Number 8 (Replaces Committee Opinion Number 695, April 2017)
This Committee Statement was developed by the American College of Obstetricians and Gynecologists Committee on Ethics in collaboration with committee members Kavita Shah Arora, MD, MBE, MS; Maryam Guiahi, MD, MSc; and Lisa H. Harris, MD, PhD.
ABSTRACT: Permanent contraception is the most used method of contraception among women aged 15–49 years and is one of the most straightforward surgical procedures an obstetrician–gynecologist can perform. At the same time, this therapeutic option is enormously complex when considered from a historical, sociological, or ethical perspective. This Committee Statement reviews ethical issues related to permanent contraception using a reproductive justice framework. Ethical counseling and shared decision making for permanent contraception should adopt a nonjudgmental, patient-centered approach, using up-to-date information about permanent contraception procedures and alternatives. Obstetrician–gynecologists should strive to avoid bringing into the clinical encounter biases around gender, race, age, and class that affect thoughts on who should or should not become a parent. Obstetrician–gynecologists should also ensure that permanent contraception requests reflect each patient's wishes, come from a desire to permanently end childbearing, and come from a preference for permanent contraception over all reversible methods as well as permanent contraception for the male partner. When difficulties in meeting a postpartum permanent contraception request are anticipated and permanent contraception is desired by the patient, transfer of care for the remainder of pregnancy should be offered. ACOG recognizes the right of all patients to unimpeded access to permanent contraception as a way of ensuring health equity, but it is unclear how to craft policies that protect from coercion but also do not create barriers to autonomously desired care. Determining the ethical balance between access and safeguards will require a collaborative interdisciplinary approach that involves a variety of stakeholders with varying perspectives.
Summary of Recommendations and Conclusions
Based on the principles outlined in this Committee Statement, the American College of Obstetricians and Gynecologists (ACOG) makes the following recommendations and conclusions:
Respect for an individual patient’s reproductive autonomy should be the primary concern guiding permanent contraception provision and policy.
Before providing permanent contraception, obstetrician–gynecologists should engage in shared decision making with their patient and include a discussion of the patient’s reproductive desires that places the patient’s wishes at the center of care. Patient counseling should include information about reversible alternatives and emphasize the permanence of these methods, with documentation of a specific discussion that the procedure will mean that the patient will not be able to spontaneously conceive in the future.
Whenever appropriate, vasectomy should be discussed during patient counseling as an option with fewer risks and greater efficacy than female permanent contraception.
Longitudinal counseling is important to minimize patient regret. It is also important to avoid paternalism by the health care professional. Respect for reproductive autonomy requires not imposing thresholds based on age or parity or both for permanent contraception.
Coercive or forcible contraceptive practices are unethical and should never be provided.
Obstetrician–gynecologists should consider their therapeutic and fiduciary roles in counseling and care recommendations and avoid actions based on individual biases about race, ethnicity, socioeconomic status, sexual orientation, and parenthood status, which can affect the interpretation of patients’ requests and influence the provision of care.
When an adult patient is without capacity to make treatment decisions and permanent contraception is considered, the physician should engage with the patient to the extent to which it is possible to gain a better understanding of their needs. The physician also should consult with the patient’s surrogate to adopt a plan that promotes what is believed to be the patient’s best interests while, at the same time, preserving the patient’s reproductive autonomy to the maximum extent possible.
Special procedural safeguards and oversights are needed when incarcerated patients request permanent contraception because of the possibility of coercion in the prison environment that impedes proper informed consent. Particular care should be taken to ensure that reversible methods have been made available to incarcerated patients and, ideally, that documentation of prior (pre-incarceration) request for permanent contraception exists.
If individual physicians or institutions will not provide surgery for permanent contraception because of personal religious beliefs or institutional policy, the patient must be informed as early as possible. The patient must also be provided with an alternative form of contraception that is acceptable to the patient or must be referred elsewhere for care. When difficulties in meeting a postpartum permanent contraception request are anticipated and such surgery is desired by the patient, transfer of care for the remainder of pregnancy should be offered.
Given the importance of reproductive autonomy, as well as the multiple barriers to equitable access to permanent contraception, permanent contraception should not be considered elective but a medically indicated, time-sensitive procedure.
Background
Respect for an individual patient’s reproductive autonomy should be the primary concern guiding permanent contraception provision and policy.
