美国国家公共电台 NPR--Why this key chance to getting permanent birth control is often missed

Why this key chance to getting permanent birth control is often missed

Transcript¹

In the wake of the U.S. Supreme² Court's historic decision to overturn Roe³ v. Wade⁴, doctors say they're seeing a surge in the number of women who want to prevent future unintended pregnancies⁵ by getting their "tubes tied."

But a lot of patients fail to actually get this surgery, because an important window of opportunity — during hospitalization right after childbirth — is often missed.

The reasons why range from too-full operating rooms to paperwork problems. This has long been a source of frustration⁶, and it's taken on new urgency now that the court's decision has created a sudden increased demand for this permanent, extremely effective method of birth control.

Tubal surgery, which involves cutting, blocking or removing the fallopian tubes that carry eggs, is the most commonly used form of contraception for women in the United States.

But studies show that about 40%-60% of women who had previously⁷ requested to have their tubes tied during a post-delivery hospital stay end up not getting it then. These women face a high rate of subsequent pregnancy⁸.

"About half of women who don't have their desired postpartum sterilization⁹ procedure will get pregnant in the next year," says Dr. Rachel Flink, an obstetrician and gynecologist in upstate New York.

Women could theoretically come back to the hospital another time, says Flink, but this type of birth control is frequently requested by people who are poor, less educated and lack insurance: "They're more likely to fall into groups of people who have difficulty accessing the health care system later."

When they're already in the hospital for the arrival of a newborn, "someone is able to watch their baby, they've already made other child care arrangements, there's no transportation issues," Flink says.

So from a patient's point of view, this can be the best possible time for tubal surgery — especially if they only have public health insurance because of pregnancy and will lose it soon after childbirth. Yet many different barriers can stand in the way.

Sometimes it's that the hospital's operating rooms are just too full, so an elective procedure that doesn't seem like an emergency never makes it onto the schedule before a patient has to be discharged. Sometimes doctors think the patient is too overweight for the surgery, even though research suggests obesity¹⁰ doesn't pose an added risk. Sometimes a doctor might try to talk younger patients out of it, saying they might change their minds. If the hospital has a religious affiliation¹¹, the surgery might just be prohibited.

And then there's one piece of paper that's especially problematic.

It's a consent form required by Medicaid, which pays for nearly half of all birth hospitalizations in the United States. This form has to be signed at least 30 days before tubal surgery is done, explains Dr. Sonya Borrero, a researcher and physician with the University of Pittsburgh School of Medicine.

"Basically what this does is create a mandatory¹² 30-day waiting period for people who rely on public funding for their health care," says Borrero, who notes that the waiting period is not required by private insurance. "So it definitely creates a kind of two-tiered system."

If a person on Medicaid signs the consent form too late, or delivers unexpectedly early, or loses the form and it's not on file, then Medicaid won't pay for the operation.

"This does impact a significant number of people with Medicaid," says Borrero, whose research suggests that taking away Medicaid-related roadblocks to getting tubal surgery could prevent more than 29,000 unintended pregnancies each year.

Dr. Kavita Shah Arora, an obstetrician and gynecologist with the University of North Carolina, vividly¹³ remembers first becoming aware of Medicaid's policies during her training in medical school.

"What I saw left me really frustrated¹⁴. It was patient after patient who really wanted permanent contraception but didn't have the form signed," she says. "It just left me feeling powerless and angry that we had artificially created this barrier to desired care."

She soon learned, however, that the consent form and waiting period date back to the 1970s and were created in response to the nation's ugly history of coercive sterilizations, which frequently targeted the poor and people of color.

Talking with patient advocacy groups made her conclude that simply getting rid of the consent form and the waiting period wasn't necessarily the right solution. After all, discrimination and the threat of reproductive abuse hasn't completely gone away — there have been recent accusations¹⁵ of unnecessary surgeries at an immigrant detention¹⁶ center, for example.

But Borrero thinks the current Medicaid regulations don't seem like the best way to protect the vulnerable, "because we have a lot of evidence showing that they are creating barriers for the people they were intended to help."

New approaches to covering the procedure

Some places are trying new approaches. A couple of years ago, West Virginia decided¹⁷ to start covering this procedure with state funds if a person wanted it but Medicaid wouldn't pay because of not waiting the required 30 days.

And one hospital in Texas has made doing tubal surgery a priority. When Dr. John Byrne started working at Parkland Hospital in Dallas, he thought to himself, "Wow, a lot of women are able to have this procedure done here."

Byrne, who is now at the University of Texas Health Science Center at San Antonio, says that Parkland Hospital acts as a "safety net" county hospital that serves low-income patients. Hospital officials set up a system to take advantage of the brief hospitalization after childbirth, knowing the burdens their patients would face if it wasn't done then. If a patient wanted this contraception, says Byrne, the hospital really wanted to ensure "that we do everything in our power to offer that."

Parkland Hospital dedicated¹⁸ one of its labor¹⁹ and delivery operating rooms to doing nothing but tubal surgery, staffed it with surgeons and an anesthesiologist, and decided to cover the costs of the procedure whenever Medicaid didn't.

The result was that nearly 90% of women who asked for their tubes to be tied after childbirth actually got the procedure, according to a study just published by Byrne and some colleagues.

And at this hospital, if the operation didn't happen, it was almost always because the patient had decided against it.

"But that study takes place in a very specific patient population, in a hospital with dedicated staffing for these procedures, and that is willing to absorb the cost of procedures," says Flink, who calls this approach "not a viable²⁰ option for most hospitals."

