How, when, and who should ask about pregnancy intentions in primary care? A qualitative study of women's preferences.

BACKGROUND: For health services to help people plan for or prevent pregnancy, health professionals need an acceptable way to identify individuals' preferences. OBJECTIVE: To assess women's views on the acceptability of specific questions about pregnancy preferences when asked by health professionals in a variety of primary care contexts. METHODS: One-to-one in-depth interviews with 13 women aged 18-48 from across the UK, involving role-play scenarios and ranking exercises. Interviews covered a range of settings and health professionals, different question wording, and ways of asking (in person or digitally). We conducted a thematic Framework Analysis, focussing on themes relating to feelings and preferences. RESULTS: Women were generally open to being asked about pregnancy preferences if they understood the rationale, it was asked in a relevant context, such as in women's health-related consultations, and there was follow-up. After signposting, an open question, such as 'How would you feel about having a baby in the next year?' was preferred in a face-to-face context as it enabled discussion. While some women valued a face-to-face discussion with a health professional, for others the privacy and convenience of a digital option was preferred; methods should be tailored to the target population. CONCLUSION: Discussion of pregnancy preferences via a range of formats is acceptable to, and valued by, women in the UK across a range of primary care settings. Acceptability to health professionals and feasibility of implementation needs further exploration and would benefit from greater public awareness of the benefits of pregnancy planning.

Comparing reproductive intentions before and during the COVID-19 pandemic: a cross-sectional study.

BACKGROUND AND AIM: Reproductive behaviors and intentions are affected by several factors, including the COVID-19 pandemic crisis. This study was conducted with the aim of comparing the intention to reproduce and its causes in Iran during the period prior to and during the COVID-19 pandemic. METHODS: This descriptive-comparative study included 425 cisgender women from 6 urban health centers and 10 rural centers in Babol city, Mazandaran province, Iran. Urban and rural health centers were selected using a multi-stage approach with proportional allocation. A questionnaire was used to collect data in relation to individual characteristics and reproductive intentions. RESULTS: Most participants aged between 20 and 29 years had a diploma level of education, were housewives and lived in the city. The intention to reproduce decreased from 11.4% before the pandemic to 5.4% during the pandemic (p = 0.006). The most common reason for wanting to have children prior to the pandemic was not having children (54.2%). During the pandemic, a desire to reach the ideal number of children was the most common reason to want to have children (59.1%), though no statistically significant difference was observed between the two periods (p = 0.303). The most common reason for not wanting to have children in both periods was having enough children already (45.2% before and 40.9% during the pandemic). The reasons for not wanting to have children had a statistically significant difference between the two periods (p < 0.001). Reproductive intentions had a statistically significant relationship with the variables of age (p < 0.001), the education level of both participants (p < 0.001) and spouses (p = 0.006), occupation (p = 0.004), and socio-economic status (p < 0.001). CONCLUSION: Despite restrictions and lockdowns, the COVID-19 pandemic had a negative impact on people's desire to reproduce in this context. Economic problems caused by the sanctions which increased during the COVID-19 crisis may be one of the reasons for a reduction in people's intentions to become parents. Future research could usefully investigate whether this decrease in the desire to reproduce will lead to significant changes in population level and future birth rates.

What does family building mean? A qualitative exploration and a new definition: a UK-based study.

