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OBJECTIVE: To evaluate the long-term effect of tubal sterilization on menstrual indices and pelvic pain. METHODS: Five hundred women undergoing sterilization were interviewed before sterilization, 6-10 months after surgery, and 3-4.5 years later. Four hundred sixty-six non-sterilized comparison women were interviewed in parallel. The study population consisted of low-income, ethnically and regionally diverse women from three participating institutions. RESULTS: When women who were taking oral contraceptives were excluded, no long-term differences was found between sterilized and nonsterilized women in terms of menstrual cycles, bleeding between periods, prolonged or heavy flow, dysmenorrhea, or noncyclic pelvic pain. Hysterectomy was uncommon (3.2%), but statistically more prevalent among sterilized women (4.55%) than nonsterilized women (2.17%) (P = .019). CONCLUSIONS: Tubal sterilization has no long-term effect on menstrual indices or pelvic pain. An increase in severe dysmenorrhea, which emerged as a disturbing but nonsignificant trend at 6-10 months, did not progress over the next 3-4.5 years. Reasons for an increased rate of hysterectomy are not clear, but may be related to a lower threshold for choosing hysterectomy as a treatment option once a woman has been sterilized.

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Changes in menstrual parameters after tubal sterilization were analyzed in ethnically diverse, poor women from three geographic areas in the United States. Two large suitable comparison groups were similarly studied. Menstrual cycles, duration of menstrual flow, and bleeding between periods were unchanged in the sterilization and comparison groups. The prevalence of dysmenorrhea increased in 10.8% of sterilized women, compared with 2.1% in the comparison groups. This difference was even more significant--16.4 and -0.5%--when usage of oral contraceptives and intrauterine devices was discounted. There was a nonsignificant increase in noncyclic pelvic pain.

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Among a group of low-income clinic patients planning to be sterilized, the vast majority--95 percent--reported believing that sterilization is the surest way to avoid getting pregnant and that it is safer than other contraceptive methods. Among a comparison group who also wanted no more children but did not plan to be sterilized, the majority also held these beliefs, but the proportion was lower (76-80 percent). In both groups, however, only between 64 and 70 percent knew that sterilization makes it impossible to have children in the future. Between 63 and 68 percent of the women in the sterilization group believed that having the operation would improve their family relationships, emotional state and other aspects of their lives, but only 35-58 percent of the comparison group held these beliefs. On the other hand, women in the comparison group were more likely than those in the sterilization group to believe that sterilization has negative health and psychological effects--for example, changes in menses (more bleeding or cramping) or defeminization. The beliefs held by both groups suggest that it is a conviction regarding the advantages of sterilization, rather than a relative unawareness of the disadvantages, that distinguishes women who plan to be sterilized from those who, although they want no more children, do not have similar plans. The study results have implications for family planning professionals: Counselors need to be aware that some women seeking sterilization may not understand its permanency or may have an unrealistic appraisal of its potential effect on their lives.(ABSTRACT TRUNCATED AT 250 WORDS)

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This study sought to determine how teenagers' actual and perceived probabilities of pregnancy are related. Data were collected from interviews with 425 women aged nineteen or younger who attended the Door, a multiservice center for youth in New York City. Subjects were asked to estimate their likelihood of becoming pregnant the last time they had intercourse, and to indicate the dates of both last intercourse and last menstrual period in order to determine their objective and subjective assessments of risk of pregnancy. It was found that the perceived probability of pregnancy was not highly correlated with actual risk: the distributions of perceived probability of pregnancy were nearly identical for both those who were and were not at actual risk. Moreover, respondents' level of knowledge about the timing of ovulation was not significantly related to the accuracy of their risk assessment. The findings also indicate that teenagers' use of contraception is guided more by their perceived risk of pregnancy than by the actual risk. Policy implications are discussed.

