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Prohibiting consent: what are the costs of denying permanent contraception concurrent with abortion care?

      Objective

      Oregon and federal laws prohibit giving informed consent for permanent contraception when presenting for an abortion. The primary objective of this study was to estimate the number of unintended pregnancies associated with this barrier to obtaining concurrent tubal occlusion and abortion, compared with the current policy, which limits women to obtaining interval tubal occlusion after abortion. The secondary objectives were to compare the financial costs, quality-adjusted life years, and the cost-effectiveness of these policies.

      Study Design

      We designed a decision-analytic model examining a theoretical population of women who requested tubal occlusion at time of abortion. Model inputs came from the literature. We examined the primary and secondary outcomes stratified by maternal age (>30 and <30 years). A Markov model incorporated the possibility of multiple pregnancies. Sensitivity analyses were performed on all variables and a Monte Carlo simulation was conducted.

      Results

      For every 1000 women age <30 years in Oregon who did not receive requested tubal occlusion at the time of abortion, over 5 years there would be 1274 additional unintended pregnancies and an additional $4,152,373 in direct medical costs. Allowing women to receive tubal occlusion at time of abortion was the dominant strategy. It resulted in both lower costs and greater quality-adjusted life years compared to allowing only interval tubal occlusion after abortion.

      Conclusion

      Prohibiting tubal occlusion at time of abortion resulted in an increased incidence of unintended pregnancy and increased public costs.

      Key words

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      References

        • Grosboll D.
        Abuse: current state of the law and remedies for abuse.
        Golden Gate University Law Review. 1980; 10: 1147-1189
      1. Cruz L. Eugenics yields dark past: some Oregonians have sad memories of forced sterilization. Statesman Journal Dec. 1, 2002.

      2. Code of Federal Regulations 42 (CFR) §§50.201-210.

        • Peipert J.F.
        • Madden T.
        • Allsworth J.E.
        • Secura G.M.
        Preventing unintended pregnancies by providing no-cost contraception.
        Obstet Gynecol. 2012; 120: 1291-1297
        • Stanek A.M.
        • Bednarek P.H.
        • Nichols M.D.
        • Jensen J.T.
        • Edelman A.B.
        Barriers associated with the failure to return for intrauterine device insertion following first-trimester abortion.
        Contraception. 2009; 79: 216-220
        • Thurman A.R.
        • Janecek T.
        One-year follow-up of women with unfulfilled postpartum sterilization requests.
        Obstet Gynecol. 2010; 116: 1071-1077
        • Borrero S.
        • Zite N.
        • Potter J.E.
        • Trussell J.
        • Smith K.
        Potential unintended pregnancies averted and cost savings associated with a revised Medicaid sterilization policy.
        Contraception. 2013; 88: 691-696
        • Mosher W.D.
        • Jones J.
        Use of contraception in the United States: 1982-2008.
        Vital Health Stat 23. 2010; : 1-44
        • Peterson H.B.
        Sterilization.
        Obstet Gynecol. 2008; 111: 189-203
        • Cheng M.C.
        • Chew S.C.
        • Cheong J.
        • et al.
        Safety of postabortion sterilization compared with interval sterilization: a controlled study.
        Lancet. 1979; 2: 682-685
        • Cheng M.C.
        • Rochat R.W.
        The safety of combined abortion-sterilization procedure.
        Am J Obstet Gynecol. 1977; 129: 548-552
        • Beauchamp T.L.
        • Childress J.F.
        Principles of biomedical ethics.
        Oxford University Press, New York, NY2009
        • Dunson D.B.
        Bayesian methods for latent trait modeling of longitudinal data.
        Stat Methods Med Res. 2007; 16: 399-415
        • Peterson H.B.
        • Xia Z.
        • Hughes J.M.
        • Wilcox L.S.
        • Tylor L.R.
        • Trussell J.
        The risk of pregnancy after tubal sterilization: findings from the US Collaborative Review of Sterilization.
        Am J Obstet Gynecol. 1996; 174: 1161-1170
        • Trussell J.
        • Guthrie K.
        Choosing a contraceptive: efficacy, safety, and personal considerations.
        in: Hatcher R.A. Trussell J. Nelson A. Cates W. Kowal D. Policar M. Contraceptive technology. 20th ed. Ardent Media, New York, NY2011
      3. US Department of Labor, Bureau of Labor Statistics. Consumer price index inflation calculator. Available at: http://www.bls.gov/data/inflation_calculator.htm. Accessed Oct. 13, 2013.

