Center for Health System Sustainability

Female sterilization occupies a paradoxical place in reproductive policy. When chosen freely, it is a safe and effective contraceptive method, yet has also been deployed as a tool of coercion and state control. This dual legacy makes the United States, where sterilization remains more common than other high-income democracies, an important case for examining how public accountability and policy design shape permanent contraceptive use. From a theoretical perspective, highly visible, accountability-driven interventions such as the 1974 Relf v. Weinberger case might be expected to generate larger behavioral changes than less visible administrative reforms, though prior scholarship offers mixed expectations about the relative influence of legal visibility versus economic incentives. To test these competing expectations, we analyze a harmonized panel of contraceptive surveys from 190 nations (1965-2010) and apply the synthetic-control method. We examine the behavioral impact of Relf as a democratic accountability event and contrast it with a later unrelated administrative change in U.S. hospital reimbursement policy in the 1990s. We find that the public outrage and litigation following Relf produced formal consent safeguards but were associated with limited changes in the national sterilization rates. In contrast, the 1990s payment reforms, aimed at cost containment, were associated with a sustained national decline. Together, these contrasting impacts suggest that reforms driven by court decisions and financial architecture may influence entrenched policies through different, potentially complementary, channels. Taken together, the findings affirm the important role of administrative levers alongside legislative activism, levers often overlooked in reproductive rights debates despite their capacity to reshape clinical practice.

Question: How did obstetric-related Emergency Medical Treatment and Labor Act (EMTALA) violations change in association with state-level abortion policy?

Findings: In this difference-in-differences analysis of EMTALA violations from 2018 to the first quarter of 2023, states with no health exceptions saw a substantial rise in obstetric-related violations that were associated with policies adopted by Texas. There was a concurrent rise in emergency department utilization, and screening failures suggest that violations may have increasingly occurred on arrival before treatment.

Meaning: The study results suggest that state abortion laws may undermine federally protected care in obstetric emergencies.

In this piece we examine three forms of coercive or otherwise involuntary care that can occur with patient consent. To do so, we examine: (1) uninformed consent, (2) contingency-based consent and (3) constrained-market consent, amongst female sterilization patients. While there is broad recognition that “coercion” in sterilization care can manifest beyond instances of overt force and clarity on what constitutes coercion within clinical care, this has not translated to accountability. The current practice of identifying coercion through discrete civil cases may facilitate a narrow understanding of its contemporary prevalence; one that does not align with definitions of coercion supported by international human rights entities. We use three acute, and widely recognized, examples—hysterectomies in ICE detention facilities, India’s sterilization camp deaths and birth control quotas for Uyghur women—as an entry point to highlight less overt contemporary forms of coercive sterilization care, pairing each example with data that explores prevalence at a broader population level. These data suggest less visible forms of coercion may persist relatively unchallenged—raising the ethical case for a functional approach to the measurement of coercion. In turn, we argue the relevant question may not be “when is coercion ethically justified in public health,” but rather, why is coercion already the status quo?

Repeated Supreme Court cases suggest uninformed sterilization care is a persistent and contemporary issue in India. This article examines patient satisfaction ratings as a potential accountability mechanism to assess normalized forms of coercion. With a sample of over 180,000 sterilized women in India, it identifies a statistically significant relationship between exposure to coercive care and odds of reporting low quality. However, over 95 percent of women who underwent a tubal ligation procedure rated their care highly even when provided with inadequate information (a recognized form of coercion), with more pronounced discordance when a patient belonged to a historically marginalized caste. System-modifiable factors, such as conditional cash transfers (CCT) to the patient and postpartum procedure timing increased reporting discordance. Using a reproductive justice lens and building on Amartya Sen’s capabilities approach, this work examines how to identify human rights violations in the routine delivery of care.

Repeated Supreme Court cases suggest uninformed sterilization care is a persistent and contemporary issue in India. This article examines patient satisfaction ratings as a potential accountability mechanism to assess normalized forms of coercion. With a sample of over 180,000 sterilized women in India, it identifies a statistically significant relationship between exposure to coercive care and odds of reporting low quality. However, over 95 percent of women who underwent a tubal ligation procedure rated their care highly even when provided with inadequate information (a recognized form of coercion), with more pronounced discordance when a patient belonged to a historically marginalized caste. System-modifiable factors, such as conditional cash transfers (CCT) to the patient and postpartum procedure timing increased reporting discordance. Using a reproductive justice lens and building on Amartya Sen’s capabilities approach, this work examines how to identify human rights violations in the routine delivery of care.

In contrast to bilateral aid, aid disbursed from multilateral institutions increased significantly at the onset of the COVID-19 pandemic. Yet, at a time when a coherent and effective multilateral response is needed most, the COVID-19 pandemic revealed a shifting landscape of donor agencies that struggle with basic functions, such as cross-national coordination. While multilaterals are uniquely positioned to transcend national priorities and respond to pandemics, functionally we find official development assistance (ODA) from these entities may increasingly mimic the attributes of bilateral aid. We explore three important, but not comprehensive, attributes of aid leading up to and during the COVID-19 pandemic: (1) earmarking, (2) donor concentration and (3) aid modality.