U.S. physicians’ perspectives on the complexities and challenges of permanent contraception provision



      Evidence shows many misconceptions exist around permanent contraception, and there are numerous barriers to accessing the procedure. This qualitative study explored physician perspectives regarding patients’ informational and decision-support needs, the complexities and challenges of counseling and access, and how these factors may differ for people living on lower incomes.

      Study design

      We conducted 15 semistructured, telephone interviews with obstetrician-gynecologists in three geographic regions of the United States to explore their perspectives on providing permanent contraception counseling and care. We analyzed the interviews using content analysis.


      Physicians discussed a tension between respecting individual reproductive autonomy and concern for future regret; they wanted to support patients’ desire for permanent contraception but were frequently concerned patients did not have the information they needed or the foresight to make high-quality decisions. Physicians also identified barriers to counseling including lack of time, lack of continuity over the course of prenatal care, and baseline misinformation among patients. Physicians identified additional barriers in providing a postpartum procedure even after thedecision was made including lack of personnel and operating room availability. Finally, physicians felt that people living on lower incomes faced more challenges in access primarily due to the sterilization consent regulations required by Medicaid.


      Physicians report numerous challenges surrounding permanent contraception provision and access. Strategies are needed to support physicians and patients to enhance high-quality, patient-centered sterilization decision making and ensure that patients are able to access a permanent contraceptive procedure when desired.


      This qualitative study demonstrates the various challenges faced by physicians to support permanent contraception decision making. These challenges may limit patients’ access to the care they desire. This study supports the need to transform care delivery models and improve the federal sterilization policy to ensure equitable patient-centered access to desired permanent contraception.


      Although the term permanent contraception has increasingly replaced the word sterilization in clinical settings, we use sterilization in some places throughout this paper as that was the standard terminology at the time the interviews were conducted and the language the interviewed physicians used.


