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Brown JA, Huff ML, Arboleda BL, Louis JM. The Relationship between Body Mass Index and Operative Complications in Patients undergoing Immediate Postpartum Tubal Ligation. Am J Perinatol 2024; 41:909-914. [PMID: 35253112 DOI: 10.1055/a-1788-4900] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
OBJECTIVE The objective of this study is to examine the relationship between body mass index (BMI) and complications for patients undergoing postpartum permanent contraception. STUDY DESIGN Retrospective cohort study of patients aged 18 or older who had a vaginal delivery at an academic hospital between 2011 and 2016 and underwent a postpartum tubal ligation during the delivery admission. There were three comparative groups: nonobese (BMI ≤ 29 kg/m2), obese (BMI 30-39 kg/m2), and morbidly obese BMI (≥40 kg/m2). The outcome of interest was composite operative complications which included any occurrence of an intraoperative, postoperative, or anesthesia complication. RESULTS A total of 921 patients were included for analysis. Average operative time was statistically longer for patients in the morbidly obese group (33 minutes) vs. the nonobese (25 minutes) and obese (29 minutes) groups (p < 0.0001). Composite complications were greater for the obese groups, but not statistically significant (5.1 vs. 6 vs. 16%, p = 0.06). Wound complications were significantly greater for the obese groups (0.8 vs. 1.5 vs. 5.5%, p = 0.01). A logistic regression model demonstrated that only operative time was predictive of operative complications. CONCLUSION Overall complications of postpartum tubal complications are low; however, our study did demonstrate significantly longer operative time and wound complications for patients with obesity. The findings of our study indicate that postpartum permanent contraception can remain as an option for these patients. Further studies may help identify the best practices to decrease operative time and subsequent wound complications. This study contributes to the limited data regarding obesity and postpartum permanent contraception. We found increased operative time and wound complications for obese patients. Additional studies may identity best practices to decrease these complications. Given our findings of overall low operative complications, postpartum permanent contraception can remain an option for obese patients.
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Affiliation(s)
- Jewel A Brown
- Department of Obstetrics and Gynecology, University of South Florida Morsani College of Medicine, Tampa, Florida
- Tampa General Circle, STC, Tampa, Florida
- Department of Obstetrics and Gynecology, University of California Davis Health, Sacramento, California
| | - Mallorie L Huff
- Department of Obstetrics and Gynecology, University of South Florida Morsani College of Medicine, Tampa, Florida
| | - Bianca L Arboleda
- Department of Obstetrics and Gynecology, University of South Florida Morsani College of Medicine, Tampa, Florida
- Department of Obstetrics and Gynecology, University of Kentucky, Lexington, Kentucky
| | - Judette M Louis
- Department of Obstetrics and Gynecology, University of South Florida Morsani College of Medicine, Tampa, Florida
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Cosgriff L, Plummer M, Concepcion G, Danvers AA. Outcomes for Women Denied Postpartum Tubal Ligation During the Initial COVID-19 Surge. WOMEN'S HEALTH REPORTS (NEW ROCHELLE, N.Y.) 2024; 5:352-357. [PMID: 38666225 PMCID: PMC11044855 DOI: 10.1089/whr.2023.0142] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Accepted: 01/13/2024] [Indexed: 04/28/2024]
Abstract
Objective To evaluate the utilization and outcomes of postpartum long-acting reversible contraception (PPLARC) following unmet postpartum bilateral tubal ligation (PPBTL) requests during a time in which elective surgeries were canceled due to the initial COVID-19 surge. Methods We conducted a mixed-methods study using an embedded design. Using a retrospective cohort design, we collected data from patients seeking PPBTL following vaginal delivery between March 15, 2020, and June 20, 2020; this reflects a time period during which elective surgery was canceled thus making PPBTL unavailable. We recorded demographic data, method of contraception at time of discharge and 18 months postpartum, and incidence of interval pregnancy at 18 months postpartum. Additionally, we conducted five semistructured interviews to gain deeper insights into patient experiences with PPLARC as a bridge method. Results Forty-five patients had unfilled PPBTL requests with follow-up data available for 35. The median age was 34 years. Ten (22%) accepted PPLARC as a bridge to interval bilateral tubal ligation (BTL). At the 18-month mark, only 1 out of 7 (14.3%) PPLARC users had undergone an interval BTL procedure, compared to 11 out of 28 (39.3%) nonusers. None of the PPLARC users experienced pregnancies, while 6 out of 28 (21.6%) nonusers became pregnant. Qualitative interviews underscored themes such as inadequate counseling preparation for unmet PPBTL requests and persistent barriers to BTL access. Conclusions Raising awareness of unmet PPBTL risks may drive greater adoption of PPLARC as a bridge method. While not a substitution for PPTBL, PPLARC provides a reliable form of interval contraception for patients seeking to delay pregnancy. It is essential to recognize that patient security with PPLARC's contraceptive efficacy may introduce delays in achieving the desired interval sterilization. Enhancing antenatal counseling on contraception options and providing transparency regarding barriers to sterilization could mitigate the challenges associated with unmet PPBTL requests.
