Will the Affordable Care Act Eliminate Perplexing Inequalities in Contraceptive Sterilization?

In the United States, just under half (48.1%) of partnered women aged 25–44 using contraception rely on sterilization for fertility control. In our recent study, Gender, Class, and Contraception in Comparative Context: The Perplexing Links between Sterilization and Disadvantage (2016), Megan Sweeney and I show that levels of contraceptive sterilization are similarly high in Australia (39.6% of partnered women aged 25–44 using contraception), but they tend to be much lower and more variable across Europe. With the exception of Australia and Belgium, female sterilization is more common than male sterilization in all of the countries studied (Austria, Bulgaria, France, Georgia, Germany, Romania, Russia, and the United States), despite the latter being simpler, more effective, less often regretted, more economical, and having lower rates of minor and major complications.

The main goal of the study was to examine persistent and gendered associations between sterilization and education in the United States in a comparative perspective. Specifically, we asked if the negative association between female sterilization and education, and the positive association between male sterilization and education extends to other low-fertility countries of Europe and Australia. Analysis of nationally representative data from the 2006-10 National Survey of Family Growth and the 2004-10 Generations and Gender Project revealed that the negative association between female sterilization and education extends to all study countries except Romania. In contrast, the positive association between male sterilization and education is largely unique to the United States. In other study countries with non-trivial levels of male sterilization (>1% of contraceptive users), we found evidence of a negative association in Australia and a non-linear association in several western European countries (Austria, Belgium, and Germany).

In most of these countries the relationship between education and sterilization was explained by differences in basic demographic background factors, primarily differences in the age at first childbearing and the number of children. However, a clear gendered pattern persisted in the United States and Belgium. Even after adjusting for all demographic background factors, the negative relationship between education and female sterilization persisted. Additionally, a positive relationship between education and male sterilization remained in the United States, whereas a non-linear relationship remained in Belgium. This indicates that educational gradients in female and male sterilization in these two countries are unlikely to be the result of basic compositional differences across socioeconomic groups, but are likely a result of the broader context of contraceptive practices and policies.

This raises the question: What aspects of contraceptive practices and policies in these two countries give rise to gendered inequalities in the use of contraceptive sterilization? In most of Europe, little research has focused on describing and explaining sterilization patterns, meaning that we know little about potential factors underlying the observed patterns in Belgium. In the United States, research has identified several factors that may contribute to differential use of sterilization by education, with US health policy and insurance regulations likely playing a key role in shaping the unique gender patterns. For example, research shows that female sterilization is relatively common among women relying on Medicaid (a government sponsored insurance program) or without insurance, whereas male sterilization is most common among men with private insurance (Anderson et al., 2012). Most publicly funded family planning clinics focus on serving women, and vasectomy services are often not offered at these clinics (Frost et al., 2012). In addition, low-income women often become eligible for Medicaid during pregnancy and may, in anticipation of soon being uninsured, opt for a postpartum sterilization because this method will not require regular contact with the health care system.

The vital role of US health policy and insurance regulations in shaping gendered inequalities in the use of contraceptive sterilization begs the question: How will the implementation of the Affordable Care Act (ACA) affect the persistent and gendered associations between sterilization and education in the United States? Two stipulations of the ACA are likely to have an impact on this association. The first is the reduction in the number of uninsured reproductive-aged women through the expansion of Medicaid and the individual mandate to buy insurance. The second is the requirement that health plans fully cover “all Food and Drug Administration approved contraceptive methods, sterilization procedures, and patient education and counselling for all women with reproductive capacity” (see http://www.hrsa.gov/womensguidelines/ for details). Together, these stipulations should increase women’s contraceptive access and options, by eliminating the financial barriers to obtaining the full range of female contraceptive methods.

Recent research by the Guttmacher Institute (Bearak et al. 2015; Finer, Sonfield and Jones 2014; Guttmacher Institute 2016) suggests that the ACA is improving women’s health coverage and is reducing financial barriers to contraception, but also that not all groups are benefitting equally (e.g., Latinas; Jones and Sonfield 2016). Thus, while the ACA may be an important mechanism to eliminating inequalities in the use of female sterilization in the United States, it is unlikely to be a sufficient mechanism. In addition, by limiting its scope to women and female contraceptive methods, the ACA may increase the imbalance in the use of female versus male sterilization. Finally, other factors will likely continue to contribute to inequalities in sterilization and contraceptive use, such as differences in the availability and accessibility of (male) sterilization, in individual preferences and knowledge, in attitudes towards health care providers, in attitudes of health care providers towards their patients, in the role of other contraceptive goals (e.g. disease prevention), and in community-level contraceptive attitudes and practices. Examining how these factors continue to affect persistent and gendered inequalities in contraceptive sterilization will be an important direction for future research.


Anderson, J.E., Jamieson, D.J., Warner, L., Kissin, D.M., Nangia, A.K. & Macaluso, M. (2012). Contraceptive sterilization among married adults: National data on who chooses vasectomy and tubal sterilization. Contraception, 85:552–557.

Bearak, J.M., Finer, L.B., Jerman, J. & Kavanaugh, M.L. (2015). Changes in out-of-pocket costs for hormonal IUDs after implementation of the Affordable Care Act: An analysis of insurance benefit inquiries. Contraception [published online first: DOI: 10.1016/j.contraception.2015.08.018].

Eeckhaut, M.C.W. & Sweeney, M.M. (2016). The perplexing links between contraceptive sterilization and (dis)advantage in ten low-fertility countries. Population Studies, 70(1):39–58.

Finer, L.B., Sonfield, A. & Jones, R.K. (2014). Changes in out-of-pocket payments for contraception by privately insured women during implementation of the federal contraceptive coverage requirement. Contraception, 89:97–102.

Frost, J.J., Gold, R.B., Frohwirth, L. & Blades, N. (2012). Variation in service delivery practices among clinics providing publicly funded family planning services in 2010. New York: Guttmacher Institute.

Guttmacher Institute (2016). Health coverage trends among U.S. women of reproductive age varied considerably with ACA implementation. Accessed February 22, 2016: http://guttmacher.org/

Jones, R.K. & Sonfield, A. (2016). Health insurance coverage among women of reproductive ae before and after implementation of the Affordable Care Act. Contraception [published online first: DOI: http://dx.doi.org/10.1016/j.contraception.2016.01.003].

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