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Bullington BW, Berg KA, Miller ES, Boozer M, Serna T, Bailit JL, Arora KS. Fulfillment of Permanent Contraception among Patients with Cesarean Delivery in a Multi-Site Cohort. Matern Child Health J 2024; 28:1338-1345. [PMID: 38864989 DOI: 10.1007/s10995-024-03966-8] [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] [Accepted: 06/01/2024] [Indexed: 06/13/2024]
Abstract
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.
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Affiliation(s)
- Brooke W Bullington
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, 135 Dauer Driver 2101 McGavran-Greenberg Hall, Chapel Hill, NC, 27599, USA.
- Carolina Population Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.
| | - Kristen A Berg
- Center for Health Care Research & Policy, Population Health Research Institute, MetroHealth Medical System, Cleveland, OH, USA
| | - Emily S Miller
- Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - Margaret Boozer
- Department of Obstetrics and Gynecology, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Tania Serna
- Department of Obstetrics and Gynecology, University of California San Francisco, San Francisco, CA, USA
| | - Jennifer L Bailit
- Department of Obstetrics and Gynecology, MetroHealth Medical System, Cleveland, OH, USA
| | - Kavita Shah Arora
- Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, Warren Alpert Medical School of Brown University, Providence, RI, USA
- Department of Obstetrics and Gynecology, University of North Carolina, Chapel Hill, NC, USA
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Viswanathan AV, Bullington BW, Berg KA, Miller ES, Boozer M, Serna T, Bailit JL, Arora KS. Ongoing contraceptive goals of patients who did not achieve desired postpartum permanent contraception prior to hospital discharge. Contraception 2024:110533. [PMID: 38945351 DOI: 10.1016/j.contraception.2024.110533] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2024] [Revised: 06/25/2024] [Accepted: 06/26/2024] [Indexed: 07/02/2024]
Abstract
OBJECTIVE To evaluate reasons for non-fulfillment and ongoing contraceptive plans of patients who desired but did not receive inpatient postpartum permanent contraception (PC). STUDY DESIGN Multi-site retrospective cohort study of 1254 patients with unfulfilled inpatient postpartum PC. We analyzed the reason for PC non-fulfillment, documented contraceptive plan, and method prescription or provision at hospital discharge, six-weeks, and one-year postpartum. RESULTS In our cohort, 44.3% of patients with unfulfilled inpatient PC did not receive any highly- or moderately-effective contraception within one year postpartum. CONCLUSIONS Removing barriers to PC fulfillment as well as contraceptive counseling that acknowledges these barriers is imperative.
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Affiliation(s)
- Ambika V Viswanathan
- Department of Obstetrics and Gynecology, University of North Carolina, Chapel Hill, NC, USA
| | - Brooke W Bullington
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, NC, USA
| | - Kristen A Berg
- Center for Health Care Research and Policy, MetroHealth Medical Center-Case Western Reserve University, Cleveland, OH, USA
| | - Emily S Miller
- Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, Alpert Medical School of Brown University, Providence, RI, USA
| | - Margaret Boozer
- Department of Obstetrics and Gynecology, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Tania Serna
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of California, San Francisco, CA, USA
| | | | - Kavita S Arora
- Department of Obstetrics and Gynecology, University of North Carolina, Chapel Hill, NC, USA.
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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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Mosley EA, Zite N, Dehlendorf C, Deal A, O'Leary R, Achilles S, Barnato AE, Hall D, Borrero S. Development of My Decision/Mi Decisión, a web-based decision aid to support permanent contraception decision making. PEC INNOVATION 2023; 3:100203. [PMID: 37693728 PMCID: PMC10483066 DOI: 10.1016/j.pecinn.2023.100203] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/27/2023] [Revised: 08/21/2023] [Accepted: 08/28/2023] [Indexed: 09/12/2023]
Abstract
Objective To develop a patient-centered, web-based decision aid to support informed and value-concordant decision making among Medicaid enrollees considering tubal sterilization. Methods We used the Ottawa Decision Support Framework and the International Patient Decision Aids Standards (IPDAS) to guide systematic development of our decision aid. We interviewed 15 obstetrician-gynecologists and 40 women, who had considered or were considering tubal sterilization. A Steering Committee-comprising healthcare providers, social scientists, reproductive health and justice advocates, and people with lived experience-provided feedback and direction. We developed English and Spanish prototypes, which were beta tested with 24 women. Results The resulting web-based My Decision/Mi Decisión tool (English/Spanish) includes written and video information about tubal sterilization procedures; an interactive table of contraception options; values clarification exercises; reflection and deliberation; knowledge checks; and a summary report to share with one's provider. Users found the decision aid to be informative, engaging, easy to use, and helpful in informing contraception decision making. Conclusion My Decision/Mi Decisión is a scalable tool that could be implemented widely to support informed decision making about tubal sterilization. Innovation This is a novel and timely web-based decision tool for tubal sterilization, when demand for permanent contraception is rapidly increasing post-Dobbs. While designed for Medicaid enrollees, further investigation will explore more generalized use.
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Affiliation(s)
- Elizabeth A. Mosley
- Department of Medicine, Division of General Internal Medicine, University of Pittsburgh, Pittsburgh, PA 15213, USA
- Center for Innovative Research on Gender Health Equity, University of Pittsburgh, Pittsburgh, PA 15213, USA
| | - Nikki Zite
- Department of Obstetrics and Gynecology, University of Tennessee Graduate School of Medicine, Knoxville, TN 37920, USA
| | - Christine Dehlendorf
- Departments of Family & Community Medicine, Obstetrics, Gynecology & Reproductive Sciences, Epidemiology & Biostatistics, University of California, San Francisco, San Francisco, CA 94143, USA
| | - Ashley Deal
- Dezudio, Pittsburgh, PA 15221, USA
- Carnegie Mellon University, Pittsburgh, PA 15213, USA
| | - Raelynn O'Leary
- Dezudio, Pittsburgh, PA 15221, USA
- Carnegie Mellon University, Pittsburgh, PA 15213, USA
| | - Sharon Achilles
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of Pittsburgh, Pittsburgh, PA 15213, USA
- Bill and Melinda Gates Foundation, Seattle, WA 98102, USA
| | - Amber E. Barnato
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, NH 03756, USA
| | - Daniel Hall
- Department of Surgery, University of Pittsburgh, Pittsburgh, PA 15213, USA
- Wolff Center, University of Pittsburgh Medical Center, Pittsburgh, PA 15213, USA
- Department of Surgery, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, PA 15213, USA
- Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, PA 15213, USA
- Geriatric Research Education and Clinical Center, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, PA 15213, USA
| | - Sonya Borrero
- Department of Medicine, Division of General Internal Medicine, University of Pittsburgh, Pittsburgh, PA 15213, USA
- Center for Innovative Research on Gender Health Equity, University of Pittsburgh, Pittsburgh, PA 15213, USA
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Bullington BW, Berg KA, Miller ES, Boozer M, Serna T, Bailit JL, Arora KS. Association Among Race, Ethnicity, Insurance Type, and Postpartum Permanent Contraception Fulfillment. Obstet Gynecol 2023; 142:920-928. [PMID: 37678912 PMCID: PMC10510813 DOI: 10.1097/aog.0000000000005328] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Revised: 04/10/2023] [Accepted: 05/05/2023] [Indexed: 09/09/2023]
Abstract
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.