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Affiliation(s)
- Lauren Cosgriff
- Department of Obstetrics, Gynecology and Women's Health, Albert Einstein College of Medicine/Montefiore Medical Center, Bronx, New York, USA
| | - Melissa Plummer
- Department of Obstetrics and Gynecology, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Gabrielle Concepcion
- Department of Obstetric and Gynecology, New York University School of Medicine, New York, New York, USA
| | - Antoinette A. Danvers
- Department of Obstetrics, Gynecology and Women's Health, Albert Einstein College of Medicine/Montefiore Medical Center, Bronx, New York, USA
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3
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Chesnokova A, Christensen T, Streaty T, McAllister A, Schachter A, Polite F, Sonalkar S. 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. [PMID: 39248319 DOI: 10.1016/j.ajog.2023.10.039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2023] [Revised: 09/29/2023] [Accepted: 10/24/2023] [Indexed: 09/10/2024]
Abstract
BACKGROUND Medicaid, unlike any other insurance mechanism, imposes a consent requirement on female patients desiring sterilization that must be completed at least 30 days, but no more than 180 days, before sterilization. Desired sterilization cannot be completed in the Medicaid population without this consent. Large-scale national evidence is lacking on the effect of this requirement. OBJECTIVE This study aimed to explore the influence of insurance status on the achievement of postpartum sterilization after a self-reported unwanted birth in a nationally representative sample. STUDY DESIGN This was a retrospective cohort analysis using data from the 2013-2015 National Survey of Family Growth. The National Survey of Family Growth uses a stratified, multistage clustered sample to make nationally representative estimates for men and women aged 15 to 44 years in the household population of the United States. The analysis was limited to a cohort of birthing people who reported their last birth as unwanted and who were insured by either Medicaid or private insurance. The survey was analyzed with the application of inverse probability of treatment weights to balance those with Medicaid and those with private insurance in addition to the survey weight. The association between completion of postpartum sterilization and insurance type was evaluated using weighted logistic regression, adjusting for demographic and clinical characteristics. RESULTS In an adjusted and inverse probability of treatment weight balanced analysis of a weighted national sample representing 4,164,304 people (416 respondents), Medicaid-insured birthing people with history of unwanted births were found to have 56% lower odds of obtaining postpartum sterilization (odds ratio, 0.44; 95% confidence interval, 0.22-0.87; P=.019) than those with private insurance. CONCLUSION This study adds to mounting evidence that insurance type plays a significant role in the achievement of desired postpartum sterilization, with individuals with Medicaid less likely to undergo the procedure. The findings call for policy reforms around sterilization policy in the United States, emphasizing the need for uniform consent procedures that do not discriminate based on insurance status.
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Affiliation(s)
- Arina Chesnokova
- Department of Obstetrics and Gynecology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA.
| | - Theresa Christensen
- Department of Obstetrics and Gynecology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Taylor Streaty
- Department of Obstetrics and Gynecology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Arden McAllister
- Department of Obstetrics and Gynecology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Allison Schachter
- Department of Obstetrics and Gynecology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Florencia Polite
- Department of Obstetrics and Gynecology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Sarita Sonalkar
- Department of Obstetrics and Gynecology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
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4
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Dahl CM, Turok D, Heuser CC, Sanders J, Elliott S, Pangasa M. Strategies for obstetricians and gynecologists to advance reproductive autonomy in a post-Roe landscape. Am J Obstet Gynecol 2024; 230:226-234. [PMID: 37536485 DOI: 10.1016/j.ajog.2023.07.055] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2023] [Revised: 07/18/2023] [Accepted: 07/26/2023] [Indexed: 08/05/2023]
Abstract
The monumental reversal of Roe vs Wade dramatically impacted the landscape of reproductive healthcare access in the United States. The decision most significantly affects communities that historically have been and continue to be marginalized by systemic racism, classism, and ableism within the medical system. To minimize the harm of restrictive policies that have proliferated since the Supreme Court overturned Roe, it is incumbent on obstetrician-gynecologists to modify practice patterns to meet the pressing reproductive health needs of their patients and communities. Change will require cross-discipline advocacy focused on advancing equity and supporting the framework of reproductive justice. Now, more than ever, obstetrician-gynecologists have a critical responsibility to implement new approaches to service delivery and education that will expand access to evidence-based, respectful, and person-centered family planning and early pregnancy care regardless of their practice location or subspecialty.
