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Abstract

Background:

There are several barriers to fulfillment of desired postpartum permanent contraception (PC). Prior research has primarily focused on the federal Medicaid sterilization policy as a barrier to PC; however, other barriers need to be examined.

Objectives:

To explore the levels and intersections of barriers to postpartum PC that exist external to the Medicaid policy.

Design:

We interviewed postpartum people with a documented desire for PC and their delivering obstetrician–gynecologist (OB–GYN) at four hospitals in the United States in 2022–2023.

Methods:

We used rapid qualitative analysis to create initial key themes and sub-themes, which we further refined using thematic analysis to explore barriers to postpartum PC.

Results:

We interviewed 81 postpartum people and 67 OB–GYNs. Barriers were identified across four levels: clinical, physician, hospital, and sociocultural. At the clinical level, participants commented on how they believed individual patient characteristics and medical history can prevent PC fulfillment prior to discharge. At the physician level, participants discussed young age, low parity, and marital status as reasons clinicians decline to provide desired PC. At the hospital level, OB–GYNs described difficulties with scheduling and staffing, and patients described a lack of PC prioritization. At the sociocultural level, participants mentioned numerous barriers to fulfillment of interval PC including finding childcare, getting appointments scheduled quickly, and transportation.

Conclusion:

Improving access to postpartum PC should be focused within and across all levels of health disparity determinants. In the cases where immediate PC is not accessible, interventions should be formulated across levels to allow timely access to interval PC. As policy reform alone will not eliminate all barriers to postpartum PC, a multi-level approach to alleviating barriers is required.

Plain language summary

Multi-level barriers to equitable postpartum permanent contraception

Why was the study done? Prior research indicates that the federal Medicaid sterilization policy poses as a barrier to permanent contraception fulfillment. Only 53% of patients with Medicaid receive their desired postpartum permanent contraception, compared to 70% of patients with private insurance. Prior research has primarily focused on the federal Medicaid sterilization policy as a barrier to permanent contraception; however, other barriers and their intersections warrant examination. What did the researchers do? The research team explored the levels and intersections of barriers to permanent contraception fulfillment that exist external to the Medicaid policy. They conducted semi-structured, qualitative interviews with postpartum patients with a documented desire for permanent contraception and their delivering obstetrician–gynecologist. What did the researchers find? Barriers to postpartum permanent contraception fulfillment are prevalent across four overarching levels: clinical, physician, hospital, and sociocultural. At the clinical level, individual patient characteristics and medical histories may prevent permanent contraception fulfillment. At the physician level, cutoffs around age, marital status, and parity may prompt physicians to decline provision. At the hospital level, staffing and scheduling issues complicate fulfillment prior to discharge. Lastly, at the sociocultural level, difficulty with childcare, transportation, and appointment scheduling may prevent interval permanent contraception fulfillment. What do the findings mean? Public health interventions should be developed across each level of determinants to improve access to permanent contraception and eliminate inequities.

Keywords

permanent contraception Kilbourne framework health determinants multi-level barriers reproductive health

Introduction

Permanent contraception (PC) is the most commonly used form of contraception in the United States for women aged 15–49.¹ Approximately half of PC procedures are performed in the immediate postpartum period, but only 39%–57% of those who desire PC postpartum receive it.^2
–4 The US Medicaid sterilization policy, which requires patients with Medicaid insurance to sign a consent form and then undergo a 30-day waiting period, is a well-documented barrier to PC.^4
–9 Initially enacted in 1978 with the intent to prevent coerced sterilization, this policy does not apply to patients with private insurance, thus creating inequities in access to contraceptive healthcare for people who are living on low incomes.³ Research suggests that while over 70% of privately insured patients receive desired postpartum PC prior to hospital discharge, only 53% of patients with Medicaid experience fulfillment.⁵

While the Medicaid policy has been the focus of much investigation surrounding barriers to PC fulfillment, there are other known barriers including provider beliefs and biases, operating room availability, and maternal medical complications.^6,7,10
–12 Existing literature is lacking on how these barriers interact with one another and collectively affect PC fulfillment from a qualitative perspective. Thus, our study explored the intersections of barriers external to the Medicaid policy from the perspectives of the stakeholders most involved in postpartum PC fulfillment: patients and their delivering obstetrician–gynecologist (OB–GYN). In this qualitative analysis, we delve into the barriers that exist in addition to the Medicaid policy.

