An updated assessment of postpartum sterilization fulfillment after vaginal delivery

Fulfillment of Permanent Contraception among Patients with Cesarean Delivery in a Multi-Site Cohort

OBJECTIVES

This study aimed to assess the association between insurance type and permanent contraception fulfillment among those with cesarean deliveries. Additionally, we sought to examine modification by the scheduled status of the cesarean.

STUDY DESIGN

We used data from a multi-site cohort study of patients who delivered in 2018-2019 at Northwestern Memorial Hospital in Illinois, MetroHealth Medical System in Ohio, or University of Alabama at Birmingham in Alabama. All patients had permanent contraception as their contraceptive plan in their medical chart during delivery hospitalization. We used logistic regression to model the association between insurance type, scheduled status of cesarean and permanent contraception fulfillment by hospital discharge. The scheduled status of cesarean delivery was examined as an effect modifier.

RESULTS

Compared to patients with private insurance, those with Medicaid were less likely to have their desired permanent contraception procedure fulfilled by hospital discharge (89.3% vs. 96.8%, p < 0.001). After adjusting for covariates, patients with Medicaid had a lower odds of permanent contraception fulfillment by hospital discharge (OR: 0.41; 95% CI: 0.21, 0.77). This association was stronger among those who had unscheduled cesarean deliveries (OR: 0.29; 95% CI: 0.12, 0.74) than those with scheduled cesarean deliveries (OR: 0.77; 95% CI: 0.32, 1.88).

CONCLUSIONS FOR PRACTICE

Compared to patients with private insurance undergoing a cesarean delivery, those with Medicaid insurance were less likely to have their desired permanent contraception fulfilled. Physicians and hospitals must examine their practices surrounding Medicaid forms to ensure that patients have valid consent forms available at the time of delivery.

National Postpartum Permanent Contraception Practices and Perceived Barriers

Single institution-level studies have demonstrated low postpartum permanent contraception fulfillment rates after vaginal birth. To explore the national scope of the problem, we collected cross-sectional survey data from faculty at 109 U.S. academic medical centers to elicit perceptions about postpartum permanent contraception practices after vaginal birth, including barriers to and changes in practice after the Dobbs v Jackson Women's Health Organization decision, a decision that eliminated the U.S. federal protection of the right to abortion. Of 68 respondent institutions, 65 (95.6%) offered postpartum permanent contraception. A large majority (87.3%) perceived there to be a problem with postpartum permanent contraception fulfillment at their institution. Respondents at institutions with postpartum permanent contraception fulfillment rates in the bottom quartile used main operating rooms (66.7% vs 25.0% respectively, P =.032) and reported institutional culture barriers (86.7% vs 50.0%, respectively, P =.054) more frequently than respondents in the top quartile. Our national data indicate that health care culture changes and the use of labor and delivery operating rooms could increase postpartum permanent contraception fulfillment.

Documentation of prenatal contraceptive counseling and fulfillment of permanent contraception: a retrospective cohort study

BACKGROUND

Barriers exist for the provision of surgery for permanent contraception in the postpartum period. Prenatal counseling has been associated with increased rates of fulfillment of desired postpartum contraception in general, although it is unclear if there is impact on permanent contraception specifically. Thus, we aimed to investigate the association between initial timing for prenatal documentation of a contraceptive plan for permanent contraception and fulfillment of postpartum contraception for those receiving counseling.

METHODS

This is a planned secondary analysis of a multi-site cohort study of patients with documented desire for permanent contraception at the time of delivery at four hospitals located in Alabama, California, Illinois, and Ohio over a two-year study period. Our primary exposure was initial timing of documented plan for contraception (first, second, or third trimester, or during delivery hospitalization). We used univariate and multivariable logistic regression to analyze fulfillment of permanent contraception before hospital discharge, within 42 days of delivery, and within 365 days of delivery between patients with a documented plan for permanent contraception in the first or second trimester compared to the third trimester. Covariates included insurance status, age, parity, gestational age, mode of delivery, adequacy of prenatal care, race, ethnicity, marital status, and body mass index.

