Female surgical sterilization is the second most commonly used contraceptive method in the US and is disproportionately used by low-income women and women of color. Whether the higher use of sterilization in these populations reflects inappropriate overutilization is unclear. On one hand, low-income and racial minority women frequently misunderstand the permanent nature of sterilization, are often unaware of reversible contraceptive alternatives, and commonly experience regret after the procedure? suggesting suboptimal decision making. On the other hand, there is evidence of substantial unmet demand for sterilization among low-income women, due to unique access barriers posed by Medicaid sterilization regulations, putting them at high risk for unintended pregnancy and the adverse health and social consequences associated with unintended pregnancy. Medicaid sterilization policy currently requires that all women requesting a federally-funded procedure complete a standardized consent form at least 30 days prior to sterilization. This policy was originally instituted in the 1970s to protect vulnerable women from coercive sterilization practices by attempting to ensure informed and voluntary consent. However, there is growing consensus that the policy is incapable of ensuring informed consent, and that the mandatory 30-waiting period impedes access to desired sterilization for many low-income women. The lack of a process that can ensure both informed consent and timely access for sterilization procedures hampers progress toward reproductive health equity for low-income women. The proposed project seeks to build and test a novel, web-based decision support tool to optimize low-income women's ability to make informed and value-concordant decisions about surgical sterilization. A decision support tool may be particularly useful in the context of sterilization decisions because this is a preference- sensitive decision with permanent implications and because there is a high level of misunderstanding about sterilization and limited awareness of alternative options among women who have undergone the surgery, indicating critical gaps in the quality of pre-sterilization counseling. Furthermore, patient-provider interactions may be complicated by a broader social and historical context in which poor and minority women's reproductive choices have not always been valued. Thus, the specific aims of this proposal are to qualitatively determine low-income women's decision support needs and preferences as well as providers' perspectives on the role of decision support around surgical sterilization (Aim 1); build a patient-directed, web-based decision aid to support women's sterilization decision making (Aim 2); and conduct a 3-site, randomized controlled trial to test the effect of the decision aid plus usual care compared to usual care alone on decision quality among 350 racially-diverse, low-income women requesting post-partum sterilization (Aim 3).
Because low-income women's decision making and provider counseling regarding surgical sterilization are often suboptimal, the proposed research seeks to build and test a decision support tool to enhance low-income women's ability to make informed and value-concordant surgical sterilization decisions. In addition to its potential clinical utility, this research has important public health and policy implications as it can inform ongoing efforts to transform the current Medicaid sterilization consent policy by offering an evidence-based tool that is truly able to ensure informed decision making in vulnerable populations. Once we help safeguard women with a process for ensuring informed consent, we can then consider shortening or waiving the 30-day waiting period that has restricted access to sterilization for many low-income women. !