Rethinking the Tubal Ligation Consent Procedure for Federally Insured Women

Summary and Comment |
May 29, 2014

Rethinking the Tubal Ligation Consent Procedure for Federally Insured Women

  1. Diane E. Judge, APN/CNP

Requiring 30-day advance consent and disallowing the opportunity to provide consent during labor violate medical ethics standards.

  1. Diane E. Judge, APN/CNP

It's time to reconsider the prerequisites for Medicaid-insured women to obtain permanent sterilization. A medical ethicist and an obstetrician/gynecologist cite two requirements faced by Medicaid-insured but not privately insured women (a 30-day waiting period between signing the consent form and obtaining the procedure, and not allowing consent during labor) that violate the standards of medical ethics, with the potential for significant adverse consequences. In an all-too-common scenario, a federally insured woman receives prenatal care at a community health center where she signs informed consent for postpartum tubal ligation (TL), then delivers at a hospital lacking access to the consent form. Discharged without the permanent contraception she desires, she is at high risk for unplanned pregnancy according to a study in which women who requested but didn't receive postpartum TL had a 47% pregnancy rate (twice that of women not requesting sterilization) during the first year after delivery.

The 1979 Medicaid consent requirements were enacted in response to many instances in which federally insured women were coerced to undergo TL because they were persuaded that continued Medicaid benefits were contingent upon sterilization. The authors argue that these requirements violate the four principles of medical ethics: balancing the least harm (nonmaleficence) with doing good (beneficence), fostering an equitable healthcare system (justice), and respecting patients' values and independence (autonomy). The requirements enacted to prevent maleficence actually inflict it by preventing women from obtaining a procedure they desire, possibly resulting in unwanted pregnancy. The waiting period and its implication that low-income women are unable to make informed choices about TL during labor — when no such restrictions apply to privately insured women — violate the principles of justice and autonomy.


The authors caution that, while medical ethics mandate revisions, it's important to safeguard the rights of those women who have “historically suffered mistreatment at the hands of the medical profession.” Just as we should not discriminate against low-income women by inappropriately encouraging sterilization, we should also avoid imposing burdens that curtail their access to reproductive options.

Editor Disclosures at Time of Publication

  • Disclosures for Diane E. Judge, APN/CNP at time of publication Nothing to disclose


Reader Comments (2)

Mary Bennett,RN Resident

As a retired nurse, and mother, I agree with Dr. DeMedio that it is unethical to offer sterilization to a woman during the pains of labor. From the woman's point of view, it feels more like coercion than an "offer". One of my friends told me how every time she would have a hard contraction, her nurse would shove a consent form in her face.
When I worked in L&D in the 1980's, I heard MANY very condescending and offensive comments by our health-care professionals (off-the-record, of course) about how "those types of people shouldn't be breeding".
As we are all human, each one of us is prone to feelings of arrogance and false pride. We must all fight against the temptation to think of ourselves as better than others. The availability of sterilization is a real Pandora's Box. There is the inevitable temptation to use it to--as Ebenezer Scrooge would say--"...decrease the surplus population" of those people that arrogant people consider inferior. We all have dignity.
To consider all this as "safeguarding" women's rights shows just how far we've descended into "newspeak" since we renamed preborn children as "products of conception".

William DeMedio Physician, Family Medicine/General Practice, Family Practice

I have seen many women offered the opportunity to obtain a tubal ligation after delivery while they were in labor. Among these women who were offered the opportunity and got the sterilization procedure I have seen no quality studies regarding how many of them were sorry they did. This should be evaluated.

In terms of ethics, simply offering this procedure to a woman during the pains of labor is unethical. Any major elective life altering procedure should be offered while the patient is free of duress. Labor pain is significant duress. Doctors are paid to do tubal ligations.

Lastly, singling out "federally insured women" for elective sterilization reminds me of things the nazis did with people that they considered less than desirable, or the forced sterilization that occurred in the United States in the past among people considered "mentally defective". A prestigious journal such as NEJM should carefully consider what they print as science and what they print as an adverse political agenda.

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