Postpartum Tubal Ligation Research Articles

Association Between Proximity to Delivery Hospital and Postpartum Contraception Choice [ID 2683622

INTRODUCTION: Proximity to prescribers may present a barrier to postpartum contraceptive care. We examine associations between postpartum contraceptive choice and residential proximity to the prescribing, delivery hospital. METHODS: After IRB approval, we collected electronic medical record data from 2020 to 2022 at an inner-city, academic hospital and used CDXGeoData to determine residential distance to the hospital. Contraceptive choice at delivery, 2 weeks, and 6 weeks postpartum, focusing on long-acting reversible contraception (LARC) versus other contraceptives, was compared across distance to hospital. RESULTS: We identified 3,705 births: 53.5% Black, 30.3% Hispanic, and 73.7% utilizing public health insurance. Residential distance to the hospital was 0–1,724 miles with 74.2% living within 10 or fewer miles. Those residing within 10 miles were more likely to be non-Black (X2 (2)=12.02; P<.01), Hispanic (X2 (2)=83.91; P<.001), single (X2 (3)=33.54; P<.001) and primiparous (X2 (3)=13.09; P<.01). Cesarean section was more frequent (32.5% versus 28.1%; X2 (2)=6.58; P<.01) and gestational age shorter (U=1171108; P<.05) for those living further from the hospital. Postpartum tubal ligation did not differ across groups. LARC uptake at discharge and 2 weeks postpartum trended towards being higher for women who lived further (X2 (1)=3.49; P=.06; aOR 1.15; 95% CI, 0.96–1.39). CONCLUSION: There is a trend towards increased LARC uptake if the patient resides further from their delivery hospital after controlling for confounding factors. Our findings add to understanding of patient preferences and barriers to care.

Outcomes for Women Denied Postpartum Tubal Ligation During the Initial COVID-19 Surge.

To evaluate the utilization and outcomes of postpartum long-acting reversible contraception (PPLARC) following unmet postpartum bilateral tubal ligation (PPBTL) requests during a time in which elective surgeries were canceled due to the initial COVID-19 surge. We conducted a mixed-methods study using an embedded design. Using a retrospective cohort design, we collected data from patients seeking PPBTL following vaginal delivery between March 15, 2020, and June 20, 2020; this reflects a time period during which elective surgery was canceled thus making PPBTL unavailable. We recorded demographic data, method of contraception at time of discharge and 18 months postpartum, and incidence of interval pregnancy at 18 months postpartum. Additionally, we conducted five semistructured interviews to gain deeper insights into patient experiences with PPLARC as a bridge method. Forty-five patients had unfilled PPBTL requests with follow-up data available for 35. The median age was 34 years. Ten (22%) accepted PPLARC as a bridge to interval bilateral tubal ligation (BTL). At the 18-month mark, only 1 out of 7 (14.3%) PPLARC users had undergone an interval BTL procedure, compared to 11 out of 28 (39.3%) nonusers. None of the PPLARC users experienced pregnancies, while 6 out of 28 (21.6%) nonusers became pregnant. Qualitative interviews underscored themes such as inadequate counseling preparation for unmet PPBTL requests and persistent barriers to BTL access. Raising awareness of unmet PPBTL risks may drive greater adoption of PPLARC as a bridge method. While not a substitution for PPTBL, PPLARC provides a reliable form of interval contraception for patients seeking to delay pregnancy. It is essential to recognize that patient security with PPLARC's contraceptive efficacy may introduce delays in achieving the desired interval sterilization. Enhancing antenatal counseling on contraception options and providing transparency regarding barriers to sterilization could mitigate the challenges associated with unmet PPBTL requests.

