Committee Opinion No. 530

Abstract

Postpartum tubal sterilization is one of the safest and most effective methods of contraception. Women who desire this type of sterilization typically undergo thorough counseling and informed consent during prenatal care and reiterate their desire for postpartum sterilization at the time of their hospital admission. Not all women who desire postpartum sterilization actually undergo the surgical procedure, and women with unfulfilled requests for postpartum sterilization have a high rate of repeat pregnancy (approaching 50%) within the following year. Potentially correctable barriers to obtaining postpartum sterilization include patient and health care provider factors, as well as hospital and health care system issues. Given the consequences of a missed procedure and the limited time frame in which it may be performed, postpartum sterilization should be considered an urgent surgical procedure. In addition, women with government insurance face barriers to sterilization procedures based on cumbersome consent requirements. The differences in the requirements surrounding consent for sterilization procedures based on the type of insurance a patient has must be addressed in order to establish fair and equitable access to sterilization procedures for all women. Policies and procedures that remove barriers to and increase efficiency in performing postpartum sterilization could reduce cancellations of the procedure. Improving consistency in accomplishing desired postpartum sterilization is an important strategy to reduce high rates of unintended pregnancy in the United States.

Recent developments have made female permanent contraception an increasingly attractive option, and pregnant women in particular ought to be counselled about it

“…Similarly, many US Medicaid beneficiaries (a very large proportion of women who deliver) miss a desired peripartum TO due to all sorts of cumbersome barriers/red tape/misplaced forms and are when Medicaid runs out, soon after delivery, unable to afford a TO or any other reliable method ― higher income women do not encounter this obstacle [ 106 , 107 ]. The protocols/administrative hoops are meant to protect minorities, women with mental problems and the intellectually challenged.…”

“…The fallout is estimated in the US alone to be up to 62,000 unfulfilled requests for postpartum sterilization, 10,000 abortions and 19,000 originally unintended births annually, at a public cost of $215 million [ 17 , 106 ]. Another US analysis showed that nearly 50% of women who missed an intended peripartum TO experienced an unintended pregnancy within a year [ 107 ]. Correspondingly, denying a woman in Oregon, USA who asks for an abortion because of a completed family a concurrent TO, results on average, over the next five years, in 1.3 unintended pregnancies and an additional $4,152 in direct medical costs, a computer simulation indicated [ 108 ].…”

“…In the US, the median of the total charges for a hysteroscopic TO is an unbelievable $7832, and for a laparoscopic TO $5068 [ 39 ]. One can imagine some patients getting rather disturbed if the obstetrician or hospital [ 106 , 107 ] had denied them the CS/TO choice. The doctor could also have a financial conflict of interests.…”

“…A study in the Netherlands, where women on average have their first child when they are 29.4 years ― average EU 28.7, Spain, Italy and Switzerland >30 years [ 3 ] ― demonstrated that a policy of not initiating counselling about a potential TO in combination with a potential CS for the ≥2 child, was 62 to 186 times more likely to end in regret, than facilitating an informed choice did [ 76 ]. An American College of Obstetricians and Gynecologists report shows that at least 25 times as many women with an unmet wish for a peripartum TO have an unintended repeat pregnancy within a year than women over 30 years of age who obtained PC develop such serious regrets that they later elect to have a reversal [ 107 ]. Facilitating the desire for a TO and paying for the occasional IVF is likely to cause the greatest happiness to the greatest number of women, plus it will be often cost-effective.…”

Prenatal contraceptive counseling and method provision after childbirth

“…The committee opinion urges that the consent for permanent contraception be simplified and standardized, and recommends that postpartum sterilization be considered an urgent surgical procedure. 52 …”