BACKGROUND: The importance of improving men's and women's knowledge of sexual and reproductive health has been emphasised in numerous global health policies. Fertility awareness literature highlights a disproportionately higher number of articles related to pregnancy-prevention compared to pregnancy-planning, which is justifiable in many contexts. However, recent concerted effort to improve fertility-awareness warrants a closer investigation of basic reproductive health terminologies. The objective of this study is to explore participants' views of "family building" and provide a definition. METHODS: We conducted 35 qualitative in-depth interviews on men, women and healthcare professionals who were sampled from a UK cross-sectional survey. We asked participants about terms such as 'family planning' and 'family building' to elicit views and explored the appropriateness of the term "family building." Data were transcribed and analysed via Framework analysis. RESULTS: When asked what 'family planning' meant to them, study participants stated that the term meant the avoidance of pregnancy. They viewed it as an "umbrella term for the use of contraception methods," that "paradoxically, the term family planning almost has a negative connotation regarding having a family," but could not state similar terminology for planning a family. Reasons cited for this perspective include the focus of school education and usage in clinical settings. CONCLUSIONS: In the absence of an explicit definition in literature, we generated a new definition for family building as follows: "Family building refers to the construction or formation of a family, which can include steps or actions taken by an individual towards having children. In contrast to family planning, the intent focuses on pregnancy planning and childbearing rather than pregnancy prevention. However, it can also include actions taken to space the number of children one has." Some balance in the global public health messages, including bridging the gap in reproductive health literature, policies, processes and practices may contribute to the effort to improve fertility knowledge. Use of appropriate terminologies help optimise reproductive health services in order to enable men and women achieve their desired fertility intentions, whatever they may be. Trial registration Not applicable.

Global health policies have emphasised the importance of improving individual's knowledge of sexual and reproductive health. Fertility awareness literature highlights a disproportionately higher number of articles related to pregnancy-prevention compared to pregnancy-planning, which is justifiable in many contexts. However, the recent concerted effort to improve fertility awareness warrants a closer investigation of basic terminologies in the field. For example, although the term family planning encompasses attaining the desired number of children and spacing pregnancies, it is almost synonymous with not having children, while there is currently no widely accepted equivalent terminology for planning to have children, either in general usage or clinical settings. We conducted 35 qualitative in-depth interviews on men, women and healthcare professionals who were sampled from a UK cross-sectional survey. When asked what 'family planning' meant to them, study participants stated avoidance of pregnancy. They viewed it as an "umbrella term for the use of contraception methods", that "paradoxically, the term family planning almost has a negative connotation regarding having a family," but could not state similar terminology for planning a family. We introduced family building and provided a new definition. We believe that some balance in the global public health messages, including revisiting widely used terminologies can help bridge the gap in reproductive health literature, and contribute to the effort to improve fertility knowledge. Additionally, this has implications for promotion of preconception and optimising reproductive health in relevant policies, processes and practices, in order to help people achieve their desired fertility intentions, whatever they may be.

Declining realisation of reproductive intentions with age.

STUDY QUESTION: What is the likelihood of having a child within 4 years for men and women with strong short-term reproductive intentions, and how is it affected by age? SUMMARY ANSWER: For women, the likelihood of realising reproductive intentions decreased steeply from age 35: the effect of age was weak and not significant for men. WHAT IS KNOWN ALREADY: Men and women are postponing childbearing until later ages. For women, this trend is associated with a higher risk that childbearing plans will not be realised due to increased levels of infertility and pregnancy complications. STUDY DESIGN, SIZE, DURATION: This study analyses two waves of the nationally representative Household, Income and Labour Dynamics in Australia (HILDA) survey. The analytical sample interviewed in 2011 included 447 men aged 18-45 and 528 women aged 18-41. These respondents expressed a strong intention to have a child in the next 3 years. We followed them up in 2015 to track whether their reproductive intention was achieved or revised. PARTICIPANTS/MATERIALS, SETTINGS, METHODS: Multinomial logistic regression is used to account for the three possible outcomes: (i) having a child, (ii) not having a child but still intending to have one in the future and (iii) not having a child and no longer intending to have one. We analyse how age, parity, partnership status, education, perceived ability to conceive, self-rated health, BMI and smoking status are related to realising or changing reproductive intentions. MAIN RESULTS AND THE ROLE OF CHANCE: Almost two-thirds of men and women realised their strong short-term fertility plans within 4 years. There was a steep age-related decline in realising reproductive intentions for women in their mid- and late-30s, whereas men maintained a relatively high probability of having the child they intended until age 45. Women aged 38-41 who planned to have a child were the most likely to change their plan within 4 years. The probability of realising reproductive intention was highest for married and highly educated men and women and for those with one child. LIMITATIONS, REASONS FOR CAUTION: Our study cannot separate biological, social and cultural reasons for not realising reproductive intentions. Men and women adjust their intentions in response to their actual circumstances, but also in line with their perceived ability to have a child or under the influence of broader social norms on reproductive age. WIDER IMPLICATIONS OF THE FINDINGS: Our results give a new perspective on the ability of men and women to realise their reproductive plans in the context of childbearing postponement. They confirm the inequality in the individual consequences of delayed reproduction between men and women. They inform medical practitioners and counsellors about the complex biological, social and normative barriers to reproduction among women at higher childbearing ages. STUDY FUNDING/COMPETING INTEREST(S): This research was partly supported by a Research School of Social Sciences Visiting Fellowship at the Australian National University and an Australian Research Council Discovery Project (DP150104248). Éva Beaujouan's work was partly funded by the Austrian Science Fund (FWF) project 'Later Fertility in Europe' (Grant agreement no. P31171-G29). This paper uses unit record data from the HILDA Survey. The HILDA Project was initiated and is funded by the Australian Government Department of Social Services (DSS) and is managed by the Melbourne Institute of Applied Economic and Social Research (Melbourne Institute). The findings and views reported in this paper, however, are those of the authors and should not be attributed to either DSS or the Melbourne Institute. The authors have no conflicts of interest.