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Affiliation(s)
- Carly M Dahl
- Department of Obstetrics and Gynecology, University of Utah Health, Salt Lake City UT; Department of Obstetrics and Gynecology, Intermountain Health, Salt Lake City UT.
| | - David Turok
- Department of Obstetrics and Gynecology, University of Utah Health, Salt Lake City UT
| | - Cara C Heuser
- Department of Obstetrics and Gynecology, University of Utah Health, Salt Lake City UT; Department of Obstetrics and Gynecology, Intermountain Health, Salt Lake City UT
| | - Jessica Sanders
- Department of Obstetrics and Gynecology, University of Utah Health, Salt Lake City UT
| | - Sarah Elliott
- Department of Obstetrics and Gynecology, University of Utah Health, Salt Lake City UT
| | - Misha Pangasa
- Department of Obstetrics and Gynecology, University of Utah Health, Salt Lake City UT
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Arora KS, Chua A, Miller E, Boozer M, Serna T, Bullington BW, White K, Gunzler DD, Bailit JL, Berg K. Medicaid and Fulfillment of Postpartum Permanent Contraception Requests. Obstet Gynecol 2023; 141:918-925. [PMID: 37103533 PMCID: PMC10154035 DOI: 10.1097/aog.0000000000005130] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2022] [Accepted: 01/12/2023] [Indexed: 04/28/2023]
Abstract
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.
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Affiliation(s)
- Kavita Shah Arora
- Department of Obstetrics and Gynecology, the Department of Epidemiology, Gillings School of Global Public Health, and the Carolina Population Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina; the Department of Obstetrics and Gynecology and the Center for Health Care Research and Policy, Population Health Research Institute, MetroHealth Medical System, Cleveland, Ohio; the Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Warren Alpert Medical School of Brown University, Providence, Rhode Island; the Department of Obstetrics and Gynecology, University of Alabama at Birmingham, Birmingham, Alabama; the Department of Obstetrics and Gynecology, University of California, San Francisco, San Francisco, California; and the Department of Sociology, Steve Hicks School of Social Work, University of Texas at Austin, Austin, Texas
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Stewart JK, Hipolito Canario DA, Daso G, Thapa D, Montgomery S, Kohi M. Use of n-Butyl-2-Cyanoacrylate for Fallopian Tube Embolization via Selective Catheterization in a Rabbit Model: Feasibility Study for Potential Nonsurgical Sterilization. J Vasc Interv Radiol 2023; 34:225-233. [PMID: 36306987 DOI: 10.1016/j.jvir.2022.10.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2022] [Revised: 10/08/2022] [Accepted: 10/16/2022] [Indexed: 11/05/2022] Open
Abstract
PURPOSE To determine whether fallopian tube embolization with n-butyl-2-cyanoacrylate (nBCA) administered via a microcatheter in a rabbit model was technically feasible and resulted in short-term tubal occlusion. MATERIALS AND METHODS In 10 female New Zealand white rabbits, the 2 cervices were cannulated using a 5-F catheter and hydrophilic guide wire transvaginally. Salpingography confirmed tubal patency bilaterally. A 2.4-F microcatheter was advanced to the distal fallopian tube, and nBCA/ethiodized oil was administered as the microcatheter was withdrawn to fill the length of the tube. A metallic coil was deployed prior to nBCA administration in half of the fallopian tubes. Rabbits were evaluated for tubal occlusion with salpingography at 1 month, followed by euthanasia and histopathologic analysis. Inflammation and fibrosis were graded from 0 (normal) to 3 (severe). RESULTS Fallopian tube embolization was technically successful in 17 (85%) of 20 fallopian tubes. Thirteen (76%) of 17 embolized fallopian tubes were occluded at 1 month on salpingography (nBCA only, 7/9; nBCA and coil, 6/8). On histopathologic analysis, direct or indirect evidence of occlusion was observed in 14 (82%) of 17 fallopian tubes. Mild or early fibrosis was observed in 65% of the tubes. The mean inflammation and fibrosis scores for the embolized tubes were 0.62 and 0.94, respectively. CONCLUSIONS This pilot study demonstrated that embolization of rabbit fallopian tubes using nBCA administered via a microcatheter is technically feasible and results in occlusion of most fallopian tubes in the short term with minimal inflammation. Investigation of efficacy in preventing pregnancy over the long term is warranted.
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Affiliation(s)
- Jessica K Stewart
- Division of Interventional Radiology, Department of Radiological Sciences, David Geffen School of Medicine at UCLA, Los Angeles, California.
