Potential unintended pregnancies averted and cost savings associated with a revised Medicaid sterilization policy

Nonfulfillment of desired postpartum permanent contraception and resultant maternal and pregnancy health outcomes

BACKGROUND

Up to half of the patients requesting postpartum permanent contraception do not undergo the desired procedure. Although nonfulfillment of desired postpartum permanent contraception is associated with increased risk of pregnancy within 12 months of delivery, its long-term reproductive and maternal health outcomes are less clear.

OBJECTIVE

This study aimed to determine the association of fulfillment of postpartum permanent contraception with number and timing of subsequent pregnancies and maternal health outcomes.

STUDY DESIGN

This was a retrospective single-center cohort chart review study of health outcomes in the 4 years following delivery (2016-2018) for 1331 patients with a documented contraceptive plan of female permanent contraception at time of postpartum discharge from 2012 to 2014. Rates of permanent contraception fulfillment within 90 days of delivery and clinical and demographic characteristics associated with permanent contraception were calculated. We determined number of and time to subsequent pregnancies, and diagnoses of medical comorbidities (hypertension, diabetes mellitus, depression, anxiety, asthma, anemia), sexually transmitted infection, and pregnancy comorbidities (preterm birth, gestational diabetes mellitus, gestational hypertension, preeclampsia, postpartum hemorrhage, low birthweight, intrauterine fetal demise) in the 4 years following delivery.

RESULTS

Of the 1331 patients desiring permanent contraception postpartum, 588 (44.1%) had their requests fulfilled within 90 days of delivery and 743 (55.8%) did not. Patients who achieved permanent contraception fulfillment tended to have attended more outpatient prenatal visits, delivered via cesarean delivery, and were older, married, college-educated, and privately insured. Patients who received their desired postpartum permanent contraception were less likely to have subsequent intrauterine pregnancies (P<.001). In those who did not achieve permanent contraception, 22 (9.0%) subsequent pregnancies occurred within 6 months of previous deliveries, and 223 (91.0%) occurred after short interpregnancy intervals (within 18 months). Of 178 continued pregnancies, 26 (14.6%) were delivered preterm. There were no differences between the 2 groups in terms of ever attending an outpatient, preventive, or emergency room visit, or in most nonreproductive health outcomes investigated.

CONCLUSION

Nonfulfillment of desired postpartum permanent contraception is associated with subsequent maternal reproductive and nonreproductive health ramifications. Given the barriers to permanent contraception, alternative plans for contraception should be discussed proactively if permanent contraception is not provided.

Ethics of a Mandatory Waiting Period for Female Sterilization

Due to a history of coerced sterilization, a federal Medicaid sterilization policy mandates that a specific consent form be signed by a patient at least thirty days prior to when the patient undergoes sterilization. However, in contemporary obstetrical practice, the Medicaid sterilization policy serves as a policy-level barrier to autonomously desired care. We review the clinical and ethical implications of the current Medicaid sterilization policy. After discussing the utility and impact of waiting periods for other surgical procedures, we explore the psychology of time required for decision-making and consider scientific understanding of regret. We argue that the current Medicaid sterilization waiting period is clinically and ethically unjustifiable and that the policy ought to be revised in light of the goals, preferences, and concerns of the people most affected by it. While the need for continued protection against coercion remains, the current mandated waiting period does little to enforce the high-quality shared decision-making that is desired for sterilization counseling.

Variation in the interpretation and application of the Medicaid sterilization consent form among Medicaid officials

OBJECTIVE

The Medicaid consent policy has been identified as a major barrier to desired permanent contraception, particularly for low-income communities and communities of color. As each state may modify their state Medicaid sterilization consent form, variation in the form has been reported. This study aims to characterize state-level variation in Medicaid Title XIX consent form interpretation and application.

STUDY DESIGN

We aimed to collect primary data from Medicaid officials in all 50 United States from January to May 2020 via a 25-question electronic survey regarding state-level consent form implementation. Questions targeted consent form details and definitions, insurance and billing, clinician correspondence, and administrative processes. We used Qualtrics XM to collect survey responses. We performed descriptive statistics on the survey responses. There were no exclusion criteria.

