Female sterilization, typically accomplished by means of tubal ligation, is a widely used method of contraception that is highly effective at preventing unintended pregnancy. Yet there appears to be unmet demand for the procedure in certain segments of the U.S. population. Specifically, low-income women and women from minority racial and ethnic groups may face substantial system-level barriers to obtaining a desired sterilization procedure. One such barrier is the federal policy regarding Medicaid-funded sterilizations. Although this policy was designed to protect vulnerable populations, we believe that it does not effectively fulfill that intention — in fact, it restricts the reproductive autonomy of the women it intends to serve. With the upcoming Medicaid expansions, the number of women affected by these barriers could increase substantially.Population Research Cente

Borrero, Sonya

Potter, Joseph E.

Trussell, James

Zite, Nikki

New England Journal of Medicine

English

PubMed

Texas ScholarWorks

PERSPECTIVEn engl j med 370;2 nejm.org january 9, 2014102Medicaid Policy on SterilizationMedicaid Policy on Sterilization — Anachronistic or Still Relevant?Sonya Borrero, M.D., Nikki Zite, M.D., Joseph E. Potter, Ph.D., and James Trussell, Ph.D.Female sterilization, typically accomplished by means of tubal ligation, is a widely used method of contraception that is highly effective at preventing un-intended pregnancy. Yet there ap-pears to be unmet demand for the procedure in certain segments of the U.S. population.1 Specifi-cally, low-income women and women from minority racial and ethnic groups may face substan-tial system-level barriers to ob-taining a desired sterilization pro-cedure.1 One such barrier is the federal policy regarding Medicaid-funded sterilizations. Although this policy was designed to pro-tect vulnerable populations, we believe that it does not effectively fulfill that intention — in fact, it restricts the reproductive autono-my of the women it intends to serve. With the upcoming Medic-aid expansions, the number of women affected by these barriers could increase substantially.The use of tubal ligation as a contraceptive method increased dramatically during the 1960s and 1970s with the legalization of contraception, improved safety of laparoscopic techniques, and the creation of federally funded family-planning programs that subsidized the costs. During those years, numerous reports of coer-cive and nonconsensual steriliza-tion of minority and poor women emerged, inciting a public out-cry in which the government was accused of racist and classist ap-plications of family-planning pro-grams. In response, in 1976, the Department of Health, Education, and Welfare developed protective regulations and a standardized consent form for publicly funded sterilization procedures. These regulations pro hibited sterilization of persons younger than 21 years of age or who were mentally in-competent or institutionalized. They also required a 72-hour waiting period before steriliza-tion; in 1978, the waiting period was extended to 30 days from the time of written informed consent. Although these regula-tions apply to both women and men, female sterilization is sig-nificantly more common than male sterilization in low-income populations, and women often desire sterilization at a specific time — after childbirth — which makes the extended waiting pe-riod particularly problematic.Because these policies have not changed since 1978, women re-questing publicly funded steril-ization must complete the “Con-sent to Sterilization” section of the Medicaid Title XIX form (Title XIX-SCF) at least 30 days and no more than 180 days before un-dergoing the procedure. In addi-tion, a signed copy of the con-sent form must be available or verified at the time of the proce-dure. If the woman is undergo-ing emergency abdominal sur-gery or a premature delivery, the 30-day waiting period may be waived, but at least 72 hours must have elapsed between the consent and the procedure.Although the policy was pre-sumably well intentioned, there is evidence that the Medicaid con-sent process may not be capable of protecting vulnerable women by ensuring that truly informed consent is obtained. Although the consent form contains language designed to confirm the wom-an’s understanding of the risks and benefits of the procedure, including the fact that the result is permanent, as well as infor-mation about the mandatory 30-day waiting period, assessments of the form’s readability indicate that it is overly complicated and its literacy level is too high for the average American adult.2 In one study assessing women’s knowledge about sterilization af-ter they had been given the Med-icaid consent form for review, more than one third of respon-dents (34%) answered incorrectly when asked about the permanence of sterilization.3 When a modified, low-literacy version of Title XIX-SCF was compared with the cur-rent form in a randomized trial involving 200 women with Medic-aid coverage, those who reviewed the modified form were more likely to know about the 30-day waiting period before the form is considered valid (a 24-percentage-point difference between groups), that nonpermanent contraceptive options as effective as sterilization are available (an 8-percentage-point difference), and that the procedure is permanent (a 16-percentage-point difference).3Beyond concerns about the consent form, the waiting period and the need for the completed form to be transferred to the de-livery unit pose logistic barriers for women who wish to undergo tubal ligation immediately after giving birth. Currently, among U.S. women sterilized within 2 years after delivery, more than 70% of procedures are done in the imme-diate postpartum period. Women report that requesting sterilization too late in pregnancy to fulfill The New England Journal of Medicine Downloaded from nejm.org at UT AUSTIN on April 3, 2018. For personal use only. No other uses without permission.  