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Affiliation(s)
- Brooke W Bullington
- Department of Epidemiology, Gillings School of Global Public Health, the Carolina Population Center, and the Department of Obstetrics and Gynecology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina; the Center for Health Care Research & Policy, Population Health Research Institute, and the Department of Obstetrics and Gynecology, MetroHealth Medical System, Cleveland, Ohio; the Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, Warren Alpert Medical School of Brown University, Providence, Rhode Island; the Department of Obstetrics and Gynecology, University of Alabama at Birmingham, Birmingham, Alabama; and the Department of Obstetrics and Gynecology, University of California, San Francisco, San Francisco, California
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An assessment of postpartum contraception rates with evolving care during the COVID-19 pandemic. SEXUAL & REPRODUCTIVE HEALTHCARE 2023; 36:100844. [PMID: 37031561 PMCID: PMC10077763 DOI: 10.1016/j.srhc.2023.100844] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2022] [Revised: 02/07/2023] [Accepted: 04/03/2023] [Indexed: 04/09/2023]
Abstract
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.
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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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Abstract
Equitable access to contraception and contraceptive education has the potential to mitigate health disparities related to unintended pregnancy. Pregnancy and the postpartum window frequently offer reduced insurance barriers to healthcare, increased interaction with healthcare systems and family planning providers, and an opportune time for many individuals to receive contraception; however, there are additional considerations in method type for postpartum individuals, and contraceptive counseling must be thoughtfully conducted to avoid coercion and promote shared decision-making. This commentary reviews method-specific considerations and suggests priorities for achieving equity in postpartum contraceptive access.
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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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Rodriguez MI, Daly A, Meath T, Watson K, McConnell KJ. Catholic sole community hospitals are associated with decreased receipt of postpartum permanent contraception among Medicaid recipients. Contraception 2023; 122:109959. [PMID: 36708859 DOI: 10.1016/j.contraception.2023.109959] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2022] [Revised: 01/03/2023] [Accepted: 01/14/2023] [Indexed: 01/27/2023]
Abstract
OBJECTIVES To examine the association of Catholic hospitals with receipt of postpartum tubal ligation and long acting, reversible contraception among Medicaid recipients. STUDY DESIGN We conducted a retrospective cohort study of live births from January 1, 2016 to October 31, 2016 to female Medicaid beneficiaries in the United States between ages 21 and 44. Our main exposure was the presence of a Catholic-affiliated sole community hospital, and our primary outcome was highly effective postpartum contraception. We examined rates of postpartum permanent contraception, along with the use of a long acting, reversible form of contraception (LARC) at 3 and 60 days are postpartum. We compared counties that had only a Catholic-affiliated hospital with counties with only a non-Catholic hospital. RESULTS Our study population included 14,545 postpartum Medicaid beneficiaries. Study participants came from 88 counties across 10 United States states. Only 7.7% of women in counties with Catholic sole community hospitals received permanent contraception by 3 days postpartum, compared to 11.3% in counties with non-Catholic sole community hospitals (RD: -3.92%; 95% CI: -6.01%, -1.83%). This difference was not mitigated by receipt of outpatient procedures or long-acting, reversible contraception. Importantly, women residing in counties with Catholic sole community hospitals were much less likely to return postpartum for an outpatient visit between 8 and 60 days postpartum than women in counties with non-Catholic sole community hospitals (35.4% vs 45.4%, RD: -9.29%; 95% CI: -16.71%, -1.86%). CONCLUSIONS In counties where the only hospital was Catholic, Medicaid recipients giving birth were significantly less likely to receive permanent contraception and to return for postpartum care. IMPLICATIONS Catholic hospitals are increasing in the United States, which may restrict access to postpartum contraception, particularly in rural areas. We found that Medicaid recipients giving birth at a Catholic sole community hospital were less likely to receive permanent contraception and to return for care.
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Affiliation(s)
- Maria I Rodriguez
- Department of Obstetrics and Gynecology, Oregon Health & Science University, Portland, OR, United States; Center for Health Systems Effectiveness, Oregon Health & Science University, Portland, OR, United States.
| | - Ashley Daly
- Center for Health Systems Effectiveness, Oregon Health & Science University, Portland, OR, United States
| | - Thomas Meath
- Center for Health Systems Effectiveness, Oregon Health & Science University, Portland, OR, United States
| | - Kelsey Watson
- Center for Health Systems Effectiveness, Oregon Health & Science University, Portland, OR, United States
| | - K John McConnell
- Center for Health Systems Effectiveness, Oregon Health & Science University, Portland, OR, United States; Department of Emergency Medicine, Oregon Health & Science University, Portland, OR, United States
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Bullington BW, Arora KS. Fulfillment of Desired Postpartum Permanent Contraception: a Health Disparities Issue. Reprod Sci 2022; 29:2620-2624. [PMID: 35713848 PMCID: PMC10120182 DOI: 10.1007/s43032-022-00912-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2021] [Accepted: 03/05/2022] [Indexed: 11/28/2022]
Abstract
Women of color experience marked disparities in fulfillment of desired postpartum permanent contraception. While many attribute the disparity to the required Medicaid sterilization consent form and 30-day waiting period established in response to forced and coerced sterilizations, the policy does not entirely explain the disparity; racial and ethnic disparities persist even within strata of insurance type. We therefore propose framing postpartum permanent contraception as a health disparities issue that requires multi-level interventions to address. Based on the literature, we identify discrete levels of barriers to postpartum permanent contraception fulfillment at the patient, physician, hospital, and policy levels that interact and compound within and between individual levels, affecting each individual patient differently. At the patient level, sociodemographic characteristics such as age, race and ethnicity, and parity impact desire for and fulfillment of permanent contraception. At the physician level, implicit bias and paternalistic counseling contribute to barriers in permanent contraception fulfillment. At the hospital level, Medicaid reimbursement, operating room availability, and religious affiliation influence fulfillment of permanent contraception. Lastly, at the policy level, the Medicaid consent form and waiting period pose a known barrier to fulfillment of desired postpartum permanent contraception. Unpacking each of these discrete barriers and untangling their collective impact is necessary to eliminate racial and ethnic disparities in permanent contraception fulfillment.
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Affiliation(s)
- Brooke W Bullington
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
- Carolina Population Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Kavita Shah Arora
- Department of Obstetrics and Gynecology, School of Medicine, University of North Carolina at Chapel Hill, 3031 Old Clinic Building, CB 7570, Chapel Hill, NC, 27599, USA.
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Stifani BM, Madden T, Micks E, Moayedi G, Tarleton J, Benson LS. Society of Family Planning Clinical Recommendations: Contraceptive Care in the Context of Pandemic Response. Contraception 2022; 113:1-12. [PMID: 35594989 PMCID: PMC9113767 DOI: 10.1016/j.contraception.2022.05.006] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2022] [Revised: 05/09/2022] [Accepted: 05/11/2022] [Indexed: 12/16/2022]
Abstract
The coronavirus disease 2019 (COVID-19) pandemic has posed a burden to healthcare systems around the world and has changed the way people access health services, including contraception. This document sets forth guidance from the Society of Family Planning for providing contraceptive care in the context of the COVID-19 pandemic, including when access to healthcare is restricted due to pandemic response. It also outlines the role of telehealth for providing contraceptive care beyond the pandemic. Clinicians can use synchronous telemedicine visits and other forms of telehealth to provide many aspects of contraceptive care. Both audio-video and audio-only visits are acceptable forms of telemedicine. Access to permanent contraception should be maintained, especially in the postpartum period. Combined hormonal contraceptive (CHC) users who have asymptomatic or mild COVID-19 infection may continue their contraceptive method, while those admitted to the hospital with severe infection should suspend CHC use until they are clinically recovered. CHC users who take Paxlovid for mild-moderate COVID-19 infection can consider a back-up contraceptive method for the duration of therapy, but clinically relevant drug interactions are unlikely. Future research should examine contraceptive outcomes in people who receive care via telemedicine; and access to telemedicine among historically excluded populations such as adolescents, people of color, people of low socioeconomic status, disabled people, or people who do not speak English as a primary language.
