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KL2: The Ethics of Reproductive Justice – Enhancing Autonomy, Improving Access, and Reducing Disparities for Long-Acting Reversible Contraception and Sterilization

This project was completed in 2019.

Abstract

A healthcare system in which 37-51% of women who desire postpartum sterilization are unable to obtain one due to a lack of a valid signed Medicaid consent form and one in which LARC is difficult to access is not delivering patient-centered, medically-appropriate, nor ethically-sound care. Prior studies have focused on the health literacy level of the current form as well as the clinical, socioeconomic, and emotional ramifications of unfulfilled sterilization requests. Women with unfulfilled sterilization requests have a higher resultant number of children; suffer a negative impact on nutrition, healthcare, education, housing, among others; and report feeling anxious and angry in regards to preventing subsequent pregnancy compared to those women with fulfilled sterilization requests. Secondly, the financial, cultural, familial, and personal barriers towards LARC acceptance are in the early phases of research. Thus, both extrinsic (logistical, clinical, and financial) and intrinsic barriers (cultural, familial, and personal) impact access and utilization of sterilization and LARC, though the precise identification of barriers and the impact of each is unknown.

This is a mixed methods study employing both rigorous qualitative and quantitative methodology to assess the experience of impacted women and the health outcomes resultant from this disparity. Completion of the KL2 program and MSCR degree are essential for me to learn the skills necessary to conduct such mentored research. This study allows for data exploration in regards to sterilization and LARC access as the data currently are incomplete or limited.

Specific Aims

We hypothesize that better understanding the extrinsic and intrinsic barriers that result in diminished access to sterilization and LARC will allow us to inform an evidence-based health policy that enhances reproductive autonomy.

 We will test our central hypothesis via three specific aims:

  1. To qualitatively identify extrinsic and intrinsic barriers to fulfilling postpartum sterilization requests and LARC utilization. We will conduct semi-structured formal in-depth interviews of Medicaid patients at MetroHealth Medical Center (MHMC) with both fulfilled and unfulfilled sterilization and LARC requests postpartum. The aspects of the current system that both enhance and detract from autonomy from a patient perspective will be analyzed qualitatively.
  2. To quantitatively assess local rates of sterilization, LARC fulfillment, and associated health outcomes. We will conduct a retrospective chart review of a large inception cohort via the electronic health record (EHR) of MHMC to quantify local rates of sterilization and LARC fulfillment and resultant unintended pregnancy rates.
  3. To pilot local, systems-based, multidisciplinary policy revisions to decrease identified barriers to sterilization and LARC fulfillment. We will translate data from Aims 1 and 2 to propose and implement hospital policy revisions that improve access and enhance autonomy by decreasing identified barriers to fulfillment.

This project was funded by the Clinical and Translational Science Collaborative of Cleveland, KL2TR0002547 from the National Center for Advancing Translational Sciences (NCATS) component of the National Institutes of Health and NIH roadmap for Medical Research.