Postpartum permanent contraceptive procedures: A 360-degree qualitative investigation

Abstract

Objectives: To explore interdisciplinary factors affecting completion of postpartum permanent contraceptive procedures (PPC) after vaginal delivery.

Study design: We conducted a multi-center qualitative study surrounding completion or non-completion of PPC at three academic institutions from July 2023-March 2024. We recruited patients who desired permanent contraceptive procedures following vaginal delivery. We conducted semi-structured interviews with patients and their nursing, obstetric, and anesthesia teams. With pre-identified areas of inquiry including barriers and facilitators, as well as inductive coding in Dedoose, we used a grounded theory approach to thematic analysis, concluding data collection after thematic saturation.

Results: We interviewed 19 patients (11 completed and eight non-completed procedures) and completed 49 staff interviews (mean 2.5/patient). We identified three major themes: (1) The antenatal focus on overcoming obstacles to PPC completion can overshadow standard perioperative counseling and hinder procedure fulfillment; (2) Healthcare workers' personal values influence their motivation to ensure these procedures are completed; (3) Obstacles are similar for completed and noncompleted procedures, with the difference often being a champion to optimize interdisciplinary collaboration and advocate for care.

Conclusions: Unlike most surgeries, the completion of PPC centers around overcoming barriers (such as operating room availability and healthcare team motivation), rather than patient needs. The propensity for clinician advocacy to detract from perioperative patient care is a novel finding, and it sustains a culture where contraceptive requests are actualized based on care-team factors rather than patient needs. Ultimately, the discretionary nature of procedure fulfillment invites bias and hinders patient-centered care.

Implications: Interdisciplinary, systems-level solutions are necessary to improve the fulfillment of desired postpartum permanent contraceptive procedures. Centering counseling and practices around patients' informational and care needs as opposed to healthcare team values and limitations could improve both provision and quality of postpartum contraceptive care.

Keywords: Female permanent contraception; Interdisciplinary; Postpartum sterilization; Salpingectomy; Tubal ligation; Vaginal delivery.