By Rebecca H. Allen, MD, MPH, Assistant Professor, Department of Obstetrics and Gynecology, Warren Alpert Medical School of Brown University, Women and Infants Hospital, Providence, RI, is Associate Editor for OB/GYN Clinical Alert.
Dr. Allen reports no financial relationships relevant to this field of study.
Synopsis: Large variations in postpartum tubal sterilization rates exist among states and hospitals that are not explained by insurance status, mode of delivery, citizenship, or demographics. This implies that barriers to postpartum tubal sterilization are preventing access to this desired method of contraception.
Source: Potter JE, et al. Hospital variation in postpartum tubal sterilization rates in California and Texas. Obstet Gynecol 2013;121:152-158.
Tubal sterilization is a highly effective, permanent, and safe method of contraception. Tubal sterilization is the second most common method of contraception used by women in the United States and the most common among women over 30 years of age.1 Approximately half of all tubal sterilizations are performed in the immediate postpartum period, following nearly 10% of all births in the United States.2 The procedure is convenient for the mother as she is already in the hospital for the delivery. Postpartum tubal sterilization can be performed during cesarean section or immediately after vaginal delivery through a small infraumblical incision up to 2 days postpartum.3 The advantages of doing the procedure immediately postpartum are that existing epidural anesthesia can potentially be used and the woman does not have to restrict food and drink in preparation for the procedure another day.4 Additionally, women do not have to prepare for an interval surgery when often the demands of caring for a newborn and/or young family can be overwhelming. Not surprisingly, postpartum sterilizations are performed more frequently in women undergoing cesarean delivery compared to vaginal delivery. Of note, sterilizations funded by Medicaid require that the woman be at least 21 years old and wait at least 30 days between signing the Medicaid consent form and having the procedure.3 The consent form remains valid for 180 days. Exceptions can be made for emergency abdominal surgery or preterm deliveries. If the sterilization is not performed postpartum and the woman still desires the procedure, it can be done at least 6 weeks after delivery either through a laparoscopic or hysteroscopic approach. This delay in surgery imposes a number of inconveniences for the patient including using a reliable gap contraceptive, arranging for additional pre-and post-operative visits, and preparing for the day of surgery when the sterilization can be performed.
Unfortunately, women often face barriers to obtaining desired postpartum tubal sterilizations.5 The study by Potter et al examined the variation in postpartum sterilization rates among hospitals in California and Texas. Both states have high unintended pregnancy rates (56% and 53%, respectively) and both have the largest number of Medicaid-covered births in the United States. The investigators were able to obtain data on virtually all deliveries and sterilizations in the two states in 2009. Information on private and Medicaid insurance status was also available. The total postpartum tubal ligation rate (proportion of births followed by a postpartum tubal ligation) was 6.7 in California and 10.2 in Texas. In California, the rates after cesarean section and vaginal delivery were 14.7 and 2.8, respectively. The corresponding rates in Texas were 19.5 and 4.9. The differences between the two states were similar among women with private insurance and Medicaid. The cesarean delivery rate was 36.6% in Texas and 33% in California but did not account for the differences. The investigators found that within each state there were large variations in the postpartum sterilization rate among hospitals, even accounting for Catholic hospitals where sterilizations are not performed. The authors could not determine exactly why the sterilization rates were so different across hospitals. For cesarean deliveries, it may be issues with obtaining Medicaid consents in a timely fashion. For vaginal deliveries, there may be barriers involving Medicaid consents, availability of staff and operating rooms, and the priority that postpartum tubal ligations receive. In addition, there may be variation in physician counseling regarding sterilization and the accessibility of equally effective alternative options such as intrauterine devices and the contraceptive implant.
Indeed, many local studies have examined such barriers to postpartum sterilization. A study of 712 women at one hospital in Chicago showed that 46% of women requesting postpartum sterilization did not obtain the procedure. The investigators found that lack of valid Medicaid sterilization consent forms, a medical condition precluding the procedure, and lack of availability of an operating room were the most common reasons the procedures were not performed.6 The same investigators also found that young age (21-25 years), African American race, request for sterilization in the second trimester, and vaginal delivery rather than cesarean section were risk factors for not obtaining a desired postpartum tubal sterilization.7 The requirement for Medicaid consent at least 30 days prior to the procedure was developed to provide a window for women to think about their decision and prevent coerced sterilizations that had occurred in the past among disadvantaged populations. Nevertheless, this requirement often becomes a barrier for women who desire the procedure.6,8-10 In addition, because Medicaid coverage can end shortly after birth for some women, lack of signed Medicaid consents prevents women from obtaining another method of contraception postpartum.5
Another study from San Antonio, Texas, of 429 women found completion of desired postpartum sterilizations to be 69%, and sterilization was more likely among women who were documented U.S. residents, married, of lower parity, had received prenatal care, and had private health insurance.8 In this study, completion of postpartum sterilization at the time of cesarean section was no different between documented and undocumented U.S. residents; however, after vaginal delivery, significantly more documented U.S. residents obtained the procedure. This is because undocumented U.S. residents in Texas on emergency Medicaid must pay out of pocket for sterilization after vaginal delivery but not at the time of cesarean delivery. Their follow-up study reported that of the women who did not receive the requested sterilization, 46.7% became pregnant in the year after delivery.11
Similarly, we examined the barriers to postpartum sterilization in our own institution.9 We performed a retrospective study from January 2007 to June 2007 among patients in the resident (often Medicaid) practice. During the study period, 626 women delivered. Of these subjects, 87 (14%) desired postpartum sterilization. Of these 87 subjects, 45 (51.7%) underwent sterilization as planned. Of the 42 women who did not receive the procedure, 22 (52.4%) changed their mind, eight (19%) did not have the required Medicaid consent form signed, four (9.5%) had prior abdominal surgery that caused the provider to cancel the procedure due to anticipated difficulty, two (4.8%) had significant anemia causing the elective procedure to be cancelled, two (4.8%) were considered too obese to be able to technically perform the procedure, two (4.8%) had chorioamnionitis, one (2.4%) had an intrauterine fetal demise at term, and one (2.4%) had no documentation. We found in multivariable analysis that cesarean delivery and older age were predictive of completion of postpartum sterilization while obesity was a risk factor for incompletion.
So what can we do to improve access to postpartum sterilization for those women who desire it? As a result of our study, we are trying to improve our antenatal contraceptive counseling and make sure that women who desire postpartum sterilization have a backup plan in case the sterilization does not happen. We also counsel obese women or those with many prior abdominal surgeries up front that they may not receive the sterilization postpartum depending on the attending physician’s assessment. The American College of Obstetricians and Gynecologists (ACOG) also recommends signing Medicaid consent forms in a timely fashion during prenatal care and ensuring that copies of the consent are transferred to the delivery unit.5 We have found that scanning consent forms into the electronic medical record has significantly helped in this regard. In addition, ACOG suggests working with hospital delivery units and obstetric anesthesia personnel to make the procedure a priority. Finally, offering immediate postpartum IUD or contraceptive implant insertion can provide an equally effective alternative if the desired sterilization is not completed.