Monthly Archives: January 2014

In a well-timed editorial in this week’s New England Journal of Medicine,  Sonya Borrero, MD and colleagues take on Medicaid’s outdated and discriminatory policy on sterilization.

That policy requires a 30 day waiting period after signing a sterilization consent  that then expires 180 days from being signed. Which can sound reasonable till you understand that most sterilizations occur immediately after giving birth in the hospital using consents that must be signed in the prenatal period. And that women with commercial insurance have no waiting period between signing consent and having their tubes tied.

Unfortunately, not every woman who wants sterilization gets her act together to sign the consent in the right time window or remembers to bring the signed consent with her when she is in labor. Especially women on Medicaid, who often have spotty or disrupted prenatal care, and frequently transfer care due to rapidly changing home and work situations. Every Ob-Gyn can tell you about the sterilizations they could not do because their patient forgot the form or just missed the signing window, the form was completed improperly or even worse, never made it to the labor floor from the clinic. 

Sterilizations policies have outlived their initial intent

The authors point out that while the Medicaid’s original policy was created as a deliberate barrier to coerced sterilization at a time when women needed these protections, current informed consent laws provide more than adequate protection against forced sterilization. Medicaid’s policy has outlived its usefulness and has become nothing more than a barrier to care that discriminates agains the very women who would most benefit from having those barriers removed – low income women.

Women who can barely take time away from work of childcare to have a baby, let alone come back 6 weeks post partum for an outpatient tubal ligation and recovery because their consent form wasn’t signed in the right time window.  Women who only get insurance coverage because they happen to be pregnant, but lose it (and birth control coverage) once they are post partum. 

The resultant costs are enormous 

It should come as no surprise then, that almost half  of women who request sterilization but fail to get it become pregnant again within a year of giving birth – twice the rate among women who did not request sterilization. The resulting cost? It’s enormous. 

In a recent cost analysis, we found that Medicaid-policy–related barriers lead to approximately 62,000 unfulfilled 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

The consent form itself is confusing and does not support informed reproductive choice

Borrero and colleagues also argue that that the current Medicaid sterilization consent is way too wordy and confusing, leaving significant numbers of women who sign it actually unaware that the procedure is considered permanent and irreversible.  

In one study assessing women’s knowledge about sterilization after they had been given the Medicaid consent form for review, more than one third of respondents (34%) answered incorrectly when asked about the permanence of sterilization. When a modified, low-literacy version of Title XIX-SCF was compared with the current form in a randomized trial involving 200 women with Medicaid 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).

Ironic, really, that women are forced to wait a month to have a procedure that they will later regret because the consent wasn’t clear enough in the first place.  Given the wide availability of safe and effective long acting contraception, these women have many more reversible options available to them to prevent pregnancy.  If the consent were to outline such options, it would go a long way toward providing clear informed decision making around family planning. 

A call for a revised policy and consent

The authors call for both shortening or removal of the 30 day waiting period and a clearer consent form that supports informed reproductive decision making. Last year, The American College of Obstetricians and Gynecologists called for similar reforms around sterilization – 

There are unfair differences in consent rules surrounding sterilization procedures based on insurance type. Obstetrician–gynecologists should advocate for fair and equitable access for women who are enrolled in Medicaid or covered by other government health insurance programs.

I fully support their recommendations.