Illegal Immigrants and the Birth Control Barrier

A significant percentage of women who request postpartum tubal ligation to prevent future pregnancies end up becoming pregnant, according to research published in Obstetrics and Gynecology. The study underscores the problem faced by illegal immigrants who opt out of the procedure, largely due to the costs involved.

“By making them pay $1,000 for two stitches, they are not going to have it done and half of them are going to get pregnant again in a year,” said Andrea Ries Thurman, MD, who co-authored the study along with Torri Janecek, DO, in a Reuters Health article.

In the study, the authors tracked women in three cohorts—those who requested postpartum tubal ligation (PPTL) and received the procedure (PPTL YES), those who requested but did not receive the procedure (PPTL NO), and a control group (those who did not request PPTL)—for 1 year postpartum.

Using data from women who gave birth at the University of Texas San Antonio between December 2007 and May 2008, Thurman and Janecek performed analyses, with the primary outcome of pregnancy within one year among women in the control group compared with those in the PPTL NO group. Secondary outcomes included birth control requested at discharge, attendance at a postpartum or other gynecology visit, contraceptive use between delivery and the postpartum visit, and request for contraception at the postpartum visit among the three cohorts.

They found that during the observation period, 429 of 1,460 women requested postpartum tubal ligation; 296 (69%) received the procedure and 133 (31%) did not. Within one year of the index delivery, 46.7% of women in the PPTL NO group became pregnant compared with 22.3% of those in the control group. Attendance at the postpartum visit was lowest for women in the PPTL YES group (12.8%), and only slightly higher among those in the PPTL NO (18.8%) and control groups (20.3%). Women in the PPTL NO group and those in the control group selected similar methods of contraception at hospital discharge.

Therefore, Thurman and Janecek concluded that women who did not receive a requested postpartum tubal ligation were more likely to become pregnant within one year of delivery than those who didn’t request permanent sterilization.

According to an online article, Thurman noted that this fact may be attributable to the high cost of the procedure. More than 10 million American women use sterilization for family planning, making it the most common method of contraception among married women between 15 and 44. However, for those who fall into a low income bracket—and particularly for those without adequate insurance—the price is too high.

Although Texas recently introduced a program to cover medical care for illegal immigrants around the time of delivery, it doesn't cover tubal ligation, which is frequently performed in the hospital immediately following delivery. The procedure costs about $1,000 if performed after a C-section and $1,800 after vaginal birth.

"The procedures probably should be free," said Thurman. "Birth control and family planning is clearly cost-effective."

For more information:

• Illegal Immigrants Want Sterilization, Get Kids
• One-Year Follow-up of Women with Unfulfilled Postpartum Sterilization Requests
• The future of women's contraception: stakes and modalities

What do you think of Dr. Thurman’s statement that the procedure should be free? What would be the implications of offering these procedures for no charge to certain patient populations?