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Use of a decision aid tool helped pregnant Medicaid patients interested in tubal sterilization achieve a higher level of understanding and less decisional conflict about the procedure compared with usual care, a multisite randomized controlled trial found.

The decision aid cohort answered 76.5% of questions assessing tubal sterilization knowledge correctly compared to 55.6% in the usual care group (P<0.001) and had lower decisional conflict scores (12.7% and 18.7% respectively, P=0.002), reported Sonya Borrero, MD, MS, of the Center for Innovative Research on Gender Health Equity at the University of Pittsburgh, and colleagues.

Importantly, those in the decision aid group had a better understanding that tubal sterilization is not easily reversible compared to the usual care group (90.1% vs 39.3%, P<0.001) and that the tubes don't spontaneously "come untied" (86.6% vs 33.7%, P<0.001), they wrote .

Study co-author Nikki Zite, MD, MPH, professor of obstetrics and gynecology at the University of Tennessee Graduate School of Medicine in Knoxville, told MedPage Today that tubal sterilization is commonly misunderstood.

"Some of it may go back to the misnomer 'tying your tubes' -- and people believing that they could just become untied or easily be untied and function properly," Zite said. She noted the tool aimed to help patients arrive at the doctor's office more aware and educated of their fertility desires.

"We know that with the right information, patients can make informed decisions and be able to control their reproductive futures," Zite said.

The web-based tool, called MyDecision/MiDecisión, was available in English and Spanish and included audio, video, and written information about tubal sterilization with some knowledge checks to assess patients' understanding.

Zite noted it's important to keep in mind the historical context of coercive sterilization, which still informs the present. Medicaid policy that was first enacted in the 1970s in response to government-forced sterilization initiatives for low-income and racial and ethnic minoritized communities requires Medicaid patients to sign a consent form at least 30 days prior, but no longer than 180 days before any permanent contraceptive procedure. While intended to ensure consent, nearly half of sterilization requests go unfulfilled due to these barriers.

Researchers noted that both the American Medical Association and the American College of Obstetricians and Gynecologists have said this consent process needs to be updated, and have suggested a plain language simplified consent form and shortening the required waiting period. Zite says she hopes MyDecision/MiDecisión can help patients and physicians alike.

"I think that physicians deal with barriers related to time and feel like sometimes counseling isn't as complete as they would like, especially about something as important as reproductive rights and permanent contraception," Zite said. If a patient utilized the tool prior to counseling with their physician, it "would help the physician to feel more comfortable moving forward with something like permanent contraception, especially in those younger or patients who've not had children yet."

Authors concluded that "the MyDecision/MiDecisión decision aid offers a scalable safeguard to help ensure that people have complete understanding about the nature of permanent contraception and alternate contraceptive options prior to consenting to the procedure" and if it is "found to be superior to the current Medicaid consent form, it could potentially replace it." Zite also noted that implementation studies and further data analysis of marginalized groups are needed.

From March 2020 through November 2023, 350 pregnant participants were randomized to either usual care or usual care plus the decision aid at outpatient obstetric clinics in Pittsburgh; Knoxville, Tennessee; and San Francisco. Eligible patients had Medicaid insurance, were 24 weeks or less pregnant, considering tubal sterilization after delivery, spoke English or Spanish, and were between the ages of 21 and 45.

Participants in San Francisco were able to complete study assessments in either English or Spanish; participants at all other sites completed study assessments in English. However, all participants were able to use the decision aid in either English or Spanish by preference. According to self-reported race and ethnicity data, 26% were Black, 26% were Hispanic, 39.1% were white, and 4% each were multiracial and other race or ethnicity; the mean age was 29.7. The primary outcomes were knowledge of tubal sterilization, measured by 10 true or false questions, and conflict about their contraceptive decision, measured by the low-literacy Decision Conflict Scale.

Authors noted that the tool should be tested among people with higher incomes and those not currently pregnant to confirm effectiveness. Also, how intervention impacts long-term satisfaction is unknown, though decisional conflict tends to correlate with longer term regret.

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