Fulfillment of Desired Postpartum Permanent Contraception: a Health Disparities Issue.

Women of color experience marked disparities in fulfillment of desired postpartum permanent contraception. While many attribute the disparity to the required Medicaid sterilization consent form and 30-day waiting period established in response to forced and coerced sterilizations, the policy does not entirely explain the disparity; racial and ethnic disparities persist even within strata of insurance type. We therefore propose framing postpartum permanent contraception as a health disparities issue that requires multi-level interventions to address. Based on the literature, we identify discrete levels of barriers to postpartum permanent contraception fulfillment at the patient, physician, hospital, and policy levels that interact and compound within and between individual levels, affecting each individual patient differently. At the patient level, sociodemographic characteristics such as age, race and ethnicity, and parity impact desire for and fulfillment of permanent contraception. At the physician level, implicit bias and paternalistic counseling contribute to barriers in permanent contraception fulfillment. At the hospital level, Medicaid reimbursement, operating room availability, and religious affiliation influence fulfillment of permanent contraception. Lastly, at the policy level, the Medicaid consent form and waiting period pose a known barrier to fulfillment of desired postpartum permanent contraception. Unpacking each of these discrete barriers and untangling their collective impact is necessary to eliminate racial and ethnic disparities in permanent contraception fulfillment.