By Melinda Young
People giving birth while receiving Medicaid have 56% lower odds of obtaining postpartum sterilization than people who gave birth while on private insurance, a new study shows.1
More than one in four women obtain a sterilization procedure for contraception, and half of those procedures are performed in the postpartum period, when it is most convenient and practical for the women and their providers. Yet, the type of insurance a woman has can greatly impact whether she receives her chosen contraceptive option.1
Investigators analyzed data from the National Survey for Family Growth and looked at the association between insurance payor type and whether someone had a tubal sterilization procedure within two months of an unwanted birth between 2013 and 2015. The researchers included women in the cohort if they recently had a live birth and they explicitly stated their pregnancy was unwanted. The dataset did not ask women whether they desired sterilization.1
The study’s findings mirror what individual OB/GYNs often see when they are working on the labor floor of a hospital.
“We have nights or days when people come in, and in room one you have a person age 35, who has two children, and this is a third pregnancy, and she decides she’s done with having kids — her family is complete, and she has private insurance, so no matter her race or background, she will receive that sterilization procedure after appropriate surgical counseling,” explains Arina Chesnokova, MD, MPH, MSHP, an assistant professor in the division of academic specialists, department of obstetrics and gynecology, Hospital of University of Pennsylvania and Philadelphia VA Medical Center in Philadelphia.
But the woman in room two, who is the same age, similar demographics, but has Medicaid insurance has a different experience. “In room two, if that woman has the exact same demographics and clinical background but happens to be on Medicaid that month because she maybe lost her job recently, and she hasn’t signed that Medicaid consent form, she won’t get the procedure,” Chesnokova says. “It’s an administrative hurdle in that instance.”
The hurdle is federal policy that requires Medicaid recipients to sign the Consent for Sterilization, Title XIX, Form at least 30 days and no more than 180 days before the sterilization procedure.1
The policy was enacted in reaction to a history of governmental and medical entities forcing women to be sterilized in past generations. A waiting period makes sense if the chief concern is that a woman will be forced to make a quick decision without having time to think about it and change her mind. But in the 21st century, the barrier is chiefly preventing people from obtaining their preferred contraception option at a time when it is easiest and most convenient for them to obtain it.
“I understand the policy around the coerced sterilization in the past, but in a lot of clinical scenarios, it ends up being the reverse of that, where we don’t trust people and trust their reproductive choices based solely on insurance,” Chesnokova says. “This type of policy doesn’t exist anywhere else.”
If the federal government were to lift the 30-day wait rule, more women would be able to choose permanent contraception and receive it through Medicaid. But if the first time they hear about the consent document is at the time they are giving birth, it is too late for them to get the procedure right then. And, for women in states that do not allow pregnant women to remain on Medicaid for very long after they give birth, it may be too late for them to schedule a later visit for the procedure.
Most states allow women to remain on Medicaid for longer than six weeks after giving birth, she notes.
On the other side of the risk-benefits ratio, there remain some instances of coerced sterilization in the United States, such as the recent reports that a prison was having women sterilized without their full understanding and consent. But those cases would not apply to Medicaid, Chesnokova says.
“And there still are stringent requirements for surgical consenting that this procedure would have to comply with,” she adds.
The study’s data are from a decade ago because the National Survey for Family Growth stopped month-to-month reporting of birth data after 2015, Chesnokova explains.
“After 2015, there was only year-to-year information, not telling the month when someone gave birth and the month when they received the sterilization procedure,” she says. “The 2013-2015 data was the last chance we had to get at more specific postpartum sterilization.”
Even with that limitation, the experiences of women receiving Medicaid and who desire postpartum sterilization are unlikely to have changed in recent years because the 30-day waiting policy still is in place, she adds.
“Medicaid’s policy hasn’t changed since 2015, so that’s our reason to think the truth hasn’t altered much in this time period,” Chesnokova says.
From the OB/GYN’s perspective, the Medicaid consent requirement means they need to be proactive with pregnant patients in discussing permanent contraception and any postpartum contraception.
“We should all be there for the patient to help them meet their reproductive goals,” Chesnokova says. “In the absence of a complete policy change — like a reversal of the Medicaid sterilization rule, which is probably not happening in the near future — we should be focused on integrating this consent into the workflow and make sure sterilization is discussed early in the pregnancy.”
Providers can discuss permanent contraception in a standardized way.
Hospital physicians who are helping a Medicaid patient give birth can discuss other options of birth control if she has not signed consent for a tubal sterilization procedure. For example, an intrauterine device (IUD) or implant could be inserted immediately postpartum. The IUD placed immediately after the woman gives birth has a higher risk of expulsion, but the implant is safe for breastfeeding and also a highly effective form of contraception, she explains.
“But, likely the reason they want sterilization is because they don’t want hormonal contraception,” Chesnokova notes. “So, we should offer all options to help them maximize their reproductive goals. If someone wants to be sterilized, they should be sterilized regardless of their insurance.”
Reference
- Chesnokova A, Christensen T, Streaty T, et al. Medicaid compared to private insurance is associated with lower rates of sterilization in people with unwanted births. Am J Obstet Gynecol 2024;230:347.e1-347.e11.