| | - Diego A Hipolito Canario
- Department of Radiology, University of North Carolina School of Medicine, Chapel Hill, North Carolina
| | - Gabrielle Daso
- Division of Interventional Radiology, Department of Radiological Sciences, David Geffen School of Medicine at UCLA, Los Angeles, California
| | - Diwash Thapa
- Department of Radiology, University of North Carolina School of Medicine, Chapel Hill, North Carolina
| | - Stephanie Montgomery
- Department of Pathology and Laboratory Medicine, University of North Carolina School of Medicine, Chapel Hill, North Carolina
| | - Maureen Kohi
- Department of Radiology, University of North Carolina School of Medicine, Chapel Hill, North Carolina
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Uaamnuichai S, Phutrakool P, Thammasitchai N, Sathitloetsakun S, Santibenchakul S, Jaisamrarn U. Does socioeconomic factors and healthcare coverage affect postpartum sterilization uptake in an urban, tertiary hospital? Reprod Health 2023; 20:23. [PMID: 36707807 PMCID: PMC9881507 DOI: 10.1186/s12978-023-01572-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2022] [Accepted: 01/20/2023] [Indexed: 01/28/2023] Open
Abstract
BACKGROUND Postpartum sterilization in Thailand has relatively few barriers compared to other countries. The procedure is covered by some healthcare plans, and paid out-of-pocket for others. We aim to determine if healthcare coverage and other socioeconomic factors affect the rate of postpartum sterilization in an urban, tertiary hospital. METHODS We conducted a secondary analysis of data from a retrospective cohort of 4482 postpartum women who delivered at our hospital. Multivariable logistic regression was conducted to determine if sterilization reimbursement affects immediate postpartum sterilization rate. RESULTS Overall immediate postpartum sterilization rate was 17.8%. Route of delivery and parity were similar in those who were reimbursed and those who were not. Women aged over 25 were more likely to have a healthcare plan that does not cover postpartum sterilization. Women whose healthcare plan reimbursed the procedure trended towards postpartum sterilization when compared to women who were not (aOR 1.05, 95% CI 0.86-1.28, p-value = 0.632). Women who delivered via cesarean section were more likely to undergo sterilization at the time of delivery (aOR = 5.87; 95% CI 4.77-7.24, p-value = < 0.001). Women aged 40-44 years were 2.70 times as likely to choose sterilization than those aged 20-24 years (aOR = 2.70; 95% CI 1.61-4.53, p-value < 0.001). CONCLUSIONS Healthcare coverage of the procedure was not associated with increased postpartum sterilization in our setting.
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Affiliation(s)
- Sutira Uaamnuichai
- grid.411628.80000 0000 9758 8584Department of Obstetrics and Gynecology, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, 1873 Rama IV Road, Patum Wan, Bangkok, 10330 Thailand
| | - Phanupong Phutrakool
- grid.7922.e0000 0001 0244 7875Chula Data Management Center, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Nareerat Thammasitchai
- grid.411628.80000 0000 9758 8584Nursing Department, King Chulalongkorn Memorial Hospital, Bangkok, Thailand
| | - Sarochinee Sathitloetsakun
- grid.7922.e0000 0001 0244 7875Department of Obstetrics and Gynecology, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Somsook Santibenchakul
- grid.411628.80000 0000 9758 8584Department of Obstetrics and Gynecology, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, 1873 Rama IV Road, Patum Wan, Bangkok, 10330 Thailand
| | - Unnop Jaisamrarn
- grid.7922.e0000 0001 0244 7875Department of Obstetrics and Gynecology, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
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McNamee K, Edelman A, Li RHW, Kaur S, Bateson D. Best Practice Contraception Care for Women with Obesity: A Review of Current Evidence. Semin Reprod Med 2022; 40:246-257. [PMID: 36746158 DOI: 10.1055/s-0042-1760214] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
The prevalence of obesity among females of reproductive age is increasing globally. Access to the complete range of appropriate contraceptive options is essential for upholding the reproductive rights of this population group. People with obesity can experience stigma and discrimination when seeking healthcare, and despite limited evidence for provider bias in the context of contraception, awareness for its potential at an individual provider and health systems level is essential. While use of some hormonal contraceptives may be restricted due to increased health risks in people with obesity, some methods provide noncontraceptive benefits including a reduced risk of endometrial cancer and a reduction in heavy menstrual bleeding which are more prevalent among individuals with obesity. In addition to examining systems-based approaches which facilitate the provision of inclusive contraceptive care, including long-acting reversible contraceptives which require procedural considerations, this article reviews current evidence on method-specific advantages and disadvantages for people with obesity to guide practice and policy.
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Affiliation(s)
| | - Alison Edelman
- Department of Obstetrics and Gynecology, School of Medicine, Oregon Health and Science University, Portland, Oregon
| | - Raymond Hang Wun Li
- Department of Obstetrics and Gynaecology, Queen Mary Hospital, University of Hong Kong, Hong Kong, Hong Kong
| | - Simranvir Kaur
- Department of Obstetrics and Gynecology, Stanford University School of Medicine, Palo Alto, California
| | - Deborah Bateson
- Faculty of Medicine and Health, Daffodil Centre, University of Sydney, Sydney, Australia
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9
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Rosser CL, J. Swartz J, Stuart GS. Unfulfilled Requests for Postpartum Tubal Ligation at a Southern Tertiary Care Center. N C Med J 2022; 83:448-453. [PMID: 36344087 PMCID: PMC9851670 DOI: 10.18043/ncm.83.6.448] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
Abstract
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.