RESULTS

We had 41 responses from 36/50 states (72% participation rate). Heterogeneity existed in the key definitions of "Premature Delivery" and "Emergency Abdominal Surgery." One in five respondents reported the consent form was only available in English. Variation among Current Procedural Terminology codes covered in each state's sterilization policy were noted. Nearly a quarter of respondents did not know how Medicaid informed healthcare providers of consent form denials. Most participants (90%) were unaware of differences between state sterilization policies.

CONCLUSION

This study demonstrates variation in terms of consent form definitions, procedures covered, correspondence with clinicians, and administrative review processes among state Medicaid offices regarding the sterilization consent form. Greater transparency is necessary in order to reduce administrative barriers to desired permanent contraception.

IMPLICATIONS

Inconsistent interpretation poses an administrative barrier to care, raises concern regarding appropriate clinician reimbursement, and can potentially lead to unnecessarily denying patients the contraceptive option of their choice. Permanent contraception policies should be equitable no matter insurance status, preserve reproductive autonomy and effectively protect vulnerable populations.

Postpartum permanent contraception: updates on policy and access

PURPOSE OF REVIEW

To describe barriers to provision of postpartum permanent contraception at patient, hospital, and insurance levels.

RECENT FINDINGS

Permanent contraception remains the most commonly used form of contraception in the United States with the majority of procedures performed during birth-hospitalization. Many people live in regions with a high Catholic hospital market share where individual contraceptive plans may be refused based on religious doctrine. Obesity should not preclude an individual from receiving a postpartum tubal ligation as recent studies find that operative time is clinically similar with no increased risk of complications in obese compared with nonobese people. The largest barrier to provision of permanent contraception remains the federally mandated consent for sterilization for those with Medicaid insurance. State variation in enforcement of the Medicaid policy additionally contributes to unequal access and physician reimbursement. Although significant barriers exist in policy that will take time to improve, hospital-based interventions, such as listing postpartum tubal ligation as an 'urgent' procedure or scheduling interval laparoscopic salpingectomy prior to birth-hospitalization discharge can make a significant impact in actualization of desired permanent contraception for patients.

SUMMARY

Unfulfilled requests for permanent contraception result in higher rates of unintended pregnancies, loss of self-efficacy, and higher costs. Hospital and federal policy should protect vulnerable populations while not preventing provision of desired contraception.

Female permanent contraception policies and occurrence at a sample of U.S. prisons and jails

OBJECTIVE(S)

Incarcerated individuals have an unmet need for contraception, yet have also been subject to coercive permanent contraception practices. Data do not exist on prison and jail policies around access to permanent contraception or how often it occurs among women in custody. We sought to describe permanent and reversible contraception policies at U.S carceral institutions and the frequency of these procedures.

STUDY DESIGN

We surveyed a convenience sample of 22 state prison systems and 6 county jails from 2016 to 2017 about female permanent contraception and reversible contraception policies. In addition, 10 prisons and 4 jails reported 6 months of monthly data on the number of postpartum permanent contraception procedures performed on women who gave birth in custody. We analyzed results for descriptive statistics.

RESULTS

Eleven prisons (50%) and 5 jails (83%) permitted female permanent contraception; 7 of these prisons and 3 of these jails allowing permanent contraception did not have a written policy about it. Six prisons and no jails provided access to permanent but not reversible contraception. Over 6 months, 3 women from 2 prisons and 4 women at 2 jails received postpartum permanent contraception.

CONCLUSION(S)

The majority of prisons and jails in our study allowed incarcerated women to have permanent contraception in custody, often without formalized policies in place. Postpartum permanent contraception occurred during the study period. Given the inherent lack of autonomy of incarceration and history of sterilization abuses in this marginalized group, policy-makers should advance policies that avoid coercive permanent contraception and increase access to reversible contraception in carceral settings.

IMPLICATIONS

Many carceral institutions permit women to undergo permanent contraception but provide no access to reversible contraception; this practice raises concern for compromised autonomy and further reproductive marginalization of a group with limited access to quality reproductive health care.

Variation by state in Medicaid sterilization policies for physician reimbursement

OBJECTIVE

To evaluate state-level variation in Medicaid sterilization reimbursement policies for physicians in terms of policy details, flexibility, and review process.

STUDY DESIGN

We reviewed state Medicaid websites and interviewed state employees to better understand reimbursement policies and implementation. We attempted to obtain policy details and instructions for physicians from all 50 state Medicaid office websites. We invited employees in all 50 state Medicaid director's offices to participate in semi-structured qualitative interviews.