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Affiliation(s)
- Bianca M. Stifani
- New York Medical College, Valhalla, NY, USA,Corresponding Author: Bianca M. Stifani, 19 Bradhurst Ave Suite 2700S, Hawthorne, NY, USA
| | - Tessa Madden
- Washington University School of Medicine, St Louis, MO, USA
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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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14
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Short-notice cancellations of laparoscopic permanent contraception. Contraception 2022; 114:49-53. [DOI: 10.1016/j.contraception.2022.04.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2022] [Revised: 04/28/2022] [Accepted: 04/29/2022] [Indexed: 11/17/2022]
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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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17
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Potter JE, Burke KL, Broussard K, Hopkins K, Grossman D, White K. Improving assessment of demand for postpartum tubal ligation among publicly insured women in Texas. Contraception 2021; 104:518-523. [PMID: 34048752 PMCID: PMC10348345 DOI: 10.1016/j.contraception.2021.05.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2021] [Revised: 05/08/2021] [Accepted: 05/10/2021] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To assess an alternative method for estimating demand for postpartum tubal ligation and evaluate reproductive trajectories of low-income women who did not obtain a desired procedure. STUDY DESIGN In a 2-year cohort study of 1700 publicly insured women who delivered at 8 hospitals in Texas, we identified those who had an unmet demand for tubal ligation prior to discharge from the hospital. We classified unmet demand as explicit or prompted based on survey questions that included a prompt regarding whether the respondent would like to have had a tubal ligation at the time of delivery. We assessed persistence of demand for permanent contraception, contraceptive use, and repeat pregnancies among all study participants who wanted but did not get a postpartum procedure. RESULTS Some 426 women desired a postpartum tubal ligation; 219 (51%) obtained one prior to discharge. Among the 207 participants with unmet demand, 62 (30%) expressed an explicit preference for the procedure, while 145 (70%) were identified from the prompt. Most with unmet demand still wanted permanent contraception 3 months after delivery (156/184), but only 23 had obtained interval procedures. By 18 months, the probability of a woman with unmet demand conceiving a pregnancy that she would likely carry to term was 12.5% (95% CI: 8.3%-18.5%). CONCLUSIONS The majority of unmet demand for postpartum tubal ligation among publicly insured women in Texas was uncovered via a prompt and would not have been evident in clinical records or from consent forms. Women unable to obtain a desired procedure had a substantial chance of pregnancy within 18 months after delivery. IMPLICATIONS Estimates of unmet demand for postpartum tubal ligation based on clinical records and consent forms likely underestimate desire for permanent contraception. Among low-income women in Texas, those with unmet demand for postpartum tubal ligation require improved access to effective contraception.
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Affiliation(s)
- Joseph E Potter
- Population Research Center, University of Texas, Austin, TX, United States.
| | - Kristen L Burke
- Population Research Center, University of Texas, Austin, TX, United States
| | - Kathleen Broussard
- Population Research Center, University of Texas, Austin, TX, United States
| | - Kristine Hopkins
- Population Research Center, University of Texas, Austin, TX, United States
| | - Daniel Grossman
- Advancing New Standards in Reproductive Health, (ANSIRH), Bixby Center for Global Reproductive Health, Department of Obstetrics, Gynecology and Reproductive Sciences, University of California, San, Francisco, Oakland, CA, United States
| | - Kari White
- Population Research Center, University of Texas, Austin, TX, United States
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Rydze RT, Wang S, Schoyer KD. Preterm birth: is it the patient or the process? Fertil Steril 2021; 115:583-584. [PMID: 33712102 DOI: 10.1016/j.fertnstert.2021.01.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2021] [Accepted: 01/11/2021] [Indexed: 11/29/2022]
Affiliation(s)
- Robert T Rydze
- Department of Obstetrics and Gynecology, Division of Reproductive Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Shunping Wang
- Department of Obstetrics and Gynecology, Division of Reproductive Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Kate D Schoyer
- Department of Obstetrics and Gynecology, Division of Reproductive Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin
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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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20
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Obstetrician-Gynecologists' Practices in Postpartum Sterilization Without a Valid Medicaid Consent Form. Obstet Gynecol 2021; 138:66-72. [PMID: 34259465 DOI: 10.1097/aog.0000000000004413] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2021] [Accepted: 03/25/2021] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To explore the practices of obstetrician-gynecologists (ob-gyns) in the United States surrounding postpartum sterilization when the Medicaid consent form was not valid. METHODS Using the American College of Obstetricians and Gynecologists' online directory, we conducted a qualitative study where we recruited ob-gyns practicing in 10 geographically diverse U.S. states for a qualitative study using semi-structured interviews conducted by telephone. We analyzed interview transcripts using the constant comparative method and principles of grounded theory. RESULTS Thirty ob-gyns (63% women, 77% nonsubspecialized, and 53% academic setting) were interviewed. Although most physicians stated that they did not perform sterilizations without a valid Medicaid sterilization form, others noted that they sometimes did due to a sense of ethical obligation toward their patient's health, being in a role with more authority or seniority, interpreting the emergency justification section of the form more broadly, or backdating the form. The physicians who said that they never went ahead without a signed form tended to work at large institutions and were concerned with losing funding and engaging in potentially illegal or fraudulent behavior. CONCLUSION Physicians' varied behaviors related to providing postpartum sterilization without a valid Medicaid consent form demonstrate that the policy is in need of revision. Unclear terminology and ramifications of the Medicaid sterilization policy need to be addressed to ensure equitable care.
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21
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Evans ML, Qasba N, Shah Arora K. COVID-19 highlights the policy barriers and complexities of postpartum sterilization. Contraception 2021; 103:3-5. [PMID: 33068611 PMCID: PMC7557287 DOI: 10.1016/j.contraception.2020.10.006] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2020] [Revised: 09/24/2020] [Accepted: 10/02/2020] [Indexed: 11/16/2022]
Abstract
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.
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Affiliation(s)
- Megan L Evans
- Department of Obstetrics and Gynecology, Tufts Medical Center, Boston, MA, United States.
| | - Neena Qasba
- Department of Obstetrics and Gynecology, University of Massachusetts Medical School-Baystate Medical Center, Springfield, 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, Cleveland, OH, United States
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22
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Arora KS, Ascha M, Wilkinson B, Verbus E, Montague M, Morris J, Einstadter D. Association between neighborhood disadvantage and fulfillment of desired postpartum sterilization. BMC Public Health 2020; 20:1440. [PMID: 32962666 PMCID: PMC7509918 DOI: 10.1186/s12889-020-09540-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2020] [Accepted: 09/14/2020] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Adequacy of prenatal care is associated with fulfillment of postpartum sterilization requests, though it is unclear whether this relationship is indicative of broader social and structural determinants of health or reflects the mandatory Medicaid waiting period required before sterilization can occur. We evaluated the relationship between neighborhood disadvantage (operationalized by the Area Deprivation Index; ADI) and the likelihood of undergoing postpartum sterilization. METHODS Secondary analysis of a single-center retrospective cohort study examining 8654 postpartum patients from 2012 to 2014, of whom 1332 (15.4%) desired postpartum sterilization (as abstracted from the medical record at time of delivery hospitalization discharge) and for whom ADI could be calculated via geocoding their home address. We determined the association between ADI and sterilization completion, postpartum visit attendance, and subsequent pregnancy within 365 days of delivery via logistic regression and time to sterilization via Cox proportional hazards regression. RESULTS Of the 1332 patients included in the analysis, patients living in more disadvantaged neighborhoods were more likely to be younger, more parous, delivered vaginally, Black, unmarried, not college educated, and insured via Medicaid. Compared to patients living in less disadvantaged areas, patients living in more disadvantaged areas were less likely to obtain sterilization (44.8% vs. 53.5%, OR 0.84, 95% CI 0.75-0.93), experienced greater delays in the time to sterilization (HR 1.23, 95% CI 1.06-1.44), were less likely to attend postpartum care (58.9% vs 68.9%, OR 0.86, CI 0.79-0.93), and were more likely to have a subsequent pregnancy within a year of delivery (15.1% vs 10.4%, OR 1.56, 95% CI 1.10-1.94). In insurance-stratified analysis, for patients with Medicaid, but not private insurance, as neighborhood disadvantage increased, the rate of postpartum sterilization decreased. The rate of subsequent pregnancy was positively associated with neighborhood disadvantage for both Medicaid as well as privately insured patients. CONCLUSION Living in an area with increased neighborhood disadvantage is associated with worse outcomes in terms of desired postpartum sterilization, especially for patients with Medicaid insurance. While revising the Medicaid sterilization policy is important, addressing social determinants of health may also play a powerful role in reducing inequities in fulfillment of postpartum sterilization.
