Permanent Contraception Research Articles

A six- year review of uptake of bilateral tubal ligation (BTL) at a tertiary health institution in Calabar, Calabar, Nigeria

Background: Bilateral tubal ligation is one of the most effective and permanent contraceptive methods. Being a permanent method of contraception, it is not readily accepted especially with the myths surrounding it’s use. The objective of this study is to document its incidence, sociodemographic characteristics, techniques, effectiveness and associated complications in the University of Calabar Teaching Hospital (UCTH), a tertiary health institution in Calabar Nigeria. Method: This is a retrospective analysis of 141 clients, who had bilateral tubal ligation at UCTH over a six-year period between January 1st 2016 and December 31st, 2021. Results: There were 141 bilateral tubal ligations done during the study period. 130 (92.2%) were done during Caesarean section, 7(5.0%) were done during repair of uterine rupture, 3(2.1%) had immediate postpartum BTL and 1(0.7%) had interval BTL. There were 4,549 Caesarean sections and 13,056 total deliveries during the period under review. Therefore, BTL was associated with 1.08% of the total deliveries. The mean age and parity of the clients were 35.9 years and 4.35 respectively. The commonest indication for BTL was previous caesarean section in 92(65.2%). Only one complication specific to tubal ligation was recorded during the study period.

Benefits and Risks of Bilateral Salpingectomy Compared With Standard Tubal Ligation During Cesarean Delivery for Permanent Postpartum Contraception.

Ovarian cancer is the second most common gynecologic malignancy, but the most deadly female reproductive cancer in the United States. Epithelial ovarian cancer makes up approximately 90% of all cases and is responsible for more than 90% of ovarian cancer deaths. Elective salpingectomy has been shown to reduce ovarian cancer risk when performed at the time of a benign hysterectomy. Data regarding the risks and benefits of opportunistic bilateral salpingectomy performed at the time of cesarean delivery are limited. We aim to review the current evidence regarding safety and benefits of opportunistic bilateral salpingectomy at the time of cesarean delivery compared with bilateral tubal ligation. Original research articles, review articles, and guidelines on contraception were reviewed. Opportunistic bilateral salpingectomy at the time of cesarean delivery is feasible and safe. Operative time may be increased up to 15 minutes for salpingectomy performed by suture ligation compared with standard tubal ligation. Women with a history of 3 or more cesarean deliveries are more likely to require an alternative procedure. It is important to counsel women that although opportunistic bilateral salpingectomy may significantly decrease the risk of ovarian cancer, it does not eliminate the risk entirely.

Impact of Group Prenatal Care on Contraceptive Use at Twelve Weeks Postpartum.

To compare the prevalence of highly effective contraceptive use by 12weeks postpartum among participants of Centering Pregnancy®, a model of group prenatal care (GPC), and traditional prenatal care (TPC), and to investigate differences in contraceptive method choice by type of prenatal care. We performed a retrospective review of all eligible patients who participated in GPC (n = 143) and a random sample of patients participating in TPC (n = 290) who followed up at our institution within 12weeks of delivery. Our primary outcome was the proportion of participants using a highly effective contraceptive method within 12weeks postpartum. Contraceptives were classified in tiers (Tier 1, long-acting reversible and permanent contraception; Tier 2, oral contraceptive pills, transdermal patch, vaginal ring, or injection; Tier 3, barrier and fertility awareness methods, withdrawal, spermicide; and no method). Tier 1 and Tier 2 methods were considered highly effective. The prevalence of highly effective contraceptive use by 12weeks postpartum was 63.6% (91 of 143) and 63.1% (183 of 290) among participants in GPC and TPC, respectively (p = 0.99). We found no difference in Tier 1 versus other method use (adjusted odds ratio (aOR) 1.05, 95% CI 0.95-1.15, p = 0.34) or Tier 2 versus other method use between groups (aOR 0.98, 95% CI 0.89-1.08, p = 0.69), in a multivariable model controlling for demographic and clinical factors. The prevalence of highly effective contraceptive use at 12weeks postpartum was not different between GPC and TPC participants in this study. GPC was not associated with increased use of Tier 1 or Tier 2 contraceptive methods.

