ABSTRACT: Postpartum tubal sterilization is one of the safest and most effective methods of contraception. Women who desire this type of sterilization typically undergo thorough counseling and informed consent during prenatal care and reiterate their desire for postpartum sterilization at the time of their hospital admission. Not all women who desire postpartum sterilization actually undergo the surgical procedure, and women with unfulfilled requests for postpartum sterilization have a high rate of repeat pregnancy (approaching 50%) within the following year. Potentially correctable barriers to obtaining postpartum sterilization include patient and health care provider factors, as well as hospital and health care system issues. Given the consequences of a missed procedure and the limited time frame in which it may be performed, postpartum sterilization should be considered an urgent surgical procedure. In addition, women with government insurance face barriers to sterilization procedures based on cumbersome consent requirements. The differences in the requirements surrounding consent for sterilization procedures based on the type of insurance a patient has must be addressed in order to establish fair and equitable access to sterilization procedures for all women. Policies and procedures that remove barriers to and increase efficiency in performing postpartum sterilization could reduce cancellations of the procedure. Improving consistency in accomplishing desired postpartum sterilization is an important strategy to reduce high rates of unintended pregnancy in the United States.
Unintended pregnancy is a serious problem in the United States that is associated with health risks and costs for a woman, her family, and society (1, 2). Women who continue with unintended pregnancies are more likely to have poor health outcomes such as low birth weight infants, infant mortality, and maternal morbidity and mortality (1, 3). Children resulting from unintended pregnancies have higher rates of developmental delay (1, 3). One half of pregnancies in the United States are unintended and often occur disproportionately in low-income and minority populations (4). A critical factor underlying this widespread problem is a lack of access to effective family planning services (1, 4–6).
Postpartum sterilization is one of the most effective and popular forms of contraception in the United States, and it is performed after 10% of all hospital deliveries (7, 8). Sterilization procedures are more common among underserved women, including those with lower levels of education and income, public health insurance or no health insurance, high parity, and those who are black or Hispanic. However, several barriers limit access to the procedure for many women, especially the poor or underserved, who desire postpartum sterilization (6, 9–12). The immediate postpartum period following vaginal delivery or at the time of cesarean delivery is the ideal time to perform sterilization because of technical ease and convenience for the woman and physician. The procedure itself should not lengthen hospitalization (13). This one-time intervention is typically covered by insurance and eliminates the risk of future pregnancy (7, 14).
Only 50% of women who request postpartum sterilization during prenatal contraception counseling actually undergo the procedure (15, 16). Failure to provide the desired sterilization creates a significant increase in cost for the woman and the health care system (17). In one study, nearly one half of women with unfulfilled postpartum sterilization requests became pregnant within 1 year, twice the rate of women who did not request sterilization (10). The direct annual cost of unintended pregnancy to the health care system measures in billions of dollars (18). Because approximately one quarter of American women rely on female sterilization for contraception, making the availability of postpartum sterilization a priority is critical to reducing unintended pregnancy (6, 10, 17). Women in the postpartum period, with the added responsibility of caring for a newborn and varying insurance coverage, often struggle to return to the outpatient office for alternative methods of contraception.
Most women are good candidates for postpartum sterilization. Occasionally, however, maternal medical disorders may complicate the ability to safely perform postpartum sterilization procedures. Assessment of hemodynamic status and consideration of anesthetic risks are important for women scheduled for postpartum sterilization. Although the safety of postpartum tubal sterilization in women with preeclampsia has not been thoroughly evaluated, in the absence of profound hemodynamic alterations, the patient can be considered a candidate for the procedure (19). Morbid obesity may present operative difficulties for performing the procedure; however, the theoretic effectiveness of the procedure should remain unaffected by the patient’s body mass index (20). When unforeseen morbidity occurs that prevents a sterilization procedure or causes a woman to decide not to undergo the procedure, alternative reversible methods of contraception should be presented to the woman, including long-acting methods that have effectiveness rates comparable to sterilization such as the intrauterine device or single-rod contraceptive implant (21).
Because most women are good candidates for postpartum sterilization and because the costs associated with lack of provision of the procedure are high, barriers must be overcome to improve the consistency of fulfilling requests for postpartum sterilization. Factors that may decrease the likelihood of a woman obtaining desired postpartum sterilization include young age and concern for patient regret, consent documents, lack of available operating rooms and anesthesia, and receiving care in a religiously affiliated hospital.
Young Age and Concern for Patient Regret
Women must be 21 years old to be eligible for a sterilization procedure covered by federal Medicaid funds, the Indian Health Service, or U.S. military health insurance. However, health care providers may be reluctant to perform sterilization in women younger than 30 years because of the increased probability of long-term regret compared with women older than 30 years (21). The majority of women younger than 30 years (80%) do not regret their sterilization decision. Long-term regret is more common among underserved women, and thorough presterilization counseling may identify women more likely to experience regret.
