Medicaid policy on sterilization: Anachronistic or still relevant?

Abstract

Female sterilization, often performed by tubal ligation, is highly effective at preventing unintended pregnancy. Low-income women and those from minority racial and ethnic groups may face barriers to access to a sterilization procedure. One barrier is the federal policy on sterilizations funded by Medicaid. Although the policy was designed to protect vulnerable populations, it actually limits the reproductive autonomy of these women. With recent Medicaid changes, the number of women affected by these barriers could increase substantially. The use of tubal ligation as a contraceptive method rose dramatically 30 to 40 years ago with the legalization of contraception, improved safety of laparoscopic techniques, and creation of federally funded family planning programs that subsidized the costs. Reports of coercive and nonconsensual sterilization of minority and poor women led to accusations that the government was racist and classist in applying family planning programs. Protective regulations and a standardized consent form were created to prohibit sterilization of persons younger than 21 years or who were mentally incompetent or institutionalized. A 72-hour waiting period before sterilization was required but then lengthened to 30 days from the time of written informed consent, which was a problem for women desiring sterilization after childbirth. Because these policies have not changed since 1978, women requesting publicly funded sterilization must complete the Medicaid “Consent to Sterilization” form greater than 30 and less than 180 days before having the procedure, at which time a signed copy of the consent form must be available or verified. If the woman is undergoing emergency abdominal surgery or a premature delivery, the 30-day waiting period may be waived, but at least 72 hours must elapse between the consent and procedure. Evidence now suggests that the Medicaid consent process does not protect vulnerable women because its language is extremely complicated and the literacy level is too high for the average American adult. The waiting period and the requirement for the completed form to be transferred to the delivery unit pose logistic barriers for women who want tubal ligation immediately after childbirth. Requesting sterilization too late in pregnancy to fulfill the 30-day waiting period, not having the form available at delivery, or delivering before the mandatory waiting period elapses prevents women from having their request for sterilization fulfilled at the time of delivery. Women with private insurance are not subject to the same regulations, so the policy creates a 2-tiered system of access, in which low-income women may not have the same reproductive autonomy as wealthier women. The ACOG Committee on Health Care for Underserved Women recommends revising Medicaid policy to create fair and equitable access to sterilization procedures. The current Medicaid consent form should be redesigned to present the pertinent information in an easier-to-read, user-friendly format or ideally replaced completely by a validated decision-support tool that can ensure an informed decision-making process. The 30-day mandatory waiting period is excessive and should be shortened or eliminated. Reducing barriers associated with Medicaid policies regarding sterilization may be one approach to reducing the high rate of unintended pregnancy and associated high costs. An ideal Medicaid policy ensures patient comprehension and facilitates access to sterilization for women who have made an informed decision to undergo the procedure.