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Affiliation(s)
- Kavita Shah Arora
- Department of Obstetrics and Gynecology, MetroHealth Medical Center, Case Western Reserve University, Cleveland, OH, USA.
| | - Mustafa Ascha
- Cleveland Institute for Computational Biology, Case Western Reserve University, Cleveland, OH, USA
| | - Barbara Wilkinson
- School of Medicine, Case Western Reserve University, Cleveland, OH, USA
| | - Emily Verbus
- School of Medicine, Case Western Reserve University, Cleveland, OH, USA
| | - Mary Montague
- School of Medicine, Case Western Reserve University, Cleveland, OH, USA
| | - Jane Morris
- Department of Obstetrics and Gynecology, MetroHealth Medical Center, Case Western Reserve University, Cleveland, OH, USA
| | - Douglas Einstadter
- Center for Health Care Research and Policy and the Departments of Medicine, and Population and Quantitative Health Sciences, MetroHealth Medical Center, Case Western Reserve University, Cleveland, OH, USA
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Welch EK, Lindberg M, Mauney D, McLeod F. Bring back the tubal: An intervention to provide postpartum tubal ligation in the underserved population. Health Care Women Int 2020; 45:113-128. [PMID: 32897839 DOI: 10.1080/07399332.2020.1805747] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2020] [Accepted: 08/01/2020] [Indexed: 10/23/2022]
Abstract
We aimed to improve educational awareness of postpartum bilateral tubal ligation (PPBTL), which we defined as a 15% improvement between pre-/post-intervention questionnaire scores. We followed patients desiring and undergoing PPBTL and reason for unfulfilled procedures from 2017-2018. OB/GYN, Nursing, and Anesthesia participated in educational sessions with pre-/post-intervention questionnaires. Comparing the first and latter six months after study initiation, PPBTLs performed increased from 39% to 54%. Fifty-two staff participated in the interventions, with a 21% improvement in scores (OB/GYN p = 0.0117, Nursing p = 0.0001, Anesthesia p = 0.0002). We conclude multidisciplinary interventions improved educational awareness, an integral part to increasing PPBTL performance in the underserved.
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Affiliation(s)
- Eva K Welch
- Department of Obstetrics & Gynecology, Inova Fairfax Medical Campus, Falls Church, Virginia, USA
- Department of Obstetrics & Gynecology, Walter Reed National Military Medical Center, Bethesda, Maryland, USA
| | - Mary Lindberg
- Department of Obstetrics & Gynecology, Inova Fairfax Medical Campus, Falls Church, Virginia, USA
| | - Donald Mauney
- Department of Anesthesiology, Geisinger Health System, Wilkes Barre, Pennsylvania, USA
| | - Francine McLeod
- Department of Obstetrics & Gynecology, Inova Fairfax Medical Campus, Falls Church, Virginia, USA
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Robinson EF, Moulder JK, Zerden ML, Miller AM, Zite NB. Preserving and advocating for essential care for women during the coronavirus disease 2019 pandemic. Am J Obstet Gynecol 2020; 223:219-220.e1. [PMID: 32405073 PMCID: PMC7219371 DOI: 10.1016/j.ajog.2020.05.022] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2020] [Revised: 05/07/2020] [Accepted: 05/11/2020] [Indexed: 11/12/2022]
Abstract
The coronavirus disease 2019 pandemic has redefined “essential care,” and reproductive healthcare has become a frequently targeted and debated topic. As obstetricians and gynecologists, we stand with our patients and others as advocates for women’s reproductive health. With the medical and surgical training to provide all aspects of reproductive healthcare, obstetricians and gynecologists are indispensable and uniquely positioned to advocate for the full spectrum of care that our patients need right now. All patients have a right to these services. Contraception and abortion care remain essential, and we need to work at the local, state, and federal levels on policies that preserve these critical services. We must also support policies that will promote expansion of care, including lengthening Medicaid pregnancy and postpartum coverage. Although we continue to see patients, this is the time to engage outside clinical encounters by participating in lobbying and other advocacy efforts to preserve essential services, protecting the health, life, and welfare of our patients during the coronavirus disease 2019 pandemic.
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Abstract
Pregnancy and the postpartum period are ideal times for health care providers to identify and address the contraceptive needs and desires of patients. In addition to the opportunity to promote healthy pregnancy spacing, individuals can also be cared for at a time when it is convenient, they have access to health care, and they are motivated to prevent repeat pregnancy. Patient-centered care using a shared medical decision-making framework can not only promote positive patient-provider interactions but also increase positive outcomes. Comprehensive provision of information on all methods and identification of contraceptive preferences can help patients select the best option.
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Affiliation(s)
- Serina Floyd
- Planned Parenthood of Metropolitan Washington, DC, Washington, DC, USA.
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26
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Morris J, Ascha M, Wilkinson B, Verbus E, Montague M, Mercer BM, Arora KS. Desired Sterilization Procedure at the Time of Cesarean Delivery According to Insurance Status. Obstet Gynecol 2019; 134:1171-1177. [PMID: 31764726 PMCID: PMC6905118 DOI: 10.1097/aog.0000000000003552] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
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.
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Affiliation(s)
- Jane Morris
- Department of Obstetrics and Gynecology, MetroHealth Medical Center, Case Western Reserve University, Cleveland, Ohio
| | - Mustafa Ascha
- Cleveland Institute for Computational Biology, Case Western Reserve University, Cleveland, Ohio
| | - Barbara Wilkinson
- School of Medicine, Case Western Reserve University, Cleveland, Ohio
| | - Emily Verbus
- School of Medicine, Case Western Reserve University, Cleveland, Ohio
| | - Mary Montague
- School of Medicine, Case Western Reserve University, Cleveland, Ohio
| | - Brian M. Mercer
- Department of Obstetrics and Gynecology, MetroHealth Medical Center, Case Western Reserve University, Cleveland, Ohio
| | - Kavita Shah Arora
- Department of Obstetrics and Gynecology, MetroHealth Medical Center, Case Western Reserve University, Cleveland, Ohio
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Mercier RJ, Perriera L, Godcharles C, Shaber A. Expedited Scheduling of Interval Tubal Ligation: A Randomized Controlled Trial. Obstet Gynecol 2019; 134:1178-1185. [PMID: 31764727 DOI: 10.1097/aog.0000000000003550] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To assess whether expedited scheduling for permanent contraception increases the proportion of patients completing interval tubal ligation within 6 months of delivery. METHODS We randomly assigned patients with unfulfilled immediate postpartum tubal ligation requests to standard scheduling after a postpartum office visit or an expedited process in which we scheduled the interval tubal ligation surgery before discharge from the hospital. The primary outcome was proportion of participants undergoing tubal contraceptive procedures within 6 months of delivery. Secondary outcomes included patient satisfaction with the scheduling process, repeat pregnancy rates, and surgical outcomes. We estimated that 122 patients (61 per group) would provide greater than 80% power to identify a 25% difference favoring expedited scheduling in the primary outcome (one-sided α of 0.05). RESULTS Between September 2016 and June 2018, 239 patients requested tubal ligation at the time of delivery; 155 were not completed. Of these, 126 patients were eligible for the study. We stopped the study at the prespecified 50% enrollment point after 67 patients enrolled, with 34 and 33 assigned to the standard and expedited arms, respectively. Fifteen participants in the expedited group, and two in the standard group completed tubal ligation within 6 months (50% vs 9%; odds ratio 10.0, CI 2.0-50.2). Delivery-to-surgery interval was 49 days in the expedited group, compared with 121 days in the standard group (P=.05). Seventeen participants in the expedited group and three in the standard group reported being very satisfied with the scheduling process (57% vs 13%, P=.03). The only two interim pregnancies both occurred in the standard group (P=.09). There were no surgical complications in any of the 17 completed tubal procedures. CONCLUSION Expedited scheduling significantly improves tubal contraceptive surgery completion and patient satisfaction. Laparoscopic or hysteroscopic tubal ligation or salpingectomy can be performed 4-6 weeks after delivery with minimal interval outpatient follow-up. CLINICAL TRIAL REGISTRATION ClinicalTrials.gov, NCT02875483.
