Medicaid and fulfillment of desired postpartum sterilization

Abstract

Objective: We sought to assess fulfillment of sterilization requests while accounting for the complex interplay between insurance, clinical and social factors in a contemporary context that included both inpatient and outpatient postpartum sterilization procedures.

Study design: This is a retrospective single-center cohort chart review study of 1331 women with a documented contraceptive plan at time of postpartum discharge of sterilization. We compared sterilization fulfillment within 90days of delivery, time to sterilization and rate of subsequent pregnancy after nonfulfillment between women with Medicaid and women with private insurance.

Results: A total of 475 of 1030 Medicaid-insured and 100 of 154 privately insured women received postpartum sterilization (46.1% vs. 64.9%, p<.001). Women with Medicaid had a longer time from delivery to completion of the sterilization request (p<.001). After adjusting for age, parity, gestational age, mode of delivery, adequacy of prenatal care, race/ethnicity, marital status and education level, private insurance status was not associated with either sterilization fulfillment [odds ratio 0.94, 95% confidence interval (CI) 0.54-1.64] or time to sterilization (hazard ratio 1.03, 95% C.I. 0.73-1.34). Of the 555 Medicaid-insured women who did not receive a postpartum sterilization, 267 (48.1%) had valid Title XIX sterilization consent forms at time of delivery. Of women who did not receive sterilization, 132 of 555 Medicaid patients and 5 of 54 privately insured patients became pregnant within 1 year (23.8% vs. 9.3%, p=.023).

Conclusion: Differences in fulfillment rates of postpartum sterilization and time to sterilization between women with Medicaid versus private insurance are similar after adjusting for relevant clinical and demographic factors. Women with Medicaid are more likely than women with private insurance to have a short interval repeat pregnancy after an unfulfilled sterilization request.

Implications: Efforts are needed to ensure that Medicaid recipients who desire sterilization receive timely services.

Keywords: Disparity; Medicaid; Postpartum contraception; Sterilization; Unintended pregnancy.

Figure 1

Kaplan-Meier survival analysis curves for time to sterilization fulfillment for Medicaid vs. privately insured postpartum women. The dashed line represents patients with Medicaid whereas the solid line represents women with private insurance.

Figure 2

Stacked column chart of proportion of patients with documented plan for sterilization who achieve sterilization within ninety days of delivery, do not achieve sterilization but do not have a subsequent pregnancy within 365 days of delivery, and women who have a subsequent pregnancy.