By Maria F. Gallo, PhD
Professor, Chair, and Associate Dean of Research, College of Public Health, Division of Epidemiology, The Ohio State University, Columbus
Over the last two decades, the number of Catholic hospitals has grown by more than 28% in the United States, while the number of secular hospitals has decreased by almost 14%.1 As of 2020, about one in six (16.8%) acute care hospital beds in the United States were in a Catholic facility. The fraction varies by state, with some states having none, while other states (Alaska, Iowa, South Dakota, Washington, and Wisconsin) have 40% of their hospital beds in Catholic hospitals. Instead of functioning as an independent hospital under local community control, almost all Catholic hospitals are part of a health system and, thus, are subject to their rules.
Restricted Services
Catholic hospitals are not permitted to provide healthcare that is considered by their religious leaders to be “intrinsically immoral.” The U.S. Conference of Catholic Bishops has published the Ethical and Religious Directives for Catholic Health Care Services to provide “authoritative” guidance on health-related issues that their religion perceives to be immoral.2 The Directives prohibit Catholic hospitals from providing services, including contraception (except for fertility-based awareness methods), abortion, and certain infertility treatments. The Directives do not allow for exceptions, even if the care is needed to protect a person’s life or health. Even though their religion does not permit the use of contraception, almost all (98%) sexually active Catholic women in the United States have used contraception, not counting “natural” or fertility-based awareness methods.3 Thus, the ban on providing contraception at Catholic hospitals does not appear to be aligned with the behaviors of Catholic patients.
Unclear or Complicated Status
Some people attend a Catholic hospital because they have limited choices. There are 46 Catholic hospitals in the United States that are the only short-term acute hospital (also known as a general hospital) in their geographic area.1 Other people might have health insurance that limits them to receiving care at a Catholic facility. However, some people are not even aware that they are attending a Catholic hospital. In a 2018 national survey that asked adult, reproductive-age women where they go for their reproductive care, 16% of women named a Catholic hospital.4 Notably, more than one-third of the women who named a Catholic hospital did not know that their hospital was Catholic. Furthermore, 50% of those who were wrong about their hospital’s Catholic status described themselves as being “sure” or “very sure” about their incorrect response. In some cases, people might be unaware of their hospital’s status because its name does not sound religious. Also, the Catholic status might not be widely advertised. A 2017-2018 review of the websites of Catholic hospitals in the United States found that 21% of the websites did not explicitly disclose the hospital’s Catholic status.5 Also, people might be unaware that a Catholic network purchased their non-Catholic hospital and that their hospital now is required to follow the Directives. On the other hand, there are examples of Catholic hospitals being sold to a secular network in which the terms of the sale have required the new network to continue to follow the Directives.1 Similarly, public hospitals that are managed by a Catholic health system or secular hospitals that have merged with a Catholic hospital might have agreed in their terms to ban services that conflict with the Directives. It can be difficult for prospective patients to find out the specifics of these agreements.
Even if people are aware of the Catholic status of their hospital, they might not realize that attending a Catholic hospital could restrict the scope of care they are able to receive. A survey using a probability sample of adult, reproductive-age women in the United States revealed that most women did not expect restrictions on care at Catholic hospitals, especially for services viewed with less stigma than abortion.6 Women did not realize that Catholic hospitals are restricted in providing contraception and female sterilization.
Postpartum Contraception
With the Supreme Court’s recent overturning of Roe v. Wade, 26 states are expected to ban abortion either at any gestational age or at approximately six or eight weeks of pregnancy.7 With reduced access to abortion, preventing an unintended (i.e., unwanted or mistimed) pregnancy will become more important. Postpartum contraception particularly is important to prevent a quick repeat pregnancy. Short interpregnancy intervals are associated with adverse maternal and infant outcomes, and, consequently, the U.S. Department of Health and Human Services identified birth spacing as a high priority in the 2030 Healthy People Objectives.8 Postpartum contraception particularly is important given that people’s fertility can return quickly. Ovulation begins to resume among nonlactating women at about four weeks postpartum and can occur as early as 27 days postpartum.9,10 Many women (32% to 71%) resume sexual intercourse before the first six to eight weeks postpartum.9 Exclusive breastfeeding is effective as contraception; however, many do not carry out their plans for lactation: In a U.S. study, almost one-third of women who stated an intention to breastfeed either did not start or stopped within six weeks of birth.11
Female Sterilization
Female sterilization, most commonly consisting of tubal ligation, is one of the most effective methods of preventing pregnancy. It is a popular method, used by about 19% of contracepting women in the United States.12 For people who do not want a future pregnancy, immediately after delivery can be a convenient time to have the procedure performed. During a cesarean delivery, sterilization can be performed while the abdomen already is open. After a vaginal delivery with an epidural, the catheter can remain in place for the tubal ligation. About half of all female sterilizations are performed postpartum.12 Failing to receive a desired sterilization could increase the risk of having a rapid repeat pregnancy; in a chart review at a single site, among those who requested but did not receive a postpartum tubal ligation, 47% had a repeat pregnancy within one year postpartum.13 In comparison, 22% of those who did not request a postpartum tubal ligation became pregnant in the first year postpartum.