An Approach to Developing a Prediction Model of Fertility Intent Among HIV-Positive Women and Men in Cape Town, South Africa: A Case Study.

As a 'case-study' to demonstrate an approach to establishing a fertility-intent prediction model, we used data collected from recently diagnosed HIV-positive women (N = 69) and men (N = 55) who reported inconsistent condom use and were enrolled in a sexual and reproductive health intervention in public sector HIV care clinics in Cape Town, South Africa. Three theoretically-driven prediction models showed reasonable sensitivity (0.70-1.00), specificity (0.66-0.94), and area under the receiver operating characteristic curve (0.79-0.89) for predicting fertility intent at the 6-month visit. A k-fold cross-validation approach was employed to reduce bias due to over-fitting of data in estimating sensitivity, specificity, and area under the curve. We discuss how the methods presented might be used in future studies to develop a clinical screening tool to identify HIV-positive individuals likely to have future fertility intent and who could therefore benefit from sexual and reproductive health counseling around fertility options.

Oocyte cryopreservation for social reasons: demographic profile and disposal intentions of UK users.

A small number of studies from the USA and Europe have provided some data on the profile and characteristics of women who have undergone oocyte cryopreservation for what has been termed elective, social or non-medical reasons; however, little is known in a UK context about which women are undergoing oocyte cryopreservation or their reproductive intentions and actions after the procedure. Drawing on data from an exploratory study of 23 UK resident women who had undergone social oocyte cryopreservation, the demographic profile of these women, their reproductive intentions and actions are discussed, as well as their attitudes and intentions towards their cryopreserved oocytes should they never require them in treatment. The study found that, at the time of oocyte cryopreservation, women were on average 36.7 years of age, were university educated, with 65% of the sample holding further postgraduate or professional qualifications. Fifty-seven per cent of the participants were in professional employment. All participants identified as heterosexual and 87% were not in a relationship at the time of cryopreserving their oocytes. Most (88%) participants stated that they would donate unwanted oocytes to research or to other women for use in fertility treatment should they never require them.

Informed reproductive decision-making: the impact of providing fertility information on fertility knowledge and intentions to delay childbearing.

OBJECTIVE: To examine the impact of providing fertility information on personal levels of fertility knowledge and intentions to delay childbearing. METHODS: Participants (n=69 young childless women) were randomly assigned to either an experimental (fertility-related) or control (alcohol-related) informational intervention group. Subsequent to the exposure to information, participants completed a questionnaire measuring fertility knowledge and intentions for reproduction. We predicted that the provision of fertility-related information would result in greater fertility knowledge and less intention to delay childbearing among young childless women. RESULTS: The young women exposed to the brief fertility information intervention were significantly more likely to respond correctly to questions testing their fertility knowledge, and reported less intention to delay childbearing than the young women in the control group. CONCLUSION: This study provided evidence that providing fertility-related information contributes to greater reproductive knowledge and may affect childbearing intentions. Future research is warranted to examine the influence of fertility information on reproductive decision-making within a theoretical framework in order to ensure that subsequent information interventions maximize their effectiveness.

