In Reply:
We would like to thank Drs. Darwin and Johnson for their thoughtful response to our article in the December 2019 issue.1 Our secondary analysis was designed to isolate the effects of the federal Medicaid sterilization policy by limiting our population to those undergoing cesarean delivery.
Drs. Darwin and Johnson point out that differential access to desired sterilization may affect obstetric decision-making surrounding route of delivery after a prior cesarean delivery. Our primary analysis of this retrospective cohort did demonstrate that women delivered by cesarean had an increased likelihood of receiving a desired tubal ligation, regardless of insurance status.2 However, underlying clinical variables that may also affect mode of delivery differed between the Medicaid and privately insured populations. While retrospective observational data cannot be used to identify causation, we agree that the interplay between desire for sterilization and decision-making surrounding mode of delivery represents rich ground for further study.
Second, while our study focused on the Medicaid sterilization policy, we agree that uninsured patients are at high risk for not receiving desired postpartum sterilizations, among other health disparities. However, while 352 patients were excluded from the entire cohort of the primary analysis due to lack of insurance, there was significant overlap in our exclusions and many of these patients did not desire postpartum sterilization. Only 75 patients who would have otherwise met inclusion criteria for this analysis (ie, delivered by cesarean delivery and desiring sterilization) were excluded due to insurance status: 48 with Medicare and 27 with no insurance (Morris et al, unpublished data, 2019). However, we agree with the authors that further study in the uninsured population is important as barriers to effective birth control are important to recognize and mitigate, though those barriers may be different than the ones faced by patients with Medicaid.
Footnotes
Financial Disclosure
Kavita Shah Arora disclosed receiving money from American Medical Association, ACOG, and American Society for Bioethics and the Humanities (reimbursement for meeting expenses). The other author did not report any potential conflicts of interest.
Contributor Information
Jane Morris, Department of Obstetrics and Gynecology, University of Cincinnati, Cincinnati, OH.
Kavita Shah Arora, Department of Obstetrics and Gynecology, MetroHealth Medical Center, Cleveland, OH.
REFERENCES
- 1.Morris J, Ascha M, Wilkinson B, Verbus E, Montague M, Mercer BM, et al. Desired sterilization procedure at the time of cesarean delivery according to insurance status. Obstet Gynecol 2019;134:1171–77. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 2.Arora KS, Wilkinson B, Verbus E, et al. Medicaid and fulfillment of desired postpartum sterilization. Contraception. 2018;97(6):559–564. doi: 10.1016/j.contraception.2018.02.012 [DOI] [PMC free article] [PubMed] [Google Scholar]