RESULTS

Of the 3103 patients with a documented expressed desire for permanent contraception at the time of delivery, 2083 (69.1%) had a documented plan for postpartum permanent contraception prenatally. After adjusting for covariates, patients with initial documented plan for permanent contraception in the first or second trimester had a higher odds of fulfillment by discharge (aOR 1.57, 95% C.I 1.24-2.00), 42 days (aOR 1.51, 95% C.I 1.20-1.91), and 365 days (aOR 1.40, 95% C.I 1.11-1.75), compared to patients who had their first documented plan in the third trimester.

CONCLUSIONS

Patients who had a documented prenatal plan for permanent contraception in trimester one and two experienced higher likelihood of permanent contraception fulfillment compared to those with documentation in trimester three. Given the barriers to accessing permanent contraception, it is imperative that comprehensive, patient-centered counseling and documentation regarding future reproductive goals begin early prenatally.

Association Among Race, Ethnicity, Insurance Type, and Postpartum Permanent Contraception Fulfillment

OBJECTIVE

To evaluate the association among race, ethnicity, insurance type, and fulfillment of permanent contraception requests.

METHODS

This is a secondary analysis of a retrospective cohort of patients who delivered at 20 or more gestational weeks in a 2-year time period at four hospitals across the United States: University of California San Francisco, Northwestern Memorial Hospital, MetroHealth Medical Center in Cleveland, and University of Alabama at Birmingham. All patients included had permanent contraception documented as their postpartum contraceptive plan. We used modified Poisson models to estimate the associations among race and ethnicity, insurance type, and fulfillment of permanent contraception before hospital discharge, within 6 weeks of delivery, and within 1 year of delivery, adjusting for age, parity, gestational age, delivery type, marital status, body mass index, insurance type, adequacy of prenatal care, and hospital site.

RESULTS

Of 2,945 people in our cohort, 1,243 (42.2%) were non-Hispanic Black, and 820 (27.8%) were Hispanic, and 882 (30.0%) were non-Hispanic White. Overall, 1,731 of 2,945 patients (58.2%) who desired postpartum permanent contraception received it before hospital discharge, 1,746 of 2,945 (59.3%) received it within 6 weeks of delivery, and 1,927 of 2,945 (65.4%) received it within 1 year of delivery. Across all racial and ethnic groups, patients with Medicaid insurance were less likely to have their desired postpartum permanent contraception procedure fulfilled compared with patients with private insurance. In unadjusted models, non-Hispanic Black patients were less likely to have their desired postpartum permanent contraception procedure fulfilled. In an examination of interaction with insurance type, non-Hispanic Black patients with private insurance were less likely to have permanent contraception fulfilled compared with non-Hispanic White patients with private insurance before adjustment. After adjustment, there were no significant associations between race and postpartum permanent contraception fulfillment among those with Medicaid or private insurance.

CONCLUSION

In unadjusted models, we find marked racial disparities in fulfillment of permanent contraception. Controlling for individual- and facility-level factors eliminated associations among race, ethnicity, insurance type, and fulfillment, likely because covariates are mediators on the pathway between racism and fulfillment.

An assessment of postpartum contraception rates with evolving care during the COVID-19 pandemic

Objective

The COVID-19 pandemic presented new care delivery obstacles in the form of scheduling procedures and safe presentation to in-person visits. Contraception provision is an indispensable component of postpartum care that was not immune to these challenges. Given the barriers to care during the initial months of the pandemic, we sought to examine how postpartum contraception, sterilization, and visit attendance were affected during this period.

Study Design.

We performed a retrospective chart review to examine contraception initiation, sterilization, and postpartum virtual and in-person visit attendance rates during the first six months (March 15 to September 7, 2020) of the COVID-19 pandemic compared to the rates in the same period in the year prior at a single tertiary academic care center. We abstracted data from the first prenatal visit through twelve weeks postpartum.

Results

With the initiation of virtual appointments, postpartum visit attendance significantly increased (94.6 % vs 88.4 %, p < 0.001) during the pandemic with no difference in overall contraception uptake (51 % vs 54.1 %, p = 0.2) or sterilization (11.0 % vs 11.5 %, p = 0.88). During the pandemic, contraception prescribed differed significantly with a trend towards patient-administered methods including pills, patches, and rings (21 % vs 16 %, p = 0.02). In both periods, there was a significantly younger mean age (p < 0.001), higher proportion of non-White and non-Asian race (p < 0.001), public insurance (p = 0.003, 0.004), and an established contraceptive plan prenatally (p < 0.001) in the group that received contraception.