A retrospective cohort study of the anesthetic management of postpartum tubal ligation

BackgroundNeuraxial anesthesia with reactivation of a labor epidural catheter is commonly utilized for postpartum tubal ligations (PPTL), although the optimal anesthetic approach is unknown. We assessed institutional anesthesia practices for PPTL, and evaluated the failure rates of reactivation of labor epidural catheters, de novo spinal anesthesia, and spinal anesthesia after failed blocks. MethodsWe conducted a single-center retrospective cohort analysis of 300 consecutive patients who underwent a PPTL and 100 having spinal anesthesia for cesarean delivery. Anesthetic management data (existing labor epidural catheter reactivation, de novo spinal anesthesia or general anesthesia) were collected from electronic medical records. Anesthetic block failure rates were determined for each anesthetic technique. ResultsThe failure rate was 15% for de novo spinal anesthesia and 23% after failed reactivation of a labor epidural catheter or spinal anesthesia. The epidural catheter reactivation failure rate was 35%. The failure rate of spinal anesthesia for cesarean delivery was 4%. Drug dosage, epidural catheter use in labor, time since epidural catheter placement or delivery, labor neuraxial technique (combined spinal-epidural, epidural), supplemental top-up doses during labor, and anesthesiologist experience did not predict neuraxial anesthesia failures. ConclusionsOur analysis revealed an unexpectedly high neuraxial anesthesia failure rate even when de novo spinal anesthesia was used for PPTL. The results are consistent with other institutions' recent findings, and are higher than spinal anesthesia failure rates associated with cesarean delivery. Further studies are required to determine optimal anesthesia dosing strategies, and to understand the mechanisms behind high neuraxial anesthesia failures for PPTL.

Provider attitudes and current practice regarding the prescription of opioid-containing pain medication for vaginal delivery.

The epidemic of opioid misuse and abuse is rampant in the United States. A large percentage of patients who go on to misuse or abuse opioids were initially legally prescribed an opioid medication by their physician. One of the most common reasons patients of reproductive age seek medical care is for pregnancy and delivery. These patients are frequently prescribed opioids. Greater than one in 10 Medicaid-enrolled women fill an opioid prescription after vaginal delivery. To assess the opioid prescribing patterns of obstetric providers following vaginal deliveries. Obstetric physicians and certified nurse midwives (CNMs) from different practice backgrounds were administered a questionnaire regarding opioid prescribing practices for patients who undergo vaginal delivery. Providers were contacted via email and completed survey via REDCap. Ninety-nine providers completed the survey between October 2018 and January 2019. Eight percent of all providers reported prescribing opioids at discharge after vaginal deliveries. There was a statistically significant difference in the proportion of physicians who provided opioid prescriptions at discharge compared to CNMs (16.7 percent vs 1.8 percent, respectively, p < .05). Common reasons for prescribing opioids at discharge included post-partum tubal ligation (56.4 percent), third- and fourth-degree lacerations (59.6 and 73.4 percent, respectively), and operative deliveries (26.6 percent). Physicians were significantly more likely to prescribe an opioid after a second-degree laceration than CNMs (19.1 percent vs 5.3 percent, p < 0.05). Practice patterns for opioid prescription vary by provider type as well as by delivery characteristics. Further study is necessary to delineate the optimal care while minimizing unnecessary opioid prescriptions.

The Impact of COVID-19 and Policy Changes on Immediate Postpartum Contraception and Permanent Contraception at an Urban Hospital: A Retrospective Cohort Study.