PIP: The relation between teenagers' actual and perceived probabilities of pregnancy was investigated. Data were collected from interviews with 425 women aged 19 or younger, who attended The Door, a multiservice center for youth in New York City. Subjects were asked to estimate their likelihood of becoming pregnant the last time they had intercourse, and to indicate the dates of both their last intercourse and last menstrual period, in order to determine both their objective and subjective risk of pregnancy. The perceived probability of pregnancy was not highly correlated with actual risk: the distributions of perceived probability were nearly identical for both those who were and who were not at actual risk. Less than 1/2 the sample correctly perceived their risk of pregnancy. About 1/3 correctly thought they not at risk for pregnancy at last coitus, and 15% were accurate in thinking that they were at risk. However, 40% incorrectly thought they were at risk for pregnancy, the "worries," and 14% thought incorrectly that they were not at risk for pregnancy, the "dangerousy misinformed." Moreover, respondents' level of knowledge about the timing of ovulation was not significantly related to the accuracy of their risk assessment. Teenagers' use of contraception is guided more by their perceived risk of pregnancy than by the actual risk. These findings offer additional evidence for educational efforts that go beyond providing information about ovulation; such interventions should teach teenagers how to apply this knowledge to themselves and emphasize that there really is no "safe period" for unprotected intercourse.

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A program model outlining goals and objectives and activities or processes by which these goals will be reached is essential to ensure effective evaluation of a contraceptive program for adolescents.

PIP: This article discusses methods of evaluating adolescent contraceptive programs in order to improve their effectiveness. Development of specific goals, and objectives and processes by which these goals will be reached is essential in constructing a program model that is evaluable. The creation of the model should include program input, processes, output, and primary, intermediate and long term effects. Such a model can then be used to evaluate whether goals are being accomplished in addition to commonly used data collection systems such as service statistics. Special sampling studies can be utilized to assess changes in patient knowledge and attitudes. Methods of measuring various indicators such as clinic attendance, contraceptive continuation, and method continuation are described. Problems in defining and calculating pregnancy rates as well as measures for program continuation is discussed. An effective program model necessitates cooperation from administrators, service providers, and evaluators in facilitating program implementation and evaluation. Internal obstacles to the model, such as staff resistance to data collection, present a challenge to evaluators and requires that necessary paperwork be simplified and well-organized.

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During the past decade, much has been written about adolescents' use of contraception and their experience of pregnancy. Few researchers, however, have distinguished between the experiences of older and younger adolescents. The purpose of this paper is to provide such a comparison. The data were collected during more than 7,000 visits made by 4,318 patients during almost 5 years of operation of an adolescent contraceptive service in the Washington Heights area of New York City. Characteristics of four groups--14 years and younger, 15-17 years, 18-19 years, and 20-21 years--were examined. The youngest teens initiated sexual intercourse 4 years earlier than the oldest group. Among those 14 or younger, 87 percent had never used contraception, and 9 percent had been pregnant. In the oldest group, more than two-thirds had used a contraceptive method, and three-fifths had already experienced a pregnancy. Results of multivariate analyses indicate that older teens are more likely to come to the clinic for contraception and to be consistent users of the first method of contraception that they select. On the other hand, younger teens are significantly more likely to revisit the clinic and to be pregnant at a second or later visit.

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This paper reviews social science research on the antecedents and consequences of voluntary sterilization. The major conclusions are that socioeconomic status has little impact on the decision to be sterilized and that sterilizations are rare among those without sons and among male non-whites. Significant others are important sources of encouragement and information, and good marital relations increase the likelihood of having the procedure performed. Most acceptors experience no change in sexual activity, quality of marital relationships, or work-related behavior, and few regret their choice. Negative consequences are more likely among those in India, those coerced into having a sterilization, those who did not understand the consequences of the procedure, those with health complications after sterilization, and those couples who have unstable marriages or who disagree about sterilization.

