By Rebecca H. Allen, MD, MPH, Editor
SYNOPSIS: A national review of inpatient permanent contraception procedures between Jan. 1, 2019, and Dec. 31, 2020, demonstrated that the rate of procedures decreased in 2020 compared with 2019, with the steepest monthly decline (14.5%) being between February and April 2020, the first wave of the COVID-19 pandemic.
SOURCE: Cathcart AM, Nezhat FR, Fitch KC, et al. Trends in permanent contraceptive procedural volume in the United States between 2019 and 2020. Am J Obstet Gynecol 2023;229:468-470.
The COVID-19 pandemic affected how clinical care was prioritized, especially in the first wave between February and April 2020. Many hospitals, in preparation for the COVID-19 surge of cases, postponed all elective surgeries. The authors of this study sought to describe what happened to the rate of permanent contraception procedures during the pandemic in the United States. This was a population-based, retrospective cohort study that used discharge data from the National Inpatient Sample, a claims database that includes all insurers and covers 98% of the United States. The authors used International Classification of Diseases, 10th Revision-Procedure Coding System (ICD-10-PCS) procedure codes for bilateral salpingectomy or bilateral tubal ligation between Jan. 1, 2019, and Dec. 31, 2020. Admissions associated with a newborn delivery were recorded. Analyses were weighted to obtain national estimates, and the monthly percentage change (MPC) in procedures was determined.
There were 352,270 permanent contraception procedures in 2019 and 304,200 in 2020 (P < 0.001). In the total sample, bilateral salpingectomy accounted for 92.7% of procedures and tubal ligation accounted for 7.3% of procedures. Approximately 60.9% of bilateral salpingectomies were performed during delivery hospitalizations and 38.9% were performed on the same hospital day as another surgical procedure (presumably hysterectomy, although the study did not specify). In contrast, practically all (99.4%) of the inpatient tubal ligation procedures were performed during delivery hospitalizations. The rate of inpatient salpingectomy and tubal ligation procedures declined sharply between February and April 2020 (-14.5%; 95% confidence interval [CI], -25.7% to -1.6%). The rate trended upward between April and July 2020 (14.8%; 95% CI, -0.3% to 32.2%) and then declined again from July to December 2020 (-2.4%; 95% CI, -4.7% to -0.1%). This rate declined more steeply among admissions without a newborn delivery (-27.5%; 95% CI, -36.8% to -16.7%) compared to those with a newborn delivery (-0.6%; 95% CI, -1.0% to -0.2%).
COMMENTARY
The COVID-19 pandemic affected the frequency of surgical procedures in United States hospitals, since elective procedures were postponed to redirect resources to COVID-19 patients as recommended by the Centers for Medicare and Medicaid Services. Which surgeries to classify as elective was left up to individual states and hospitals. Permanent contraception procedures should be a priority to complete for patients who desire them. The American College of Obstetricians and Gynecologists recommends that institutions designate postpartum sterilizations as nonelective procedures, since they are critically important to women’s health and need to be completed during the patient’s postpartum stay.1 Nevertheless, many hospitals and states deemed permanent contraception procedures to be elective during the COVID-19 pandemic because they required personal protective equipment and operating room resources.2
This study shows the effect of those policies, which is similar to what we experienced in my hospital system during the pandemic. The study did show a protective effect of admissions with newborn deliveries. In other words, if the patient already was admitted to the hospital to give birth, they were more likely to have their permanent contraception procedure completed. Admissions for other surgeries where bilateral salpingectomy also was performed experienced a sharp decline, especially in the first wave of the pandemic. This is similar to what has been documented for a decline in the rates of hysterectomy during the pandemic.3 Since this study examined only inpatient admissions, it is not surprising that they found a similar decrease in the rate of permanent contraception procedures performed as part of another surgery. This is a major study limitation, since the vast majority of interval (not postpartum) permanent contraception procedures are performed as outpatient surgeries. This study was not able to capture those, but I imagine an even steeper decline would be noted.
This study also revealed the extent to which bilateral salpingectomy has overtaken tubal interruption as a method of permanent contraception in the United States, at least after delivery and during other concomitant surgeries. Opportunistic salpingectomy is a strategy recommended to decrease the rates of epithelial ovarian cancer.4 Bilateral salpingectomy has clearly overtaken tubal ligation as the method of choice for permanent contraception procedures, even during the postpartum period. This is an impressive adoption of a new surgical practice in the United States that was first introduced into the literature in 2010.5
REFERENCES
- American College of Obstetricians and Gynecologists. Access to postpartum sterilization. Committee Opinion No. 827. Published June 2021. https://www.acog.org/clinical/clinical-guidance/committee-opinion/articles/2021/06/access-to-postpartum-sterilization
- Evans ML, Qasba N, Arora KS. COVID-19 highlights the policy barriers and complexities of postpartum sterilization. Contraception 2021;103:3-5.
- Emont J, Wen T, Friedman AM, Wright JD. Trends in hysterectomy rates associated with the coronavirus disease 2019 (COVID-19) pandemic. Obstet Gynecol 2023;141:592-601.
- American College of Obstetricians and Gynecologists. Opportunistic salpingectomy as a strategy for epithelial ovarian cancer prevention. Committee Opinion No. 774. Published April 2019. https://www.acog.org/clinical/clinical-guidance/committee-opinion/articles/2019/04/opportunistic-salpingectomy-as-a-strategy-for-epithelial-ovarian-cancer-prevention
- Miller D, Finlayson S. Preventing ovarian cancer. OVCARE. http://www.ovcare.ca/prevention/preventing_ovarian_cancer/
