Abstract
Women of color experience marked disparities in fulfillment of desired postpartum permanent contraception. While many attribute the disparity to the required Medicaid sterilization consent form and 30-day waiting period established in response to forced and coerced sterilizations, the policy does not entirely explain the disparity; racial and ethnic disparities persist even within strata of insurance type. We therefore propose framing postpartum permanent contraception as a health disparities issue that requires multi-level interventions to address. Based on the literature, we identify discrete levels of barriers to postpartum permanent contraception fulfillment at the patient, physician, hospital, and policy levels that interact and compound within and between individual levels, affecting each individual patient differently. At the patient level, sociodemographic characteristics such as age, race and ethnicity, and parity impact desire for and fulfillment of permanent contraception. At the physician level, implicit bias and paternalistic counseling contribute to barriers in permanent contraception fulfillment. At the hospital level, Medicaid reimbursement, operating room availability, and religious affiliation influence fulfillment of permanent contraception. Lastly, at the policy level, the Medicaid consent form and waiting period pose a known barrier to fulfillment of desired postpartum permanent contraception. Unpacking each of these discrete barriers and untangling their collective impact is necessary to eliminate racial and ethnic disparities in permanent contraception fulfillment.
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References
Daniels K, Abma JC. Current contraceptive status among women aged 15-49: United States, 2015-2017. NCHS Data Brief; 327, https://www.cdc.gov/nchs/data/databriefs/db327_tables-508.pdf#3. (2018, accessed 1 November 2021).
Access to postpartum sterilization. ACOG committee opinion summary, Number 827. Obstet Gynecol. 2021;137:1146–7.
Block-Abraham D, Arora KS, Tate D, et al. Medicaid consent to sterilization forms: historical, practical, ethical, and advocacy considerations. Clin Obstet Gynecol. 2015;58:409–17.
Borrero S, Zite N, Potter JE, et al. Medicaid policy on sterilization — anachronistic or still relevant? 2014; 370: 102–104. https://doi.org/10.1056/NEJMp1313325
White K, Potter JE. Reconsidering racial/ethnic differences in sterilization in the United States. Contraception. 2014;89:550–6.
Thurman AR, Janecek T. One-year follow-up of women with unfulfilled postpartum sterilization requests. Obstet Gynecol. 2010;116:1071–7.
Cleland J, Conde-Agudelo A, Peterson H, et al. Contraception and health. Lancet (London, England). 2012;380:149–56.
Harris L, Wolfe T. Stratified reproduction, family planning care and the double edge of history. Curr Opin Obstet Gynecol. 2014;26:539–44.
Borrero S, Zite N, Potter J, et al. Medicaid policy on sterilization–anachronistic or still relevant? N Engl J Med. 2014;370:102–4.
Jensen JT. Permanent contraception: modern approaches justify a new name. Contraception. 2014;89:493–4.
Zite N, Wuellner S, Gilliam M. Failure to obtain desired postpartum sterilization: Risk and predictors. Obstet Gynecol. 2005;105:794–9.
Zite N, Wuellner S, Gilliam M. Barriers to obtaining a desired postpartum tubal sterilization. Contraception. 2006;73:404–7.
Boardman L, DeSimone M, Allen R. Barriers to completion of desired postpartum sterilization. Rhode Island Medical Journal, https://pubmed.ncbi.nlm.nih.gov/23641425/ (2013, accessed 5 October 2021).
Wolfe KK, Wilson MD, Hou MY, et al. An updated assessment of postpartum sterilization fulfillment after vaginal delivery. Epub ahead of print 2017. DOI: https://doi.org/10.1016/j.contraception.2017.05.005.
Morris J, Ascha M, Wilkinson B, et al. Desired sterilization procedure at the time of cesarean delivery according to insurance status. Obstet Gynecol. 2019;134:1171–7.
Hahn TA, McKenzie F, Hoffman SM, et al. A prospective study on the effects of medicaid regulation and other barriers to obtaining postpartum sterilization. J Midwifery Womens Health. 2019;64:186–93.
Keisler-Starkey K, Bunch LN. Health insurance coverage in the United States: 2019 Current Population Reports.
Downing RA, LaVeist TA, Bullock HE. Intersections of ethnicity and social class in provider advice regarding reproductive health. Am J Public Health. 2007;97:1803.
Dehlendorf C, Ruskin R, Grumbach K, et al. Recommendations for intrauterine contraception: a randomized trial of the effects of patients’ race/ethnicity and socioeconomic status. Am J Obstet Gynecol. 2010;203(319):e1–319.e8.
Gomez A, Wapman M. Under (implicit) pressure: young Black and Latina women’s perceptions of contraceptive care. Contraception. 2017;96:221–6.
Kathawa CA, Arora KS. Implicit bias in counseling for permanent contraception: historical context and recommendations for counseling. 2020; 4: 326–329. https://home.liebertpub.com/heq.
Arora K, Wilkinson B, Verbus E, et al. Medicaid and fulfillment of desired postpartum sterilization. Contraception. 2018;97:559–64.