PIP: This paper reviews social science research on the antecedents and consequences of voluntary sterilization. The major conclusions are that socioeconomic status has little impact on the decision to be sterilized and that sterilizations are rare among those without sons and among male nonwhites. Significant others are important sources of encouragement and information, and good marital relations increase the likelihood of having the procedure performed. Most acceptors experience no change in sexual activity, quality of marital relationships, or work-related behavior, and few regret their choice. Negative consequences are more likely among those in India, those coerced into having a sterilization, those who did not understand the consequences of the procedure, those with health complications after sterilization, and those couples who have unstable marriages or who disagree about sterilization. An inverse relationship between sterilization and socioeconomic status seems to result when other methods of contraception are not easily available to those of lower socioeconomic status. In other instances the procedure appears to be 1st adopted in upper socioeconomic groups and then these groups are emulated in the lower classes. Very few couples without children or with only 1 child have voluntary sterilizations. On the other hand, most sterilizations occur among high parity couples. Religion does not appear to be an influential factor in choosing sterilization. Although it may not effect individual behavior, some religious institutions' opposition to sterilization may effect its availability,e.g. in countries where Catholicism or Islam dominate. The frequency of female sterilization is about the same among blacks, whites and Hispanics, although a little higher for blacks and Hispanics. The low rate of sterilization among black and Hispanic men is usually explained by a culture value, e.g. the relationship between ability to conceive and masculinity. The 3 major motivations for being sterilized are: financial, completed family size and dislike of other contraceptive methods. Research has not yet shown the importance of attitudinal and personality correlates of voluntary sterilization. The most consistent personality factor is that sterilized men have a lower than average need for social approval. Data support the hypothesis that there may be hidden impacts of sterilization that have been only infrequently captured. Some studies showed decreased sexual functioning and elevated levels of psychological disturbance among men who reported being satisfied with their vasectomies.

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PIP: Compares characteristics of teenage patients attracted to a traditional family planning clinic and an adolescent oriented clinic, and studies the success of each in promoting contraceptive use. Data were collected from 2 clinics operating in the same physical site in an urban hospital. The traditional family planning clinic (Day Clinic) serves both teenage and older women. The Young Adult Clinic (YAC) serves only patients 21 or younger and operates 2 evenings a week. The 2 clinics have an overlapping staff and medical services are identical in each, except that patients of the YAC are offered counseling, and admission to the clinic is simplified. The data from each clinic covers 2 years. Results show that the most important difference between the clinics is that the YAC attracts 3 1/2 times as many teens as the Day Clinic. Different background characteristics of the patients account for differences in contraceptive method utilization, revisit patterns, and pregnancy rates within the 2 clinics, rather than clinic differences. YAC patients are likely to be younger, and less likely to have been pregnant before. Thus, the YAC offers more of an opportunity for primary prevention of pregnancy. The authors concluded that the major benefit of offering an adolescent only evening clinic lies in its ability to attract young women who might not otherwise receive services.^ieng

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PIP: Documents nurse midwives' role in providing contraceptive and counseling services to young people who are most at risk for unwanted pregnancy. Data studied is from a clinic which operates during the late afternoon and early evening in an urban hospital. A physician is responsible for the overall supervision of the clinic, but nurse midwives play a major role in patient care and provision of services. The data compares nurse midwives and physicians in the clinic with regard to patient load, characteristics, contraceptive methods chosen, revisit patterns, and problems. Patients of both nurse midwives and physicians had similar characteristics and past histories. Findings show that nurse midwives often carry the largest share of the patient load and have maintained slightly higher revisit rates and similar oral contraceptive continuation rates, in comparison with physicians. Most important, patients of nurse midwives are no more likely than those of physicians to report method related problems. The lack of significant differences is regarded as encouraging. This suggests that nurse midwives can play a valuable role in the increasing number of counseling and contraceptive programs for young people.^ieng

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The data included in this paper demonstrate that the Hoffman scheme for conceptualizing the values of children applies about as well to responses from children aged 10 to 18 as it does to the responses of adults. Some of the same variables related to adult perceptions of values of children show similar relationships among children. Data are included from both mothers and children in the families sampled. Alternative wording of the questions about the values of children indicates that while children and mothers may be aware of the dominant cultural values, they may not have internalized these for themselves.