Copyright © 2014 Massachusetts Medical Society. All rights reserved. n engl j med 370;2 nejm.org january 9, 2014PERSPECTIVE103Medicaid Policy on Sterilizationthe 30-day waiting period, not hav-ing the form present at the time of delivery, or delivering before the mandatory waiting period had elapsed prevented them from having their request for steriliza-tion fulfilled at the time of deliv-ery.1 Moreover, because women with private insurance are not subject to the same regulations, the policy creates a two-tiered system of access, in which low-income women may not be able to exercise the same degree of reproductive autonomy as their wealthier counterparts. Inequitable access is compounded by the fact that many Medicaid beneficiaries who do not receive a desired sterilization during the immedi-ate postpartum period may miss their window of opportunity, since pregnancy-related Medicaid eligi-bility ends shortly after delivery. These issues recently prompted the American College of Obstet-rics and Gynecology Committee on Health Care for Underserved Women to recommend revising Medicaid policy to create fair and equitable access to sterilization procedures.1Preventing women from ob-taining a desired sterilization puts them at high risk for unin-tended pregnancy. In one study, 47% of women who requested but did not receive a postpartum sterilization became pregnant dur-ing the first year after delivery — over twice the rate of pregnancies in women who did not request sterilization.4 Unfortunately, un-intended pregnancy remains a prevalent and substantial issue in the United States, since such pregnancies are associated with numerous adverse health and so-cial consequences for women and their families. In addition, unintended pregnancy is costly for society, with direct annual public costs of billions of dol-lars. Reducing barriers associat-ed with Medicaid policy regard-ing sterilization may be one approach to making a dent in the stubbornly high rate of un-intended pregnancy and the high costs associated with it. In a re-cent cost analysis, we found that Medicaid-policy–related barriers lead to approximately 62,000 un-fulfilled requests for postpartum sterilization annually, resulting in an estimated 10,000 abortions and 19,000 unintended births in the subsequent year, at a public cost of $215 million (see chart).5Discussions about modifying federal policy on sterilization need to be thoughtful and sensi-tive to the fact that there is a larger social and historical con-text in which the reproductive behavior of low-income and mi-nority women has commonly been negatively stereotyped and their fertility less valued than that of other women. Unfortunately, as recent allegations that nearly 150 incarcerated women in California underwent coercive sterilizations between 2006 and 2010 attest, protection for vulnerable women is still needed. However, given the high rate of unintended preg-nancy, enhancing access to each woman’s contraceptive method of choice is also critical. An ideal Medicaid policy or process would strive to meet these two goals by ensuring patient comprehension and facilitating access to steril-ization for women who have made an informed decision to undergo the procedure.To this end, we believe that the current Medicaid Title XIX sterilization consent form needs to be either redesigned, in order to present the pertinent informa-tion in an easier-to-read, user-friendly format, or ideally re-placed altogether by a validated decision-support tool that can more effectively ensure an in-formed decision-making process. Outcomes of PostpartumSterilization RequestsWomen with Unfulfilled Sterilization Request5,00010,00015,000020,00025,00030,00019,000Unintendedbirths10,000AbortionsSterilizationsobtained53%Unfulfilledsterilizationrequests dueto Medicaidpolicy barriers24%Unfulfilledsterilizationrequests dueto other reasons23% Estimated Annual Number of Requests for Postpartum Sterilization That Go Unfulfilled Because of Medicaid Policy Barriers, and Unintended Pregnancies in the Subsequent Year.The pie chart shows the outcomes of the estimated 255,000 requests for federally funded, postpartum sterilizations made each year. In the subsequent year, an estimated 29,000 un intended pregnancies will occur among the 62,000 women with sterilization requests that are unfulfilled because of Medicaid policy barriers, costing taxpayers $215 million annually. Estimates are based on a cost-analysis model described in Borrero et al.5The New England Journal of Medicine Downloaded from nejm.org at UT AUSTIN on April 3, 2018. For personal use only. No other uses without permission.  