Every Saturday The CSPH highlights news or recent research in the field of human sexuality. This week we’re discussing a study from the latest issue of the journal Contraception, analyzing the differences—particularly type of insurance and number of previous births—between women who receive sterilizations versus intrauterine devices (IUDs) after pregnancy.
Of all the numerous contraceptive methods available for females, the two that are considered the most effective, after total sexual abstinence, are sterilization surgery and the insertion of an IUD. Besides their effectiveness however, they are entirely different: while an IUD is a reversible, removable method, sterilization is permanent. They are also marked by wildly different usage rates and disparities in usage across racial, class, and educational lines. Thus, understanding the factors that affect who uses each method is important for understanding the dynamics of choice in reproductive healthcare. For this reason, Drs. Baldwin, Rodriguez, and Edelman, researchers from Oregon Health and Science University’s (OHSU) Department of Obstetrics and Gynecology, embarked upon a retrospective cohort study that examined hospital records of births, type of insurance, and sterilization/IUD insertion procedures to understand the demographic differences in contraceptive usage.
Of the 835 females who had undergone IUD insertion or a sterilization at OHSU during the study period, 475 were ultimately retained for analysis—those whose records were incomplete, who had not undergone the procedure following a pregnancy, or who had Emergency Medicaid, as it does not cover either procedure were not included in the final study. Ultimately, those enrolled comprised of 223 IUD and 253 sterilization recipients. All were American citizens or legal immigrants (because of the restrictions on who is eligible for insurance in Oregon) and had either public (state or federal Medicare or Medicaid) or private insurance at the time of their procedure. Due to Oregon law, all women regardless of insurance status prior to pregnancy are covered under Medicaid for up to a year after giving birth, so all participants had equivalent financial access to their contraceptive procedures.
There were two significant areas of differences between those who received IUDs versus sterilization. Women with public insurance were significantly more likely to choose sterilization than an IUD (77% versus 23%, respectively). However, when parity (the number of children previously borne) was considered alongside insurance, it was found that participants, regardless of insurance status, were more likely to receive IUDs if they had only one or fewer prior births and were more likely to be sterilized if they had three or more. For women with two prior birth experiences, insurance was significant: 79% of publicly insured women opted for sterilization as opposed to 33% of those with private insurance.
In the United States, insurance status tends to serve as a proxy for class status and, all too often, racial/ethnic and citizenship status. As the researchers noted in this discussion, those disadvantaged in these realms are significantly more likely to undergo sterilization than women with private insurance. This may be due to a number of reasons, particularly education. Although current IUDs are incredibly safe and effective, there was a time in our country’s history where they had a poorer reputation for safety and ethics. Those without access to current education and medical information possibly have not received or internalized knowledge of the more recent products. The researchers also noted access barriers such as a lack of childcare or transportation, as well as cultural norms that perpetuate sterilization in certain communities where it has long been employed.
Unfortunately, due to the limitations inherent in this study—an inability to include undocumented immigrants in analysis; to significantly represent women who had experienced miscarriage or abortion; and incomplete records that did not allow for a racial/ethnic analysis—it raises more questions than it answers. A study that only looks at hospital and insurance records without surveying the physicians or patients affected can never understand the full breadth of factors affecting contraceptive decisions; it only invites speculation. Simultaneously, however, this study still addresses a topic too important and complex to be ignored: quality and equality in health care. In the wake of the Supreme Court’s upholding of the Affordable Care Act, which includes numerous provisions for ensuring quality in health care, studies such as this one that consider not just if women are receiving care, but how this care is delivered and received take on greater importance.
The United States does not have a spotless history with respect to reproductive health interventions. Our country has a dark past of sterilization where eugenics and coercion—of withholding accurate or complete information about sexual and reproductive health—against the most disadvantaged members of our populations are commonplace. This study reflects that legacy.
There is nothing wrong with women receiving sterilizations if they comprehensively understand their options, and if they are acting under their own agency to make the full choice about a non-reversible contraceptive method: women who have had all the children they wanted, who are concerned about the health or social risks of continued pregnancy, or for innumerable other reasons may know sterilization to be the best choice for them. Yet too often, women are merely not aware of their options or the alternatives, and for that reason, reproductive health care is a social justice issue. More research such as this that qualitatively seeks to understand who is making which choices and what factors lead to their health seeking decisions is vital for making the field of sexual health fairer for all.