Time to change Medicaid sterilization wait period

Executive Summary

U.S. health policy requires Medicaid beneficiaries to wait 30 days before tubal sterilization. In a journal analysis, national experts argue that this practice violates healthcare justice, as elective tubal sterilization is readily available to women with a private source of payment.

• Postpartum sterilization has the advantage of one-time hospitalization, which results in ease and convenience for the woman. Its efficacy and effectiveness were demonstrated in the U.S. Collaborative Review of Sterilization (CREST) Study, a large, prospective multicenter observational study of more than 10,000 women undergoing transabdominal sterilization who were followed up to 14 years.
• In The Crest Study, Postpartum Partial Salpingectomy Had The Lowest 5-year And 10-year Cumulative Pregnancy Rates: 6.3 Per 1,000 And 7.5 Per 1,000 Procedures, Respectively.

U.S. health policy requires Medicaid beneficiaries to wait 30 days before tubal sterilization. In a journal analysis, national experts argue that this practice violates healthcare justice, as elective tubal sterilization is readily available to women with a private source of payment.¹

In 2011–2013, 61.7% or 37.6 million of the 60.9 million women ages 15-44 in the United States were using a method of contraception; of that group, 15.5% relied on female sterilization, surpassed only by birth control pills (16%).² Tubal sterilizations are performed after 10% of all hospital deliveries.³ Postpartum sterilization has the advantage of one-time hospitalization, which results in ease and convenience for the woman. Its efficacy and effectiveness was demonstrated in the U.S. Collaborative Review of Sterilization Study, a prospective multicenter observational study of more than 10,000 women undergoing transabdominal sterilization who were followed up to 14 years.⁴ Postpartum partial salpingectomy had the lowest 5-year and 10-year cumulative pregnancy rates: 6.3 per 1,000 and 7.5 per 1,000 procedures, respectively.⁴

While elective tubal sterilization is readily available to women with a private source of payment, this situation is not the case for Medicaid beneficiaries who are required to wait 30 days, which can be impractical unless the paperwork is concluded well in advance of the birth, note authors of the current analysis.

“Regardless of who pays, the ethical and legal standard for the performance of elective tubal sterilization for permanent contraception for all patients is oral and written informed consent,” stated Lawrence McCullough, PhD, a co-author of the analysis in a statement released with its publication. McCullough is the associate director for education and holder of the Dalton Tomlin Chair in Medical Ethics and Health Policy in the Center for Medical Ethics and Health Policy at Baylor College of Medicine in Houston, where he also is professor of medicine and medical ethics, professor of family and community medicine, and faculty associate of Baylor’s Huffington Center on Aging.

Compulsory sterilization programs existed in the United States until the middle decades of the 20th Century. Initially, such programs targeted intellectually disabled and mentally ill patients. However, many African American women and deaf, blind, epileptic, physically deformed, and low-income women were sterilized against their will.⁵ In 1979, U.S. federal legislation was enacted that aimed to enhance women’s health rights by regulating the process of consent and documentation before receiving publicly funded surgical sterilization.

Amirhossein Moaddab, MD, lead author and visiting post-doctoral fellow in Baylor’s Department of Obstetrics and Gynecology, noted, “The intent was good, but the unintended consequence four decades later is to restrict access based on source of payment. The reality of clinical practice is that nearly 50% of annual deliveries are paid for by Medicaid and therefore necessitate the signed federal consent form and waiting period.”

In the current analysis, the authors examine the concept of healthcare justice in professional obstetric ethics. They then explain how it originates in the ethical concepts of medicine as a profession and of being a patient, and they explore its deontologic and consequentialist dimensions. The deontologic or rule-based dimension judges the morality of an action based on its adherence to a rule or rules, while the consequentialist dimension judges the morality of an action on its consequences.

“We conclude that Medicaid policy allocates access to elective tubal sterilization differently, based on source of payment and gender, which violates health care justice in both its deontologic and consequentialist dimensions,” said senior author Frank Chervenak, MD, Given Foundation Professor and chairman of the Department of Obstetrics and Gynecology at Weill Medical College of Cornell University in New York City. “Obstetricians should invoke health care justice in women’s health care as the basis for advocacy for needed change in law and health policy, to eliminate health care injustice in women’s access to elective tubal sterilization.”

The Committee on Health Care for Underserved Women of the American College of Obstetrics and Gynecology issued a committee opinion in January that reviewed barriers to contraceptive access and offered strategies to improve access.⁶ Revision of the federal consent mandate in order to create fair and equitable access to sterilization services for women enrolled in Medicaid or covered by other government insurance would improve access, the opinion states.⁶

REFERENCES

1. Moaddab A, McCullough LB, Chervenak FA, et al. Health care justice and its implications for current policy of a mandatory waiting period for elective tubal sterilization. Am J Obstet Gynecol 2015; doi:10.1016/j.ajog.2015.03.049.
2. Daniels K, Daugherty J, Jones J. Current Contraceptive Status among Women Aged 15–44: United States, 2011–2013. Hyattsville, MD: National Center for Health Statistics; 2014.
3. Kaunitz AM, Harkins G, Sanfilippo JS. Obstetric sterilization following vaginal or cesarean delivery: A technical update. OBG Manage 2008; 20:S1-S8.
4. Peterson HB, Xia Z, Hughes JM, et al. The risk of pregnancy after tubal sterilization: Findings from the U.S. Collaborative Review of Sterilization. Am J Obstet Gynecol 1996; 174(4):1161-1168; discussion 1168-1170.
5. Diekema DS. Involuntary sterilization of persons with mental retardation: An ethical analysis. Ment Retard Dev Disabil Res Rev 2003; 9(1):21-26.
6. Committee on Health Care for Underserved Women. Committee opinion no. 615: Access to contraception. Obstet Gynecol 2015; 125(1):250-255.