RESULTS

We were able to collect data from 48 states' websites for analysis, conducted 15 telephone interviews, and received 4 written responses from state Medicaid employees. State policies varied greatly in terms of degree of instruction available online to clinicians, number of content-related and logistical changes made compared to the federal policy, type of procedures included, corrections permitted, flexibility in terms of surgeon and procedure changes, review process, reasons for and ramifications of denial, and date of last policy revision.

CONCLUSION

There is need for increased transparency and instruction by state Medicaid offices as well as revision of the Medicaid policy to account for the contemporary clinical practice of female permanent contraception. Clinicians should communicate with state Medicaid employees in order to clarify important policy details and obtain greater understanding of their state's review process and ramifications to ensure their clinical practice is both correct and reimbursable.

IMPLICATIONS

Greater consistency between states in terms of Medicaid policy and implementation is crucial to ensuring physicians are fairly reimbursed for their work, and female permanent contraception remains an accessible contraceptive method for women.

COVID-19 highlights the policy barriers and complexities of postpartum sterilization

Multiple barriers exist to sterilization in the postpartum period. One such barrier, the Medicaid Title XIX sterilization policy, requires publicly insured patients to complete a sterilization consent form at least 30 days prior to their scheduled procedure. While this policy was set in place in the 1970s to address the practice of coerced sterilization among marginalized women, it has served as a significant barrier to obtaining the procedure in the contemporary period. The COVID-19 pandemic has highlighted specific complexities surrounding postpartum sterilization and created additional barriers for women desiring this contraceptive method. Despite the time constraints to perform postpartum sterilization, some hospital administrators, elective officials, and state Medicaid offices deemed sterilization as "elective." Additionally, as the Center for Medicare and Medicaid Services (CMS) has revised telemedicine reimbursement and encouraged its increased use, it has provided no guidance for the sterilization consent form, use of oral consents, and change to the sterilization consent form expiration date. This leaves individual states to create policies and recommended procedures that may not be accepted or recognized by CMS. These barriers put significant strain on patients attempting to obtain postpartum sterilization, specifically for patients with lower incomes and women of color. CMS can support reproductive health for vulnerable populations by providing clear guidance to state Medicaid offices, extending the 180-day expiration of a sterilization consent form signed prior to the pandemic, and allowing for telemedicine oral consents with witnesses or electronic signatures.

Perceptions and practice of state Medicaid officials regarding informed consent for female sterilization

OBJECTIVE

To explore the attitudes, beliefs, and interpretations of individual state Medicaid office employees regarding their state's postpartum sterilization policy and its impact on patient care.

STUDY DESIGN

We invited employees in all 50 state Medicaid director's offices who self- or peer-identified as best informed about the sterilization policy to participate in semi-structured qualitative interviews. Using a pilot-tested interview guide, we transcribed, coded, and analyzed each interview. We attempted to obtain supplemental data, including relevant policy details and instructions for physicians in the state, from all 50 state Medicaid office websites.

RESULTS

We collected data from 15 telephone interviews, four written responses, and 48 states' websites for analysis. Participants had varying responses regarding the impact of the Medicaid-mandated sterilization consent form in terms of informed consent as well as the utility and ramifications of the waiting period. State policies varied in terms of the age of consent, complexity of the form, availability of translations, use of unclear terminology, and the consent-obtaining process.

CONCLUSION

State Medicaid employees have differences in opinions regarding the intent of the Medicaid-mandated sterilization consent form and policies. Better understanding of the variation in individual state policies that may contribute to inequitable access to sterilization is necessary.

IMPLICATIONS

Provision of consistent guidelines and widespread coordination of the Medicaid sterilization policies in identified areas impacting informed consent may reduce existing obstacles and provide more equitable access to contraceptive care.

Attitudes and beliefs of obstetricians-gynecologists regarding Medicaid postpartum sterilization - A qualitative study

OBJECTIVE

To explore the attitudes and beliefs of obstetrician-gynecologists in the United States (US) regarding the Medicaid postpartum sterilization policy.

STUDY DESIGN

We recruited obstetrician-gynecologists practicing in ten geographically diverse US states for a qualitative study using the American College of Obstetricians and Gynecologists directory. We conducted semi-structured interviews via telephone, professionally transcribed, and analyzed using the constant comparative method and principles of grounded theory.

