Medicaid compared to private insurance is associated with lower rates of sterilization in people with unwanted births

Background: Medicaid, unlike any other insurance mechanism, imposes a consent requirement on female patients desiring sterilization that must be completed at least 30 days, but no more than 180 days, before sterilization. Desired sterilization cannot be completed in the Medicaid population without this consent. Large-scale national evidence is lacking on the effect of this requirement.

Objective: This study aimed to explore the influence of insurance status on the achievement of postpartum sterilization after a self-reported unwanted birth in a nationally representative sample.

Study design: This was a retrospective cohort analysis using data from the 2013-2015 National Survey of Family Growth. The National Survey of Family Growth uses a stratified, multistage clustered sample to make nationally representative estimates for men and women aged 15 to 44 years in the household population of the United States. The analysis was limited to a cohort of birthing people who reported their last birth as unwanted and who were insured by either Medicaid or private insurance. The survey was analyzed with the application of inverse probability of treatment weights to balance those with Medicaid and those with private insurance in addition to the survey weight. The association between completion of postpartum sterilization and insurance type was evaluated using weighted logistic regression, adjusting for demographic and clinical characteristics.

Results: In an adjusted and inverse probability of treatment weight balanced analysis of a weighted national sample representing 4,164,304 people (416 respondents), Medicaid-insured birthing people with history of unwanted births were found to have 56% lower odds of obtaining postpartum sterilization (odds ratio, 0.44; 95% confidence interval, 0.22-0.87; P=.019) than those with private insurance.

Conclusion: This study adds to mounting evidence that insurance type plays a significant role in the achievement of desired postpartum sterilization, with individuals with Medicaid less likely to undergo the procedure. The findings call for policy reforms around sterilization policy in the United States, emphasizing the need for uniform consent procedures that do not discriminate based on insurance status.