Methods

Study design and eligibility criteria

This qualitative analysis is a component of a broader qualitative study focused on decision-making surrounding postpartum PC. We recruited postpartum patients with a documented desire for PC at the time of delivery hospitalization between March 2022 and January 2023 and their delivering OB–GYN for semi-structured, qualitative interviews. Eligible patients were English- or Spanish-speaking, 21 years or older, and delivered at one of four US institutions: MetroHealth Medical Center in Cleveland, OH; Northwestern Memorial Hospital in Chicago, IL; University of Alabama at Birmingham in Birmingham, AL; and University of California San Francisco in San Francisco, CA. Patients were excluded if they were not between 6 and 10 weeks postpartum, as to allow time to obtain either immediate or interval PC and to minimize recall bias. Delivering OB–GYNs were selected based on the participation of their patient. OB–GYNs who delivered for more than one participating patient were interviewed for each included patient. Verbal informed consent was obtained from all individual participants included in the study.

Recruitment and data collection

We contacted eligible participants by phone and email up to three times. We initially planned to recruit 25 patients (100 patients total) from each site but reached thematic saturation after 81 interviews and stopped recruitment. Our research team created interview guides using existing literature and refined them based on pilot interviews with three patients and three OB–GYNs from each site.^4,8,10
–12 Patient interview guides explored experiences deciding on and seeking PC and any barriers faced. Clinician interview guides explored clinicians’ perspectives on navigating patients’ desired PC and included questions on the patient’s contraceptive plan, decision to pursue PC, and any barriers that arose. Four female (two White, one Black, one Asian) research assistants with formal master’s or doctoral-level training in qualitative methodology conducted ⩽1 h long semi-structured interviews over video-conferencing software when the patient was approximately 6 weeks postpartum. Participants received a $100 gift card for their participation upon completion. We audio-recorded, deidentified, and professionally transcribed the interviews verbatim through Landmark Associates.¹³

Data analysis

We deductively developed an initial codebook based on existing literature and interview guides.^4,8,10
–12 We then inductively formulated additional codes through two coding passes. Four trained research assistants individually coded each transcript using NVivo 14 (Lumivero) software, and one co-investigator (BWB) double-coded 10% of transcripts.¹⁴ The study team met repeatedly during the coding process to compare coding and resolve any discrepancies. Two team members (SL and KSA) used rapid qualitative analysis to identify initial key themes, which we further refined into sub-themes using thematic content analysis in Microsoft Excel.¹⁵ After inductive analysis, we used the Kilbourne framework to conceptualize where the themes fit into different levels of health determinants.¹⁶ The Kilbourne framework was selected by authors for its emphasis on requiring comprehensive, multi-level interventions to target health disparity issues. In this sub-analysis, we focus on discussions from patients and clinicians on the main barriers to postpartum PC fulfillment for patients with Medicaid insurance.

Ethical codes

This project was reviewed and approved by the Institutional Review Board at MetroHealth Medical Center (IRB #20-00026) with reliant review at remaining sites. The reporting of this study conforms to the COREQ guidelines (see Supplemental File 1).¹⁷

Results

Demographic information of the 81 patients and 67 clinicians included in this analysis is outlined in Table 1. Barriers are prevalent in our findings across the four overarching adapted Kilbourne levels: clinical barriers, physician barriers, hospital barriers, and sociocultural barriers. These levels align with the Kilbourne framework regarding drivers of health disparities, though policy-level barriers were conceptualized as larger sociocultural factors given our desire to characterize and understand barriers external to the Medicaid sterilization policy for this analysis (Figure 1).