Objective: At the onset of the COVID-19 pandemic, in addition to increased use of telemedicine visits and a temporary suspension of interval tubal ligations, providers at the University of Maryland Medical Center were encouraged to counsel patients interested in long-acting reversible contraception (LARC) about immediate postpartum placement. We assessed immediate postpartum contraception uptake following these policy changes. Materials and Methods: In this retrospective cohort study, we compared patients who delivered a live born infant(s) before the pandemic ("pre-COVID cohort," December 16, 2019-March 1, 2020) and at the beginning of the pandemic ("during-COVID cohort," March 16-May 31, 2020). We collected electronic medical record data, including sociodemographic characteristics and contraception choices antenatally and through 1 year postpartum for 631 patients (321 pre-COVID, 310 during-COVID). Results: Odds of immediate postpartum LARC use in the during-COVID cohort were 33% higher than in the pre-COVID cohort, but this was not statistically significant (adjusted odds ratio 1.33, 95% confidence interval: 0.81-2.19). We found no difference in numbers of patients who received immediate postpartum tubal ligation (10% pre-COVID vs. 11% during-COVID). No patients in the during-COVID cohort obtained interval tubal ligations within 6 months of delivery. Contraceptive choices differed at postpartum visits (p = 0.03), with a decrease in delayed postpartum LARC placement in the during-COVID cohort (15% pre-COVID vs. 8% during-COVID). Conclusions: When COVID-19-related hospital policies prompted increased counseling on immediate postpartum LARC and suspension of interval tubal ligations, patients tended to be more likely to choose immediate postpartum LARC. Situational resource restrictions and targeted counseling may influence patient choices and access to desired contraceptive methods.

A reusable, low-cost model to improve resident confidence in performance of postpartum tubal ligation

Proficiency in postpartum abdominal sterilization is a core objective that residents must acquire during residency as outlined by the Council on Resident Education in Obstetrics and Gynecology. Surgical sterilization remains a popular and effective form of contraception in the United States; however, many women requesting immediate postpartum tubal ligation are unable to have the procedure given institutional barriers and variations in practice. Additionally, increasing use of long-term reversible contraceptives has contributed to declining immediate postpartum sterilization rates, which may ultimately impact an Obstetrics and Gynecology resident’s ability and confidence to perform this procedure. Our goal was to develop a reusable, low-cost model to improve resident familiarity and confidence with postpartum tubal ligation. A 3-dimensional model was developed that represents key anatomic structures encountered during tubal ligation and allows residents to perform all procedure steps. Materials and costs were determined. The model was piloted during scheduled simulation time. Residents evaluated the model’s realism and reported confidence in performing the tubal ligation pre- and post-simulation with a 5-point Likert scale . Four reusable models were created for $21.56 each. All PGY level residents (n=12) successfully performed the procedure with most having performed less than 5 postpartum tubal ligations previously. Resident confidence in performing postpartum tubal ligation improved significantly post-simulation (2.58 vs 3.42/5, p=0.005). Residents strongly agreed that the model replicated the steps (4.83/5), resembled the abdominal wall (4.58/5) and peritoneal cavity (4.73/5), and was similar in difficulty to a live procedure (3.2/5). All residents strongly agreed practicing on this model could improve surgical technique (5/5). This model fills a gap in sterilization simulation and resident training. It is low-cost and easily reproducible, closely resembles the pelvic anatomy, allows for completing the steps of the procedure and can be used for resident education to improve confidence with immediate postpartum sterilization.

Legal medicine aspects of female sterilization: our experience.

The most frequent sterilization procedures include postpartum tubal ligation, laparoscopic tubal disruption or salpingectomy, and hysteroscopic tubal occlusion. It may be performed via laparoscopy, mini-laparotomy, or hysteroscopy. Safety, efficacy, short-term complications, long-term complications, and non-contraceptive benefits of sterilization are different for each procedure. Female sterilization has become an important professional liability problem in obstetrics and gynecology. We analyzed 6 cases of surgical sterilization that have been the subject of civil proceedings. We review indications, contraindications, and complications associated with each sterilization procedure. In our small number of cases, women who have undergone sterilization performed negligently are entitled to recover damages for wrongful conception, negligence, and wrongful birth. We also consider the issue of female sterilization of minors. Tubal sterilization can be performed with different techniques, chosen in light of the various situations involved, with the goal of reducing as many as possible any failures. Thorough and complete communication of information is of primary importance. Sterilization is the most widely used birth control method around the world. The procedure is generally safe and highly effective. As reported in the literature, the decision concerning method depends on the setting, the surgeon's experience, the country's economic development, and the woman's preference, but we think that some techniques present a greater risk of failure and expose the surgeon to malpractice litigation.

