Medicaid compared to private insurance is associated with lower rates of sterilization in people with unwanted births.

BACKGROUND: Medicaid, unlike any other insurance mechanism, imposes a consent requirement on female patients desiring sterilization that must be completed at least 30 days, but no more than 180 days, before sterilization. Desired sterilization cannot be completed in the Medicaid population without this consent. Large-scale national evidence is lacking on the effect of this requirement. OBJECTIVE: This study aimed to explore the influence of insurance status on the achievement of postpartum sterilization after a self-reported unwanted birth in a nationally representative sample. STUDY DESIGN: This was a retrospective cohort analysis using data from the 2013-2015 National Survey of Family Growth. The National Survey of Family Growth uses a stratified, multistage clustered sample to make nationally representative estimates for men and women aged 15 to 44 years in the household population of the United States. The analysis was limited to a cohort of birthing people who reported their last birth as unwanted and who were insured by either Medicaid or private insurance. The survey was analyzed with the application of inverse probability of treatment weights to balance those with Medicaid and those with private insurance in addition to the survey weight. The association between completion of postpartum sterilization and insurance type was evaluated using weighted logistic regression, adjusting for demographic and clinical characteristics. RESULTS: In an adjusted and inverse probability of treatment weight balanced analysis of a weighted national sample representing 4,164,304 people (416 respondents), Medicaid-insured birthing people with history of unwanted births were found to have 56% lower odds of obtaining postpartum sterilization (odds ratio, 0.44; 95% confidence interval, 0.22-0.87; P=.019) than those with private insurance. CONCLUSION: This study adds to mounting evidence that insurance type plays a significant role in the achievement of desired postpartum sterilization, with individuals with Medicaid less likely to undergo the procedure. The findings call for policy reforms around sterilization policy in the United States, emphasizing the need for uniform consent procedures that do not discriminate based on insurance status.

Does socioeconomic factors and healthcare coverage affect postpartum sterilization uptake in an urban, tertiary hospital?

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.

Postpartum sterilization is an effective and popular method of contraception. In our hospital, postpartum sterilization is easily accessible compared to other countries where there are barriers such as mandatory waiting time, limited operating rooms and anesthesiologists. We examine factors that affect sterilization rates and found that older women and women with more children were more likely to choose postpartum sterilization. We also found that women who delivered by cesarean section were more likely to choose sterilization. Interestingly, whether the woman's healthcare plan covers postpartum sterilization does not affect the likelihood of sterilization.

Female permanent contraception trends and updates.

Permanent contraception remains one of the most popular methods of contraception worldwide. This article has reviewed recent literature related to demographic characteristics of users, prevalence of use and trends over time, surgical techniques, and barriers to obtain the procedure. We have emphasized the patient's perspective as a key element of choosing permanent contraception. This review has incorporated sections on salpingectomy, hysteroscopy, unmet need, impact of policies at religiously affiliated institutions, and reproductive coercion.

Outcomes for Women Denied Postpartum Tubal Ligation During the Initial COVID-19 Surge.

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.

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

OBJECTIVE: The COVID-19 pandemic presented new care delivery obstacles in the form of scheduling procedures and safe presentation to in-person visits. Contraception provision is an indispensable component of postpartum care that was not immune to these challenges. Given the barriers to care during the initial months of the pandemic, we sought to examine how postpartum contraception, sterilization, and visit attendance were affected during this period. STUDY DESIGN: We performed a retrospective chart review to examine contraception initiation, sterilization, and postpartum virtual and in-person visit attendance rates during the first six months (March 15 to September 7, 2020) of the COVID-19 pandemic compared to the rates in the same period in the year prior at a single tertiary academic care center. We abstracted data from the first prenatal visit through twelve weeks postpartum. RESULTS: With the initiation of virtual appointments, postpartum visit attendance significantly increased (94.6 % vs 88.4 %, p < 0.001) during the pandemic with no difference in overall contraception uptake (51 % vs 54.1 %, p = 0.2) or sterilization (11.0 % vs 11.5 %, p = 0.88). During the pandemic, contraception prescribed differed significantly with a trend towards patient-administered methods including pills, patches, and rings (21 % vs 16 %, p = 0.02). In both periods, there was a significantly younger mean age (p < 0.001), higher proportion of non-White and non-Asian race (p < 0.001), public insurance (p = 0.003, 0.004), and an established contraceptive plan prenatally (p < 0.001) in the group that received contraception. CONCLUSION: As virtual postpartum visits were instituted, contraception initiation and sterilization were maintained at pre-pandemic rates and visit attendance rose despite the obstacles to care presented by the COVID-19 pandemic. Provision of virtual postpartum visits may be a driver to maintain contraception and sterilization rates at a time, such as early in the COVID-19 pandemic, when patient care is at risk to be disrupted by social distancing, isolation, and avoidance of medical campuses.

