By Melinda Young
EXECUTIVE SUMMARY
Permanent contraception involving bilateral tubal salpingectomy (complete removal of the fallopian tubes) is an increasingly popular choice in the United States, particularly among people who just gave birth.
- Salpingectomies are safe, common, and linked to a reduction in ovarian cancers.
- Barriers to patients receiving this procedure postpartum include the Medicaid 30-day waiting period, which does not work for pregnant patients who were not given contraceptive counseling and offered the consent form to sign at least a month before their delivery.
- Some Medicaid patients may not access prenatal care until very late in their pregnancy, so they may not receive postpartum permanent contraception even if it is their desire to have the procedure.
Permanent contraception, specifically fallopian tube surgery, is the most common contraception method used both in the United States and throughout the world, and its popularity is growing as more people are choosing this method in the wake of the safe and effective use of bilateral tubal salpingectomy.1-4
From 2000 to 2013, there was a 77% increase in salpingectomies, and tubal blockage or ligation rates decreased. Data show that salpingectomies became a more popular method of permanent contraception especially after 2010. This change in demand coincided with studies that linked the procedure to a reduction in ovarian cancers, since the most fatal ovarian cancers originate in the fallopian tubes.2
Research also has shown in the past 15 years that tubal blockage or ligation is not more effective at preventing pregnancy than intrauterine devices (IUDs). Bilateral tubal salpingectomy is more effective than any other approach to birth control.4,5
There are no reported cases of spontaneous pregnancy after total bilateral salpingectomy that was performed for permanent contraception. There was a case reported in 2024 of a woman who was pregnant following a bilateral salpingectomy that had a left tubal remnant, making it an unintended partial salpingectomy.6,7
Evidence shows that permanent contraception procedures are safe, effective, and popular. The chief problem is access. For example, the Medicaid sterilization policy’s signed consent form waiting period for term and preterm births can serve as a barrier to postpartum patients receiving permanent contraception at a time that is most desirable or convenient for them, research shows.8
Most physicians — 70.2% in one study — have negative feelings about the Medicaid 30-day waiting period, says Suzanna Larkin, MPH, a research specialist in the department of obstetrics and gynecology at the University of North Carolina School of Medicine in Chapel Hill. She answered questions via email.8
“Around 50% of physicians directly stated that the waiting period is a barrier to receiving care,” Larkin says.8 “This is particularly true for patients who present late in pregnancy or experience unplanned preterm births and thus miss the opportunity to have the necessary consent completed in time.”
Physicians also said they were concerned about the inequity of the Medicaid sterilization policy because it does not apply to patients with private insurance. Physicians participating in the study described how Medicaid recipients face additional hurdles compared to those on private insurance, she adds. “[This is] effectively creating a two-class system where only certain patients have the ability to make immediate actionable decisions about permanent contraception,” Larkin explains.
One physician participant told researchers, “I think that supposedly the tubal ligation forms came out in an effort to decrease unwanted sterilization amongst those who were socioeconomically disadvantaged. I find it to be a barrier to care.”8
Socioeconomic factors in a person’s neighborhood also can affect their likelihood of receiving adequate prenatal care and achieving their desired postpartum permanent contraception, research shows.9 “Our study identified a few key factors related to patients’ fulfillment of postpartum permanent contraception,” says Kristen A. Berg, PhD, CRC, an assistant professor of medicine in the Center for Health Care Research and Policy, Population Health and Equity Research Institute, The MetroHealth System at Case Western Reserve University in Cleveland, OH. Berg answered questions via email.
“First, for all patients, those who received adequate prenatal care were more likely to achieve their desired permanent contraception by hospital discharge after delivering their babies,” she adds. “Second, the socioeconomic characteristics of the neighborhoods where patients lived seemed to matter to whether or not they received their permanent contraception via those characteristics’ impacts on whether patients had adequate prenatal care.”
For instance, patients who lived in less economically strained neighborhoods, where there also was less economic inequality, and those who lived in neighborhoods with overall higher education levels generally were more likely to receive adequate prenatal care, she explains. “Having adequate prenatal care, in turn, was related to achieving that desired permanent contraception,” Berg adds.
Berg’s study found that relationships between neighborhoods and prenatal care and permanent contraception were most apparent among patients with Medicaid vs. private insurance.9 “This finding may reflect the unique regulatory constraints faced by patients with Medicaid: The federal requirement for a 30-day waiting period between consent and permanent contraception procedure creates a critical dependency on timely and consistent prenatal care,” Berg explains.
Another new study found that patients with Medicaid insurance and who delivered preterm were less likely than those who delivered at term to undergo desired permanent contraception.10 “Patients who delivered preterm at less than 37 weeks’ gestation were less likely to undergo desired permanent contraception in adjusted analyses comparing to those delivering at term, extending from hospital discharge to one year postpartum,” says Claire Jensen, MD, MSCR, a maternal-fetal medicine fellow in the division of maternal-fetal medicine at the University of North Carolina at Chapel Hill. Jensen answered questions via email.