COVID-19 Infection as a Barrier to Postpartum Tubal Ligation [ID: 1355689

INTRODUCTION: About half of patients who do not obtain a requested postpartum tubal ligation experience pregnancy within the following year. There are many challenges to fulfilling postpartum tubal requests. Obstacles are exacerbated for those without private insurance, including Medicaid consent form requirements. Our institution considers postpartum tubal ligations “elective” and created policy prohibiting them for COVID-positive patients. We aimed to study how this creates additional barriers and delays to care for our patients. METHODS: This retrospective study identified patients with documented COVID infection at time of vaginal delivery who were unable to receive a requested postpartum tubal ligation at our institution between February 2020 and February 2022. Sociodemographic information, documented contraception ultimately obtained, and documented future unintended pregnancy were evaluated. Institutional review board approval was obtained. RESULTS: In a 2-year period, 24 patients were unable to receive requested postpartum tubal ligations at our institution because of COVID infection. 42% (n=10) of such patients were uninsured and 54% (n=13) had Medicaid. 92% (n=22) were Hispanic/Latinx. Average age was 33, and average number of prior pregnancies was 5. Only 21% (n=5) received an interval tubal ligation after delivery; no uninsured patients received an interval tubal ligation. Of the remaining patients (n=19), 37% (n=7) never received any contraception, 37% (n=7) received long-acting reversible contraceptives, and 26% (n=5) received another type of contraception. One patient had a future documented unintended pregnancy. CONCLUSION: Our institution's policy not to perform postpartum tubal ligations for COVID-positive patients prevented about 80% of patients requesting permanent sterilization after vaginal delivery from ever accessing this procedure.

Cancellation of Postpartum Tubal Ligations During COVID-19 and Alternative Contraceptive Methods in Women With Public Insurance: A 2-Year Update [ID: 1373829

INTRODUCTION: During the COVID-19 pandemic, postpartum bilateral tubal ligations (ppBTLs) were deemed “elective” and cancelled from March through June 2020. For patients with public insurance, the postpartum represents a brief interval in which contraception is covered and access to surgery is readily available. METHODS: We reviewed publicly insured patients who consented for ppBTLs after vaginal deliveries at our institution from March to June 2020 in whom procedures were cancelled. We analyzed alternative contraception chosen at discharge and up to 6 months postpartum. Two years later, we reviewed the same patients to evaluate contraceptive practice and pregnancy outcomes. RESULTS: After 275 vaginal deliveries, 25 ppBTLs were cancelled. Subsequently, 12 (48%) women were discharged without contraception. Seven (28%) and 14 (56%) women were not using contraception 6 weeks and 6 months postpartum, respectively. Two years later, six (24%) women returned pregnant; three without contraception, one using oral contraceptive pills, one using condoms, and one with a perforated intrauterine device (IUD). Two are currently pregnant and one underwent abortion with IUD placement. Three experienced uncomplicated vaginal deliveries, after which two received ppBTLs and one did not return for follow-up. CONCLUSION: As a result of pandemic policy, many women were unable to access ppBTLs and failed alternative means of contraception. As a result, nearly one-quarter of these patients became pregnant. Obstetrician–gynecologists should ensure that contraception counseling and pregnancy intention are addressed at each prenatal appointment. Physicians must also lobby for an expansion of postpartum insurance coverage and better advocate for services that provide women reproductive autonomy.

Active COVID-19 infection as a barrier to postpartum tubal ligation

ObjectivesTo identify patients unable to obtain postpartum bilateral tubal ligations (ppBTLs) due to policy prohibiting “elective” procedures for COVID-positive patients at a single academic medical center in New Jersey. ResultsUpon retrospective chart review of patients requesting ppBTLS, of 110 ppBTL requests between identified via retrospective chart review between February 1, 2020, and February 28, 2022, 24 (22%) were canceled due to COVID infection. Of these patients, 10 (42%) were uninsured, 13 (54%) had Medicaid, and 22 (92%) were Hispanic/Latinx. Postpartum, five (21%) obtained interval tubal ligation, seven (37%) never received contraception, and one had a future pregnancy. ConclusionsThis policy affected uninsured patients by preventing access to permanent contraception.

