Women's Reproductive Health

ISSN: 2329-3691 (Print) 2329-3713 (Online) Journal homepage: https://www.tandfonline.com/loi/uwrh20

Exploring Experiences with Sterilization among

Nulliparous Women

Karina M. Shreffler, Stacy Tiemeyer, Julia McQuillan & Arthur L. Greil

To cite this article: Karina M. Shreffler, Stacy Tiemeyer, Julia McQuillan & Arthur L. Greil (2020)
Exploring Experiences with Sterilization among Nulliparous Women, Women's Reproductive Health,
7:1, 36-48, DOI: 10.1080/23293691.2019.1690306

To link to this article: https://doi.org/10.1080/23293691.2019.1690306

Published online: 19 Feb 2020.

Submit your article to this journal

Article views: 29

View related articles

View Crossmark data

Full Terms & Conditions of access and use can be found at

https://www.tandfonline.com/action/journalInformation?journalCode=uwrh20
WOMEN'S REPRODUCTIVE HEALTH
2020, VOL. 7, NO. 1, 36–48
https://doi.org/10.1080/23293691.2019.1690306

Exploring Experiences with Sterilization among

Nulliparous Women
Karina M. Shrefflera, Stacy Tiemeyera, Julia McQuillanb, and Arthur L. Greilc
a
Department of Human Development and Family Science, Oklahoma State University, Tulsa, Oklahoma,
USA; bDepartment of Sociology, The University of Nebraska at Lincoln, Lincoln, Nebraska, USA;
c
Department of Sociology, Alfred University, Alfred, New York, USA

ABSTRACT ARTICLE HISTORY

Although nulliparous women who are sterilized appear voluntarily Received 18 January 2019
“childfree,” the majority report non-contraceptive reasons for their Revised 8 August 2019
surgical procedure. Using an analytical subsample of the National Accepted 29 August 2019
Survey of Fertility Barriers, we examined 105 women’s closed- and
KEYWORDS
open-ended responses about the reasons for their sterilization sur- Sterilization; reproduction;
geries and whether their sterilization occurred before their childbear- regret; childlessness;
ing desires were met. We found considerable heterogeneity in the childfree; NSFB
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.

Introduction
By age 44, nearly one-third of women in the United States 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 classi-
fied 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 contra-
ceptive 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 steril-
ization 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 sur-
geries 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

CONTACT Karina M. Shreffler, PhD karina.shreffler@okstate.edu Department of Human Development and Family
Science, Oklahoma State University, 700 N. Greenwood Ave., Tulsa 74106, OK, USA.
ß 2019 Society for Menstrual Cycle Research
 WOMEN'S REPRODUCTIVE HEALTH 37

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 the 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 problem-
atic 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 chil-
dren 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 25–45 in
2004–2006, 12% were voluntarily childfree, 38% reported a biomedical barrier (e.g., ster-
ilization, 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., the 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 liga-
tion (46%) reported a reason other than solely for contraceptive purposes (Shreffler,
McQuillan, Greil, & Gallus, 2016). Further, simply asking women if the surgery pre-
vented them from having children that they had wanted might hide conflict and uncer-
tainty. For example, the health conditions that can lead to surgical sterilization (e.g.,
endometriosis, tumors, cysts) are often painful. Therefore, women might elect steriliza-
tion 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 sur-
vey 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 ¼ 105),
NSFB participants were selected at random, which provided us with a unique opportun-
ity to examine the subset of nulliparous sterilized women within this nationally repre-
sentative sample. Second, we know of no other random sample studies that include
open-ended questions about reproductive choices, barriers, and regrets.
38 K. M. SHREFFLER ET AL.

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, 2016), 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 nullipar-
ous 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
4794 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 ¼ 7.86, Range ¼ 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
the average educational attainment of some college (M ¼ 14.96, SD ¼ 2.48). The aver-
age level of family income fell in the $40,000–$49,000 range (M ¼ 8.03, SD ¼ 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 sur-
gery that makes it difficult or impossible to have a baby?” where 1 ¼ yes and 0 ¼ no.
The wording of this question allowed for a broader measure of surgical sterilization
 WOMEN'S REPRODUCTIVE HEALTH 39

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 were assessed with a ques-
tion that asked whether the surgery prevented participants from having children that
they had wanted to have (1 ¼ yes; 0 ¼ 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 associ-
ated with something less than full “voluntariness,” but they may represent various
degrees of “involuntariness.” Those who felt pressured by others into surgical steriliza-
tion 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 et al.’s (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 ¼ 9), non-contraceptive
sterilization including situational (e.g., financial, age, and relationship) factors and health
problems (n ¼ 72), suggestion/pressure from others (n ¼ 14), and other reasons (n ¼ 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 types 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 ques-
tions asked participants: “We have asked you many questions. If you could change any-
thing 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, an indicator of the degree of vulnerability to bias and discrimination,
was assessed using standard questions and coding schemes based on U.S. Census rec-
ommendations, 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 resour-
ces, was an ordinal variable that ranged from 1 (lowest) to 12 (highest). Intimate part-
ner 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.
40 K. M. SHREFFLER ET AL.