      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Contraception
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Daniels K
        • Abma JC.
        Current contraceptive status among women aged 15-49: United States, 2017-2019.
        NCHS Data Brief. 2020; 388: 1-8
        • Borrero S
        • Reeves MF
        • Schwarz EB
        • Bost JE
        • Creinin MD
        • Ibrahim SA.
        Race, insurance status, and desire for tubal sterilization reversal.
        Fertil Steril. 2008; 90: 272-277
        • Eeckhaut MCW.
        Intersecting inequalities: education, race/ethnicity, and sterilization.
        J Fam Issues. 2020; 41: 1905-1929
        • Borrero S
        • Nikolajski C
        • Rodriguez KL
        • Creinin MD
        • Arnold RM
        • Ibrahim SA.
        Everything I Know I Learned from My Mother...or Not”: perspectives of African-American and White women on decisions about tubal sterilization.
        J Gen Intern Med. 2009; 24: 312-319
        • Borrero S
        • Abebe K
        • Dehlendorf C
        • Schwarz EB
        • Creinin MD
        • Nikolajski C
        • et al.
        Racial variation in tubal sterilization rates: role of patient-level factors.
        Fertil Steril. 2011; 95: 17-22
        • Harris LH
        • Wolfe T.
        Stratified reproduction, family planning care and the double edge of history.
        Curr Opin Obstet Gynecol. 2014; 26: 539-544
        • White K
        • Hopkins K
        • Potter JE
        • Grossman D.
        Knowledge and attitudes about long-acting reversible contraception among Latina women who desire sterilization.
        Women's Health Issues. 2013; 23: e257-e263
        • Schmidt JE
        • Hillis SD
        • Marchbanks PA
        • Jeng G
        • Peterson HB.
        Requesting information about and obtaining reversal after tubal sterilization: findings from the U.S. collaborative review of sterilization.
        Fertil Steril. 2000; 74: 892-898
        • Eeckhaut MCW
        • Sweeney MM
        • Feng L.
        Desire for sterilization reversal among U.S. females: increasing inequalities by educational level.
        Perspect Sex Reprod Health. 2018; 50: 139-145
        • Shreffler KM
        • McQuillan J
        • Greil AL
        • Johnson DR.
        Surgical sterilization, regret, and race: contemporary patterns.
        Social Sci Res. 2015; 50: 31-45
        • Danvers AA
        • Evans TA.
        Risk of sterilization regret and age: an analysis of the National Survey of Family Growth, 2015–2019.
        Obstet Gynecol. 2022; 139: 433-439
        • Allyn DP
        • Leton DA
        • Westcott NA
        • Hale RW.
        Presterilization counseling and women's regret about having been sterilized.
        J Reprod Med. 1986; 31: 1027-1032
        • Henshaw SK
        • Singh S.
        Sterilization regret among U.S. couples.
        Fam Plann Perspect. 1986; 18: 238
        • Kimport K
        • Dehlendorf C
        • Borrero S.
        Patient-provider conversations about sterilization: a qualitative analysis.
        Contraception. 2017; 95: 227-233
        • Lawrence RE
        • Rasinski KA
        • Yoon JD
        • Curlin FA.
        Factors influencing physicians’ advice about female sterilization in USA: a national survey.
        Hum Reprod. 2011; 26: 106-111
        • Zite N
        • Wuellner S
        • Gilliam M.
        Barriers to obtaining a desired postpartum tubal sterilization.
        Contraception. 2006; 73: 404-407
        • Potter JE
        • White K
        • Hopkins K
        • McKinnon S
        • Shedlin MG
        • Amastae J
        • et al.
        Frustrated demand for sterilization among low-income Latinas in El Paso, Texas.
        Perspect Sex Repro H. 2012; 44: 228-235
        • Department of Health, Education, and Welfare
        Sterilization under medicaid. 42. 1978
        • American College of Obstetricians and Gynecologists
        ACOG committee opinion: access to postpartum sterilization. 827. 2012
        • Borrero S
        • Zite N
        • Potter JE
        • Trussell J.
        Medicaid policy on sterilization—anachronistic or still relevant?.
        N Engl J Med. 2014; 370: 102-104
        • Darney PD.
        New kinds of injustice for women?.
        Am J Obstet Gynecol. 2015; 212: 693-694
        • Block-Abraham D
        • Arora K
        • Tate D
        • Gee R.
        Medicaid consent to sterilization forms: historical, practical, ethical, and advocacy considerations.
        Clin Obstet Gynecol. 2015; 58: 409-417
        • Brown BP
        • Chor J.
        Adding injury to injury: ethical implications of the medicaid sterilization consent regulations.
        Obstet Gynecol. 2014; 123: 1348-1351
        • Henderson CE
        • Ringel LE
        • Nezan H
        • Rezai S
        • Sherman S.
        Postpartum sterilization: underserved women struggle with bureaucratic laws and regulations.
        NYSBA Health Law J. 2014; 19: 49-53
        • Uttley L
        • Khaikin C.
        Growth of catholic hospitals and health systems.
        MergerWatch. 2016; : 1-13
        • Hill EL
        • Slusky DJG
        • Ginther DK.
        Reproductive health care in Catholic-owned hospitals.
        J Health Econ. 2019; 65: 48-62
        • Elo S
        • Kyngäs H.
        The qualitative content analysis process.
        J Adv Nurs. 2008; 62: 107-115
        • QSR International
        NVivo qualitative data analysis software.
        • Gomez AM
        • Fuentes L
        • Allina A
        Women or LARC first? Reproductive autonomy and the promotion of long-acting reversible contraceptive methods.
        Perspect Sex Reprod Health. 2014; 46: 171-175
        • Stern AM.
        Sterilized in the name of public health: race, immigration, and reproductive control in modern California.
        Am J Public Health. 2005; 95: 1128-1138
        • Arora KS
        • Castleberry N
        • Schulkin J.
        Obstetrician-gynecologists’ counseling regarding postpartum sterilization.
        Int J Womens Health. 2018; 10: 425-429
        • Stacey D
        • Légaré F
        • Lewis K
        • Barry MJ
        • Bennett CL
        • Eden KB
        • et al.
        Decision aids for people facing health treatment or screening decisions.
        Cochrane Database Syst Rev. 2017; 2017: 1-284
        • Joseph-Williams N
        • Abhyankar P
        • Boland L
        • Bravo P
        • Brenner AT
        • Brodney S
        • et al.
        What works in implementing patient decision aids in routine clinical settings? A rapid realist review and update from the International Patient Decision Aid Standards Collaboration.
        Med Decis Making. 2021; 41: 907-937
        • Madden T
        • Mullersman JL
        • Omvig KJ
        • Secura GM
        • Peipert JF.
        Structured contraceptive counseling provided by the Contraceptive CHOICE Project.
        Contraception. 2013; 88: 243-249
        • Dehlendorf C
        • Krajewski C
        • Borrero S.
        Contraceptive counseling: best practices to ensure quality communication and enable effective contraceptive use.
        Clin Obstet Gynecol. 2014; 57: 659-673