Copyright © 2014 Massachusetts Medical Society. All rights reserved. PERSPECTIVEn engl j med 370;2 nejm.org january 9, 2014104In addition, we believe that the 30-day mandatory waiting period is excessive and should be short-ened considerably or eliminated — a change that could also ad-dress the problem of failed trans-fer of the completed federal doc-ument to the delivery unit.Although the principles behind the Medicaid policy remain rele-vant, it is in dire need of mod-ification. Measures to promote informed decision making regard-ing sterilization, rather than strin-gent and restrictive regulations, can simultaneously protect vulner-able populations and allow women to reduce their risk of unintended pregnancy. Thus, revisiting and amending sterilization policy rep-resents an opportunity to honor women’s reproductive autonomy, create more equitable access to sterilization, save a substantial amount of health care dollars, and prevent unintended pregnancy.Disclosure forms provided by the authors are available with the full text of this article at NEJM.org.From the Division of General Internal Medi-cine, University of Pittsburgh School of Medicine, and the Center for Health Equity, Research, and Promotion, Veterans Affairs Pittsburgh Healthcare System — both in Pittsburgh (S.B.); the Department of Ob-stetrics and Gynecology, University of Ten-nessee Graduate School of Medicine, Knox-ville (N.Z.); the Population Research Center, University of Texas at Austin, Austin ( J.E.P.); the Office of Population Research, Prince-ton University, Princeton, NJ ( J.T.); and the Hull York Medical School, Hull, United Kingdom (J.T.).1. Committee on Health Care for Underserved Women. Access to postpartum  sterilization. Committee opinion no. 530. Washington, DC: American College of  Obstetricians and Gyne-cologists, July 2012 (http://www.acog.org/Resources_And_Publications/Committee_ Opinions/Committee_on_Health_Care_for_Underserved_Women/Access_to_ Postpartum_Sterilization).2. Zite NB, Philipson SJ, Wallace LS. Con-sent to Sterilization section of the Medicaid-Title XIX form: is it understandable? Contra-ception 2007;75:256-60.3. Zite NB, Wallace LS. Use of a low-literacy informed consent form to improve women’s understanding of tubal sterilization: a ran-domized controlled trial. Obstet Gynecol 2011;117:1160-6.4. Thurman AR, Janecek T. One-year follow-up of women with unfulfilled postpartum sterilization requests. Obstet Gynecol 2010; 116:1071-7.5. Borrero S, Zite N, Potter JE, Trussell J, Smith K. Potential unintended pregnancies averted and cost savings associated with a revised Medicaid sterilization policy. Contra-ception 2013;88:691-6.DOI: 10.1056/NEJMp1313325Copyright © 2014 Massachusetts Medical Society.Medicaid Policy on SterilizationMom at Bedside, Appears CalmSuzanne Koven, M.D.We carry a nylon lunch bag everywhere we go, royal blue with purple trim, containing two plastic syringes, each preload-ed with 5 mg of liquid Valium, plus packets of surgical lubricant and plastic gloves. At the first sign of blinking or twitching, we lay him on his left side, tug down the elastic waist of his pants, part his small buttocks, and insert the gooped-up tip. Within mo-ments, the motion stops, as if an engine has been switched off. Then he falls into a deep sleep. When he relaxes, so do we.He’s 5 years old, the first time. Our babysitter takes him to a pizza place for lunch. He laughs mid-slice, blinks his eyes several times, slumps to the floor, and climbs back onto his chair. She hesitates — what was that? — and then calls 911. She pages me. I keep the message stored in my beeper, periodically daring myself to relive my first reading of it.I meet them in the ER at the community hospital near our home, showily flashing my down-town hospital ID tag. Soon my husband rushes in, wearing the ID from his downtown hospital. All the tests are negative, they say. Bring him back if something else happens.Something else happens. The next day, I skip work and keep him home from school. He sits happily in front of cartoons while I pace and polish, pace and fold. Maybe the babysitter overreacted, I reason. Maybe he’s just a goofy kid. The moment I stop watching him, he cries, “Look, Mommy! Look what my hand can do!”Downtown. No mistaking it this time. Grand mal, big and bad, right on the gurney. Lumbar puncture. MRI. All negative. Be-fore we go home, the neurologist asks if we have further questions. “Just one,” I say. “What do we do if he does it again?” The neurolo-gist seems surprised. His raised eyebrows silently ask, “Aren’t you both doctors?” He hands us a pamphlet.Dilantin. Chewable yellow tri-angles three times a day. Trian-gles to first grade and the beach and day camp and a sleepover. The other kid has cochlear im-plants. “Don’t worry,” his mother says, accepting my baggie of pills. “My kid comes with instructions, too.” We become members of an exclusive club no one wants to join.One day, almost exactly a year later, the school nurse calls. “It’s been 10 minutes and it’s not The New England Journal of Medicine Downloaded from nejm.org at UT AUSTIN on April 3, 2018. For personal use only. No other uses without permission.  Copyright © 2014 Massachusetts Medical Society. All rights reserved. 