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Affiliation(s)
- Casey L Rosser
- Department of Obstetrics and Gynecology, Kaiser San Bernadino County, Fontana, California
| | - Jonas J. Swartz
- Department of Obstetrics and Gynecology, Duke University School of Medicine, Durham, North Carolina.
| | - Gretchen S Stuart
- Department of Obstetrics and Gynecology, University of North Carolina School of Medicine, Chapel Hill, North Carolina
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10
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Chen MJ, Kair LR, Schwarz EB, Creinin MD, Chang JC. Future Pregnancy Considerations after Premature Birth of an Infant Requiring Intensive Care: A Qualitative Study. Womens Health Issues 2022; 32:484-489. [PMID: 35491347 PMCID: PMC9532354 DOI: 10.1016/j.whi.2022.03.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2021] [Revised: 03/09/2022] [Accepted: 03/24/2022] [Indexed: 11/16/2022]
Abstract
BACKGROUND Postpartum contraception counseling and method use vary widely among patients who had a preterm birth. We performed this study to explore what issues and concerns individuals with preterm infants requiring intensive care describe as influencing their postpartum contraceptive choices. METHODS We conducted a qualitative study using semi-structured interviews with participants who gave birth to a singleton preterm infant admitted to the neonatal intensive care unit (NICU). We explored pregnancy, childbirth, postpartum care, and NICU experiences, as well as future reproductive plans and postpartum contraceptive choices. Two coders used a constant-comparative approach to code transcripts and identify themes. RESULTS We interviewed 26 participants: 4 (15%) gave birth at less than 26, 6 (23%) at 26 to 27 6/7, 8 (31%) at 28 to 31 6/7, and 8 (31%) at 32 to 36 6/7 weeks of gestation. We identified three main themes related to future pregnancy plans and contraception choice. First, participants frequently described their preterm birth and their infants' NICU hospitalization as traumatic experiences that affected plans for future pregnancies. The loss of control in predicting or preventing a future preterm birth and uncertainty about their premature child's future medical needs resulted in participants wanting to avoid going through the same experience with another child. Second, participants chose contraception based on previous personal experiences, desired method features, and advice from others. Last, having a preterm birth did not result in any ambivalence among those who desired permanent contraception. CONCLUSIONS Preterm birth influences future pregnancy plans. When discussing reproductive goals with patients, clinicians should be aware of potential trauma associated with a premature birth, assess for whether patients want to discuss contraception, and center the conversation around individual needs if patients do desire contraceptive counseling.
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Affiliation(s)
- Melissa J Chen
- Department of Obstetrics and Gynecology, University of California, Davis, Sacramento, California.
| | - Laura R Kair
- Department of Pediatrics, University of California, Davis, Sacramento, California
| | - E Bimla Schwarz
- Division of General Internal Medicine, Department of Medicine, University of California, San Francisco, San Francisco General Hospital, San Francisco, California
| | - Mitchell D Creinin
- Department of Obstetrics and Gynecology, University of California, Davis, Sacramento, California
| | - Judy C Chang
- Departments of Obstetrics, Gynecology & Reproductive Sciences and Internal Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
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11
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Russell CB, Qasba N, Evans ML, Frankel A, Arora KS. Variation in the interpretation and application of the Medicaid sterilization consent form among Medicaid officials. Contraception 2022; 109:57-61. [PMID: 35038447 PMCID: PMC9403908 DOI: 10.1016/j.contraception.2022.01.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2021] [Revised: 01/01/2022] [Accepted: 01/07/2022] [Indexed: 11/03/2022]
Abstract
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.
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Affiliation(s)
- Colin B Russell
- University of Michigan, Department of Obstetrics and Gynecology, Ann Arbor, MI, United States; Tufts University School of Medicine, Boston, MA, United States.
