From Relf v. Weinberger to Drive-Through Delivery: Democratic Responsiveness and Administrative Levers in US Sterilization Policy

Female sterilization occupies a paradoxical place in reproductive policy. When chosen freely, it is a safe and effective contraceptive method, yet it has also been deployed as a tool of coercion and state control. This dual legacy makes the United States-where sterilization is more common than in 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 events such as the 1974 Relf v. Weinberger case might be expected to generate larger behavioral changes than less visible administrative reforms would achieve. To test these mechanisms, the authors analyze a harmonized panel of contraceptive surveys from 190 nations (1965-2010) and apply the synthetic-control method. They examine the behavioral impact of Relf as a democratic accountability event and contrast it with early 1990s hospital reimbursement reforms. They find that the public outrage and litigation following Relf were associated with limited changes in national sterilization prevalence. In contrast, the 1990s payment reforms were associated with a sustained downward shift in prevalence. Together, these contrasting impacts suggest that reforms driven by court decisions and financial architecture may influence entrenched policies through different and potentially complementary channels.