Access to Postpartum Sterilization

ABSTRACT: Sterilization is one of the most effective and popular forms of contraception in the United States, relied upon by 18.6% of women aged 15–49 years using contraception. Nearly half of procedures are performed during the postpartum period, yet many women who desire postpartum sterilization do not actually undergo the procedure. Factors that may decrease the likelihood of a patient obtaining desired postpartum sterilization include patient-related factors, physician-related factors, lack of available operating rooms and anesthesia, federal consent requirements, and receiving care in some religiously affiliated hospitals. In all discussions and counseling regarding contraception, including postpartum sterilization, it is important to engage in shared decision making while supporting personal agency and patient autonomy. Equitable access to postpartum sterilization is an important strategy to ensure patient-centered care while supporting reproductive autonomy and justice when it comes to decisions regarding family formation. This revision includes updates on barriers to postpartum sterilization and guidance for contraceptive counseling and shared decision making.

Recommendations

The American College of Obstetricians and Gynecologists makes the following recommendations regarding access to postpartum sterilization:

• With approximately one fifth of women in the United States relying on female sterilization for contraception, making postpartum sterilization readily available for all people is critical to providing adequate care.

• In the absence of a medical contraindication to surgery, every effort should be made to complete requested immediate postpartum sterilization.

• When unforeseen morbidity exists that prevents a sterilization procedure or causes an individual to decide not to undergo the procedure, alternatives should be discussed, including the full range of reversible methods of contraception and male sterilization.

• Obstetrician–gynecologists must respect patient autonomy and support personal agency by resisting the inclination to deny postpartum sterilization to patients because of physician ideals and values, rather than appropriate clinical concerns.

• Physicians and patients should have a comprehensive, accurate, unbiased, and patient-centered discussion about sterilization with shared decision making and informed consent.

• Physicians should seek to understand the values their patients hold regarding fertility, surgery, sterilization, and nonpermanent contraceptive methods.

• Institutions should consider designating postpartum sterilizations as nonelective procedures, which indicates its high priority to staff and schedulers. Emphasis on the nonelective nature of the procedure might increase the success in scheduling these procedures with such a short notice.

• Sterilization policies and forms should be modified in order to create fair and equitable access for individuals regardless of insurance status or type.

• Hospital systems and obstetric health care practitioners should develop appropriate policies and procedures to ensure that the federal sterilization consent form is signed in the prenatal period and is available at the time of delivery.

• Patients who desire postpartum sterilization who are receiving maternity care at religiously affiliated hospitals, or from clinicians with religious objections, should be informed early in prenatal care of any restrictive policies or personal objections and should be referred to a practitioner or hospital that will be able to accommodate their request.

Introduction

Sterilization is one of the most effective and popular forms of contraception in the United States, relied upon by 18.6% of women aged 15-49 years using contraception 1. Nearly half of procedures are performed during the postpartum period, yet many women who desire postpartum sterilization do not actually undergo the procedure 2 3 4. Sterilization procedures are more common among women with lower incomes, public health insurance or no health insurance, high parity, those who are Black or Hispanic, and those with lower levels of education. However, multiple barriers limit access to the procedure for many individuals, especially the economically marginalized or those with limited health care access 5 6 7 8 9 10 11. The immediate postpartum period after vaginal delivery or at the time of cesarean delivery may be the ideal time to perform sterilization because of technical ease for the physician and convenience for the patient. Childbirth also may be the only time some people access health care. The procedure itself should not lengthen hospitalization 12. This one-time intervention is typically covered by insurance and eliminates the risk of future undesired pregnancy 13 14.

Only 39–57% of women who request postpartum sterilization during prenatal contraceptive counseling actually undergo the procedure 2 3 4 10. The likelihood of successful completion is lower after vaginal delivery than cesarean section 2 15. Even when the postpartum sterilization interval was extended to include sterilization up to 90 days postpartum, only 46% of Medicaid enrollees and 65% of those who were privately insured received sterilization 16.

