For many women who don’t want to have more children, childbirth offers a safe and convenient time for adopting the permanent form of birth control known formally as tubal ligation, and informally as having your tubes tied. For women whose health care is covered by Medicaid, senseless bureaucracy can make this difficult.
A patient we will call Sofia (we aren’t using her real name to protect her privacy) is a perfect example of this issue. She had wanted to have a tubal ligation after she delivered her fourth child in March. The timing was bad: It was the peak of Covid-19 in Massachusetts, where Sofia was having her baby, and staffing and resource limitations meant she was unable to get the procedure as planned. She left the hospital with a plan to reschedule her procedure for later.
Once elective surgeries began to start up again in June, Sofia was scheduled to rebook her tubal ligation and go over pre-op instructions. But because it had been more than six months since she had signed the paperwork that Medicaid requires from all women seeking this procedure, she needed to have an in-person visit before she could be booked for her surgery — a telehealth visit wasn’t allowed since she had to physically sign the paperwork again. When Sofia came in to sign the paperwork, the pregnancy test she had at the visit (which is routinely done before this type of surgery) was positive.
Tubal ligation, the second most common method of birth control in the United States, is used more by Black and Hispanic women and women with public or no health insurance. Many women desiring this procedure have it done immediately after giving birth, while they have ready access to care.
If a woman covered by Medicaid wants her tubes tied, she must complete the “Consent to Sterilization” section of Medicaid’s Title XIX form at least 30 days, and no more than 180 days, before having the procedure. An emergency waiver still requires a 72-hour waiting period, though in obstetrics, emergencies rarely last 72 hours.
All too often, a patient covered by Medicaid who receives prenatal care at a community health center delivers her baby at a hospital lacking access to her prenatal records, including the signed consent form — and by that time it is too late to resign. If any of the requirements are not met, Medicaid will not pay for the procedure.
As a result of these barriers, only about 53% of desired tubal ligations are actually performed.
This policy began in 1978 as a way to protect publicly insured women from forced sterilization, at a time when federally insured women were often victims of reproductive coercion. Although initially well-intentioned, many experts agree that this policy now paradoxically discriminates against publicly insured women by imposing additional burdens to getting the permanent contraception they desire and restricting their reproductive autonomy.
As a result, many Medicaid patients leave the hospital with no contraception and at higher risk of unintended pregnancies, not to mention the additional physical and emotional toll that comes with pregnancy and delivery. Women covered by Medicaid are particularly at risk for unintended pregnancy and have limited access to care, as they can lose their insurance coverage soon after delivering a baby.
Although vasectomies covered by Medicaid also include these limitations, only five states explicitly cover permanent male contraception in their state regulated health plans. Contrary to tubal ligation, vasectomy rates tend to increase with more education and higher socioeconomic status and so are more common among men covered by private insurance.
Privately insured patients, female and male, can get a tubal ligation or vasectomy whenever they choose, without any prerequisite paperwork or 30-day waiting period. This creates two standards of care whereby those with private insurance have ready access to permanent contraception while those on public insurance are not afforded the same timely access.
The Covid-19 pandemic has amplified these barriers as the disease radically changes the way medicine is practiced. In obstetrics and gynecology, many outpatient visits, including prenatal visits and routine gynecology visits, have been converted to telemedicine to minimize patients’ unnecessary exposure to high-risk hospital and clinic settings. Many hospitals during the pandemic, including the ones we work in, have updated their standard procedures for obtaining consents, recommending verbal consent to sign on behalf of a patient to minimize contact.
Medicaid, however, has made it clear that even during Covid-19, patients must still sign the Medicaid-specific consent form in person for the procedure to be covered. This means adding an unnecessary, burdensome office visit that takes time away from work for the patient as well as increases the risk of exposure to SARS-CoV-2, the virus that causes Covid-19, for her and her baby.
Patients like Sofia, who had signed the consent form before Covid-19 and had their procedures delayed have now fallen outside the 180-day waiting period and must come in for an office visit to sign it again, and then wait another 30 days to schedule a procedure they have already been counseled about and expressed a desire to have done.
We live and work in Massachusetts, a state that values reproductive justice and maternal health. With nearly half of pregnancies being unintended, one important step to reducing maternal mortality is by giving women the choice and the agency to make decisions about their fertility – and allowing patients who wish to prevent pregnancy to do so.
There were ample missed opportunities for preventing Sofia’s unplanned pregnancy. The waiting period for tubal ligation mandated by Medicaid was an unnecessary and archaic barrier before Covid-19, and even more challenging and pertinent now.
The pandemic will undoubtedly bring more unanticipated and unplanned barriers to accessing and receiving health care. In other parts of the health care system, it has spawned flexibility, resourcefulness, and rapid adaptation. It should trigger the same response in Medicaid. We urge policymakers to take advantage of this forward momentum: allow electronic signatures, expand telemedicine capabilities for consent, extend the 180-day expiration and, in doing so, give publicly insured women the reproductive autonomy they need and deserve.
Divya Dethier is in her final year of residency in obstetrics and gynecology at Brigham and Women’s Hospital and Massachusetts General Hospital in Boston. Megan L. Evans is an obstetrician and gynecologist at Tufts Medical Center and assistant professor of obstetrics and gynecology at Tufts University School of Medicine in Boston. Erin Tracy Bradley is an obstetrician and gynecologist at Massachusetts General Hospital and associate professor of obstetrics, gynecology, and reproductive biology at Harvard Medical School.