Permanent contraception is the most used method of contraception among females aged 15–49 years (18.1%) and is more common than male permanent contraception (5.6%) 1. Compared with male permanent contraception, most methods of female permanent contraception are slightly less effective, more costly, and carry more risk 2. Although permanent contraception procedures (historically referred to as sterilization) are among the most straightforward of surgical procedures an obstetrician–gynecologist (ob-gyn) performs, this therapeutic option is enormously complex when considered from a historical, sociological, or ethical perspective 3; in the United States, many women with low incomes and from racially or ethnically minoritized groups were involuntarily sterilized as part of state and federally funded programs 4 5 6. It is important to note that coerced sterilizations continue to occur, whether explicitly (such as in the California penal system as described below, contemporary groups offering inducements for patients with substance use disorder to undergo sterilization, or with hysterectomies performed on women in the custody of U.S. Immigration and Customs enforcement in Georgia [7]) or implicitly, given potential differential counseling regarding contraception based on race, ethnicity, socioeconomic status, and other demographic factors 8. An ethical approach to the provision of permanent contraception should, therefore, promote access for patients who wish to use permanent contraception as a method of contraception but at the same time safeguard against coercive or otherwise unjust uses.
Use of Language
This Committee Statement reviews ethical issues related to permanent contraception. The American College of Obstetricians and Gynecologists (ACOG) recognizes and supports the gender diversity of all patients who seek obstetric and gynecologic care. In the original portions of this document, the authors seek to use gender-inclusive language or gender-neutral language. When describing research findings, this document uses gender terminology reported by investigators. To review ACOG's policy on inclusive language, see https://www.acog.org/clinical-information/policy-and-position-statements/statements-of-policy/2022/inclusive-language. For this Committee Statement, we primarily focus on permanent contraception for those with pregnancy potential (rather than, for example, vasectomy). We use the term permanent contraception rather than sterilization to recognize a patient's active and informed decision to complete or forgo childbearing.
This Committee Statement also reflects the importance of using a reproductive justice framework when considering the ethical provision of permanent contraception. In this framework, “reproductive rights” are something broader than access to contraception and abortion alone; that is, a reproductive justice framework, as defined by the Black women who first originated the term, recognizes that reproductive rights include the right to have children, not to have children, and to parent in safe and humane conditions 9. A reproductive justice framework also necessarily acknowledges how gender, race, and socioeconomic status shape reproductive health care experiences, care provision, and reproductive health policy.
Ethical Issues and Considerations
Before providing permanent contraception, obstetrician–gynecologists should engage in shared decision making and include a discussion of a patient's reproductive desires that places the patient's wishes at the center of care. Patient counseling should include information about reversible alternatives and emphasize the permanence of these methods, with documentation of a specific discussion that the procedure will mean that the patient will not be able to spontaneously conceive in the future.
An ethical approach to permanent contraception requires that ob-gyns recognize an individual's legitimate claims to avoid pregnancy or pursue pregnancy when desired. With this background, issues emerge regarding the ethical use of permanent contraception in contemporary obstetric and gynecologic practice.
Ethical Provision of Permanent Contraception Requires Careful Counseling
Ethical counseling and shared decision making involve three broad considerations: 1) the content of information presented, 2) the process of conveying information, and 3) self-reflection on the part of the ob-gyn. Content should include the most up-to-date information about permanent contraception procedures and alternatives 10 11. The counseling process should be nonjudgmental, and physicians should recognize patients as individuals with varying desires and priorities 12. Finally, ob-gyns should strive to avoid bringing into the clinical encounter biases around gender, race, age, and class that affect thoughts on who should or should not become a parent and any preconceived notions regarding the appropriate size of families and desires to remain childless.
Counseling Content
Obstetrician–gynecologists have an ethical duty to ensure that all patients understand the risks and benefits of and alternatives to permanent contraception (including noncontraceptive benefits, such as possible cancer risk reduction) and that permanent contraception should be considered essentially irreversible, albeit with occasional failures and concomitant ectopic pregnancy risk 13. Long-acting reversible contraceptive methods should be raised as additional options for patients who have completed childbearing or do not ever wish to become pregnant 14 15. Risk factors for later requesting reversal surgery should be discussed, particularly young age and marital or relationship difficulties or other significant life stressors at the time of the request.
Whenever appropriate, vasectomy should be discussed during patient counseling as an option with fewer risks and greater efficacy than female permanent contraception.
