Why this key chance for birth control is often missed : Shots - Health News Doctors say they're seeing a surge in the number of women who want their "tubes tied." But hospital capacity, paperwork, religion and personal opinion are just some of the reasons requests get denied.

Why this key chance to getting permanent birth control is often missed

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The most common form of contraception used by women in the United States is a permanent procedure colloquially known as getting your tubes tied. The Supreme Court's abortion ruling and the abrupt bans on abortion in some states have drawn even more interest in that procedure. Melanie Maykin is a maternal fetal medicine specialist in Hawaii, and she says she often sees pregnant women who say, after this baby, I'm done.

MELANIE MAYKIN: Individuals really know, like, I want my tubes out. I'm - this is the last child for me. My husband is not going to get a vasectomy. You know, I've either tried IUDs or some other form or the pill, and it just didn't work for me.

INSKEEP: They want the surgery performed right after birth, when they're already in the hospital. But as NPR's Nell Greenfieldboyce reports, this window of opportunity is often missed.

NELL GREENFIELDBOYCE, BYLINE: The tubes, of course, are the fallopian tubes, which carry eggs from the ovaries. Surgeons can cut, block or remove them. Rachel Flink is an obstetrician-gynecologist in upstate New York. She says for many women, the few days of hospitalization after childbirth are a rare chance to get this surgery done.

RACHEL FLINK: Someone's able to watch their baby. They've already made other child care arrangements. There's no transportation issues.

GREENFIELDBOYCE: She says these practical matters are important because this type of birth control is frequently relied on by people who tend to be poor, with lower levels of education and public health insurance or no insurance at all.

FLINK: They're more likely to fall into groups of people who have difficulty accessing the health care system later.

GREENFIELDBOYCE: Flink says if someone wants their tubes tied and this doesn't happen during the brief hospitalization after childbirth, there's real consequences.

FLINK: About half of women who don't have their desired postpartum sterilization procedure will get pregnant in the next year.

GREENFIELDBOYCE: So the stakes are high, especially in places where it's now much harder to get an abortion. And here's the trouble. A lot of women leave the hospital without getting the tubal surgery they requested. For example, Flink and some colleagues did a study at Strong Memorial Hospital in Rochester and found that the majority of women who asked for this procedure weren't able to have it. They were discharged from the hospital with their tubes intact.

FLINK: I certainly had a sense that we weren't completing all of them or close to all of them. But the fact that it was fewer than half, I think, was a little bit of a shock.

GREENFIELDBOYCE: Those findings are consistent with studies in other hospitals, which have found that about 40 to 60% of requests go unfulfilled. There's a lot of reasons why. Sometimes it's that the operating rooms are just too full, so a procedure that doesn't seem like an emergency isn't a priority. Sometimes doctors believe the patient is too overweight for the surgery, even though research says it's safe, or they'll try to talk a younger patient out of it, arguing that she might change her mind. If the hospital has a religious affiliation, the surgery could be prohibited. And then there's paperwork, specifically one piece of paper that seems to really be causing problems.

SONYA BORRERO: Those who are requesting a federally funded procedure must fill out a standardized consent form.

GREENFIELDBOYCE: Sonya Borrero is a doctor with the University of Pittsburgh School of Medicine. She says this consent form is required by Medicaid, which pays for nearly half of all births in the U.S. The form has to be signed at least 30 days before tubal surgery.

BORRERO: Basically, what this does is create a mandatory 30-day waiting period for people who rely on public funding for their health care.

GREENFIELDBOYCE: Private insurance doesn't require a waiting period.

BORRERO: So it definitely creates kind of a two-tiered system.

GREENFIELDBOYCE: That makes it harder for people on public assistance to get this kind of birth control. If a woman signs the consent form too late or delivers unexpectedly early or loses her copy of the form and it's not on file, well, Medicaid won't pay for the operation.

BORRERO: This does impact a significant number of people with Medicaid.

GREENFIELDBOYCE: This consent form and the waiting period were created back in the 1970s, as the nation grappled with an ugly history of coercive sterilizations, which especially targeted the poor and people of color. The threat of reproductive abuse hasn't completely gone away. There's been recent accusations of unnecessary surgeries at an immigrant detention center, for example. But Borrero says it's not clear that the current Medicaid regulations are the best way to protect the vulnerable.

BORRERO: Because we have a lot of evidence showing that they're creating barriers for the people that they were intended to help.

GREENFIELDBOYCE: Her research suggests that these barriers result in over 29,000 unintended pregnancies each year. Some places are trying new approaches. Kavita Arora is a physician at the University of North Carolina who studies access to tubal surgery. She says a couple years ago...

KAVITA ARORA: West Virginia, to my knowledge, became the first state that actually waived the waiting period completely for female permanent contraception.

GREENFIELDBOYCE: She says if a woman wants her tubes tied but Medicaid won't pay because she hasn't waited 30 days, West Virginia covers it with state funds.

ARORA: And so it really creates, in essence, a natural experiment.

GREENFIELDBOYCE: And one hospital has made a similar change with dramatic effects. John Byrne is now with the University of Texas Health Science Center at San Antonio. He's worked other places. And when he was at Parkland Hospital in Dallas, he saw the number of tubal surgeries and thought...

JOHN BYRNE: Wow, a lot of women are able to have this procedure done here.

GREENFIELDBOYCE: That's because Parkland Hospital had set up a system that included a dedicated operating room, a team of surgeons, plus an anesthesiologist, and money to pay for it whenever Medicaid wouldn't.

BYRNE: They really wanted to make sure that patients, if they wanted or requested that a procedure be done, that we do everything in our power to offer that.

GREENFIELDBOYCE: He and some colleagues just published a study showing at this hospital, nearly 90% of women who asked for their tubes to be tied after childbirth actually had the procedure. And when the operation didn't happen, it was almost always because the patient had decided against it.

Nell Greenfieldboyce, NPR News.


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