Female sterilization, the second most commonly used contraceptive method in the United States, is commonly performed during the postpartum period. However, women with Medicaid insurance are half as likely to obtain a desired postpartum sterilization as those with private insurance. Compounding this disparity, women of color with Medicaid insurance are less likely to achieve sterilization fulfillment compared to white women with Medicaid insurance. Sterilization non-fulfillment puts women at high risk of subsequent unintended pregnancy with a short interpregnancy interval and the associated risks to maternal and infant health. There are significant policy barriers to equitable postpartum sterilization that impact those with Medicaid but not private insurance. However, the federal Medicaid policy (including specific consent form and subsequent thirty- day waiting period) was established in 1976 due to coerced sterilizations on women of color and low socioeconomic status. Therefore, sensitive consideration of the complex social and cultural backdrop is required to balance protection of a vulnerable population with the unintended consequence of disparities in sterilization fulfillment. Furthermore, barriers at the patient, provider, and hospital level have also been noted, though it is unclear the extent to which these barriers interact. Advocating for the complete removal of the Medicaid sterilization process, then, ignores both the complex history as well as the additional, non-policy barriers to equitable postpartum sterilization. The overall objective for this proposal is to determine the discrete barriers at various levels of analysis (patient, provider, hospital, and policy). The central hypothesis is that the layering of barriers individually and collectively contributes to disparities in postpartum sterilization fulfillment for the Medicaid population. The rationale for the project is that identifying and understanding potential barriers is the critical next step to eradicating the disparities surrounding postpartum sterilization. Guided by strong preliminary data, this hypothesis will be tested through an explanatory sequential mixed methods design by pursuing three specific aims: 1) Model the association between Medicaid insurance and sterilization fulfillment after adjusting for clinical and demographic differences in a pooled multi-institution sample (patient- and policy- level barriers aim); 2) Identify the attitudes, beliefs, and practices of postpartum women and their obstetricians regarding postpartum sterilization (patient-, provider-, hospital-, and policy-level barriers aim); 3) Assess the impact of hospital and state policy barriers on postpartum sterilization (hospital- and policy-level barriers aim). The approach is innovative because it departs from the status quo by shifting focus away from studying barriers individually and toward the identification and assessment of various layers of barriers. This contribution will be significant because it is expected to inform an evidence-based and patient-centered health policy to eradicate health disparities and improve clinical outcomes due to sterilization non-fulfillment and resultant unintended pregnancies.
The proposed research is relevant to public health because the systematic identification and assessment of barriers to postpartum sterilization is necessary to ensure equitable fulfillment of desired postpartum contraception. Lack of fulfillment to desired postpartum sterilization and the resultant unintended, short-interval pregnancies lead to disparities in clinical and public health outcomes for women of color and low socioeconomic status. Thus, the proposed research is relevant to the NIH's mission in understanding factors affecting the non-use of contraception, developing effective interventions, and mitigating disparities in reproductive health.