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Since there are data to indicate that the composition of clinic staff is important in attracting and maintaining contact with adolescents seeking contraceptive services, in this paper the importance of age, sex, and ethnicity of counselors and medical providers is examined. Female clients of the Young Adult Clinic at Columbia-Presbyterian Hospital, New York City--most of them low-income blacks or Hispanics--were asked to complete questionnaires. The 150 respondents, aged 16-21 years, used a 4-point rating scale of very important = 4 to not important at all = 1. The findings indicated that the sex of the counselor and examiner was more important to female teenagers than ethnicity or age. Clinic administrators seeking to provide contraceptive services to teenagers should make an effort to include at least one female counselor and medical provider. However none of these characteristics was very important to the majority of patients. These findings are discussed in the context of the literature on the provision of contraceptive services to teenagers and on patient preferences for counselors or therapists in general.

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This paper critically reviews the effectiveness of adolescent family planning programs in the United States. Various models for evaluating family planning programs and the findings from empirical studies of adolescent programs are reviewed. During the past decade there have been major increases in the availability and utilization of contraceptive services by adolescents. Most of those who are sexually active are now aware that these services exist. Program continuation rates among adolescents are not high, in part, because of the sporadic nature of adolescent sexual activity. Data on contraceptive continuation and pregnancy rates in these programs are limited, since few studies follow up clinic noncontinuers. Among clinic continuers pregnancy rates are relatively low, suggesting that at least some programs are effective in reducing pregnancy and/or fertility rates (number of children born) in their target populations. Ecological analyses seem to indicate that programs have had an impact on adolescent marital fertility.

PIP: This article briefly reviews the literature on methods of evaluating international family planning programs and uses the findings as a framework for summarizing available information on the effectiveness of adolescent contraceptive programs in the U.S. Current models for evaluating contraceptive programs usually employ systems approaches, with increasing emphasis being placed on global impacts such as lower fertility or socioeconomic change. Recent empirical studies of adolescent programs in the U.S. have provided information on the aviailability and utilization of services, changes in knowledge levels of adolescents, clinic and contraceptive continuation, and pregnancy rates and fertility. Major increases have occurred in the past decade in knowledge and use of services by teenagers, but program continuation rates are not high because of the sporadic nature of adolescent sexual activity. Few studies follow up clinic noncontinuers, limiting available data on contraceptive continuation and pregnancy rates. Studies of the impact of family planning programs on adolescent fertility using varied methodologies suggest that at least some programs are effective in reducing pregnancy or fertility rates among teenagers. A comprehensive evaluation model for adolescent programs is needed which adapts existing frameworks to the particular interests and needs of adolescent services, addressing such problems as the high proportion of sexually active teenagers not receiving services, inadequate knowledge of pregnancy risks and contraceptive usage, late approach to clinic services, and sporadic use of contraception.

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Telephone survey data gathered from residents of a New York City neighborhood indicate that Hispanics are significantly less likely to approve of sex education for adolescents than are either blacks and whites. Hispanics also perceive the appropriate ages for sex education to be older, and are more conservative about the topics and places for sex education than are the other ethnic groups. These differences remain after controls are introduced for sex, age, religion, education, number of children in the household, family income, or perception of teenage pregnancy as a problem. Age and education, however, are also important predictors of attitudes toward sex education.

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PIP: Results of an evaluation of the impact of 1 of 4 population education units offered as part of the 9th grade urban studies curriculum in the Baltimore City school system are reported. The theme of the unit, called B-more or Baltimore, is that Baltimore City has qualities and problems similar to those of other urban areas but is also unique. 908 students exposed to the B-more unit and 205 controls participated in the evaluation in the fall of 1978. Gathering of demographic information on students participating in the evaluation was restricted. The impact of the B-more unit was measured along knowledge, attitude and behavior dimensions through written questionnaires and verbal interview questions. The unit was found to have succeeded in increasing knowledge about Baltimore's resources, increasing ability to utilize these resources, and teaching basic population and urban concepts. Students exposed to the B-more unit were more knowledgeable about their urban environment as illustrated by mapping tasks, and the majority reported that they had learned things that were new and/or important to them from the curriculum. B-more students had more positive attitudes toward the Baltimore suburbs than control students and more negative attitudes toward population growth. Little evidence was noted of changes in behavior resulting from the B-more unit. Recommendations are offered for strengthening the B-more unit and its impact on students.^ieng

