Tubal Sterilizations Increased Post-Dobbs, Remain Higher in Abortion-Ban States
Initial rate increased by 18% in abortion-ban states
November 1, 2024 6 minutes read
New research answers a question OB/GYNs and others in the reproductive health community have been asking since the U.S. Supreme Court overturned Roe v. Wade in June 2022: Have abortion bans resulted in higher levels of women opting for permanent contraception?
The answer is yes.
The study found that immediately after the Supreme Court’s June 24, 2022 decision in Dobbs v. Jackson Women’s Health Organization, which overturned Roe, tubal sterilization rates increased by 19% in states with abortion bans and by 17% in states with abortion protections.1
After the first month post-Dobbs, the rate of permanent contraception procedures stabilized in states with abortion protections but maintained a 3% monthly increase in states with abortion bans.1
The initial spike in procedures was a one-time shock for all states included in the study, but some states also experienced a continued increase in the subsequent months, says Xiao Xu, PhD, an associate professor in the department of obstetrics and gynecology at Columbia University Vagelos College of Physicians and Surgeons in New York.
“People reacted to the news, and afterwards it was less dramatic,” she says. “After that one-time shock in protective states, there is no month-by-month increase in procedures. It was a one-time reaction in protected states.”
The increase in tubal sterilization procedures is an association with the timing of the Dobbs decision. But the evidence is clear that more women are opting for permanent contraception since states began abortion bans in mid-2022.
Researchers examined data on 4.8 million women from January 2021 to December 2022. They divided data by month, including more than 60 million person months. They found that for the 18 months before the Supreme Court’s June 24, 2022, decision in Dobbs, tubal sterilization rates were stable. Even in that period, the rates were higher in states that would later ban abortion than they were in states that later protected abortion.1
“In the banned states, the average before the Dobbs ruling was 3.6 procedures per 10,000 person months,” Xu says.
“After Dobbs, it was 3.9 procedures per 10,000 person months,” she says. “That was a significant increase.”
In states that have abortion protections in place, the baseline was 1.8 procedures per 10,000 person months; after Dobbs, it was 1.9 procedures per 10,000 person months.
“Statistically, that was a significant increase but smaller magnitude than in banned states,” Xu explains.
The nation’s increase in tubal sterilization procedures post-Dobbs suggests that people need more information about their contraception options — especially when they live in places where abortion is banned, and that option is extremely limited if they become pregnant.
“I would want to make sure they’re well-informed about those options,” says Eleanor Bimla Schwarz, MD, MS, professor of medicine and chief of the division of general internal medicine in the School of Medicine at the University of California San Francisco.
Schwarz published a new study that found a failure rate of 2.9% to 5.2% for tubal sterilization. Pregnancy after the sterilization procedure was more common than it is for people who use long-acting reversible contraceptives (LARC) such as the implant and the hormonal intrauterine device (IUD).2
It is up to OB/GYNs and reproductive health clinicians to educate women about all of their options and their pregnancy rates, she says. (See “Up to 1 in 20 People Can Get Pregnant After Tubal Sterilization Procedure,” in this issue.)
“For some people, the surgical approach [works],” Schwarz says. “My goal is to make sure people are making informed decisions, and they end up using a method that they feel is the best method for them.”
The study about the increase in tubal sterilizations post-Dobbs used a commercial database and identified women of reproductive age (18 to 49 years of age) who had continuous insurance coverage and no diagnosis codes for cancer. They looked for procedure codes related to tubal ligation or salpingectomy. They did not pull data on hysterectomy procedures.1
The tubal procedure study did not include people who obtained permanent contraception through Medicaid. Investigators wanted to have data broken down by month, and the commercial data source provided that option.
“For us to get access to the Medicaid population, we need a different data source,” Xu says. “Our data was based on women with insurance that could pay for the procedure.”
Another new study on sterilizations that compared a Medicaid population with a privately insured cohort found that people with Medicaid received lower rates of sterilization procedures postpartum than did people with private insurance.3
The Medicaid data study concluded that the federal government should remove requirements that prevent Medicaid patients from obtaining this procedure after giving birth, such as a signed consent form with a 30-day delay and 180-day expiration date.3
“Insurance was a significant factor in not obtaining sterilization,” says Arina Chesnokova, MD, MPH, MSHP, an assistant professor in the division of academic specialists, department of obstetrics and gynecology, Hospital of University of Pennsylvania and Philadelphia VA Medical Center in Philadelphia. (See “Medicaid Rules Are Huge Obstacle to Women Receiving Permanent Contraception Postpartum,” in this issue.)
The study about tubal procedures before and after Dobbs divided states between those with total or near-total bans for abortion and states with limited abortion rights and those with state laws that explicitly recognized abortion rights.1
Tubal sterilization use over time was highest in the states with abortion bans, followed by states with limited abortion restrictions, and lowest in states with abortion protections.1
“We were not surprised,” Xu says. “We did the study because we had heard that abortion was becoming more difficult to access after the Dobbs ruling and that more women were turning to contraception.”
Investigators expected to see greater use of all contraception but were not certain that permanent contraception use over time also would have increased.
“We wanted to look at the full impact of the Dobbs decision and consider all different types of contraception use,” she explains.
“The most important implication of our finding is that the Dobbs ruling and state abortion laws that came after that ruling appeared to have had an impact on the broader issue of women’s healthcare — not just on abortion alone, but also healthcare decision-making,” Xu says.
More research is needed to see if tubal procedure rates continued to remain higher than baseline in the two years after the Dobbs decision, she notes.
“We only had the six months after the June 24, 2022, decision,” Xu says. “It would be helpful to get more longer-time data to see if this was a one-time increase or if it had a more sustained impact.”
Also, the study was based on women who had insurance that would help them pay for the procedure. Further research could assess data about whether some women wanted the procedure but were turned away because of the cost or other access issues.
References
- Xu X, Chen L, Desai VB, et al. Tubal sterilization rates by state abortion laws after the Dobbs decision. JAMA 2024; Sep. 11. do10.1001/jama.2024.16862. [Online ahead of print].
- Schwarz EB, Chiang AY, Lewis CA, et al. Pregnancy after tubal sterilization in the United States, 2002 to 2015. NEJM Evid 2024;3:1-10.
- Chesnokova A, Christensen T, Streaty T, et al. Medicaid compared to private insurance is associated with lower rates of sterilization in people with unwanted births. Am J Obstet Gynecol 2024;230:347.e1-347.e11.
Melinda Young has been a healthcare and medical writer for 30 years. She currently writes about contraceptive technology.
A new study on tubal sterilization found that, after an initial spike in tubal procedures nationwide immediately after the Dobbs decision that overturned Roe v. Wade, sterilization rates maintained a 3% monthly increase in states with abortion bans.
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