A Peoria physician is expressing concern about a two-tiered system of access to reproductive health care for women seeking a tubal ligation. For women with private insurance, the process is easy; for women on Medicaid, there are hurdles and time constraints imposed by federal regulations.

Dr. Rahmat Na’Allah said the system treats poor women as stupid and wealthy women as smart.

When a woman on Medicaid is hospitalized giving birth, she can’t request and receive a tubal ligation while she is hospitalized unless she has signed paperwork 30 days in advance but not more than 180 days after signing the paperwork. Women on private insurance do not have this signed paperwork requirement.

That means a woman giving birth without the paperwork has to reschedule another hospitalization in the future –– something increasingly difficult to plan with a newborn in the house and limited available leave from work.

The requirement likely stems from a period when forced sterilizations were occurring. That is no longer the case today.

Dr. Na’Allah said allowing this antiquated regulation to remain means women deal with more unwanted pregnancies and more unwanted babies.

“Poor women can decide for themselves when they don’t want more babies. We need to get this rule changed,” she said.

Universal access to comprehensive contraception is a basic human right supported by the United Nations.

This 30-day requirement is “treating poor women as too stupid to decide they don’t want more babies,” Dr. Na’Allah said.

“Maybe once people abused women and forced them to have their tubes tied but not now. Now this rule is limiting access.”

If the hospital goes ahead with the procedure without the paperwork, the hospital pays the cost or bills the patient.

The American College of OBGYNs also advocates for eliminating this signed consent requirement. It has issued a position contending this requirement creates an “undue burden” and the rules “must be revised to create fair and equitable access for women enrolled in Medicaid or covered by other government insurance.”

The organization states, in part: “Although the original intent was to protect women from being sterilized against their will, the lack of a timely signature on the federal consent form now interferes with patient autonomy because it has become a common reason for lack of provision of desired postpartum sterilization. In addition, the lack of availability or failed transfer of the completed federal consent document to the delivery unit can result in cancellation of sterilization procedures. Women with commercial or private insurance who desire sterilization are not mandated to follow the same consent rules—signing a consent form at least 30 days in advance—to obtain the procedure, thus creating a two-tiered system of access.

“With possible Medicaid expansions under the Patient Protection and Affordable Care Act, this federal regulation will adversely affect an even larger population of women. The regulation places an undue burden on women and health care providers and must be revised in order to create fair and equitable access for women enrolled in Medicaid or covered by other government insurance.”

The complete statement can be accessed at acog.org.

EverThrive Illinois, a not-for-profit organization, works on improving the health of women, children and families. The organization does not have a position paper on consent forms for tubal ligations but interim executive director Kathy Waligore wrote in response to a query that the issue is complicated: “The consent procedures are a federal requirement which have been in place since the ‘70s and were enacted as a direct response to coercive sterilization and sterilization of women by the state without consent. While the world has changed since this was enacted, loosening consent requirements for state funded sterilization procedures is a difficult policy conversation. Of course, other people do not face this barrier, but that is because other payers may not have the same fraught history as government. That said, we know that this can create barriers or delays for those seeking sterilization as their preferred method.”

She stated that EverThrive recommends policies be developed “to ensure that everyone, especially folks from the most marginalized communities, can get their preferred contraception.”

In addition to this two-tiered system of access, Dr. Na’Allah is alarmed about another problem facing women in Peoria on Medicaid – lack of access to obgyn doctors. There is a critical shortage of gynecologists in Peoria who see women on Medicaid. She said young doctors often struggle with enormous student debt and have difficulty with the long delays in Medicaid reimbursements and therefore restrict their practices to patients with private insurance.

That is creating a critical medical care gap in Peoria.

“My concern is coming from frustration over the need. This is a call-out to providers in our area. We need more gynecologists who will come here and will accept public aid patients,” she said. “The state can do a better job with reimbursement and recruiting. We need to see more private gynecologists taking public aid patients.”

When women come for prenatal care later in pregnancies, the likelihood of complications is higher.

In the 10 years she has been practicing medicine in Peoria, Dr. Na’Allah has seen patients accessing pre-natal care later and later in their pregnancies, often not until they are 30 weeks into the pregnancy.

In an upcoming issue of Community Word, Dr. Na’Allah will discuss a protocol she devised to provide more patients with prenatal care. She presented her work at an international conference in Toronto five months ago.