Medicaid and Fulfillment of Postpartum Permanent Contraception Requests

Permanent contraception (or sterilization) is one of the most common forms of contraception in the United States.1,2 However, only 39–57% of patients who desire postpartum permanent contraception ultimately undergo the procedure.3–5 Patients with unfulfilled postpartum permanent contraception requests have a high risk of pregnancy in the year after delivery, twice the risk of patients who did not desire postpartum permanent contraception.6 These subsequent pregnancies have short interpregnancy intervals and are therefore associated with poor maternal and neonatal outcomes, including fetal growth restriction, preeclampsia, preterm birth, and neonatal morbidity and mortality.7 Improving the fulfillment of desired postpartum permanent contraception requests serves an important need, both to respect a patient’s autonomous reproductive choice and to improve future pregnancy outcomes and public health.5

There are marked disparities in the fulfillment of desired postpartum permanent contraception, including disparities by race, ethnicity, and socioeconomic status.5,8 Much of the prior literature has focused on disparities by insurance type. Patients with Medicaid insurance are less likely to undergo a desired postpartum permanent contraception procedure and are more likely to have a subsequent pregnancy within 1 year.9 This disparity may be caused, in part, by the federally mandated sterilization consent form and 30-day waiting period for patients with Medicaid insurance. This policy was developed in the 1970s in response to incidences of forced and coerced sterilization of women of color, women with low income, and women with disabilities.4

Prior studies have linked Medicaid with insurance-based disparities in the fulfillment of desired postpartum permanent contraception.10–14 However, many of these studies impose stringent inclusion criteria, excluding participants on the basis of their maternal age, weeks of gestation at birth, or mode of delivery.6,10,14,15 Other studies have a limited follow-up period, looking only at permanent contraception fulfillment up until hospital discharge.6,10,14,15 In addition, many studies take a predictive rather than etiologic approach and do not control for many important potential confounders that may affect both insurance type and permanent contraception fulfillment such as age, race, parity, and marital status.10–16 It is notable that a prior study that accounted for the comprehensive experience of postpartum permanent contraception with broader inclusion criteria and a follow-up period of 365 days after delivery found that Medicaid insurance status was not associated with permanent contraception fulfillment.9 Rather, Medicaid insurance served as a proxy for clinical and demographic factors that constituted barriers to the equitable provision of postpartum permanent contraception. Thus, it remains unclear whether the Medicaid policy itself is truly a causative barrier to care.

However, each of these prior chart review studies examining insurance type and permanent contraception fulfillment was conducted at a single institution, inhibiting our understanding of the effect of the Medicaid policy more broadly.6,10–16 Prior multisite studies either have been conducted in one state or have assessed rates of permanent contraception procedures performed, whereas focusing on differences between desire and fulfillment is critical to understand the role of the Medicaid policy.17,18 Thus, we aimed to assess the association of Medicaid insurance with fulfillment of desired permanent contraception in a multisite study after accounting for clinical and demographic factors also associated with decision making and fulfillment surrounding permanent contraception. We hypothesized that patients with Medicaid insurance would have similar rates of fulfillment of permanent contraception and subsequent short interval repeat pregnancy compared with those with private insurance after adjusting for relevant covariates.

METHODS

This is a retrospective cohort study of patients who delivered at or beyond 20 weeks of gestation between January 1, 2018, and December 31, 2019, at four hospitals across the United States: the University of California San Francisco; Northwestern Memorial Hospital in Chicago, Illinois; MetroHealth Medical System in Cleveland, Ohio; and the University of Alabama at Birmingham. These four hospitals were specifically chosen for variation in geographic location, delivery volume (3,000, 12,500, 3,000, and 4,400, respectively), hospital type (private, private, public, and public, respectively), faculty models (employed, mix of employed and private, employed, and employed, respectively), and patient population (largely privately insured, heterogeneous patient population, largely publicly insured, and largely publicly insured, respectively). We included patients with permanent contraception as their documented contraceptive plan. We defined documented contraceptive plan as either the plan documented in the discharge summary or the last inpatient postpartum progress note if no contraceptive plan was documented in the discharge summary. This was determined by manual review at the University of California San Francisco, and MetroHealth Medical System and through informatics at Northwestern Memorial Hospital and the University of Alabama at Birmingham. For patients with more than one delivery for whom permanent contraception was documented as their contraceptive plan in the study timeframe, we included only the first pregnancy. We excluded patients who had peripartum mortality, those who previously received permanent contraception but were pregnant through the use of in vitro fertilization, those with planned cesarean hysterectomy attributable to suspected placenta accreta spectrum, and those without complete data across study variables.