Failure to provide desired sterilization may result in considerable consequences. One study found that 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 7. Moreover, pregnancy-related Medicaid eligibility ending shortly after delivery makes the ability to obtain sterilization beyond the postpartum period, and in some cases even an alternative form of contraception, difficult, if not impossible 17. Additionally, 57% of women resume sexual activity by 6 weeks postpartum, and approximately 40% of women do not return for a postpartum visit due to childcare obligations, inability to get time off from work, lack of transportation, unstable housing, and communication barriers 18 19 20. Women with unfulfilled sterilization requests due to maternal medical conditions or lack of a valid Medicaid consent report feeling frustrated, angry, dissatisfied, and anxious regarding their inability to prevent repeat pregnancy 21. With approximately one fifth of women in the United States relying on female sterilization for contraception, making postpartum sterilization readily available for all people is critical to providing adequate care 5 7 17.

Most individuals are appropriate candidates for postpartum sterilization and the costs associated with lack of provision of the procedure are high, therefore barriers must be overcome to improve the consistency of fulfilling requests for the procedure. Factors that may decrease the likelihood of a patient obtaining desired postpartum sterilization include patient-related factors, physician-related factors, lack of available operating rooms and anesthesia, federal consent requirements, and receiving care in some religiously affiliated hospitals. This document delineates these barriers for patients who have already chosen postpartum sterilization as their desired method of contraception. Discussion of decision making and recommendations for postpartum contraceptive counseling can be found in other American College of Obstetricians and Gynecologists documents 13 18 22.

Patient- and Physician-Related Factors

Most people are candidates for postpartum sterilization. Occasionally, chronic and acute maternal medical conditions may complicate the ability to safely perform the procedure, and when present, these conditions must be considered carefully. However, in the absence of a medical contraindication to surgery, every effort should be made to complete requested immediate postpartum sterilization. An example of a condition that frequently leads to unfulfilled immediate postpartum sterilization requests is morbid obesity 4 11. Perceived risks of longer operative time, greater surgical complications, and technical difficulty with successfully completing the procedure have been common reasons for physician refusal to proceed with the procedure in the patient with obesity 23; approximately one quarter of unfulfilled sterilization requests were denied specifically due to body habitus 4. Additionally, patients may have been dissuaded by the counseling of a reluctant practitioner, who may heavily emphasize surgical risks or the potential need for a larger incision 4. There is a lack of evidence to support denial of postpartum sterilization to patients with obesity. In fact, one study found that women with a body mass index greater than or equal to 30 undergoing postpartum tubal ligation did not have clinically significant longer operative times compared with women with a body mass index less than 30, nor did they experience greater surgical or postoperative risks, larger incision lengths, or decreased ability to perform the procedure 23. In general, no medical condition absolutely restricts a person’s eligibility for sterilization with the exception of allergies to materials 24. When unforeseen morbidity exists that prevents a sterilization procedure or causes an individual to decide not to undergo the procedure, alternatives should be discussed, including the full range of reversible methods of contraception and male sterilization.

Sterilization requests sometimes go unfulfilled because of the patient’s decision to delay or forego sterilization 4 11 21. Among Medicaid enrollees with adequate consent documentation, up to 50% do not undergo the procedure because they changed their minds 4 21. Individuals may develop misgivings about the permanent nature of the procedure, have a change in pregnancy intention, experience fears about the procedure or anesthesia, or have neonatal complications 21 25. Patient autonomy dictates that practitioners respect an individual’s decision not to proceed in these, and any other patient-determined instances. In all discussions and counseling regarding contraception, including postpartum sterilization, it is important to engage in shared decision making while supporting personal agency and patient autonomy.

Practitioner bias also can influence the likelihood of an individual obtaining postpartum sterilization. Individuals of color and with low socioeconomic status have reported negative experiences with physicians who were disrespectful and paternalistic, and physicians or staff who treated them poorly or with neglect 21 26. Those experiences can adversely affect patients’ decisions about contraceptive options, including sterilization. A survey of obstetricians themselves found that they often dissuaded individuals from undergoing sterilization unless the patient persisted in her request 26. Physicians might decline to perform sterilization for various reasons including a patient’s young age, educational level, insurance status, low parity, and medical or surgical history; a physician’s concern for patient regret, competing clinical demands, or personal religious beliefs; or disagreement by a patient’s partner 26. Obstetrician–gynecologists must respect patient autonomy and support personal agency by resisting the inclination to deny postpartum sterilization to patients because of physician ideals and values, rather than appropriate clinical concerns.