Factors associated with the uptake of long-acting reversible contraception among female sex workers in post-conflict Northern Uganda: a cross-sectional study

BackgroundLong-acting reversible contraception (LARC) is the most effective and reliable contraception option for female sex workers (FSWs) who desire future fertility. Unlike the other reversible contraceptive methods, LARC use requires only periodic users’ involvement at the time of application and re-application. However, only a few studies on LARC uptake among FSWs are available in Uganda. To fill this knowledge gap, we examined factors associated with the uptake of LARC among FSWs in post-conflict Northern Uganda.MethodsWe conducted a cross-sectional study among adult FSWs operating in the post-conflict Gulu district in Northern Uganda. We collected quantitative data among 280 FSWs of reproductive ages (18–49 years) who were neither pregnant nor using permanent contraception. We utilized a pretested semi-structured questionnaire to gather information from each participant through face-to-face interviews. We collected data on socio-demographic characteristics, sex work-related characteristics, obstetric history, HIV status, and LARC uptake. Data were then entered into EPI INFO 7, cleaned, and analyzed using multivariable Poisson regression in STATA 14.0 to obtained adjusted prevalence ratios (PR).ResultsAmong the study participants: the mean age (SD, range) was 26.5 (5.9, 18–45) years, 48.6% reported at least one unintended pregnancy during sex work, and 37.4% had at least one induced abortion. Meanwhile, only less than two in three (58.6%) participants were using LARC. At multivariable level, factors that remained independently associated with LARC uptake included: longer duration of sex work (adjusted PR = 1.44, 95% CI: 1.03–2.02), higher parity (adjusted PR = 1.13, 95% CI: 1.02–1.26), history of unintended pregnancies during sex work (adjusted PR = 1.24 CI: 1.01–1.51), and being a brothel/lodge-based FSWs (adjusted PR = 1.28, 95% CI: 1.01–1.63).ConclusionsThe above findings revealed a gap in the uptake of LARC among FSWs in post-conflict Northern Uganda influenced by duration of sex work, parity, unintended pregnancies during sex work, and place of sex work. Interventions to improve LARC uptake should target the newly recruited FSWs with low parity and the non-brothel/lodge-based FSWs.

Utilization of long acting and permanent contraceptive methods and associated factor among women of reproductive age in west Guji zone, Southwest Ethiopia

BackgroundIncreasing access to family planning helps to ensure the reproductive right, decrease unintended pregnancy, improve the health and nutritional status of children, reduction of maternal mortality, and enhance longer birth spacing. However, there is continually low utilization of long acting and permanent contraceptive methods among low and middle-income countries. This study aimed to assess the utilization of long acting and permanent contraceptive methods (LAPMs) and associated factors among women of reproductive age in the West Guji Zone, Ethiopia.MethodsAn institution-based cross-sectional study was carried out among 507 women of reproductive age in the West Guji Zone, Southwest Ethiopia from April 15 to May 15, 2018. Data were collected by a structured, pretested, and interview-based questionnaire with open ended and closed ended questionnaire, then entered, and analyzed by SPSS Version 20. Bivariable and multivariate logistic regression analyses were carried out. A 95% confidence interval (CI) AND P-value < 0.05 was considered to declare statistically significant variables.ResultThe current utilization of LAPMs at West Guji zone among the reproductive-aged group was found to be 51.1%. More than the median of participants had negative altitude (72.4%) and poor knowledge (57%) towards the LAPMs. Educational status of women, the number of alive children, acceptance of utilization of LAPMs, how treated by other staff, and waiting time during service delivery are significant determinant factors of LAPMs.ConclusionOverall, more than half of women had a negative attitude and poor knowledge of LAPMs. Educational status of women, the number of alive children, acceptance of utilization of LAPMs, how treated by other staff, and waiting time during service delivery were factors affecting utilization of LAPMs. Therefore, sustained, and appropriate information on LAPMs should be provided to raise knowledge and build the attitude of women and the community. Treating the clients with respect, reducing the waiting time, and collaborative work with health extension worker will enhance utilization of LAPMs.