Catholic sole community hospitals are associated with decreased receipt of postpartum permanent contraception among Medicaid recipients

ObjectivesTo examine the association of Catholic hospitals with receipt of postpartum tubal ligation and long acting, reversible contraception among Medicaid recipients. Study designWe conducted a retrospective cohort study of live births from January 1, 2016 to October 31, 2016 to female Medicaid beneficiaries in the United States between ages 21 and 44. Our main exposure was the presence of a Catholic-affiliated sole community hospital, and our primary outcome was highly effective postpartum contraception. We examined rates of postpartum permanent contraception, along with the use of a long acting, reversible form of contraception (LARC) at 3 and 60 days are postpartum. We compared counties that had only a Catholic-affiliated hospital with counties with only a non-Catholic hospital. ResultsOur study population included 14,545 postpartum Medicaid beneficiaries. Study participants came from 88 counties across 10 United States states. Only 7.7% of women in counties with Catholic sole community hospitals received permanent contraception by 3 days postpartum, compared to 11.3% in counties with non-Catholic sole community hospitals (RD: -3.92%; 95% CI: -6.01%, -1.83%). This difference was not mitigated by receipt of outpatient procedures or long-acting, reversible contraception. Importantly, women residing in counties with Catholic sole community hospitals were much less likely to return postpartum for an outpatient visit between 8 and 60 days postpartum than women in counties with non-Catholic sole community hospitals (35.4% vs 45.4%, RD: -9.29%; 95% CI: -16.71%, -1.86%). ConclusionsIn counties where the only hospital was Catholic, Medicaid recipients giving birth were significantly less likely to receive permanent contraception and to return for postpartum care. ImplicationsCatholic hospitals are increasing in the United States, which may restrict access to postpartum contraception, particularly in rural areas. We found that Medicaid recipients giving birth at a Catholic sole community hospital were less likely to receive permanent contraception and to return for care.

Access to postpartum tubal ligation services in Cape Town, South Africa – an observational study

Many women receiving antenatal care in public health services in Cape Town choose bilateral tubal ligation as their preferred method of postpartum contraception during their antenatal course. If the sterilisation does not occur immediately, these women are discharged on an alternative form of contraception and, ideally, an interval date for bilateral tubal ligation is arranged. To assess the access to tubal ligation services in the Metro West area of Cape Town, South Africa, in women who request permanent contraception following delivery, looking specifically at the number of women requesting bilateral tubal ligation who receive the procedure intrapartum, immediately postpartum or as an interval procedure. Other objectives included determining the reproductive outcomes if bilateral tubal ligation was not performed, investigating the alternative forms of contraception provided and to study the demographics of the population requesting bilateral tubal ligation as a form of contraception. The study was conducted as a cross-sectional observational study collecting data over a period of 3 months, from June 2019 to August 2019. Maternity case records for deliveries between June 2019 and August 2019 from four facilities were reviewed. The facilities, representing all levels of care, were Vanguard Midwife Obstetric Unit, Wesfleur Hospital (district hospital), New Somerset Hospital (regional hospital), Groote Schuur Hospital (tertiary hospital). There were 260 women who requested tubal ligation as their choice of contraception. Only 50% of these received a tubal ligation. Of the 131 tubal ligations performed, 2 were interval sterilisations. Ninety-one percent (120/131) of the tubal ligations were done at the time of caesarean section. Of the 129 women who received alternative forms of contraception, 13 women had a recurrent pregnancy. The study suggests that only 50% of women requesting tubal ligation as form of contraception actually end up receiving the procedure. Alternative forms of contraception are widely used and relied upon, but not without risks of recurrent pregnancy. Interval tubal ligation was not easily accessed by those women who were referred for the procedure.

Unfulfilled Requests for Postpartum Tubal Ligation at a Southern Tertiary Care Center.

