National Partnership for Women & Families

Monthly Women's Health Research Review

Researchers launch consortium to investigate religious restrictions on reproductive care

Summary of "The Research Consortium on Religious Healthcare Institutions: Studying the impact of religious restrictions on women's reproductive health," Freedman/Stulberg, Contraception, March 24, 2016.

Despite increased media attention on the experiences of women who are denied reproductive health care at Catholic hospitals, there is relatively little research examining the effect of religious restrictions on medical services, according to Lori Freedman, assistant professor at University of California-San Francisco's Advancing New Standards in Reproductive Health, and Debra Stulberg, assistant professor at the University of Chicago.

Background

"Catholic hospitals and other religious institutions are a large and growing part of the US healthcare system," Freedman and Stulberg wrote, noting that seven of the 12 largest hospital systems in the United States as of 2015 were Catholic, while another two were affiliated with other Christian religious. Moreover, the researchers noted that the number of Catholic hospitals increased by 16 percent between 2001 and 2011, "while secular non-profits, religious (non-Catholic) non-profits, and public hospitals all decreased in number."

Freedman and Stulberg explained that patient care at Catholic hospitals follows the U.S. Conference of Catholic Bishops' Ethical and Religious Directives for Catholic Health Care Services. The directives, which are enforced by the local bishop, "prohibit doctors at Catholic hospitals from providing contraception, sterilization, abortion, and most infertility treatments," as well as certain "aspects of care for women with pregnancy complications, for lesbian, gay, bisexual and transgender (LGBT) patients, and for patients at the end of life," the researchers wrote.

The researchers cited several recent incidents in which patients were denied appropriate care at Catholic hospitals, including a Michigan-based hospital that denied care to a woman experiencing a miscarriage and an Irish hospital that refused to provide appropriate care to a woman experiencing a miscarriage who died from the resulting infection. Relatedly, an Arizona-based Catholic hospital that did approve a life-saving abortion was subsequently stripped of its Catholic affiliation and the authorizing staff member excommunicated.

The media attention around such incidents has spurred legal challenges, legislative efforts to increase transparency regarding offered services and calls to CMS to investigate, the researchers wrote, adding that recent research shows "most people do not think religious authorities should be able to dictate the care that women can receive." However, the researchers noted that despite this public attention, "research on the effects of religious restrictions remains limited."

Freedman and Stulberg discussed the few surveys and interviews with medical staff on the topic, such as one survey that found "a decreased likelihood of prescribing emergency contraception at religious facilities" and another that found 19 percent of the 43 percent of primary care physicians who had worked at a religiously affiliated facility "had experienced conflict with the institution over its religious policies for patient care." Moreover, according to the researchers, 22 percent of U.S. OB-GYNs "identified their primary place of practice as religious, and 37% of these had experienced a conflict: 52% among ob-gyns working in Roman Catholic facilities, 17% in Christian non-Catholic facilities, 9% in Jewish, and 16% in other religious facilities," Freedman and Stulberg wrote. In addition, they cited research showing that OB-GYNs trained in religious hospitals are "significantly less likely" than those trained in non-religious hospitals "to self-report competence in family planning procedures ... despite being equally interested in offering these services."

Freedman and Stulberg also noted that OB-GYNs who worked at Catholic hospitals have "expressed frustrations about not being able to offer what they consider standard care, such as post-partum tubal ligation and timely miscarriage management." Other research has shown that "some ob-gyns and emergency medicine physicians were restricted by their Catholic hospital in the care they could provide for patients with ectopic pregnancy." However, despite individual instances covered by the media or mentioned by interviewed OB-GYNs, there is a lack of research "on how women's outcomes are affected by the religion of the hospital where they seek care," the researchers wrote.

Further, the researchers noted that "particularly little is known" about "the patient's experience of religious institutions." They explained, "It remains unclear whether women who have been denied care due to religious hospital policy are informed about their options; and nationwide, it is unknown whether women have the knowledge and resources they need to make informed decisions about where to go for reproductive care."

Freedman and Stulberg wrote that they established the Research Consortium on Religious Healthcare Institutions "to create an infrastructure for researchers to translate and disseminate findings from their studies addressing key gaps in knowledge with the long-term goal of advancing evidence-based policy." The consortium, which held its first meeting in November 2015, has three goals: "to increase medical, social science, and public health research on religious healthcare institutions; to encourage policy-relevant research in this area; and to strengthen research translation and dissemination."

Areas of inquiry

Participants at the consortium's inaugural meeting identified several areas of inquiry, which the researchers wrote should act "as a list of research priorities for the Consortium going forward."

