Surgical Sterilization Among Women and Use of Condoms -- Baltimore, 1989-1990

Since 1980, surgical sterilization among women has become the most common contraceptive method used among women aged greater than 30 years in the United States and is used by 28% of women aged 15-44 years (1). A previous report of women in drug treatment suggested that women who have been surgically sterilized were less likely to report condom use -- an effective measure for prevention of human immunodeficiency virus (HIV) infection and sexually transmitted diseases (STDs) -- than were nonsterilized women (2). This report summarizes a study of the relation between surgical sterilization, risk status for STDs and HIV, and use of condoms among women who reside in two inner-city, minority neighborhoods in Baltimore.

During November 1989-February 1990, as part of the baseline evaluation for a community-based HIV-prevention program, the Baltimore City Health Department and Johns Hopkins University, in cooperation with CDC, interviewed 766 women aged 17-35 years residing in the two neighborhoods by telephone using random-digit dialing. Self-reported data from sterilized and nonsterilized women were analyzed and risk indices were created for personal risk * and partner risk **. Of the 766 women, 210 (44 sterilized and 166 nonsterilized) women aged 20-35 years were asked additional questions about their attitudes toward condom use.

Surgical sterilization increased directly with age to 45% among women aged 30-35 years (Table 1). In comparison, condom use declined with increasing age, regardless of sterilization status. Analysis including stratification by age group indicated that sterilized and nonsterilized women were similar by education level, race, and work status; however, sterilized women were more likely to have ever been pregnant and ever been married (Table 2).

Women in both groups were similar in attitudes about HIV and HIV prevention, including perceptions of community norms; perceived self-efficacy in avoiding HIV infection; perceived condom efficacy for STD/HIV protection; condom acceptability; concern about HIV; concerns about injecting-drug use, HIV, and STDs; the ability to communicate with partners about HIV infection; and the ability to refuse sex. However, sterilized women were somewhat less likely (71%) than nonsterilized women (90%) to believe that condoms prevent pregnancy (p=0.02).

More than one third of both sterilized (35%) and nonsterilized (37%) women had a personal and/or a partner risk factor for STDs (Table 2). Although nonsterilized women were more likely to report personal risk factors for STD/HIV infection and sterilized women were more likely to report risk factors for their partners, these differences were not statistically significant (Table 2).

Among women who had been sterilized, 78% reported never using a condom currently compared with 46% of nonsterilized women, while 3% of sterilized and 14% of nonsterilized women reported always using condoms (Table 2). This association persisted when the analysis included stratification by age group (odds ratio=0.30; 95% confidence interval=0.20-0.47) (Table 2).

Reported by: JS Santelli, MD, LG Burwell, PhD, C Rozsenich, MHS, Baltimore City Health Dept; M Augustyn, PhD, DD Celentano, ScD, JE Rolf, PhD, R Wallach, B Beverly, MS, Johns Hopkins School of Hygiene and Public Health. Div of Sexually Transmitted Diseases and HIV Prevention, National Center for Prevention Svcs, CDC.

Editorial Note

Editorial Note: Failure to use condoms during intercourse with partners at risk for STDs, including HIV infection, increases the risk for acquiring STDs. The findings in Baltimore are consistent with a previous study of surgical sterilization among women who were surveyed while enrolled in drug-treatment clinics in Philadelphia and underscore the need for educating women who have been surgically sterilized and others about the importance of condom use as a means for preventing STDs and HIV infection (2).

Surgical sterilization is more common among women who are older and who reside in low socioeconomic, inner-city, and minority communities (1). In these communities, women have been disproportionately affected by the HIV epidemic (3).

Women who plan surgical sterilization should be offered counseling before and after sterilization regarding their need for continued barrier protection; unless women, including those who have been sterilized, are involved in mutually monogamous relationships with uninfected partners who have no risk behaviors (e.g., injecting-drug use), condoms should be used during sexual intercourse. In addition, public health messages addressing the risks for HIV, STDs, cervical cancer, and other reproductive health concerns should include women who are surgically sterilized as well as those who are not.

The Baltimore City Health Department is using these findings to develop outreach strategies to increase condom use and to prevent HIV infection among all reproductive-aged women.

References

1. Mosher WD. Contraceptive practice in the United States, 1982-1988. Fam Plann Perspect 1990;22:198-205.

2. CDC. HIV-risk behaviors of sterilized and nonsterilized women in drug-treatment programs -- Philadelphia, 1989-1991. MMWR 1992;41:149-52.

3. Chu SY, Buehler JW, Berkelman RL. Impact of the human immunodeficiency virus epidemic on mortality in women of reproductive age, United States. JAMA 1990;264:225-9.

• Defined as having more than one sex partner during the year preceding the survey, using injecting drugs during the month preceding the survey, ever being in drug treatment, receiving money or drugs for sex, receiving STD treatment during the 6 months preceding the survey, using drugs at last sexual episode, or using alcohol at last sexual episode (which is associated with nonuse of condoms). ** Defined as, during the 6 months preceding the survey, having sex with someone who had an STD, had AIDS, was a prostitute, was an injecting-drug user, or was bisexual/homosexual.

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