| | - Neena Qasba
- University of Massachusetts Medical School-Baystate Medical Center, Department of Obstetrics and Gynecology, Springfield, MA, United States
| | - Megan L Evans
- Tufts Medical Center, Department of Obstetrics and Gynecology, Boston, MA, United States
| | - Angela Frankel
- Tufts University School of Medicine, Boston, MA, United States
| | - Kavita Shah Arora
- Department of Obstetrics and Gynecology, MetroHealth Medical Center, Case Western Reserve University, Cleveland OH, United States; Department of Bioethics - Case Western Reserve University, Biomedical Research Building, Cleveland, OH, United States
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12
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Byrne JJ, Smith EM, Saucedo AM, Doody KA, Holcomb D, Spong CY. Accessibility to postpartum tubal ligation after a vaginal delivery: When the Medicaid policy is not a limiting factor. Contraception 2022; 109:52-56. [PMID: 34971610 DOI: 10.1016/j.contraception.2021.11.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2021] [Revised: 11/22/2021] [Accepted: 11/22/2021] [Indexed: 11/03/2022]
Abstract
OBJECTIVE To describe rates of postpartum sterilization and indications for unfulfilled requests when Medicaid policy is not a limiting factor. STUDY DESIGN We conducted a single-institution, retrospective review. Women who requested postpartum tubal ligation after vaginal delivery from August 2015 to March 2019 were studied. Select demographic characteristics were compared between those who did and did not undergo the procedure. Reasons for why the procedure was cancelled, alternate contraceptive plans, and subsequent pregnancies were collected. Statistical analysis included the t test and chi-squared test, with p < 0.05 considered significant. RESULTS A total of 4103 patients requested postpartum tubal ligation following vaginal delivery. About 3670 (89.4%) procedures were performed and 433 (10.6%) were canceled. Of the 433, 423 (98%) were not performed at patient request; 10 (2 %) were cancelled based on physician recommendation. Of these, 3 were due to significant maternal anemia in the setting of refusal of blood products, 1 due to anesthesia concerns, 1 for increased body mass index, and 1 due to delivery events. Alternative contraception methods were offered; 72 (28% of patients not receiving a tubal ligation) received Depo Provera prior to discharge. One-fourth (n = 110, 25.4%) did not keep the postpartum follow-up appointment. 83 (19.2%) of the 433 patients had at least one subsequent pregnancy. Although over half expressed interest at the time of discharge in long-acting reversible contraceptives, only 20% obtained this method at the postpartum visit. CONCLUSIONS Postpartum sterilization was predominantly achieved, among women whose requests were unfulfilled, the majority (98%) were at patient request with a minority by physician recommendation. IMPLICATIONS When the availability of postpartum tubal ligation is independent of Medicaid reimbursement and the hospital system and providers are organized to support timely access to permanent postpartum contraception, the majority of tubal ligations requests can be fulfilled following vaginal delivery.
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Affiliation(s)
- John J Byrne
- Department of Obstetrics and Gynecology, University of Texas Southwestern Medical Center, Parkland Health and Hospital System, Dallas, Texas.
| | - Emma M Smith
- Department of Obstetrics and Gynecology, University of Texas Southwestern Medical Center, Parkland Health and Hospital System, Dallas, Texas
| | - Alexander M Saucedo
- Department of Obstetrics and Gynecology, University of Texas Southwestern Medical Center, Parkland Health and Hospital System, Dallas, Texas
| | - Kaitlin A Doody
- Department of Obstetrics and Gynecology, University of Texas Southwestern Medical Center, Parkland Health and Hospital System, Dallas, Texas
| | - Denisse Holcomb
- Department of Obstetrics and Gynecology, University of Texas Southwestern Medical Center, Parkland Health and Hospital System, Dallas, Texas
| | - Catherine Y Spong
- Department of Obstetrics and Gynecology, University of Texas Southwestern Medical Center, Parkland Health and Hospital System, Dallas, Texas
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Henkel A, Beshar I, Goldthwaite LM. Postpartum permanent contraception: updates on policy and access. Curr Opin Obstet Gynecol 2021; 33:445-452. [PMID: 34534995 DOI: 10.1097/gco.0000000000000750] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
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.
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Affiliation(s)
- Andrea Henkel
- Division of Family Planning Services & Research, Department of Obstetrics & Gynecology, Stanford University, Stanford, California, USA
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14
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Ng J, Ho D, Patel JM, Esguerra C, Schuster M, Amico J. Investigating Barriers to Completion of Postpartum Tubal Ligation: A Retrospective Chart Review. South Med J 2021; 114:675-679. [PMID: 34729609 DOI: 10.14423/smj.0000000000001316] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
OBJECTIVES To identify the completion rate for postpartum tubal ligation (PPTL) and predictors of noncompletion of PPTL in a central New Jersey population. METHODS We conducted a retrospective chart review at a tertiary care center in New Jersey for patients delivering during an 18-month period. We used the electronic medical record to identify all of the patients who had documented desire for a PPTL at the time of admission. We calculated the rate of PPTL completion and identified predictors of completion and risk factors for noncompletion. We recorded any documented reasons for cancellation and choice of contraception after noncompletion. RESULTS Of 626 women who requested PPTL on admission, 508 (81.2%) procedures were performed. The most common reasons for noncompletion were patient changing her mind (38.1%) and unknown/not documented (22.9%). Cesarean delivery was the strongest predictor of completion, with 93.4% completion among cesarean deliveries compared with 65.6% among vaginal deliveries (P < 0.01). Lack of insurance also was associated with noncompletion (P < 0.01). There was no difference in body mass index (P = 0.75), gravidity (P = 0.99), parity (P = 0.72), or high-risk status (P = 0.47) between completed and noncompleted PPTL. CONCLUSIONS Cesarean delivery is a strong predictor of PPTL completion, most likely because of easier availability of the operating room, anesthesia, and ancillary staff. Body mass index, gravidity, and parity are not associated with PPTL completion. Future research should focus on exploring whether this association is system, provider, or patient dependent.