Accessibility to postpartum tubal ligation after a vaginal delivery: When the Medicaid policy is not a limiting factor.

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.

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

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

Effect of simethicone on reducing operative difficulty associated with bowel interference during minilaparotomy for modified Pomeroy salpingectomy: A randomized controlled trial.

OBJECTIVE: To examine the effect of simethicone on reducing operative difficulty associated with bowel interference during minilaparotomy for postpartum modified Pomeroy partial salpingectomy. STUDY DESIGN: We enrolled 20-45-year-old women planning the procedure from March 2018 to February 2019. We randomized participants to chew simethicone 160 mg with water 50 mL 2-8 h before surgery or no treatment. The participants were not blinded; however, surgeons, care providers, and outcome assessors were blinded to the study allocation. We measured surgeon-rated operative difficulty using a 10-cm visual analog scale that represented the difficulty perceived to be resulting from bowel interference. Secondary outcomes included operative time and intraoperative and postoperative complications. RESULTS: We enrolled 60 women in each group; baseline characteristics and procedural profiles were comparable. Women in the intervention group used simethicone a median of 157 min (interquartile range 127-192) before the procedure. Surgeons rated the procedure difficulty score as 4.8 in the simethicone group and 4.5 in the control group (p = 0.57). Operative time in the two groups were 26 and 24 min, respectively (p = 0.14). We found no difference in intraoperative adverse events including blood loss and mesosalpinx tear, postoperative morbidities, hospital stay, and patient-rated satisfaction scores. CONCLUSION: Preprocedural simethicone has no demonstrable benefit in reducing operative difficulty caused by bowel interference during minilaparotomy for postpartum tubal sterilization. IMPLICATIONS: Preprocedural simethicone as given in this study did not result in reduced bowel interference and improved procedure difficulty. Further research examining simethicone in this setting would not be worthwhile as clinically meaningful benefit is unlikely.

Patients' perceptions toward and the driving factors of decision-making for opportunistic bilateral salpingectomy at the time of cesarean section.

OBJECTIVE: Enough data can be found in the literature regarding the protective effect of tubal ligation on gynecological cancers. In addition, a large body of evidence revealed that prophylactic bilateral salpingectomy had no significant negative effect on the ovarian function, quality of life, sexuality, surgery duration, and cost-effectivity. This study was aimed at exploring the underlying factors that motivate women for either opportunistic bilateral salpingectomy (OBS) or tubal ligation, particularly focusing on their preferences, knowledge, and beliefs toward female sterilization, satisfaction from counseling, and body image following the salpingectomy. MATERIALS AND METHODS: A total of 54 patients who had undergone surgical sterilization with either OBS or tubal ligation were included in this prospective cohort study. The acceptance rate of the OBS at the time of cesarean section among pregnant women seeking surgical sterilization was calculated. The underlying reasons for women's acceptance or refusal for salpingectomy were assessed by a non-validated data collection tool that had 14 open-ended questions focusing on the women's preferences, knowledge, beliefs toward female sterilization, satisfaction from counseling, and body image following the salpingectomy. RESULTS: The acceptance rate of OBS at the time of cesarean section among pregnant women and electively among non-pregnant women were 93.5% (n=43/46) and 75% (6/8), respectively. The main driving factors influencing the decision of preferring OBS over tubal ligation were the risk-reducing effect for ovarian cancer and superior pregnancy prevention. CONCLUSION: The acceptance rate of OBS at the time of cesarean section was found to be very high, and it should therefore be offered at the time of cesarean section to women who desire permanent contraception.

