National Partnership for Women & Families

Monthly Women's Health Research Review

Study examines Catholic hospitals' referral practices for reproductive health care services

Summary of "Referrals for services prohibited in Catholic health care facilities," Stulberg et al., Perspectives on Sexual and Reproductive Health, July 2016.

"In the United States, Catholic health care institutions account for 15% of all acute care hospitals, sponsor 17% of hospital beds and, in some regions, are the sole community hospital," according to Debra Stulberg of the University of Chicago and colleagues.

According to the researchers, providers who work in Catholic hospitals must adhere to the Ethical and Religious Directives for Catholic Health Care Services. The directives prohibit many common reproductive health services, including those related to abortion, contraception, fertility and sterilization.

The researchers noted that the Committee on Ethics of the American College of Obstetricians and Gynecologists states that a provider "who cannot, for reasons of conscience, provide a patient with a requested and medically accepted reproductive health service has a duty to give the patient a timely referral to a provider who can." The committee also "advises health care institutions to ensure that patients have access to safe and legal reproductive care," stressing that "patient medical needs -- not provider values -- should be the leading consideration."

According to the researchers, little is known about the referral practices of OB-GYNs who work in Catholic hospitals. To gain a better understanding, the researchers sought "to assess [such providers'] perceptions of whether referrals for services prohibited by church doctrine are routinely offered in Catholic facilities, how these referrals are handled and whether patients' needs are met by the process."

Methodology

For the study, the researchers in 2011 and 2012 conducted telephone interviews with 27 physicians located in 15 states throughout the United States who "had experience working in Catholic health care facilities." Of the 27 respondents, 18 worked in a Catholic hospital at the time of the interview and nine previously worked in Catholic hospitals. All but one respondent had experience working or training in a non-Catholic hospital.

During the interviews, respondents were asked "about their experiences with the health care institutions in which they worked and about how religious hospital policies affected their patient care." Other questions included "how their values meshed with those of their employer and peers; and how they handled clinical services, including abortion, contraception, sterilization and infertility treatment."

Respondents also were asked if they "had any ethical or moral objections to various forms of contraception, sterilization, assisted reproductive technology and abortion in specific clinical scenarios," such as terminating a pregnancy resulting from rape or failed contraception. In addition, they were asked "to identify their religious affiliation and to rate how important their religion was in their own life."

Findings

Overall, the researchers found respondents' "[a]ttitudes on abortion varied, but no physician expressed personal moral objection to contraception, sterilization or assisted reproductive technology."

Respondents reported numerous ways they became familiar with their hospital's policies and expectations for reproductive health care, "including formal consultation with the ethics committee on specific cases, instructions or direct feedback from hospital administrators or departmental leaders, and stories or advice from colleagues."

According to the researchers, some respondents worked at both Catholic and non-Catholic facilities, which enabled to them to continue providing care to patients for whom treatment was barred at a Catholic facility. However, many respondents worked only at a Catholic facility and had to decide whether to offer only permitted services, offer prohibited services at offices outside the hospital or provide referrals for barred services. Overall, 24 respondents reported referring patients to non-Catholic facilities for services their Catholic hospital prohibited.

After reviewing the transcripts the researchers identified "[t]hree key features of the referral process...in physicians' discussions of their Catholic hospital experiences: hospitals' attitudes toward referrals, referral type (direct vs. indirect) and the role of financial incentives."

Hospitals' attitudes toward referrals

According to the researchers, some respondents said their Catholic hospitals encouraged referrals, while others "recounted scenarios in which referrals, especially for services considered less politically contentious than abortion ... were passively tolerated." One respondent "described working in a Catholic hospital in which providers understood that referring a patient for an abortion would be treated as a violation of professional community norms."

Overall, the researchers wrote that respondents detailed the "complexity of referrals when caring for patients who had life-threatening complications during pregnancy," with some feeling that "the hospital 'dumped' or 'punted'" patients referred to non-Catholic facilities for abortion care. For example, one respondent relayed how a colleague was told by a Catholic hospital to send a pregnant patient in need of chemotherapy to another facility for abortion care.

Regarding contraception, respondents were able to provide care in some circumstances, such as to treat irregular menstrual cycles, but were required to provide referrals in other instances. Relatedly, one physician said while providers were able to get their patients access to oral contraception by "fabricating medical justifications," they had to provide referrals for patients seeking other forms of contraception, such as an intrauterine device.

Referral type

"[F]or most referrals, both the physician and the hospital or office staff are involved in facilitating the patient's transition of care," the researchers wrote. However, they noted that for abortion care, "some providers were pressured not to directly facilitate the referral, and especially not to ask nurses or staff to do so," while others were only permitted to issue "indirect referrals -- in which the provider would tell the patient that she could access the services elsewhere but would not help her do so."

