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Background: Removal of the fallopian tubes at the time of hysterectomy or interval sterilization has become routine practice to prevent ovarian cancer. While emerging as a strategy, uptake of this procedure at the time of cesarean delivery for pregnant women seeking permanent sterilization has not been widely adopted due to perceptions of increased morbidity and operative difficulty with a lack of available data in this setting., Objective: We sought to conduct a cost-effectiveness analysis comparing strategies for long-term sterilization and ovarian cancer risk reduction at the time of cesarean delivery, including bilateral tubal ligation, opportunistic salpingectomy, and long-acting reversible contraception., Study Design: A decision-analytic and cost-effectiveness model was constructed for pregnant women undergoing cesarean delivery who desired permanent sterilization in the US population, comparing 3 strategies: (1) bilateral tubal ligation, (2) bilateral opportunistic salpingectomy, and (3) postpartum long-acting reversible contraception. This theoretic cohort consisted of 110,000 pregnant women desiring permanent sterilization at the time of cesarean delivery and ovarian cancer prevention at an average of 35 years who were monitored for an additional 40 years based on an average US female life expectancy of 75 years. The primary outcome measure was the incremental cost-effectiveness ratio. Effectiveness was measured as quality-adjusted life years. Secondary outcomes included: the number of ovarian cancer cases and deaths, procedure-related complications, and unintended and ectopic pregnancies. The 1-, 2-, and 3-way and Monte Carlo probabilistic sensitivity analyses were performed. The willingness-to-pay threshold was set at $100,000., Results: Both bilateral tubal ligation and bilateral opportunistic salpingectomy with cesarean delivery have favorable cost-effectiveness ratios. In the base case analysis, salpingectomy was more cost-effective with an incremental cost-effectiveness ratio of $23,189 per quality-adjusted life year compared to tubal ligation. Long-acting reversible contraception after cesarean was not cost-effective (ie, dominated). Although salpingectomy and tubal ligation were both cost-effective over a wide range of cost and risk estimates, the incremental cost-effectiveness ratio analysis was highly sensitive to the uncertainty around the estimates of salpingectomy cancer risk reduction, risk of perioperative complications, and cost. Monte Carlo probabilistic sensitivity analysis estimated that tubal ligation had a 49% chance of being the preferred strategy over salpingectomy. If the true salpingectomy risk of perioperative complications is >2% higher than tubal ligation or if the cancer risk reduction of salpingectomy is <52%, then tubal ligation is the preferred, more cost-effective strategy., Conclusion: Bilateral tubal ligation and bilateral opportunistic salpingectomy with cesarean delivery are both cost-effective strategies for permanent sterilization and ovarian cancer risk reduction. Although salpingectomy and tubal ligation are both reasonable strategies for cesarean patients seeking permanent sterilization and cancer risk reduction, threshold analyses indicate that the risks and benefits of salpingectomy with cesarean delivery need to be better defined before a preferred strategy can be determined., (Copyright © 2018. Published by Elsevier Inc.)

Objective: We sought to assess fulfillment of sterilization requests while accounting for the complex interplay between insurance, clinical and social factors in a contemporary context that included both inpatient and outpatient postpartum sterilization procedures., Study Design: This is a retrospective single-center cohort chart review study of 1331 women with a documented contraceptive plan at time of postpartum discharge of sterilization. We compared sterilization fulfillment within 90days of delivery, time to sterilization and rate of subsequent pregnancy after nonfulfillment between women with Medicaid and women with private insurance., Results: A total of 475 of 1030 Medicaid-insured and 100 of 154 privately insured women received postpartum sterilization (46.1% vs. 64.9%, p<.001). Women with Medicaid had a longer time from delivery to completion of the sterilization request (p<.001). After adjusting for age, parity, gestational age, mode of delivery, adequacy of prenatal care, race/ethnicity, marital status and education level, private insurance status was not associated with either sterilization fulfillment [odds ratio 0.94, 95% confidence interval (CI) 0.54-1.64] or time to sterilization (hazard ratio 1.03, 95% C.I. 0.73-1.34). Of the 555 Medicaid-insured women who did not receive a postpartum sterilization, 267 (48.1%) had valid Title XIX sterilization consent forms at time of delivery. Of women who did not receive sterilization, 132 of 555 Medicaid patients and 5 of 54 privately insured patients became pregnant within 1 year (23.8% vs. 9.3%, p=.023)., Conclusion: Differences in fulfillment rates of postpartum sterilization and time to sterilization between women with Medicaid versus private insurance are similar after adjusting for relevant clinical and demographic factors. Women with Medicaid are more likely than women with private insurance to have a short interval repeat pregnancy after an unfulfilled sterilization request., Implications: Efforts are needed to ensure that Medicaid recipients who desire sterilization receive timely services., (Copyright © 2018. Published by Elsevier Inc.)