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Affiliation(s)
- June Ng
- From the Department of Obstetrics, Gynecology, and Women's Health, Albert Einstein College of Medicine/Montefiore Medical Center, Bronx, New York, the Department of Obstetrics, Gynecology, and Reproductive Sciences Rutgers-Robert Wood Johnson Medical School, New Brunswick, New Jersey, the Department of Obstetrics and Gynecology, Johns Hopkins Medicine, Baltimore, Maryland, and the Department of Family Medicine and Community Health Rutgers - Robert Wood Johnson Medical School, New Brunswick, New Jersey
| | - Diana Ho
- From the Department of Obstetrics, Gynecology, and Women's Health, Albert Einstein College of Medicine/Montefiore Medical Center, Bronx, New York, the Department of Obstetrics, Gynecology, and Reproductive Sciences Rutgers-Robert Wood Johnson Medical School, New Brunswick, New Jersey, the Department of Obstetrics and Gynecology, Johns Hopkins Medicine, Baltimore, Maryland, and the Department of Family Medicine and Community Health Rutgers - Robert Wood Johnson Medical School, New Brunswick, New Jersey
| | - Jharna M Patel
- From the Department of Obstetrics, Gynecology, and Women's Health, Albert Einstein College of Medicine/Montefiore Medical Center, Bronx, New York, the Department of Obstetrics, Gynecology, and Reproductive Sciences Rutgers-Robert Wood Johnson Medical School, New Brunswick, New Jersey, the Department of Obstetrics and Gynecology, Johns Hopkins Medicine, Baltimore, Maryland, and the Department of Family Medicine and Community Health Rutgers - Robert Wood Johnson Medical School, New Brunswick, New Jersey
| | - Cybill Esguerra
- From the Department of Obstetrics, Gynecology, and Women's Health, Albert Einstein College of Medicine/Montefiore Medical Center, Bronx, New York, the Department of Obstetrics, Gynecology, and Reproductive Sciences Rutgers-Robert Wood Johnson Medical School, New Brunswick, New Jersey, the Department of Obstetrics and Gynecology, Johns Hopkins Medicine, Baltimore, Maryland, and the Department of Family Medicine and Community Health Rutgers - Robert Wood Johnson Medical School, New Brunswick, New Jersey
| | - Meike Schuster
- From the Department of Obstetrics, Gynecology, and Women's Health, Albert Einstein College of Medicine/Montefiore Medical Center, Bronx, New York, the Department of Obstetrics, Gynecology, and Reproductive Sciences Rutgers-Robert Wood Johnson Medical School, New Brunswick, New Jersey, the Department of Obstetrics and Gynecology, Johns Hopkins Medicine, Baltimore, Maryland, and the Department of Family Medicine and Community Health Rutgers - Robert Wood Johnson Medical School, New Brunswick, New Jersey
| | - Jennifer Amico
- From the Department of Obstetrics, Gynecology, and Women's Health, Albert Einstein College of Medicine/Montefiore Medical Center, Bronx, New York, the Department of Obstetrics, Gynecology, and Reproductive Sciences Rutgers-Robert Wood Johnson Medical School, New Brunswick, New Jersey, the Department of Obstetrics and Gynecology, Johns Hopkins Medicine, Baltimore, Maryland, and the Department of Family Medicine and Community Health Rutgers - Robert Wood Johnson Medical School, New Brunswick, New Jersey
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Abstract
ABSTRACT Sterilization is one of the most effective and popular forms of contraception in the United States, relied upon by 18.6% of women aged 15-49 years using contraception. Nearly half of procedures are performed during the postpartum period, yet many women who desire postpartum sterilization do not actually undergo the procedure. Factors that may decrease the likelihood of a patient obtaining desired postpartum sterilization include patient-related factors, physician-related factors, lack of available operating rooms and anesthesia, federal consent requirements, and receiving care in some religiously affiliated hospitals. In all discussions and counseling regarding contraception, including postpartum sterilization, it is important to engage in shared decision making while supporting personal agency and patient autonomy. Equitable access to postpartum sterilization is an important strategy to ensure patient-centered care while supporting reproductive autonomy and justice when it comes to decisions regarding family formation. This revision includes updates on barriers to postpartum sterilization and guidance for contraceptive counseling and shared decision making.
