Base Permanent Contraception Counseling on Patients’ Preferences
August 1, 2023 7 minutes read
Increasingly, reproductive health providers are meeting with patients who are interested in a permanent contraceptive method. The U.S. Supreme Court’s decision to overturn abortion rights has resulted in more people looking for options to end their ability to have children.
Roadblocks to these procedures include a patient’s personal concerns about the procedure or future regret, as well as insurance/cost concerns, and clinicians who turn them down because they are too young or have no or too few children.
When clinicians discuss permanent contraception, the first thing they should know is to avoid using the term “sterilization” because of its association with historical transgressions, including forced sterilization of people of color. The word brings up historical concerns about eugenic or social engineering approaches, which were performed when few contraceptive options were available, says Jeffrey T. Jensen, MD, MPH, the Leon Speroff endowed professor and vice chair of obstetrics and gynecology at the Oregon Health & Science University School of Medicine.
“The idea of sterilization became linked with this idea of state control,” Jensen explains. “Because of that, most states as they revised their laws — and, in fact, Medicaid — had requirements that meant potential patients needed to establish a special consent of intent prior to having the procedure done.”
Medicaid still requires a 30-day waiting period for permanent contraception that is not a typical requirement of private insurance.1 “If you are a woman and receiving assistance from the government for healthcare, you are considered too weak and vulnerable and cannot consent without a 30-day cooling-off period after signing a consent form,” Jensen notes. “This presents a barrier.”
For people with significant challenges to receiving timely reproductive healthcare — including difficulty finding child care, transportation, or getting time off of work — the 30-day wait is a barrier to receiving care. (For more information, see the story in this issue on barriers to permanent contraception.)
Another barrier is how programs and policies promote long-acting reversible contraception (LARC) and impede reproductive autonomy, especially among people of color. Low-income Black and Latina women are more likely to be recommended LARC than are white women of the same economic status, according to a recent paper.1
It is important for providers to ensure patients know all their contraception options, including permanent contraception, says Kavita Shah Arora, MD, MBE, MS, division director of the division of general obstetrics, gynecology, and midwifery and an associate professor with tenure at The University of North Carolina at Chapel Hill.
“We know, given racism and bias, that different patients are counseled differently by clinicians,” Arora explains. “It could be a clinician talks to one patient and says, ‘You should consider getting your tubes tied,’ and the same clinician talks to a different patient of a different race and economic, marital status, and demographic factors and counsels them differently.”
The patient’s demographics should not change how providers counsel them on contraception. “Clinicians should counsel in a way that minimizes their biases and that removes barriers,” Arora says. “If it’s what the patient desires, and the patient is well-informed in a way that minimizes our biases, and we accept some fluidity in that decision-making, then those decisions should be respected and upheld.” Barriers caused by the Medicaid consent form and hospital availability should be minimized, she adds.
Shared decision-making is a method that may remove clinician bias from the equation. The World Health Organization offers a decision-making tool for family planning clients and providers.2
The tool lists these five principles:
- “The client makes the decisions.”
- “The provider helps the client consider and make decisions that best suit that client.”
- “The client’s wishes are respected whenever possible.”
- “The provider responds to the client’s statements, questions, and needs.”
- “The provider listens to what the client says in order to know what to do next.”
Arora recommends breaking the conversation into these three pieces:
- Choice talk: “Tell them information about all the options of contraception. This should be the same for each patient,” Arora explains. “That needs to be standardized because people don’t often present all the options to all patients.”
- Options talk: “This is the part where we talk to patients and ask, ‘What are your preferences? What are you looking for in a method of birth control? Are you looking for something that is most effective? Do you want something that doesn’t use hormones? Are you looking for something that helps with your periods, or are you looking for something that helps with acne?’” Arora explains.
- Decision talk: “This is where you have a conversation that is bidirectional with the patient,” Arora says. “You take patient preferences in mind, which they just decided, and you come to a decision together about which birth control would be recommended.”
