In the wake of the U.S. Supreme Court's historic decision to overturn Roe v. Wade, doctors say they're seeing a surge in the number of women who want to prevent future unintended pregnancies by getting their "tubes tied."
But a lot of patients fail to actually get this surgery, because an important window of opportunity — during hospitalization right after childbirth — is often missed.
The reasons why range from too-full operating rooms to paperwork problems. This has long been a source of frustration, and it's taken on new urgency now that the court's decision has created a sudden increased demand for this permanent, extremely effective method of birth control.
Tubal surgery, which involves cutting, blocking or removing the fallopian tubes that carry eggs, is the most commonly used form of contraception for women in the United States.
But studies show that about 40%-60% of women who had previously requested to have their tubes tied during a post-delivery hospital stay end up not getting it then. These women face a high rate of subsequent pregnancy.
"About half of women who don't have their desired postpartum sterilization procedure will get pregnant in the next year," says Dr. Rachel Flink, an obstetrician and gynecologist in upstate New York.
Women could theoretically come back to the hospital another time, says Flink, but this type of birth control is frequently requested by people who are poor, less educated and lack insurance: "They're more likely to fall into groups of people who have difficulty accessing the health care system later."
When they're already in the hospital for the arrival of a newborn, "someone is able to watch their baby, they've already made other child care arrangements, there's no transportation issues," Flink says.
So from a patient's point of view, this can be the best possible time for tubal surgery — especially if they only have public health insurance because of pregnancy and will lose it soon after childbirth. Yet many different barriers can stand in the way.
Sometimes it's that the hospital's operating rooms are just too full, so an elective procedure that doesn't seem like an emergency never makes it onto the schedule before a patient has to be discharged. Sometimes doctors think the patient is too overweight for the surgery, even though research suggests obesity doesn't pose an added risk. Sometimes a doctor might try to talk younger patients out of it, saying they might change their minds. If the hospital has a religious affiliation, the surgery might just be prohibited.
Problems with Medicaid
And then there's one piece of paper that's especially problematic.
It's a consent form required by Medicaid, which pays for nearly half of all birth hospitalizations in the United States. This form has to be signed at least 30 days before tubal surgery is done, explains Dr. Sonya Borrero, a researcher and physician with the University of Pittsburgh School of Medicine.
"Basically what this does is create a mandatory 30-day waiting period for people who rely on public funding for their health care," says Borrero, who notes that the waiting period is not required by private insurance. "So it definitely creates a kind of two-tiered system."
If a person on Medicaid signs the consent form too late, or delivers unexpectedly early, or loses the form and it's not on file, then Medicaid won't pay for the operation.
"This does impact a significant number of people with Medicaid," says Borrero, whose research suggests that taking away Medicaid-related roadblocks to getting tubal surgery could prevent more than 29,000 unintended pregnancies each year.
Dr. Kavita Shah Arora, an obstetrician and gynecologist with the University of North Carolina, vividly remembers first becoming aware of Medicaid's policies during her training in medical school.
"What I saw left me really frustrated. It was patient after patient who really wanted permanent contraception but didn't have the form signed," she says. "It just left me feeling powerless and angry that we had artificially created this barrier to desired care."
She soon learned, however, that the consent form and waiting period date back to the 1970s and were created in response to the nation's ugly history of coercive sterilizations, which frequently targeted the poor and people of color.
Talking with patient advocacy groups made her conclude that simply getting rid of the consent form and the waiting period wasn't necessarily the right solution. After all, discrimination and the threat of reproductive abuse hasn't completely gone away — there have been recent accusations of unnecessary surgeries at an immigrant detention center, for example.
But Borrero thinks the current Medicaid regulations don't seem like the best way to protect the vulnerable, "because we have a lot of evidence showing that they are creating barriers for the people they were intended to help."
New approaches to covering the procedure
Some places are trying new approaches. A couple of years ago, West Virginia decided to start covering this procedure with state funds if a person wanted it but Medicaid wouldn't pay because of not waiting the required 30 days.
And one hospital in Texas has made doing tubal surgery a priority. When Dr. John Byrne started working at Parkland Hospital in Dallas, he thought to himself, "Wow, a lot of women are able to have this procedure done here."
Byrne, who is now at the University of Texas Health Science Center at San Antonio, says that Parkland Hospital acts as a "safety net" county hospital that serves low-income patients. Hospital officials set up a system to take advantage of the brief hospitalization after childbirth, knowing the burdens their patients would face if it wasn't done then. If a patient wanted this contraception, says Byrne, the hospital really wanted to ensure "that we do everything in our power to offer that."
Parkland Hospital dedicated one of its labor and delivery operating rooms to doing nothing but tubal surgery, staffed it with surgeons and an anesthesiologist, and decided to cover the costs of the procedure whenever Medicaid didn't.
The result was that nearly 90% of women who asked for their tubes to be tied after childbirth actually got the procedure, according to a study just published by Byrne and some colleagues.
And at this hospital, if the operation didn't happen, it was almost always because the patient had decided against it.
"But that study takes place in a very specific patient population, in a hospital with dedicated staffing for these procedures, and that is willing to absorb the cost of procedures," says Flink, who calls this approach "not a viable option for most hospitals."
She recently looked to see how many post-childbirth tubal procedures got done where she was working, Strong Memorial Hospital in Rochester, N.Y., and found that the majority of women who'd requested it left the hospital with their tubes still intact.
"I certainly had a sense that we weren't completing all of them or close to all of them," says Flink. "But the fact that it was fewer than half, I think was a little bit of a shock."