RESULTS

We interviewed thirty obstetrician-gynecologists (63.3% women, 76.7% non-subspecialized, and 53.3% academic setting). Participants largely described the consent form as unnecessary, paternalistic, an administrative hassle, a barrier to desired patient care, and associated with worse health outcomes. Views on the waiting period's utility and impact were mixed. Many participants felt the sterilization policy was discriminatory. However, some participants noted the policy's importance in terms of the historical basis, used the form as a counseling tool to remind patients of the permanence of sterilization, felt the policy prompted them to counsel regarding sterilization, and protected patients in contemporary medical practice.

CONCLUSION

Many physicians shared concerns about the ethics and clinical impact of the Medicaid sterilization policy. Future revisions to the Medicaid sterilization policy must balance prevention of coercion with reduction in barriers to those desiring sterilization in order to maximize reproductive autonomy.

IMPLICATIONS

Obstetrician-gynecologists are key stakeholders of the Medicaid sterilization policy. Obstetrician-gynecologists largely believe that revision to the Medicaid sterilization policy is warranted to balance reduction of external barriers to desired care with a process that enforces the need for counseling regarding contraception and reviewing patient preference for sterilization throughout pregnancy in order to minimize regret.

Using Deliberative and Qualitative Methods to Recommend Revisions to the Medicaid Sterilization Waiting Period

BACKGROUND

Sterilization is used by one-quarter of women in the United States for contraception and is a preferred birth control method among women with Medicaid. A history of coercive sterilization practices in the United States led to federal regulation of consent for Medicaid sterilization (including a mandated waiting period); this regulation can be a barrier to sterilization in Medicaid-insured women. This study aimed to develop a revised model of Medicaid sterilization policy grounded in the experiences of women impacted by current regulations.

METHODS

This prospective study used in-depth interviews with 32 Medicaid-insured women who had obtained or tried to obtain sterilization to elicit recommendations regarding the Medicaid waiting period. Deliberative methods (a planning cell including 20 key community stakeholders) were used to evaluate women's recommendations and propose a revised policy for sterilization under Medicaid.

RESULTS

In-depth interview data demonstrated that women were often not made aware of the 30-day waiting period during informed consent before sterilization. Once informed about the policy, women described the Medicaid waiting period as "unfair," because it did not apply to all women. After deliberating women's recommendations to change the policy, key stakeholders came to a consensus around replacing the current waiting period policy with an improved consent process that would acknowledge the problematic history of coercive sterilization. Participants could not endorse removing the waiting period altogether without evidence that the health system had shifted away from coercive sterilization practices.

CONCLUSIONS

Using deliberative methods and the recommendations of women with Medicaid insurance, community stakeholders recommended developing a revised Medicaid sterilization consent policy that acknowledged the historical context of this procedure.

Sterilisations at delivery or after childbirth: Addressing continuing abuses in the consent process

Non-consensual sterilisation is not only a historic abuse. Cases of unethical treatment of women around the time of a pregnancy continue in the Twenty-First Century in five continents. Sterilisation is being carried out by some healthcare professionals at the time of delivery, or soon afterwards, without valid consent. A range of contemporary examples of such practices is given. Respecting women's autonomy should be the touchstone of the consent process. Avoidance of force, duress, deception and manipulation should go without saying. Ethnic minority communities and women living with HIV, in particular, are being targeted for this kind of abuse. Attempts have been made in various countries and by international professional organisations to introduce clinical guidelines to steer health professionals away from this malpractice. Survivors have sought justice in domestic and international courts. This paper critically assesses the evidence on the practical, ethical and legal issues around the handling of consent for these procedures. Suggestions are made about possible regulatory responses that address abuse, whilst maintaining access for those individuals who freely elect to undergo these procedures.

A Prospective Study on the Effects of Medicaid Regulation and Other Barriers to Obtaining Postpartum Sterilization

INTRODUCTION

This study aimed to assess unfulfilled sterilization requests, specifically regarding issues with the Medicaid consent for sterilization, and determine the proportion of women who subsequently received interval sterilization by 3 months postpartum.