Variation in the interpretation and application of the Medicaid sterilization consent form among Medicaid officials

ObjectiveThe Medicaid consent policy has been identified as a major barrier to desired permanent contraception, particularly for low-income communities and communities of color. As each state may modify their state Medicaid sterilization consent form, variation in the form has been reported. This study aims to characterize state-level variation in Medicaid Title XIX consent form interpretation and application. Study designWe aimed to collect primary data from Medicaid officials in all 50 United States from January to May 2020 via a 25-question electronic survey regarding state-level consent form implementation. Questions targeted consent form details and definitions, insurance and billing, clinician correspondence, and administrative processes. We used Qualtrics XM to collect survey responses. We performed descriptive statistics on the survey responses. There were no exclusion criteria. ResultsWe had 41 responses from 36/50 states (72% participation rate). Heterogeneity existed in the key definitions of “Premature Delivery” and “Emergency Abdominal Surgery.” One in five respondents reported the consent form was only available in English. Variation among Current Procedural Terminology codes covered in each state's sterilization policy were noted. Nearly a quarter of respondents did not know how Medicaid informed healthcare providers of consent form denials. Most participants (90%) were unaware of differences between state sterilization policies. ConclusionThis study demonstrates variation in terms of consent form definitions, procedures covered, correspondence with clinicians, and administrative review processes among state Medicaid offices regarding the sterilization consent form. Greater transparency is necessary in order to reduce administrative barriers to desired permanent contraception. ImplicationsInconsistent interpretation poses an administrative barrier to care, raises concern regarding appropriate clinician reimbursement, and can potentially lead to unnecessarily denying patients the contraceptive option of their choice. Permanent contraception policies should be equitable no matter insurance status, preserve reproductive autonomy and effectively protect vulnerable populations.

Permanent method of postpartum contraception (Bilateral tubal ligation): Experience at the Rivers State University Teaching Hospital

Background: Bilateral tubal ligation is the most common and popular method of permanent contraception in women. It is an effective method of contraception. Objectives: To determine the rate, trend, indications, complications and outcome of bilateral tubal ligation (BTL) at the Rivers State University Teaching Hospital (RSUTH). Methods: This was a cross-sectional study of all cases of bilateral tubal ligation done at the RUTH from 1st January 2018 to 31st December 2020. Data collected were analyzed using IBM, Statistical Product and Service Solution (SPSS), version 25.0 (Armonk, NY). Result: There were 12,406 deliveries and 153 cases of BTL; giving the prevalence of BTL as 1.23% or 12.3 per 1000 deliveries or 1 in 81 deliveries with a decreasing pattern of use. Of the 153 cases of BTL, 148 were done during a caesarean section while 5 with the repair of uterine rupture. Most of the cases were done electively and modified Pomeroy&rsquo;s method was the commonest technique used by surgeons. The mean age and gestational age of the women at delivery were 35.0 SD 3.6 years, 95% confidence interval 34.8 to 35.6 and 37.4 SD 1.5 (95% CI 37.2 to 37.6) respectively. Majority were booked [145(94.8%)], multipara [138(90.2%)], Christians [147(96.1)] and had tertiary level education [84(54.9)]. Parity was significantly associated with BTL [X2 =11.203, p=0.004, (95%CI:0.0441,0.052)] while the association with other sociodemographic variables did not attain significance. The mean foetal weight was 3.05 SD 0.57 kg, 95% confidence interval: 2.92 to 3.18. There were no maternal or foetal complications from the procedure during the period of review. Conclusion: The prevalence of BTL in RSUTH is low and with a decreasing trend. The procedure was carried out mostly during caesarean section. However, other forms such as mini-laparotomy and laparoscopic surgery should be encouraged to create high uptake of the permanent method of contraception especially in our environment, where aversion for caesarean section is high.