Physicians and patients should have a comprehensive, accurate, unbiased, and patient-centered discussion about sterilization with shared decision making and informed consent. Components of pre-sterilization counseling should include a discussion of the patient’s reproductive desires, details of the procedure itself, specific risks and benefits of the surgical procedure, and a review of all alternatives to sterilization, including long-acting reversible contraceptives (LARC) and male sterilization 26 27. Particular emphasis should be placed on the permanence of the procedure, because this may not be fully understood by some patients or may be underemphasized by some clinicians 28. It is important to also reassure patients that their signature on the consent form is nonbinding and that they can change their mind at any point after completing the form 27. Practitioners also must be mindful of the timing of the discussion and signing of the Medicaid sterilization consent form to ensure compliance with regulations, as well as to avoid coercion.

Counseling should be performed in an empathetic, nonbiased, and nonjudgmental manner. Physicians should be cognizant of the unspoken assumptions and implicit biases they hold, which may result in different counseling strategies for individuals of different backgrounds. Women of color in particular have historically experienced contraceptive coercion and forced sterilization resulting from attempts to limit the fertility of those whose childbearing has been less valued 29 30. Physicians should seek to understand the values their patients hold regarding fertility, surgery, sterilization, and nonpermanent contraceptive methods. The integration of this approach into medical training will help ensure early consideration of patient autonomy in reproductive decision making.

Individuals who are incarcerated require special consideration. The United States has a history of coercive sterilization practices on people who are incarcerated or institutionalized, with documented violations as recently as 2010 31. Prisons and jails are environments that, by their nature, diminish an individual’s autonomy and the ability to make decisions. Some have concluded that “The coercive nature of the prison environment undermines a person’s ability to give meaningful consent to the irreversible destruction of fertility” 31. Incarcerated individuals have described coercive practices by prison health care practitioners and personnel including rewards to those who agree to be sterilized or punishments for those who don’t 31.

Respect for an individual woman’s reproductive autonomy should be the primary concern that guides sterilization provision and policy 22. Given the inherent conflict between incarceration and autonomy, irreversible procedures like sterilization should not be routinely performed during incarceration. Sterilization should only rarely be provided to incarcerated patients who request it, and only after they have been given access to all reversible methods of contraception, including LARC, and after documentation of the patient’s preincarceration request for sterilization is available. Special procedural safeguards and oversight are needed when incarcerated women are sterilized because of the likelihood that the coercive environment of prison impedes true informed consent 22.

Lack of Available Operating Rooms or Anesthesia

Inadequate hospital resources can hinder a patient from obtaining desired postpartum sterilization. Lack of operating room space or unavailability of anesthesia personnel can account for 10–33% of unfulfilled procedures 2 3 4 11 25. Typically, postpartum sterilization procedures are performed in labor and delivery operating rooms with obstetric anesthesia personnel. Performing postpartum sterilization may be difficult 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. Institutions should consider designating postpartum sterilizations as nonelective procedures, which indicates its high priority to staff and schedulers. Emphasis on the nonelective nature of the procedure might increase the success in scheduling these procedures with such a short notice 4. Use of an existing epidural catheter is an efficient and convenient way to provide anesthesia for sterilization after a vaginal delivery 32. Alternatively, spinal and general anesthesia also are safe and effective.

In situations when sterilization is not accomplished during the hospital stay, implementing an expedited surgical scheduling system may increase the likelihood of individuals undergoing an interval procedure by removing the barrier of additional visits 33. Scheduling a tentative surgery date for procedure completion before hospital discharge, with subsequent telephone confirmation of surgery and review of preoperative instructions, might improve access for patients 33. It is still preferable, however, to complete desired sterilizations immediately postpartum. Use of a multidisciplinary approach to address systems issues, including collaboration with key partners such as the anesthesia team, and 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.

