Reduced health insurance payments for hospital births changed U.S. sterilization rates more than a landmark civil rights case aimed at ending coercive practices, according to a new study.
The research found that 1990s hospital payment changes had a stronger measurable effect on female sterilization than the legal and consent reforms that followed Relf v. Weinberger in 1974.
Female sterilization has long been one of the most common birth control methods in the U.S. About 11.5% of U.S. women ages 15 to 49 use it as their primary contraceptive method, nearly the same share as the pill.
The procedure also carries a history tied to coercion, racial targeting, invalid consent, and state control. The new study examined how policy, health care payment rules, and reproductive access shaped sterilization decisions over time.
The authors, a health economist and a political scientist, focused on two major turning points. One was the public outrage and legal reform after Relf v. Weinberger, and the other was a quieter change in hospital birth payments during the 1990s.
The Relf case involved two Black girls who were sterilized without valid consent. Their mother was told the girls would receive a temporary birth control shot, but doctors instead performed tubal ligation, a permanent procedure that blocks the fallopian tubes.
The case exposed broader patterns in federally funded sterilizations in the early 1970s. Court records showed minors and people unable to legally consent had been sterilized with federal funds.
The court also found evidence that sterilization was sometimes presented as a condition for families to keep welfare or other government benefits. The ruling said federally funded medical procedures require informed and uncoerced consent.
After the case, federal reforms added consent protections, including a 30-day waiting period and a minimum age of 21 for federally funded sterilizations. The study found those reforms slowed the growth of female sterilization but did not reverse the trend.
Female sterilization still increased nationally. The rate rose from about 5% in 1970 to about 13% in 1975, paused briefly after the ruling and new consent rules, then continued to climb.
By 1990, nearly 1 in 4 married women ages 15 to 49 had been sterilized. The study also found no meaningful shift in the groups most exposed to state-targeted sterilization, including younger Black women in the South.
The second turning point came in 1992, during what became known as the drive-through delivery era.
Insurers began paying hospitals fixed amounts for births, meaning hospitals received the same payment whether a patient stayed one night or two after delivery.
Hospitals responded by sending more women home after one night when births were uncomplicated. The 1996 Newborns’ and Mothers’ Health Protection Act tried to end that practice, but shorter postpartum stays continued as providers and payers looked to cut costs.
That shorter stay changed access to postpartum sterilization. Tubal ligation is easier to provide immediately after birth while a patient remains hospitalized, but shorter stays gave providers less time to schedule and perform the procedure.
The study found that the 1990s payment changes were associated with the first national decline in sterilization rates since the 1960s. Unlike the Relf reforms, the administrative payment shift altered how care happened inside hospitals.
To estimate the effect, researchers compared U.S. sterilization trends with trends in countries that had similar patterns. Those comparisons helped estimate what U.S. sterilization rates might have looked like without the Relf ruling or the hospital payment changes.
The researchers did not isolate individual medical decisions. They tracked national patterns in how often sterilization was used and compared visible legal reform with less visible payment policy.
Their finding: public outrage and consent reform mattered, but health care payment logistics mattered more. Insurance rules changed the timing, availability, and practical delivery of postpartum sterilization.
The authors said sterilization itself is not inherently good or bad. It is a highly effective form of permanent contraception, and many patients actively choose it.
The issue is whether people receive a real choice. In reproductive care, limited access, narrow options, poor timing, or payment rules can shape decisions even without an explicit denial or threat.
The question has become more urgent since Dobbs v. Jackson Women’s Health in 2022, when the U.S. Supreme Court allowed states to set their own abortion laws. Other researchers have found increases in permanent contraception since then, especially among younger adults and in states with abortion bans.
The study argues that coercion can exist inside the structure of health care. Patients are not always directly forced into or blocked from care, but systems can narrow options until the remaining choice no longer fits their needs.