To ensure informed consent and protect women from coercion, federal regulations require specific sterilization consent for women enrolled in Medicaid or covered by other government insurance for all sterilization procedures, not just postpartum sterilization. This consent form must be signed at least 30 days before the procedure in order for a health care provider or health care facility to be reimbursed, and it remains valid for 180 days; if the consent form is not signed, the patient will receive a bill for services. Furthermore, reimbursement to the hospital for the delivery and postpartum care may be denied because of an improperly completed or incomplete federal consent form. Although the original intent was to protect women from being sterilized against their will, the lack of a timely signature on the federal consent form now interferes with patient autonomy because it has become a common reason for lack of provision of desired postpartum sterilization (15, 16, 22, 23). In addition, the lack of availability or failed transfer of the completed federal consent document to the delivery unit can result in cancellation of sterilization procedures (14). Women with commercial or private insurance who desire sterilization are not mandated to follow the same consent rules—signing a consent form at least 30 days in advance—to obtain the procedure, thus creating a two-tiered system of access. With possible Medicaid expansions under the Patient Protection and Affordable Care Act, this federal regulation will adversely affect an even larger population of women. The regulation places an undue burden on women and health care providers and must be revised in order to create fair and equitable access for women enrolled in Medicaid or covered by other government insurance. Until this is accomplished, hospital systems and obstetric health care providers should develop appropriate policies and procedures to ensure that the federal consent form is obtained in the prenatal period and is available at the time of delivery. If a woman covered by Medicaid does not receive her desired sterilization, she may not be eligible for coverage of any contraceptive method because Medicaid insurance often ends shortly after the birth (17).
Lack of Available Operating Rooms or Anesthesia
Inadequate hospital resources can hinder a woman from obtaining her desired postpartum sterilization. Typically, postpartum sterilization procedures are performed in labor and delivery operating rooms with obstetric anesthesia personnel. Performing postpartum sterilization may be impossible when several deliveries are imminent or when inadequate staffing occurs in a hospital’s labor and delivery ward. From the patient’s perspective, she has been counseled and anticipates the procedure; she remains without oral intake for many hours and may be separated from her newborn only to face a canceled procedure. By its very nature, a postpartum sterilization procedure cannot be scheduled in advance, a fact that increases the difficulty of obtaining an operating room. Consideration of other operative sites within the hospital, such as the main operating room, could increase the likelihood that sterilization procedures would be accomplished. Emphasis on the urgent nature of the procedure, rather than considering it elective, may increase the success in scheduling these procedures with such a short notice. Use of an existing epidural catheter is an efficient and convenient way to provide anesthesia for sterilization after a vaginal delivery (24). Additionally, an understanding on the part of the entire health care team of the importance of accomplishing the procedure and its effect on individual and public health could increase the commitment to postpartum sterilization.
Receiving Care in a Religiously Affiliated Hospital
Policies at some religiously affiliated hospitals may pose a barrier to reproductive health services (25). For example, approximately 10% of U.S. hospitals are Catholic and operate according to specific directives that prohibit the performance of sterilization within the institution. Although some religiously affiliated hospitals have developed arrangements for the provision of select reproductive health services at alternate sites, they cannot address the needs of women who desire postpartum sterilization. Lack of access to postpartum contraception in religiously affiliated institutions is a barrier to the timely initiation of contraception and could lead to increased unintended pregnancy rates (26). Women receiving maternity care through a religiously affiliated health care site should be provided with information related to all types of reproductive health services, including postpartum sterilization, with appropriate referral to institutions that perform the procedure when requested.
Conclusions and Recommendations
Access to postpartum sterilization is an important strategy to reduce high rates of unintended pregnancy in the United States. The following conclusions and recommendations are presented by the American College of Obstetricians and Gynecologists:
- Postpartum sterilization is a highly effective method of contraception.
- Given the consequences of a missed procedure and the limited time frame in which it may be performed, postpartum sterilization should be considered an urgent surgical procedure.
- Obstetrician–gynecologists should identify and eliminate barriers that restrict access to postpartum sterilization. Obstetrician–gynecologists need to identify themselves as champions or patient advocates for postpartum sterilization in their respective hospitals and help to coordinate administration and health care staff in streamlining access to the procedure.
- Increasing access and availability of postpartum sterilization may not only directly improve outcomes for women desiring the procedure, but may decrease overall costs to the health care system.
- There are unfair differences in consent rules surrounding sterilization procedures based on insurance type. Obstetrician–gynecologists should advocate for fair and equitable access for women who are enrolled in Medicaid or covered by other government health insurance programs.
American College of Obstetricians and Gynecologists
American College of Obstetricians and Gynecologists. Postpartum sterilization. Patient Education Frequently Asked Questions FAQ052. Washington, DC: American College of Obstetricians and Gynecologists; 2011. Available at: http://www.acog.org/~/media/For %20Patients/faq052.pdf?dmc=1&ts=20120515T1249134768. Retrieved April 2, 2012.
American College of Obstetricians and Gynecologists. Postpartum sterilization. Patient Education Pamphlet AP052. Washington, DC: American College of Obstetricians and Gynecologists; 2011.
U.S. Department of Health and Human Services Consent for Sterilization. Available at: www.hhs.gov/forms/HHS-687.pdf.
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