Conclusion

As virtual postpartum visits were instituted, contraception initiation and sterilization were maintained at pre-pandemic rates and visit attendance rose despite the obstacles to care presented by the COVID-19 pandemic. Provision of virtual postpartum visits may be a driver to maintain contraception and sterilization rates at a time, such as early in the COVID-19 pandemic, when patient care is at risk to be disrupted by social distancing, isolation, and avoidance of medical campuses.

Medicaid and Fulfillment of Postpartum Permanent Contraception Requests

OBJECTIVE

To evaluate the association between Medicaid insurance and fulfillment of postpartum permanent contraception requests.

METHODS

We conducted a retrospective cohort study of 43,915 patients across four study sites in four states, of whom 3,013 (7.1%) had a documented contraceptive plan of permanent contraception at the time of postpartum discharge and either Medicaid insurance or private insurance. Our primary outcome was permanent contraception fulfillment before hospital discharge; we compared individuals with private insurance with individuals with Medicaid insurance. Secondary outcomes were permanent contraception fulfillment within 42 and 365 days of delivery, as well as the rate of subsequent pregnancy after nonfulfillment. Bivariable and multivariable logistic regression analyses were used.

RESULTS

Patients with Medicaid insurance (1,096/2,076, 52.8%), compared with those with private insurance (663/937, 70.8%), were less likely to receive desired permanent contraception before hospital discharge (P≤.001). After adjustment for age, parity, weeks of gestation, mode of delivery, adequacy of prenatal care, race, ethnicity, marital status, and body mass index, private insurance status was associated with higher odds of fulfillment at discharge (adjusted odds ratio [aOR] 1.48, 95% CI 1.17-1.87) and 42 days (aOR 1.43, 95% CI 1.13-1.80) and 365 days (aOR 1.36, 95% CI 1.08-1.71) postpartum. Of the 980 patients with Medicaid insurance who did not receive postpartum permanent contraception, 42.2% had valid Medicaid sterilization consent forms at the time of delivery.

CONCLUSION

Differences in fulfillment rates of postpartum permanent contraception are observable between patients with Medicaid insurance and patients with private insurance after adjustment for clinical and demographic factors. The disparities associated with the federally mandated Medicaid sterilization consent form and waiting period necessitate policy reassessment to promote reproductive autonomy and to ensure equity.

Swartz J, Stuart GS. Unfulfilled Requests for Postpartum Tubal Ligation at a Southern Tertiary Care Center

BACKGROUND Nationally, multiple barriers lead only 50% of women who request postpartum tubal ligation to receive it prior to discharge. We aimed to identify characteristics associated with unfulfilled requests for postpartum tubal ligation at a tertiary medical center in the South.METHODS We conducted a retrospective chart review of all women delivering a live infant with a documented desire for postpartum sterilization between September 1, 2018, and November 30, 2018. The primary outcome was receipt of postpartum sterilization prior to discharge. We used chi-square and Mann Whitney U tests for descriptive analyses.RESULTS One thousand seventy-two women delivered a live infant at our institution during our sampling frame. One hundred twenty-four had a documented desire for postpartum sterilization (124/1072, 12%). Eighty-one women (81/124, 65%) received their postpartum sterilization and 43 women (43/124, 35%) did not. Women who delivered by cesarean were more likely to receive their postpartum sterilization (63/68; 93%) than if they delivered vaginally (18/56; 32%) (P < .001). Lack of valid Medicaid consent (P = .006) was associated with unfulfilled requests for postpartum sterilization following vaginal delivery while BMI > 40 (P = .158) approached significance.LIMITATIONS Our sample is small and from a single institution. Additionally, the specific reason for tubal ligation nonfulfillment was often not documented.CONCLUSIONS In this Southern institution, women delivering vaginally, those without a valid Medicaid consent form, and women with BMI > 40 were less likely to receive desired postpartum sterilization. Multipronged process changes are needed to fulfill patients' sterilization requests.