“Notably, the odds of fulfillment of permanent contraception were lower among subsets of patients undergoing cesarean or among patients insured by Medicaid who delivered preterm,” she adds. Patients who had an adverse neonatal outcome, including neonatal intensive care unit (NICU) admission or low appearance, pulse, grimace, activity, and respiration (APGAR) scores at delivery, had a higher prevalence of permanent contraception fulfillment, she says.
“Because the Medicaid sterilization policy has been cited as a barrier to fulfillment of permanent contraception, we looked at when the form was signed during pregnancy and whether the form was valid at delivery to explore if this affected fulfillment of permanent contraception,” Jensen says. “These factors didn’t differ among patients delivering preterm compared to term.” However, only about 60% of patients who desired permanent contraception had a valid consent form in both groups, she adds.
Research shows that barriers to permanent contraception after giving birth can last up to one year postpartum.10 “The best time to address patients’ long-term contraceptive plans is prenatally,” Jensen says.
“Following delivery, loss of pregnancy Medicaid, the physical and emotional challenges inherent to postpartum recovery, and competing personal/family demands may lead to lower prioritization among patients for fulfillment of permanent contraception,” she explains. “Specifically, among patients who deliver preterm, a unique barrier is that an earlier and often unplanned delivery can further limit available opportunities for patients and their providers to engage in shared decision-making regarding planned permanent contraception, whether or not the Medicaid waiting period has been met.”
Physicians should mention the Medicaid waiting period for permanent contraception in early prenatal care visits, suggests Joline Hartheimer, MD, MPH, a family medicine resident physician at Swedish First Hill Family Medicine Residency in Seattle, WA. She answered questions via email.
“[It’s] part of providing comprehensive informed consent about all contraceptive methods available postpartum,” she says. “When mentioning the waiting period, it is important to provide the relevant historical context behind the form about the history of forced sterilization in the U.S., so that patients can understand the intent of the form and use it to inform their reproductive health decisions.”
Melinda Young has been a healthcare and medical writer for 30 years. She currently writes about contraceptive technology.
References
1. Higgins JA, Cason P, Sanders JN. Sexuality and contraception. In: Cason P, Cwiak C, Edelman A, et al, eds. Contraceptive Technology. 22nd ed. Contraceptive Technology Communications;2025:185-186.
2. Jobe B. Tubal ligation vs. salpingectomy: Which is right for your patient? GE HealthCare. Jan. 11, 2022. https://www.volusonclub.net/empowered-womens-health/tubal-ligation-vs-salpingectomy-which-is-right-for-your-patient/
3. Mills K, Marchand G, Sainz K, et al. Salpingectomy vs tubal ligation for sterilization: A systematic review and meta-analysis. Am J Obstet Gynecol. 2021;224(3):258-268.e4.
4. Kurtzman L. Tubal ligation no better than IUD at preventing pregnancy. University of California San Francisco. Feb. 22, 2022. https://www.ucsf.edu/news/2022/02/422321/tubal-ligation-no-better-iud-preventing-pregnancy
5. Sajid H. Bilateral tubal ligation: A guide to permanent contraception. SehatHub. Jan. 21, 2025. https://sehathub.com/bilateral-tubal-ligation-exploring-options-for-birth-control
6. Brown JA, Hou MY. Permanent contraception. In: Cason P, Cwiak C, Edelman A, et al, eds. Contraceptive Technology. 22nd ed. Contraceptive Technology Communications;2025:228.
7. Lim L, Fuentes H. Spontaneous intrauterine pregnancy after tubal sterilization: A case report. SAGE Open Med Case Rep. 2024;12:2050313X241251732. https://pmc.ncbi.nlm.nih.gov/articles/PMC11056091/
8. Larkin S, Bullington BW, Berg KA, et al. Obstetrician-gynecologist perspectives and counseling practices on the U.S. Medicaid waiting period for permanent contraception. Women’s Health Issues. 2025;35:83-88.
9. Berg KA, Bullington BW, Gunzler DD, et al. Neighbourhood socioeconomic position, prenatal care and fulfilment of postpartum permanent contraception: Findings from a multisite cohort study. Repro Female Child Health. 2024;3:e64.
10. Chalem A, Jensen CE, Bullington BW, et al. Association between preterm birth and fulfillment of desired permanent contraception. Matern Child Health J. 2025;29:396-404.
Permanent contraception, specifically fallopian tube surgery, is the most common contraception method used both in the United States and throughout the world, and its popularity is growing as more people are choosing this method in the wake of the safe and effective use of bilateral tubal salpingectomy.
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