Sterilization, male and female combined, is the most common use of contraception in the United States. Despite the lower risk, higher cost-efficacy, and high efficacy of vasectomy compared with female sterilization, more US women rely on female sterilization than male sterilization. Reasons for low use of vasectomy include lack of knowledge and misconceptions about the procedure, lack of access, provider bias, and patient preferences. This article will provide a basic overview of male and female sterilization, an exploration of vasectomy barriers, and ways obstetrician-gynecologists can increase vasectomy uptake including regular recommendation of vasectomy to patients in long-term committed relationships considering sterilization.

Objective: Cross-sectional studies have found that low-income and racial/ethnic minority women are more likely to use female sterilization and less likely to rely on a partner's vasectomy than women with higher incomes and whites. However, studies of pregnant and postpartum women report that racial/ethnic minorities, particularly low-income minority women, face greater barriers in obtaining a sterilization than do whites and those with higher incomes. In this paper, we address this apparent contradiction by examining the likelihood a woman gets a sterilization following each delivery, which removes from the comparison any difference in the number of births she has experienced., Study Design: Using the 2006-2010 National Survey of Family Growth, we fit multivariable-adjusted logistic and Cox regression models to estimate odds ratios and hazard ratios for getting a postpartum or interval sterilization, respectively, according to race/ethnicity and insurance status., Results: Women's chances of obtaining a sterilization varied by both race/ethnicity and insurance. Among women with Medicaid, whites were more likely to use female sterilization than African Americans and Latinas. Privately insured whites were more likely to rely on vasectomy than African Americans and Latinas, but among women with Medicaid-paid deliveries reliance on vasectomy was low for all racial/ethnic groups., Conclusions: Low-income racial/ethnic minority women are less likely to undergo sterilization following delivery compared to low-income whites and privately insured women of similar parities. This could result from unique barriers to obtaining permanent contraception and could expose women to the risk of future unintended pregnancies., Implications: Low-income minorities are less likely to undergo sterilization than low-income whites and privately insured minorities, which may result from barriers to obtaining permanent contraception, and exposes women to unintended pregnancies., (Copyright © 2014 Elsevier Inc. All rights reserved.)

Objective: Medicaid sterilization policy, which includes a mandatory 30-day waiting period between consent and the sterilization procedure, poses significant logistical barriers for many women who desire publicly funded sterilization. Our goal was to estimate the number of unintended pregnancies and the associated costs resulting from unfulfilled sterilization requests due to Medicaid policy barriers., Study Design: We constructed a cost-effectiveness model from the health care payer perspective to determine the incremental cost over a 1-year time horizon of the current Medicaid sterilization policy compared to a hypothetical, revised policy in which women who desire a postpartum sterilization would face significantly reduced barriers. Probability estimates for potential outcomes in the model were based on published sources; costs of Medicaid-funded sterilizations and Medicaid-covered births were based on data from the Medicaid Statistical Information System and The Guttmacher Institute, respectively., Results: With the implementation of a revised Medicaid sterilization policy, we estimated that the number of fulfilled sterilization requests would increase by 45%, from 53.3% of all women having their sterilization requests fulfilled to 77.5%. Annually, this increase could potentially lead to over 29,000 unintended pregnancies averted and $215 million saved., Conclusion: A revised Medicaid sterilization policy could potentially honor women's reproductive decisions, reduce the number of unintended pregnancies and save a significant amount of public funds., Implication: Compared to the current federal Medicaid sterilization policy, a hypothetical, revised policy that reduces logistical barriers for women who desire publicly funded, postpartum sterilization could potentially avert over 29,000 unintended pregnancies annually and therefore lead to cost savings of $215 million each year., (© 2013.)

