Abstract
Background:
Nationally, multiple barriers lead only 50% of women who request postpartum tubal ligation to receive it prior to discharge. We aimed to identify characteristics associated with unfulfilled requests for postpartum tubal ligation at a tertiary medical center in the South.
Methods:
We conducted a retrospective chart review of all women delivering a live infant with a documented desire for postpartum sterilization between September 1, 2018 and November 30, 2018. The primary outcome was receipt of postpartum sterilization prior to discharge. We used chi square and Mann Whitney U- tests for descriptive analyses.
Result(s):
One thousand seventy-two women delivered a live infant at our institution during our sampling frame. One hundred twenty-four had a documented desire for postpartum sterilization (124/1072, 12%). Eighty-one women (81/124, 65%) received their postpartum sterilization and 43 women (43/124, 35%) did not. Women who delivered by cesarean were more likely to receive their postpartum sterilization (63/68; 93%) than if they delivered vaginally (18/56; 32%) (p < 0.001). Lack of valid Medicaid consent (p = 0.006) was associated with unfulfilled requests for postpartum sterilization following vaginal delivery while BMI >40 (p = 0.158) approached significance.
Limitations
Our sample is small and from a single institution. Additionally, the specific reason for tubal ligation non-fulfillment was often not documented.
Conclusion(s):
In this Southern institution, women delivering vaginally, those without a valid Medicaid consent form, and women who were morbidly obese were less likely to receive desired postpartum sterilization. Multipronged process changes are needed to fulfill patients’ sterilization requests.
Keywords: Postpartum, tubal ligation, contraception
Introduction
Surgical sterilization, especially immediately postpartum bilateral tubal ligation (PPBTL), is the most popular method of contraception in the United States [1,2]. Surgical sterilization is significantly more commonly utilized by women of ethnic and racial minorities, women in the South, women in underserved communities, and women with public insurance—the same cohort of women disproportionately affected by unintended pregnancy [2–4]. Half of the 600,000 sterilization procedures occurring in the U.S. annually are performed in the immediate postpartum period, with 8-10% of all hospital deliveries followed by PPBTL. However, only 50% of women who request PPBTL during prenatal contraceptive counseling actually receive it despite its known safety and efficacy [5–8]. More strikingly, up to 50% of women discharged with an unmet sterilization request will become pregnant within one year, which is twice as high as those who had not initially requested PPBTL [6]. Less than 10% of women discharged without their desired PPBTL will have this procedure performed within the following 27 months [9].
Barriers impeding fulfillment of PPBTL requests can be categorized into factors related to the patient themselves, the hospital system, the provider, or the payer. In North Carolina, 54% of all deliveries are covered by Medicaid compared to 43% nationally [10–11]. Being insured by Medicaid is a known barrier to fulfillment of postpartum sterilization due to federal requirements mandating completion of a consent form between 30 and 180 days prior to the procedure [5, 12–13]. While many studies have reported on barriers to fulfillment of PPBTL across the country, none have focused on the Southern U.S, where historic rates of sterilization are of the highest [3,14].
The primary objective of our study was to identify characteristics associated with unfulfilled requests for PPBTL at a tertiary medical center in the South. We hypothesized that having Medicaid insurance and lack of a valid federal consent form would be associated with unfulfilled requests for PPBTL in our cohort. The identification of other potentially modifiable characteristics in our cohort could help our hospital and other Southern health care systems reevaluate their approach to PPBTL. Our second objective was to identify perceived barriers to providing PPBTL identified by labor and delivery personnel.
Methods
We performed a retrospective cohort study at North Carolina Women’s Hospital in Chapel Hill, North Carolina. We also performed a cross-sectional survey of all obstetric providers and clinical support staff on labor and delivery. This study was approved by the University of North Carolina Institutional Review Board (Study# 18-2955, Reference ID 241373).
North Carolina Women’s Hospital is a tertiary referral center serving women throughout the state. In 2019, 4,065 women delivered a live infant at NC Women’s Hospital with the majority of births covered by public insurance (56%)[15]. Thirty percent of women who delivered at NC Women’s Hospital had a cesarean delivery in calendar year 2019. NC Women’s Hospital is a teaching hospital where fellows, residents, and medical students are integral to the clinical care provided. Postpartum tubal ligation procedures at this institution are performed either intraoperatively at the time of cesarean section, or after vaginal delivery via infraumbilical minilaparotomy.