Knowledge, perception, and acceptance of vasectomy among male teachers in secondary schools in chikun local government area of Kaduna State, Nigeria

Background: Family planning programs have historically been focused on women. This has reinforced the misconception that family planning is largely a woman's responsibility, with the man playing a peripheral role. Vasectomies are a safe, effective, permanent, and cost-effective modern method of contraception which has poor global uptake in spite of its many benefits. Aim: This study aims to assess the knowledge, perception, and acceptance of vasectomy among male teachers in secondary schools in Chikun Local Government Area of Kaduna State, Nigeria. Materials and Methods: A cross-sectional descriptive study was carried out using a pretested interviewer-administered questionnaire. A total of 178 male teachers were selected using a multistage random sampling technique. Data were collected and analyzed using SPSS version 23, and the results were presented using tables. Chi-square test of proportion was used to test for association. Fisher's exact test was used where conditions for Chi-square test were not met. The level of statistical significance was set at P < 0.05. Results: The mean age of the respondents was 37 ± 7.4 years. Only a small proportion of teachers (6.7%) had good knowledge on vasectomy. Only 5.6% of the teachers had a positive perception about vasectomy, and majority (92.1%) were unwilling to accept to carry out the procedure. The age of the teachers and number of children they had were found to have a statistically significant association with their acceptance of vasectomy (P = 0.004 and P < 0.0001, respectively). Conclusion: Majority of the respondents had poor knowledge and negative perception toward vasectomy with a lot of misconceptions. Acceptance of vasectomy was also poor. Intermittent awareness campaigns on family planning methods should be carried out in the community by the local government health authority, and vasectomy should be discussed in detail to improve awareness and dispel misconceptions.

Accessibility to postpartum tubal ligation after a vaginal delivery: When the Medicaid policy is not a limiting factor

To describe rates of postpartum sterilization and indications for unfulfilled requests when Medicaid policy is not a limiting factor. We conducted a single-institution, retrospective review. Women who requested postpartum tubal ligation after vaginal delivery from August 2015 to March 2019 were studied. Select demographic characteristics were compared between those who did and did not undergo the procedure. Reasons for why the procedure was cancelled, alternate contraceptive plans, and subsequent pregnancies were collected. Statistical analysis included the t test and chi-squared test, with p < 0.05 considered significant. A total of 4103 patients requested postpartum tubal ligation following vaginal delivery. About 3670 (89.4%) procedures were performed and 433 (10.6%) were canceled. Of the 433, 423 (98%) were not performed at patient request; 10 (2 %) were cancelled based on physician recommendation. Of these, 3 were due to significant maternal anemia in the setting of refusal of blood products, 1 due to anesthesia concerns, 1 for increased body mass index, and 1 due to delivery events. Alternative contraception methods were offered; 72 (28% of patients not receiving a tubal ligation) received Depo Provera prior to discharge. One-fourth (n=110, 25.4%) did not keep the postpartum follow-up appointment. 83 (19.2%) of the 433 patients had at least one subsequent pregnancy. Although over half expressed interest at the time of discharge in long-acting reversible contraceptives, only 20% obtained this method at the postpartum visit. Postpartum sterilization was predominantly achieved, among women whose requests were unfulfilled, the majority (98%) were at patient request with a minority by physician recommendation. When the availability of postpartum tubal ligation is independent of Medicaid reimbursement and the hospital system and providers are organized to support timely access to permanent postpartum contraception, the majority of tubal ligations requests can be fulfilled following vaginal delivery.

The demand for family planning to limit childbearing satisfied with female permanent contraception in Sub-Saharan Africa: a meta-analysis of demographic and health surveys