She recently looked to see how many post-childbirth tubal procedures got done where she was working, Strong Memorial Hospital in Rochester, N.Y., and found that the majority of women who'd requested it left the hospital with their tubes still intact.

"I certainly had a sense that we weren't completing all of them or close to all of them," says Flink. "But the fact that it was fewer than half, I think was a little bit of a shock."

1 transcript   

n.抄本，誊本，副本，肄业证书

参考例句：

• A transcript of the tapes was presented as evidence in court.一份录音带的文字本作为证据被呈交法庭。
• They wouldn't let me have a transcript of the interview.他们拒绝给我一份采访的文字整理稿。

2 supreme   

adj.极度的，最重要的；至高的，最高的

参考例句：

• It was the supreme moment in his life.那是他一生中最重要的时刻。
• He handed up the indictment to the supreme court.他把起诉书送交最高法院。

3 roe   

n.鱼卵；獐鹿

参考例句：

• We will serve smoked cod's roe at the dinner.宴会上我们将上一道熏鳕鱼子。
• I'll scramble some eggs with roe?我用鱼籽炒几个鸡蛋好吗？

4 wade   

v.跋涉，涉水；n.跋涉

参考例句：

• We had to wade through the river to the opposite bank.我们只好涉水过河到对岸。
• We cannot but wade across the river.我们只好趟水过去。

5 pregnancies   

怀孕，妊娠( pregnancy的名词复数 )

参考例句：

• Since the wartime population needed replenishment, pregnancies were a good sign. 最后一桩倒不失为好现象，战时人口正该补充。
• She's had three pregnancies in four years. 她在四年中怀孕叁次。

6 frustration   

n.挫折，失败，失效，落空

参考例句：

• He had to fight back tears of frustration.他不得不强忍住失意的泪水。
• He beat his hands on the steering wheel in frustration.他沮丧地用手打了几下方向盘。

7 previously   

adv.以前，先前（地）

参考例句：

• The bicycle tyre blew out at a previously damaged point.自行车胎在以前损坏过的地方又爆开了。
• Let me digress for a moment and explain what had happened previously.让我岔开一会儿，解释原先发生了什么。

8 pregnancy   

n.怀孕，怀孕期

参考例句：

• Early pregnancy is often accompanied by nausea.怀孕早期常有恶心的现象。
• Smoking during pregnancy increases the risk of miscarriage.怀孕期吸烟会增加流产的危险。

9 sterilization   

n.杀菌，绝育；灭菌

参考例句：

• Sterilization by filtration is subject to one major theoretical limitation. 过滤灭菌具有一个理论上的局限性。 来自辞典例句
• Sterilization is a treatment that frees the treated object of all living organisms. 灭菌处理是从处理对象排除一切生活的生物。 来自辞典例句

10 obesity   

n.肥胖，肥大

参考例句：

• One effect of overeating may be obesity.吃得过多能导致肥胖。
• Sugar and fat can more easily lead to obesity than some other foods.糖和脂肪比其他食物更容易导致肥胖。

11 affiliation   

n.联系，联合

参考例句：

• There is no affiliation between our organization and theirs,even though our names are similar.尽管两个组织的名称相似，但我们之间并没有关系。
• The kidnappers had no affiliation with any militant group.这些绑架者与任何军事组织都没有紧密联系。

12 mandatory   

adj.命令的；强制的；义务的；n.受托者

参考例句：

• It's mandatory to pay taxes.缴税是义务性的。
• There is no mandatory paid annual leave in the U.S.美国没有强制带薪年假。

13 vividly   

adv.清楚地，鲜明地，生动地

参考例句：

• The speaker pictured the suffering of the poor vividly.演讲者很生动地描述了穷人的生活。
• The characters in the book are vividly presented.这本书里的人物写得栩栩如生。

14 frustrated   

adj.挫败的，失意的，泄气的v.使不成功( frustrate的过去式和过去分词 )；挫败；使受挫折；令人沮丧

参考例句：

• It's very easy to get frustrated in this job. 这个工作很容易令人懊恼。
• The bad weather frustrated all our hopes of going out. 恶劣的天气破坏了我们出行的愿望。 来自《简明英汉词典》

15 accusations   

n.指责( accusation的名词复数 )；指控；控告；（被告发、控告的）罪名

参考例句：

• There were accusations of plagiarism. 曾有过关于剽窃的指控。
• He remained unruffled by their accusations. 对于他们的指控他处之泰然。

16 detention   

n.滞留，停留；拘留，扣留；(教育)留下

参考例句：

• He was kept in detention by the police.他被警察扣留了。
• He was in detention in connection with the bribery affair.他因与贿赂事件有牵连而被拘留了。

17 decided   

adj.决定了的，坚决的；明显的，明确的

参考例句：

• This gave them a decided advantage over their opponents.这使他们比对手具有明显的优势。
• There is a decided difference between British and Chinese way of greeting.英国人和中国人打招呼的方式有很明显的区别。

18 dedicated   

adj.一心一意的；献身的；热诚的

参考例句：

• He dedicated his life to the cause of education.他献身于教育事业。
• His whole energies are dedicated to improve the design.他的全部精力都放在改进这项设计上了。

19 labor   

n.劳动，努力，工作，劳工；分娩；vi.劳动，努力，苦干；vt.详细分析；麻烦

参考例句：

• We are never late in satisfying him for his labor.我们从不延误付给他劳动报酬。
• He was completely spent after two weeks of hard labor.艰苦劳动两周后，他已经疲惫不堪了。

20 viable   

adj.可行的，切实可行的，能活下去的

参考例句：

• The scheme is economically viable.这个计划从经济效益来看是可行的。
• The economy of the country is not viable.这个国家经济是难以维持的。