Objectif : Examiner les effets de l'offre de renseignements en matière de fertilité sur les niveaux personnels de connaissances au sujet de la fertilité et sur les intentions de différer la grossesse. Méthodes : Les participantes (n = 69 jeunes femmes sans enfants) ont été affectées au hasard à un groupe d'intervention informationnelle expérimental (traitant de fertilité) ou témoin (traitant d'alcool). À la suite de leur exposition aux renseignements, les participantes ont rempli un questionnaire mesurant les connaissances en matière de fertilité et les intentions en matière de procréation. Nous avions prédit que l'offre de renseignements traitant de fertilité entraînerait une amélioration des connaissances au sujet de la fertilité et une atténuation de l'intention de reporter la grossesse chez les jeunes femmes sans enfants. Résultats : Les jeunes femmes exposées à une brève intervention informationnelle traitant de fertilité ont été considérablement plus susceptibles de répondre correctement aux questions visant leurs connaissances au sujet de la fertilité; de plus, elles étaient moins susceptibles de signaler une intention de reporter la grossesse que les jeunes femmes du groupe témoin. Conclusion : Les données issues de cette étude indiquent que l'offre de renseignements traitant de fertilité contribue à l'amélioration des connaissances au sujet de la procréation et pourrait influencer les intentions en ce qui concerne la grossesse. La tenue d'autres recherches s'avère justifiée pour examiner l'influence des renseignements traitant de fertilité sur le processus décisionnel en matière de procréation dans un cadre théorique, de façon à ce que l'on puisse s'assurer que les interventions informationnelles subséquentes maximisent leur efficacité.

The impact of the COVID-19 pandemic on reproductive intentions and contraceptive use among females in Jeddah, Saudi Arabia.

OBJECTIVE: Pandemics have affected many people's social and emotional lives. Conception planning, contraceptive usage, and pregnancy intentions are activities with minimal research. This study is the first to evaluate how the COVID-19 pandemic influenced reproductive plans and contraceptive use among women during the pandemic in Jeddah, Saudi Arabia, in 2022. METHODS: A cross-sectional survey was conducted by sending an online questionnaire to married women from Jeddah, Saudi Arabia. The questionnaire included demographics, personal obstetrics information, changes in pregnancy intentions owing to the COVID-19 pandemic, and questions about contraceptive usage. Qualitative data were presented as frequencies, and a χ2 test was performed to determine the relationships among the variables. RESULTS: A total of 639 women enrolled in the study; most participants were 25-34 years old, and most indicated they changed their reproductive intentions during the pandemic (49%). Family planning accounted for 25.8% of participants who changed their reproductive intentions. Only 17.5% changed their choices because of fear of the COVID-19 impact. The percentage of women using contraception was significantly reduced during the lockdown, to 36.8%. Oral contraceptive pills were the most frequently used method during the curfew period (17.5%). CONCLUSION: The COVID-19 lockdown affected the reproductive intentions of most women in Jeddah, and it significantly reduced contraceptive use.

Associations between unintended fatherhood and paternal mental health problems: A systematic review and meta-analysis.

