Demand for tubal ligations up across Michigan in Roe aftermath — but many are being denied
Ashley Steffen went under the knife about a month after the U.S. Supreme Court overturned Roe v. Wade in June, reversing the constitutional right to abortion.
Steffen, 37, of Lansing, is among a growing number of women to seek a sterilization procedure known as tubal ligation in the months since the ruling in Dobbs v. Jackson Women’s Health Organization left abortion access up to states to decide.
“I would not have done it if I knew abortion access would be guaranteed in Michigan,” said Steffen, who said she has never wanted children.
“Now, I'm very relieved. … I don't want to risk it.”
'Now seems like the time to pursue this’
The number of people calling to schedule consultations for sterilization procedures at the University of Michigan has doubled since the Dobbs ruling, said Dr. Charisse Loder, assistant professor in the department of obstetrics and gynecology at Michigan Medicine.
“I used to see one or two patients who wanted to have consultations for sterilization in a week, and now I'm seeing two to four in a week,” Loder said.
“Patients often say, ‘This is something I've been thinking about for a while and now seems like the time to pursue this.’ Or they've said things like: ‘I'm worried about the political climate or I'm worried about my access to birth control or sterilization in the future.’
“Not every patient brings up the political climate or the Dobbs decision, but many more do without any prompting.”
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Though demand is up, getting a tubal ligation — which involves cutting, blocking or removing the fallopian tubes to prevent eggs from being fertilized and released into the uterus — isn’t always as simple as making an appointment with a gynecologist.
‘No, I won't do your sterilization’
Sometimes, doctors foist their own beliefs upon their patients, refusing for religious reasons or because they deem a person too young or too single to be able to make the decision, said Dr. Halley Crissman, an obstetrician-gynecologist who also is associate medical director for Planned Parenthood of Michigan and an adjunct clinical professor at the University of Michigan.
“I've seen people show up in clinic with literally a binder of notes from friends and family members and sometimes partners attesting that they have been consistent and persistent with their plan not to have biologic children because they've been turned away by different providers before,” she said.
“They're so worried walking in the door that I, too, am going to say, ‘No, I won't do your sterilization’ that they literally show up with a signed note from their husband or their pastor or their parents.
“It’s hard to see that and not recognize the paternalism, the pronatalism and the injustice in that.”
Another obstacle for as many as 1 in 4 Michiganders seeking tubal ligation surgery is the waiting period mandated by Medicaid and Medicare that requires a sterilization consent form to be signed at least 30 days prior to the procedure but not more than 180 days in advance.
When that rule was created, it was meant to be protective, not prohibitive, Loder said.
“Historically, people who are disabled or people of color, men and women were coercively sterilized without consent or knowledge,” she said. “That happened to thousands of people in the early 1900s until the 1970s. And then in the 1970s, regulations came about to protect people, saying that patients who had federally qualified insurance, like Medicare or Medicaid, needed to sign a form 30 days before a sterilization procedure.
“And this was, at the time, the approach to preventing someone from being coerced on the day of surgery into a sterilization procedure."
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Waiting period interferes with getting procedure
In some ways, the requirement now has become a barrier to receiving care, she acknowledged − one that can put a hurdle in the way of low-income people on federally subsidized insurance that doesn't exist for wealthier people with private insurance.
Even though the 30-day waiting period can be waived for people undergoing emergency abdominal surgery or are delivering a baby prematurely, the law requires that there be at least 72 hours between when a person signs the consent forms and the procedure — too long for many to have tubal ligation immediately after childbirth or following emergency surgery.
As many as 50% of people who ask for a tubal ligation after delivering a baby are denied the procedure because they did not have the consent forms completed at least 30 days in advance, Loder said.
Those who are denied tubal ligation procedures are at high risk for repeat pregnancy. A 2010 study published in the journal Obstetrics & Gynecology found that about 47% of women who were refused sterilization after delivering a baby became pregnant within the following year — more than twice the rate of those in the control group.
Catholic hospitals won't do tubal ligation
That's one of Catherine Walker-Russell's greatest fears.
The 37-year-old from Harrison Township scheduled a tubal ligation surgery just before the coronavirus pandemic struck in the spring of 2020.
"COVID hit and the surgery was deemed unessential," Walker-Russell said. "It was pushed back."
While she waited for hospitals to resume elective surgeries, Walker-Russell discovered she was pregnant with her fourth child.
She chose to go through with the pregnancy despite multiple complications. She had heart problems, gestational diabetes and a history of preterm birth. The baby wasn't growing well and was considered intrauterine growth restricted.
Doctors told Walker-Russell this baby should be her last.
"They knew she was going to have to come early because of her health complications and my health complications. So we had all the paperwork set and ready to go," she said. "It was already in the plans for me to have a tubal after my C-section with her."
It was an ideal time to have the procedure because it could be done using the same incision used to deliver the baby while Walker-Russell was still under anesthesia — thus eliminating the need for a second surgery and additional risks of repeated anesthesia.
However, Walker-Russell was denied the procedure. That's because she delivered her daughter at a Catholic hospital − Ascension St. John on Detroit's east side.