We abstracted data from electronic medical records, including demographic and clinical information, documentation of contraceptive plan, provision of permanent contraception, and documentation of subsequent pregnancy within 1 year after delivery. We reviewed both outpatient and inpatient medical records. One trained research assistant abstracted clinical data at each hospital. The lead researcher at each site audited 1% of all study records to ensure accuracy, and research assistants communicated weekly to ensure abstraction consistency across sites. Insurance status at the time of delivery was obtained directly from the medical records at each institution through informatics assistance.

Our primary outcomes were time from delivery to permanent contraception fulfillment as a dichotomous variable before hospital discharge, within 6 weeks of delivery, and within 365 days of delivery. Six weeks after delivery was chosen because it is the clinical end of the postpartum period and the timeframe at which Medicaid coverage expires in many states. Secondary outcomes included postpartum visit attendance, rate of subsequent pregnancy, and validity of the Medicaid sterilization consent form. Subsequent pregnancy was defined as a binary variable within 365 days of delivery for those with an unfulfilled postpartum permanent contraception request. Subsequent pregnancy was determined from documentation of 1) either positive urine or serum pregnancy test, 2) presentation for prenatal care, or 3) notation of pregnancy care at an outside hospital in clinical documentation. We determined whether the Medicaid sterilization consent forms were valid if 1) a waiting period of at least 30 days had elapsed between when the forms were signed and when delivery occurred for patients delivering after 37 weeks of gestation, 2) a waiting period of 72 hours was permitted if delivery occurred before 37 weeks of gestation, and 3) both the patient and a health care professional had signed the consent form. Although state-level variation regarding interpretation of the Medicaid sterilization policy exists, this standardized definition was used clinically at all four sites and thus was used for analysis.19,20 This federal policy does not pertain to those with private insurance. However, in California, unlike in the other states in our sample, a separate sterilization consent form and waiting period also apply to those with private insurance.

Our primary exposure in this analysis was insurance type, which was abstracted from billing records and categorized as binary (Medicaid insurance or private insurance). If a patient had more than one insurance plan including Medicaid, the patient was analyzed as having Medicaid insurance because the sterilization consent policy applies to secondary insurance holders as well. Given California state policy requiring a similar waiting period for those with private insurance, we conducted stability analyses both 1) shifting University of California San Francisco patients to the Medicaid group to model a key predictor of presence of a required consent form and waiting period and 2) removing University of California San Francisco patients from analysis completely.

We recorded maternal age at delivery (continuous; in years), self-reported race (categorical; Black, White, Asian, none of the above, or declined and unknown), self-reported ethnicity (categorical; Hispanic or non-Hispanic), parity before delivery (binary; less than two, two or more), weeks of gestation at delivery (continuous), delivery type (binary; vaginal or cesarean), adequacy of prenatal care as determined by the Kotelchuck21 Index (binary; adequate or inadequate), and body mass index (BMI, calculated as weight in kilograms divided by height in meters squared) (continuous). The Kotelchuck Index uses timing of initiation of prenatal care and number of prenatal visits to classify adequacy of prenatal care as inadequate, intermediate, adequate, or adequate plus. For this analysis, the categories were consolidated as adequate (adequate and adequate plus) or inadequate (inadequate and intermediate). We prespecified all covariates for multivariable analyses. These covariates were chosen because they are factors that affect contraceptive decision making or fulfillment of desired permanent contraception. We acknowledge that race is both largely reflective of individual, familial, and cultural preference for a specific method of contraception and a proxy for bias and structural racism in the provision of contraceptive care.

We calculated tests for differences in demographic and clinical variables across Medicaid insurance and private insurance categories using t tests and χ2 tests for continuous and proportional outcomes, respectively. We examined the association between insurance type and the odds of achieving permanent contraception fulfillment at hospital discharge, 6 weeks (42 days) postpartum, and 365 days postpartum through multivariable logistic regression, estimating robust SEs to correct for any clustering across study site. We calculated variance inflation factor scores for each predictor to assess multicollinearity. There was no meaningful multicollinearity between covariates given that the maximum variance inflation factor score was 3.01.22 Finally, we present the differences in rate of subsequent pregnancy within 365 days of delivery between groups descriptively. We performed statistical analyses using R 4.0.4.23 All tests were two tailed, and an α of .05 was considered statistically significant. Simulations of models indicated that a sample size of 2,100 participants across all four sites who desired permanent contraception was necessary to identify a statistically significant effect (defined as P<.05 for the coefficient representing insurance) in 85% of simulations (95% CI 0.71–0.90). IRB approval was received from MetroHealth Medical System.