METHODS

The authors conducted a prospective observational cohort study of women who gave birth over an 8-month period and requested immediate postpartum sterilization. Records of women with unfulfilled requests were reviewed up to 3 months postpartum to determine rates of postpartum follow-up and interval sterilization. Primary analysis examined unfulfilled sterilization requests associated with the Medicaid consent form and, secondarily, all other reasons for unfulfilled requests, as well as alternative contraceptive methods chosen.

RESULTS

Of the 334 women who requested immediate postpartum sterilization, 173 (52%) received the requested sterilization and 161 (48%) did not. Among those whose request was unfulfilled, 91 (56.5%) still wanted the procedure, and of those women, more than two-thirds were unable to receive it because of Medicaid consent issues. Within this group, only 6 received interval sterilization by 3 months postpartum; more than one-third received a form of long-acting reversible contraception, and 24.6% did not receive postpartum care.

DISCUSSION

A sizable proportion of women requesting postpartum sterilization have unfulfilled requests because of an issue with the Medicaid consent and also have a low likelihood of receiving interval sterilization by 3 months postpartum. The Medicaid consent may create barriers for women requesting postpartum sterilization, the vast majority of whom face subsequent barriers obtaining interval sterilization, thereby increasing the risk for unintended pregnancy in an at-risk population. This has important implications for reproductive justice efforts to protect vulnerable populations while minimizing barriers to desired care.

Patient-provider conversations about sterilization: A qualitative analysis

OBJECTIVES

Although female sterilization is the second most commonly used contraceptive method in the US, research suggests that providers may serve as barriers to desired sterilization.

STUDY DESIGN

We conducted a modified grounded theory analysis of audio-recorded contraceptive counseling visits with 52 women who specified on a previsit survey that they wanted no future children and a supplemental analysis of visits with 14 women who wanted or were unsure about future children in which sterilization was mentioned.

RESULTS

Sterilization was discussed in only 19 of the 52 visits, primarily with patients who were older women with children. Although some framed sterilization positively, many clinicians discouraged patients from pursuing sterilization, encouraging them instead to use long-acting reversible methods and framing the permanence of sterilization as undesirable. In the 33 remaining sessions, sterilization was not mentioned, and clinicians largely failed to solicit patients' future reproductive intentions. We found no clear patterns regarding discussion of sterilization in the 14 supplemental cases.

CONCLUSION

Clinicians did not discuss sterilization with all patients for whom it might have been appropriate and thus missed opportunities to discuss sterilization as part of the full range of appropriate methods. When they did discuss sterilization, they only infrequently presented the method in positive ways and more commonly encouraged patients to choose a long-acting reversible method instead. Clinicians may want to reflect on their counseling practices around sterilization to ensure that counseling is centered on patient preferences, rather than driven by their own assumptions about the desirability of reversibility.

IMPLICATIONS

Clinicians often fail to discuss sterilization as a contraceptive option with potentially appropriate candidates and, when they do, often discourage its selection. Clinicians should consider assessing reproductive intentions to ensure that potentially relevant methods are included in counseling.

Improving Medicaid: three decades of change to better serve women of childbearing age

Over the past 3 decades, major changes enhanced Medicaid's role in improving the health of women and perinatal outcomes. Reforms in the 1980s and 1990s had impact not only on coverage but also on current policy debates. Whether or not states expand eligibility under the Affordable Care Act, Medicaid is important. Increased coverage for well-woman visits, preconception care, and contraceptive methods are opportunities in gynecology. As a critical source of maternity coverage, Medicaid can improve prenatal care, reduce preterm births, limit early elective deliveries, and increase postpartum visits. Obstetrician-gynecologists play a role in translating coverage into access to quality services.

Update on permanent contraception options for women

PURPOSE OF REVIEW

Permanent methods are the most commonly used contraceptive options worldwide. Even with the increase in popularity and accessibility of long-acting reversible methods, there remains high demand for permanent options, especially among women in developing countries.

RECENT FINDINGS

Traditional methods of permanent contraception, such as postpartum tubal ligation and interval surgical tubal occlusion or electrocautery by mini-laparotomy or laparoscopy are well tolerated and highly effective. Bilateral total salpingectomy for ovarian cancer risk reduction is currently being investigated. Hysteroscopic tubal occlusion reduces or eliminates the need for anesthesia, but requires surgical training and specialized equipment. Alternative permanent contraception methods are being explored including immediately effective hysteroscopic methods, and nonsurgical permanent contraception methods that have the potential to improve access and reduce cost.