The decision among the various methods is ultimately a matter of patient preference, and a patient's priorities and life contexts ought to determine contraceptive choice. A patient's clearly articulated desire for permanent prevention of future pregnancies should be respected. Patients may choose permanent contraception because their male partners are unwilling to consider vasectomy; the permanent contraception decision, although autonomous, may result from ideas about masculinity or other gender norms about who is responsible for family planning. Although ob-gyns might feel uncomfortable about the possibility of perpetuating inequitable gender norms by performing female permanent contraception in these situations, doing so is ethically permissible and may ultimately represent the decision that is optimal for a patient given their specific circumstances. Obstetrician–gynecologists should also be aware of and able to discuss relevant laws or regulations that may constrain permanent contraception provisions, such as Medicaid minimum-age and waiting-period requirements. In addition, ob-gyns should be aware that some patients may have insurance coverage restricted to pregnancy and the immediate postpartum period and may have limited access to permanent contraception or other contraceptive options outside of this window 11.
Counseling Process
The goal of permanent contraception counseling—and counseling more generally—is to adopt a patient-centered approach in which decision making is shared between a patient and their physician. However, when patients consider an irreversible decision such as permanent contraception, it is possible that a physician may feel a protective impulse to help a patient avoid regret 16. However, this beneficent desire to “protect” a patient from the consequences of a permanent decision is a form of medical paternalism and should be avoided because it overrides or undermines patient autonomy. For example, physicians may hesitate to provide requested permanent contraception to young patients in the face of knowledge that, for most people, full cognitive maturation—including the ability to incorporate long-term goals into complex decision making—is not reached until the mid-20s 17. When young patients, patients of color, unmarried patients, and patients experiencing significant life stressors request permanent contraception, a protective impulse may be engendered because of the knowledge that, in the past, patients in these demographic groups disproportionately sought reversal information later in life 18 19.
Longitudinal counseling is important to minimize patient regret. It is also important to avoid paternalism by the health care professional. Respect for reproductive autonomy requires not imposing thresholds based on age or parity or both for permanent contraception.
Patients—not their physicians—are the ultimate experts on what is important and meaningful to them. Further, being a fully autonomous person with decisional capacity carries the risk of decisional regret, and eliminating all risk of regret is not possible. Denying permanent contraception to those who request it comes at the cost of limiting the ability of patients to fully express their reproductive autonomy regarding when and whether to become pregnant and to parent. This phenomenon has been coined the “dignity of risk” 20. When a physician or an institution restricts decisional capacity, the risk of regret may be reduced; however, eliminating decisional authority is ethically more problematic than decisional regret 20. Furthermore, any steps to verify sustained intent, such as requiring a mental health consultative visit before permanent contraception, no matter how well-meaning, serve as an additional barrier to care and should be discouraged as routine practice. When in doubt about the advisability of proceeding with requested permanent contraception, it is recommended that the physician err on the side of respecting a patient's decisional and reproductive autonomy.
Some ob-gyns decline to perform permanent contraception procedures because of religious beliefs or other moral values. In such cases, the physician should provide an alternative form of contraception that is equally acceptable to the patient or refer the patient to another health care professional, as should be the case whenever a conscience claim prevents care provision 21. In other cases, a physician who generally performs surgery for permanent contraception may feel a specific patient is not a candidate for the surgery due to medical comorbidities. This recommendation should be discussed proactively and referred to another physician for a second opinion if possible. When a referral is not immediately feasible in time-sensitive situations such as postpartum permanent contraception, physicians are urged to be mindful of individual bias in practice patterns and the ramifications to long-term health and reproductive autonomy of not fulfilling requests for postpartum contraception.
Conversely, coercing or forcing a patient to undergo permanent contraception they do not desire, or about which they are unsure or unaware, is always unacceptable. Examples of coercion and forcible sterilization include withholding other health care to incentivize permanent contraception, threatening to involve the child welfare system if a patient fails to consent to permanent contraception, or performing sterilization without a patient's knowledge during other surgical treatment.
Coercive or forcible contraceptive practices are unethical and should never be provided.
