HMN 2026: How Health-insurer payment changes had larger impact on female sterilization rates than landmark civil rights case

Female sterilization has played a much bigger role in U.S. reproductive history than many people realize. For decades, it has been one of the most common forms of birth control in the country. Its history is layered—from outright coercion and racial targeting to rights-based reform and bureaucratic redesign.

The best available estimates suggest that well over 600,000 sterilization procedures are performed annually in the U.S.—and data from the 2024 KFF Women’s Health Survey show that one in four women between the ages of 18 and 64 report they have had a sterilization procedure. Yet despite its importance as a family planning tool, female sterilization has also been used as an instrument of coercion and state control in the U.S.

Liana Woskie, Ph.D. MSc, assistant professor of community health at Tufts and lead author of a new paper, “Relf v. Weinberger to Drive-Through Delivery: Unpacking Democratic Responsiveness and Administrative Levers in U.S. Sterilization Policy,” revisits the 1970s civil rights case Relf v. Weinberger and analyzes nearly 50 years of sterilization trends. The study is published in the Journal of Health Politics, Policy and Law.

The findings from Woskie and her co-investigator suggest that while highly visible civil-rights litigation reshaped consent policy, less-obvious changes in health-insurer payments to providers implemented in the 1990s had a larger measurable effect on national sterilization rates—raising fresh questions about U.S. health systems and women’s autonomy.

Below is additional context from Dr. Woskie in Q&A format.

What did this study examine?

We revisited the Relf case, in which two Black girls were sterilized without valid consent, and examined how the public outrage and litigation that followed reshaped U.S. sterilization trends over nearly 50 years. Using a synthetic control design, we compared sterilization trends in the United States with other countries. This allowed us to estimate how U.S. sterilization rates changed following the rights-based consent reforms implemented in 1974, and then to compare those changes with the effects of less-visible managed care reimbursement reforms in the 1990s that shortened postpartum hospital stays.

Why focus on sterilization policy?

Female sterilization has played a much bigger role in U.S. reproductive history than many people realize. For decades it has been one of the most common forms of birth control in the country. Its history is layered—from outright coercion and racial targeting to rights-based reform, bureaucratic redesign and lack of access.

I wanted to understand what actually changed practice over time. Was it the highly visible civil-rights litigation in the 1970s? Or was it quieter, health-insurer payment reforms in the 1990s? This study unpacks that longer arc and asks which types of policy interventions actually shifted behavior at a national level.

What did the analysis reveal?

We found that the Relf case was associated with slowed growth in U.S. female sterilization, but it did not fundamentally redirect national trends. We also did not see a meaningful shift in the populations most at risk of state-targeted sterilization—particularly among young Black women in the southern United States.

In contrast, administrative payment reforms in the 1990s were associated with the first national declines in sterilization since the 1960s. Shortened postpartum hospital stays meant fewer providers were able to schedule and bill for tubal ligation or other sterilization procedures while women were still admitted.

Is this good or bad news?

Overall sterilization rates are not inherently “good” or “bad.” Sterilizing procedures like tubal ligation or hysterectomy are highly effective forms of birth control. Many women want them and, especially recently, some face significant barriers to obtaining them. But seeing how responsive national sterilization patterns are to payment reform raises an uncomfortable question: to what extent do sterilizations truly reflect patient preferences, versus policy choices?

Why does this research matter now?

Sterilization remains incredibly common in the U.S. The most recent CDC data from the 2022–2023 National Survey of Family Growth show that 11.5 percent of women ages 15 to 49 use female sterilization as their contraceptive method—essentially tied with the pill at 11.4 percent and comparable to long-acting reversible contraceptives at 10.5 percent.

At the same time, abortion access has narrowed dramatically in many states. We’re seeing renewed uptake of sterilization in contexts where abortion is restricted, while others face barriers in accessing wanted procedures because of consent rules, hospital logistics, or insurance timing. Understanding how policy shapes access to one of the country’s most common, and permanent, forms of birth control is central right now.

What should policymakers take from this?

One big takeaway is that quieter changes to payment and hospital incentives appear to have a profound impact on reproductive autonomy.

If we care about patient choice, we have to pay attention to the details that enable choice: Medicaid coverage windows, reimbursement design, and the day-to-day rules that determine whether someone can actually get the care they’re asking for.

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