RESULTS

We identified 43,915 deliveries during the study period, 43,261 to patients who had either Medicaid insurance or private insurance. In this cohort, the request rate for postpartum permanent contraception was 8%. Fifteen percent of patients with Medicaid insurance and 4% of patients with private insurance had a documented plan of permanent contraception at the time of postpartum hospital discharge. Of the total deliveries during the study period, 3,013 (6.86%) met inclusion criteria and were included in the current analysis (Fig. 1). Of these 3,013 patients, 223 were at the University of California San Francisco, 787 were at Northwestern Memorial Hospital, 837 were at the MetroHealth Medical System, and 1,166 were at the University of Alabama at Birmingham. Overall, 2,076 of the 3,013 patients (68.9%) desiring permanent contraception had Medicaid insurance and 937 (31.1%) had private insurance. Patients with Medicaid insurance compared with those with private insurance tended to be younger, had higher parity before delivery, had not received adequate prenatal care, had vaginal delivery, and were more likely to be Black, Hispanic, and unmarried and to have higher BMIs (Table 1).

F1Fig. 1.:

Flowchart of the pooled, multicenter, retrospective cohort.

T1Table 1.:

Demographic and Clinical Characteristics by Insurance Type for Patients Who Desired Postpartum Permanent Contraception, 2018–2019 (N=3,013)

Patients with Medicaid insurance compared with those with private insurance were less likely to receive desired permanent contraception before hospital discharge (52.8% vs 70.8%, P≤.001), within 6 weeks of delivery (54.1% vs 71.4%, P<.001), or by 365 days postpartum (60.9% vs 74.9%, P<.001). Of patients with Medicaid insurance who ultimately achieved fulfillment of permanent contraception (n=1,248), 86.5% (n=1,080) did so by the time of hospital discharge after delivery. Of patients on private insurance who ultimately achieved fulfillment of permanent contraception (n=589), 94.2% (n=555) did so by hospital discharge. After multivariable-adjusted logistic regression, the association between Medicaid insurance status and permanent contraception fulfillment was statistically significant at every time point (Table 2). Delivery by cesarean was the covariate most significantly associated with fulfillment of permanent contraception at every time point. Of the 2,076 patients with Medicaid insurance who desired permanent contraception, 1,233 (59.4%) had a valid Medicaid sterilization form at the time of delivery.

T2Table 2.:

Univariable and Multivariable Logistic Regression Results of Permanent Contraception Fulfillment by Discharge and at 42 Days and 365 Days Postpartum, Predicted by Clinical and Demographic Characteristics (N=3,013)

The rate of postpartum visit attendance was 38.4% (n=798) for patients with Medicaid insurance and 33.1% (n=310) for patients with private insurance (P=.005). Among those with unfulfilled requests for postpartum permanent contraception, 63 patients (6.4%) with Medicaid insurance and 12 patients (4.4%) with private insurance had documentation of a subsequent pregnancy within 365 days of delivery. We do not present statistical analyses for subsequent pregnancy given the low risk of subsequent pregnancy in the study population.

Of the 980 patients with Medicaid insurance who did not receive desired postpartum permanent contraception by discharge, 414 (42.2%) had valid Medicaid sterilization consent forms at the time of delivery, 320 (32.6%) did not have a form signed before delivery, and 245 (25%) had forms signed before delivery but the required waiting period had not elapsed. Seventeen patients (1.7%) did not have a valid form by 42 days after delivery, and 7 patients (0.7%) did not have a valid form at any point within a year of delivery.

Results of the supplementary analyses shifting University of California San Francisco patients to the Medicaid group (Appendix 1, available online at https://links.lww.com/AOG/D81) and removing them from analysis altogether (Appendix 2, available online at https://links.lww.com/AOG/D81) demonstrate the stability of the overall study results.

DISCUSSION

In this multisite analysis, we report a difference in postpartum permanent contraception fulfillment between patients with Medicaid insurance and those with private insurance after controlling for demographic and clinical factors that are known to be associated with contraceptive decision making. The current study is in contrast to prior single-site study at MetroHealth Medical System, in which the association between Medicaid insurance and permanent contraception fulfillment was not statistically significant after multivariable analysis.9 We hypothesize that this is attributable to hospital-level factors such as institutional culture regarding the priority placed on urgency of permanent contraception surgery, workflow patterns to ensure that Medicaid sterilization forms are signed during antepartum care, and operating room availability.20,24–26 However, the current findings suggest that Medicaid policy contributes to inequities in desired postpartum contraception fulfillment.