Medicaid Title XIX Sterilization Consent Form

The history of sterilization practices in the United States includes numerous abuses perpetrated against multiple communities, particularly economically marginalized women and women of color. The eugenics movement of the early twentieth century notoriously forced sterilization as a means of population control on those members of society who were deemed “unfit to reproduce,” including institutionalized individuals, disabled persons, women with low incomes, women of color, immigrants, and those labeled “mentally incompetent” or “feeble-minded” by society 29. The first eugenics sterilization law was enacted in 1907 in Indiana, and then 32 additional states subsequently passed sterilization laws that were supported by the 1927 Supreme Court ruling Buck v Bell 34. This ruling upheld state statutes permitting compulsory sterilization of “the unfit for the protection and health of the state” 29 34. Forced and coercive sterilization practices supported by federally funded state sterilization programs continued through the 1970s and were later used as a means of punishment, as extortion to ensure receipt of public assistance, under threat of deportation, and to “address” poverty and childbearing outside of marriage, among other reasons 29 34. Women of color were particularly targeted. Law 116 in Puerto Rico, a law that made sterilization legal and free without offering alternative methods of birth control, resulted in the sterilization of approximately one third of Puerto Rican women by 1968 35. Forced sterilization of Native American women by the Indian Health Service in the 1960s and 1970s resulted in one out of every four Native American women being sterilized without their knowledge or consent 36. The practice of sterilizing Black women involuntarily, and in some cases without their knowledge, became so common in the South that within Black communities the practice became known as a “Mississippi appendectomy,” a phrase made popular by Civil Rights leader Fannie Lou Hamer who herself suffered this violation 37 38. It is estimated that between 1909 and 1979, over 60,000 forcible sterilizations occurred within U.S. state-organized programs, including over 20,000 women in California alone. These women were disproportionately immigrants, working class, or had low incomes, African Americans, Native Americans, and Latina 29 34.

In 1976, in response to the public outcry against sterilization abuses that had become well-publicized, the Department of Health, Education and Welfare developed protective regulations and a standardized consent form for publicly funded sterilization procedures. The regulations prohibited sterilization of women younger than age 21 or who were “mentally incompetent” and instituted a 72-hour waiting period, later extended to 30 days, between the time of consent and the sterilization procedure 39. For individuals with federally funded health insurance, the Consent for Sterilization Form (Title XIX form) is required before undergoing any sterilization procedure including postpartum sterilization, interval sterilization, and hysterectomy. This form must be signed at least 30 days before the date of the procedure in order for a practitioner or health care facility to be reimbursed, and it remains valid for 180 days. The only exception is in cases of emergency abdominal surgery or premature delivery. In these situations, the consent must be signed at least 72 hours before the procedure.

Although the original intent was to protect the reproductive rights of individuals and prevent forced or coerced sterilizations, some have expressed concern that failure to meet sterilization consent requirements has itself begun to restrict patient autonomy and has become a barrier to desired postpartum sterilization. Sterilization consent form barriers are estimated to be the direct cause of 24–44% of unfulfilled requests 3 4 21 25 39. If the consent form is not signed or if the required waiting period has not elapsed, the sterilization procedure costs will not be reimbursed, and expenses become the responsibility of the patient. Lack of availability or failed transfer of the completed federal consent document to the delivery unit can result in cancellation of sterilization procedures 4 14 40. Reimbursement to the hospital for the delivery and postpartum care may be denied because of an improperly completed or incomplete sterilization form. Furthermore, confusion may exist as to how to interpret the 30-day waiting period. Clinicians or hospital systems may interpret the form to require a patient’s signature 30 days before the patient’s due date rather than procedure date . To avoid this confusion, health care practitioners should consider performing counseling and obtaining signatures at a specified time period during the pregnancy, for example around the 28th week of gestation. This will allow compliance with both the procedure and due dates.

