Out of Date Policy Limits Access to Postpartum Sterilization
I hadn’t recognized her underneath the swelling, bruises, and lacerations. I had been her delivery nurse eight months earlier, when she had begged for a tubal ligation that we could not provide.
The patient’s pregnancy was full term and she had signed the consent form 23 days prior, seven days shy of sterilization eligibility according to the Centers for Medicare and Medicaid. She was discharged with the intention of receiving an interval sterilization procedure. This visit, she was a victim of intimate partner violence and at 19 weeks pregnant, she was suffering from a placental abruption and hemorrhage. The fetus had no heartbeat.
Childbirth may be the only time some patients access care, and the immediate postpartum period is a safe time to obtain permanent contraception. Bureaucratic federal policies, however, stand in the way. If a Medicaid beneficiary desires sterilization, they must sign the consent form and uphold the stipulations as described here. These regulations were published in the Federal Register in 1978 in response to a harrowing history of involuntary sterilization. The policy details a mandatory waiting period, forcing the patient to wait at least 30 days for the procedure after signature. The only exceptions are for preterm deliveries or emergency abdominal surgeries, in which the waiting period remains inconvenient at 72 hours.
When announcing these rules the agency admitted that the waiting periods chosen were arbitrary, and that “existing information does not permit precise predictions as to the effects of the proposed choices.” Today, there is abundant evidence that the policy paradoxically discriminates against the publicly insured by imposing barriers that restrict reproductive autonomy.
Between 50 and 60 percent of postpartum sterilizations are unfulfilled, and up to 47% of those forced to delay may have an unplanned pregnancy within one year. Failure to possess a valid and timely Medicaid consent is one of the most cited reasons for this. Patients who are discharged with unfulfilled sterilization requests are at an increased risk of unintended, short-interval, and subsequent high-risk pregnancies. Adverse outcomes associated with these include preterm labor/birth, low birth weight, uterine rupture, hemorrhage/blood transfusion, cardiovascular disease, hypertension, thrombotic events, interpersonal violence and more.
Women with unfulfilled sterilization requests report feeling frustrated, angry, dissatisfied, and anxious regarding their inability to prevent repeat pregnancies. They deserve better.
Medicaid covers nearly half of all births in the United States. Most subscribers identify as black and Hispanic, and are more likely to be of fair or poor health, single mothers, those of low-income, and be without a high school diploma. Sterilization rates among Medicaid beneficiaries are lower than privately insured individuals, even after controlling for hospital and patient factors. And when the sterilization interval was extended to include sterilization up to 90 days postpartum, only 46% of Medicaid enrollees compared to 65% of the privately insured received sterilization.
Scheduling this procedure as an outpatient is also problematic. If it has been longer than 180 days from consent signature, the patient will need to sign the consent again, and the clock gets set for the 30-day wait once more. Still, in 14 states where postpartum Medicaid coverage has not been extended to 12 months, the coverage period expires 60 days after birth and the family will be uninsured if they do not meet the state Medicaid eligibility levels.
The policy as it currently stands not only limits individual agency, but reinforces current racial and economic disparities in a country with an already staggering maternal mortality rate. A cost-effectiveness model estimated that upon revision the number of fulfilled sterilization requests would increase by 45%, leading to more than 29,000 unintended pregnancies being averted, and saving $215 million.
Abolishing or significantly reducing the waiting periods would ensure more equitable access independent of insurance status. A supplemental shared decision-making tool should be created to assist in assuring informed consent. Agency officials should collaborate with clinical experts and patients with lived experiences when revising this policy. Systems for tracking unfulfilled sterilization requests at the state and federal levels should be adopted, including adding criteria to PRAMS surveys. Clinically, providers in obstetrics need to make a point to ask about postpartum contraception as early the first trimester.
To support these changes, people should stay vigilant for invitations for public comment in the Federal Register and Unified Agenda, submit comments on Regulations.gov, request meetings, mail in written petitions, and reach out to their state’s CMS medical consultant for women’s health. While the history of involuntary sterilization is critical to reflect on, it is imperative to consider changes to policies that, even when initially benevolent, currently obstruct patient sovereignty and advance inequity. This regulation needs to be amended to safeguard evidence-based, patient-centered, equitable, and ethical health care.
Amanda Cassidy, MSN, APRN, WHNP-BC, CLC is a Women’s Health Nurse Practitioner in Maternal Fetal Medicine and an August ’23 Doctor of Nursing Practice graduate at Duke University School of Nursing. She resides in New York City.
