Association between neighborhood disadvantage and fulfillment of desired postpartum sterilization

Abstract

Background Adequacy of prenatal care is associated with fulfillment of postpartum sterilization requests, though it is unclear whether this relationship is indicative of broader social and structural determinants of health or reflects the mandatory Medicaid waiting period required before sterilization can occur. We evaluated the relationship between neighborhood disadvantage (operationalized by the Area Deprivation Index; ADI) and the likelihood of undergoing postpartum sterilization. Methods Secondary analysis of a single-center retrospective cohort study examining 8654 postpartum patients from 2012 to 2014, of whom 1332 (15.4%) desired postpartum sterilization (as abstracted from the medical record at time of delivery hospitalization discharge) and for whom ADI could be calculated via geocoding their home address. We determined the association between ADI and sterilization completion, postpartum visit attendance, and subsequent pregnancy within 365 days of delivery via logistic regression and time to sterilization via Cox proportional hazards regression. Results Of the 1332 patients included in the analysis, patients living in more disadvantaged neighborhoods were more likely to be younger, more parous, delivered vaginally, Black, unmarried, not college educated, and insured via Medicaid. Compared to patients living in less disadvantaged areas, patients living in more disadvantaged areas were less likely to obtain sterilization (44.8% vs. 53.5%, OR 0.84, 95% CI 0.75–0.93), experienced greater delays in the time to sterilization (HR 1.23, 95% CI 1.06–1.44), were less likely to attend postpartum care (58.9% vs 68.9%, OR 0.86, CI 0.79–0.93), and were more likely to have a subsequent pregnancy within a year of delivery (15.1% vs 10.4%, OR 1.56, 95% CI 1.10–1.94). In insurance-stratified analysis, for patients with Medicaid, but not private insurance, as neighborhood disadvantage increased, the rate of postpartum sterilization decreased. The rate of subsequent pregnancy was positively associated with neighborhood disadvantage for both Medicaid as well as privately insured patients. Conclusion Living in an area with increased neighborhood disadvantage is associated with worse outcomes in terms of desired postpartum sterilization, especially for patients with Medicaid insurance. While revising the Medicaid sterilization policy is important, addressing social determinants of health may also play a powerful role in reducing inequities in fulfillment of postpartum sterilization.

Neighborhood conditions and birth outcomes

“…43 Living in a disadvantaged neighborhood (operationalized by the ADI), was also associated with worse outcomes in terms of desired postpartum sterilization. 44 Other factors that may contribute to neighborhood disadvantage, including fatal police violence, have also been linked to adverse birth outcomes. 45 A unique aspect of our study was that we also had detailed information on neighborhood perceptions, which provides information about how individuals feel about their neighborhoods, as opposed to solely focusing on extrinsic measures, which may not reflect where individuals spend their time.…”

Ethics of a Mandatory Waiting Period for Female Sterilization

“…Ideally, revision of the sterilization policy would move decision‐making to the more preferable shared decision‐making model 68 . The decision to undergo sterilization involves many factors, often individual to the patient, including effectiveness, permanence, the perceived hassle of short‐acting contraception, and a lack of hormones, among others 69 . When counseling women and other patients about sterilization, clinicians should explore the social and psychological factors influencing the request (including who may be influencing a patient's decision‐making) and make sure patients understand the permanence of the procedure; the risk of complications, including failure; the potential psychological consequences of permanently ending childbearing capacity, including regret; and the availability of other, long‐acting, reversible methods 70 .…”

“…14 Individual-level disparities are compounded by community factors, with patients in more disadvantaged areas (who tend to be Black) less likely to obtain desired sterilization than those in less disadvantaged areas. 15 Thus, as opponents of the waiting period predicted in 1976, the regulation has significantly exacerbated some disparities.…”

“…68 The decision to undergo sterilization involves many factors, often individual to the patient, including effectiveness, permanence, the perceived hassle of short-acting contraception, and a lack of hormones, among others. 69 When counseling women and other patients about sterilization, clinicians should explore the social and psychological factors influencing the request (including who may be influencing a patient's decision-making) and make sure patients understand the permanence of the procedure; the risk of complications, including failure; the potential psychological consequences of permanently ending childbearing capacity, including regret; and the availability of other, long-acting, reversible methods. 70 In one study, commons reasons for not obtaining postpartum sterilization (other than the federal Medicaid policy) included the permanence of sterilization, fear of the surgery or of anesthesia, provider influence, and individual medical complications.…”

“…In addition to gender disparities, there are racial disparities in sterilization completion rates, with Black and Hispanic women with Medicaid less likely to receive their desired postpartum sterilization procedures than White women with Medicaid 14 . Individual‐level disparities are compounded by community factors, with patients in more disadvantaged areas (who tend to be Black) less likely to obtain desired sterilization than those in less disadvantaged areas 15 . Thus, as opponents of the waiting period predicted in 1976, the regulation has significantly exacerbated some disparities.…”