Fulfillment of Desired Postpartum Permanent Contraception: a Health Disparities Issue

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.

Desired Sterilization Procedure at the Time of Cesarean Delivery According to Insurance Status

OBJECTIVE

To evaluate whether women with Medicaid are less likely than their privately insured counterparts to receive a desired sterilization procedure at the time of cesarean delivery.

METHODS

This is a secondary analysis of a single-center retrospective cohort examining 8,654 postpartum women from 2012 to 2014, of whom 2,205 (25.5%) underwent cesarean delivery. Insurance was analyzed as Medicaid compared with private insurance. The primary outcome was sterilization at the time of cesarean delivery. Reason for sterilization noncompletion and Medicaid sterilization consent form validity were recorded. Secondary outcomes included postpartum visit attendance, outpatient postpartum sterilization, and subsequent pregnancy within 365 days of delivery.

RESULTS

Of the 481 women included in this analysis, 78 of 86 (90.7%) women with private insurance and 306 of 395 (77.4%) women with Medicaid desiring sterilization obtained sterilization at the time of cesarean delivery (relative risk 0.85, 95% CI 0.78-0.94). After multivariable logistic regression, gestational age at delivery (1.02 [1.00-1.03]), adequacy of prenatal care (1.30 [1.18-1.43]), and marital status (1.09 [1.01-1.19]) were associated with achievement of sterilization at the time of cesarean delivery. Sixty-four (66.0%) women who desired but did not receive sterilization at the time of cesarean delivery did not have valid, signed Medicaid sterilization forms, and 10 (10.3%) sterilizations were not able to be completed at the time of surgery owing to adhesions. Sterilization during cesarean delivery was not associated with less frequent postpartum visit attendance for either the Medicaid or privately insured population. Rates of outpatient postpartum sterilization were similar among those with Medicaid compared with private insurance. Among patients who did not receive sterilization at the time of delivery, 15 patients (each with Medicaid) had a subsequent pregnancy within the study period.

CONCLUSION

Women with Medicaid insurance received sterilization at the time of cesarean delivery less frequently than privately insured counterparts, most commonly due to the absence of a valid Medicaid sterilization consent form as well as adhesive disease. The constraints surrounding the Medicaid form serve as a significant barrier to achieving desired sterilization.

Relationship between body mass index and operative time in women receiving immediate postpartum tubal ligation

OBJECTIVES

The aim of the study was to (1) assess the relationship between body mass index (BMI) and operative time during immediate postpartum tubal ligation procedures and to (2) determine whether operative time is non-inferior in women with BMI ≥30 versus women with BMI <30 and in women with BMI ≥40 versus women with BMI <40.

STUDY DESIGN

We conducted a retrospective cohort study of women who received immediate postpartum tubal ligations following vaginal delivery from 2013 to 2017 at a university hospital. We abstracted demographic information, patient and procedural characteristics, and clinical outcomes. We assessed the relationship between BMI and operative time via linear regression. We also conducted non-inferiority analysis to determine whether the mean operative time in women with BMI ≥30 was non-inferior to the mean operative time in women with BMI <30, within a non-inferiority margin of 10 min. We compared intraoperative and postoperative complications in the two groups.

RESULTS

A total of 279 women were included for analysis, among whom N=79 (28%) had a BMI of 25-29.9 and N=171 (61%) had a BMI ≥30. Demographic characteristics were similar in both groups. We found that operative time increased by 35 s for each one-point increase in BMI (p<.01). Although mean operative time was 46.1 min (n=171; 95% CI 43.7, 48.6 min) for women with BMI ≥30 and 40.6 min (n=108; 95% CI 37.9 min, 43.4 min) for women with BMI <30, (p<.01), it was non-inferior within a 10-min margin. There was no difference in rates of intraoperative or postoperative complications, incision length, total anesthesia time, and median length of stay between women with BMI ≥30 and BMI <30.

CONCLUSION

There is a small increase in postpartum tubal ligation operative time with increasing BMI. However, among women who received immediate postpartum tubal ligations at our institution, women with BMI ≥30 versus BMI <30 had operative times that were non-inferior within a 10-min margin.