Heath care quality

The researchers identified health care quality as one area of inquiry, noting that while the Catholic directives "prohibit and limit many aspects of reproductive healthcare" and while prior research shows that physicians do not always feel they can offer the standard of care at Catholic hospitals, "the prevalence of specific deviations from standard care is unknown." The researchers added, "How the Directives are enforced varies, and the resulting patterns of care are not well understood."

The researchers also wrote that medical records are another aspect of this area of inquiry. They explained that physicians, for example, document contraception as being prescribed for non-contraceptive reasons to help a patient access birth control. According to the researchers, while the practice at an individual level "may be intended to benefit the patient ... the risks to the patient of being labeled with medical conditions, or to the physician if falsifying a record, are poorly understood."

The researchers outlined several possible research questions that fall under this area of inquiry, including why a Catholic hospital enforces all or parts of the directives and whether patients "suffer as a result," such as through the "mismanagement of reproductive emergencies" or the refusal of sterilization or LGBT care.

Disparities

The researchers noted that Catholic hospitals tend to care for the same number of Medicaid beneficiaries and provide the same amount of charity care as other non-public hospitals, despite their historical reputation of serving the poor. However, "some regions are saturated with Catholic health care." They called for more research into disparities, such as how "racial, socioeconomic, and geographic groups [are] differentially impacted by religious restrictions" and how "religious ownership of the hospital affect[s] other disparities in reproductive health care."

Transparency

Freedman and Stulberg also called for more research into transparency, questioning, "What do individual patients, the public, and policy makers know about Catholic health care?" They noted that additional research was needed into whether patients can discern whether a hospital is Catholic and what it means for their health care access. According to the researchers, further research also is needed to determine to what extent Catholic hospitals disclose their religious affiliation in marketing materials. Sample questions in this area included "the implications of Catholic ownership for care" and what disclosures a patient should receive regarding religious restrictions on care before receiving any health care services.

Systems adequacy

The researchers also pinpointed systems adequacy as an area of inquiry, asking how the expansion of Catholic health care systems and insurance coverage restricts reproductive care and affects patients. Freedman and Stulberg listed several possible questions in this category, such as determining how far Catholic restrictions are expanding into non-hospital health care services, including insurance companies and physician offices; whether these entities can be held accountable for reproductive care via quality metrics for reimbursement or other measures of care; and how religious restrictions might affect provider "training and the resulting competencies in the provider population of a region."

Public opinion and policy

Freedman and Stulberg wrote that assessing "public opinion about religious health care can help gauge the political will for change," while "[p]olicy research can show how state and federal policies may be more or less protective against loss of service to religious hospital growth and mergers." The researchers outlined several research questions, including measuring support for religious restrictions on care from "Catholics, the public, and Catholic hospital employees"; the "tipping point for action" in instances "[w]hen government regulatory bodies did act to limit mergers or loss of services within them"; and whether such government oversight has protected reproductive health care access during mergers.

Inside Catholic health care

The researchers also called for studies examining Catholic hospitals' "organizational dynamics and power structures and ... institutional variation." According to Freedman and Stulberg, such research might investigate what compels hospitals and other organizations to comply with the directives; how the directives are enforced at the hospital level, including any workarounds; and whether "there [are] critics of the Directives on the inside."

Historical and international context

Freedman and Stulberg wrote that research comparing current Catholic care in the United States to historical care and care provided in other nations "can paint a fuller picture of the context of current Catholic healthcare institutional structures." Questions in this area of research could include comparisons between religious restrictions on care in U.S. Catholic hospitals with Catholic hospitals in other nations and how "Catholic hospitals [have] changed their role in health care over time."

Religious restrictions in non-Catholic hospitals

According to Freedman and Stulberg, "Research relating to non-Catholic hospitals impacted by religious restrictions" -- such as Jewish, Mormon or other non-Catholic Christian hospitals -- "is particularly scant." They suggested further research into whether and how "the 25% of religious hospitals that are not Catholic restrict reproductive health care" and how many hospitals might be complying with the Catholic directives "because of a relationship with a Catholic health care network."

Next steps

By exploring the above topics, the researchers wrote that the Consortium "will continue to develop an academic community for researchers studying religious healthcare institutions, and to foster communication between researchers and advocates in the field through research briefs of peer-reviewed, empirical studies of healthcare impacted by religious restrictions."

They wrote, "Given the immensity of the religious healthcare sector today which systematically restricts and prohibits care most integral to the lives of women of reproductive age, an academic focus on the topic is long overdue." Freedman and Stulberg concluded by calling on researchers to contribute to the outlined research objectives, noting, "By joining this conversation, researchers can make a noticeable difference in closing this knowledge gap."