Objective To assess the percentage of the demand for family planning to limit childbearing satisfied with female permanent contraception (FPC) in sub-Saharan Africa (SSA) and the disparities by sociodemographic characteristics (educational status, wealth, religion, and area of residence). Study design This study was a secondary data analysis of Demographic and Health Surveys conducted in SSA. Countries with a standard DHS conducted between 2010 and 2019 were eligible for inclusion. We performed a meta-analysis with a random-effects model to estimate the percentage of the demand for family planning to limit childbearing satisfied with FPC and differences by sociodemographic characteristics. Results Demographic and Health Surveys (2010–2018) of 33 countries, with a total of 67,476 women with a demand for family planning to limit childbearing were included in this study. The pooled percentage of the demand for family planning to limit childbearing satisfied with FPC was 4.13% (95%CI = 2.43–6.23%, I = 99.36%, p = 0.001). The percentage ranged from 0.26% (95%CI = 0.10–0.67) in Angola to 26.85% (95%CI = 25.86–27.85%) in Malawi. The demand for family planning to limit childbearing satisfied with FPC was significantly higher in women from rich households (PR = 1.41, 95%CI = 1.21–1.65, p < 0.001). However, the differences by educational status, religion, or area of residence were not statistically significant. Conclusions The uptake of FPC among women with a demand for family planning to limit childbearing is low in many countries in SSA. Multilevel interventions are needed to address the barriers that may be limiting informed and voluntary uptake of FPC in SSA.

The use of long-acting and permanent contraceptive methods (LAPMs) among women who have completed childbearing in Indonesia: does informed choice matter?

Objectives This study examined factors associated with long-acting and permanent contraceptive methods use among married women who completed childbearing in Indonesia. Methods Data were extracted from the 2017 Indonesia Demographic and Health survey. Subjects of this study comprised 12,790 (weighted) married women aged 15–49 years who completed their childbearing and used modern contraceptive methods. Logistic regression adjusted for complex sample was used to assess factors associated with LAPMs use among women in Indonesia. Results Only 28% of the participants used long-acting and permanent contraceptive methods. Older women, higher number of living children, higher educational level, informed choice, and living in urban areas were associated with higher likelihood of adopting long-acting and permanent contraceptive methods. Women who received comprehensive counselling on contraceptive methods were more likely to adopt long-acting and permanent contraceptive methods compared with women who did not receive comprehensive counselling on contraceptive methods (AOR = 1.23; 95% CI: 1.07–1.41). Women who attained secondary (AOR = 1.31; 95% CI: 1.14–1.50) or higher (AOR = 2.36; 95% CI: 1.91–2.91) educational level were more likely to use long-acting and permanent contraceptive methods compared to women with primary education or less. The use of long-acting and permanent contraceptive methods was higher among women aged 35–49 (AOR = 1.41; 95% CI: 1.24–1.61) and women who have three or more living children (AOR = 1.75; 95% CI: 1.57–1.96) than their counterparts. Conclusion The use of long-acting and permanent contraceptive methods was still low, even though there were more than half of women completed childbearing. The informed choice had a key role in improving long-acting and permanent contraceptive methods uptake. Training programs on contraceptive counselling for health providers and improving couple’s awareness on the effectiveness of long-acting and permanent contraceptive methods were suggested to increase long-acting and permanent contraceptive methods adoption.

Postpartum contraceptive use among pregnant women who delivered at Cipto Mangunkusumo General Hospital: A descriptive study

HIGHLIGHT1. As maternal mortality rate (MMR) is still high, there should be ways to reduce the rate, one of which is the prevention of conception through contraceptive methods. 2. A descriptive study was conducted to all patients giving birth in a national hospital between 2016 to 2019 covering data on the patients, including age, parity, the origin of referral, and type of contraception.3. Most patients who gave birth in the hospital had postpartum contraception, especially permanent contraception and long-term contraception. ABSTRACTObjectives: The maternal mortality rate in Indonesia is one of the highest in the world at 305 out of 100.000 live birth. One of the best ways to reduce MMR is conception prevention through contraceptive methods. According to 2018 Demographic and Health Survey, Indonesia’s Contraceptive Prevalence Rate is as low as 57%, not even reaching the 2015 Millenium Development Goals target of 65%. We conducted a study on postpartum contraceptive use in Dr. Cipto Mangunkusumo National Central General Hospital (RSCM) to see the use of contraception in RSCM so that it can be an example of how contraception is used in RSCM for patients who give birth here.Materials and Methods: A descriptive study was conducted from all patients giving birth in RSCM from 2016 until 2019, data including patient data, consisting of patient age, parity, the origin of referral, and type of contraception, are input from the medical recordResults: There were 5,596 deliveries, consisting of 3,785 C-sections and 1,811 vaginal deliveries. As much as 5332 (95.3%) of subjects had postpartum contraception, 725 (13.67%) of which received tubectomy, and most of which received long-term contraceptive methods (IUD 4414 (82.78%) and implant 44 (0.82%)). As many as 1.065 subjects were more than 35 years of age, 6,2% of which did not use any postpartum contraception. As many as 984 subjects were RSCM bookcases, 6,9% of which did not use any postpartum contraception.Conclusion: Most patients giving birth in RSCM had postpartum contraception, especially permanent contraception and long-term contraception. The contraception profile in RSCM alone can neither describe nor represent the condition and distribution of contraceptive methods in Indonesia because RSCM is a national referral and medical education center whose cases are relatively more complex.