Sometimes external factors may affect a patient's request for permanent contraception. For example, a patient may request permanent contraception because of partner pressure or lack of insurance coverage or resources for the reversible options they would prefer. Once again, careful dialogue is paramount, including discussion of comprehensive contraceptive options and acknowledgement of potential fluidity in contraceptive decision making over time 22. If the only reason for proceeding with permanent contraception is partner pressure, physicians should work diligently to address issues of reproductive coercion, including potential safety issues. If lack of availability of the patient's preferred reversible method leads to a permanent contraception request, physicians should work with patients to find low-cost reversible options if these methods are acceptable to the patient. Further, physicians may increasingly encounter patients desiring permanent contraception as a response to restrictive local and state reproductive health policies. Although individual clinicians cannot change these external structural factors, they should, “educate, empower, and trust [their] patients to make decisions that are right for them, while taking into account the new legislative structural barriers to reproductive autonomy.” 23
Provided that counseling has followed the principles outlined in this document, it is ethically acceptable to perform permanent contraception postpartum, after an abortion, or during other reproductive care. However, requests for permanent contraception should be discussed before the primary procedure or event, at a time when the patient can decide without the pressure of time, review the risks and benefits of permanent contraception, think about alternative contraceptive methods, and make contingency plans in the event of obstetric or neonatal complications or other unanticipated events. Permanent contraception generally should be avoided when the permanent contraception decision is first made during labor or other acute care or when acute events (eg, uterine rupture) raise concern that future childbearing is inadvisable or unsafe. Although there may be rare instances in which permanent contraception is warranted, in such situations physicians generally should offer other contraceptive methods and revisit the question of permanent contraception later. Conversely, when there are unexpected neonatal outcomes that might affect a patient's decision for permanent contraception, alternatives—including long-acting reversible contraceptive methods—should be offered. Nevertheless, even after such unexpected outcomes, shared decision making can be used and permanent contraception still offered and provided when appropriate.
Counseling and Self-Reflection––Gender, Race, Class, Ability Status, and Parenthood
African American, Native American, and Latina women are 1.2–2 times more likely to have undergone permanent contraception than White women after controlling for age, parity, insurance status, marital status, vasectomy use, and a range of other variables 23 24 25. Women with public insurance or no insurance are approximately 1.4 times more likely to have undergone permanent contraception than women with private insurance 24. Although these data may reflect patient preferences, the reasons for these differences are not clear and raise concerns that all patients do not have equal access to the full range of reversible contraceptive methods. Patients who historically have been disenfranchised may have concerns about future inadequate insurance coverage. Additionally, it is possible that patients with low incomes and patients of color may be counseled differently about contraception than White patients or those with private insurance 8.
Obstetrician–gynecologists should consider their role in counseling and care recommendations and avoid actions based on individual biases about race, ethnicity, socioeconomic status, sexual orientation, and parenthood status, which can affect the interpretation of patients' requests and influence the provision of care.
Studies suggest that patient race, ethnicity, and socioeconomic status affect physician attitudes and practices around reversible contraception and permanent contraception, which raises concerns regarding differential counseling 26 27. For example, among patients with identical medical histories, patient race or ethnicity and socioeconomic status influenced recommendations for intrauterine contraception in ways that may reflect racial, ethnic, and social-class stereotypes 27 28 29.
When an adult patient is without capacity to make treatment decisions and permanent contraception is considered, the physician should engage with the patient to the extent to which it is possible to gain a better understanding of their needs. The physician also should consult with the patient's surrogate to adopt a plan that promotes what is believed to be the patient's best interests while, at the same time, preserving the patient's reproductive autonomy to the maximum extent possible.
In the case of permanent contraception, the risks of acting on stereotypes or of viewing patients solely in terms of their demographics are dual. Desired permanent contraception might be denied because a patient belongs to a demographic group that disproportionately seeks reversal information, was historically victimized, or that a physician believes should have children. On the other hand, undesired sterilization might be performed inappropriately based on a patient’s membership in a category for which reproduction has been undervalued. This dichotomy is further complicated in the case of a patient without decision-making capacity. It is important to note that local hospital policies, state laws, and federal Medicaid statutes may require a physician to discuss permanent contraception with a judge in the case of patients with cognitive disabilities. More broadly, a patient-centered approach that focuses on the reproductive desires of an individual patient can mitigate some of the potentially negative effects of health care inequities, particularly with regard to race, class, and ability.
Permanent Contraception and Reversal
In one national, cross-sectional analysis, approximately 10% of women who had undergone prior surgery for permanent contraception subsequently underwent surgery to reverse the permanent contraception or were definitely interested in reversal 19. In this study, young age at the time of sterilization was significantly associated with regret. In prior studies, women from racially or ethnically minoritized groups also were more likely than White women to seek reversal information or to report that a permanent contraceptive procedure prevented them from having desired children 23 25. In one report, one-half of the women from racially or ethnically minoritized groups who were young and unmarried at the time of permanent contraception ultimately requested information about reversal 30. Women who request permanent contraception in conjunction with a recent pregnancy (including at the time of cesarean delivery, postpartum, or at the time of abortion) may be more likely to be dissatisfied with their decision; however, the data are inconsistent 18 31.