BACKGROUND: Unintended pregnancies are linked to adverse parental mental health, yet little attention has been given to this relationship in fathers specifically. We aimed to meta-analyse associations between unintended pregnancies and mental health problems in fathers with children aged ≤36 months. METHODS: We conducted keyword searches of Medline, CINAHL, Academic Search Complete, PsycInfo and Embase to February 2, 2022, and hand searched included reference lists. RESULTS: Of 2826 records identified, 23 studies (N = 8085 fathers), reporting 29 effects, were eligible for meta-analysis. Included studies assessed depression, anxiety, stress, parenting stress, post-traumatic stress disorder (PTSD), alcohol misuse and psychological distress. Pooled estimates, from random effects meta-analyses, for all mental health outcomes (k = 29; OR = 2.28) and depression only (k = 19; OR = 2.36), showed that the odds of reporting mental health difficulties were >2-fold higher in men reporting unintended births compared with those reporting intended births. However, there was no evidence of association with anxiety (k = 2) or stress (k = 2). Overall, mental health problems were greater in low-income countries. No differences were found across parity, timepoint of mental health assessment, or instruments used to measure mental health symptoms. LIMITATIONS: Analyses were limited by the use of retrospective assessment of pregnancy intention, and heterogeneity of measures used. Further, assessment of fathers' mental health was restricted to the first year postpartum. This review was limited to English language studies. CONCLUSIONS: Unintended pregnancies present an identifiable risk for postpartum mental health problems in fathers.

Reproductive Intentions Affected by Perceptions of Climate Change and Attitudes toward Death.

Adverse climate change poses a threat to the health of pregnant women and unborn children and has a negative impact on the quality of life. Additionally, individuals with a high awareness of the consequences of climate change may be accompanied by a fear of the inevitable end, such as a fear of death. This, in turn, may discourage planning for offspring. Thus, both the perception of climate change and fear of death can have implications for reproductive intentions. Only a few studies to date indicate that concerns about climate change, especially when combined with attitudes towards death, may influence the formation of attitudes and reproductive plans. Thus, current research is aimed at looking at reproductive intentions from the perspective of both climate change concerns and the fear of death. This study was conducted from December 2020 to February 2021. A total of 177 childless males and females (58.8%) took part in the study. The Death Anxiety and Fascination Scale (DAFS) and Climate Change Perception Questionnaire (CCPQ) were completed online. Overall, 63.8% of respondents displayed a positive reproductive intention. Multivariable logistic regression analysis found that, in addition to the young age of respondents, the likelihood of positive reproductive intentions increases with death anxiety and decreases with death fascination and with climate health concerns. The results indicate that both climate change concerns and the fear of death are relevant to reproductive plans-positive reproductive intentions increase with death anxiety and decrease with death fascination and with climate health concerns. The results fill the gap in the existing research on predictors of reproductive intentions and can be used for further scientific exploration and practical activities addressing the issues of the determinants of decisions about having children. The individual consequences of climate change are clearly taken into account in the context of offspring planning and, therefore, should be considered in the design of social and environmental actions.

Primary care patients' preferences for reproductive health service needs assessment and service availability in New York Federally Qualified Health Centers.

OBJECTIVES: Expanding reproductive health services in primary care could increase access to preconception and contraceptive services. We assessed patients' preferences around wording, frequency and staffing for reproductive health service needs assessment and availability of a range of reproductive health services in primary care. STUDY DESIGN: We implemented a cross-sectional anonymous survey of adults in the waiting rooms of four Federally Qualified Health Centers (FQHCs) in New York State in 2017. We present descriptive findings on preferences, including preferences among four questions on reproductive health needs assessment, and differences by socio-demographic characteristics. RESULTS: We had an 89.4% response rate. Of 1,071 respondents, 68.8% self-reported gender as female, 26.5% male and 4.1% transgender/other, while 40.8% self-identified as black non-Hispanic, 32.2% white non-Hispanic, 17.6% Hispanic and 9.4% other. A third had no preferred reproductive health needs assessment question (34.5%), while another third preferred, "Can I help you with any reproductive health services today such as birth control or planning a healthy pregnancy?" (31.5%). Respondents wanted to be asked by a doctor (43.9%) or nurse/medical assistant (21.1%). Females wanted to be asked at every visit (52.9%) more than males (43.9%) and transgender/other individuals (34.1%, p < 0.01). The majority would like to be able to access contraception (59.0%) and sexually transmitted infection (STI) testing (55.4%) at their FQHC. CONCLUSIONS: Most patients supported inclusion of reproductive health discussions and contraception and STI services at these FQHCs. Among those with a preference, patients preferred to be asked about reproductive health service needs rather than pregnancy intentions or desires. IMPLICATIONS: Primary care settings should consider routine inclusion of reproductive health needs assessments over screening for pregnancy intentions or desires. Primary care settings which do not currently provide contraception and sexually transmitted infection testing should consider making these services available.