In the 1970s, concern about coercive sterilization of low-income and minority women in the United States led the US Department of Health, Education, and Welfare to create strict regulations for federally funded sterilization procedures. Although these policies were instituted to secure informed consent and protect women from involuntary sterilization, there are significant data indicating that these policies may not, in fact, ensure that consent is truly informed and, further, may prevent many low-income women from getting a desired sterilization procedure. Given the alarmingly high rates of unintended pregnancy in the United States, especially among low-income populations, we feel that restrictive federal sterilization policies should be reexamined and modified to simultaneously ensure informed decision-making and honor women's reproductive choices.

Female sterilisation is a safe and effective form of permanent birth control. In the United States (US), it is still the second most commonly used form of contraception overall and is the most frequently used method among married women and among women over 30 years of age. Although several European countries have noted a sharp decline in the number of women electing tubal sterilisation in recent years, such trends have not been as obvious in the US. While female sterilisation remains popular, there are considerable system-level barriers to getting the procedure for certain segments of the population as well as emerging concerns about appropriate utilisation of this contraceptive method in light of newer, reversible options and the knowledge that regret after permanent contraception is high. Given the complexity of this decision-making process, it is critical that providers ensure at the very least that women are aware of the potential disadvantages of tubal occlusion and are knowledgeable of other highly effective contraceptive methods that are available but vastly underutilised in the US, namely, vasectomy, intrauterine contraceptives, and implants.

In FY 1990, the federal and state governments spent $504 million to provide contraceptive services and supplies, according to results of a survey of state health, social services and Medicaid agencies conducted by The Alan Guttmacher Institute. Medicaid accounted for 38 percent of all public funds spent on contraceptive services, Title X provided 22 percent, and two federal block-grant programs--Social Services and Maternal and Child Health--together were responsible for 12 percent of public expenditures. State governments accounted for the remaining 28 percent of public funding. Although public expenditures for contraceptive services have risen by $154 million over the past decade, when inflation is taken into account, expenditures have actually fallen by one-third. Since 1980, the proportion of public contraceptive expenditures contributed by Title X has been cut virtually in half, while the proportion contributed by state governments has nearly doubled. When inflation is taken into account, Title X expenditures for contraceptive services have fallen by almost two-thirds since 1980. The federal and state governments together spent $95 million to subsidize sterilization services in 1990, and $65 million to provide abortion services. The federal government was the major source of funding for sterilization services but provided less than one percent of the cost of abortion services. Because of changes over time in survey methodology and the difficulties some states had in separating out expenditures by type of care, these data are approximations.

In FY 1987, the federal and state governments spent +386 million to provide family planning services. Medicaid was the leading source of public funding, accounting for 36 percent of all public monies spent on family planning. Title X of the Public Health Service Act provided 34 percent of total public funds, and two block-grant programs--Social Services and Maternal and Child Health--together were responsible for 17 percent of public support in this area. State governments, which spent a total of +50 million of their own revenues for family planning services, accounted for the remaining 13 percent of public funding. The federal and state governments together spent +65 million to subsidize contraceptive sterilization services in FY 1987. The federal government provided 97 percent of the funding, 88 percent through the Medicaid program. In addition, the federal and state governments spent +64 million to provide 189,000 abortions to poor women; less than one percent of these funds were contributed by the federal government. These data come from a survey of state health, welfare and Medicaid agencies carried out by The Alan Guttmacher Institute and should be viewed as approximations rather than as precise figures.