Post-ablation tubal sterilization syndrome: Does route of sterilization matter?

ObjectiveTo compare the prevalence of clinical post-ablation tubal sterilization syndrome among women who underwent abdominal (i.e., peripartum or laparoscopic) vs hysteroscopic permanent contraception in addition to endometrial ablation. Study DesignThis study was a retrospective cohort study conducted at an academic medical center. We included women (N = 188) who successfully underwent both endometrial ablation and permanent contraception between 2005 and 2017. Forty-one women underwent hysteroscopic permanent contraception and 147 underwent abdominal (i.e., peripartum or laparoscopic) permanent contraception. The primary outcome was the prevalence of clinical post-ablation tubal sterilization syndrome, as defined by new or worsening cyclic pelvic pain after completion of both procedures. ResultsThe overall prevalence of the syndrome was 19.1% (34 of 178 women who followed up), with no detected difference between those who underwent hysteroscopic (6 of 38, 15.8%) vs abdominal permanent contraception (28 of 140, 20.0%, p = 0.55). In multivariate regression modeling, when adjusted for race, parity, gynecologic pathologies, hormonal medication use, and the presence of baseline pain (both pelvic and non-pelvic) only younger patient age was marginally associated with increased odds of the syndrome (aOR 1.85, 95% CI 1.01– 3.45, p = 0.05), while abdominal as compared to hysteroscopic permanent contraception was not (aOR 1.29, 95% CI 0.59–2.84, p = 0.53). Of the 28 patients with clinical post-ablation tubal sterilization syndrome who underwent hysterectomy and/or salpingectomy as treatment for their pain, none showed signs of hematosalpinx or hematometra at the time of surgery or on final pathology. ConclusionWe did not find evidence that route of permanent contraception affects the risk of post-ablation tubal sterilization syndrome development. Younger patients may be at higher risk of this syndrome.

Contraceptive plans before preoperative assessment and at procedure in surgical abortion patients

To describe changes in contraceptive method plans pre-appointment, after counseling, and post-procedure in patients having an abortion. We reviewed electronic medical records of University of California, Davis Health patients who had an operating room abortion from January 2015 to December 2016. We excluded persons with procedures for fetal anomaly or demise. We extracted patient demographics and contraceptive plans reported at each encounter (telephone intake, pre-operative appointment, and day of abortion). We evaluated individual contraceptive plans across the encounters, identified patient characteristics that contributed to plan change, and created a multivariable logistic regression model for predictors of contraception method plan change from telephone intake to post-procedure. The 747 patients had a mean gestational age of 16 4/7 ± 5 0/7 weeks with 244 (32.7%) <15 weeks and 235 (31.5%) ≥20 weeks. At telephone intake, 273 (36.4%) wanted a long-acting method (139 [50.9%] intrauterine device [IUD]; 99 [36.3%] implant; 35 [12.3%] unspecified), 11 (3.9%) permanent contraception, and 248 (33.2%) a less effective or no method; 215 (28.8%) stated they were undecided. Most (357/433 [82.4%]) patients who planned a reversible method based on the telephone intake obtained that or a similar method. Of the 273 patients planning a long-acting method, 258 (94.5%) received an IUD (158 [40.9%]) or implant (100 [36.6%]). Of the 215 undecided patients, 88 (40.9%) received an IUD and 55 (25.6%) an implant. No demographic factors predicted a change in method plan. Most patients will receive the method they initially identified at the telephone intake after an abortion, especially those planning an IUD or implant. Undecided patients are commonly open to discussing options.

