Medicaid policy on sterilization--anachronistic or still relevant?

F sterilization, typically accomplished by means of tubal ligation, is a widely used method of contraception that is highly effective at preventing unintended pregnancy. Yet there appears to be unmet demand for the procedure in certain segments of the U.S. population.1 Specifically, low-income women and women from minority racial and ethnic groups may face substantial system-level barriers to obtaining a desired sterilization procedure.1 One such barrier is the federal policy regarding Medicaidfunded sterilizations. Although this policy was designed to protect vulnerable populations, we believe that it does not effectively fulfill that intention — in fact, it restricts the reproductive autonomy of the women it intends to serve. With the upcoming Medicaid expansions, the number of women affected by these barriers could increase substantially. The use of tubal ligation as a contraceptive method increased dramatically during the 1960s and 1970s with the legalization of contraception, improved safety of laparoscopic techniques, and the creation of federally funded family-planning programs that subsidized the costs. During those years, numerous reports of coercive and nonconsensual sterilization of minority and poor women emerged, inciting a public outcry in which the government was accused of racist and classist applications of family-planning programs. In response, in 1976, the Department of Health, Education, and Welfare developed protective regulations and a standardized consent form for publicly funded sterilization procedures. These regulations pro hibited sterilization of persons younger than 21 years of age or who were mentally incompetent or institutionalized. They also required a 72-hour waiting period before sterilization; in 1978, the waiting period was extended to 30 days from the time of written informed consent. Although these regulations apply to both women and men, female sterilization is significantly more common than male sterilization in low-income populations, and women often desire sterilization at a specific time — after childbirth — which makes the extended waiting period particularly problematic. Because these policies have not changed since 1978, women requesting publicly funded sterilization must complete the “Consent to Sterilization” section of the Medicaid Title XIX form (Title XIX-SCF) at least 30 days and no more than 180 days before undergoing the procedure. In addition, a signed copy of the consent form must be available or verified at the time of the procedure. If the woman is undergoing emergency abdominal surgery or a premature delivery, the 30-day waiting period may be waived, but at least 72 hours must have elapsed between the consent and the procedure. Although the policy was presumably well intentioned, there is evidence that the Medicaid consent process may not be capable of protecting vulnerable women by ensuring that truly informed consent is obtained. Although the consent form contains language designed to confirm the woman’s understanding of the risks and benefits of the procedure, including the fact that the result is permanent, as well as information about the mandatory 30day waiting period, assessments of the form’s readability indicate that it is overly complicated and its literacy level is too high for the average American adult.2 In one study assessing women’s knowledge about sterilization after they had been given the Medicaid consent form for review, more than one third of respondents (34%) answered incorrectly when asked about the permanence of sterilization.3 When a modified, low-literacy version of Title XIXSCF was compared with the current form in a randomized trial involving 200 women with Medicaid coverage, those who reviewed the modified form were more likely to know about the 30-day waiting period before the form is considered valid (a 24-percentagepoint difference between groups), that nonpermanent contraceptive options as effective as sterilization are available (an 8-percentage-point difference), and that the procedure is permanent (a 16-percentagepoint difference).3 Beyond concerns about the consent form, the waiting period and the need for the completed form to be transferred to the delivery unit pose logistic barriers for women who wish to undergo tubal ligation immediately after giving birth. Currently, among U.S. women sterilized within 2 years after delivery, more than 70% of procedures are done in the immediate postpartum period. Women report that requesting sterilization too late in pregnancy to fulfill