Requests for reversal information or procedures often are interpreted by researchers as evidence of “regret” but may represent other phenomena—including that, at the time of permanent contraception, a patient misunderstood (or was misinformed about) the permanence of the procedure, was coerced, or chose permanent contraception under the constraints of structural issues such as poverty or lack of access to reversible methods. Indeed, dissatisfaction with a decision for permanent contraception is most likely in women whose reasons for permanent contraception are issues other than a desire for no further children (eg, marital or relationship difficulties or other stressful life circumstances) 32. This points to the need for ob-gyns to ensure that permanent contraception requests reflect each patient's wishes, come from a desire to permanently end childbearing, and come from a preference for permanent contraception over all reversible methods as well as permanent contraception for the male partner.
Permanent Contraception for Incarcerated Patients
Between 2006 and 2010, more than 140 women underwent publicly funded tubal ligations in California prisons. Although these women signed consent forms, researchers analyzing these cases afterward showed that many consent forms were not properly completed, violations of the waiting period occurred, and procedures were undesired 33. The women also reported significant pressure from prison and hospital physicians to undergo sterilization 34.
Prison is an environment intended to restrict liberty; thus, ensuring proper informed consent and shared decision making is challenging. The concept of autonomy is diminished in a setting in which all choices and behaviors are monitored and potentially punished, sometimes in idiosyncratic or unpredictable ways 34. All “choices” in prison are made with implicit and explicit threats of disciplinary action for “wrong” choices and, thus, are made in situations of significant constraint, if not coercion. Researchers who investigated these cases concluded, “The coercive nature of the prison environment undermines a person's ability to give meaningful consent to the irreversible destruction of fertility” 34. Although women are not wholly without decisional agency to make medical-care choices while incarcerated, in the setting of historical and contemporary abuses, irreversible procedures such as permanent contraception should not be performed routinely there.
Special procedural safeguards and oversight are needed when incarcerated patients request permanent contraception because of the possibility of coercion in the prison environment that impedes proper informed consent. Particular care should be taken to ensure that reversible methods have been made available to incarcerated patients and, ideally, that documentation of prior (pre-incarceration) request for permanent contraception exists.
At the same time, some incarcerated patients may genuinely desire permanent contraception, may have requested it previously, and may not have access to health care outside of the prison system. A policy of denying all requests for permanent contraception in prison may impinge on some patients' authentic desire to control their fertility permanently.
Access to Permanent Contraception in Catholic-Affiliated Health Systems
Some Catholic-affiliated hospitals and some employer-based insurers affiliated with Catholic and other religious organizations may prohibit permanent contraception based on interpretation of and adherence to religious doctrine, reducing patient autonomy 35 36 37 38. The Ethical and Religious Directives for Catholic Health Care Services prohibit “direct sterilizations” with the primary indication of contraception 38. However, there is significant diversity of practice within Catholic hospitals due to a lack of uniform interpretation or application of these directives. In one study analyzing Catholic hospitals in seven states, 48% provided a total of 20,073 direct sterilizations 39.
As of 2016, one in six patients in the United States received care in a Catholic-affiliated institution 37 40. Nationwide, 35.3% of counties have higher than 20% Catholic hospital market share, affecting 38.7% of reproductive-aged women 41. Moreover, most women in these systems are not aware of the restrictions on reproductive health care that they might experience 39 42 43. Some physicians develop “workarounds” (eg, designating one particular operating room as a nonreligious entity), but these do not always guarantee that an individual patient will be able to receive the care they request on any given day 44. At this time, based on a recent survey of religiously affiliated teaching hospitals, access to permanent contraception does not appear to be an issue in other religiously affiliated health care systems 37.
Historically, some workarounds included offering hysterectomy for an indication that would not conflict with religious doctrine—although the true underlying motivation for the surgery was permanent contraception 44. There are anecdotal reports that elective cesarean delivery was offered for similar reasons: permanent contraception surgery could be done surreptitiously during the cesarean delivery, and some religiously affiliated hospitals had formal or informal policies of allowing permanent contraception after multiple prior cesarean deliveries. The risks to patients of hysterectomy and cesarean delivery are greater than those of permanent contraception procedures alone or vaginal birth with postpartum permanent contraception. Thus, patients should be well-informed of these comparative risks, and barriers to receipt of desired permanent contraception should be removed to the extent possible.