Table 1.

Characteristics of postpartum patients and clinicians, self-reported.

Characteristic	Patients	Clinicians
N	81	67
Age, median [IQR]	33 [31, 38]	44 [36, 54]
Gender, N (%)
Women	81 (100%)	57 (85%)
Men	0 (0%)	10 (15%)
Other	0 (0%)	0 (0%)
Race, N (%)
White	32 (40%)	46 (69%)
Black	28 (35%)	7 (10%)
Asian	3 (4%)	10 (15%)
Other	18 (22%)	4 (6%)
Ethnicity, N (%)
Hispanic	26 (32%)	2 (3%)
Non-Hispanic	55 (68%)	65 (97%)
PC fulfilled, N (%)	44 (54%)	—
Insurance status
Public	46 (57%)	—
Private	35 (43%)	—

Figure 1.

Adapted Kilbourne framework: factors impacting postpartum PC fulfillment.

Clinical barriers

Some patients and OB–GYNs commented on how individual patient characteristics and medical history can raise concerns about safety that may prevent PC fulfillment prior to discharge. The most common patient characteristic mentioned was body mass index (BMI). A patient reflected on how they had not been counseled during pregnancy regarding BMI being a potential barrier. She said, “They said [at the time of delivery]. . . something about my BMI. . . just ‘cause I was overweight is why I couldn’t get my tubes tied. I’ve never heard of that.” One OB–GYN stated, “Sometimes the other issue we have because of our patient population, is size. BMI of over 50 after a vaginal delivery. . . like a postpartum sterilization procedure isn’t in my comfort level, and I don’t think it’s in most of my partners’ comfort levels.” Other clinicians brought up variation in practice related to BMI cutoffs for postpartum PC after a vaginal delivery, as the procedure carries increased surgical risks for patients with obesity. One OB–GYN reflected this, saying, “If the mom has a habitus, or BMI, that prevents the ability to actually feel her uterus and assess her tubes from a very small incision, she may be encouraged also to wait ‘till an interval time to get her tubes tied.” However, another clinician commented that, despite the surgical risks, use of a threshold BMI for immediate postpartum PC results in disparities, stating, “The other thing that is very unjust was the—many times providers [will] be like, ‘Well, she’s too fat for a postpartum tubal.’”

Patients and clinicians also mentioned other clinical safety issues that impacted PC fulfillment. A patient reflected on how prior abdominal surgeries made their doctors apprehensive to perform surgery: “The doctor—I had a different—two-different doctors said they didn’t feel comfortable [to perform the surgery] due to the fact of my scar tissue and abdominal issues I’ve had in the past.” One OB–GYN explained: “[With] certain medical conditions like cardiac disease . . . surgery would be technically more challenging. Or if they postoperatively had a significant postpartum hemorrhage and were already anemic. Then that would give me pause about operating electively on them, in that time window.”

Physician barriers

Both patients and OB–GYNs discussed young age and low parity as reasons clinicians decline to provide desired PC given clinicians’ concern surrounding the potential increased risk of regret. One patient reflected with frustration on previous attempts to receive PC several years before the index pregnancy and stated, “I told [the doctor] I wanted that (PC). . . I wanted to get them tied. Then the doctor at [another clinic], she said that I was too young and that maybe I was gonna want more. I’m like, ‘No, I want them tied’. She’s like ‘Well you’re too young. You will maybe want some more (children) when you’re older’. She didn’t end up tying them even though I had the C-section, and she could have done it there.” This experience was echoed in one clinician’s explanation that they do not usually offer PC to young patients or patients with low parity: “I think maybe sometimes in the women who are younger and maybe they’ve had two or three kids, maybe if they’re really young, we maybe don’t bring up to them about sterilization. . . Other than that, we try to make sterilization available to people.” Conversely, one clinician stated that they may encourage PC in patients with large families. “For those moms who already have larger families or [who] I see [are] underneath significant social stressors thinking about it, I may really nudge them in that direction. Yes, I know there is underlying bias from myself with that. People who I know medically will suffer from future pregnancies or psychologically may suffer, I may strongly push them towards a sterilization,” stated the clinician.