In addition to the obstacles mentioned earlier, the sterilization consent has posed problems due to poor readability of the form and difficulty with comprehension of its content, especially among individuals who are non-English speaking and those with low health literacy 41. Procedures are prohibited from being covered for women younger than age 21, limiting access to this population. In most cases of postpartum sterilization, in order to sign the federal form within required time regulations, an individual would need to sign it during a prenatal visit. For people who face challenges receiving prenatal care this poses another obstacle 4. One particularly affected community may be immigrants. Depending on the state of residence and an individual’s legal status, many immigrants are barred from obtaining health insurance, thus they are less likely to access prenatal care. Additionally, many immigrants, even those who have health insurance, are increasingly less likely to access medical care due to fear of anti-immigrant rhetoric and policies 30.

Individuals 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 and prohibition to choose sterilization during labor—to obtain the procedure, which some advocates describe as a two-tiered system of access. Because individuals covered by Medicaid are more likely to be in a lower socioeconomic stratum and are more likely to belong to minority groups, these rules continue to promote inequity. They also imply that people who are economically marginalized do not have the same decisional capacity about their reproduction as other people 42. Some feel these regulations penalize women for receiving public insurance 42. The utility of the waiting period has been questioned by Medicaid-insured and privately insured patients alike, with both groups of women reporting the wait did not or would not affect their decision. Many of them had been considering sterilization well before the final month of pregnancy so the 30-day wait was arbitrary 27.

Given historical injustices perpetrated against certain groups of women and more recent sterilization abuses that have persisted (women in California prisons coercively sterilized as recently as 2010), it is imperative that a process of some kind exists to safeguard patients’ rights 39. The fight to end unconsented sterilizations that resulted in the current policy was necessary and must not be forgotten. However, the current system may place unreasonable burden on patients who request sterilization and add barriers for clinicians seeking to provide requested care. Sterilization policies and forms should be modified in order to create fair and equitable access for individuals regardless of insurance status or type, while remaining sensitive to the historical context in which the reproduction of women with low incomes and minority women has been negatively stereotyped and their fertility less valued than other women 39. Measures to promote informed decision making regarding sterilization and to reduce restrictions include development of a standardized, validated decision support tool, or redesign of the existing form to include content better able to be understood by individuals with low health literacy 28 39 43. It is also crucial to develop standardized forms in multiple languages with clear instructions on how to properly complete the form. Redefining the validity time frame (ie, considering the form valid 24 hours after signature and extending validity to 1 year from signature date) should be considered 39 40. Hospital systems and obstetric health care practitioners should develop appropriate policies and procedures to ensure that the federal sterilization consent form is signed in the prenatal period and is available at the time of delivery. One way to ensure availability on delivery units is through the use of electronic health records (EHR). Scanning sterilization consent forms into EHR can not only address the issue of lack of a physical form when the patient presents for delivery, but it also can allow for sharing consents across institutions 4. Whatever revisions to the policy and form occur, they must be sensitive to historical and sociological contexts, thoughtful of underlying medical inequities, and careful of the ethical challenges while continuing to safeguard the rights of individuals who have historically been mistreated.

Receiving Care in a Religiously Affiliated Hospital

Policies at some religiously affiliated hospitals can pose a barrier to reproductive health services 44. 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 44 45. One in seven patients in the United States currently receives care in a religiously affiliated institution 45, and most women receiving care are not aware of the restrictive policies they might experience 46. Although some religiously affiliated hospitals have developed arrangements for the provision of select reproductive health services at alternate sites, they often cannot address the needs of those 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 repeat pregnancy rates 47. Individuals who receive maternity care through a religiously affiliated health care site should be provided with information related to all types of reproductive health services early in prenatal care, including postpartum sterilization. Patients who desire postpartum sterilization who are receiving maternity care at religiously affiliated hospitals, or from clinicians with religious objections, should be informed early in prenatal care of any restrictive policies or personal objections and should be referred to a practitioner or hospital that will be able to accommodate their request.

Conclusion

Equitable access to postpartum sterilization is an important strategy to ensure patient-centered care while supporting reproductive autonomy and justice when it comes to decisions regarding family formation.