This week, a leaked draft opinion from the Supreme Court suggests that a decision to overturn Roe v. Wade, the landmark 1973 decision that secured Americans’ right to an abortion, is likely to happen in the near future.
While nothing has changed — yet — and abortion remains legal, it highlights the many challenges people face if they don’t want to have more or any children.
Just one of these obstacles is access to tubal ligation (better known as getting your tubes tied), a surgical procedure intended to permanently prevent pregnancy by cutting, clipping, or blocking both fallopian tubes. After a tubal ligation, a person continues to ovulate, but sperm can’t reach the eggs.
It seems like the surgery should be a straightforward elective procedure just like a vasectomy. However, many people, particularly those who are young, haven’t had children, or are on Medicaid — the government-sponsored health insurance program for low-income patients — find it difficult or nearly impossible to get a tubal ligation.
“There are numerous barriers for people who are desiring a tubal sterilization to be able to execute or act on that decision, and I think the implications of unfulfilled sterilization requests in a post-Roe world are simply heightened,” said Dr. Sonya Borrero, an internal medicine physician and professor at the University of Pittsburgh School of Medicine who counsels patients before these procedures. “We need to look at our clinical practice and policies to ensure that people are able to access the contraceptive methods of their choosing, whatever that might be”
Sterilization is the most common contraceptive method among women in the US, according to the CDC. Overall, about 18% of women using birth control choose this option, more than oral contraceptive pills (13%) or long-acting reversible contraceptives like IUDs (10%).
However, given how difficult it is for some people to get the surgery, there likely remains an unmet demand, despite it being a safe and effective option that could prevent thousands of unintended pregnancies.
Still, experts warn that better access to contraceptive methods like sterilization isn’t an alternative to abortion.
"Access to abortion care improves the health and well-being of those who need it, and data have long shown that restrictions to access to care only cause harm. Quite simply, people will always need access to abortion,” Dr. Jen Villavicencio, lead for equity transformation at the American College of Obstetricians and Gynecologists, said in a statement sent to BuzzFeed News.
“Contraception fails, lives change, unexpected complications occur,” Villavicencio said. “No matter what an individual’s reason for an abortion, it is essential that they have access to an abortion when they need it."
Many doctors won’t perform tubal ligations for certain patients
Dozens of people have gone public with their experiences trying to find a doctor who is willing to perform the surgery, especially if they are childless or younger.
Some doctors seem to have a difficult time taking their patient’s decision at face value. Healthcare professionals have denied people the procedure because they think a patient is too young, will change their mind, or might find a new partner who will convince them to have kids. They’ve even asked them to see a psychologist and write a paper defending their decision.
Research on the topic has mostly included cis women, but experts we spoke to say transgender and nonbinary people likely face similar barriers to reproductive care that may be even more complicated and limiting.
“It's not that these are malicious or mal-intended doctors,” said Borrero, who is also the director of the Center for Innovative Research on Gender Health Equity at the University of Pittsburgh. “Most of the time they want to honor people's decision-making but they don't believe that people have the foresight to make decisions, which is really problematic.”
These interactions are steeped in bias and textbook examples of statistical risk profiling, she said.
Studies suggest anywhere between 1% to 26% of people who have tubal ligation end up regretting their decision. People ages 18–24 who have the procedure are nearly eight times more likely to get a reversal than those sterilized at age 30 or older, ACOG says, with people of color seeking information about reversal more often than white people. (While you can have the operation reversed, there’s no guarantee fertility can be restored.)
“Personally, I do not believe that the doctor's role is to determine who will or will not regret their decision. But rather it should be to give people the information they need to make the decision that's right for them,” Borrero said. “They should recognize that some people will regret their decision. That's natural.”
The main physician organization for obstetricians and gynecologists, ACOG, agrees. “Although physicians understandably wish to avoid precipitating sterilization regret in women, they should avoid paternalism as well,” according to the ACOG’s Committee on Ethics, which notes that “sterilization is a route to reproductive autonomy for women.”
Some people may decide to reverse a tubal ligation because they were initially pressured to have one by a family member, partner, or healthcare provider, while others may have chosen sterilization because they were undergoing stressful life circumstances or misinformed. Healthcare providers should explain that tubal ligation is permanent during pre-surgery counseling, however, “in practice, this may or may not happen,” Borrero said.
Meanwhile, doctors aren’t nearly as hesitant when it comes to performing vasectomies, which one 1994 study showed about 5% of men regret. And this, Borrero speculates, comes down to the characteristics of those who seek them.
Most tubal ligation patients have lower incomes and are people of color, while those who choose to get vasectomies — which are safer, more effective, and less expensive than tubal ligation — are predominantly white and wealthy, she said. So similar internalized biases about who’s capable of making sound decisions are likely at play.
