30-day wait before tubal sterilization is unjust, say Ob/GYN experts

Current U.S. health policy requires Medicaid beneficiaries to wait 30 days before tubal sterilization. Ob/gyn experts argue that this violates health care justice as elective tubal sterilization is readily available to women with a private source of payment. Writing in the American Journal of Obstetrics & Gynecology, they urge obstetricians to advocate for change to eliminate health care injustice in women's access to elective tubal sterilization.

One of the most common forms of contraception in the U.S. is tubal sterilization after childbirth, which accounts for about half of the half million female sterilization procedures done every year. The timing has the advantage of one-time hospitalization, which results in ease and convenience for the woman. The U.S. Collaborative Review of Sterilization Study indicates the high efficacy and effectiveness of postpartum tubal sterilization.

But while elective tubal sterilization is readily available to women with a private source of payment, this is not the case for Medicaid beneficiaries who are required to wait 30 days, which can be impractical unless the paperwork is concluded well in advance of the birth. "Regardless of who pays, the ethical and legal standard for the performance of elective tubal sterilization for permanent contraception for all patients is oral and written informed consent," stated senior author Lawrence McCullough, PhD, of the Center for Medical Ethics and Health Policy, Baylor College of Medicine.

The authors explain that compulsory sterilization programs existed in the U.S. until the middle decades of the 20th century. Initially, these programs targeted intellectually disabled and mentally ill patients; however, many African American women and deaf, blind, epileptic, physically deformed, and low-income women were sterilized against their will. In 1979, U.S. federal legislation was enacted that aimed to enhance women's health rights by regulating the process of consent and documentation before receiving surgical sterilization (both tubal sterilization and hysterectomy) that is publicly funded.

"The intent was good, but the unintended consequence four decades later is to restrict access based on source of payment," noted lead author Amirhossein Moaddab, MD, Visiting Post-Doctoral Fellow in the Department of Obstetrics and Gynecology, Baylor College of Medicine. "The reality of clinical practice is that nearly 50% of annual deliveries are paid for by Medicaid and therefore necessitate the signed federal consent form and waiting period."

The authors discuss the concept of health care justice in professional obstetric ethics and explain how it originates in the ethical concepts of medicine as a profession and of being a patient. They also explore its deontologic and consequentialist dimensions. The "deontologic" or "rule"-based dimension judges the morality of an action based on its adherence to a rule or rules. The "consequentialist" dimension judges the morality of an action on its consequences.

"We conclude that Medicaid policy allocates access to elective tubal sterilization differently, based on source of payment and gender, which violates health care justice in both its deontologic and consequentialist dimensions," said senior author Frank A. Chervenak, MD, of the Department of Obstetrics and Gynecology, Weill Medical College of Cornell University/New York-Presbyterian Hospital. "Obstetricians should invoke health care justice in women's health care as the basis for advocacy for needed change in law and health policy, to eliminate health care injustice in women's access to elective tubal sterilization."

Commenting on the article, noted expert Philip Darney, MD, MSc, Distinguished Professor of Obstetrics, Gynecology, and Reproductive Sciences at the University of California, San Francisco and Director of the Bixby Center for Global Reproductive Health, added, "Childbirth provides a convenient and economical opportunity for permanent contraception. This opportunity is denied to about 60,000 of the women who select it every year because of rules that the public insurance consent process applies to those who need their post-partum sterilizations paid for by Medicaid."

Dr. Darney emphasized that when women cannot present evidence of having met the 30-day requirement the consequences to them can be severe: half of those who never intended to become pregnant again do so, nearly 20% within a year. Some of these women have pregnancy-associated illnesses like diabetes and hypertension that make subsequent pregnancies risky. "A 'post-partum tubal' is the easiest (and cheapest) way for them to avoid recurring illness. Individual obstetricians and their professional organizations should protest the injustice, describe the health and financial costs of the current consent process, and prevail on government health care officials to change the regulations. The arguments of McCullough, Chervenak, and colleagues will provide excellent background for official deliberations," he concluded.