        • Rodriguez M.I.
        • Angus L.
        • Elman E.
        • Darney P.D.
        • Caughey A.B.
        Financial effect of instituting Deficit Reduction Act documentation requirements in family planning clinics in Oregon.
        Contraception. 2011; 83: 537-541
        • Rodriguez M.I.
        • Caughey A.B.
        Cost-effectiveness analyses and their role in improving healthcare strategies.
        Curr Opin Obstet Gynecol. 2013; 25: 487-493
        • Schwarz E.B.
        • Smith R.
        • Steinauer J.
        • Reeves M.F.
        • Caughey A.B.
        Measuring the effects of unintended pregnancy on women's quality of life.
        Contraception. 2008; 78: 204-210
        • Salomon J.A.
        • Vos T.
        • Hogan D.R.
        • et al.
        Common values in assessing health outcomes from disease and injury: disability weights measurement study for the Global Burden of Disease Study 2010.
        Lancet. 2012; 380: 2129-2143
        • Lilford R.J.
        • Pauker S.G.
        • Braunholtz D.A.
        • Chard J.
        Decision analysis and the implementation of research findings.
        BMJ. 1998; 317: 405-409
        • Gilliam M.
        • Davis S.D.
        • Berlin A.
        • Zite N.B.
        A qualitative study of barriers to postpartum sterilization and women's attitudes toward unfulfilled sterilization requests.
        Contraception. 2008; 77: 44-49
        • Sivin I.
        Copper T. IUD use and ectopic pregnancy rates in the United States.
        Contraception. 1979; 19: 151-173
        • Kost K.
        • Singh S.
        • Vaughan B.
        • Trussell J.
        • Bankole A.
        Estimates of contraceptive failure from the 2002 National Survey of Family Growth.
        Contraception. 2008; 77: 10-21
        • Schippert C.
        • Soergel P.
        • Staboulidou I.
        • et al.
        The risk of ectopic pregnancy following tubal reconstructive microsurgery and assisted reproductive technology procedures.
        Arch Gynecol Obstet. 2012; 285: 863-871
        • Hillis S.D.
        • Marchbanks P.A.
        • Tylor L.R.
        • Peterson H.B.
        Poststerilization regret: findings from the United States Collaborative Review of Sterilization.
        Obstet Gynecol. 1999; 93: 889-895
        • Schmidt J.E.
        • Hillis S.D.
        • Marchbanks P.A.
        • Jeng G.
        • Peterson H.B.
        Requesting information about and obtaining reversal after tubal sterilization: findings from the US Collaborative Review of Sterilization.
        Fertil Steril. 2000; 74: 892-898
        • Boeckxstaens A.
        • Devroey P.
        • Collins J.
        • Tournaye H.
        Getting pregnant after tubal sterilization: surgical reversal or IVF?.
        Hum Reprod. 2007; 22: 2660-2664
        • Finer L.B.
        • Kost K.
        Unintended pregnancy rates at the state level.
        Perspect Sex Reprod Health. 2011; 43: 78-87
        • Finer L.B.
        • Henshaw S.K.
        Disparities in rates of unintended pregnancy in the United States, 1994 and 2001.
        Perspect Sex Reprod Health. 2006; 38: 90-96
        • Peterson H.B.
        • Xia Z.
        • Hughes J.M.
        • Wilcox L.S.
        • Tylor L.R.
        • Trussell J.
        The risk of ectopic pregnancy after tubal sterilization: US Collaborative Review of Sterilization Working Group.
        N Engl J Med. 1997; 336: 762-767
        • Sivin I.
        Dose- and age-dependent ectopic pregnancy risks with intrauterine contraception.
        Obstet Gynecol. 1991; 78: 291-298
        • Saraiya M.
        • Berg C.J.
        • Shulman H.
        • Green C.A.
        • Atrash H.K.
        Estimates of the annual number of clinically recognized pregnancies in the United States, 1981-1991.
        Am J Epidemiol. 1999; 149: 1025-1029
        • Witsenburg C.
        • Dieben S.
        • Van der Westerlaken L.
        • Verburg H.
        • Naaktgeboren N.
        Cumulative live birth rates in cohorts of patients treated with in vitro fertilization or intracytoplasmic sperm injection.
        Fertil Steril. 2005; 84: 99-107
      4. Oregon Center for Health Statistics. Oregon Vital Statistics 2011 Annual Report Volume 1. Portland, OR: Oregon Health Authority, Oregon Public Health Division, February 2013.

        • Zite N.
        • Wuellner S.
        • Gilliam M.
        Failure to obtain desired postpartum sterilization: risk and predictors.
        Obstet Gynecol. 2005; 105: 794-799
      5. World Health Organization. Ensuring human rights in the provision of contraceptive information and services. Geneva, Switzerland 2014. Available at: http://www.who.int/reproductivehealth/publications/family_planning/human-rights-contraception/en/. Accessed March 2, 2014.

        • Borrero S.
        • Abebe K.
        • Dehlendorf C.
        • et al.
        Racial variation in tubal sterilization rates: role of patient-level factors.
        Fertil Steril. 2011; 95: 17-22
        • Zite N.B.
        • Wallace L.S.
        Use of a low-literacy informed consent form to improve women's understanding of tubal sterilization: a randomized controlled trial.
        Obstet Gynecol. 2011; 117: 1160-1166
        • Borrero S.
        • Zite N.
        • Potter J.E.
        • Trussell J.
        Medicaid policy on sterilization–anachronistic or still relevant?.
        N Engl J Med. 2014; 370: 102-104
        • Committee on Ethics
        Sterilization of women, including those with mental disabilities. ACOG committee opinion no. 371. July 2007.
        Obstet Gynecol. 2007; 110: 217-220
        • Sonfield A.
        • Gold R.B.
        Public funding for family planning, sterilization and abortion services, FY 1980-2010.
        Guttmacher Institute, New York2012 (Available at:) (Accessed Feb. 28, 2014)