Her obstetrician worked out of only two hospitals in the area, Beaumont Hospital, Grosse Pointe, and St. John, which has a Level III neonatal intensive care unit. She picked St. John, which was better equipped to care for her premature baby, she said.
Walker-Russell told the Free Press that when she asked about tubal ligation, "They said, 'Absolutely not. We are not doing a tubal. We are a Catholic hospital.' And I told them, 'I have a medical exemption. I cannot have any more children. ... For me to get pregnant again is a complete risk to my health.' But they would absolutely not do a tubal."
'Judged morally wrong' by the church
Catholic hospitals abide by the Ethical and Religious Directives for Catholic Health Care Services established by the U.S. Conference of Catholic Bishops, Holly Fournier, associate director of communications for the Archdiocese of Detroit, told the Free Press in a previous interview.
The directives are based on the Catholic Church's teaching that life begins at conception and that sexual intercourse is a sacred act of procreation. The directives prohibit the use of contraception, as well as sterilization procedures, abortion and in vitro fertilization.
"Catholic health care does not offend the rights of individual conscience by refusing to provide or permit medical procedures that are judged morally wrong by the teaching authority of the Church," the document says.
It is the responsibility of the local bishop to hold all Catholic health care facilities in a diocese accountable, Fournier said. In the Archdiocese of Detroit, that person is Archbishop Allen Vigneron.
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As the reach of Catholic health systems grows nationally — it's estimated that one in six patients in the U.S. is treated at Catholic health care facilities, according to the 2020 Community Catalyst analysis — increasing numbers of people are being denied reproductive health care, Loder said.
"As a physician, my main goal and focus is to provide care that's safe for my patient in a way that they want to be cared for," Loder said. "And when there's an interference with that — whether that's from hospital, a law, the Supreme Court — that's really interfering with the personal relationship that a doctor and their patient have with each other and affecting patient's health and ability to achieve their optimal health.
"It makes me think as an OB-GYN, where would I want to be employed and what kind of care can I provide in a variety of situations. I would hate to be the provider who couldn't provide a really safe procedure for someone who needed it and wanted it because of a hospital system."
Seven Michigan counties had only Catholic health systems in 2019, according to a Free Press review of Michigan Department of Licensing and Regulatory Affairs data. Ten Michigan counties had no hospitals at all.
'It was very traumatizing' to be told no
"What I'm hearing from my patients is that they've seen doctors who are imparting their own beliefs on their patients, their own concerns or potentially religious or cultural beliefs about when a person should be able to decide about pregnancy or how many children a person should be able to have," she said.
"Those physicians are preventing patients from getting care that they want. This is a personal decision for my patients. And they should, as long as they're capable of consenting and have capacity to make decisions for themselves, be able to decide if they want to have a sterilization procedure or not."
To Walker-Russell, it's unacceptable. "It was very traumatizing," she said, to be told she couldn’t have the tubal ligation after she delivered her daughter.
"No matter what my beliefs are, if my health is at risk ... if I am of sound mind and want to make the decision to say, ‘I don't want any more children,’ they shouldn't be able to say, ‘Well, we're a Catholic hospital, we're not going to do it’ — especially for any women experiencing medical issues."
Another pregnancy, she said, would be “life-threatening for me." So for now, she's taking birth control pills and has been weighing her options.
‘You're too young. You can't make this decision.’
State law requires that a person be at least 21 to undergo a sterilization procedure. Crissman told the story of a patient that young who recently came to her office for a tubal ligation consultation.
The patient “has talked to multiple other providers and has been told, ‘You're too young. You don't know. You can't make this decision,’ ” Crissman said. But after being informed of other reversible options of birth control — such as an IUD, pills and the Nexplanon implant, the person still chose permanent sterilization.
“Yes, that person is young. Is there some small possibility of regret? Yeah, that is possible. But who am I to decide that the small potential for regret means that I should not allow somebody to make a really important, informed decision about their body, their bodily autonomy — that I get to decide, yes, this person needs to remain at risk of pregnancy or (without) a type of contraception that that feels right to them?”
'Women are being treated like we’re subhuman'
Jenna Raut, 23, of South Lyon, is worried about that. She has been researching tubal ligation procedures and hopes to have surgery within the next six months.
“I'm scared of what they're going to say,” Raut said. “They're still going to probably say, ‘Give it a few years.' … It’s very nerve-racking.
“I've known my whole life that I never want to have kids and I've talked to older women and they always tell me about their experiences and how hard it is to have a tubal ligation.
“One of my old co-workers was in her mid-40s, had four kids and was rejected for a tubal ligation a few times. I think it might have taken two or three tries, and she also needed consent from her husband.”
Raut said the Supreme Court’s ruling in the Dobbs v. Jackson case made her more committed to having the sterilization procedure.
“Women are being treated like we’re subhuman and like we can't make our own decisions and that we have to be punished for something that may not even be our fault,” she said. “It’s really sad that women aren't taken seriously in 2022.”
Contact Kristen Jordan Shamus: kshamus@freepress.com. Follow her on Twitter @kristenshamus.
This article originally appeared on Detroit Free Press: Tubes-tied procedure in Michigan: Permanent birth control often denied
