Solutions to Ending Barriers to Permanent Contraception
May 1, 2025
By Melinda Young
Among various barriers to permanent contraception, the Medicaid waiting period is one of the chief challenges for the many pregnant women who are receiving Medicaid during their pregnancy. It is a 30-day waiting period that begins when a person signs the Medicaid sterilization form.
One way physicians can help address this barrier is by prioritizing having patients sign the form in a timely fashion during prenatal care, 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.
“Additionally, hospital systems should have centralized documentation across sites regarding patients’ desire for contraception and universal screening for contraceptive goals,” Jensen adds. Documenting and reviewing patients’ goals should be done multiple times during prenatal care and inpatient hospitalization. This informs and allows for shared decision-making in advance of delivery, she explains.
“Offering opportunities to increase contact with a healthcare system, including streamlining referral processes for elective postpartum sterilization procedures, may also improve post-discharge fulfillment,” Jensen says. “Patients at risk of preterm delivery should also receive counseling regarding the association between short interpregnancy intervals and recurring preterm birth as part of contraceptive counseling,” she adds.
Reproductive counseling and information about permanent contraception should be centered around patients’ interests and needs. “We believe that a patient-centered approach, including shared decision-making, has the greatest potential to maximize patient autonomy,” 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.
“Given that this approach is a conversation between both parties, clinician biases are a potential limitation,” Larkin adds. “The first step is for clinicians to take a step back to reflect on how their own biases may affect their counseling and focus on providing evidence-based medical information.”
As bilateral salpingectomy emerges as an increasingly popular option for permanent contraception, OB/GYNs should provide patients with evidence-based information about the procedure, along with discussing other methods, Larkin suggests. They need to be sure that the discussion is clear, informative, patient-centered, and non-directive, she says.
“Counseling should include all information, such as effectiveness, benefits, and risks, that allows the patient to make an informed contraceptive decision that aligns with their reproductive values, goals, and preferences,” she adds.
Providers will find that some patients are positive about the waiting period, telling researchers that they like the idea because it allows them time to be certain about their desire for permanent contraception, according to a new study.1 “I think it’s a good safety measure to make sure that people are a hundred percent convinced that that’s what they want to do,” a 40-year-old patient told researchers. The same person also changed their mind about permanent contraception.1
Other patients, who want permanent contraception, find the waiting period to be an obstacle to people achieving their goal. “I still want to get my tubes tied but I do not have an appointment yet.… I shouldn’t have had to wait as long … I had to wait and wait for [my healthcare providers] to let me know,” a 27-year-old patient told investigators. The same person wanted permanent contraception but was not able to obtain it.1
“Participants described how the waiting period made them feel like their physicians did not support their reproductive healthcare decisions, as physicians often have to act as enforcers of the waiting period policy,” says Joline Hartheimer, MD, MPH, a family medicine resident physician at Swedish First Hill Family Medicine Residency in Seattle, WA. She answered questions via email.
“Others placed the blame onto physicians for their long waits for desired contraception,” she adds. Because of the waiting period, people did not receive permanent contraception immediately postpartum and had to wait for limited outpatient surgical slots, she explains. “Physicians are not the ones who designed the waiting period policy, but as enforcers they can be seen by patients as obstacles to reproductive autonomy,” Hartheimer says.
“One Black patient felt particularly stigmatized by their clinicians due to not meeting the requirements of the waiting period, and felt it was unfair that she had to wait when other, privately insured patients do not have to wait since they are not subject to the waiting period,” she adds. “We did not ask about provider bias in particular in our study; however, several patients did reference feelings of paternalism and sexism when describing their views of the form and how it was explained to them by their physicians.”
The 30-day waiting period is especially burdensome for pregnant patients who seek prenatal care late in their pregnancy. “Without adequate prenatal care, patients with Medicaid insurance may not have the necessary healthcare contacts through all of those clinic visits to complete consent requirements within that mandated time frame,” 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. “In contrast, patients with private insurance typically face fewer procedural barriers to postpartum permanent contraception,” Berg adds.
Berg’s new study looked at how a person’s neighborhood socioeconomic position intersected with prenatal care and fulfilment of postpartum permanent contraception, finding a small but measurable partial indirect effect. People who lived in neighborhoods with less economic hardship and inequality and greater educational attainment were likely to have adequate prenatal care, and this predicted their receiving permanent contraception by discharge, the study finds.2 “Socioeconomic factors and prenatal care can impact access to permanent contraception through a few different mechanisms,” Berg explains.
Education about permanent contraception is very important because patients often have heard misinformation on the topic. “Some examples of misinformation include patients being completely unaware that the waiting period existed despite signing the form and thinking the waiting period was a deadline for getting the procedure done,” Hartheimer says.
“In addition, some patients believed that the waiting period existed for logistical reasons like the application being processed by Medicaid services or to allow time for the hospital to prepare for their surgery,” she adds. “Few patients were aware of the historical context of forced sterilization that contributed to the creation of the waiting period.”
Having Medicaid instead of private insurance also led to disparity in whether a person obtained postpartum permanent contraception.2 The 30-day waiting period creates a notable dependency on prenatal care, since patients must have contact with a healthcare provider well before delivery to complete the requirement, Berg says.
“This insurance-based disparity highlights how policy requirements might inadvertently amplify the effects of socioeconomic disadvantage for vulnerable populations,” Berg explains. “Socioeconomic disadvantage can constrain access to prenatal care through a few different pathways. Transportation barriers in under-resourced neighborhoods can make it very difficult for patients to get to appointments, especially if healthcare facilities are not close to their homes,” she says.
“At the individual level, socioeconomic disadvantage often brings work scheduling inflexibility or childcare constraints, which both can make it incredibly difficult for patients to get to appointments,” Berg adds. “When patients face these barriers and have less contact with the healthcare system, they may miss critical opportunities to complete consent requirements or discuss contraceptive options thoroughly with providers.”
The research shows that certain patient vulnerabilities can create barriers to achieving desired contraception, and these vulnerabilities include high-risk pregnancies that require enhanced monitoring, as well as having limited transportation access, inflexible work schedules, and caregiving responsibilities, she says.
“Skilled providers navigate these challenges, and our research findings reinforce the value of early, comprehensive contraceptive counseling for vulnerable patients,” Berg says. “Building on existing best practices, our research suggests that discussing permanent contraception options early in the care relationship and clarifying procedural timing requirements can help support patients in achieving their reproductive goals — particularly when complex social circumstances are present.”
Melinda Young has been a healthcare and medical writer for 30 years. She currently writes about contraceptive technology.
References
1. Hartheimer JS, Bullington BW, Berg KA, et al. Postpartum patient perspectives on the US Medicaid waiting period for permanent contraception. Open Access J Contracept. 2025;16:31-41.
2. 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. Reprod Female Child Health. 2024;3:e64.
Among various barriers to permanent contraception, the Medicaid waiting period is one of the chief challenges for the many pregnant women who are receiving Medicaid during their pregnancy. It is a 30-day waiting period that begins when a person signs the Medicaid sterilization form.
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