Why It's So Difficult to Get Your Tubes Tied
Why It's So Difficult to Get Your Tubes Tied
A combination of Medicaid red tape and patriarchal attitudes get in the way
Welcome back Chaise Lounge readers! This week we will take an in-depth look at the barriers that patients face when they request a tubal ligation immediately after giving birth. Between Medicaid rules and doctors who want to “save” them from their own poor decisions, patients are having difficulty obtaining this needed surgery, especially in the wake of the overturning of Roe. Please read carefully and contact your state legislators!
Old attitudes at work in thwarting parents who want to share kid duties
Late last week, another mom from my hometown of Chapel Hill, sent out this tweet. The responses were pure gold in terms of the variety of ways that people thought about the issue. Some said thought that giving out email addresses to a woman would cause “marital friction”. Other dads straight up admitted that they won’t or don’t do the scheduling. The tweet garnered so much attention, that the New York Times wrote a piece about it. Part of the problem is that schools and daycares continue to feed the beast by only calling mothers. And some women also contribute to the problem by excluding the dads from planning. The article suggested creating a shared email address and calendar for schools so that all family planning is in one place. How do you and your spouse handle this?
Hope for the future x2
Addison Gardner, a 12-year-old girl in middle school, addressed the West Virginia legislature on Wednesday morning showing grace and bravery beyond her years. The legislature was taking public comment on an abortion restriction bill being considered in the House. Take a listen and hear the passion in her voice.
Ok, bear with me here because I have to first post something very disgusting, but I promise, something good comes out of it. Early this week, Rep. Matt Gaetz (FL) insulted women who protest for their bodily autonomy. Take a listen.
But the young woman who Gaetz was referring to, 19-year-old Olivia Julianna, was not having it. She used Gaetz’s insulting speech against him and as of this morning has raised over $500K for abortion funds nationwide. You can learn more about Ms. Julianna and her work in this Washington Post feature article. And they are still taking donations!
Why It's So Difficult to Get Your Tubes Tied
As states across the United States enact strict new laws limiting abortion access, people feel powerless to stop legislatures from taking away their bodily autonomy. Feelings of devaluation as a citizen and a frightening lack of control over reproductive health leave those who can become pregnant and their partners with few options. And with some pharmacists making executive decisions not to dispense certain drugs, like contraceptives, people do not know what will happen next. Will all birth control become illegal? A year ago, that question would have been thought to be outrageous, but the Supreme Court and Congress have let us know that at least some of them are thinking about it.
What can people do to recover some of their bodily autonomy? Stories of people hoarding Plan B pills, creating networks for transporting patients across state lines, and networks to mail abortion medication are just some of the ways that people are trying to maintain some sense of autonomy over their reproductive systems.
Doctors are also seeing large increases in people seeking sterilization operations including vasectomies and tubal ligations. Vasectomies are outpatient surgery unrelated to a current pregnancy, so they are easier to schedule and have completed. But for tubal surgeries, many patients want the surgery done immediately after having given birth to avoid another pregnancy. There are a host of issues preventing patients from obtaining the procedure including patriarchal attitudes from doctors worried the patient will change their mind and arcane Medicaid rules around consent forms leaving patients feeling helpless.
Medicaid pays for almost half of all births in the United States, and as a result, the rules governing the dispersal of those funds control the reproductive health of many Americans, in particular, those who are poor. These patients are trapped by Medicaid’s rules. Medicaid requires those requesting tubal surgery immediately after giving birth to sign a consent form at least 30 days and not more than 180 days before delivery. Many times, this simply does not happen and patients are unable to have the surgery when they are already in the hospital.
In fact, a prospective study on publicly insured participants requesting immediate postpartum sterilization found that 56% of requests went unfulfilled, and in over two-thirds of those cases, problems with the Medicaid consent form were cited as the reason.
The consent form was developed back in the 1970s in an effort to prevent the coercion of sterilization, especially among poor and minority populations. While the intentions were good, the medical community has realized that the consent form actually creates a barrier to tubal surgery for this population of patients. Many times, the hospital where the patient is giving birth is far from home. Patients have already made arrangements for the care of their other children and have taken time off of work, so having the opportunity to have the operation at the same time as giving birth is a gift. It can be very difficult for these patients to make a return trip to the hospital for the operation. Additionally, in many states, these patients lose their healthcare coverage soon after giving birth, so returning for the operation means that it may not be covered by Medicaid.
While it is unlikely that Medicaid will rescind the use of the consent form, voters could encourage their legislatures to help. There is already one example of a state that has agreed to pay for tubal ligations if the consent form was not signed in time. In 2020, West Virginia passed a law directing the state’s Department of Health and Human Services to cover the cost of tubal ligations for Medicaid patients when the form was not signed 30 days before birth.
There are ways that the medical community could change practices to help these patients as well. Because many patients receive their prenatal care in community health settings, sometimes the form does not get to the hospital with the patient records because the medical systems do not “talk” to one another. Perhaps the community health settings can work out some method of communication to make sure that the form travels with the patient. Some doctors give their patients a copy of the form and instruct them to take a picture of the form on their phone in the event it gets lost.
According to an article by NPR, one hospital in Dallas, Parkland Hospital recognized the issue and decided to do something about it. They turned over one of the Labor and Delivery operating rooms to just doing tubal ligations. The hospital absorbed the cost of the operation when the consent form had not been signed in time. One would imagine that the specter of having to pay for the operations out of their budget might spur the staff to make sure those forms were signed! As a result of this change in practice, over 90 percent of patients at this hospital who requested tubal ligation received it.
So there are ways that hospitals and legislatures can work around the Medicaid consent form. Additionally, pressure could be put on Medicaid to change the rules around the consent form altogether. For example, why can’t the patient sign the form at any of their prenatal visits? Why does it have to be between 180-30 days before birth? There is no real reason for these arbitrary deadlines, so why not lift them?
The other issue that women come up against when requesting tubal ligations is patriarchal attitudes from doctors. Recent articles in Vice and Insider mention cases where women who requested tubal ligations were refused by their doctors for all sorts of reasons including:
Being “too young”
Requiring husband’s permission
Not having children yet and “you’ll regret it”
Not having had a male child yet
Requiring the patient to undergo a mental health evaluation
Men who request vasectomies very rarely are questioned about their decision and are not required to have mental health evaluations or obtain spousal permission. It would appear that the patriarchy is alive and well in many medical practices in spite of the 2017 guidance from the American College of Obstetricians and Gynecologists (ACOG) reviewing the practice and encouraging doctors to respect the autonomy and decision-making of their patients.
Of course, permanent sterilization is not the answer for everyone as we face the new strict abortion bans nationally. But for those who know that they are finished having children, there should be no artificial barriers to obtaining the surgery. I have already contacted my legislators here in North Carolina to see if we can follow West Virginia’s lead and finance the tubal ligations denied because of the Medicaid consent forms. They were unaware of the issue and are looking into it. You can do the same. We must use every lever of persuasion and power to make sure that people have the choices available to them to allow them life, liberty, and the pursuit of happiness.