If individual physicians or institutions will not provide surgery for permanent contraception because of personal religious beliefs or institutional policy, patients must be informed as early as possible and should be provided with an alternative form of contraception that is acceptable to the patient or be referred elsewhere for care. When difficulties in meeting a postpartum permanent contraception request are anticipated and such surgery is desired by the patient, transfer of care for the remainder of pregnancy should be offered 21.
Additionally, institutions that prohibit such methods should be transparent about restrictions to care, including when patients call to schedule appointments 45 46. When difficulties in meeting a postpartum permanent contraception request are anticipated and permanent contraception is desired by the patient, transfer of care for the remainder of pregnancy should be offered. For example, if postpartum permanent contraception or permanent contraception at the time of cesarean delivery cannot be provided or cannot be guaranteed because of unstable or unpredictable workaround options, patients should be informed. Patients who prioritize postpartum permanent contraception should be offered transfer of care.
An Ethical Approach to Permanent Contraception Care and Policy
ACOG recognizes the right of all patients to unimpeded access to permanent contraception as a way of ensuring health equity.
Given the importance of reproductive autonomy, as well as the multiple barriers to equitable access to permanent contraception, permanent contraception should not be considered elective but a medically indicated, time-sensitive procedure.
The time-sensitive nature of permanent contraception is especially important postpartum. The current Medicaid sterilization policy is a barrier to the equitable provision of permanent contraception 16 26 47 48 49 50 51 52 53. At the same time, ACOG recognizes that not all patients have equal opportunities to fulfill their reproductive wishes and are likely differentially at risk of coercive sterilization practices 54. Indeed, coercive or involuntary sterilizations were documented in California prisons during the same period in which there were calls to loosen restrictions on Medicaid-funded permanent contraception surgeries 34. It is unclear how to craft policies that protect from coercion but also do not create barriers to autonomously desired care; the tension between liberal access and protective safeguards is difficult to navigate and operationalize ethically.
Determining the ethical balance between access and safeguards will require a collaborative, interdisciplinary approach that involves stakeholders with varying perspectives. Such a group might include ob-gyns and other women's health care professionals, bioethicists, health policy experts, historians, social scientists of reproduction and gender, state and federal Medicaid officials, reproductive justice advocates, representatives from advocacy groups for patients of color, as well as patients with a variety of experiences surrounding permanent contraception and sterilization. Examples of the latter include patients who successfully received permanent contraception, patients who have had permanent contraception requests unfulfilled, patients who have undergone nonconsensual sterilization, and patients who have undergone consensual permanent contraception but feel regret regarding their decision.
Conclusion
This Committee Statement outlines an approach to providing permanent contraception within a reproductive justice framework that recognizes that all patients have a right to pursue and prevent pregnancy. In this framework, respect for an individual patient's reproductive autonomy should be the primary concern guiding permanent contraception provision and policy. Coercive or forcible sterilization practices are unethical and should never be provided. Ethical permanent contraception care requires access to permanent contraception for patients who request it. It simultaneously requires protections from unjust or coercive practices, particularly for patients with low incomes, incarcerated patients, and patients whose fertility and parenting have historically been devalued or stereotyped as problematic or in need of control or surveillance. The College recognizes that there is tension in these dual needs. Negotiating the ethical nuances of this tension will require the care and attention of multiple stakeholders working collaboratively to define care practices and policies that meet the needs of all patients as fully as possible.
Conflict of Interest Statement
All ACOG committee members and authors have submitted a conflict of interest disclosure statement related to this published product. Any potential conflicts have been considered and managed in accordance with ACOG's Conflict of Interest Disclosure Policy. The ACOG policies can be found on acog.org. For products jointly developed with other organizations, conflict of interest disclosures by representatives of the other organizations are addressed by those organizations. The American College of Obstetricians and Gynecologists has neither solicited nor accepted any commercial involvement in the development of the content of this published product.
Dr. Guiahi: The findings and conclusions in this article are those of the authors and do not necessarily reflect the views of Planned Parenthood Federation of America, Inc. Dr. Arora: NIH funding regarding disparities in postpartum permanent contraception.