If the shared decision-making process leads to the patient selecting permanent contraception, then the next step would be to decide on the exact surgery and to receive counseling on that procedure. “Obtain consent, and make sure patients understand it is permanent and not easily reversible,” Arora says. “They will not be able to have children afterward and should be aware of the risk and complications after surgery.”
The patients will sign an informed consent form. If they have Medicaid insurance, the 30-day waiting period begins then.
Another way to open a discussion of options is the one key question: “Do you want to be pregnant in the next year?” Jensen says.
“That gives an opportunity to talk about contraception,” Jensen adds. “Among individuals who are not seeking pregnancy, it’s always appropriate in counseling to bring up permanent contraception as an option, presenting it out there as part of the mix.”
Permanent contraception is highly effective. It is a solution that does not require continuous use of medications and devices. “It needs to be offered as something that is appropriate, and ‘It may be appropriate for you,’” Jensen says. “That’s not pushing a method on anyone; it’s allowing women to have all the options available.”
In the United States, 27% of women will use a permanent contraceptive method at some point, according to a survey by the Centers for Disease Control and Prevention. Black women are more likely than white or Hispanic women to use a permanent contraceptive method, with 37% using that method at some point in their lifetime.3
Although it is a very common method of contraception, some clinicians are not comfortable discussing it with patients, particularly if patients are young and have no children. For example, one 30-year-old woman posted on Reddit that her physician denied her a permanent contraception procedure. “I just had my first appointment to discuss sterilization today (on the fence between a tubal or a partial hysterectomy). I went with the Dr. I’ve seen previously because all the ones on the list within 150 miles of me aren’t on my insurance. I talked to the Dr. for two minutes before she told me she wouldn’t do the procedure because I didn’t give a good enough reason,” the woman wrote.4
The woman went on to say that she had known for 10 years that she did not want children. She decided to move from birth control to permanent contraception after the overturn of Roe v. Wade, since her state was passing laws restricting abortion.4 A common theme among Reddit discussions about permanent contraception is that women feel they must lie or exaggerate their reasons for seeking the procedure to get their physician to perform it.
Clinicians could learn something about their own biases from reading these social media posts. The ethical approach is to counsel on options and believe women when they say this is something they want.
“I trust her,” Jensen says. “I go over some information, and we talk about how there are reversible alternatives that might be more acceptable and more useful for her.”
Some people will have regrets, and others will not. But it is not the OB/GYN’s job to decide whether patients can live with possible future regret. “We’ve done a survey around the country and had interviews with gynecologists,” Arora says. “There is bias toward not recommending or not performing permanent contraception based on the patient having a younger age or a lower number of children.”
The American College of Obstetricians and Gynecologists recommends against this bias. “It’s paternalistic to say that we are worried that you may regret your decision as you get older and don’t have as many children,” Arora explains.
The physician does not know the patient’s life better than the patient. “We’ve overvalued our discomfort at being a potential instrument for regret, and we’ve undervalued the patient’s ability to make decisions for their own life,” Arora adds.
Regret is a part of life, so it should not be used as a reason to deny patients permanent contraception. “In almost 40 years of doing this, I’ve seen far more women burdened, damaged, and distressed by excess fertility than infertility,” Jensen says. “My philosophy is to trust women, trust and verify, and if they want to risk operations, then they should have it — even if they regret it someday.”
REFERENCES
- Bullington BW, Sata A, Arora KS. Shared decision-making: The way forward for postpartum contraceptive counseling. Open Access J Contracept 2022;13: 121-129.
- World Health Organization. Decision-Making Tool for Family Planning Clients and Providers. 2005.
- Jones J, Mosher W, Daniels K. Current contraceptive use in the United States, 2006-2010, and changes in patterns of use since 1995. Natl Health Stat Report 2012;60:1-25.
- “Denied a sterilization because my reasons weren’t good enough.” r/WelcomeToGilead. Reddit. July 2022.
Increasingly, reproductive health providers are meeting with patients who are interested in a permanent contraceptive method. Roadblocks to these procedures include a patient’s personal concerns about the procedure or future regret, as well as insurance/cost concerns, and clinicians who turn them down because they are too young or have no or too few children.
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