Annals of Epidemiology 28 (2018) 447e451

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Annals of Epidemiology
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Original article

Correlates of long-acting reversible contraception versus sterilization

use in advanced maternal age
Shelby N. Apodaca, MD a, *, Melissa D. Mendez, MD a, Sheralyn S. Sanchez, MPH a,
Zuber D. Mulla, PhD a, b
a
Obstetrics and Gynecology, Paul L. Foster School of Medicine, Texas Tech University Health Sciences Center El Paso, El Paso
b
Julia Jones Matthews Department of Public Health, Texas Tech University Health Sciences Center, Lubbock

a r t i c l e i n f o a b s t r a c t

Article history: Purpose: To identify correlates associated with choosing long-acting reversible contraception (LARC)
Received 17 May 2017 over female sterilization (FS) from a subsample of women aged 35 to 44 years in a nationally repre-
Accepted 13 March 2018 sentative survey.
Available online 16 March 2018
Methods: We analyzed data from women aged 35 to 44 years from the 2011e2013 National Survey of
Family Growth Female Respondent File (n ¼ 1532). Data were analyzed using SAS 9.3 software. All
Keywords:
analyses accounted for the complex survey sample design. Multinomial logistic regression was used to
Advanced maternal age
identify factors associated with choosing LARC versus FS. A domain analysis was performed focusing on
Female sterilization
Intrauterine device
women aged 35 to 44 years.
Long-acting reversible contraception Results: Approximately 90% of the surveyed women had not received counseling or information about
United States birth control in the past 12 months. Factors associated with using an LARC method versus FS were higher
level of education, birth outside of the United States, and higher number of lifetime male sexual partners.
Factors associated with using FS versus an LARC method were non-Hispanic black race and women who
had not had a checkup related to using a birth control method in the last 12 months.
Conclusions: The results of our study suggest that a large proportion of women of advanced maternal age
in the United States have not received contraceptive counseling in the past 12 months. Providers should
focus on providing comprehensive contraceptive and sterilization counseling to women aged 35 to
44 years, especially those using unreliable, reversible contraception.
© 2018 Elsevier Inc. All rights reserved.

Introduction among women with public or no insurance, women with higher

Female sterilization (FS) is one of the most common methods of
contraception worldwide, used by one in three women of repro-
ductive age [1]. Previous studies have shown that women aged 35
to 44 years choose FS as a method of contraception more commonly
than younger women [2]. In fact, the 2006e2010 National Survey of
Family Growth (NSFG) reported that 10.2 million women were
sterilized in the United States, with 37% of women aged 35 to 39
years and 51% of women aged 40 to 44 years reporting FS as their
primary contraceptive method. The 2006e2010 and 2011e2013
NSFG both found permanent FS to be more common among
disadvantaged women with lower levels of education and income,
The authors report no conflicts of interest.
* Corresponding author. Texas Tech University Health Sciences Center El Paso,
4801 Alberta Avenue, El Paso, TX 79905. Tel.: 915-215-5000; fax: 915-545-6946.
E-mail address: shelby.apodaca@ttuhsc.edu (S.N. Apodaca).
parity, and among black and Hispanic women [3,4].
Interestingly, however, between 1995 and 2006, total steriliza-
tion procedures among unsterilized women in the United States
aged 15 to 44 years fell by 12%, despite a 4% population growth
within this demographic [5]. It has been speculated that this
decline in FS in the United States may be a result of more women
having access to reversible contraception alternatives due to
improvements in family planning education resource availability
and possibly increased insurance coverage of long-acting reversible
contraceptive (LARC) methods, such as intrauterine devices and
etonogestrel subdermal implants [5]. Prior data from NSFG results
have showed an increase in overall LARC method use by women in
the United States from 1.3% in 2002 to 7.2% in 2011e2013 [3,4].
Women with incomplete childbearing, medical comorbidities, or
those unwilling to accept the surgical risks of permanent
sterilization should be encouraged to use an LARC method. Women
should be informed that LARC methods carry a lower risk of
morbidity, mortality, and regret as compared with FS, and the

https://doi.org/10.1016/j.annepidem.2018.03.005
1047-2797/© 2018 Elsevier Inc. All rights reserved.

