PRINCETON, N.J.—Tubal ligation – commonly referred to as having one's "tubes tied" – is widely used to prevent unintended pregnancies. However, current Medicaid policies create roadblocks for low-income women trying to obtain the procedure, according to a review written by researchers at Princeton University's Woodrow Wilson School and other U.S. institutions.
Under a Medicaid rule enacted in 1978, women must currently wait 30 days after signing a written consent form to obtain a tubal ligation. This requirement is prohibitive for many women who want to receive the procedure after giving birth, the researchers write in the New England Journal of Medicine, and creates a "two-tiered system of access" as women with private insurance are not subject to the same limitation. With the upcoming expansion of Medicaid under the Affordable Care Act, even more women could be affected by these restrictions.
"Although the principles behind the Medicaid policy remain relevant, it is in dire need of modification," said James Trussell, an author of the paper and the Charles and Marie Robertson Professor of Public and International Affairs at the Woodrow Wilson School of Public and International Affairs, faculty associate at the School's Office of Population Research and professor of economics. "The 30-day mandatory waiting period is excessive and should be shortened or eliminated. In addition, the current consent form should be redesigned so it is easier to read and more user-friendly. Or, it should be replaced by another tool that can effectively ensure informed decision-making processes."
In their review, "Medicaid Policy on Sterilization – Anachronistic or Still Relevant?" Trussell and his colleagues – Sonya Borrero at the University of Pittsburgh, Nikki Zite at the University of Tennessee and Joseph E. Potter at the University of Texas at Austin – state that low-income women are unable to exercise the same degree of reproductive autonomy as their wealthier counterparts due to this two-tiered system of access. This is compounded by the fact that many women with Medicaid coverage won't have insurance to cover this procedure since pregnancy-related Medicaid eligibility ends shortly after delivery.
Medicaid's sterilization policy was first developed in 1976 by the Department of Health, Education and Welfare (now the Department of Health and Human Services) to protect against nonconsensual sterilizations for men and women. The initial waiting period of 72 hours was extended to 30 days in 1978, and the form has not been updated since then.
One recent academic study assessed the form as being "overly complicated" and written at too high of a literacy level for the average American adult. When testing the readability of the form, the study found that more than a third of women answered incorrectly when asked about the consequences of sterilization after they read the form. The researchers then administered a lower-literacy version of the form to the same women. The findings showed that women had a better understanding of the 30-day waiting period and the nonpermanent contraceptive options available.
But even if the form is improved and women have a better understanding of the policy, the researchers are still concerned about the effects of the waiting period and its societal cost.
"While we certainly don't want to return to the days when low-income women were coerced into agreeing to sterilization, we feel that the current rule – while well-meaning – goes too far in the other direction," said Trussell. "These barriers put women at a greater risk for unintended pregnancy. And this is a substantial issue in the United States with direct public costs of billions of dollars."
Another study reports that 47 percent of women who requested but did not receive the sterilization procedure right after giving birth became pregnant within the first year after delivery. This is twice the pregnancy rate of women who didn't request sterilization, the authors write. The reasons women didn't have the procedure include: requesting sterilization too late, not having the form at the time of delivery or delivery before the waiting period had elapsed.
Trussell and his colleagues write there are roughly 62,000 unfulfilled tubal ligation requests annually resulting in an around 10,000 abortions and 19,000 unintended births at a public cost of $215 million.
"Reducing barriers associated with these Medicaid policies may be one approach to making a dent in this stubbornly high rate of unintended pregnancy and the high costs associated with it," Trussell said. "Not only that, but revisiting and amending sterilization policy will honor women's reproductive autonomy and create more equitable access to sterilization for women of all income levels."
The paper, "Medicaid Policy on Sterilization – Anachronistic or Still Relevant?" was first published online Jan. 9, 2014, in the New England Journal of Medicine.
Affiliations of the authors of the paper include Princeton's Office of Population Research; the Division of General Internal Medicine, University of Pittsburgh School of Medicine; the Center for Health Equity, Research and Promotion, Veterans Affairs Pittsburgh Healthcare System; the Department of Obstetrics and Gynecology, University of Tennessee Graduate School of Medicine; the Population Research Center, University of Texas; and the Hull York Medical School, Hull, United Kingdom.
New England Journal of Medicine