With an abortion ban almost certain following the Senate passage of a bill on Saturday, some Hoosiers are turning to long-term contraceptives, like IUDs, while others consider a more permanent option: sterilization.
Katie McHugh, an obstetrician-gynecologist and abortion provider in Indianapolis, said she has heard more people talking about seeking the procedure since the U.S. Supreme Court overturned federal abortion protections in late June.
“Most of the patients that I am seeing for abortion care are saying, ‘I will never put myself in this position again because in the future I may not be able to choose abortion,’” she said. “My colleagues are seeing an increase in requested surgical consults in their offices.”
McHugh said currently a majority of her practice is abortion care but she performs the full scope of reproductive healthcare, including sterilization and delivery.
Sterilization or tubal ligation, commonly referred to as “getting your tubes tied,” cuts the fallopian tube which connects the ovaries, where egg cells reside, from the uterus, where an embryo may implant and grow.
In recent years, tubal ligation has evolved to tubal removal, or salpingectomy, which extracts the entire tube, rather than leaving two severed ends, and reduces a person’s risk for ovarian cancer, as analyzed in the American Journal of Obstetrics and Gynecology. Under a ligation, a patient could possibly find a specialist to repair the fallopian tube but couldn’t do so with a tubal removal, though the Mayo Clinic reports that reversals aren’t always effective.
Unlike a hysterectomy, which completely removes the uterus, patients can still get their periods with a tubal removal and, rarely, use in vitro fertilization to implant a fertilized egg and potentially give birth.
Tubal ligations and removals are considered an irreversible method of contraception and a permanent form of sterilization.
Paternalism in healthcare limits options for parents
Some doctors won’t perform the procedures at all, while others require patients seeking the procedure to already have children or support from their partner.
A 2010 research article surveyed 1,154 OBGYNs and reported that as many as 70% of physicians “would attempt to dissuade her, depending on her characteristics.”
Over half, 59%, of physicians would discourage a 26-year-old patient whose partner disagreed but that percentage fell to 47% if the patient was 36 years old.
For a patient whose partner agreed, 32% would discourage the 26-year-old patient while just 10% would discourage the 36-year-old.
McHugh, the Indianapolis OBGYN, said she would assist a patient regardless of their partner’s buy-in or number of children. McHugh, along with 40 other Hoosier OBGYNs, appears on a crowd-sourced and widely shared list of doctors who will perform the procedure across the country regardless of “marital status or number of children.”
“Not every patient has that experience with every physician. Different physicians have different feelings about that and some physicians feel strongly that the partner should be included or that a patient should have already had children in order to make these decisions,” McHugh said. “That is not based on any guidance or evidence… without mincing words, it is a function of misogyny in medicine and paternalism.”
Paternalism, as McHugh uses it, occurs “when a physician or other healthcare professional makes decisions for a patient without the explicit consent of the patient,” according to the Missouri University School of Medicine. Doctors may believe they know their patient’s wants better than their patient.
Doctors may refuse to perform the surgery on a patient because they believe they will regret it later or find a new partner who wants children. This practice of considering the partner’s wants isn’t common for those who seek vasectomies, which are also considered a permanent form of sterilization.
“What we know from medical literature, as well as an outpouring of personal stories… is that most patients have to shop around to find a physicians that will listen to them and believe them when they say they don’t want to be a parent or that they feel their family size is complete,” McHugh said. “That’s the real tragedy – for a patient to feel that their physician is not hearing them and doesn’t respect their choice.”
Risks of sterilization lower than childbirth
McHugh said conversations with her patients on reproductive healthcare revolve around their decisions about their bodies – from their fertility to their ideal family size and parenting plans – as well as their careers and life goals.
“When people come to me and they talk about, ‘I never wanted to be a parent; that’s not going to change. I want this surgery so that I never have to worry about that.’ That is a completely valid and respectable position to take,” McHugh said. “I have no issues discussing that and planning for that surgery.”
Like any surgery, tubal removal comes with risks, including risks with anesthesia, blood clots, bleeding or infection, and possible damage to surrounding organs, including the uterus, bowel or bladder.
“I would never say that abortion does not have some risk – although in comparison to childbirth, it is exponentially safer,” McHugh said. “(Tubal removal) is not a procedure to be taken lightly… but it is certainly a safer procedure than undergoing a full pregnancy with all of the changes that happen in pregnancy and then the risks with delivery.”
Indiana has the third-highest maternal mortality rate in a country with the worst maternal health in the developed world. According to the Indiana Maternal Mortality Review Committee, 60 Hoosiers died in 2019 during or up to a year following a pregnancy. In comparison, just two people died in the country in 2018 due to complications from a legal abortion.
The Centers for Disease Control and Prevention do not report current numbers for deaths associated with tubal sterilizations, but reported 29 deaths between 1977 and 1981, with 11 deaths due to complications with general anesthesia.
Expense of procedure, consent form a hurdle for many
Despite the relative safety of the procedure, the cost can be prohibitive since some insurances don’t cover the full cost, which includes a full operating room and anesthesia.
To reduce the cost, some patients opt to schedule their tubal removal during their delivery, which McHugh said is the most convenient time for both the parent and the medical team.
McHugh said the uterus is much bigger than normal postpartum, making it more accessible for the physician. The tubal removal can be scheduled at the same time for someone receiving a Cesarean section, or C-section. For a vaginal delivery, the removal can be scheduled the next day under an epidural rather than general anesthesia, making it a safer procedure.
“Those are very accessible, very cost-effective times to do it because you’re already in the hospital and all of the charges are covered under the fee schedule covering the delivery,” McHugh said.
But for patients using Medicaid, which covered 39% of Indiana births in 2020, they must complete a consent form 30 days before the procedure, which complicates the timing for thousands of parents who qualify for emergency Medicaid during their pregnancy.
“This really basic and simple reproductive care procedure is made more complicated by our governmental processes,” McHugh said.
The 30-day waiting period stems from the atrocities of Indiana’s eugenics laws, starting in 1907 and ending in 1974. Over 2,300 Hoosiers were involuntarily sterilized to discourage “reproduction by the feeble-minded,” including those incarcerated – whether in jail or in an asylum – and “epileptics.”
According to the University of Vermont, Indiana’s sterilization efforts disproportionately targeted “Ishmaelites,” or Black Americans recently freed or who had escaped slavery, Native American tribe members and the poor. Medicaid coverage in Indiana seeks to provide healthcare for the poor, many of whom are people of color.
To deter physicians who might encourage their patients to be sterilized, the consent form requires 30 days between signatures and the procedure, now a national standard recognized by the American College of Obstetricians and Gynecologists.
Indiana also requires Hoosiers seeking sterilization procedures be at least 21 years old and competent to make medical decisions.
Doctors anxiously await final bill
For now, doctors wait for legislators to make the final decision on abortion. Lawmakers have repeatedly said the abortion ban isn’t designed to change Hoosier access to contraception, but advocates have concerns. Republican senators turned down an amendment guaranteeing access to contraception last week.
“I’m very concerned and I am paying very close attention to what they are doing because I feel intensely scared about the ability to decide what happens to my body; I’m scared about my patients abilities to decide what happens to their bodies,” McHugh said. “I fear what this means for all of our privacy and all of our health care in the future.”