IMPLICATIONS

While increasing body mass index slightly increases the operative time for immediate postpartum tubal ligations, this increase in time does not appear to be clinically significant.

Women's preferences for permanent contraception method and willingness to be randomized for a hypothetical trial

OBJECTIVE

To understand women's preferences for permanent contraception by salpingectomy or tubal occlusion following standardized counseling and evaluate the practicality of a future randomized trial.

STUDY DESIGN

We invited pregnant and non-pregnant women planning permanent contraception at the University of California, Davis (UCD) and University of Tennessee (UT) Obstetrics and Gynecology clinics to participate. We enrolled women when they received routine counseling and signed procedure consent. Participants received standardized information sheets reviewing permanent contraception options based on pregnancy status then completed an anonymous survey with questions about demographics, method preference, and willingness to participate in a hypothetical randomized trial comparing salpingectomy and tubal occlusion. We evaluated predictors for salpingectomy preference using multivariable analysis.

RESULTS

From July 2015 to October 2016, we enrolled 75 women at UCD and 63 women at UT. Overall, respondents preferred salpingectomy (63.0%); among the 47 women not currently pregnant at both sites, 40 (85.1%) preferred salpingectomy, most commonly because of higher efficacy. Although population characteristics differed significantly between the sites, only UCD site (aOR 4.2; 95% CI 1.9, 9.4) and non-pregnancy status (aOR 4.2; 95% CI 1.6, 10.8) predicted preference for salpingectomy in the multivariable model. Most participants (n=84, 60.9%) would not be willing to be randomized to a theoretical trial comparing salpingectomy and tubal occlusion procedures.

CONCLUSION

Among a diverse group of women from two different areas in the U.S. given a choice of permanent contraception methods, salpingectomy is preferred over tubal occlusion. Most women planning a permanent contraceptive procedure would not agree to a randomized comparison of these methods.

IMPLICATIONS STATEMENT

Salpingectomy, which offers theoretically higher efficacy and potentially greater ovarian cancer protection compared to tubal occlusion, is preferred by the majority of patients and should be offered to all women seeking permanent contraception. Differences in method choices less likely reflect the patient population and more likely the counseling provided.

Medicaid and fulfillment of desired postpartum sterilization

OBJECTIVE

We sought to assess fulfillment of sterilization requests while accounting for the complex interplay between insurance, clinical and social factors in a contemporary context that included both inpatient and outpatient postpartum sterilization procedures.

STUDY DESIGN

This is a retrospective single-center cohort chart review study of 1331 women with a documented contraceptive plan at time of postpartum discharge of sterilization. We compared sterilization fulfillment within 90days of delivery, time to sterilization and rate of subsequent pregnancy after nonfulfillment between women with Medicaid and women with private insurance.

RESULTS

A total of 475 of 1030 Medicaid-insured and 100 of 154 privately insured women received postpartum sterilization (46.1% vs. 64.9%, p<.001). Women with Medicaid had a longer time from delivery to completion of the sterilization request (p<.001). After adjusting for age, parity, gestational age, mode of delivery, adequacy of prenatal care, race/ethnicity, marital status and education level, private insurance status was not associated with either sterilization fulfillment [odds ratio 0.94, 95% confidence interval (CI) 0.54-1.64] or time to sterilization (hazard ratio 1.03, 95% C.I. 0.73-1.34). Of the 555 Medicaid-insured women who did not receive a postpartum sterilization, 267 (48.1%) had valid Title XIX sterilization consent forms at time of delivery. Of women who did not receive sterilization, 132 of 555 Medicaid patients and 5 of 54 privately insured patients became pregnant within 1 year (23.8% vs. 9.3%, p=.023).

CONCLUSION

Differences in fulfillment rates of postpartum sterilization and time to sterilization between women with Medicaid versus private insurance are similar after adjusting for relevant clinical and demographic factors. Women with Medicaid are more likely than women with private insurance to have a short interval repeat pregnancy after an unfulfilled sterilization request.

IMPLICATIONS

Efforts are needed to ensure that Medicaid recipients who desire sterilization receive timely services.