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 (a ¼ 0.77 in the full sample). Importance of successful
career and importance of leisure are continuous variables (1 ¼ low importance and
4 ¼ high importance). Religiosity is a 4-item scale that includes questions about the
importance of religious beliefs and behaviors (a ¼ .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 sur-
vey responses, nationally representative sample) by employing a survey-driven narrative
construction technique (Kazyak et al., 2016). This approach entailed converting the sur-
vey 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 sur-
vey 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 expe-
riences 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 steril-
ization surgeries for many women. Similar to Kazyak et al. (2016), 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 catego-
ries 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 expe-
riences 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 the 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'S REPRODUCTIVE HEALTH 41

Table 1. Descriptive statistics for women who are nulliparous and sterilized by reason for
sterilization.
Total Voluntary Non-contraceptive Suggested pressure Other
(n ¼ 105) (n ¼ 9%) (n ¼ 69%) (n ¼ 13%) (n ¼ 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 0.75 1.89 0.40 2.71 0.73 2.73 0.63 2.50 0.88
Importance of career 3.50 0.76 3.89 0.33 3.37 0.84 3.77 0.44 3.44 0.73
Importance of leisure 3.48 0.74 3.89 0.33 3.49 0.70 3.38 0.87 3.11 0.93
Religiosity 0.93 3.04 2.37 3.37 0.61 3.02 1.47 2.74 0.08 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.

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 years across the
groups, and some women in all groups had experienced pregnancy, miscarriage,
and abortion.

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
42 K. M. SHREFFLER ET AL.

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 spe-
cialist 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, ela-
borated: “I had no interest in childrearing, baby-rearing, no interest in conceiving, hav-
ing, 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 rea-
sons 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 years 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 pre-
vented 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 years 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.
 WOMEN'S REPRODUCTIVE HEALTH 43

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 hysterec-
tomy. 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 hysterec-
tomy 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 expe-
riences. 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 chil-
dren, 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 rea-
son 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 partici-
pant, 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 paral-
lel time as life course transitions (or lack of transitions) in domains of life such as edu-
cation, 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 mother-
hood (McQuillan et al., 2008). Still, some health care providers might assume that any
44 K. M. SHREFFLER ET AL.

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 &
Gynecologists, 2017). Conversely, some women may experience ambivalence regarding
sterilizing surgeries and the desire to have children. Therefore, in our survey-driven nar-
rative 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 steriliza-
tion procedures, which included mostly hysterectomies but also some tubal ligation sur-
geries and treatments for cancer. Although some voluntarily childfree women opted for
sterilization to prevent pregnancy, others were sterilized for reasons other than contra-
ception, 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 nar-
ratives that reflect the “conversation” between the interviewer and the participant
(Kazyak et al., 2016), we would have focused more on encouraging open-ended com-
ments 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 counseling 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
 WOMEN'S REPRODUCTIVE HEALTH 45

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 childbear-
ing 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 (Br€ uderl et al., 2016). We know of no similar data in the
United States.
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 provide anchors for recall that could help women to recall accur-
ately 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 &
McMullin, 1999).
Finally, the sample size is small; nulliparous women who had been sterilized com-
prised less than 3% of the full representative sample. Still, although this number pre-
vents 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 regard-
ing the complex nature of the degree of voluntariness of both sterilization surgeries and
childlessness that would be difficult or impossible to discover through quantitative ana-
lysis alone. The richness of the NSFB dataset, including the use of open-ended data to
better explain survey responses, allows for a 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 child-
free and involuntarily childless. Researchers who categorize women into these groups
must be thoughtful about the distinctions. Among women who have not been sterilized,
46 K. M. SHREFFLER ET AL.

this is relatively easy in a large, nationally representative survey through fertility inten-
tions and desires measures. It is more difficult to categorize women who have com-
pleted 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 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, fib-
roids) occur (Sullivan, 2005). Our data cannot fully tease out, however, whether differ-
ences 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 neces-
sary 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’ recommenda-
tions 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 poten-
tially biased) treatment options that women are offered depending upon their
race/ethnicity.

Conclusions
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 steriliza-
tion 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 neces-
sarily convey whether women meet the criteria for being voluntarily childfree or invol-
untarily 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,
 WOMEN'S REPRODUCTIVE HEALTH 47

it is important for providers not to decide that they alone 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 & Gynecologists, 2017).

Disclosure statement
The authors have no conflict of interest to declare.

Author’s Note
The content is solely the responsibility of the authors and does not necessarily represent the
official view of the National Institutes of Health. An earlier version of this paper was presented
at the 2017 Population Association of America annual conference in Chicago, IL.

Funding
This research was supported by the National Institutes of Health [R01-HD044144 and
P20GM109097].

