R01: Multi-Level Factors Affecting Postpartum Sterilization

This is an ongoing project with funding until 2024.

Abstract

Female sterilization, the second most commonly used contraceptive method in the United States, is commonly performed during the postpartum period. However, women with Medicaid insurance are half as likely to obtain a desired postpartum sterilization as those with private insurance. Compounding this disparity, women of color with Medicaid insurance are less likely to achieve sterilization fulfillment compared to white women with Medicaid insurance. Sterilization non-fulfillment puts women at high risk of subsequent unintended pregnancy with a short interpregnancy interval and the associated risks to maternal and infant health. There are significant policy barriers to equitable postpartum sterilization that impact those with Medicaid but not private insurance. However, the federal Medicaid policy (including specific consent form and subsequent thirty-day waiting period) was established in 1976 due to coerced sterilizations on women of color and low socioeconomic status. Therefore, sensitive consideration of the complex social and cultural backdrop is required to balance protection of a vulnerable population with the unintended consequence of disparities in sterilization fulfillment. Furthermore, barriers at the patient, provider, and hospital level have also been noted, though it is unclear the extent to which these barriers interact. Advocating for the complete removal of the Medicaid sterilization process, then, ignores both the complex history as well as the additional, non-policy barriers to equitable postpartum sterilization. The overall objective for this proposal is to determine the discrete barriers at various levels of analysis (patient, provider, hospital, and policy).

Specific Aims

Our central hypothesis is that the layering of barriers individually and collectively contributes to disparities in postpartum sterilization fulfillment for the Medicaid population.

 We will test our central hypothesis via three specific aims:

1. Model the association between Medicaid insurance and sterilization fulfillment after adjusting for clinical and demographic differences in a pooled multi-institution sample (patient- and policy-level barriers aim). We will employ random effects multivariable regression to validate our single-institution findings on a multi-state level at four high-volume obstetric institutions serving diverse patient populations. We hypothesize that clinical and demographic differences between those patients who utilize Medicaid versus private insurance will account for the disparity in sterilization fulfillment rates. 
2. Identify the attitudes, beliefs, and practices of postpartum women and their obstetricians regarding postpartum sterilization (patient-, physician-, hospital-, and policy-level barriers aim). We will analyze qualitative data from semi-structured interviews of women whose postpartum sterilization requests were fulfilled (10) and unfulfilled (15) and their delivering obstetrician at each site (total 200 interviews). By exploring the experiences of women, practice patterns of their physician, impact of hospital and state policies, and specific reasons for either fulfillment or non-fulfillment of sterilization, we will inform modeling and interpretation of empirical findings, guiding analyses of barriers in a patient-centered context. 
3. Assess the impact of hospital and state policy barriers on postpartum sterilization (hospital- and policy-level barriers aim). We will employ fixed effects regression of the database from Aim #1 to analyze the association of institutional and state policies (delineated in Aim #2) and hospital-level differences in sterilization preference and access. We hypothesize that institutions with more permissive hospital/state sterilization policies will have fewer disparities in the achievement of postpartum sterilization. 

This project is funded through the National Institute of Health’s NICHD R01 HD098127