Clinicians also discussed how they consider their patient’s marital status when determining whether to encourage PC. One clinician stated:

We serve a population that’s more so unmarried. Sometimes, I think providers are concerned that if a patient is either unmarried, even if they have three or four children, that eventually when they—if they do decide to get married, then—and decide to have more children—then they become so concerned about the possibility of that, given the performance of a permanent procedure. Those are two things that I think are more so in our population that could affect and alter that relationship.

Hospital barriers

Hospital-level barriers were noted by clinicians at each of our sites. Several patients and clinicians mentioned difficulties with scheduling and staffing as hospital-level barriers to PC fulfillment after a vaginal delivery prior to discharge. This was reflected by one patient who commented, “The day after I gave birth, he (their doctor) told me, there’s a possibility that they’re just going to cancel it because of how busy we are.” Another patient faced a similar experience, stating, “The day of birth, the doctor I spoke to came in and said that they were double-booked and that they wanted me to wait to see if someone cancelled or if they could squeeze me in to have the tubal ligation. I felt hesitant. To me, I envisioned a rushed tubal ligation. I pictured people being overworked.” The patient ultimately did not have their PC fulfilled prior to discharge. This phenomenon was further explained by a clinician: “If the patient delivers vaginally, the ideal thing would be to immediately go back [to the OR] and do the tubal ligation. That’s not always possible. It could be due to room issues, it could be due to. . . anesthesia issues.”

Some patients and OB–GYNs commented on how PC is not considered a priority procedure given the need to prioritize what is deemed as more time-sensitive care. This left several patients feeling that the hospital staff did not prioritize their desire to get PC. For instance, one patient remarked: “It was just a matter of they didn’t wanna do it. They wanted me to wait six weeks. . . It wasn’t a priority. It was just when they got to it. I was in the hospital for about a week or two [for other health reasons] before I even had my baby. They knew that’s what I wanted.” This was explained from the perspective of one clinician commenting on medical triage: “I don’t ever wanna put undue stress on my nursing staff, so if they say they honestly cannot accommodate [PC], I’m not gonna push my agenda through. I think that not pissing off the nurses is more important than someone’s tubal ligation.” Another OB–GYN echoed, “I think that our role as obstetricians and delivering babies healthy is more important than sterilization.”

In further explanation for why PC may not be considered a priority procedure, some clinicians discussed how tubal ligation may not be possible due to hospital barriers such as OR availability or scheduling. One OB–GYN commented, “I have never recommended or scheduled a postpartum tubal ligation for a vaginal delivery in the hospital. I always ask the patient to go for an interval tubal ligation.” A patient remarked on how PC was not an option after vaginal delivery: “The doctor was saying that because you can only do this tubal ligation if you do a C-section because you’re already in there (the OR). We can only do that procedure together.”

Some patients reported feeling pressured by hospital staff to deliver by cesarean section in order to receive PC prior to discharge. One patient commented, “When I was going into labor they were trying to pressure me to have a C-section. I think they was trying to do that so they could go ahead and tie my tubes during the C-section, but no. I ended up pushing the baby out. I feel like they were trying to pressure me to have a C-section.” Another patient described how they were counseled toward a cesarean delivery given their history of a prior cesarean and desire for PC: “I told them, ‘No. I don’t want a C-section because of the aftermath. . . I can’t be in my bed for two weeks’. Then she (the clinician) is like, ‘Well, we might not be able to do the tube tying the same day you give birth’.”