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

OBJECTIVE: To explore the attitudes and beliefs of obstetrician-gynecologists in the United States (US) regarding the Medicaid postpartum sterilization policy. STUDY DESIGN: We recruited obstetrician-gynecologists practicing in ten geographically diverse US states for a qualitative study using the American College of Obstetricians and Gynecologists directory. We conducted semi-structured interviews via telephone, professionally transcribed, and analyzed using the constant comparative method and principles of grounded theory. RESULTS: We interviewed thirty obstetrician-gynecologists (63.3% women, 76.7% non-subspecialized, and 53.3% academic setting). Participants largely described the consent form as unnecessary, paternalistic, an administrative hassle, a barrier to desired patient care, and associated with worse health outcomes. Views on the waiting period's utility and impact were mixed. Many participants felt the sterilization policy was discriminatory. However, some participants noted the policy's importance in terms of the historical basis, used the form as a counseling tool to remind patients of the permanence of sterilization, felt the policy prompted them to counsel regarding sterilization, and protected patients in contemporary medical practice. CONCLUSION: Many physicians shared concerns about the ethics and clinical impact of the Medicaid sterilization policy. Future revisions to the Medicaid sterilization policy must balance prevention of coercion with reduction in barriers to those desiring sterilization in order to maximize reproductive autonomy. IMPLICATIONS: Obstetrician-gynecologists are key stakeholders of the Medicaid sterilization policy. Obstetrician-gynecologists largely believe that revision to the Medicaid sterilization policy is warranted to balance reduction of external barriers to desired care with a process that enforces the need for counseling regarding contraception and reviewing patient preference for sterilization throughout pregnancy in order to minimize regret.

Barriers and outcomes associated with unfulfilled requests for permanent contraception following vaginal delivery.

OBJECTIVES: To identify barriers to postpartum permanent contraception procedures after vaginal delivery and to explore contraceptive and reproductive outcomes of women who experience unfulfilled requests. STUDY DESIGN: We performed a retrospective cohort study of women requesting postpartum permanent contraception after vaginal delivery from 7/1/11 to 6/30/14 at Strong Memorial Hospital in Rochester, NY. We ascertained patient characteristics and outcomes through electronic medical records and birth certificate data search. RESULTS: Of 189 women in our sample, 78 (41.3%) had a postpartum permanent contraception procedure. Factors associated with unfulfilled requests in adjusted analysis included BMI ≥40 (OR 3.71, 95% CI 1.46-9.48 compared to BMI <35), federal sterilization consent signed ≥36 weeks (OR 5.10, 95% CI 1.64-15.86 compared to <36 weeks) and delivery in the latter half of the week (Wednesday-Saturday) (OR 2.02, 95% CI 1.08-3.79). Documented reasons for unfulfilled permanent contraception requests included patient changing her mind related to procedural issues (21, 18.9%), invalid consent (20, 18.0%), maternal obesity (17, 15.3%), lack of operating room availability (14, 12.6%) and ambivalence about permanent contraception (5, 4.5%). Of 57 women who planned for interval permanent contraception and had institutional follow-up over the subsequent year, 14 (24.6%) had a procedure, 8 (14.0%) initiated long-acting reversible contraception, and 13 (22.8%) became pregnant. CONCLUSIONS: Fewer than half of women obtained desired postpartum permanent contraception after vaginal delivery, with logistical issues and obesity being the most common reported barriers. Health care providers should advocate for access to postpartum permanent contraception, as well as discuss prenatally the individualized probability of nonfulfillment and importance of alternative contraceptive plans. IMPLICATIONS: Logistical barriers and inappropriate antenatal preparation contribute to the fact that over half of women do not obtain desired postpartum permanent contraception after vaginal delivery. To respect reproductive autonomy and improve care, clinicians and other health officials should eliminate barriers to immediate postpartum permanent contraception while increasing access to alternative options.

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

INTRODUCTION: This study aimed to assess unfulfilled sterilization requests, specifically regarding issues with the Medicaid consent for sterilization, and determine the proportion of women who subsequently received interval sterilization by 3 months postpartum. METHODS: The authors conducted a prospective observational cohort study of women who gave birth over an 8-month period and requested immediate postpartum sterilization. Records of women with unfulfilled requests were reviewed up to 3 months postpartum to determine rates of postpartum follow-up and interval sterilization. Primary analysis examined unfulfilled sterilization requests associated with the Medicaid consent form and, secondarily, all other reasons for unfulfilled requests, as well as alternative contraceptive methods chosen. RESULTS: Of the 334 women who requested immediate postpartum sterilization, 173 (52%) received the requested sterilization and 161 (48%) did not. Among those whose request was unfulfilled, 91 (56.5%) still wanted the procedure, and of those women, more than two-thirds were unable to receive it because of Medicaid consent issues. Within this group, only 6 received interval sterilization by 3 months postpartum; more than one-third received a form of long-acting reversible contraception, and 24.6% did not receive postpartum care. DISCUSSION: A sizable proportion of women requesting postpartum sterilization have unfulfilled requests because of an issue with the Medicaid consent and also have a low likelihood of receiving interval sterilization by 3 months postpartum. The Medicaid consent may create barriers for women requesting postpartum sterilization, the vast majority of whom face subsequent barriers obtaining interval sterilization, thereby increasing the risk for unintended pregnancy in an at-risk population. This has important implications for reproductive justice efforts to protect vulnerable populations while minimizing barriers to desired care.