Women delivering a live infant were included in the cohort if their desire to receive PPBTL was documented in the electronic health record upon admission to labor and delivery between September 1, 2018 and November 30, 2018. Confirmation and documentation of planned postpartum contraception method upon admission to labor and delivery is standard practice at NC Women’s Hospital. We abstracted data from the electronic health records for characteristics known to be associated with fulfillment of desired PPBTL requests, as well as sociodemographic characteristics and insurance coverage. For women with unfulfilled requests for PPBTL, we abstracted data for documented contraception plan at time of postpartum discharge as well as fulfillment of interval sterilization between the time of postpartum discharge and the time of data abstraction, which was a maximum of seven months from the index delivery.
The primary outcome was PPBTL status at the time of discharge from the hospital. Descriptive analysis was performed using chi-square and Mann Whitney U-tests where appropriate and can be seen in Table 1. We planned logistic regression model for further characterization of risk factors for non-fulfillment of tubal ligation but did not have an adequate sample size. STATA (Version 14, College Station, Texas) was used for all data analysis.
Table 1:
Characteristics of 124 women at a Southern tertiary care hospital who did or did not receive a requested postpartum bilateral tubal ligation
| Characteristic | Did Receive PPBTL N=81 | Did Not Receive PPBTL N=43 | P Value | |||
|---|---|---|---|---|---|---|
| N | (%) | N | (%) | |||
| Age | ||||||
| ≤ 24 | 1 | (1) | 2 | (5) | ||
| 24-29 | 19 | (23) | 11 | (26) | ||
| 30-34 | 25 | (31) | 16 | (37) | ||
| ≥ 35 | 36 | (44) | 14 | (33) | 0.396 | |
|
| ||||||
| Parity | ||||||
| 1 | 1 | (1) | 1 | (2) | ||
| 2 | 24 | (30) | 8 | (19) | ||
| ≥ 3 | 56 | (69) | 34 | (79) | 0.330 | |
|
| ||||||
| Race/Ethnicity | ||||||
| Non-Hispanic White | 35 | (43) | 11 | (26) | ||
| Hispanic | 25 | (31) | 15 | (35) | ||
| Non-Hispanic Black | 15 | (19) | 13 | (30) | ||
| Other, multiracial | 6 | (7) | 4 | (9) | 0.212 | |
|
| ||||||
| BMI1* | ||||||
| < 30 | 27 | (34) | 7 | (17)* | ||
| 30 - 39 | 39 | (49) | 25 | (60) | ||
| ≥ 40 | 14 | (18) | 10 | (24) | 0.135 | |
|
| ||||||
| Mode of Delivery | ||||||
| Vaginal | 18 | (22) | 38 | (88) | ||
| Cesarean | 63 | (78) | 5 | (12) | 0.000 | |
|
| ||||||
| Primary Insurance | ||||||
| Medicaid | 39 | (48) | 26 | (60) | ||
| Emergency Medicaid | 4 | (5) | 1 | (2) | ||
| Medicare | 6 | (7) | 3 | (7) | ||
| Private | 32 | (40) | 13 | (30) | 0.652 | |
Hypothesis testing with chi-square and Mann Whitney U-tests
Due to rounding, does not equal 100
BMI not calculated for 2 subjects who did not have height documented.
To better inform our understanding of practice at our institution, we conducted a survey of all obstetric providers (attendings, residents, fellows, certified nurse midwives) and clinical support staff who work on labor and delivery. The objective of this survey was to identify perceived barriers to PPBTL fulfillment by labor and delivery staff. The survey consisted of two multiple-choice questions. The first question asked respondents to choose factors they thought were the greatest barriers to fulfillment of PPBTL at our institution. If they selected either “patient obesity” or “patient declining”, a follow-up question sought further detail. (Box 1) The final question asked the respondent to describe their primary role on labor and delivery for context.
Box 1. Survey administered to staff working on the labor and delivery unit at North Carolina Women’s Hospital.