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448 S.N. Apodaca et al. / Annals of Epidemiology 28 (2018) 447e451
efficacy of each LARC method is nearly 100% [6e8]. In addition,
outcomes of The Contraceptive CHOICE Project in 2014 indicate that
the majority of reproductive-aged women will choose an LARC
method when barriers of cost, knowledge, and access are removed
[9]. In the literature, characteristics of women who choose LARC
methods have not been directly compared with women who choose
FS. And furthermore, there are a limited number of studies in the
published literature that examine the factors that influence the
contraceptive choices of women in their later reproductive years.
Among women aged 35 to 44 years in the 2011e2013 NSFG, only
5.3% were using an LARC method, compared with 11.1% of women
aged 25 to 34 years [3]. These findings may be related to multiple
factors, including increased use of FS, lack of recent contraceptive
counseling, financial constraints, or limited access to care [3,10].
Women aged 40 to 44 years are less likely to have received any type
of contraceptive counseling in the past 2 years, despite a continued
risk of unintended pregnancy and increased pregnancy risks
associated with advanced maternal age [11]. It is important to
understand the characteristics of women of advanced maternal age
and their contraceptive choices to provide this population with
adequate care, counseling, and appropriate contraception to
prevent unplanned and potentially high-risk pregnancies. The
objective of our study is to identify correlates associated with
choosing long-acting reversible contraception over FS from a
subsample of women aged 35 to 44 years in a nationally
representative survey.
Methods
The NSFG was established by the Centers for Disease Control
and Prevention's National Center for Health Statistics to collect and
analyze data on factors affecting men's and women's reproductive
health. Sample respondents for the 2011e2013 NSFG were selected
based on screening interviews in selected households and
information was collected using in-person interviews. The Female
Respondent File contained data from interviews with 5601 women
aged 15 to 44 years, and the response rate was 73.4% [12]. Approval
from the Texas Tech University Health Sciences Center at El Paso
Institutional Review Board for the Protection of Human Subjects
deemed the study exempt from formal Institutional Review Board
review.
For our study, we used the 2011e2013 NSFG Female Respondent
File described previously; however, we only analyzed data from the
1532 female participants who were 35 to 44 years of age with at
least one lifetime male sexual partner. This cohort represents the
civilian household population of 19,981,021 women aged 35 to
44 years in the United States (this figure is arrived at by summing
the sample weights). Women without at least one lifetime male
sexual partner were excluded, as these women are highly unlikely
to be using any type of contraception, especially FS. Contraceptive
use in our cohort was categorized into the following three groups
which are defined below in the Data analysis section: FS, LARC
methods, and other methods.
Twelve characteristics of the women in our cohort were
examined in our analysis, listed in Tables 1 and 2. The character-
istics we included were chosen from the available survey questions
in the NSFG questionnaire, based on clinical practice pattern
observations and agreed on by two physicians. The characteristics
chosen were intended to reflect a range of demographics, socio-
economic statuses, differences in access to care and presence of
high-risk behaviors (i.e., multiple sexual partners, recent treatment
of a sexually transmitted disease, etc.). Categories within each of
the 12 characteristics, listed in Tables 1 and 2, were derived directly
from the NSFG questionnaire and redistributed into less than or
equal to five categories to reduce the potential for sparse data bias.
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The redistributed categories were agreed on by two physicians and
a maternal health epidemiologist. Referent values were chosen
based on the United States public health norms (i.e., non-Hispanic
white race, high school graduate, born in the United States, etc.) or
based on expected standard of care (i.e., annual physical exam with
contraceptive counseling), and agreed on by two physicians and a
maternal health epidemiologist.
Data analysis
The 2011e2013 NSFG Female Respondent File was analyzed
using procedures in SAS 9.3 (SAS Institute, Inc., Cary, NC) that are
indicated when analyzing data from a complex survey sample
design. Weighted prevalence estimates were calculated using the
SURVEYFREQ procedure and the appropriate cluster, strata, and
weight variables. Subjects ranged in age from 15 to 44 years. Our
subjects of interest, however, were women aged 35 through
44 years. Deleting women from the sample who were outside of
this age range would disrupt the weighted nature of the dataset,
hence a dichotomous domain variable was created (age 35 years
with 1 lifetime male sexual partner vs. not in the aforementioned
category) and incorporated into our analyses.
A three-level categorical outcome variable was created using the
CONSTAT1 variable. CONSTAT1 is described as the, “Current
contraceptive status (first priority code) (RECODE),” in the online
codebook [13]. The three levels were FS (which served as the
referent outcome group), LARC (defined as Norplant or Implanon
implant or intrauterine device), and none of the aforementioned.
The detailed definition of FS, obtained by examining the STRLOPER
recode variable, is as follows: tubal ligation or sterilization,
hysterectomy, or other operation or type unknown. A multinomial
logistic regression model was fit using the SURVEYLOGISTIC
procedure by specifying the glogit link function. The appropriate
cluster, strata, and weight variables were also specified. The
DOMAIN statement (rather than the BY statement) was used to
properly calculate odds ratios (ORs) for the two domains described
previously. We were interested in estimating ORs for women aged
35 to 44 years for the outcome of LARC versus FS, and therefore the
results for the younger age stratum and for contraceptive methods
other than LARC or FS were not reported. The predictor variables that
were included in the logistic regression model were chosen based on
their clinical or epidemiologic importance. ORs were reported along
with 95% Wald confidence intervals (CIs) and P values.
Results
Characteristics of the sample
In our cohort, 489 women (31.3%) were using FS, 83 women
(5.4%) were using an LARC method, and 960 women (63.4%) were
not classified in any of the aforementioned two categories. This
final group of women was labeled as other (Table 1). Women in the
other category included 152 who were using male sterilization, 122
who were using an oral contraceptive, 115 who were using the male
condom, and 27 who were pregnant at the time of the survey
interview. More than half of the women in our cohort (59.5%) were
currently married to a person of the opposite sex with an additional
10% of women who were not married, but living with an opposite
sex partner. The ethnic distribution was 61.5% non-Hispanic white,
18.4% Hispanic, 13.6% non-Hispanic black, and 6.4% non-Hispanic
other. Almost one-fifth of the women were born outside of the
United States (17.7%). Nearly 90% of women had at least a high
school diploma or equivalent, with 16.3% having a masters,
doctorate, or professional degree. Approximately 18% of the women
in our cohort were born outside of the United States. Fewer than
 S.N. Apodaca et al. / Annals of Epidemiology 28 (2018) 447e451 449