The History of Female Surgical Sterilization: A Social and Ethics Perspective

Introduction Female surgical sterilization is one of the most common methods of contraception used in the United States. Unfortunately, the development of sterilization procedures is rooted in racism, eugenics, and misogyny. It is this history that provides the impetus for this companion review, which accompanies our concurrent review on the history of female surgical sterilization. We first present the basis of coercive sterilization practices in the United States, the eugenics movement. The eugenics movement, which gained popularity in the United States in the early 20th century, promoted the idea that certain individuals should be discouraged or actively prevented from reproducing, especially through coercive sterilization practices. Second, we discuss the coercive sterilization practices of the early 20th century that became the foundation for coercive practices in our more recent history. During the early part of the 20th century, coerced sterilization became a state mandated procedure for those considered to be “unfit” to reproduce. A link between intelligence and race, and the disproportionate effect of eugenics policies on women provided the setup for the coerced sterilization of women from southern and eastern Europe, black women, Native American women, Hispanic, and Latinx women. We move on to discuss the coercive practices that took place in the mid-20th century, namely in the 1960s and 1970s. Our presentation includes the involuntary sterilization of women of Mexican origin in the 1960s at the Los Angeles County Medical Center, and the sterilization of thousands of Native American women in the 1970s. We then present examples of coercive sterilization in the 21st century, including the sterilization female inmates in California state prisons without appropriate consent, and reports of hysterectomies performed on women in a Georgia immigration detention center without their knowledge or consent. Finally, we include a discussion on the continued control over the reproductive choices of some individuals. We discuss the creation of a standard sterilization consent and policy for patients with Medicaid, which were intended to protect women from coercive sterilization practices; in reality, these policies have become barriers to obtaining a desired method of permanent contraception for low-income and minority women. We also examine the barriers to reproductive health care individuals face when seeking care at Catholic-based institutions, which now account for 4 of the 10 largest health care systems in the United States. Understanding the social history of surgical sterilization in the United States is of paramount importance to provide a more complete review of the history of the procedure. As surgeons who perform tubal sterilizations, obstetrician-gynecologists have an obligation to acknowledge the historical physical and social harm associated with the procedure, and advocate for better policies and practices that preserve patients' reproductive dignity. (J GYNECOL SURG 37:465)

A retrospective cohort study of tubal occlusion or salpingectomy for permanent contraception in Australia.

Laparoscopic permanent contraception was previously accomplished most commonly using tubal occlusion procedures. Bilateral salpingectomy (BS) has recently been introduced as an alternative due to possibly superior contraception and greater protection against ovarian cancer. The aim of this study is to assess uptake, feasibility and perioperative outcomes of laparoscopic BS as an alternative to tubal occlusion in Australia. A retrospective review of permanent female contraception at two Australian hospitals from January 2014 through December 2020 was performed. The primary outcome was the uptake of BS. Secondary outcomes were feasibility, procedure length, number of ports, perioperative complications and admission length. A total of 414 women were included; 92 (22.2%) underwent BS and 322 (77.8%) underwent tubal occlusion. There was a slow uptake of BS from 2014 to 2016 (0-3.2%), with a steep uptake from 2017 to 2020 (30-72%) (P=0.001). Procedure feasibility was 96.8% (62/64) and 99.3% (282/284) for BS and tubal occlusion group, respectively (P=0.64). BS procedure time was longer by 23min (P<0.001). Three or more surgical ports were used in all cases of BS compared to 4.5% of the tubal occlusion group (P<0.001). There were no intraoperative complications. There were nine and six postoperative complications in the tubal occlusion versus BS group, respectively (P=0.10). The median admission length was 7.1 (tubal occlusion) versus 7.3 (BS) h (P=0.10), with five unintended overnight admissions. BS is an increasing choice for permanent contraception. It appears equally feasible as tubal occlusion but typically requires a longer procedure time and a minimum of three surgical ports.