Question 1: In your experience, what are the two biggest reasons postpartum tubal ligations after vaginal delivery may not be completed on labor and delivery prior to patient discharge? (Select TWO choices from below)
Answer choices [in drop down radio button format]:
Lack of sufficient RN staffing
Lack of sufficient Scrub staffing
Lack of sufficient MD staffing
No OR availability
Anesthesia unavailable
- Patient declining
- Secondary Question: please select the option below that best describes the patient’s reasoning or your perception of their reasoning for declining [select one]:
- Too long NPO and hungry,
- No longer desires permanent contraception
- Fear of anesthesia
- Desire for hospital discharge
- Other [write in free text]
- Patient obesity
- Secondary Question: what do you perceive to be the biggest concern related to obesity as it pertains to postpartum tubal ligation.
- Technical difficulty of procedures [select one]:
- Fear of Complications
- Both
- Other [write in free text]
Clinical volume on labor and delivery
Lack of mature Medicaid consent
Attending unable/unwilling to perform BTL
Other [write in free text]
Question 2:
What is your role on labor and delivery?
Answer choices [in drop down radio button format]:
Obstetrics & Gynecology resident
Obstetrics & Gynecology fellow
Obstetrics & Gynecology attending
Certified Nurse Midwife
Registered Nurse
Operating room staff
Obstetrics Anesthesia attending
Obstetrics Anesthesia fellow
Prefer not to say
Other
Results
One thousand seventy-two women delivered at NC Women’s Hospital between September 1, 2018 and November 30, 2018. Of these, one hundred twenty-four women had a documented desire for PPBTL and thus were included in our cohort (124/1072; 12%). Forty-three women (43/124, 35%) did not receive their PPBTL prior to discharge [Figure 1].
Figure 1:
Screening and Recruitment Process
Characteristics of the women who did not receive their PPBTL were similar to those who did (Table 1). Age, race, ethnicity, gravidity, and parity were similar in both groups. Most women in both groups had Medicaid or Presumptive Medicaid. Those who delivered by cesarean were much more likely to receive their postpartum tubal ligation (63/68; 93%) than those who delivered vaginally (18/56; 32%) (p < 0.001). Age, parity, race/ethnicity, primary insurance provider, nor BMI were statistically different among these groups.
We performed a sub-group analysis of the 70 women with Medicaid or Emergency Medicaid (Table 2). In this sub-group, cesarean delivery remained highly associated with PPBTL fulfillment. Having a valid federal consent form on file was also associated with fulfillment of PPBTL. Eighty-six percent of women with Medicaid who received their sterilization had a valid Medicaid consent on file compared to only 52% of women with unfulfilled requests (p = 0.006).
Table 2:
Risk factors associated with unfulfilled requests for postpartum sterilization among the 70 women who had Medicaid or Emergency Medicaid
| Characteristic | Did Receive PPBTL N=43 | Did Not Receive PPBTL N=27 | P Value | ||||
|---|---|---|---|---|---|---|---|
| N | (%) | N | (%) | ||||
| BMI1* | |||||||
| < 30 | 15 | (35) | 3 | (11) | |||
| 30 - 39 | 21 | (49) | 17 | (63) | |||
| ≥ 40 | 7 | (16) | 7 | (26) | 0.079 | ||
|
| |||||||
| Mode of Delivery | |||||||
| Vaginal | 10 | (23) | 25 | (93) | |||
| Cesarean | 33 | (77) | 2 | (7) | 0.000 | ||
|
| |||||||
| Type of Medicaid | |||||||
| Medicaid | 39 | (91) | 26 | (96) | |||
| Emergency Medicaid | 4 | (9) | 1 | (4) | 0.642 | ||
|
| |||||||
| Consent Status | |||||||
| Valid Consent on File | 37 | (86) | 14 | (52) | |||
| Invalid Consent on File | 2 | (5) | 5 | (19) | |||
| No Consent on File | 4 | (9) | 8 | (29) | 0.006 | ||
Data presented as N (%). Mann Whitney U-tests were used to detect differences between categorical variables
In our cohort, 56 women had a vaginal delivery (56/124). Only 18 of the 56 women (32%) received their desired PPBTL following a vaginal delivery. None of the measured sociodemographic or personal characteristics predicted successful fulfillment of desired tubal ligation among those delivering vaginally after a subgroup analysis. We did not observe a statistically significant association between BMI and tubal ligation completion after vaginal delivery. However, there was a non-significant trend toward lower probability of completion among women with BMI >30 (11/41; 27%) and BMI > 40 (1/9; 11%) as compared to BMI <30 (7/14; 50%) (p= 0.158).