BACKGROUND Nationally, multiple barriers lead only 50% of women who request postpartum tubal ligation to receive it prior to discharge. We aimed to identify characteristics associated with unfulfilled requests for postpartum tubal ligation at a tertiary medical center in the South.METHODS We conducted a retrospective chart review of all women delivering a live infant with a documented desire for postpartum sterilization between September 1, 2018, and November 30, 2018. The primary outcome was receipt of postpartum sterilization prior to discharge. We used chi-square and Mann Whitney U tests for descriptive analyses.RESULTS One thousand seventy-two women delivered a live infant at our institution during our sampling frame. One hundred twenty-four had a documented desire for postpartum sterilization (124/1072, 12%). Eighty-one women (81/124, 65%) received their postpartum sterilization and 43 women (43/124, 35%) did not. Women who delivered by cesarean were more likely to receive their postpartum sterilization (63/68; 93%) than if they delivered vaginally (18/56; 32%) (P < .001). Lack of valid Medicaid consent (P = .006) was associated with unfulfilled requests for postpartum sterilization following vaginal delivery while BMI > 40 (P = .158) approached significance.LIMITATIONS Our sample is small and from a single institution. Additionally, the specific reason for tubal ligation nonfulfillment was often not documented.CONCLUSIONS In this Southern institution, women delivering vaginally, those without a valid Medicaid consent form, and women with BMI > 40 were less likely to receive desired postpartum sterilization. Multipronged process changes are needed to fulfill patients' sterilization requests.

A Prospective Quality Improvement Initiative to Address the Barriers to Postpartum Tubal Ligation Among Multiparous Women.

Unmet need for postpartum tubal ligation (PPTL) is still high in low-middle income countries. The commonly observed barriers are issues with the consent forms, non-availability of operation theater, lack of knowledge, patient desire for more children, partner opposition and social non-acceptance. Considering the unmet need and the barriers, this quality improvement (QI) initiative was conducted to increase the frequency of PPTL among multiparous women by 50% from baseline. This QI was conducted at a tertiary care teaching hospital over a period of 18 months. The study consisted of three phases. Baseline observations during the pre-intervention phase over six months, intervention phase consisting of three Plan-Do-Study-Act (PDSA) cycles over 12 months and post-intervention surveillance phase over a period of three months. In the first PDSA cycle, hospital and provider barriers were focused on. The patient barrier was addressed in the secondcycle. The barrier at the level of partner and family members was addressed in the third cycle. The baseline prevalence of PPTL in the studied population over a period of six months was 30.2%. After the first PDSA cycle, the prevalence of PPTL performed increased from 30.2% to 49.5%. The prevalence increased to 68.8% after the second cycle. A further increase to 74.4% was observed after the third intervention. There was a satisfactory continuation rate of 72% at the end of the post-intervention follow-up phase conducted over four months. This QI initiative proved effective and sustainable over time. There was continuous motivation among the service providers to educate and counselwomen for PPTL. Ultimately, we were able to address the low prevalence of PPTL through minor modifications in our hospital strategies.

Assessing the Barriers to Postpartum Tubal Ligation Among Multiparous Women.

Background: Unmet demands for postpartum tubal ligation are estimated to be greater than the actual number of tubal ligations done, especially in low-resource settings. Through this study, we therefore assessed the barriers to postpartum tubal ligation in the developing world.Materials and Methods: It is a prospective cohort study including 3671 multiparous women from northern India. Recruited patients were given survey questionnaires during their antenatal and postpartum period which evaluated the patient-related, healthcare facility-related and social factors which were the determining factors for the unfulfillment of their desire for permanent sterilization.Results: Out of the recruited population, 1576 women wished to undergo tubal ligation. Following attrition, a total of 1024 were followed up prospectively. Of them, sterilization was successfully done only in 309 (30.18%) participants. A large proportion of mothers had their demand unmet (715 mothers; 69.82%). Out of them, 505 (70.63%) women stated that tubal ligation was not done because they did not deliver by Caesarean section. Insufficient counselling regarding tubal ligation was quoted by 325 (45.45%) mothers. Majority of the participants denied tubal ligation as they were not given enough information about the procedure (589 participants; 82.38%). While 568 (79.44%) mothers had changed their mind after delivery, 257 (35.94%) thought that their health was not fit to undergo the procedure and 213 (29.79%) mothers wanted more children in the future. We found that there was strong opposition from their male partners (56.78%).Conclusion: Postpartum tubal ligation is of paramount importance in women with completed families, especially in developing countries. This prospective study addressed the barriers to tubal ligation, which would help combat future unintended pregnancies.