In FY 1985, the federal and state governments spent $398 million to provide contraceptive services and supplies. The two leading sources of funding were the Medicaid program and Title X of the Public Health Service Act. The former accounted for $137 million, or 34 percent of all public expenditures; and the latter program accounted for $133 million, also 34 percent. Two blockgrant programs--Social Services and Maternal and child Health--provided $40 million and $23 million, respectively; together, they were responsible for 16 percent of public support for contraceptive services. State governments, which spent $64 million of their own revenues, accounted for another 16 percent of funding. The federal and state governments together spent $64 million to subsidize sterilizations in FY 1985. The federal government provided 94 percent of the funding--84 percent through the Medicaid program. In addition, the states and the federal government spent $66 million to subsidize 188,000 abortions; in this case, however, the federal government contributed less than one percent of the funds used. These data come from a survey of state agencies, and should be viewed as approximations rather than as precise figures.

The cost of contraception is one factor that affects the choice of a birth control method. An analysis of the first-year costs for the various methods, based on fees charged by private physicians and supplies purchased at drugstores, shows that the cost can be considerable and that there are large differences in cost between methods. Prescription contraceptives--the pill, IUD and diaphragm--are by far the most expensive of the reversible methods because they require medical supervision, but supplies alone are also more expensive for prescription methods than for nonprescription methods. First-year cost is highest for the pill-$172, compared with $160 for the diaphragm and $131 for the IUD. The mean of $154 for these three prescription methods is almost four times the mean first-year cost of $40 for condoms and foam. Sterilization necessitates the largest initial expenditure, and the cost of tubal ligation-$1,180-is almost five times the cost of vasectomy-$241. However, sterilization represents a one-time cost, while the other methods involve recurring expenses that may add up to more than the cost of sterilization over time. The methods that are associated with the lowest failure rates-sterilization, the pill and the IUD-are among the most expensive. To offset the costs of contraception, 4.6 million American women obtained low-cost care from subsidized family planning clinics in 1980.

The federal government and the states spent $328 million to support the provision of contraceptive services in fiscal 1982, 13 percent less than they had spent the previous year. Federal funds for family planning services came from Title X of the Public Health Service Act, Title XIX of the Social Security Act (Medicaid), and the Maternal and Child Health (MCH) and Social Services block grants, which are administered by the states. Title X continued to provide the largest, although a diminishing, share of public funds for contraceptive services--36 percent of all such funds in 1982. (In 1980, Title X had accounted for 44 percent of public funding.) Medicaid expenditures for family planning totaled $94 million; $17 million was spent under the MCH block grant, and $46 million under the Social Services block grant. State governments contributed an additional $53 million, about the same figure reported for the previous year, indicating that the states did not use their own funds to soften the impact of cuts in federal expenditures for contraceptive services in 1982. The federal government and the states spent an estimated $55 million, almost all of it through Medicaid, to provide sterilization services for poor women. The states spent $67 million and the federal government spent $1 million to provide abortions for 210,000 indigent women. These figures come from the 11th annual survey of state health and welfare agencies and state Medicaid programs by The Alan Guttmacher Institute (AGI). The AGI conducted this survey in January 1983 to determine the levels and sources of public funding for contraceptive, sterilization and abortion services in each state during FY 1982.

In 1983, the federal and state governments spent +340 million to provide contraceptive services--four percent more than they spent during the previous year. Title X of the Public Health Service Act, still the leading source of funding, accounted for +117 million, or 34 percent of all public expenditures. Almost as important was the +108 million (32 percent of total expenditures) provided through Title XIX of the Social Security Act (Medicaid). Two block-grant programs--Social Services and Maternal and Child Health--provided +38 million and +19 million, respectively; together, the two were responsible for 17 percent of public support for contraceptive services. State governments, which spent +58 million of their own revenues, provided an additional 17 percent of funding. Some public expenditures for contraceptive services were made in all the states. Nearly all of the four percent increase in total public funds between 1982 and 1983 was due to a 15 percent rise in Medicaid reimbursements. The federal and state governments together spent +69 million to provide about 73,000 sterilizations in 1983. Ninety percent of sterilization expenditures were made by the federal government--86 percent through the Medicaid program. In addition, the states and the federal government spent +71 million to provide 216,000 abortions in 1983. Unlike public funding for either contraceptive services or sterilization, almost all of the funding for abortion came from the states rather than from the federal government.