Sociocultural barriers

Some patients and clinicians reflected on sociocultural barriers to receiving an interval procedure for patients who did not receive PC prior to discharge. Finding childcare was one of the obstacles mentioned. “I think it’s really hard to come back and forth from the hospital when you have a new baby,” thought one clinician. A patient remarked, “I wanted it to be like, now that I’m at the hospital, they might as well tie my tubes while I’m there. Because of complications, I wasn’t able to. Then moving forward, I had to find a babysitter to stay with the kids.” Other participants also mentioned scheduling and transportation as barriers to receiving interval PC. A clinician explained, “It’s really about them coming [back]. They don’t come back for their postpartum visit nearly as often. When they come back, they’re pregnant a year later. That’s frustrating, but it’s partly about transportation and partly about priorities of what’s going on in their world.”

Another OB–GYN listed major logistical barriers to their patient’s interval PC fulfillment: “The schedule, the availability of surgical scheduling, the availability for the patient to have childcare or time off from work, depending on whether they’re working and where, if they are working. There are sometimes transportation or other issues.” This clinician later mentioned how these barriers ultimately prevent desired interval PC fulfillment, saying, “I have a lot of patients who would have been a candidate for a postpartum tubal and, for one reason or another, just didn’t get it, and then end up not getting their desired form of birth control. That’s, I think, a gap in the care that we can offer patients because often those [with] planned interval tubals, they end up coming back in a year and a half, pregnant, and that’s maybe not what they wanted. I think we could do a better job there.”

Discussion

Patients and clinicians in our study identified barriers to postpartum PC fulfillment at the clinical-, physician-, hospital-, and sociocultural levels. These levels build upon the adapted Kilbourne health disparities framework, which identifies four levels of factors that influence PC fulfillment: individual-, physician-, hospital-, and policy-level (Figure 1).⁶ We bring attention to another layer—sociocultural—that includes barriers such as childcare, scheduling, and transportation and draws from socioecological models of contraceptive decision-making.^18
–20 Thus, while researchers have paid considerable attention to the Medicaid policy as a barrier to PC, it is critical to examine the existence of barriers within and across all levels to achieving equitable postpartum PC.

Importantly, the Kilbourne framework suggests that although factors exist in these discrete levels, they also interact with each other to have varying effects on patients’ fulfillment of PC.⁶ Our findings suggest that hospital-level barriers such as limited staffing or scheduling may influence counseling at the physician level. Such operational and administrative barriers may also lead to increased stress and burnout for OB–GYNs and healthcare professionals as they struggle to promote patient autonomy within structural constraints. Several patients in our study reported feeling pressured to undergo a cesarean delivery to get their desired postpartum PC procedure, which is concerning. Physicians should ensure that patients are fully aware of how a vaginal delivery may impact PC fulfillment in order to make informed decisions about their birthing plan.²¹

Furthermore, age-, marital-, and parity-based cutoffs for PC were described by both patients and OB–GYNs in our study. These cutoffs are likely due to literature highlighting the increased risk of regret for PCs performed at a younger age, as well as prior research that clinicians may discourage PC among those with low parity.^10,22 Yet, the American College of Obstetricians and Gynecologists states that physicians should avoid using these discrete cutoffs in the provision of PC as they are paternalistic.^2,23 Similarly, OB–GYNs in our study described how BMI-based cutoffs are utilized to avoid harm given the risk of increased technical difficulty and surgical complications with elevated BMI, though the impact on disparities in PC fulfillment from doing so is important to recognize.²⁴ Our findings from patient interviews indicate that this surgical reasoning may not be relayed to patients—either during their prenatal care or during their delivery hospitalization. Shared decision-making conversations in which evidence regarding risk of regret, surgical difficulty, and potential for complications should be presented and balanced with patients in a collaborative manner.

Finally, there are numerous sociocultural barriers to fulfillment of interval PC including finding childcare, scheduling, and transportation. This reflects the need for greater policy changes including postpartum Medicaid coverage expansion and paid parental leave and universal childcare that can alleviate the aforementioned sociocultural barriers. One study found that expedited scheduling of interval PC significantly improves fulfillment and patient satisfaction.²⁵ Thus, interventions should be developed across each level of determinants to allow timely access to interval PC and eliminate scheduling and logistical barriers.