Only 19 of the 43 women with unmet requests had a documented reason for tubal ligation unfulfillment in the medical record with the remaining 24 having no documented explanation. Two of the 19 women had tubal ligations attempted that were unsuccessful. Three had documentation listing patient obesity as the reason the PPBTL was not performed following vaginal delivery. Nine of the 19 had documentation reporting that they elected either to pursue an interval tubal ligation or to use an alternative form of contraception. Two had confirmation that a problem with the Medicaid consent was the reason for unfulfillment and the remaining three sited other reasons: lack of insurance, surgical history, and unclear fetal prognosis as reasons PPBTL was unfulfilled.
We wanted to learn more about subsequent contraception use by the 43 women in our cohort who did not receive their desired PPBTL. At the time of discharge, 23 of the 43 women (53%) did not have an alternative contraceptive plan documented. Twenty of the 43 women (47%) did have an alternative contraceptive plan documented in their chart. Data abstraction from the electronic health records for this project occurred between three and seven months following hospital discharge from the index delivery. Only eight women had received their desired tubal ligation by seven months postpartum.
Survey results from staff on labor and delivery demonstrated that staff perceptions of reasons for unfulfilled PPBTL differed from documentation in the electronic health record [figure 2]. Overall, 114 of 184 eligible persons completed the survey (114/184; 62%). The respondents self-identified as OB/GYN attendings (17/98; 17%), OB/GYN fellows (8/98; 8%), OB/GYN residents (19/98; 19%), certified nurse midwives (5/98; 5%), registered nurses (35/98; 36%), OB Anesthesia sub-specialists (11/98; 11%), operating room staff (1/98; 1%), and other staff (2/98; 2%). The most commonly reported barriers to fulfillment of desired postpartum sterilization by our L&D staff were “clinical volume on labor and delivery (L&D) too high” (70/98; 71%) and “lack of sufficient nurse staffing” (49/98; 63%). Patient factors including obesity, patient declining, and lack of Medicaid consent were less commonly selected.
Figure 2:
Response to Labor and Delivery personnel survey on perceived barriers to fulfillment of postpartum bilateral tubal ligation.
Discussion
In our cohort in North Carolina, we found that one third (35%) of women were discharged with unmet sterilization requests. Further, 68% of women delivering vaginally were discharged with unmet requests for PPBTL which is higher than previously described [5, 16–17].
In both our survey and cohort, we found that extrinsic factors as opposed to strictly patient factors may present the biggest barriers to fulfillment of PPBTL requests at our institution. This is in contrast to the existing literature regarding barriers to PPBTL which focus primarily on patient factors. [7–9, 16–17] The lack of documentation as to why PPBTL was not performed specifically for the majority of women in our cohort limits our ability to develop actionable interventions.
While originally drafted with the goal of protecting women’s reproductive autonomy, the federally mandated Medicaid Consent has repeatedly been identified as a barrier to fulfillment of postpartum sterilization requests [16,18]. This is particularly important in North Carolina where both the percentage of publicly funded deliveries as well as the desire for postpartum sterilization are of the highest in the country [3, 10–11, 14–15]. Among women with Medicaid in our cohort, the absence of a valid federal consent form was again associated with unfulfilled requests for PPBTL. For women with Medicaid who do not have a valid Medicaid consent on file, it may be that they are more likely to have their PPBTL fulfilled at the time of Cesarean than they are following a vaginal delivery given the need in this group for scheduling of a separate operative procedure that will not be covered by insurance as opposed to adding to an already ongoing covered procedure.
Prior research suggests risk factors for failure to complete PPBTL may be distinct for vaginal and cesarean delivery. Studies of completion of PPBTL after vaginal delivery have identified obesity, OR time, and gravidity as barriers in this population [16,19]. Our sample size was insufficient to limit our analysis to women with one delivery type. However, we did perform exploratory subgroup analyses among women with each delivery type and noted non-significant trends toward differing predominant barriers depending on the mode of delivery.