Table 1
Characteristics of 1532 women aged 35 to 44 years in the 2011e2013 National Survey of Family Growth

Variable Frequency Weighted percent 95% Confidence interval

Current contraceptive status

Female sterilization 489 31.3 27.5e35.0
Long-acting reversible contraception 83 5.4 3.5e7.2
Other 960 63.4 59.4e67.3
Current marital or cohabitating status
Not married but living with opposite sex partner 160 10.0 8.0e12.1
Widowed, divorced or annulled, or separated for reasons marital discord 306 17.6 14.9e20.3
Never been married 274 12.9 10.3e15.6
Currently married to a person of the opposite sex 792 59.5 55.2e63.7
Hispanic ethnicity and race
Hispanic 349 18.4 13.9e22.9
Non-Hispanic black 304 13.6 10.7e16.5
Non-Hispanic other 100 6.4 3.0e9.9
Non-Hispanic white 779 61.5 56.2e66.9
Highest grade or year of school ever attended
12th grade or less, no diploma (nor GED) 190 10.4 8.3e12.4
High school graduate (high school diploma or GED) 388 24.8 21.2e28.4
Some college but no degree, or associate degree in college/university 433 27.6 23.5e31.6
Bachelor's degree 294 21.0 16.9e25.0
Master's, doctorate, or professional degree 227 16.3 12.6e19.9
Born outside of the United States
Yes 301 17.7 14.1e21.2
No, refused, or do not know 1231 82.3 78.8e85.9
In the last 12 mo, for how many months did you have any job for pay?
Refused, do not know, no months, 1 mo, or 2 mo 403 21.4 18.4e24.4
3e5 mo 56 3.2 1.7e4.8
6e8 mo 83 4.1 2.8e5.4
9e11 mo 89 7.1 5.0e9.1
12 mo 901 64.2 60.0e68.4
In the past 12 mo, was there any time that you did not have any health insurance or coverage?
Yes 413 22.9 19.5e26.4
No, refused, or do not know 1119 77.1 73.6e80.5
Parity
0 266 15.5 12.5e18.5
1 300 15.7 13.3e18.0
2 474 34.5 30.8e38.3
3 306 21.6 18.3e25.0
4 186 12.7 10.0e15.3
Number of lifetime male sexual partners
1e3 542 37.7 33.2e42.2
4e6 444 31.1 27.3e34.9
7e9 188 10.7 9.1e12.4
10 358 20.5 17.6e23.3
Had a checkup or medical test related to using a birth control method in the past 12 mo
Yes 219 15.4 12.2e18.5
No or refused 1313 84.6 81.5e87.8
Received counseling or information about birth control in the past 12 mo
Yes 148 9.9 7.7e12.2
No or refused 1384 90.1 87.8e92.3
Received counseling or information about getting sterilized in the past 12 mo
Yes 74 5.6 3.6e7.6
No, refused, or do not know 1458 94.4 92.4e96.4
Received counseling for, tested or treated for a sexually transmitted disease in the past 12 mo
Yes 160 8.0 6.2e9.9
No, refused, or do not know 1372 92.0 90.1e93.8