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Affiliation(s)
- Rebecca J Mercier
- Department of Obstetrics and Gynecology, Sidney Kimmel Medical College, Thomas Jefferson University, and the Department of Obstetrics and Gynecology, Einstein Healthcare Network, Philadelphia, Pennsylvania
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Flink-Bochacki R, Flaum S, Betstadt SJ. Barriers and outcomes associated with unfulfilled requests for permanent contraception following vaginal delivery. Contraception 2019; 99:98-103. [DOI: 10.1016/j.contraception.2018.11.005] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2018] [Revised: 11/09/2018] [Accepted: 11/11/2018] [Indexed: 10/27/2022]
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Hahn TA, McKenzie F, Hoffman SM, Daggy J, Tucker Edmonds B. A Prospective Study on the Effects of Medicaid Regulation and Other Barriers to Obtaining Postpartum Sterilization. J Midwifery Womens Health 2018; 64:186-193. [PMID: 30411465 DOI: 10.1111/jmwh.12909] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2018] [Revised: 08/21/2018] [Accepted: 08/21/2018] [Indexed: 11/27/2022]
Abstract
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.
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Arora KS, Wilkinson B, Verbus E, Montague M, Morris J, Ascha M, Mercer BM. Medicaid and fulfillment of desired postpartum sterilization. Contraception 2018; 97:559-564. [PMID: 29490290 DOI: 10.1016/j.contraception.2018.02.012] [Citation(s) in RCA: 39] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2017] [Revised: 02/12/2018] [Accepted: 02/21/2018] [Indexed: 10/17/2022]
Abstract
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.
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Affiliation(s)
- Kavita Shah Arora
- Department of Obstetrics and Gynecology, MetroHealth Medical Center, Case Western Reserve University, Cleveland, OH.
| | | | - Emily Verbus
- School of Medicine, Case Western Reserve University, Cleveland, OH
| | - Mary Montague
- School of Medicine, Case Western Reserve University, Cleveland, OH
| | - Jane Morris
- Department of Obstetrics and Gynecology, MetroHealth Medical Center, Case Western Reserve University, Cleveland, OH
| | - Mustafa Ascha
- Department of Epidemiology and Biostatistics, Case Western Reserve University, Cleveland, OH
| | - Brian M Mercer
- Department of Obstetrics and Gynecology, MetroHealth Medical Center, Case Western Reserve University, Cleveland, OH
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Moroz L, Riley LE, D'Alton M, Brown HL, Davis AR, Foley M, Graves CR, Sheffield JS, Zerden ML, Bryant AS. SMFM Special Report: Putting the "M" back in MFM: Addressing education about disparities in maternal outcomes and care. Am J Obstet Gynecol 2018; 218:B2-B8. [PMID: 29175250 DOI: 10.1016/j.ajog.2017.11.592] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2017] [Accepted: 11/20/2017] [Indexed: 11/30/2022]
Abstract
At the 36th Annual meeting of the Society for Maternal-Fetal Medicine (SMFM), leaders in the field of maternal-fetal medicine (MFM) convened to address maternal outcome and care inequities from 3 perspectives: (1) education, (2) clinical care, and (3) research. Meeting attendees identified knowledge gaps regarding disparities within the provider community; reviewed possible frameworks to address these knowledge gaps; and identified models with which to address key clinical issues. Collaboration and communication between all stakeholders will be needed to gain a better understanding of these prevailing disparities and formulate strategies to eliminate them.
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Affiliation(s)
- Leslie Moroz
- Columbia University Irving Medical Center, New York, NY
| | | | - Mary D'Alton
- Columbia University Irving Medical Center, New York, NY
| | | | - Anne R Davis
- Columbia University Irving Medical Center, New York, NY
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Coffman JC, Herndon BH, Thakkar M, Fiorini K. Anesthesia for Non-delivery Obstetric Procedures. Anesthesiology 2018. [DOI: 10.1007/978-3-319-74766-8_52] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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McKenzie C, Akdagli S, Abir G, Carvalho B. Postpartum tubal ligation: A retrospective review of anesthetic management at a single institution and a practice survey of academic institutions. J Clin Anesth 2017; 43:39-46. [PMID: 28985581 DOI: 10.1016/j.jclinane.2017.09.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2017] [Revised: 09/02/2017] [Accepted: 09/23/2017] [Indexed: 11/30/2022]
Abstract
STUDY OBJECTIVE The primary aim was to evaluate institutional anesthetic techniques utilized for postpartum tubal ligation (PPTL). Secondarily, academic institutions were surveyed on their clinical practice for PPTL. DESIGN An institutional-specific retrospective review of patients with ICD-9 procedure codes for PPTL over a 2-year period was conducted. Obstetric anesthesia fellowship directors were surveyed on anesthetic management of PPTL. SETTING Labor and delivery unit. Internet survey. PATIENTS 202 PPTL procedures were reviewed. 47 institutions were surveyed; 26 responses were received. MEASUREMENTS Timing of PPTL, anesthetic management, postoperative pain and length of stay. MAIN RESULTS There was an epidural catheter reactivation failure rate of 26% (18/69 epidural catheter reactivation attempts). Time from epidural catheter insertion to PPTL was a significant factor associated with failure: median [IQR; range] time for successful versus failed epidural catheter reactivation was 17h [10-25; 3-55] and 28h [14-33; 5-42], respectively (P=0.028). Epidural catheter reactivation failure led to significantly longer times to provide surgical anesthesia than successful epidural catheter reactivation or primary spinal technique: median [IQR] 41min [33-54] versus 15min [12-21] and 19min [15-24], respectively (P<0.0001). Fifty-eight percent (15/26) of respondents routinely leave the labor epidural catheter in-situ if PPTL is planned. Sixty-five percent (17/26) and 7% (2/26) would not attempt to reactivate the epidural catheter for PPTL if >8h and >24h post-delivery, respectively. CONCLUSIONS Epidural catheter reactivation failure increases with longer intervals between catheter placement and PPTL. Failed epidural catheter reactivation increases anesthetic and operating room times. Our results and the significant variability in practice from our survey suggest recommendations on the timing and anesthetic management are needed to reduce unfulfilled PPTL procedures.