The non-significant trend toward lower completion rate with BMI >40 warrants further examination in a larger study. There is recent data demonstrating that PPBTL following a vaginal delivery is safe among women with BMI above 30 kg/m2, is not associated with more postoperative complications, and does not require significantly more operative time [5,19–20]. Further investigation of outcomes of PPBTL among obese women may help us better understand how we can best meet the reproductive needs of this population. Although not identified as an impediment by staff when surveyed, at least three women have “obesity” documented as the reason desired PPBTL was unfulfilled following vaginal delivery. Further training in surgical techniques to provide this service to obese postpartum women might help uphold reproductive autonomy for this population.
Additionally, we noted that we have inadequate systems to help patients who have expressed that they do not desire future pregnancies when a requested PPBTL does not occur. Given that non-fulfillment is a frequent occurrence in our setting and is associated with a high risk of pregnancy in the next year, we need to facilitate access to alternative contraception for these patients while systems factors are being addressed to increase fulfillment rates.
We identified system- and provider-level barriers that impede patients’ reproductive autonomy. In contrast to prior data, patient-level factors were less important in our setting. Our responsibility to support our patients’ “human right to maintain personal bodily autonomy, have children, not have children, and parent the children [they] have in safe and sustainable communities,” requires that we improve our healthcare delivery systems to ensure access to postpartum tubal ligation for those who request it [21–22].
Table 3:
Characteristics associated with fulfillment of postpartum sterilization among women who had vaginal delivery (N=56) and women who had cesarean delivery (N=68)
| Vaginal Delivery | Cesarean Delivery | ||||||||
|---|---|---|---|---|---|---|---|---|---|
|
| |||||||||
| Characteristic | Did Receive PPBTL N=18 | Did Not Receive PPBTL N=38 | Did Receive PPBTL N=63 | Did Not Receive PPBTL N=5 | |||||
| N | (%) | N | (%) | N | (%) | N | (%) | ||
| Age | |||||||||
| ≤ 24 | 0 | (0) | 2 | (5) | 1 | (0) | 0 | (0) | |
| 24-29 | 7 | (39) | 9 | (24) | 12 | (40) | 2 | (40) | |
| 30-34 | 7 | (39) | 15 | (39) | 18 | (20) | 1 | (20) | |
| ≥ 35 | 4 | (22) | 12 | (32) | 32 | (40) | 2 | (40) | |
|
| |||||||||
| Parity | |||||||||
| 1 | 0 | (0) | 0 | (0) | 1 | (2) | 1 | (20) | |
| 2 | 3 | (17) | 8 | (21) | 21 | (33) | 0 | (0) | |
| ≥ 3 | 15 | (83) | 30 | (79) | 41 | (65) | 4 | (80) | |
|
| |||||||||
| Race/Ethnicity | |||||||||
| Non-Hispanic White | 7 | (39) | 10 | (26) | 28 | (44) | 1 | (20) | |
| Hispanic | 7 | (39) | 13 | (34) | 18 | (29) | 2 | (40) | |
| Non-Hispanic Black | 4 | (22) | 11 | (29) | 11 | (17) | 2 | (40) | |
| Other, multiracial | 0 | (0) | 4 | (11) | 6 | (10) | 0 | (0) | |
|
| |||||||||
| BMI1* | |||||||||
| < 30 | 7 | (39) | 7 | (18) | 20 | (32) | 0 | (0) | |
| 30 - 39 | 10 | (56) | 22 | (58) | 29 | (46) | 3 | (60) | |
| ≥ 40 | 1 | (6) | 8 | (21) | 13 | (21) | 2 | (40) | |
|
| |||||||||
| Primary Insurance | |||||||||
| Medicaid | 10 | (56) | 24 | (63) | 29 | (46) | 2 | (40) | |
| Presumptive Medicaid* | 0 | (0) | 3 | (8) | 4 | (6) | 0 | (0) | |
| Medicare | 2 | (11) | 1 | (3) | 4 | (6) | 0 | (0) | |
| Private | 6 | (33) | 10 | (26) | 26 | (41) | 3 | (60) | |
Due to rounding, does not equal 100.
BMI not calculated for 2 subjects who did not have height documented.
Presumptive Medicaid = Emergency/Pregnancy Medicaid
Acknowledgements
Dr. Swartz receives funding from the NIH (K12HD103083-01).
Carly Rowe MSW & Zoe N. Diener MSPH contributed to this research.
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