Arora K, Castleberry N, Schulkin J. Variation in waiting period for Medicaid postpartum sterilizations: results of a national survey of obstetricians-gynecologists. Am J Obstet Gynecol. 2018;218:140–1.
Arora KS, Castleberry N, Schulkin J. Obstetrician-gynecologists’ counseling regarding postpartum sterilization. Int J Womens Health. 2018;10:425.
Kilbourne AM, Switzer G, Hyman K, et al. Advancing health disparities research within the health care system: a conceptual framework. Am J Public Health. 2006;96:2113–121. https://doi.org/10.2105/AJPH.2005.077628.
Harris L. Interdisciplinary perspectives on race, ethnicity, and class in recommendations for intrauterine contraception. Am J Obstet Gynecol. 2010;203:293–5.
Goulding A, Bauer A, Muddana A, et al. Provider counseling and women’s family planning decisions in the postpartum period. J Womens Health (Larchmt). 2020;29:847–53.
Yee L, Simon M. Perceptions of coercion, discrimination and other negative experiences in postpartum contraceptive counseling for low-income minority women. J Health Care Poor Underserved. 2011;22:1387–400.
Arora K, Ponsaran R, Morello L, et al. Attitudes and beliefs of obstetricians-gynecologists regarding Medicaid postpartum sterilization - a qualitative study. Contraception. 2020;102:376–82.
Bouma-Johnston H, Ponsaran R, Arora K. Variation by state in Medicaid sterilization policies for physician reimbursement. Contraception. 2021;103:255–60.
Henkel A, Beshar I, Goldthwaite L. Postpartum permanent contraception: updates on policy and access. Curr Opin Obstet Gynecol.
Schueler K, Hebert L, Wingo E, et al. Denial of tubal ligation in religious hospitals: consumer attitudes when insurance limits hospital choice. Contraception. 2021;104:194–201.
Batra P, Rodriguez K, Cheney AM. Using deliberative and qualitative methods to recommend revisions to the medicaid sterilization waiting period. Womens Health Issues. 2020;30:260–7.
Harrison D, Cooke C. An elucidation of factors influencing physician willingness to perform elective female sterilization. Obstet Gynecol. 1988;72:565–70.
Lawrence RE, Rasinski KA, Yoon JD, et al. Factors influencing physicians’ advice about female sterilization in USA: a national survey. Hum Reprod. 2011;26:106.
Williams A, Kajiwara K, Soon R, et al. Recommendations for contraception: examining the role of patients’ age and race. 77.
White K, Potter J, Hopkins K, et al. Variation in postpartum contraceptive method use: results from the pregnancy risk assessment monitoring system (PRAMS). Contraception. 2014;89:57–62.
Starr K, Martins S, Watson S, et al. Postpartum contraception use by urban/rural status: an analysis of the michigan pregnancy risk assessment monitoring system data. Womens Health Issues. 2015;25:622–7.
Callegari L, Zhao X, Schwarz E, et al. Racial/ethnic differences in contraceptive preferences, beliefs, and self-efficacy among women veterans. Am J Obstet Gynecol. 2017;216:12–25.
Jackson A, Karasek D, Dehlendorf C, et al. Racial and ethnic differences in women’s preferences for features of contraceptive methods. Contraception. 2016;93:406–11.
Kramer R, Higgins J, Godecker A, et al. Racial and ethnic differences in patterns of long-acting reversible contraceptive use in the United States, 2011–2015. Contraception. 2018;97:399–404.
Madden T, Secura GM, Nease R, et al. The role of contraceptive attributes in women’s contraceptive decision making HHS public access. Am J Obs Gynecol. 2015;213:46–7.
Iseyemi A, Zhao Q, McNicholas C, et al. Socioeconomic status as a risk factor for unintended pregnancy in the contraceptive CHOICE project. Obstet Gynecol. 2017;130:609–15.
Acknowledgements
The authors gratefully acknowledge Kristen Berg, PhD; Emily Miller, MD; Kari White, PhD; Tania Serna, MD; Margaret Boozer, MD; Jennifer Bailit, MD; and Douglas Gunzler, PhD.
Funding
Brooke Bullington received support from the National Institute of Child Health and Human Development (NICHD) (T32HD52468, PI Julie Daniels and Andrew Olshan) and an infrastructure grant for population research to the Carolina Population Center at University of North Carolina at Chapel Hill (P2CHD050924, PI Elizabeth Frankenberg). Dr. Arora is funded by 1R01HD098127 from the Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD) branch of the National Institutes of Health (NIH). This manuscript is solely the responsibility of the authors and does not necessarily represent the official views of the NIH.
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Bullington, B.W., Arora, K.S. Fulfillment of Desired Postpartum Permanent Contraception: a Health Disparities Issue. Reprod. Sci. 29, 2620–2624 (2022). https://doi.org/10.1007/s43032-022-00912-3
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DOI: https://doi.org/10.1007/s43032-022-00912-3