Concordance of Desired and Administered Postpartum Contraceptives among Emergency and Full Scope Medicaid Patients.

To determine if concordance of contraceptive preference and uptake differ between postpartum recipients of emergency versus full scope Medicaid. We performed a historical cohort study of patients who delivered at a safety-net hospital in Denver, Colorado in 2016. In our public system, all patients had access to immediate postpartum tubal ligation and all forms of reversible contraception in outpatient clinics. We used data from electronic health records to compare contraceptive preferences and uptake between patients with full scope and emergency Medicaid at hospital discharge and by 12weeks postpartum. We then compared contraceptive concordance (use of the same method as desired during delivery admission) between the groups at time of postpartum discharge and by 12weeks postpartum. We examined 693 women; 349 (50.1%) had emergency Medicaid and 344 (49.9%) had full scope Medicaid. The mean age at delivery was 27.9years, and most patients were Hispanic (74%). Women with emergency Medicaid were less likely to receive their desired method of postpartum contraception before hospital discharge (53.6% vs. 66.9%; p<.01). One-half of the patients with emergency Medicaid who did not receive their desired method of immediate postpartum contraception were unable to obtain it based on insurance ineligibility. By 12weeks postpartum, the rates of concordance did not differ by insurance status: 52.4% of patients with emergency Medicaid and 55.2% of patients with full scope Medicaid received their desired method of contraception (p=.46). Emergency Medicaid recipients, largely recent and/or unauthorized immigrants, have high demand for highly effective postpartum contraceptives. Although emergency Medicaid recipients initially had lower rates of receipt of their desired contraceptive during the hospital stay compared with those with full scope Medicaid, they ultimately had similar concordance rates by 12weeks postpartum. We suspect this finding was in part due to free access to all methods of contraception in our outpatient clinics during the postpartum course. Systemic barriers should be reduced to ensure better access to postpartum contraceptives for all patients, regardless of insurance coverage, to improve reproductive equity.

A Standardized Protocol for Post-Partum Salpingectomy with Suture Ligation: A Prospective Feasibility Study

Our objective is to define a standard protocol for post-partum salpingectomy and provide a prospective assessment of safety and feasibility of such a procedure. Thus, a protocol for performing post-partum salpingectomy in limited-resource environments was created based on contemporary practices for tubal ligation. Gravidae presenting for post-partum tubal ligation following vaginal delivery or at time of cesarean were prospectively approached and, if consent was obtained, enrolled. Outcomes were compared to a historical cohort of gravidae who underwent standard post-partum tubal ligation following vaginal birth or at the time of cesarean as per institutional standard of care. The primary outcome was operative time. One hundred and fifty-seven subjects underwent post-partum salpingectomy following cesarean or vaginal delivery (on post-partum days 0–2). Post-partum salpingectomy performed after vaginal delivery (n = 97) resulted in slightly longer operative times (39.1 ± 11.8 vs. 34.3 ± 13.1 min, p = 0.003) and slightly greater blood loss (21.0 ± 22.0 vs. 13.4 ± 17.3 mL, p = 0.001) than modified Pomeroy tubal ligation (n = 200). Post-partum salpingectomy at cesarean resulted in no difference in estimated blood loss, but slightly longer operative times compared to Parkland tubal ligations (99.5 ± 47.3 vs. 86.5 ± 33.9 min, p = 0.048). Surgical complications for post-partum salpingectomy were similar to controls, regardless of when the procedure was performed. In conclusion, a standardized protocol created for post-partum salpingectomy using suture ligation is feasible and safe.

