Postpartum permanent contraception: updates on policy and access

Abstract

Purpose of reviewTo describe barriers to provision of postpartum permanent contraception at patient, hospital, and insurance levels. Recent findingsPermanent contraception remains the most commonly used form of contraception in the United States with the majority of procedures performed during birth-hospitalization. Many people live in regions with a high Catholic hospital market share where individual contraceptive plans may be refused based on religious doctrine. Obesity should not preclude an individual from receiving a postpartum tubal ligation as recent studies find that operative time is clinically similar with no increased risk of complications in obese compared with nonobese people. The largest barrier to provision of permanent contraception remains the federally mandated consent for sterilization for those with Medicaid insurance. State variation in enforcement of the Medicaid policy additionally contributes to unequal access and physician reimbursement. Although significant barriers exist in policy that will take time to improve, hospital-based interventions, such as listing postpartum tubal ligation as an 'urgent' procedure or scheduling interval laparoscopic salpingectomy prior to birth-hospitalization discharge can make a significant impact in actualization of desired permanent contraception for patients. SummaryUnfulfilled requests for permanent contraception result in higher rates of unintended pregnancies, loss of self-efficacy, and higher costs. Hospital and federal policy should protect vulnerable populations while not preventing provision of desired contraception.

Editorial: Updates in contraception and abortion care: turbulence, upheaval, and chaos, but keeping calm and continuing to care

“…In their review on ‘Second-Trimester Abortion Care for those with Complex Medical Conditions’, Henkel and Blumenthal provide a plethora of pointers for providers engaged in the care of such patients. Perhaps aptly subtitled ‘don’t be scared, be prepared!’, the review provides the evidence base for how providers can gain both competence and confidence in already clinically complicated cases while providing second-trimester abortion care [4]. Key among their review's findings are that first, the most commonly seen complications (with an overall rate of 1.5%) include hemorrhage, cervical laceration, retained products of conception, and infection; second, a previous cesarean delivery creates significant risk for complicated dilation and evacuation because of the increased risk of hemorrhage, abnormal placentation, and distorted anatomy; third, as some medications used in chronic illness interact with some used for the procedure, clinicians must recognize potential contraindications and choose appropriate pharmacologic and nonpharmacologic alternatives; and finally, fourth, the decision to continue, interrupt, or modify anticoagulation in the periabortion period should be individualized for those in the second trimester to weigh the risk of thromboembolism with the risk of hemorrhage.…”

Editorial: Updates in contraception and abortion care: reviews from both the clinical and social science sides of the aisle

“…From their perspective of reducing health inequities perhaps their most important conclusion is that ''there is evidence that Medicaid policies originally enacted to protect vulnerable populations acts as a barrier to receiving desired permanent contraception resulting in more unfulfilled requests. In qualitative studies, people find this barrier ''unfair'', and providers describe it as ''arbitrary'' [4].…”