Medicaid-funded sterilizations are inaccessible
The US Department of Health, Education, and Welfare developed regulations for publicly funded sterilizations in 1976 that were initially designed to protect women from coercive procedures but instead made access to them much more difficult.
In addition to having a doctor confirm that they are 21 or older and “mentally competent,” people on Medicaid must now wait 30 days after signing a consent form before having a tubal ligation. That’s a problem because most people want the procedure performed right after giving birth because it can be combined with a C-section or performed via a small incision after a vaginal birth. But if they deliver before their due date, then they’ll have to wait.
Medicaid coverage for pregnant people traditionally lasts for 60 days postpartum, so if they sign the consent form but don’t give birth within that window, they lose the opportunity to have a tubal ligation. And if they forget to bring the form with them on delivery day, they’re out of luck, Borrero said.
(On April 1, a “state plan amendment” went into effect that allows states to extend pregnancy-related Medicaid coverage up until one year; the extension will only last five years unless Congress extends it further or makes it permanent.)
These regulations apply to both types of sterilization, but tubal ligation procedures are much more common, particularly in low-income communities.
In addition, the tubal ligation consent form's language is "overly complicated," Borrero and colleagues said in a 2015 perspective published in the New England Journal of Medicine. One study found over a third of women responded incorrectly to a question about whether tubal ligation was permanent after reading the form, suggesting people are vulnerable to misunderstanding the procedure and what it means for them.
Then there’s an onslaught of logistical issues within the hospital system that prevent people from getting the procedure, Borrero said. Those include staffing shortages and insufficient operating rooms at the time of delivery when most people want to have the procedure.
Part of the reason why there are so many barriers to tubal ligation is “the long legacy of sterilization abuses in this country,” Borrero said. In the past, many women who lived in poverty, were of color, and had physical and mental disabilities were sterilized without consent.
Doctors performed over 60,000 “forcible” sterilizations through government-organized programs from 1909 to 1979, according to the ACOG. Between 2006 and 2010, over 140 incarcerated women in California were sterilized following pressure from prison and hospital staff, and more recently, immigrant women detained in an ICE detention center in Georgia allege they were sterilized without their consent.
What happens when people are denied a tubal ligation
People who are denied tubal ligation or other contraceptives are at high risk of getting pregnant within the next year.
About 47% of women who requested tubal ligation postpartum but did not receive it became pregnant in the first year after delivery, according to a 2010 study published in the journal Obstetrics & Gynecology. That’s more than twice the rate of pregnancies in women in the study who didn’t request to have their tubes tied. (About 31% of people in the study requested but didn’t receive a tubal ligation.)
While not all unintended pregnancies are unwanted, they do come with health risks that are experienced disproportionately by some people.
For example, over half of all pregnancies in 2008 were unintended (that percentage declined to 45% in 2011), the CDC says, with 75% of them occurring in teens and the highest rates found among Black and Hispanic women, those with low incomes, women without a high school degree, and unmarried women.
Studies show women who have unintended pregnancies are more likely to experience mental health issues, unstable relationships, physical and psychological abuse, and poor nutrition when pregnant. They also face high risks of miscarriage, giving birth to low-weight babies, and having delayed prenatal care.
Children of unintended pregnancies face some risks too, such as poor mental health and higher rates of dropping out of school.
Denying people access to tubal ligations also has profound societal and economic consequences. Borrero and her team found that Medicaid-related barriers lead to about 62,000 unfulfilled requests annually for postpartum sterilization.
This results in approximately 10,000 abortions and 19,000 unintended births in the next year, costing taxpayers $215 million annually.
While tubal ligations are considered safe procedures, they do carry risks of their own, such as bleeding, infection, damage to surrounding organs, and ectopic pregnancy, which is when an egg is fertilized outside the uterus in the rare event pregnancy occurs after the surgery.
What you can do to ensure your reproductive wishes are respected
It may not be ideal, but if you run into a doctor who’s denying a request for a tubal ligation, it’s possible to find another physician or team with a more patient-centered approach. It’s also always a good idea to do your own research so you know what to expect and whether other contraceptive options may better suit your needs.
But this really isn’t a “you” problem — it’s a systemic one, Borrero said.
For starters, major changes must be made in how medical providers approach conversations about sterilization with their patients. “This means centering patience preferences around what they want for their body,” Borrero said.
Then there are the issues with Medicaid coverage for pregnant people. Borrero believes it should be permanently extended to at least one year postpartum so people have more time to receive the contraceptive method of their choice, as well as shortening or eliminating the 30-day wait period.
Lastly, hospital policies surrounding sterilization should change so that procedures like tubal ligation are no longer considered “elective,” which would heighten their priority in the hospital system and ensure people get the care they need when they need it.
Some of these are long-term goals, “but I think that movement is really taking hold,” Borrero said.
Correction: Sonya Borrero is the director of the Center for Innovative Research on Gender Health Equity at the University of Pittsburgh. The university was misstated in an earlier version of this post.