Disseminating PCOR findings to Reduce Racial Disparities in Surgical Sterilization

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Abstract: This proposal, submitted in response to RFA-HS-22-001, in the priority area of “improving maternal health,” is prompted by long-standing racial and ethnic disparities in use of permanent contraception (historically called “surgical sterilization”). In the US, permanent contraceptive procedures are most commonly performed on women of color, women with chronic conditions such as diabetes, and those residing in rural communities. Although permanent contraception aligns well with some patients’ reproductive life plans, reports that 10% of women regret having undergone these procedures are troubling. These regrets and racial disparities are especially problematic given recent PCOR demonstrating that long-acting reversible contraceptives, such as hormonal IUDs are both more effective and less likely to cause pelvic pain than permanent contraceptive procedures. To disseminate PCOR about the comparative safety and real-world effectiveness of alternatives to permanent contraception, we will adapt the advance care planning (ACP) framework, which has been used to ensure that patients receive medical care when approaching their end of life that aligns with their personal treatment goals. This paradigm is a critical tool for supporting patients in making complex medical decisions, by emphasizing elicitation of values, communication skill building, and shared decision-making. By preparing patients approaching the end of their reproductive life to more effectively communicate to clinicians their personal values, priorities, and treatment goals, we will adapt the ACP model for reproductive life planning (RLP), with input from patients (Aim 1, focus groups) and clinicians (Aim 2, semi-structured interviews). We will then conduct an individual-level randomized clinical trial comparing this approach to disseminating PCOR relevant to discussions of permanent contraception with 300 women who identify as Black or have a chronic condition such as diabetes, and who wish to avoid future pregnancy (Aim 3). In evaluating this intervention, our experienced multi-disciplinary team will carefully examine patient-reported outcomes related to communication and satisfaction with care. We will also rigorously analyze heterogeneity of treatment effects by clinical and patient-level contextual factors to inform the potential need for future refinement of this ACP-RLP paradigm. By increasing equitable access to alternatives to permanent contraception, this project strives to increase the proportion of US women who are using a method of contraception that aligns with their personal preferences and reduce the proportion of individuals who regret having undergone a permanent contraceptive procedure.