Medicaid Policy on Sterilization — Anachronistic or Still Relevant?

Female sterilization, typically
accomplished by means of
tubal ligation, is a widely used
method of contraception that is
highly effective at preventing unintended
pregnancy. Yet there appears
to be unmet demand for
the procedure in certain segments
of the U.S. population.1 Specifically,
low-income women and
women from minority racial and
ethnic groups may face substantial
system-level barriers to obtaining
a desired sterilization procedure.1
One such barrier is the
federal policy regarding Medicaidfunded
sterilizations. Although
this policy was designed to protect
vulnerable populations, we
believe that it does not effectively
fulfill that intention — in fact, it
restricts the reproductive autonomy
of the women it intends to
serve. With the upcoming Medicaid
expansions, the number of
women affected by these barriers
could increase substantially

Borrero, S.

Zite, N.

Potter, J.E.

Princeton University Open Access Repository

Sonya Borrero

Nikki Zite

Joseph E. Potter

James Trussell

Crossref

Obstetrical & Gynecological Survey

Medicaid Policy on Sterilization

Female sterilization, often performed by tubal ligation, is highly effective at preventing unintended pregnancy. Low-income women and those from minority racial and ethnic groups may face barriers to access to a sterilization procedure. One barrier is the federal policy on sterilizations funded by Medicaid. Although the policy was designed to protect vulnerable populations, it actually limits the reproductive autonomy of these women. With recent Medicaid changes, the number of women affected by these barriers could increase substantially.
The use of tubal ligation as a contraceptive method rose dramatically 30 to 40 years ago with the legalization of contraception, improved safety of laparoscopic techniques, and creation of federally funded family planning programs that subsidized the costs. Reports of coercive and nonconsensual sterilization of minority and poor women led to accusations that the government was racist and classist in applying family planning programs. Protective regulations and a standardized consent form were created to prohibit sterilization of persons younger than 21 years or who were mentally incompetent or institutionalized. A 72-hour waiting period before sterilization was required but then lengthened to 30 days from the time of written informed consent, which was a problem for women desiring sterilization after childbirth.
Because these policies have not changed since 1978, women requesting publicly funded sterilization must complete the Medicaid “Consent to Sterilization” form greater than 30 and less than 180 days before having the procedure, at which time a signed copy of the consent form must be available or verified. If the woman is undergoing emergency abdominal surgery or a premature delivery, the 30-day waiting period may be waived, but at least 72 hours must elapse between the consent and procedure.
Evidence now suggests that the Medicaid consent process does not protect vulnerable women because its language is extremely complicated and the literacy level is too high for the average American adult. The waiting period and the requirement for the completed form to be transferred to the delivery unit pose logistic barriers for women who want tubal ligation immediately after childbirth. Requesting sterilization too late in pregnancy to fulfill the 30-day waiting period, not having the form available at delivery, or delivering before the mandatory waiting period elapses prevents women from having their request for sterilization fulfilled at the time of delivery. Women with private insurance are not subject to the same regulations, so the policy creates a 2-tiered system of access, in which low-income women may not have the same reproductive autonomy as wealthier women.
The ACOG Committee on Health Care for Underserved Women recommends revising Medicaid policy to create fair and equitable access to sterilization procedures. The current Medicaid consent form should be redesigned to present the pertinent information in an easier-to-read, user-friendly format or ideally replaced completely by a validated decision-support tool that can ensure an informed decision-making process. The 30-day mandatory waiting period is excessive and should be shortened or eliminated.
Reducing barriers associated with Medicaid policies regarding sterilization may be one approach to reducing the high rate of unintended pregnancy and associated high costs. An ideal Medicaid policy ensures patient comprehension and facilitates access to sterilization for women who have made an informed decision to undergo the procedure

Potter, Joseph E

Medicaid policy on sterilization: Anachronistic or still relevant?

Medicaid Policy on Sterilization — Anachronistic or Still Relevant?

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