due to sterilizations that were necessary to address health problems, or whether there were differences in cultural meanings, structural access, or health care providers’ recommendations depending on the women’s racial group membership. These are important distinctions because of policy implications; if surgeries are necessary for health problems that are disparate by race/ethnicity, then that would suggest a need to target racial health disparities. On the other hand, if providers’ recommendations for treatment options differ due to women’s racial group membership, then that would suggest the need to educate health care providers about differential (and potentially biased) treatment options that women are offered depending upon their race/ethnicity.

Conclusion

The goal of the present study was to increase understanding of the reasons why women elect sterilization and the choices, barriers, and psychosocial consequences of sterilization among nulliparous women. Our findings illustrate considerable heterogeneity in the experiences and attitudes of the participants. We found that simply knowing whether the surgery was for contraceptive or non-contraceptive reasons does not necessarily convey whether women meet criteria for being voluntarily childfree or involuntarily childless (Bulcroft & Teachman, 2004). From a survey research perspective, our findings suggest the need to ask women what the surgery that resulted in sterilization means to them rather than presuming that one type of surgery is simply contraceptive and other types are not. In addition, from a care provision perspective, it is important for health care providers to seek to understand the meaning of surgeries that result in sterilization for the women who undergo them. From a reproductive justice framework, it is important for providers not to decide that they along know what is best for women (e.g., not recommending sterilization surgery if women are nulliparous, recommending certain surgeries for health concerns), but instead to communicate to women the full implications of the decision and to work with them to make the choice that is best for them (American College of Obstetricians and Gynecologists, 2017).