New Web-Based Decision Aid Can Help with Permanent Contraception
November 1, 2023 5 minutes read
The most commonly used contraceptive method, tubal sterilization, is on the rise. Requests for the procedure have increased since the U.S. Supreme Court overturned Roe v. Wade.1,2
“Because the Supreme Court decision in Dobbs v. Jackson Women’s Health Organization overturned Roe v. Wade and federal protection of abortion care, we have been seeing an increased demand for permanent contraception,” says Elizabeth A. Mosley, PhD, MPH, an assistant professor of medicine at the University of Pittsburgh Center for Innovative Research on Gender Health Equity. “This includes both tubal sterilization and vasectomy. The research is emerging, but early accounts tell us that people are Google-searching [these procedures] more frequently.”
A study at the University of Michigan revealed that the tubal sterilization request rate increased in the months following the Dobbs decision. It decreased to baseline after six months, which could have been due to the demand being met, crisis fatigue, or a decreased sense of urgency after abortion access in Michigan was temporarily protected.2
Increased demand suggests the need for comprehensive counseling on sterilization procedures, as well as alternatives. Clinicians could benefit from offering a patient-centered decision aid that educates people about permanent contraception. Mosley and colleagues studied a decision aid, titled My Decision/Mi Decisión, which was designed for people who are pregnant and enrolled in Medicaid.1
“The purpose of this tool is to increase people’s knowledge about tubal sterilization and other methods of contraception and to decrease any decisional conflict they feel about their contraceptive decision — whether or not they ultimately choose to have tubal sterilization,” explains Mosley, an affiliate faculty member at Emory University Center for Reproductive Health Research in the Southeast. “It was designed originally for and tested among people who are currently pregnant and enrolled in Medicaid. But we will be testing it with other groups soon, and we believe the tool will be valuable and useful for anyone who is considering tubal sterilization.”
When Mosley and colleagues began the study just before the pandemic, the overturn of Roe was not on the horizon. But by the time the study was restarted after the pandemic’s research pause ended, people were beginning to see a possible future without a constitutional right to abortion care. Interest in permanent contraception appeared to increase around the time the Supreme Court’s decision in Dobbs v. Jackson Women’s Health Organization was leaked in May 2022.
“At first, we heard anecdotal evidence right after Dobbs overturned Roe v. Wade about an increase in tubal sterilization and vasectomy,” Mosley says.
Then, they saw a study from the University of Michigan about an increase in tubal sterilization requests. Investigators queried electronic health records to identify patients scheduled for tubal sterilization in 2019, 2021, and 2022. They found that in 2022, there were 658 sterilization requests at a single institution. This compared with 402 requests in 2019 and 430 requests in 2021. The mean monthly sterilization request rate from May 2022 to September 2022 was significantly higher than rates over the same months in 2019 and 2021.2
“Interest is increasing, and that’s complicated,” Mosley says. “Ideally, people would not be pushed toward permanent contraception because of policy constraints around abortion.”
It is important to ensure people are making educated, informed, and value-concordant decisions. “We’re worried this rapid decline in abortion access seems to be increasing people’s interest in permanent contraception, which was already the most common form of contraception,” Mosley says. “We worry people are making decisions under pressure from policies — especially when people’s options are constrained.”
Decisions about contraception are even more important now that abortion care is banned or severely restricted in half of the states. Patients need education about permanent contraception, including the fact that sterilization is permanent.
“A lot of people at baseline think tubal sterilization can be easily reversed,” Mosley says. “We need to show them other options that work just as well but are not permanent.”
A decision tool about permanent contraception is needed for multiple reasons. (For more information, see the story in this issue about how the tool works.)
“First, studies suggest knowledge about tubal sterilization is poor, and people misunderstand the permanence of the procedure, thinking it can be easily reversed or that the tubes can come untied,” Mosley explains. “People need basic education about these procedures and about pregnancy in general.”
A permanent procedure can end someone’s reproductive capacity for the rest of their lives, so it is an important decision with lifelong implications. “There are equally effective contraception methods that are reversible, which many people do not realize,” Mosley says.
Another reason for education on the topic involves examples of coercive sterilization. Historians need not look far to find examples of coercive sterilization. On Sept. 14, 2020, Project South and other watchdog groups filed a complaint on behalf of detained immigrants at the Irwin County Detention Center in Georgia. Their complaint, sent to the Office of Inspector General in the U.S. Department of Homeland Security and to three other governmental officials, states that LaSalle Corrections, which is a private prison company, had committed medical neglect at the detention center. The complaint says they fabricated medical records and performed hysterectomies at an alarming rate on immigrant women under U.S. Immigration and Customs Enforcement custody. One detainee said women who received hysterectomies were confused about why they had one. She called it “an experimental concentration camp.”3
In another contemporary example, the Center for Investigative Reporting said California prisons authorized sterilizations of nearly 150 female inmates between 2006 and 2010. The former inmates said the tubal ligations were performed under coercion.4
Most people in the 21st century would incorrectly assume that forced sterilization was only in the past — 19th- and 20th-century medical atrocities and eugenics projects that were inflicted on vulnerable populations in the early decades of surgical gynecological treatment.4
“To prevent that kind of abuse, advocates in the 1970s pushed for a 30-day mandatory waiting period and a standardized consent form,” Mosley says.5
This led to the 30-day waiting period for Medicaid patients seeking permanent contraception. “While intended to prevent coercive sterilization, that process has unfortunately created unintended barriers to wanted permanent contraception services, including both tubal sterilization and vasectomy,” Mosley explains. “In the case of tubal sterilization, our research team has documented that patients experience many barriers to wanted permanent contraception, including not having the consent form signed on time and lack of timely operating room availability.”
These barriers suggest innovative education on the procedures is needed. Clinicians need to ensure patients are making informed decisions about permanent contraception to reduce the likelihood that someone regrets their decision.
“This is something providers do worry about,” Mosley notes. “We hope that our tool can help providers feel more confident that their patients are making informed and value-concordant decisions.”
REFERENCES
- Mosley EA, Zite N, Dehlendorf C, et al. Development of My Decision/Mi Decisión, a web-based decision aid to support permanent contraception decision making. PEC Innov 2023;3:100203.
- Liang AC, Gliwa C, Loder CM, et al. Tubal sterilization requests at a single institution following the Supreme Court decision to overturn the constitutional right to abortion. JAMA 2023;330:374-375.
- Project South. Lack of medical care, unsafe work practices, and absence of adequate protection against COVID-19 for detained immigrants and employees alike at the Irwin County Detention Center. Sept. 14, 2020.
- Ko L. Unwanted sterilization and eugenics programs in the United States. PBS: Independent Lens. Jan. 29, 2016.
- Borrero S, Zite N, Potter JE, Trussell J. Medicaid policy on sterilization — anachronistic or still relevant? N Engl J Med 2014;370:102-104.
- Mosley EA, Monaco A, Zite N, et al. U.S. physicians’ perspectives on the complexities and challenges of permanent contraception provision. Contraception 2023;121:109948.
The most commonly used contraceptive method, tubal sterilization, is on the rise. Requests for the procedure have increased since the U.S. Supreme Court overturned Roe v. Wade. Increased demand suggests the need for comprehensive counseling on sterilization procedures, as well as alternatives. Clinicians could benefit from offering a patient-centered decision aid that educates people about permanent contraception.
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