Limitations

This study has several limitations. Participants were recruited from secular, urban hospitals with relatively high access to reproductive health services, thus excluding perspectives of those receiving care at religiously affiliated or rural hospitals and affecting the generalizability to non-urban regions. Second, only the clinicians who performed the delivery were interviewed. Therefore, we did not capture the perspectives of other clinicians who provided care earlier in the patient’s pregnancy and may have encouraged or discouraged PC. Lastly, while English- or Spanish-speaking patients could have been recruited into the study, all participants in our study preferred for interviews to be conducted in English. Thus, we were unable to capture perspectives from important non-English-speaking patient subpopulations. Future studies should aim to include more diverse perspectives in their cohort.

Conclusions

Even beyond the well-documented barrier posed by the Medicaid consent policy, additional multi-level barriers to postpartum PC exist and intersect that lead to inequities in fulfillment. Physicians, hospitals, and policymakers should focus on eliminating these issues to make PC accessible and equitable by implementing actionable interventions such as improved scheduling and staffing, minimizing administrative burdens, and prioritizing shared decision-making.

Supplemental Material

sj-docx-1-whe-10.1177_17455057251325977 – Supplemental material for Multi-level barriers to equitable postpartum permanent contraception

Supplemental material, sj-docx-1-whe-10.1177_17455057251325977 for Multi-level barriers to equitable postpartum permanent contraception by Suzanna Larkin, Brooke W Bullington, Kristen A Berg, Kari White, Margaret Boozer, Tania Serna, Emily S Miller, Jennifer L Bailit and Kavita Shah Arora in Women’s Health

Supplemental Material

sj-docx-2-whe-10.1177_17455057251325977 – Supplemental material for Multi-level barriers to equitable postpartum permanent contraception

Supplemental material, sj-docx-2-whe-10.1177_17455057251325977 for Multi-level barriers to equitable postpartum permanent contraception by Suzanna Larkin, Brooke W Bullington, Kristen A Berg, Kari White, Margaret Boozer, Tania Serna, Emily S Miller, Jennifer L Bailit and Kavita Shah Arora in Women’s Health

Supplemental Material

sj-docx-3-whe-10.1177_17455057251325977 – Supplemental material for Multi-level barriers to equitable postpartum permanent contraception

Supplemental material, sj-docx-3-whe-10.1177_17455057251325977 for Multi-level barriers to equitable postpartum permanent contraception by Suzanna Larkin, Brooke W Bullington, Kristen A Berg, Kari White, Margaret Boozer, Tania Serna, Emily S Miller, Jennifer L Bailit and Kavita Shah Arora in Women’s Health

Footnotes

Acknowledgements

We are grateful to Madison Lyleroehr, MS (Department of Medical Social Sciences, Northwestern University Feinberg School of Medicine, Chicago, IL); Tiffany Lee, MPH, MS (Department of Obstetrics and Gynecology, University of California San Francisco, San Francisco, CA); and Rosylen Quinny (Department of Obstetrics and Gynecology, University of Alabama at Birmingham, Birmingham, AL) who performed the interviews as well as Arzice Chua (MetroHealth Medical System, Cleveland, OH) who recruited patients for interviews. These individuals were compensated for their work. We thank Madeline Thornton, MPH (School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC); Sumaiya Mubarack, MD (Department of Obstetrics and Gynecology, Beth Israel Deaconess Medical Center, Boston, MA); Joline Hartheimer, MPH (School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC); and Dhweeja Dasarathy, BA (School of Medicine, Vanderbilt University, Nashville, TN) who coded the interview transcripts. We also acknowledge our participants for sharing their vital perspectives for this study.

Declarations

ORCID iD

Suzanna Larkin

Supplemental material

Supplemental material for this article is available online.

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Supplementary Material

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