Resumption of postpartum sexual activity and menses among HIV-infected women on lifelong antiretroviral treatment compared to HIV-uninfected women in Africa.

OBJECTIVE: To determine time from delivery to resumption of sexual activity and menses among HIV-infected women on antiretroviral treatment (ART) and HIV-uninfected women. METHODS: HIV-infected women on ART and HIV-uninfected women were recruited from five health facilities at delivery and followed prospectively for a maximum of 1 year in Blantyre, Malawi from January 2016 to September 2017. Sociodemographic, clinical, and laboratory data were collected at delivery and 1.5, 3, 6, 9, and 12 months. Descriptive, time to event Kaplan-Meier, and multivariable Cox proportional hazards analyses were conducted. RESULTS: Data on 878 women (460 [52.4%] HIV-uninfected and 418 [47.6%] HIV-infected, P=0.156) who attended at least one follow-up visit were analyzed. Among HIV-uninfected compared to HIV-infected women, respectively, the median number of days to resumption of sexual activity was 180 vs 181; to irregular menses was 82 vs 71; and to regular menses was 245 vs 366. In multivariable models, being married was associated with early resumption of sexual activity (hazard ratio [HR] 1.91, P<0.001), and being HIV-infected and use of an effective method of family planning were associated with later start of regular menses (HR<1.0, P<0.050). CONCLUSION: Counseling of women on reproductive intentions should start early irrespective of HIV infection or use of ART.

The injection or the injection? Restricted contraceptive choices among women living with HIV.

Historically, women living with HIV (WLWH) have been vulnerable to biased advice from healthcare workers regarding contraception and childbearing. However, antiretroviral therapy (ART) has made motherhood safer, prompting a re-examination of whether contraceptive services enable the realisation of WLWH's reproductive intentions. We use longitudinal quantitative data on contraceptive choice and use, and childbearing intentions collected in (up to) six interviews between entry into antenatal care (ANC) and 18 months post-partum from a cohort of 471 ART-initiated WLWH in Cape Town, South Africa. Thirty-nine of these women were randomly selected for in-depth interview where they described experiences of contraception services and use. We find high prevalence of injectable contraceptive (IC) use after birth (74%). With increasing post-partum duration, greater proportions of women discontinue this method (at 18 months 21% were not using contraception), while desires for another child remain stable. We find little consistency between method choice and use: many women who elected to use the intrauterine device, sterilisation or oral contraceptives at first ANC visit are using IC after birth. Women commonly report receiving an IC shortly after birth, including those who had previously chosen to use another method or no method. Among WLWH, injectables dominated the contraceptive method mix. Despite a human rights-grounded policy and attempts to introduce new methods, contraceptive services in South Africa remain largely unchanged over time. Women are frequently unable to make autonomous contraceptive choices. Despite low desires for future pregnancy, we observed high rates of contraceptive discontinuation, resulting in heightened risk of unintended pregnancy.

HIV status, fertility intentions, and contraception in the era of expanded access to antiretroviral therapy: A case study of rural Mozambique.

Provision of effective contraception to HIV-positive women of reproductive age is critical to effective management of HIV infection and prevention of both vertical and horizontal HIV transmission in developing countries. This exploratory retrospective study examines contraceptive use during the prolonged post-partum period in a sample of 285 HIV-positive and HIV-negative women who gave birth at four rural maternity clinics in a high HIV-prevalence region in Mozambique. Multivariate analyses show no significant variations by HIV status in contraceptive timing (mean time to first contraceptive use of 7.1 months) or prevalence (31% at time of survey) but detect a moderating effect of fertility intentions: while HIV status makes no difference for women wishing to stop childbearing, among women who want to continue having children, or are unsure about their reproductive plans, HIV-positive status is associated with higher likelihood of contraceptive use. Regardless of HIV status, virtually no condom use is reported. These results are situated within the context of a rapidly widening access to post-partum antiretroviral therapy in the study site and similar sub-Saharan settings.