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Affiliation(s)
- Christine McKenzie
- Department of Anesthesiology, UNC Medical Center, 101 Manning Drive, Chapel Hill, NC 27516, United States
| | - Seden Akdagli
- Department of Anesthesiology, SUNY Downstate Medical Center, 450 Clarkson Avenue, Brooklyn, NY 11203, United States
| | - Gillian Abir
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, 300 Pasteur Drive, Stanford, CA 94305, United States
| | - Brendan Carvalho
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, 300 Pasteur Drive, Stanford, CA 94305, United States.
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Contraception After Delivery Among Publicly Insured Women in Texas: Use Compared With Preference. Obstet Gynecol 2017; 130:393-402. [PMID: 28697112 DOI: 10.1097/aog.0000000000002136] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To assess women's preferences for contraception after delivery and to compare use with preferences. METHODS In a prospective cohort study of women aged 18-44 years who wanted to delay childbearing for at least 2 years, we interviewed 1,700 participants from eight hospitals in Texas immediately postpartum and at 3 and 6 months after delivery. At 3 months, we assessed contraceptive preferences by asking what method women would like to be using at 6 months. We modeled preference for highly effective contraception and use given preference according to childbearing intentions using mixed-effects logistic regression testing for variability across hospitals and differences between those with and without immediate postpartum long-acting reversible contraception (LARC) provision. RESULTS Approximately 80% completed both the 3- and 6-month interviews (1,367/1,700). Overall, preferences exceeded use for both-LARC: 40.8% (n=547) compared with 21.9% (n=293) and sterilization: 36.1% (n=484) compared with 17.5% (n=235). In the mixed-effects logistic regression models, several demographic variables were associated with a preference for LARC among women who wanted more children, but there was no significant variability across hospitals. For women who wanted more children and had a LARC preference, use of LARC was higher in the hospital that offered immediate postpartum provision (P<.035) as it was for U.S.-born women (odds ratio [OR] 2.08, 95% CI 1.17-3.69) and women with public prenatal care providers (OR 2.04, 95% CI 1.13-3.69). In the models for those who wanted no more children, there was no significant variability in preferences for long-acting or permanent methods across hospitals. However, use given preference varied across hospitals (P<.001) and was lower for black women (OR 0.26, 95% CI 0.12-0.55) and higher for U.S.-born women (OR 2.32, 95% CI 1.36-3.96), those 30 years of age and older (OR 1.82, 95% CI 1.07-3.09), and those with public prenatal care providers (OR 2.04, 95% CI 1.18-3.51). CONCLUSION Limited use of long-acting and permanent contraceptive methods after delivery is associated with indicators of health care provider and system-level barriers. Expansion of immediate postpartum LARC provision as well as contraceptive coverage for undocumented women could reduce the gap between preference and use.
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Wolfe KK, Wilson MD, Hou MY, Creinin MD. An updated assessment of postpartum sterilization fulfillment after vaginal delivery. Contraception 2017; 96:41-46. [PMID: 28578151 DOI: 10.1016/j.contraception.2017.05.005] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2017] [Revised: 05/10/2017] [Accepted: 05/21/2017] [Indexed: 10/19/2022]
Abstract
OBJECTIVE To describe sterilization completion rates after vaginal delivery and indications for unfulfilled procedures. STUDY DESIGN We used labor and delivery operating room and delivery logs to identify all women over 20years of age with a completed live vaginal birth beyond 24weeks gestation over a 33-month period (March 1, 2012 to November 30, 2014). We reviewed the electronic medical records of all of these patients and identified those who requested a sterilization procedure as indicated in a physician's admission note or antenatal record. RESULTS We identified 3514 live vaginal births beyond 24weeks gestation during the study period of which 219 requested postpartum sterilization. Sterilization occurred in 114 (52%). The most common reason for unfulfilled procedures was lack of valid federally mandated consent (n=46 [44%]). Fifty-nine percent (27 of 46) of these women had little or no prenatal care. Only one (0.5%) woman had documented completion of consent with the required time elapsed prior to delivery and no consent form available. Of the women with valid consent documentation, the most common indication for an unfulfilled procedure was patient refusal (n=30 [51%]). Body mass index was an independent predictor of an unfulfilled procedure (p<.001) among women with adequate consent. CONCLUSIONS Inability to complete federally mandated consent is a principal cause of unfulfilled postpartum sterilization and primarily affects women desiring sterilization who lack sufficient prenatal care. Of women who meet consent criteria, the primary reason women eligible for sterilization did not undergo the procedure was due to withdrawing their request. IMPLICATIONS Because women commonly do not undergo a requested sterilization after vaginal deliveries, antepartum counseling should include alternate contraception choices. Documented consent that fulfills all federally mandated criteria remains the most common barrier to requested sterilization after vaginal delivery; providers and policymakers should work together to help unburden women from this mandate.
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Affiliation(s)
- Kristen K Wolfe
- Department of Obstetrics and Gynecology, University of California, Davis Health
| | - Machelle D Wilson
- Department of Public Health Sciences, University of California, Davis
| | - Melody Y Hou
- Department of Obstetrics and Gynecology, University of California, Davis Health
| | - Mitchell D Creinin
- Department of Obstetrics and Gynecology, University of California, Davis Health.
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Patient-provider conversations about sterilization: A qualitative analysis. Contraception 2016; 95:227-233. [PMID: 27823943 DOI: 10.1016/j.contraception.2016.10.009] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2016] [Revised: 10/26/2016] [Accepted: 10/27/2016] [Indexed: 11/20/2022]
Abstract
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.
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Starr KA, Martins SL, Watson S, Gilliam ML. Postpartum Contraception Use by Urban/Rural Status: An Analysis of the Michigan Pregnancy Risk Assessment Monitoring System Data. Womens Health Issues 2015; 25:622-7. [PMID: 26253826 DOI: 10.1016/j.whi.2015.06.014] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2014] [Revised: 06/02/2015] [Accepted: 06/30/2015] [Indexed: 11/26/2022]
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Trends and Disparities in Postpartum Sterilization after Cesarean Section, 2000 through 2008. Womens Health Issues 2015; 25:634-40. [PMID: 26329256 DOI: 10.1016/j.whi.2015.07.006] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2014] [Revised: 04/15/2015] [Accepted: 07/06/2015] [Indexed: 11/20/2022]
Abstract
PURPOSE Tubal sterilization patterns are influenced by factors including patient race, ethnicity, level of education, method of payment, and hospital size and affiliation. However, less is known about how these factors influence tubal sterilizations performed as secondary procedures after cesarean sections (C-sections). Thus, this study examines variations in the prevalence of postpartum tubal sterilizations after C-sections from 2000 to 2008. METHODS We used data from the National Hospital Discharge Survey to estimate odds ratios for patient-level (race, marital status, age) and system-level (hospital size, type, region) factors on the likelihood of receiving tubal sterilization after C-section. RESULTS A disproportionate share of postpartum tubal sterilizations after C-section was covered by Medicaid. The likelihood of undergoing sterilization was increased for Black women, women of older age, and non-single women. Additionally, they were increased in proprietary and government hospitals, smaller hospital settings, and the Southern United States. CONCLUSIONS Our findings indicate that Black women and those with Medicaid coverage in particular were substantially more likely to undergo postpartum tubal sterilization after C-section. We also found that hospital characteristics and region were significant predictors. This adds to the growing body of evidence that suggests that tubal sterilization may be a disparity issue patterned by multiple factors and calls for greater understanding of the role of patient-, provider-, and system-level characteristics on such outcomes.
