Sterilization or Permanent Contraception as a Family Planning Method – KFF

Report on Permanent Contraception Access and Coverage in the United States in the Context of Sustainable Development Goals

This report analyzes the landscape of permanent contraception, or sterilization, in the United States, focusing on its alignment with the United Nations Sustainable Development Goals (SDGs). Access to safe, effective, and affordable family planning is a cornerstone of SDG 3 (Good Health and Well-being), particularly Target 3.7, which calls for universal access to sexual and reproductive health-care services. Furthermore, disparities in access, coverage, and procedural burden between genders directly relate to SDG 5 (Gender Equality) and SDG 10 (Reduced Inequalities). The legal and institutional frameworks governing these services are examined through the lens of SDG 16 (Peace, Justice and Strong Institutions).

Analysis of Permanent Contraception Methods

Permanent contraception is the most prevalent form of family planning in the U.S. The two primary methods, tubal ligation for individuals with female reproductive organs and vasectomy for those with male reproductive organs, are both nearly 100% effective, contributing to the objectives of SDG 3. However, significant disparities exist in their usage, cost, and associated risks, highlighting challenges to achieving SDG 5.

Tubal Ligation

• Procedure: An outpatient surgical procedure involving the removal or blockage of the fallopian tubes. It is effective immediately.
• Prevalence: Utilized by one in four women aged 18-64, with higher rates among women with lower incomes and those on Medicaid. This demographic data underscores the importance of equitable access as outlined in SDG 10.
• Effectiveness and Risks: The failure rate is less than 1% in the first year. While generally safe, it is more invasive and carries a higher risk of complications than a vasectomy. Reversal is a costly and invasive process not typically covered by insurance.

Vasectomy

• Procedure: A less invasive outpatient procedure to block the vas deferens, often performed under local anesthesia.
• Prevalence: Utilized by approximately 11% of men aged 18-64, with higher rates among white men, those with higher incomes, and individuals with private insurance. This disparity points to socio-economic and gender-based inequalities in reproductive health responsibilities, a key concern for SDG 5.
• Effectiveness and Risks: Vasectomies are safer, less expensive, and more effective than tubal ligations. However, they are not effective immediately, requiring an alternative contraceptive method for two to four months.

Insurance Coverage and Economic Barriers: An SDG Perspective

Financial accessibility is critical for achieving universal health coverage as envisioned in SDG 3. Disparities in insurance mandates for sterilization procedures create significant inequalities, undermining both SDG 5 and SDG 10.

Private Insurance and the Affordable Care Act (ACA)

The ACA mandates that most private insurance plans cover female sterilization without cost-sharing, a significant step towards fulfilling SDG 3. However, this federal requirement does not extend to vasectomies. This policy gap perpetuates gender inequality (SDG 5) by placing the procedural and financial burden of permanent contraception disproportionately on women. A minority of states have addressed this disparity through local legislation:

1. California
2. Illinois
3. Maryland
4. New Jersey
5. New Mexico
6. New York
7. Oregon
8. Vermont
9. Washington

Medicaid Coverage and Systemic Inequalities

Medicaid provides crucial family planning coverage for low-income populations. While states must cover female sterilization, federal regulations introduce barriers that conflict with SDG 10 (Reduced Inequalities). A mandatory 30-day waiting period between signing a consent form and the procedure is required for federally funded sterilizations. This policy, intended to prevent historical abuses, now creates a significant hurdle for publicly insured women that privately insured individuals do not face, representing a systemic inequality in access to care.

Institutional and Systemic Barriers to Access

The achievement of health-related SDGs depends on strong, just, and inclusive institutions (SDG 16). In the U.S., legal and institutional policies create significant barriers to accessing sterilization services.

Religious Exemptions and Provider Refusals

Federal laws, such as the Church Amendments, and laws in 19 states permit healthcare providers and institutions to refuse to provide sterilization services based on religious or moral objections. These refusal policies can severely limit or eliminate access to care in certain geographic areas, disproportionately affecting rural and underserved communities and undermining the principle of universal access central to SDG 3.

The Role of Faith-Based Health Systems

The increasing consolidation of healthcare under Catholic-affiliated systems, which adhere to directives prohibiting sterilization, presents a major challenge to reproductive health access. These institutions often receive public funding (e.g., Medicare, Medicaid) yet restrict care options for the diverse populations they serve. This practice limits patient autonomy and creates critical gaps in care, particularly for postpartum sterilization, directly impeding progress on SDG 3 and SDG 5.

Impact of Legal Precedents on Contraceptive Choices

The 2022 Supreme Court decision in Dobbs v. Jackson Women’s Health Organization has significantly altered the reproductive health landscape, impacting family planning decisions and efforts to achieve SDG 3 and SDG 5.

The Post-Dobbs Landscape and Reproductive Autonomy

Following the ruling, which ended the federal constitutional right to abortion, there has been a reported increase in patient requests for permanent contraception. OBGYNs in states with abortion bans or restrictions have noted a particularly sharp rise in demand for sterilization. This trend suggests that individuals are seeking permanent methods in response to diminished reproductive autonomy, a key component of gender equality (SDG 5) and well-being (SDG 3).

Emerging Trends and Demographics

Early research indicates a demographic shift among those seeking sterilization post-Dobbs. An increasing number of younger adults (under 35) and childless individuals, particularly men seeking vasectomies, are opting for permanent contraception. This reflects a proactive strategy to manage reproductive health in a more restrictive legal environment, highlighting the profound impact of institutional and legal decisions (SDG 16) on individual health choices and long-term family planning.

