Reduced health insurance payments for hospital births had a bigger impact on sterilization rates than correcting an injustice

Public outrage over the forced sterilization of poor, Black women had less impact on female sterilization rates in the U.S. than a policy changing how post-birth care is delivered. DisobeyArt/iStock via Getty Images Plus

For decades, female sterilization has been one of the most common forms of birth control in the U.S.: 11.5% of U.S. women, ages 15-49, use female sterilization as their primary contraceptive method – nearly identical to the pill.

But the history of sterilization is also deeply entangled with coercion in the form of racial targeting, invalid consent and state control.

As a health economist and a political scientist, we wanted to better understand what factors influence women's choices around contraception and sterilization. Our recent study found that a policy change in the 1990s which reduced the length of hospital stays for women giving birth appears to have inadvertently had a more meaningful effect on female sterilization rates in the U.S. than a landmark civil rights intervention in the 1970s.

This leads us to believe that seemingly innocuous, practical policy changes may exert greater influence on women's reproductive choices than even public outrage over an injustice.

In 1974, the case of Relf v. Weinberger revealed that between 100,000-150,000 girls and women, most of them poor and Black, were sterilized each year at federally funded public health clinics from 1970 to the time the case was heard.

Looking at inflection points

In our study, we revisited Relf v. Weinberger, a 1974 civil rights case that involved the sterilization of two Black girls – the Relf sisters – without valid consent. The girls' mother was told they were receiving a birth control shot that would temporarily prevent pregnancy. Instead, doctors subjected them to an unwanted tubal ligation surgery, in which the fallopian tubes are sealed off to permanently prevent pregnancy.

The Relf sisters were not alone: In the the early 1970s, the sisters' case helped bring to light broader patterns in federally funded sterilization that included invalid consent and pressure tied to public benefits. Though the U.S. District Court did not find that each of these sterilizations had been coerced per se, it did find strong evidence that minors and people legally unable to consent had been sterilized with federal funds, and that sterilization was often presented as a requirement for families to maintain welfare or other government benefits. The court ruled that federally funded medical procedures require informed, uncoerced consent.

Our study examined how the public outrage, litigation and consent reforms that followed reshaped U.S. sterilization trends in the 50 years after the court ruled in favor of the Relf girls.

We then compared those effects with another, less visible inflection point in the history of female reproductive health that began in 1992, often called the "drive-through delivery" era. At this time, insurance companies instituted fixed payments to hospitals for each birth. This meant that hospitals received the same payment whether women giving birth stayed one night or two nights afterward. The practical effect was that more women who had uncomplicated births were sent home after just one night in the hospital.

The 1996 Newborns' and Mothers' Health Protection Act was meant to end this era, but the shift towards shorter postpartum stays persisted in an effort to cut costs.

This shortened hospital stay after birth posed a problem for women who wanted to be sterilized: Tubal ligation is logistically easy to provide immediately postpartum, while a patient is already hospitalized after giving birth. But when insurers pushed shorter postpartum stays, providers had less time to schedule and perform the procedure, meaning fewer women ended up getting the surgery.

How we did the study

We compared U.S. sterilization trends with those in other countries that had similar trends. Those countries gave us a way to estimate what U.S. sterilization patterns might have looked like if the Relf ruling or changes to hospital payment policies had not occurred. We did not look at individual medical decisions in isolation, but instead tracked patterns in how often sterilization is used across the country.

We asked a simple but important question: What actually changed sterilization practices over time? Was it the highly visible public backlash invoked by the Relf ruling? Or was it a quieter administrative change in how childbirth care was organized and paid for?

We found that the Relf case and subsequent consent reforms, including a 30-day waiting period and minimum age of 21 for federally funded sterilizations, slowed growth in U.S. female sterilization but did not reverse the broader trend. Female sterilization was still becoming more common: The national rate rose from about 5% in 1970 to about 13% in 1975. After a brief pause following the ruling and the new consent rules, it continued climbing. BY 1990, nearly 1 in 4 married women aged 15-49, were sterilized.

Nor did we see a meaningful shift in the populations most at risk of state-targeted sterilization: younger Black women in the South.

By contrast, the administrative payment reforms of the 1990s were associated with the first national declines in sterilization since the 1960s.

Why it matters

Sterilization is not inherently good or bad. It is a highly effective and often desired form of permanent contraception.

That matters now more than ever. In the 2022 case of Dobbs v. Jackson Women's Health, the U.S. Supreme Court ruled that states can set their own abortion laws, essentially limiting abortion access for many Americans. Since this ruling, our colleagues have found increases in permanent contraception, particularly among younger adults and in states with abortion bans.

In another study, we described limiting patient choices by not providing adequate birth control options as a problem of coercion built into the very structure of the healthcare system.

The issue is not always that patients are forced into, or denied, care altogether. Often, they are offered a narrowed set of options that may look like choice, but do not fit what best meets their needs. A person with diabetes, for example, may technically have access to insulin, but only to a formulation, device or at a pharmacy location that is hard to use safely or access in their daily life.

In reproductive care, we argue that restricting options in this way can be a form of coercion, even when it is less visible.

Tubal ligation is logistically simplest after a woman gives birth, but shortened postpartum hospital stays have made it more difficult for patients who want the procedure to get it at that time. SDI Productions/E+ via Getty Images

A two-way problem

At the same time, many patients report being unable to obtain sterilization when they do want it because of Medicaid consent rules, hospital logistics, staffing limits, insurance timing or institutional restrictions.

So the problem goes two ways: Some people are pushed toward permanent contraception by a restrictive reproductive policy environment, while others are blocked from obtaining it when they want it.

That tension is precisely why sterilization is such an important issue. If rates rise or fall in response to payment incentives, discharge practices or insurance rules, it calls into question whether patient decisions are straightforward expressions of free choice. This is true for reproductive care broadly but has unique human rights implications when the method is permanent.

Our findings suggest that sterilization trends are highly responsive to policy shifts, and not only those driven by public outrage. This raises an uncomfortable question: To what extent do trends in sterilization rates truly reflect what people want, and to what extent do they reflect the choices patients were steered toward by the design of the healthcare system?

The authors do not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and have disclosed no relevant affiliations beyond their academic appointment.