References
Abma, J. C., & Martinez, G. G. (2006). Childlessness among older women in the United States:
Trends and profiles. Journal of Marriage and Family, 68, 1045–1056.
American College of Obstetricians and Gynecologists. (2017). Opinion No. 695: Sterilization of
women: Ethical issues and considerations. Obstetrics and Gynecology, 129e, 109–116.
Br€
uderl, J., Hank, K., Huinink, J., Nauck, B., Neyer, F. J., Walper, S., et al. (2016). The German
family panel (pairfam) [GESIS Data Archive, Cologne, ZA5678 Data file Version 7.0.0].
Retrieved from https://www.pairfam.de/en/.
Bulcroft, R., & Teachman, J. (2004). Ambiguous constructions: Development of a childless or
childfree life course. In M. Coleman and L. H. Ganong (Eds.), Handbook of contemporary fam-
ilies. Newbury Park, CA: Sage Publications.
Connidis, I. A., & McMullin, J. A. (1999). Permanent childlessness: Perceived advantages and dis-
advantages among older persons. Canadian Journal on Aging/La Revue Canadienne du
Vieillissement, 18(4), 447–465.
Daniels, K., Daugherty, J. D., & Jones, J. (2014). Current contraceptive status among women aged
15–44: United States, 2011–2013. NCHS Data Brief, 173, 1–8.
Elder, G. H., Jr., Johnson, M. K., & Crosnoe, R. (2003). The emergence and development of life
course theory. In J. T. Mortimer & M. J. Shanahan (Eds.), Handbook of the life course
(pp. 3–19). York, UK: Kluwer/Plenum.
Elson, J. (2008). Am I still a woman? Hysterectomy and gender identity. Philadelphia, PA: Temple
University Press.
Emerson, R., Fretz, R., & Shaw, L. (1995). Writing ethnographic fieldnotes. Chicago, IL: University
of Chicago Press.
England, P. (2016). Sometimes the social becomes personal: Gender, class, and sexualities.
American Sociological Review, 81(1), 4–28.
Groves, R. M., Mosher, W. D., Lepkowski, J. M., & Kirgis, N. G. (2009). Planning and develop-
ment of the continuous National Survey of Family Growth. Vital and Health Statistics, 1(48),
1–64.
48 K. M. SHREFFLER ET AL.

Ireland, M. S. (1993). Reconceiving women: Separating motherhood from female identity. New
York, NY: Guildford Press.
Johnson, D. R., McQuillan, J., Jacob, M. C., Greil, A. L., Lacy, N., & Scheuble, L. K. (2009).
National Survey of Fertility Barriers methodology report. Lincoln, NE: Bureau of Sociological
Research.
Johnson, K. M., Greil, A. L., Shreffler, K. M., & McQuillan, J. (2018). Fertility and infertility:
Toward an integrative research agenda. Population Research and Policy Review, 37(5), 641–666.
Kazyak, E., Park, N., McQuillan, J., & Greil, A. L. (2016). Attitudes toward motherhood among
sexual minority women in the United States. Journal of Family Issues, 37(13), 1771–1796.
Lechner, L., Bolman, C., & Van Dalen, A. (2007). Definite involuntary childlessness: Associations
between coping, social support, and psychological distress. Human Reproduction, 22(1),
288–294.
McQuillan, J., Greil, A. L., Shreffler, K. M., Gentzler, K. C., Hill, P. W., & Hathcoat, J. (2012).
Does the reason matter? Childlessness specific distress among US women. Journal of Marriage
and Family, 74(5), 1166–1181.
McQuillan, J., Greil, A. L., Shreffler, K. M., & Tichenor, V. (2008). The importance of mother-
hood among women in the contemporary United States. Gender & Society, 22, 477–496.
Meier, S., Sundstrom, B., DeMaria, A. L., & Delay, C. (2019). Beyond a legacy of coercion: Long-
acting reversible contraception (LARC) and social justice. Women’s Reproductive Health, 6(1),
17–33.
Powell, B. C., Alabaster, A., Simmons, S., Garcia, C., Martin, M., McBride-Allen, S., & Littell,
R. D. (2017). Salpingectomy for sterilization: Change in practice in a large integrated health
care system, 2011–2016. Obstetrics & Gynecology, 130(5), 961–967.
Schwerdtfeger, K. L., & Shreffler, K. M. (2009). Trauma of pregnancy loss and infertility among
mothers and involuntarily childless women in the United States. Journal of Loss and Trauma,
14(3), 211–227.
Shoupe, D. (2016). LARC methods: Entering a new age of contraception and reproductive health.
Contraceptive and Reproductive Medicine, 1(4). doi:10.1186/s40834-016-0011-8
Shreffler, K. M., McQuillan, J., Greil, A. L., & Gallus, K. L. (2016). Reasons for tubal sterilization,
regret, and depressive symptoms. Journal of Reproductive and Infant Psychology, 34(3),
304–313.
Shreffler, K. M., McQuillan, J., Greil, A. L., & Johnson, D. R. (2015). Surgical sterilization, regret,
and race: Contemporary patterns. Social Science Research, 50, 31–45.
Sullivan, R. (2005). The age pattern of first-birth rates among U.S. women: The bimodal 1990s.
Demography, 42(2), 259–273.
Umberson, D., Pudrovska, T., & Reczek, C. (2010). Parenthood, childlessness, and well-being: A
life course perspective. Journal of Marriage and Family, 72(3), 612–629.
Wager, M. (2000). Childless by choice? Ambivalence and the female identity. Feminism &
Psychology, 10, 389–395.