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PIP: The author comments on the lack of evaluation of population education, and argues that such work has been stalled by confusion over what population education is and what it is supposed to do. Contradictory opinions about what is to be included in or excluded from the definition of population education, and whether it should be "value-fair" or "value-based" are cited, as well as various opinions concerning whether the impact should be measured in terms of a difference in knowledge, attitudes, or behavior, over a long or short period. The author suggests that evaluation requires a series of research choices, and proposes a framework for guiding evaluation wherein choices may be made in several dimensions to specify exactly what is being evaluated.^ieng

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PIP: While the best data at present indicate that adolescent fertility is declining in the developing world, it is still very high relative to the developed world. Access by teenage women to family planning information does not seem to be restricted (except in the cases of abortion and sterilization), if only because much of adolescent fertility takes place in marriages or other sanctioned unions, nor is there much evidence that they are proportionally underrepresented as family planning acceptors. However, services are rarely designed to meet the special needs of young clients. The health and social consequences of adolescent childbearing are a major cause of concern. High maternal, neonatal, and infant mortality have been documented, and U.S. studies show that teenage mothers suffer education and income deficits. Future trends toward urbanization seem likely to exacerbate these problems, and the large number of people entering adolescence in the developing world could have a major demographic effect. In the U.S., recognition of the need for special services to teenagers only became a high priority when teenage fertility had reached 20% of total births. It appears that reassessment of the low priority now being given to adolescent fertility in the developing countries is in order.^ieng

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PIP: Although surveys have documented the ignorance of American teenagers on sexual matters, and other data suggest that a substantial segment of the public favors a sex education program in the schools, implementation has been limited. A questionnaire designed to test the feelings of public school teachers, students and community members was undertaken in a stable, conservative town of 1000 in Ohio. Respondents were asked to indicate which of 17 sex education topics should be included in a curriculum, the appropriate grade level for each, and whether each should be required or elective. They also ranked potential types of instructors, indicated interest in adult sex education, and rated desirability of student-parent and coeducational classes. The 1st choice for teacher type was a "sex education specialist," followed by a physician. Slightly over 1/2 of teachers favored parent-child sex education classes, but fewer than 25% of students did. Almost 2/3 of students favored coed classrooms for sex education, while 47.5% of teachers, about 1/3 of parents of school-age children, and fewer than 1/4 of persons without school-age children saw this as desirable. Teachers were most in favor of adult sex education (83.8%), and nearly 2/3 of all adults responded positively. A majority of all respondents favored including all 17 topics listed in a curriculum, but modal percentages of parents and persons without school-age children favored dropping masturbation and abortion from the sex education classroom, and homosexuality and premarital sexual relationships also met substantial opposition. Most groups agreed that with few exceptions sex education topics were most appropriate for grades 7-9. Although an expected strong resistence to sex education was not found, cautious administrators can find a number of reasons to avoid implementing sex education.^ieng

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PIP: The purpose of this paper is the examination of use and awareness of population education materials among 2 national samples of population education teachers. A 1974 sample included 593 teachers taken from 3 sources: participants in workshops, institutes, and training programs in population education between 1971-73; subscribers to the Population Reference Bureau publication, "Interchange," and population educators named by principals in a random sample of 1000 secondary schools. A 1976 survey sampled from lists of secondary school teachers maintained by the National Science Teachers Association, stratified to reflect national proportions of teachers of general science, environmental and earth science, social studies, and biology. Both surveys used mail questionnaires, with response rates of 47 and 46% resepctively. Educators were asked about their use and awareness of 20 population education materials (2 bogus materials were also included to check for overstatement). Data were also gathered form publishers of the materials to assess the availability and dissemination strategies of these materials. The inescapable conclusion is that, with few exceptions, these materials are finding little use in U.S. secondary school classrooms. The majority of the actual materials were reportedly used less than the bogus materials. Some evidence was found that suggest that training of teachers in population education increases to some degree the utilization of the materials. If dissemination of population materials is to be successful, materials have to be provided to larger numbers of teachers and instruction must be given on how best to utilize them within already established curricula.^ieng

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