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White K, Potter JE, Zite N. Geographic Variation in Characteristics of Postpartum Women Using Female Sterilization. Womens Health Issues 2015; 25:628-33. [PMID: 26232310 DOI: 10.1016/j.whi.2015.06.011] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2014] [Revised: 06/15/2015] [Accepted: 06/29/2015] [Indexed: 10/23/2022]
Abstract
BACKGROUND Southern states have higher rates of female sterilization compared with other areas of the United States, and the reasons for this are not well understood. We examined whether low-income and racial/ethnic minority women, who were previous targets of coercive practices, disproportionately report using sterilization in the South. METHODS We used data from 12 states participating in the Pregnancy Risk Assessment Monitoring System that collected information on women's contraceptive method use between 2006 and 2009. We categorized states according to geographic region: South, Midwest/West, and Northeast. Within each region, we computed the percentage of women using sterilization according to their demographic and obstetric characteristics and estimated multivariable-adjusted prevalence ratios to evaluate whether the same characteristics were associated with sterilization use. FINDINGS The percentage of postpartum women using sterilization ranged from 5.0% to 9.9% in the Northeast, 8.9% to 10.6% in the Midwest/West, and 11.6% to 22.4% in the South. Women in nearly all subgroups in Southern states were more likely to use sterilization than women in the Northeast. After multivariable adjustment, there were no differences in the prevalence of sterilization for Blacks compared with Whites in the Northeast (0.76; 95% CI, 0.55-1.06), Midwest/West (0.91; 95% CI, 0.80-1.04), and South (0.96; 95% CI, 0.85-1.07). Women with Medicaid-paid deliveries (vs. private insurance) had a higher prevalence of sterilization in all regions (p < .05). CONCLUSIONS These findings do not indicate that low-income and racial/ethnic minority women in the South use sterilization at disproportionately higher rates compared with other regions, and suggest that other differences, such as social norms and family planning policies, may contribute to this geographic variation.
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Affiliation(s)
- Kari White
- Department of Health Care Organization & Policy, University of Alabama at Birmingham, Health Care Organization & Policy, Birmingham, Alabama.
| | - Joseph E Potter
- University of Texas at Austin, Population Research Center, Austin, Texas
| | - Nikki Zite
- Department of Obstetrics and Gynecology, University of Tennessee, Graduate School of Medicine, Knoxville, Tennessee
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Abstract
A central goal of The Academy of Breastfeeding Medicine is the development of clinical protocols for managing common medical problems that may impact breastfeeding success. These protocols serve only as guidelines for the care of breastfeeding mothers and infants and do not delineate an exclusive course of treatment or serve as standards of medical care. Variations in treatment may be appropriate according to the needs of an individual patient.
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Affiliation(s)
- Pamela Berens
- 1 Department of Obstetrics and Gynecology, University of Texas , Houston, Texas
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James-Hawkins L, Sennott C. Low-income women's navigation of childbearing norms throughout the reproductive life course. QUALITATIVE HEALTH RESEARCH 2015; 25:62-75. [PMID: 25185163 DOI: 10.1177/1049732314548690] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/26/2023]
Abstract
Shifts in family structure have affected age norms about both teenage childbearing and reproductive sterilization, but we lack research examining how childbearing norms are connected across the reproductive life course. Drawing on interviews from 40 low-income women in Colorado, we explored linkages between early childbearing and the desire for early sterilization. Specifically, we examined two narratives women use to negotiate competing norms throughout the reproductive life course. The low-income women in our study characterized their teenage childbearing experiences negatively and justified them using a "young and dumb" narrative. Women also asserted that reversible contraceptives do not work for them, using a "hyper-fertility" narrative to explain both their early childbearing and their desire for early sterilization. Our results illustrate the influence of mainstream social norms about childbearing timing on low-income women's lives and provide evidence of how women use narratives to explain and justify their violation of childbearing norms.
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Potter JE, Hopkins K, Aiken ARA, Hubert C, Stevenson AJ, White K, Grossman D. Unmet demand for highly effective postpartum contraception in Texas. Contraception 2014; 90:488-95. [PMID: 25129329 PMCID: PMC4207725 DOI: 10.1016/j.contraception.2014.06.039] [Citation(s) in RCA: 72] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2014] [Revised: 06/24/2014] [Accepted: 06/25/2014] [Indexed: 11/16/2022]
Abstract
OBJECTIVES We aimed to assess women's contraceptive preferences and use in the first 6 months after delivery. The postpartum period represents a key opportunity for women to learn about and obtain effective contraception, especially since 50% of unintended pregnancies to parous women occur within 2 years of a previous birth. METHODS We conducted a prospective cohort study of 800 postpartum women recruited from three hospitals in Austin and El Paso, TX. Women aged 18-44 who wanted to delay childbearing for at least 24 months were eligible for the study and completed interviews following delivery and at 3 and 6 months postpartum. Participants were asked about the contraceptive method they were currently using and the method they would prefer to use at 6 months after delivery. RESULTS At 6 months postpartum, 13% of women were using an intrauterine device or implant, and 17% were sterilized or had a partner who had had a vasectomy. Twenty-four percent were using hormonal methods, and 45% relied on less effective methods, mainly condoms and withdrawal. Yet 44% reported that they would prefer to be using sterilization, and 34% would prefer to be using long-acting reversible contraception (LARC). CONCLUSIONS This study shows a considerable preference for LARC and permanent methods at 6 months postpartum. However, there is a marked discordance between women's method preference and actual use, indicating substantial unmet demand for highly effective methods of contraception. IMPLICATIONS In two Texas cities, many more women preferred long-acting and permanent contraceptive methods (LAPM) than were able to access these methods at 6 months postpartum. Women's contraceptive needs could be better met by counseling about all methods, by reducing cost barriers and by making LAPM available at more sites.
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Affiliation(s)
- Joseph E Potter
- Population Research Center, University of Texas at Austin, TX, USA.
| | - Kristine Hopkins
- Population Research Center, University of Texas at Austin, TX, USA
| | - Abigail R A Aiken
- Population Research Center, University of Texas at Austin, TX, USA; LBJ School of Public Affairs, University of Texas at Austin, TX, USA
| | - Celia Hubert
- Population Research Center, University of Texas at Austin, TX, USA
| | | | - Kari White
- Health Care Organization and Policy, University of Alabama at Birmingham, AL, USA
| | - Daniel Grossman
- Ibis Reproductive Health, Oakland, CA, USA; Bixby Center for Global Reproductive Health, Department of Obstetrics, Gynecology and Reproductive Sciences, University of California San Francisco, San Francisco, CA, USA
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Krashin JW, Edelman AB, Nichols MD, Allen AJ, Caughey AB, Rodriguez MI. Prohibiting consent: what are the costs of denying permanent contraception concurrent with abortion care? Am J Obstet Gynecol 2014; 211:76.e1-76.e10. [PMID: 24799310 DOI: 10.1016/j.ajog.2014.04.039] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2013] [Revised: 03/15/2014] [Accepted: 04/30/2014] [Indexed: 11/17/2022]
Abstract
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.
