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COMMITTEE OPINION
Number 530 • July 2012 (Reaffirmed 2016)
Committee on Health Care for Underserved Women
This information should not be construed as dictating an exclusive course of treatment or procedure to be followed.
Unintended pregnancy is a serious problem in the United immediate postpartum period following vaginal delivery
States that is associated with health risks and costs for or at the time of cesarean delivery is the ideal time to
a woman, her family, and society (1, 2). Women who perform sterilization because of technical ease and conve-
continue with unintended pregnancies are more likely nience for the woman and physician. The procedure itself
to have poor health outcomes such as low birth weight should not lengthen hospitalization (13). This one-time
infants, infant mortality, and maternal morbidity and intervention is typically covered by insurance and elimi-
mortality (1, 3). Children resulting from unintended nates the risk of future pregnancy (7, 14).
pregnancies have higher rates of developmental delay Only 50% of women who request postpartum steril-
(1, 3). One half of pregnancies in the United States are ization during prenatal contraception counseling actually
unintended and often occur disproportionately in low- undergo the procedure (15, 16). Failure to provide the
income and minority populations (4). A critical factor desired sterilization creates a significant increase in cost
underlying this widespread problem is a lack of access to for the woman and the health care system (17). In one
effective family planning services (1, 4–6). study, nearly one half of women with unfulfilled postpar-
Postpartum sterilization is one of the most effective tum sterilization requests became pregnant within 1 year,
and popular forms of contraception in the United States, twice the rate of women who did not request sterilization
and it is performed after 10% of all hospital deliveries (10). The direct annual cost of unintended pregnancy to
(7, 8). Sterilization procedures are more common among the health care system measures in billions of dollars (18).
underserved women, including those with lower levels Because approximately one quarter of American women
of education and income, public health insurance or no rely on female sterilization for contraception, making the
health insurance, high parity, and those who are black or availability of postpartum sterilization a priority is critical
Hispanic. However, several barriers limit access to the to reducing unintended pregnancy (6, 10, 17). Women
procedure for many women, especially the poor or under- in the postpartum period, with the added responsibility
served, who desire postpartum sterilization (6, 9–12). The of caring for a newborn and varying insurance coverage,
often struggle to return to the outpatient office for alter- the consent form is not signed, the patient will receive
native methods of contraception. a bill for services. Furthermore, reimbursement to the
Most women are good candidates for postpartum hospital for the delivery and postpartum care may be
sterilization. Occasionally, however, maternal medical denied because of an improperly completed or incom-
disorders may complicate the ability to safely perform plete federal consent form. Although the original intent
postpartum sterilization procedures. Assessment of hem- was to protect women from being sterilized against their
odynamic status and consideration of anesthetic risks are will, the lack of a timely signature on the federal consent
important for women scheduled for postpartum steriliza- form now interferes with patient autonomy because
tion. Although the safety of postpartum tubal sterilization it has become a common reason for lack of provision
in women with preeclampsia has not been thoroughly of desired postpartum sterilization (15, 16, 22, 23). In
evaluated, in the absence of profound hemodynamic addition, the lack of availability or failed transfer of the
alterations, the patient can be considered a candidate for completed federal consent document to the delivery
the procedure (19). Morbid obesity may present operative unit can result in cancellation of sterilization procedures
difficulties for performing the procedure; however, the (14). Women with commercial or private insurance
theoretic effectiveness of the procedure should remain who desire sterilization are not mandated to follow the
unaffected by the patient’s body mass index (20). When same consent rules—signing a consent form at least 30
unforeseen morbidity occurs that prevents a sterilization days in advance—to obtain the procedure, thus creating
procedure or causes a woman to decide not to undergo a two-tiered system of access. With possible Medicaid
the procedure, alternative reversible methods of contra- expansions under the Patient Protection and Affordable
ception should be presented to the woman, including Care Act, this federal regulation will adversely affect an
long-acting methods that have effectiveness rates com- even larger population of women. The regulation places
parable to sterilization such as the intrauterine device or an undue burden on women and health care providers
single-rod contraceptive implant (21). and must be revised in order to create fair and equitable
Because most women are good candidates for post- access for women enrolled in Medicaid or covered by
partum sterilization and because the costs associated other government insurance. Until this is accomplished,
with lack of provision of the procedure are high, barriers hospital systems and obstetric health care providers
must be overcome to improve the consistency of fulfilling should develop appropriate policies and procedures to
requests for postpartum sterilization. Factors that may ensure that the federal consent form is obtained in the
decrease the likelihood of a woman obtaining desired prenatal period and is available at the time of delivery. If a
postpartum sterilization include young age and concern woman covered by Medicaid does not receive her desired
for patient regret, consent documents, lack of available sterilization, she may not be eligible for coverage of any
operating rooms and anesthesia, and receiving care in a contraceptive method because Medicaid insurance often
religiously affiliated hospital. ends shortly after the birth (17).
Young Age and Concern for Patient Regret Lack of Available Operating Rooms or
Women must be 21 years old to be eligible for a steriliza- Anesthesia
tion procedure covered by federal Medicaid funds, the Inadequate hospital resources can hinder a woman from
Indian Health Service, or U.S. military health insurance. obtaining her desired postpartum sterilization. Typically,
However, health care providers may be reluctant to postpartum sterilization procedures are performed in
perform sterilization in women younger than 30 years labor and delivery operating rooms with obstetric
because of the increased probability of long-term regret anesthesia personnel. Performing postpartum steril-
compared with women older than 30 years (21). The ization may be impossible when several deliveries are
majority of women younger than 30 years (80%) do not imminent or when inadequate staffing occurs in a hos-
regret their sterilization decision. Long-term regret is pital’s labor and delivery ward. From the patient’s per-
more common among underserved women, and thor- spective, she has been counseled and anticipates the
ough presterilization counseling may identify women procedure; she remains without oral intake for many
more likely to experience regret. hours and may be separated from her newborn only to
face a canceled procedure. By its very nature, a postpar-
Consent Documents tum sterilization procedure cannot be scheduled in
To ensure informed consent and protect women from advance, a fact that increases the difficulty of obtaining
coercion, federal regulations require specific sterilization an operating room. Consideration of other operative sites
consent for women enrolled in Medicaid or covered by within the hospital, such as the main operating room,
other government insurance for all sterilization proce- could increase the likelihood that sterilization procedures
dures, not just postpartum sterilization. This consent would be accomplished. Emphasis on the urgent nature
form must be signed at least 30 days before the procedure of the procedure, rather than considering it elective,
in order for a health care provider or health care facility may increase the success in scheduling these procedures
to be reimbursed, and it remains valid for 180 days; if with such a short notice. Use of an existing epidural