Patient-provider conversations about sterilization: A qualitative analysis.

OBJECTIVES: Although female sterilization is the second most commonly used contraceptive method in the US, research suggests that providers may serve as barriers to desired sterilization. STUDY DESIGN: We conducted a modified grounded theory analysis of audio-recorded contraceptive counseling visits with 52 women who specified on a previsit survey that they wanted no future children and a supplemental analysis of visits with 14 women who wanted or were unsure about future children in which sterilization was mentioned. RESULTS: Sterilization was discussed in only 19 of the 52 visits, primarily with patients who were older women with children. Although some framed sterilization positively, many clinicians discouraged patients from pursuing sterilization, encouraging them instead to use long-acting reversible methods and framing the permanence of sterilization as undesirable. In the 33 remaining sessions, sterilization was not mentioned, and clinicians largely failed to solicit patients' future reproductive intentions. We found no clear patterns regarding discussion of sterilization in the 14 supplemental cases. CONCLUSION: Clinicians did not discuss sterilization with all patients for whom it might have been appropriate and thus missed opportunities to discuss sterilization as part of the full range of appropriate methods. When they did discuss sterilization, they only infrequently presented the method in positive ways and more commonly encouraged patients to choose a long-acting reversible method instead. Clinicians may want to reflect on their counseling practices around sterilization to ensure that counseling is centered on patient preferences, rather than driven by their own assumptions about the desirability of reversibility. IMPLICATIONS: Clinicians often fail to discuss sterilization as a contraceptive option with potentially appropriate candidates and, when they do, often discourage its selection. Clinicians should consider assessing reproductive intentions to ensure that potentially relevant methods are included in counseling.

Recent developments have made female permanent contraception an increasingly attractive option, and pregnant women in particular ought to be counselled about it.

BACKGROUND: Despite the increased prevalence of reversible contraception, global unintended pregnancy rates are stable. Mistakes, method failures, side effects, alcohol, stock-outs, fears, costs, delays, myths, religious interference, doctors with other priorities, traditions and lack of health professionals may all factor in. Yet these unintended pregnancies - nearly a hundred million annually - cause much individual suffering, and in the long run, can aggravate conflicts, poverty, forced emigration and climate change. Presently, non-poor women postpone childbearing because of longer educational trajectories and careers. Sterilisations are therefore less often regretted or coerced. For poor-resourced women with a completed family, an unwanted pregnancy often has serious consequences, including crossing the (extreme) poverty line in the wrong direction, choosing an unsafe abortion, or even death. Caesarean sections (CSs), which currently stand at around 23 million annually, are increasing. On an "intention-never-to-become-pregnant-again" analysis, choosing a partial, and even more so a total bilateral tubectomy to be implemented during an - anyway performed - CS is by far the most reliable and safe contraceptive choice compared to meaning to start female or male sterilisation or any other contraceptive method later, and it reduces the chance of a future ovarian carcinoma substantially. CSs make subsequent pregnancies more dangerous. Simultaneously, they provide convenient, potentially cost-free opportunities for voluntary permanent contraception (PC): particularly important if there is no guaranteed future access to reliable contraception, safe abortion and well-supervised labour. PARTIAL SOLUTION: Millions of women are within reach of attaining freedom from the "tyranny of excessive fertility" when they have a CS. Therefore, any woman who might conceivably be of the firm opinion that her family will be (over) completed after delivery should antenatally have "what if you have a CS" counselling to assess whether she would like a tubectomy/ligation. Yet many are not provided with this option: leading to frequent regret, more often than having been giving that choice would. CONCLUSION: Withholding antenatal counselling about the option of PC for in case the delivery might become a CS is very prevalent, yet often more medically risky, and morally questionable than when, even in labour, a doctor sometimes decides in the absence of earlier counselling, considering numerous factors, to provide the choice to undergo a concurrent sterilisation if s/he is convinced that would be in the patient's best interest.