1. Which SDGs are addressed or connected to the issues highlighted in the article?

1. SDG 3: Good Health and Well-being

   The article is fundamentally about health services, specifically permanent contraception (sterilization) as a form of family planning. It discusses the safety, effectiveness, and availability of medical procedures like tubal ligations and vasectomies. The text also covers insurance coverage (Affordable Care Act, Medicaid) and access to these services, which are core components of ensuring healthy lives and promoting well-being.

2. SDG 5: Gender Equality

   The article addresses gender equality by highlighting disparities in healthcare access and policy related to reproductive health. It points out that the Affordable Care Act’s contraceptive coverage mandate applies to sterilization for women but not for men. It also discusses the historical context of coercive sterilization practices directed at women, particularly women of color and those with low incomes. The disproportionate burden of contraception, as evidenced by the higher rates of female sterilization compared to the safer and cheaper male vasectomy, is a key gender issue.

3. SDG 10: Reduced Inequalities

   The article extensively details inequalities in access to sterilization services based on various factors. These include:

   • Economic Status: Disparities between individuals with private insurance versus those on Medicaid are noted, such as the 30-day waiting period for sterilization procedures required for Medicaid recipients, which is not imposed on privately insured patients. Sterilization rates are also broken down by income level.
   • Geography: Access to services varies by state, depending on whether a state mandates vasectomy coverage or allows providers to refuse services on religious grounds. The growing dominance of Catholic-affiliated hospitals in certain areas is presented as a barrier that creates geographic inequality.
   • Gender: As mentioned under SDG 5, federal policy creates an inequality by mandating coverage for female sterilization but not male sterilization.

2. What specific targets under those SDGs can be identified based on the article’s content?

1. Target 3.7: Ensure universal access to sexual and reproductive health-care services.

   This target is central to the article. The text is entirely focused on a specific set of family planning services (sterilization). It examines the mechanisms for access (private insurance, Medicaid, Title X) and the significant barriers that prevent universal access, such as cost for the uninsured, policy hurdles like the 30-day waiting period for Medicaid, and service refusal by faith-based providers.

2. Target 3.8: Achieve universal health coverage, including financial risk protection and access to quality, affordable essential health-care services.

   The article directly discusses universal health coverage by analyzing how different insurance schemes cover sterilization. It details the ACA’s requirement for private plans to cover female sterilization without cost-sharing, which provides financial risk protection. It also mentions the out-of-pocket costs for those without coverage (up to $6,000 for tubal ligation), highlighting the importance of insurance in making these essential services affordable.

3. Target 5.6: Ensure universal access to sexual and reproductive health and reproductive rights.

   This target is addressed through the lens of gender. The article highlights how reproductive choices are affected by policy and access. The fact that federal law mandates coverage for female sterilization but not for the “safer, cheaper, and even more effective” male procedure points to an imbalance in reproductive responsibility and access. The discussion of the *Dobbs* ruling and the subsequent increase in women seeking permanent contraception underscores the connection between abortion access and other reproductive rights and choices.

4. Target 10.3: Ensure equal opportunity and reduce inequalities of outcome, including by eliminating discriminatory laws, policies and practices.

   The article identifies several policies that lead to unequal outcomes. The federal Medicaid regulation imposing a 30-day waiting period on low-income women is a prime example of a policy that creates a barrier not faced by wealthier, privately insured individuals. Similarly, laws allowing providers to refuse services based on religious objections create unequal access to care. The article also notes that some states have passed legislation to counter these inequalities, such as requiring private insurers to cover vasectomies.

3. Are there any indicators mentioned or implied in the article that can be used to measure progress towards the identified targets?

1. Proportion of the population with access to essential health services (related to Target 3.7 & 3.8).

   The article provides specific data points that can serve as indicators of access:

   • The number of states (9) that require state-regulated private health insurance plans to cover vasectomies.
   • The number of states (32) that have extended family planning services to uninsured populations through Medicaid expansion programs.
   • The number of states (19) with laws allowing providers to refuse sterilization services, which is an indicator of barriers to access.
   • The share of acute-care hospitals that are Catholic-affiliated (e.g., “7 of the 25 largest health systems”), which can be used as a proxy indicator for reduced access in certain regions.

2. Proportion of population with their need for family planning satisfied by modern methods (related to Target 3.7 & 5.6).

   The article provides direct statistics from the 2024 KFF Women’s Health Survey that measure the uptake of a modern contraceptive method:

   • “One in four women between the ages of 18 and 64 report they have had a sterilization procedure.”
   • “One in ten (11%) men ages 18 to 64 say they have undergone a sterilization procedure.”
   • The article also provides this data disaggregated by income, insurance type, and race, allowing for a more detailed analysis of who is using these services.

3. Proportion of population facing large out-of-pocket health expenditures (related to Target 3.8).

   While not providing a population percentage, the article implies this indicator by stating the potential out-of-pocket costs for sterilization procedures. It notes that a tubal ligation can cost up to $6,000 and a vasectomy up to $1,000 for those without insurance. It contrasts this with the $0 cost for most people with ACA-compliant or Medicaid coverage, directly illustrating how insurance provides financial protection against high health expenditures.

4. Proportion of population reporting discrimination or harassment (related to Target 10.3).

   The article implies this indicator by referencing policies and practices that are discriminatory in effect. The 30-day waiting period for Medicaid patients is described as a “burden on publicly insured women… that women with private insurance do not face.” The historical context of “coercive practices and abuses” against women of color, low-income women, and women with disabilities is a direct reference to discrimination that policies now seek to prevent, albeit by creating new burdens.

4. Create a table with three columns titled ‘SDGs, Targets and Indicators” to present the findings from analyzing the article. In this table, list the Sustainable Development Goals (SDGs), their corresponding targets, and the specific indicators identified in the article.

Source: kff.org