SUMMARY

Permanent contraception methods are an important part of the contraceptive methods mix designed to meet the needs of women who have completed desired family size or wish never to become pregnant. Current surgical approaches to permanent contraception are well tolerated and highly effective. The development of a highly effective nonsurgical approach could simplify the provision of permanent contraception.

Health care justice and its implications for current policy of a mandatory waiting period for elective tubal sterilization

Tubal sterilization during the immediate postpartum period is 1 of the most common forms of contraception in the United States. This time of the procedure has the advantage of 1-time hospitalization, which results in ease and convenience for the woman. The US Collaborative Review of Sterilization Study indicates the high efficacy and effectiveness of postpartum tubal sterilization. Oral and written informed consent is the ethical and legal standard for the performance of elective tubal sterilization for permanent contraception for all patients, regardless of source of payment. Current health care policy and practice regarding elective tubal sterilization for Medicaid beneficiaries places a unique requirement on these patients and their obstetricians: a mandatory waiting period. This requirement originates in decades-old legislation, which we briefly describe. We then introduce the concept of health care justice in professional obstetric ethics and explain how it originates in the ethical concepts of medicine as a profession and of being a patient and its deontologic and consequentialist dimensions. We next identify the implications of health care justice for the current policy of a mandatory 30-day waiting period. We conclude that Medicaid policy allocates access to elective tubal sterilization differently, based on source of payment and gender, which violates health care justice in both its deontologic and consequentialist dimensions. Obstetricians should invoke health care justice in women's health care as the basis for advocacy for needed change in law and health policy, to eliminate health care injustice in women's access to elective tubal sterilization.

Worldwide research productivity in emergency contraception: a bibliometric analysis

BACKGROUND

The main goal of this study was to assess worldwide research activity in emergency contraception (EC) using bibliometric indicators.

METHODS

Data in SciVerse Scopus were searched for documents pertaining to emergency contraception. Data obtained were then exported to Microsoft Excel and analyzed using Statistical Package for Social Sciences.

RESULTS

A total of 2142 documents were published about EC worldwide. Documents were written in 27 different languages and were published from 78 countries. Publications in EC started on late 1960s. Total number of citations for published EC documents was 30154 while median citation per document was six. The h-index of the retrieved documents was 58. The leading country in EC research was United States of America with a total of 559 documents (26.10%). One hundred and ninety five (9.10%) documents were published in Contraception journal. The leading institution in EC research and publications was Princeton University (50; 2.33%) followed by University of California, San Francisco (34; 1.59%).

CONCLUSIONS

The present data revealed that there is a worldwide increasing interest in EC research. Willingness of health policy makers to make EC accessible to the public will determine the future of EC research activity and future of EC as a contraceptive method.

Prohibiting consent: what are the costs of denying permanent contraception concurrent with abortion care?

OBJECTIVE

Oregon and federal laws prohibit giving informed consent for permanent contraception when presenting for an abortion. The primary objective of this study was to estimate the number of unintended pregnancies associated with this barrier to obtaining concurrent tubal occlusion and abortion, compared with the current policy, which limits women to obtaining interval tubal occlusion after abortion. The secondary objectives were to compare the financial costs, quality-adjusted life years, and the cost-effectiveness of these policies.

STUDY DESIGN

We designed a decision-analytic model examining a theoretical population of women who requested tubal occlusion at time of abortion. Model inputs came from the literature. We examined the primary and secondary outcomes stratified by maternal age (>30 and <30 years). A Markov model incorporated the possibility of multiple pregnancies. Sensitivity analyses were performed on all variables and a Monte Carlo simulation was conducted.

RESULTS

For every 1000 women age <30 years in Oregon who did not receive requested tubal occlusion at the time of abortion, over 5 years there would be 1274 additional unintended pregnancies and an additional $4,152,373 in direct medical costs. Allowing women to receive tubal occlusion at time of abortion was the dominant strategy. It resulted in both lower costs and greater quality-adjusted life years compared to allowing only interval tubal occlusion after abortion.

CONCLUSION

Prohibiting tubal occlusion at time of abortion resulted in an increased incidence of unintended pregnancy and increased public costs.