Permanent contraception post-Dobbs: implications for research and practice

Three years after Dobbs v. Jackson Women’s Health, we are just beginning to quantify the scope and magnitude of its effects. The direct health, social, and economic consequences of being denied abortion care have been extensively documented, even before Dobbs (1). But abortion bans obstruct control over pregnancy and childbearing, which may also influence contraceptive decision-making, a phenomenon that has received very little empirical attention until recently. Emerging evidence suggests shifting geographic and sociodemographic patterns in permanent contraceptive use after the Dobbs decision. This literature raises important questions around evaluation and interpretation of policy-induced changes in permanent contraception, and the implications of these shifts for reproductive autonomy and person-centered contraceptive care.

The impact of Dobbs has not been equally distributed. It is therefore critical that researchers document where and for whom its consequences are most pronounced. Wahlstedt et al. (2) use national electronic medical record (EMR) data to assess differences in permanent contraception procedure rates in the 6 months after the Dobbs ruling relative to the same 6-month period in 2021. They quantify changes across state policy environments, individual states, and sociodemographic subgroups. Findings suggest that, while vasectomies increased after Dobbs across legal landscapes, an increase in tubal sterilization procedures was only observed in states that banned abortion and states deemed nonhostile to abortion. They also found a statistically significant increase in both male and female procedures post-Dobbs among people aged 18–30 years, an increase in vasectomies among single men, and an increase in tubal sterilizations among Hispanic women. Generally consistent with other studies (3–5), these findings suggest that some people may be making contraceptive decisions they otherwise would not have made in response to Dobbs.

Much early research in this area has relied on EMR data to document short-term changes in vasectomy and/or tubal sterilization procedures from before to after Dobbs. These data offer “real time” insights into the population of patients seen within a single facility or health system, with some databases aggregating EMR data across health systems nationally. Studies relying on medical record data to assess variation in sterilization procedure rates over time should be interpreted with caution. Electronic medical record data only capture services provided within a health system or group of health systems, complicating identification of the true population of patients who are eligible (i.e., people without permanent contraception). Although denominator misclassification is always possible when using administrative data to study contraceptive uptake, the issue is particularly salient for understanding variation in permanent contraception across smaller subgroups without a lookback period. Uncertainty around the organizations included in national EMR data over time is another limitation of these data. For example, if the health systems contributing data to an EMR database change from the pre- to post-period, this could bias estimates in an unknown direction. Restricting the study population to individuals seen within organizations contributing data for the duration of the study period is one way to address this limitation. Other data sources, including insurance claims and survey data, may be better suited to quantifying long-term shifts in permanent contraception, although each have their own limitations and are generally less timely relative to EMR data.

Descriptive studies offer insights into patterns of service use, which can inform quasi-experimental designs necessary to establish causal evidence on the effects of Dobbs. Using an interrupted-time series design with national EMR data, our team evaluated changes in monthly permanent contraception procedures for females and males aged 18–30 in the years before, compared to the 15 months after Dobbs (5). We found an abrupt increase in both tubal sterilization and vasectomies nationally, although the magnitude of the increase was greater for tubal procedures. In another interrupted time-series analysis using national commercial claims data, Xu et al. (3) found an increase in tubal sterilization procedures in states where abortion was banned, protected, and where abortion access was limited after the Dobbs decision; however, a sustained monthly increase (i.e., change in trend) was only observed in banned states. Similarly, Strasser et al. (4) leverage difference-in-differences and event-study designs to evaluate changes in tubal sterilization and vasectomy before and after Dobbs across age groups in states deemed likely to ban abortion relative to those not likely to ban abortion in response to the decision. They found an increase in tubal sterilization and vasectomy procedures among 19–26-year-olds in states likely and unlikely to ban abortion, with a more pronounced increase among young people living in states likely to ban abortion. They did not find a significant increase among 27–44-year-olds. Importantly, interrupted time series, difference-in-differences, and event-studies account for preintervention trends in outcomes—albeit in different ways. Because the Dobbs decision appears to have impacted contraceptive use nationally—including states where abortion access is protected—identification of a true (i.e., unexposed) comparison group in the United States is arguably not possible.

Importantly, studies relying on administrative data alone cannot tell us about unmet need. They cannot disentangle the extent to which observed changes are driven by increased demand for permanent contraception or increased willingness of providers to perform the procedure. Through concurrent analysis of qualitative data collected via text message from 14–24-year-olds, Strasser et al. (4) offers insight into potential reasons for observed shifts in contraceptive preferences post-Dobbs. They find that young people’s interest in permanent contraception was largely driven by fears around bodily autonomy and shifting fertility desires. More research on contraceptive care-seeking experiences and method satisfaction will be necessary to elucidate the full implications of Dobbs.

This emerging literature suggests that Dobbs is obstructing reproductive autonomy beyond abortion access. Moving forward, research should critically engage with the who, where, and why of shifting contraceptive preferences post-Dobbs. Young, Black, Latine, Indigenous poor, and disabled people who can get pregnant are more likely to be directly impacted by restrictive abortion policies. These populations already experience disproportionate barriers to person-centered contraceptive care, and Dobbs may exacerbate these barriers. In the context of a sociopolitical environment hostile to bodily autonomy, and a tiered healthcare system that produces inequitable access to quality care, clinicians need to trust the contraceptive decisions people make for themselves. Ensuring access to the full range of contraceptive methods and person-centered contraceptive counseling is necessary, but not sufficient. Contraception will never be a solution to restrictive abortion policy, and policymakers, clinicians, and researchers would do well to keep this in mind.