However, one respondent noted that for tubal ligations and other prohibited services, "an indirect referral handout was seen as too informative" by a local bishop. According to that respondent, the hospital was even barred from distributing a form listing alternative providers where patients could access contraception.

Hospitals' financial incentive

Some respondents raised the issue of their hospital's financial incentive not to lose patients -- especially for lucrative services -- when Catholic doctrine prompted them to refer patients to non-Catholic facilities.

"When the hospital's business interest and its moral teaching were in conflict, physicians reported that they received mixed messages from hospital authorities," the researchers wrote, adding, "For example, some respondents described infertility treatment as a service that hospitals wanted to hold on to, even if they had to make creative arrangements for the aspects prohibited by Catholic doctrine." To do so, one respondent described how her Catholic facility arranged to provide banned fertility services off-campus.

Another respondent described how she was brought up for review on claims that she had provided "an illicit abortion" by inducing labor in a patient at 19 weeks of pregnancy whose membranes had ruptured. During the review, she said she would have to stop accepting referrals for patients between 18 and 24 weeks of pregnancy if she was not able to offer labor induction. Her response prompted other hospital officials after her review to tell her to keep accepting such patients "'because we're a referral hospital, and you start losing referrals for one thing, and you'll lose referrals for all kinds of things.'"

Other findings

Respondents varied on whether they felt they could address patients' medical needs while following their Catholic hospitals' restrictive policies. The researchers wrote, "For the most part, obstetrician-gynecologists expressed acceptance that for outpatient services perceived as nonurgent or elective, their patients could get care at nearby non-Catholic providers," such as Planned Parenthood, a women's clinic or the public health department.

However, some respondents repeatedly expressed frustration with "the shortage of abortion providers in their communities," the researchers wrote. They added, "One respondent explained that at one time, patients seeking abortions at Catholic hospitals could be referred to nearby non-Catholic hospitals, but this type of referral had become more challenging with the dwindling numbers of abortion providers."

Some respondents also detailed cases "in which they felt that referring a patient to an outside provider put the patient's health at risk." For example, respondents noted that a patient's health could be jeopardized in cases when OB-GYNs lacked access to hormonal contraception to treat acute bleeding and voiced concerns about not being able to provide tubal ligations during a cesarean section or immediately after delivery.

In addition, some respondents noted that financial barriers among low-income patients made referrals an inappropriate solution to providing needed reproductive health care, such as contraception.

Discussion

"Obstetrician-gynecologists working in Catholic facilities commonly reported referring patients to other providers for reproductive services not permitted under Catholic religious directives," the researchers wrote. They noted, "While some reported that their employers openly encouraged them to make such referrals, others had to hide these referrals or make them outside of normal institutional channels," particularly for abortion care.

Overall, the researchers wrote, "Referrals allowed some of these obstetrician-gynecologists to feel their patients' medical needs were met, with three commonly cited exceptions": patients seeking tubal ligation immediately postpartum or in conjunction with a cesarean section; patients facing financial barriers; and patients in need of emergency treatment.

The differences in care highlighted in the study "raise issues about whether Catholic hospitals are providing a different standard of care to women than non-Catholic hospitals," the researchers wrote. Further, they noted that the "limited number of abortion providers in some areas made referral an inadequate strategy to meet patients' needs," which could be "compounded in Catholic facilities that serve as sole community hospitals, where getting to another hospital for urgent treatment may be especially difficult."

To date, the researchers noted that "[l]ittle research has been done on referrals for reproductive health services." They wrote, "Prominent bioethicists and obstetrician-gynecologists have debated whether physicians who hold a personal moral objection to abortion should be required to refer patients to a physician who will safely provide it." However, they added such experts "have not addressed the behavior of institutions (or the physicians within them) when the objection comes from the religious denomination sponsoring the institution, rather than from individual physicians."

The researchers wrote, "Our study shows how these complex teachings translate into daily practice in Catholic hospitals, and the findings hold important implications for patient care and public policy." They explained that "the prevalence of Catholic health care in the United States" makes it "highly likely that these hospitals serve patients needing comprehensive health care."

According to the researchers, "The wide range of referral patterns in Catholic hospitals described by the obstetrician-gynecologists we interviewed is probably attributable, at least in part, to the lack of clear guidance from professional norms." They also noted that "individuals charged with enforcing doctrine in Catholic hospitals, such as ethics committee members, clergy and hospital administrators, may be responding to conflicting messages and may be passing this confusion on to the physicians in their facilities."

The researchers recommended that OB-GYNs and the facilities in which they work "put in place referral practices that help patients access [reproductive health care] services not provided on-site." They also argued that "policymakers should require [Catholic facilities] to offer such referrals and to ensure that patients are well informed about the limitations to the care available in their facilities."