US doctors say that since the controversial overturning by the Supreme Court of Roe v Wade in June 2022, sterilisations in certain states have tripled, with a wave of young people asking for permanent birth control like tubal ligations or vasectomies.
The US Supreme Court Roe v Wade ruling, in 1973, found that the Constitution of the United States generally protected a right to have an abortion. In 2022, reports Medpage Today, this was overturned in Dobbs v Jackson Women’s Health Organisation.
Forty-one US states across the country have bans or restrictions on abortion, according to the Guttmacher Institute, and in recent years, anti-abortion groups have advocated for restricting contraception access.
Recent research published in JAMA Health Forum shows how big that wave of young people is nationally.
University of Pittsburgh researcher Jackie Ellison, PhD, and her co-authors used TriNetX, a national medical record database, to look at how many 18- to 30-year-olds were getting sterilised before and after the ruling, and found sharp increases among both male and females.
Tubal ligations doubled from June 2022 to September 2023, and vasectomies increased over three times during that same time, Ellison said. Even with that increase, women are still being sterilised much more often than men. Vasectomies have levelled off at the new higher rate, while tubal ligations still appear to be increasing.
Tubal ligations among young people had been slowly rising for years, but the Dobbs v. Jackson ruling had a discernible impact.
“We saw a pretty substantial increase in both tubal ligation and vasectomy procedures in response to Dobbs,” Ellison said.
The data were not broken out by state. But in states like Montana, where the future of abortion rights is deeply uncertain, ob/gyns and urologists say they are noticing the phenomenon.
Montana-based ob/gyn Gina Nelson, MD, said she’s seeing women of all ages, with and without children, seeking sterilisation because of the Dobbs decision.
The biggest change was among young patients who don’t have children, which she added was a big shift from when she started practising 30 years ago.
She said she believes she is better equipped to talk them through the process now than she was in the 1990s, when she first had a 21-year-old patient ask for sterilisation.
“I wanted to respect her rights, but I also wanted her to consider a number of future scenarios,” she said, “so, I actually made her write an essay for me, and then she brought it in, jumped through all the hoops, and I tied her tubes.”
Nelson said she doesn’t make patients do that today but still believes she is responsible for helping patients deeply consider what they’re requesting.
She schedules time with patients for conversations about the risks and benefits of all their birth control options, and she believes that helps her patients make an informed decision about whether to move forward with permanent birth control.
The American College of Obstetricians and Gynaecologists (ACOG) supports Nelson’s practice.
Louise King, MD, an assistant professor of obstetrics at Harvard Medical School in Boston, who helps lead ACOG’s ethics committee, said providers are accepting the idea of listening to their patients, not deciding for them whether they can get permanent contraception based on age or whether they have children.
Helena-based ob/gyn Alexis O’Leary, DO, sees a divide between younger and older providers when it comes to female sterilisation. O’Leary finished her residency six years ago – and noted that older providers were more reluctant to sterilise younger patients.
“I will routinely see patients who have been denied by other people because of, ‘Ah, you might want to have kids in the future’, or ‘Are you sure you want to do this? It’s not reversible’,” she said.
This article is from a partnership that includes MTPR, NPR and KFF Health News.
Study details
Changes in Permanent Contraception Procedures Among Young Adults Following the Dobbs Decision
Jacqueline Ellison, Brittany Brown-Podgorski, Jake Morgan.
Published in JAMA Health Forum on 12 April 2024
Discussion
On June 24, 2022, the US Supreme Court’s decision in Dobbs v Jackson Women’s Health Organisation overturned the constitutional right to abortion, permitting states to further restrict or ban abortion care. As of January 2024, 21 states have done so. This structural barrier to exercising control over pregnancy and childbearing will indirectly affect contraceptive decision-making.
Early research has documented increased demand for permanent contraception in the months following Dobbs, including tubal sterilisation and vasectomy. This change may reflect fears of restricted access to abortion and/or contraception. However, no research, to our knowledge, has evaluated the differential effect of Dobbs on permanent contraception among men relative to women or among younger adults who are more likely to have an abortion and to experience sterilisation regret. We therefore evaluated changes in tubal ligation and vasectomy following Dobbs among younger adults.
Methods
We used data from the TriNetX platform for this cross-sectional study. These continuously updated medical record data are largely from academic medical centres and affiliated clinics in all 4 US census regions. We used an interrupted time series study design, fitting seasonally adjusted segmented autoregressive models to assess level and slope changes in procedure rates before (January 1, 2019, to May 31, 2022) and after (June 1, 2022, to September 30, 2023) Dobbs. Sensitivity analyses with a truncated pre-Dobbs observation window (April 1, 2021, to May 31, 2022) were conducted using Stata, version 17.1 (StataCorp LLC). This research was deemed exempt from review and the need for informed consent by the Boston University Institutional Review Board owing to the use of de-identifed patient data. We followed the (STROBE) reporting guideline.
Using monthly aggregate counts of tubal ligations and vasectomies, we calculated rates per 100 000 person-months among female and male patients aged 18 to 30 years. Individuals with an encounter for evaluation and management each month and no permanent contraception documented previously were included in the denominator. Visits for evaluation and management, tubal sterilisation, and vasectomy procedures were identified using Current Procedural Terminology and International Statistical Classification of Diseases, Tenth Revision codes.
Results
Observed permanent contraception procedure rates, estimates, and seasonally adjusted models for 22 063 348 person-months (36.9% male and 63.1% female) are presented in the Figure. Prior to Dobbs, the monthly permanent contraception rate increased by 2.84 and 1.03 procedures per 100 000 person-months among female and male patients, respectively. Dobbs was associated with an immediate level increase of 58.02 procedures and 5.31 procedures per month among female patients. Among male patients, it was associated with a level increase of 26.99 procedures and no significant change in the number of procedures per month. Findings were robust to sensitivity analyses.
Discussion
We observed an abrupt increase in permanent contraception procedures among adults aged 18 to 30 years after Dobbs. The increase in procedures for female patients was double that for male patients. These patterns offer insights into the gendered dynamics of permanent contraceptive use and may reflect the disproportionate health, social, and economic consequences of compulsory pregnancy on women and people with the capacity to become pregnant.
This study has several limitations. The TriNetX platform does not capture state or healthcare organisation identifiers. We were therefore unable to assess the potential outcomes of state abortion policy or account for changes in the sample attributable to fluctuations in the organisations contributing data over the study period. Additionally, our findings do not provide insight into the differential experiences of black, Indigenous, Hispanic, disabled, immigrant, and low-income women, who disproportionately encounter interference and coercion in their contraceptive decision-making.
The abrupt increase in permanent contraception rates may indicate a policy-induced change in contraceptive preferences. Dobbs may have also increased a sense of urgency among individuals who were interested in permanent contraception before the decision. Changes in contraceptive decision-making must be considered to understand the short- and long-term implications of Dobbs on reproductive autonomy.
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