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Affiliation(s)
- Jamie W Krashin
- Department of Obstetrics and Gynecology, Oregon Health and Science University, Portland, OR
| | - Alison B Edelman
- Department of Obstetrics and Gynecology, Oregon Health and Science University, Portland, OR
| | - Mark D Nichols
- Department of Obstetrics and Gynecology, Oregon Health and Science University, Portland, OR
| | - Allison J Allen
- Department of Obstetrics and Gynecology, Oregon Health and Science University, Portland, OR
| | - Aaron B Caughey
- Department of Obstetrics and Gynecology, Oregon Health and Science University, Portland, OR
| | - Maria I Rodriguez
- Department of Obstetrics and Gynecology, Oregon Health and Science University, Portland, OR
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White K, Potter JE. Reconsidering racial/ethnic differences in sterilization in the United States. Contraception 2014; 89:550-6. [PMID: 24439673 PMCID: PMC4035437 DOI: 10.1016/j.contraception.2013.11.019] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2013] [Revised: 11/20/2013] [Accepted: 11/24/2013] [Indexed: 10/25/2022]
Abstract
OBJECTIVE Cross-sectional studies have found that low-income and racial/ethnic minority women are more likely to use female sterilization and less likely to rely on a partner's vasectomy than women with higher incomes and whites. However, studies of pregnant and postpartum women report that racial/ethnic minorities, particularly low-income minority women, face greater barriers in obtaining a sterilization than do whites and those with higher incomes. In this paper, we address this apparent contradiction by examining the likelihood a woman gets a sterilization following each delivery, which removes from the comparison any difference in the number of births she has experienced. STUDY DESIGN Using the 2006-2010 National Survey of Family Growth, we fit multivariable-adjusted logistic and Cox regression models to estimate odds ratios and hazard ratios for getting a postpartum or interval sterilization, respectively, according to race/ethnicity and insurance status. RESULTS Women's chances of obtaining a sterilization varied by both race/ethnicity and insurance. Among women with Medicaid, whites were more likely to use female sterilization than African Americans and Latinas. Privately insured whites were more likely to rely on vasectomy than African Americans and Latinas, but among women with Medicaid-paid deliveries reliance on vasectomy was low for all racial/ethnic groups. CONCLUSIONS Low-income racial/ethnic minority women are less likely to undergo sterilization following delivery compared to low-income whites and privately insured women of similar parities. This could result from unique barriers to obtaining permanent contraception and could expose women to the risk of future unintended pregnancies. IMPLICATIONS Low-income minorities are less likely to undergo sterilization than low-income whites and privately insured minorities, which may result from barriers to obtaining permanent contraception, and exposes women to unintended pregnancies.
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Affiliation(s)
- Kari White
- Health Care Organization and Policy, University of Alabama at Birmingham, Birmingham, AL 35294, USA.
| | - Joseph E Potter
- Population Research Center, University of Texas at Austin, Austin, TX 78712, USA
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Borrero S, Zite N, Potter JE, Trussell J, Smith K. Potential unintended pregnancies averted and cost savings associated with a revised Medicaid sterilization policy. Contraception 2013; 88:691-6. [PMID: 24028751 PMCID: PMC3830666 DOI: 10.1016/j.contraception.2013.08.004] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2013] [Revised: 08/05/2013] [Accepted: 08/07/2013] [Indexed: 11/17/2022]
Abstract
OBJECTIVE Medicaid sterilization policy, which includes a mandatory 30-day waiting period between consent and the sterilization procedure, poses significant logistical barriers for many women who desire publicly funded sterilization. Our goal was to estimate the number of unintended pregnancies and the associated costs resulting from unfulfilled sterilization requests due to Medicaid policy barriers. STUDY DESIGN We constructed a cost-effectiveness model from the health care payer perspective to determine the incremental cost over a 1-year time horizon of the current Medicaid sterilization policy compared to a hypothetical, revised policy in which women who desire a postpartum sterilization would face significantly reduced barriers. Probability estimates for potential outcomes in the model were based on published sources; costs of Medicaid-funded sterilizations and Medicaid-covered births were based on data from the Medicaid Statistical Information System and The Guttmacher Institute, respectively. RESULTS With the implementation of a revised Medicaid sterilization policy, we estimated that the number of fulfilled sterilization requests would increase by 45%, from 53.3% of all women having their sterilization requests fulfilled to 77.5%. Annually, this increase could potentially lead to over 29,000 unintended pregnancies averted and $215 million saved. CONCLUSION A revised Medicaid sterilization policy could potentially honor women's reproductive decisions, reduce the number of unintended pregnancies and save a significant amount of public funds. IMPLICATION Compared to the current federal Medicaid sterilization policy, a hypothetical, revised policy that reduces logistical barriers for women who desire publicly funded, postpartum sterilization could potentially avert over 29,000 unintended pregnancies annually and therefore lead to cost savings of $215 million each year.
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Affiliation(s)
- Sonya Borrero
- Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA; Center for Health Equity, Research, and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA, USA.
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White K, Hopkins K, Potter JE, Grossman D. Knowledge and attitudes about long-acting reversible contraception among Latina women who desire sterilization. Womens Health Issues 2013; 23:e257-63. [PMID: 23816156 DOI: 10.1016/j.whi.2013.05.001] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2012] [Revised: 05/07/2013] [Accepted: 05/08/2013] [Indexed: 10/26/2022]
Abstract
BACKGROUND There is growing interest in increasing the use of long-acting reversible contraception (LARC), and suggestions that such methods may serve as an alternative to sterilization. However, there is little information about whether women who do not want more children would be interested in using LARC. METHODS We conducted semistructured interviews with 120 parous Latina women in El Paso, Texas, who wanted a sterilization but had not obtained one. We assessed women's awareness of and interest in using the copper intrauterine device (IUD), levonorgestrel intrauterine system (LNG-IUS), and etonogestrel implant. FINDINGS Overall, 51%, 23%, and 47% of women reported they had heard of the copper IUD, LNG-IUS, and implant, respectively. More women stated they would use the copper IUD (24%) than the LNG-IUS (14%) or implant (9%). Among women interested in LARC, the most common reasons were that, relative to their current method, LARC methods were more convenient, effective, and provided longer-term protection against pregnancy. Those who had reservations about LARC were primarily concerned with menstrual changes. Women also had concerns about side effects and the methods' effectiveness in preventing pregnancy, preferring to use a familiar method. CONCLUSIONS Although these findings indicate many Latina women in this setting do not consider LARC an alternative to sterilization, they point to an existing demand among some who wish to end childbearing. Efforts are needed to improve women's knowledge and access to a range of methods so they can achieve their childbearing goals.
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Affiliation(s)
- Kari White
- University of Alabama at Birmingham, Health Care Organization & Policy, Birmingham, Alabama, USA.
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Nguyen BT, Shih G, Turok DK. Putting the man in contraceptive mandate. Contraception 2013; 89:3-5. [PMID: 24210279 DOI: 10.1016/j.contraception.2013.10.001] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2013] [Revised: 09/28/2013] [Accepted: 10/01/2013] [Indexed: 11/24/2022]
Affiliation(s)
- Brian T Nguyen
- Department of Obstetrics and Gynecology, Oregon Health and Sciences University, 3181 Southwest Sam Jackson Park Road, Box L466, Portland, OR 97239, USA.
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Potter JE, Stevenson AJ, White K, Hopkins K, Grossman D. Hospital variation in postpartum tubal sterilization rates in California and Texas. Obstet Gynecol 2013; 121:152-8. [PMID: 23262940 DOI: 10.1097/aog.0b013e318278f241] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To estimate variation across hospitals in the rate of postpartum sterilization. METHODS All hospitals with deliveries in California and Texas in 2009 were included. Proportion of live singleton deliveries with postpartum sterilization was calculated by hospital, insurance status (Medicaid compared with private insurance), type of delivery, and state. RESULTS Within each insurance status in California and Texas, we found wide variations across hospitals in postpartum tubal sterilization rates. This variability was not explained by disparities in hospital cesarean delivery rates. Some, but not all, of this variation was attributable to the absence of sterilizations in Catholic hospitals. Overall, postpartum tubal sterilization rates were higher in Texas than in California (10.2% compared with 6.7%), and this difference was found among both public insurance and private insurance patients. Interval sterilizations were more frequent in California, but the difference was not large enough to offset the difference in postpartum sterilization. CONCLUSIONS The variation in postpartum tubal sterilization rates across hospitals is substantial and exists even among hospitals without religious affiliations. Large-scale studies are needed to assess the demand for, and the barriers to, obtaining postpartum sterilization. LEVEL OF EVIDENCE II.
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Affiliation(s)
- Joseph E Potter
- Population Research Center, University of Texas at Austin, Austin, Texas 78712, USA.
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