Abstract: Postpartum sterilization is a form of permanent contraception that is widely utilized in the United States. A tubal ligation is the most used procedure, and the access to it varies widely. Significant disparities exist in the uninsured and marginalized population as well as for Medicaid recipients. The strict regulations for Medicaid recipients stemmed from a history of utilizing these procedures as vehicles of oppression. This paper argues that denying postpartum sterilization procedures are unethical and examines this proposition through the ethical principles of justice, autonomy, beneficence, and non-maleficence. Ultimately, policy reforms are necessary to reduce barriers to access and create a more equitable reproductive landscape.

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Introduction

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Postpartum permanent sterilizations are a popular method of contraception in the United States. 18.6% of women aged 15-49 utilized permanent sterilization as their form of contraception.[1] However, there are many disparities and ethical principles to discuss. Uninsured individuals, recipients of state Medicaid, and marginalized patients are often subject to denials due to either physician objection or insurance problems. This paper will examine the ethics of postpartum sterilization denial for patients in marginalized and uninsured patients, arguing that denying postpartum patients from obtaining a tubal ligation due to insurance status or physicians' personal beliefs, guided by the ethical principles of autonomy, justice, and beneficence, further perpetuates inequity of these groups. This essay will evaluate the history of postpartum sterilizations, the right to reproductive autonomy, and explore potential policy changes.

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Discussion

 

     Bilateral tubal ligation is a form of permanent sterilization that was once utilized as a means of medical oppression. Individuals with medical disabilities and members of the Black, Indigenous, or Latinx community were subjected to nonconsensual sterilization procedures.[2] In 1927, the unfortunate outcome of Buck v. Bell sided with the State of Virginia’s sterilization law. Physicians completed a sterilization procedure on Carrie Buck without appropriate consent from her medical decision maker.[2] On the other hand, individuals who would seek out permanent contraception were subjected to a formula. If their age and parity multiplied together was greater than 120, then an individual could undergo a tubal ligation.[3] Otherwise, their physician would deem the request inappropriate and deny it, further potentiating the notion of paternalism in healthcare. 

      In 1976, in response to the growing debate behind the ethical implications of coercive reproductive practices, the Department of Health and Human Services enacted a 72-hour waiting period between signing the Medicaid consent form for permanent sterilization and the procedure itself.[2] The waiting period was later expanded to 30 days prior to the procedure with a provision for early delivery or emergent abdominal surgeries. Although this policy change significantly reduced the frequency of coercive sterilizations, the new process offers its own set of ethical dilemmas. 

     This process is not uniform. For instance, a pregnant individual with private insurance can decide 3 days prior to delivery that they desire a permanent sterilization. There is a required waiting period, and the insurance program will likely cover the cost.[4] In contrast, pregnant individuals who are uninsured and covered by a hospital’s charity care system are subject to highly variable guidelines. Most guidelines do not include postpartum sterilization under their policy. Such variations in the practice of contraceptive methods perpetuate the inequities of maternal and obstetric care. About 50% of individuals with Medicaid who wanted to receive a permanent sterilization were unable to obtain it, due to physician preference or consent problems.[5] One year after the denial of a postpartum tubal ligation, 46.7% of women became pregnant despite requesting a form of permanent contraception. This is in opposition to the 22.3% in the control group who did not request a postpartum tubal ligation.[6] 

     When considering the philosophical and clinical ethical principles, reproductive autonomy should supersede a physician’s potential personal conflicts.[7] The American College of Obstetricians and Gynecologists (ACOG) recommend utilizing a shared-decision making model which includes counseling on alternative options, including Long-Acting Reversible Contraception. One study on obstetrician/gynecologists and their view of permanent contraception found that some Ob/Gyns will only continue with the procedure if the patient insists despite some push-back.[4] Although this may be viewed as paternalism, it could be justified via the principle of beneficence. The physician is allowing the patient to make their decision, but they want to ensure that the individual is making the best decision for themselves. If a physician were to deny a patient permanent sterilization by citing conscientious objection, it is first, unethical to do so, because it violates the principle of autonomy. However, if the physician continues to deny the procedure, it is their obligation to find an alternative.[4] 

     In a similar manner, the ethical implications of a religious institution denying postpartum sterilization procedures is nuanced. Ultimately, ACOG recommends that obstetrician/gynecologists who practice at religious institutions which enforce policies against sterilization procedures should inform their patients early in pregnancy.[4] An adequate lead time upholds beneficence because this allows the patient to decide next steps and alternative sterilization options. This same argument can be made for insurance companies who solely contract at religious institutions. It would be unethical, and a violation of autonomy, to withhold this information and disturb a patient’s informed decision-making capacity. The practice of institutions denying sterilization procedures is often backed by the principle of religious freedom. However, how can this be justified if the local religiously affiliated hospital is the only one who accepts Medicaid or even the only one in the area? Should patients be subject to the religious doctrine of the institution if it is the only option to access care? 

     Moving onto beneficence, physicians may cite that they feel their patient is not “ready” to not have children due to a low parity, young age, or several other factors or that there may be some form of regret. Although physicians are able, and recommended, to address these concerns during consultation, they must remind themselves that the power of decision-making lies solely in the hands of their patients. A patient’s lived experiences are unique to themselves and may not incite regret following the procedure. 

Lastly, the principle of justice is central to my argument. Individuals of marginalized groups and inadequate access to care are the most subject to the bureaucracy associated with permanent sterilization barriers. Although the waiting period allows patients to feel more comfortable with their decision, it also incites regret and confusion.[8] The 30-day period was originally created to reduce coercion, but it can sometimes increase barriers to care. For example, stories of pregnant women being unaware that they would need to bring the signed consent form upon admission to the maternity ward delayed their access to care. As mentioned above, private insurance lacks these barriers. 

     Perhaps the most marginalized group is the indigent/charity care population. These individuals are unable to receive the sterilization procedure because many hospitals, both religiously affiliated and independent, refuse to cover the procedure. However, policy level changes should be made because this could help reduce healthcare spending. The single cost of the procedure could offset the cost of a future unwanted pregnancy. The potential savings for the charity care population specifically has not been studied. However, a similar model was studied for Medicaid patients. By improving the logistics of the Medicaid sterilization policy, the estimated fulfilled requests could increase from 53.3% to 77.5%. Consequently, 29,000 unintended pregnancies could be prevented and reduce costs by $215 million annually.[9]

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Conclusion

 

     Postpartum sterilization is a pinnacle of reproductive autonomy. However, current policy may reduce this autonomy by creating barriers, reducing the impact of beneficence, and perpetuating inequities. While a lengthy informed consent process provides safety we should work towards addressing inequities in postpartum tubal denial to increase justice in reproductive medicine.

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