The sum of the sampling weights is 19,981,021 women.

half of women (36%) did not have any form of employment within
the last 12 months, and 22.9% of women in our cohort reported a
time in the past 12 months when they did not have health
insurance.
Approximately 85% of women in our cohort had at least one
child. Most women in our study had fewer than seven lifetime
male sexual partners (68.8%); however, 20.5% had at least 10
lifetime male sexual partners. The vast majority of the studied
women had not had a checkup or medical test related to using a
birth control method in the last 12 months (84.6%), received
counseling or information about birth control in the past
12 months (90.1%), or received counseling or information about
getting sterilized in the past 12 months (94.4%). Only 8% of women
in our cohort reported receiving counseling, testing, or treatment
for a sexually transmitted disease during this same 12 month time
period.
Results of the multivariable analysis
Non-Hispanic black women compared with non-Hispanic white
women (OR ¼ 0.38, 95% CI ¼ 0.15e0.99, P ¼ .047) were more likely
to use FS rather than an LARC method. Conversely, women who
obtained a bachelor's degree, compared with female high school
graduates (OR ¼ 2.68, 95% CI ¼ 1.08e6.64, P ¼ .03), women who
were born outside of the United States (OR ¼ 7.09, 95%
CI ¼ 2.47e20.35, P ¼ .0003), and women who had seven to nine

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450 S.N. Apodaca et al. / Annals of Epidemiology 28 (2018) 447e451

Table 2
Adjusted* odds ratios (ORs) for using LARC versus female sterilization in 1532 women aged 35 to 44 years

Possible risk factor OR (95% CI) P-value

Current marital or cohabitating status

Not married but living with opposite sex partner 0.69 (0.23e2.04) .50
Widowed, divorced or annulled, or separated for reasons marital discord 0.54 (0.23e1.29) .16
Never been married 0.59 (0.24e1.42) .23
Currently married to a person of the opposite sex 1 (Referent) d
Hispanic ethnicity and race
Hispanic 1.18 (0.51e2.76) .70
Non-Hispanic black 0.38 (0.15e0.99) .047
Non-Hispanic other 0.65 (0.13e3.30) .60
Non-Hispanic white 1 (Referent) d
Highest grade or year of school ever attended
12th grade or less, no diploma (nor GED) 0.57 (0.11e3.15) .52
High school graduate (high school diploma or GED) 1 (Referent) d
Some college but no degree, or associate degree in college/university 1.57 (0.56e4.37) .39
Bachelor's degree 2.68 (1.08e6.64) .03
Master's, doctorate, or professional degree 1.72 (0.59e4.99) .32
Born outside of the United States
Yes 7.09 (2.47e20.35) .0003
No, refused, or do not know 1 (Referent) d
In the last 12 mo, for how many months did you have any job for pay?
Refused, do not know, no months, 1 mo, or 2 mo 0.87 (0.39e1.96) .74
3e5 mo 0.83 (0.22e3.14) .79
6e8 mo 1.32 (0.27e6.57) .73
9e11 mo 0.44 (0.09e2.24) .33
12 mo 1 (Referent) d
In the past 12 mo, was there any time that you did not have any health insurance or coverage?
Yes 0.80 (0.35e1.83) .60
No, refused, or do not know 1 (Referent) d
Parity
0 1.05 (0.25e4.36) .95
1 0.91 (0.33e2.49) .86
2 1 (Referent) d
3 0.75 (0.28e2.04) .58
4 0.55 (0.23e1.32) .18
Number of lifetime male sexual partners
1e3 1 (Referent) d
4e6 1.64 (0.57e4.67) .36
7e9 3.10 (1.08e8.87) .04
10 1.38 (0.46e4.17) .57
Had a checkup or medical test related to using a birth control method in the past 12 mo
Yes 1 (Referent) d
No or refused 0.09 (0.03e0.28) <.0001
Received counseling or information about birth control in the past 12 mo
Yes 1 (Referent) d
No or refused 0.85 (0.24e3.02) .80
Received counseling or information about getting sterilized in the past 12 mo
Yes 1 (Referent) d
No, refused, or do not know 4.41 (0.82e23.81) .08
Received counseling for, tested or treated for a sexually transmitted disease in the past 12 mo
Yes 1 (Referent) d
No, refused, or do not know 2.20 (0.75e6.47) .15
*
Each odds ratio is adjusted for the remaining variables found in the table.