Update on incidence of inpatient tubal ligation and long-acting reversible contraception in the United States

Inpatient insertion of long-acting reversible contraception and immediate postpartum tubal ligation allow women to initiate highly effective contraception before hospital discharge. We measured rates of intrauterine device and contraceptive implant initiation and tubal ligations performed during delivery hospitalizations from 2016 to 2018 from a representative sample of US hospital discharges. We used the 2016 to 2018 National Inpatient Sample database, a 20% sample of all community hospital discharges in the United States, to identify delivery hospitalizations with concomitant intrauterine device insertion, contraceptive implant insertion, or tubal ligation. We performed weighted multivariable logistic regression to examine associations between possible predictors (age, delivery mode, payer, geographic region, and year) and odds of long-acting reversible contraception and tubal ligation, and to compare characteristics of users. This sample included 2,216,638 discharges, representing 20% of 11,083,180 delivery hospitalizations across the United States. Intrauterine device insertion increased from 2.2 per 1000 deliveries (2016) to approximately 5.0 per 1000 deliveries (2018; P<.0001); implant insertion increased from 0.3 per 1000 deliveries (2016) to 2.5 per 1000 deliveries (2018; P<.0001); tubal ligation procedures decreased (64.2 to 62.1 per 1000 deliveries; P<.0001). Women who underwent a cesarean delivery had higher odds of having a tubal ligation than those who had a vaginal delivery (adjusted odds ratio, 8.83; 95% confidence interval, 8.73-8.97). Women aged <25 years had 7 times higher odds of receiving long-acting reversible contraception than of receiving tubal ligation (adjusted odds ratio, 7.38; 95% confidence interval, 6.90-7.90). Women with public insurance had almost 5 times the odds of receiving long-acting reversible contraception compared with those with commercial insurance (adjusted odds ratio, 4.83; 95% confidence interval, 4.59-5.06). Rates of long-acting reversible contraception insertion continue to increase while the rates of inpatient postpartum tubal ligations slowly decline. Variations in patient characteristics are associated with receiving long-acting reversible contraception or tubal ligation.

The Relationship between Body Mass Index and Operative Complications in Patients undergoing Immediate Postpartum Tubal Ligation.

The objective of this study is to examine the relationship between body mass index (BMI) and complications for patients undergoing postpartum permanent contraception. Retrospective cohort study of patients aged 18 or older who had a vaginal delivery at an academic hospital between 2011 and 2016 and underwent a postpartum tubal ligation during the delivery admission. There were three comparative groups: nonobese (BMI ≤ 29 kg/m2), obese (BMI 30-39 kg/m2), and morbidly obese BMI (≥40 kg/m2). The outcome of interest was composite operative complications which included any occurrence of an intraoperative, postoperative, or anesthesia complication. A total of 921 patients were included for analysis. Average operative time was statistically longer for patients in the morbidly obese group (33 minutes) vs. the nonobese (25 minutes) and obese (29 minutes) groups (p < 0.0001). Composite complications were greater for the obese groups, but not statistically significant (5.1 vs. 6 vs. 16%, p = 0.06). Wound complications were significantly greater for the obese groups (0.8 vs. 1.5 vs. 5.5%, p = 0.01). A logistic regression model demonstrated that only operative time was predictive of operative complications. Overall complications of postpartum tubal complications are low; however, our study did demonstrate significantly longer operative time and wound complications for patients with obesity. The findings of our study indicate that postpartum permanent contraception can remain as an option for these patients. Further studies may help identify the best practices to decrease operative time and subsequent wound complications. This study contributes to the limited data regarding obesity and postpartum permanent contraception. We found increased operative time and wound complications for obese patients. Additional studies may identity best practices to decrease these complications. Given our findings of overall low operative complications, postpartum permanent contraception can remain an option for obese patients.

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.