Women's decision making for postpartum sterilization: does the Medicaid waiting period add value?

OBJECTIVES: Currently, patients with federally funded insurance are required to sign a sterilization consent form (SCF) at least 30 days prior to sterilization, while privately insured patients are not. Although this policy was designed to protect the reproductive rights of vulnerable populations, it has had the unintended effect of creating a disparity in access to an effective contraceptive method. Our qualitative study aims to clarify the decision-making process surrounding postpartum sterilization and assess if patients perceive that the SCF adds value. STUDY DESIGN: We interviewed 25 women who underwent postpartum sterilization procedures, 10 with private insurance and 15 with Medicaid. Topics discussed included reproductive history, reason for choosing sterilization, decision-making timeline and value of the SCF. We transcribed and coded the interviews and identified themes. RESULTS: Participant responses indicated that decision-making processes were similar between patients with private insurance and those with Medicaid. For most women, the decision to undergo sterilization took place over the course of their reproductive lives. Participants expressed that nonbiased provider counseling, autonomy and information from other women were helpful to their decision making. Most subjects felt that the SCF might benefit other women but did not/would not affect their own decision making. CONCLUSIONS: We did not find evidence suggesting that women with private insurance and women with Medicaid should be subjected to disparate restrictions on sterilization based on differences in decision-making processes. Characteristics of the decision-making process that women value, which in this population did not include the SCF, should be prioritized. IMPLICATIONS: Given the potential negative consequences associated with the SCF including its disproportionate burden on women of low socioeconomic status, the lack of value added to the decision-making process for postpartum sterilization reported by our participants provides further evidence for reevaluation of the policy.

Obstetrician-gynecologists' counseling regarding postpartum sterilization.

INTRODUCTION: Obstetrician-gynecologists (ob-gyns) play a prominent role in counseling patients regarding sterilization, offering alternative contraception, fulfilling sterilization requests, and referring patients if unable to provide the service due to a personal moral belief. Therefore, we sought to better characterize the counseling practices of ob-gyns with respect to postpartum sterilization. MATERIALS AND METHODS: This is a prospective, electronic survey-based study of 1,000 ob-gyn members of the American College of Obstetricians and Gynecologists, half of whom are members of the Collaborative Ambulatory Research Network. RESULTS: A total of 188 of 957 surveyed physicians (19.6%) opened and responded to the survey, after accounting for exclusions. Age (31.9%), body mass index (28.7%), and medical history (27.1%) were the three most frequent reasons for an ob-gyn reported declining to perform sterilization in a patient requesting sterilization. Medical history (36.2%), parity (31.9%), and availability of alternative contraception (27.7%) were the three most frequent reasons that an ob-gyn reported recommending postpartum sterilization in a patient not requesting sterilization. CONCLUSION: Our study has identified both medical and nonmedical factors that impact ob-gyns likelihood to recommend either toward or against postpartum sterilization. Nonmedical factors included clinical logistical issues such as availability of the operating room as well as considerations of a patient's age, parity, gestational age at delivery, and whether the husband was in agreement. Physicians should be cautious of inappropriately blending medical decision-making with paternalistic counseling.

Postpartum tubal ligation: A retrospective review of anesthetic management at a single institution and a practice survey of academic institutions.

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.

Reconsidering racial/ethnic differences in sterilization in the United States.

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.

Barriers to completion of desired postpartum sterilization.

Tubal sterilization is a highly effective, permanent, and safe method of contraception. Many women who desire postpartum sterilization do not obtain the procedure due to barriers. We performed a retrospective cohort study examining patients from a single obstetrics practice who delivered between 1/1/07 and 6/30/07 at Women and Infants Hospital in Providence, RI. During the study period, 626 women in the practice delivered. Of these subjects, 87 (14%) desired postpartum sterilization. Of these 87, 45 (51.7%) underwent sterilization as planned. In multivariable analysis controlling for age, BMI, delivery mode and marital status, older age (OR 2.15, 95% CI 1.12, 4.12, p=0.02) and cesarean delivery (OR 19.65, 95% CI 3.75, 103.1, p < 0.001) were associated with completion of postpartum sterilization and being married (OR 0.10, 95% CI 0.02, 0.56, p=0.009) and having a higher BMI (OR 0.60, 95% CI 0.39, 0.91, p=0.02) were associated with incompletion. Only half of women who request postpartum sterilization antenatally end up obtaining the procedure.