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Schueler KE, Hebert LE, Wingo EE, Freedman LR, Stulberg DB. Denial of tubal ligation in religious hospitals: Consumer attitudes when insurance limits hospital choice. Contraception 2021; 104:194-201. [PMID: 33657425 DOI: 10.1016/j.contraception.2021.02.011] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2020] [Revised: 02/17/2021] [Accepted: 02/24/2021] [Indexed: 11/17/2022]
Abstract
OBJECTIVES Postpartum tubal ligation provides demonstrated benefits to women, but access to this procedure is threatened by restrictions at Catholic healthcare institutions. We aimed to understand how insured employees assign responsibility for postpartum sterilization denial and how it impacts their view of the quality of care provided. STUDY DESIGN We conducted a nationally representative, cross-sectional survey of employees at Standard and Poor's (S&P) 500 companies utilizing a dual panel drawn from Amerispeak, a probability-based research panel, and a non-probability panel. Respondents answered questions about a scenario of a woman denied a tubal ligation due to Catholic hospital policy when her employer-sponsored insurance provided no other hospital choices. Of 1113 eligible panel members, 1001 (90%) completed the survey. Weighted analysis accounted for complex survey design. RESULTS In response to the tubal ligation denial scenario, 42% of respondents rated hospital quality-of-care as poor or very poor. Sixty percent felt that something should have been done differently, with about half assigning responsibility to the religiously-affiliated hospital for not providing the procedure and half to the insurance company for not including secular hospitals in its network. Finding employers/insurance companies responsible was more common with higher education (RRR = 3.17; 95% CI: 1.58-6.33 some college; RRR = 4.26; 95% CI: 2.10-8.62 bachelor's or more) and less common among non-white respondents (RRR = 0.54; 95% CI: 0.31-0.97). Three quarters of respondents thought the employer should have intervened. CONCLUSIONS The majority of insured employees do not think women should be denied postpartum tubal ligation. They assign hospitals, insurers, and employers responsibility to remove barriers to care. IMPLICATIONS Most people who receive health insurance through a large employer disapprove of Catholic hospital restrictions when the patient's insurance restricts her hospital choice. To improve access to comprehensive reproductive care, employers and insurers should assure employees have in-network coverage of hospitals without religious restrictions.
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Affiliation(s)
- Kellie E Schueler
- Pritzker School of Medicine, University of Chicago, Chicago, IL, USA
| | - Luciana E Hebert
- Institute for Research and Education to Advance Community Health, Washington State University, Seattle, WA, USA
| | - Erin E Wingo
- Department of Family and Community Medicine, University of California San Francisco, San Francisco General Hospital, San Francisco, CA, USA
| | - Lori R Freedman
- Department of Obstetrics, Gynecology & Reproductive Sciences, University of California San Francisco, San Francisco, CA, USA; Advancing New Standards in Reproductive Health (ANSIRH), University of California San Francisco, Oakland, CA, USA
| | - Debra B Stulberg
- Department of Family Medicine, University of Chicago, Chicago, IL, USA.
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Russell CB, Evans ML, Qasba N, Frankel A, Arora KS. Medicaid sterilization consent forms: variation in rejection and payment consequences. Am J Obstet Gynecol 2020; 223:934-936. [PMID: 32710831 DOI: 10.1016/j.ajog.2020.07.034] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2020] [Revised: 07/12/2020] [Accepted: 07/21/2020] [Indexed: 11/29/2022]
Affiliation(s)
- Colin B Russell
- Department of Obstetrics and Gynecology, University of Michigan, 1500 E Medical Center Drive, Ann Arbor, MI 48109; Tufts University School of Medicine, Boston, MA.
| | - Megan L Evans
- Department of Obstetrics and Gynecology, Tufts Medical Center, Boston, MA
| | - Neena Qasba
- Department of Obstetrics and Gynecology, University of Massachusetts Medical School-Baystate, Springfield, MA
| | | | - Kavita Shah Arora
- Department of Obstetrics and Gynecology, MetroHealth Medical Center, Case Western Reserve University, Cleveland, OH; Department of Bioethics, Case Western Reserve University, Cleveland, OH
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Abstract
OBJECTIVE To evaluate the association of increasing body mass index (BMI) on postpartum tubal ligation safety and estimate the rates of procedure complication. METHODS We conducted a single-institution, retrospective review. Women undergoing postpartum permanent contraception after vaginal delivery from August 2015 to March 2019 were studied. Our primary outcome included a composite morbidity of intraoperative complications (bleeding requiring additional surgery, and extension of incision), blood transfusion, aborted procedure, anesthetic complication, readmission, wound infection, venous thromboembolism, ileus or small bowel obstruction, incomplete transection, and subsequent pregnancy. Statistical analysis included t test, χ test, and Wilcoxon rank-sum test, with P<0.05 considered significant. RESULTS During the study period, 3,670 women were studied: 263 were underweight or normal weight (BMI 24.9 or lower), 1,044 were overweight (25-29.9), 1,371 had class I obesity (30-34.9), 689 had class II obesity (35-39.9), and 303 had class III obesity (40 or higher) at the time of admission. Composite morbidity occurred in 49 cases (1.3%) and was not significantly different across the BMI categories (P=.07). Twelve cases of incomplete transection were noted on pathology reports; however, none of these accounted for the six subsequent pregnancies that were identified. There were no deaths or events leading to death noted in the study population. The length of time to complete the procedure increased across BMI categories (23 minutes in women with normal weight, and 31 in women with class III obesity) (P<.001). CONCLUSION There was no association between increased BMI and morbidity with women undergoing postpartum tubal ligation. Postpartum tubal ligation should be considered a safe and reasonable option for women, regardless of BMI.
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Abstract
This review highlights proposed pandemic-adjusted modifications in obstetric care, with discussion of risks and benefits based on available evidence. We suggest best practices for balancing community-mitigation efforts with appropriate care of obstetric patients.
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