Another important factor associated with fulfillment of permanent contraception was route of delivery. Delivery by cesarean was strongly associated with permanent contraception fulfillment in this multisite study, much as in previous single-site work. The likely reason is that delivering vaginally can pose a logistical barrier for those who wish to achieve permanent postpartum contraception fulfillment. Differences in cesarean delivery by insurance status may contribute to disparities in permanent contraception fulfillment; the cesarean delivery rate was much lower among patients with Medicaid insurance. Future research examining insurance-based differences in mode of delivery and whether contraceptive decision making affects mode of delivery is needed. Developing and implementing hospital policies to coordinate postpartum permanent contraception for patients who undergo vaginal delivery may help to mitigate barriers at the health care professional and hospital levels.27

There were also associations between permanent contraception fulfillment and weeks of gestation at delivery, marital status, and parity. It is important to note that the American College of Obstetricians and Gynecologists counsels against paternalistic thresholds based on demographic and clinical criteria before the fulfillment of permanent contraception.3 Although potentially having a preterm birth, having fewer children, or starting a new relationship may increase the risk of subsequent regret, patients should be free to ultimately make autonomous decisions about their health and health care.28–30 Furthermore, given the increased likelihood of patients from minoritized races to have Medicaid insurance, it is also important to note the potential effects of implicit biases on the provision of permanent contraception.28,31

In our study, fewer than half of patients with Medicaid insurance with unfulfilled postpartum permanent contraception requests had valid Medicaid sterilization forms at the time of delivery, although most forms were valid by 42 days after delivery. The lack of a valid Medicaid sterilization form has been shown to be a barrier to inpatient postpartum permanent contraception in previous studies.5,8,10,11 However, we are not able to determine the effect size of the Medicaid sterilization policy compared with surgeon and operating room availability and plan for outpatient permanent contraception through minimally invasive surgery, among other factors, on sterilization fulfillment.

As a retrospective cohort study, our investigation is affected by data limitations attributable to potential transfers of care. It is unclear whether the patients who did not follow up did not fulfill their permanent contraception at all or sought care elsewhere. This has a potentially disproportionate effect on patients with Medicaid insurance as a result of the need for the signed Medicaid sterilization consent forms to be transferred to obtain permanent contraception in a timely fashion. Similarly, lack of follow-up of patients seeking care elsewhere would likely underestimate subsequent pregnancy after nonfulfillment. Finally, given the inclusion criteria of plan for permanent contraception at the time of postpartum discharge, some patients had already received their procedure. Other patients may have initially desired permanent contraception during antepartum care or early in their delivery hospitalization but decided on another method of contraception if they were unable to undergo surgery for permanent contraception during their delivery admission.

In this multisite study, differences in fulfillment rates of postpartum permanent contraception remained significant after adjustment for relevant clinical and demographic factors. This indicates that Medicaid insurance is associated with disparities in permanent contraception fulfillment, potentially as a result of the Medicaid sterilization consent form and waiting period. It is imperative to reconsider the unintended consequences of the federal sterilization and revise accordingly to promote reproductive autonomy and mitigate health disparities.

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Perceptions and practice of state Medicaid officials regarding informed consent for female sterilization. Contraception 2020;102:368–75. doi: 10.1016/J.CONTRACEPTION.2020.07.092 27. Mercier RJ, Perriera L, Godcharles C, Shaber A. Expedited scheduling of interval tubal ligation: a randomized controlled trial. Obstet Gynecol 2019;134:1178–85. doi: 10.1097/AOG.0000000000003550 28. Kathawa CA, Arora KS. Implicit bias in counseling for permanent contraception: historical context and recommendations for counseling. Health Equity 2020;4:326–9. doi: 10.1089/HEQ.2020.0025 29. Patient-centered contraceptive counseling. ACOG Committee Statement No. 1. American College of Obstetricians and Gynecologists. Obstet Gynecol 2022;139:350–3. doi: 10.1097/AOG.0000000000004659 30. Amalraj J, Arora KS. Ethics of a mandatory waiting period for female sterilization. Hastings Cent Rep 2022;52:17–25. doi: 10.1002/HAST.1405 31. Bullington BW, Arora KS. 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