versus one to three lifetime male sexual partners (OR ¼ 3.10, 95%
CI ¼ 1.08e8.87, P ¼ .04) were more likely to use an LARC method
rather than FS. Women who had not had a checkup relating to using
a birth control method in the past 12 months versus women who
did have a checkup (OR ¼ 0.09, 95% CI ¼ 0.03e0.28, P < .0001) were
significantly more likely to use FS rather than an LARC method.
Discussion
In our study, factors that were significantly associated with the
choice of an LARC method over FS were non-Hispanic white race,
higher level of education, birth outside of the United States, and a
higher number of lifetime male sexual partners. Women of non-
Hispanic black race and women without a checkup or medical
test relating to using a birth control method in the last 12 months
were significantly more likely to use FS over an LARC method.
Interestingly, marital, employment, and health insurance statuses,
as well as parity, were not significantly associated with either FS or
LARC.
Advanced maternal age, defined as age 35 years or older at the
time of delivery, is associated with an increased risk of adverse
perinatal outcomes including intrauterine fetal demise, pre-
eclampsia, gestational diabetes, cesarean delivery, and maternal
death [14e16]. It is important in this population of women to
provide reliable contraception. However, most women in our
cohort had not had a checkup, medical test, counseling, or infor-
mation provided to them relating to contraception or permanent
sterilization in the last 12 months. Reasons for these findings
include completion of a male or female permanent sterilization
procedure less than 12 months ago, lack of health insurance,
financial constraints, or a missed opportunity by the woman's
provider to provide counseling during a visit within the past

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 S.N. Apodaca et al. / Annals of Epidemiology 28 (2018) 447e451
12 months [11]. Nevertheless, only 44% of women in our cohort
were using either male sterilization or FS for contraception, but
90.1% of women reported not having received counseling or infor-
mation about birth control in the past 12 months. The results of our
study indicate that women of advanced maternal age in the United
States continue to receive inadequate contraceptive counseling, as
compared with younger women [9].
A limitation of the 2011e2013 NSFG is that the information was
self-reported. Data were not validated using the survey
respondents' medical records. Our study was also limited by the
number of that risk factor correlates that could be analyzed due to
the small number of women in the LARC method group. We
strategically restricted the number of predictor variables used in
our study to avoid overfitting our logistic regression model and
inducing potential sparse data bias [17]. In addition, while the
2011e2013 NSFG was designed to be nationally representative of
the female civilian noninstitutionalized population aged 15
through 44 years, the survey was not designed or intended to
produce specified estimates or results for individual states [18].
Thus, our study is not likely applicable to specific states and regions
within the United States, especially those with differing
demographic and racial compositions.
As stated previously, reliable contraception regardless of
reversibility or permanence is necessary to prevent unintentional
pregnancies in the United States, especially in women of advanced
maternal age due to their increased risk for numerous pregnancy
complications [14e16]. Our study calls attention to the paucity of
information regarding reversible contraception and sterilization
provided to women in their later reproductive years. We encourage
providers who treat reproductive-aged women, not only obstetri-
cians and gynecologists, to focus on providing contraceptive and
sterilization counseling to women aged 35 to 44 years, especially
those using unreliable, reversible contraception [19]. Women with
complete family status should be offered both permanent sterili-
zation and LARC methods. Available surgical procedures, as well as
the different LARC methods should be discussed and explained.
Providers should place a secondary emphasis on providing this
comprehensive contraceptive counseling to non-Hispanic black
women who have historically, and continue to have, an increased
incidence of FS as compared with similar aged non-Hispanic white
women [3,4]. Future studies should focus on analyzing the per-
ceptions of women of advanced maternal age regarding complete
family status, LARC methods, and FS, and reasons for nonuse to
provide better contraceptive counseling to patients in this age
group. Unplanned pregnancies in women aged 35 to 44 years are of
public health interest, and further efforts should be taken to pre-
vent these potentially high risk pregnancies.
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451
Acknowledgments
Funding: This research did not receive any specific grant from
funding agencies in the public, commercial, or not-for-profit
sectors.
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