April 13, 1993

A new trend in family planning: Young women of limited means have tubes tied

By Pamela Ferdinand, Herald Staff Writer

Miami

Young, low-income women in Florida -- most of them already mothers -- are more and more having their tubes tied. At age 22, Margaret Mack ended her child-bearing days. She lived with her three small children, mother, and unemployed brother in a cheap, two-bedroom apartment. Medicaid card in hand, she went to a Broward health clinic. She felt she could not afford more children and disliked condoms and the pill.

"The lady tried to make me not do it. I was too young, she said, but I told her this was what I wanted."

Nationwide, sterilization is the leading form of birth control for women over 30. Most younger women rely on the pill. But Medicaid statistics in Florida show that, increasingly, sterilization is the contraceptive of choice for women like Margaret Mack -- young and poor.

In the past four years, tubal ligations rose more than 30 percent among low-income women younger than 25 in Florida. Medicaid spending for their procedures nearly tripled to almost $2.7 million.

Many of the young, low-income women who choose sterilization say they cannot afford -- financially or emotionally -- to have more children. They have already tried other methods of birth control and are either unfamiliar with or unwilling to try newer, long-term contraceptives. So they decided on a permanent solution.

"When you don't have money and you have babies, it's a nightmare," said Rickie Solinger, author of Wake Up Little Susie, a book on single pregnancy. "Women who don't have resources are feeling pushed to . . . where sterilization is the only responsible thing they can do. That's new, and that's different."

For the fiscal year starting July 1, 1989, 6,353 low-income women were sterilized in Florida. In the nine months after July 1, 1992, an estimated 8,673 low-income women underwent the procedure, according to Tallahassee-based Consultec Inc., a billing agency for the Florida Department of Health and Rehabilitative Services.

For the 1989-90 fiscal year, 2,676 women under age 25 chose the procedure. The number since July 1, 1992, increased to 3,538, Consultec reported. In Dade and Broward, most were black.

Women are considered sterile immediately following the procedure, which blocks or separates each fallopian tube so that eggs cannot travel from the ovaries to the uterus.

Young women -- many of whom had teenage pregnancies -- choose sterilization for various reasons. The lack of federal and state funding for abortion in Florida does not appear to be a major factor, health care workers agree.

"Most women who want to get abortions generally do, even if it's a financial hardship," said Michael Policar, vice president of medical affairs for Planned Parenthood Federation of America. "I've never counseled a single woman who said, 'I'm considering sterilization because if I get pregnant again, nobody will pay for the abortion.' "

Health clinic workers say they hear other reasons for sterilization: It eliminates the hassle of daily birth control and its potential failure and side effects. Male partners often refuse to use contraception or to undergo vasectomies.

Also, not all young women are reliable users of contraceptives. Remembering to take pills can be difficult, prescriptions must be refilled, and diaphragms can be awkward to manage, clinic workers suggest.

Many young women are unfamiliar with or are unwilling to try newer, legal long-term contraceptives such as Norplant, time-release capsules placed under the skin every five years, and Depo-Provera, a synthetic hormone injected every three months. Medicaid covers both options, as well as other forms of contraception including the pill and diaphragm.

Alma Rodriguez, 24 years old, mother for the first time at 16, now the mother of four, says she has never heard of Norplant. She and her husband, Geraldo, eloped and left Mexico when she was 14. Ten years later, they live in a Davie mobile home with their children. After rent, they have less than $200 a week to spend.

Her mother and an older sister both had sterilizations. Last year, after an unplanned pregnancy, Rodriguez did the same. "I feel fine," Rodriguez said. "I think I feel fine."

Pressed, she said that she is not entirely sure that she will not want more children in the future.

Her uncertainty is not unusual. To be sterilized under Medicaid rules, the woman must be 21 and she must sign a consent form. To minimize second thoughts, and to prevent sterilization abuse by doctors, the government requires a 30-day waiting period between the signing and the date of surgery.

Still, a 1988 study by the Alan Guttmacher Institute in New York shows that the younger the woman, the higher the chances of regret.

"You take a woman who's 40, she doesn't want to risk pregnancy between 40 and 50," said Sally Skull, HRS operations and management consultant in Broward. "But a 21- to 24-year-old who makes the decision -- there are too many years that her life circumstances can change."

Dr. Garry Wachtel, a private Tamarac gynecologist, agreed, calling tubal ligation a "heavy-duty decision." Chances of reversal are slim, he said, and that procedure is expensive.

"I tell these patients to consider the possibility that something may happen to their children," he said.

Others praise these young, low-income women.

"They don't want any more children because they've got all they can handle," said Joyce Tarnow, administrator of The Womens' Clinic in Fort Lauderdale. "I admire the fact that they are taking control of their lives."