Barriers to salpingectomy for permanent contraception: A qualitative study with obstetricians and gynaecologists.

Consideration of risk-reducing bilateral salpingectomy has been recommended instead of tubal occlusive procedures for female sterilisation due to the role of the Fallopian tubes in the aetiology of serous ovarian malignancies. This study identified barriers to performing salpingectomy for permanent contraception. Twenty-two semi-structured interviews were conducted with Australian gynaecologists, and transcripts analysed qualitatively. Barriers to performing bilateral salpingectomy included: (a) patient factors (younger age and risk of regret); (b) operative complexity and complications (particularly risk of bleeding); (c) surgeon factors (lack of awareness of guidelines supporting salpingectomy; less comfort with laparoscopic surgery); and (d) practical system challenges (including cost and equipment availability).

Postpartum permanent contraception: updates on policy and access.

To describe barriers to provision of postpartum permanent contraception at patient, hospital, and insurance levels. Permanent contraception remains the most commonly used form of contraception in the United States with the majority of procedures performed during birth-hospitalization. Many people live in regions with a high Catholic hospital market share where individual contraceptive plans may be refused based on religious doctrine. Obesity should not preclude an individual from receiving a postpartum tubal ligation as recent studies find that operative time is clinically similar with no increased risk of complications in obese compared with nonobese people. The largest barrier to provision of permanent contraception remains the federally mandated consent for sterilization for those with Medicaid insurance. State variation in enforcement of the Medicaid policy additionally contributes to unequal access and physician reimbursement. Although significant barriers exist in policy that will take time to improve, hospital-based interventions, such as listing postpartum tubal ligation as an 'urgent' procedure or scheduling interval laparoscopic salpingectomy prior to birth-hospitalization discharge can make a significant impact in actualization of desired permanent contraception for patients. Unfulfilled requests for permanent contraception result in higher rates of unintended pregnancies, loss of self-efficacy, and higher costs. Hospital and federal policy should protect vulnerable populations while not preventing provision of desired contraception.

POSTER ABSTRACTS: P54 THE ASSOCIATION OF PAYER STATUS WITH POSTPARTUM STERILIZATION FOLLOWING UNINTENDED PREGNANCY

Objectives: Patients with public insurance in the US face disparate administrative barriers to obtaining permanent contraception, as compared with those with private insurance. We sought to evaluate the association of public insurance status with postpartum sterilization utilization following an unwanted pregnancy in a nationally representative sample.

Contraceptive Use Among Women in the United States Aged 18-44 Years with Selected Medical Contraindications to Estrogen.

Objective: Medical contraindications to estrogen limit women's contraceptive options. This study assessed the association between selected medical contraindications to estrogen on contraceptive use and examined whether contraindications serve as a barrier to the prevention of unintended pregnancy. Materials and Methods: We analyzed women aged 18-44 at risk of unintended pregnancy participating in the 2017 Behavioral Risk Factor Surveillance System. Survey questions queried women regarding contraceptive use and contraindications to estrogen use. We assessed the most recently used contraceptive method and compared the odds of women using each category of contraception (no methods, less effective methods, pill/patch/ring, injection, intrauterine device, implant, permanent contraception) between those with and without potential contraindications to estrogen using multinomial logistic regression models. Results: This study included 32,098 women, of whom 16% had one or more potential contraindications to estrogen. There were significant differences in contraceptive choice by potential contraindication status (p < 0.01). Fifteen percent of women with potential contraindications reported using estrogen-containing methods (pill, patch, or ring) compared with 20% of women with no potential contraindication. Women with potential contraindications to estrogen more frequently used permanent contraception (odds ratio [OR] vs. pill/patch/ring: 1.48 95% confidence interval [CI]: 1.17-1.88) or no contraceptive method (OR vs. pill/patch/ring: 1.37 95% CI: 1.07-1.75) after adjustment for race, age, marital status, and income. Conclusions: Potential medical contraindications to estrogen are associated with permanent contraception and the use of no contraception. These results portray a complicated relationship but could suggest a lack of access to other contraceptive options.