Because the Directives prohibit Catholic hospitals from performing sterilization (e.g., tubal ligations or vasectomies) for contraceptive purposes, we conducted an analysis to evaluate whether women who recently delivered at a Catholic hospital were less likely to be using birth control during the postpartum period compared to women who delivered at a non-Catholic hospital.2,14 It is possible that Catholic hospitals could fail to enforce their rules prohibiting the provision of contraception, or providers at Catholic hospitals might find ways to work around them.15 We used data from the Pregnancy Risk Assessment Monitoring System (PRAMS) from five states — Alaska, Illinois, Maine, Oregon, and Wisconsin — from 2015 to 2018. Conducted annually by the Centers for Disease Control and Prevention (CDC) and state health departments, PRAMS surveys a representative sample of women who gave birth in the last two to six months and includes questions on current contraception use. We were able to link the respondent’s survey data to her type of delivery hospital (Catholic vs. non-Catholic) from her baby’s birth certificate.
We found that at two to six months postpartum, women who delivered at a Catholic hospital were about half as likely to have had female sterilization as women who delivered at another type of hospital.14 This difference remained after adjusting for women’s age, race/ethnicity, education, insurance status, and parity (adjusted prevalence ratio [aPR], 0.49; 95% confidence interval [CI], 0.37-0.65). On the other hand, we did not find a difference in the prevalence of using a highly effective reversible method of contraception at two to six months postpartum by birth hospital type (aPR, 0.96; 95% CI, 0.90-1.03). A limitation of the research was that PRAMS did not capture when the method was initiated postpartum. Thus, women might have obtained contraception from other sources (e.g., at the six-week postpartum visit) rather than have received it during their hospital stay. It could be that we found a difference by delivery hospital type for female sterilization, but not for other highly effective methods, because of the difficulty in obtaining sterilization after hospital discharge during the early postpartum period for logistical, financial, or other reasons. It also is possible that hospitals following the Directives could have provided a highly effective, hormonal method (but not female sterilization) for noncontraceptive purposes, such as managing menorrhagia, and thus are not less likely to provide highly effective reversible contraception compared to their non-Catholic counterparts.
Following the Supreme Court’s decision in Dobbs v. Jackson Women’s Health Organization, access to legal abortion will become much more restricted for many people in the United States. Thus, it is important that those wanting to use contraception to avoid pregnancy be able to access their preferred method, including female sterilization. The American College of Obstetricians and Gynecologists recommends that facilities consider designating postpartum sterilization as a nonelective procedure to try to reduce institutional barriers to carrying it out at a short notice.12 Despite this recommendation designed to reduce barriers to accessing postpartum sterilization, the growth in Catholic hospitals in the United States means that an increasing number of people will face difficulty in obtaining female sterilization if they desire the procedure following childbirth.
REFERENCES
- Solomon T, et al. Bigger and bigger: The growth of Catholic health systems. Community Catalyst 2020. https://www.communitycatalyst.org/resources/publications/document/2020-Cath-Hosp-Report-2020-31.pdf
- United States Conference of Catholic Bishops. Ethical and Religious Directives for Catholic Health Care Services. 6th ed. United States Conference of Catholic Bishops; 2018. https://www.usccb.org/about/doctrine/ethical-and-religious-directives/upload/ethical-religious-directives-catholic-health-service-sixth-edition-2016-06.pdf
- Jones RK, et al. Countering conventional wisdom: New evidence on religion and contraceptive use. Guttmacher Institute. Published April 2011. https://www.guttmacher.org/report/countering-conventional-wisdom-new-evidence-religion-and-contraceptive-use
- Wascher JM, et al. Do women know whether their hospital is Catholic? Results from a national survey. Contraception 2018;98:498-503.
- Takahashi J, et al. Disclosure of religious identity and health care practices on Catholic hospital websites. JAMA 2019;321:1103-1104.
- Stulberg DB, et al. Women’s expectation of receiving reproductive health care at Catholic and non-Catholic hospitals. Perspect Sex Reprod Health 2019;51:135-142.
- Nash E, et al. 26 states are certain or likely to ban abortion without Roe: Here’s which ones and why. Guttmacher Institute. Updated April 19, 2022. https://www.guttmacher.org/article/2021/10/26-states-are-certain-or-likely-ban-abortion-without-roe-heres-which-ones-and-why
- U.S. Department of Health and Human Services. Pregnancy and childbirth. Healthy People 2030. https://health.gov/healthypeople/objectives-and-data/browse-objectives/pregnancy-and-childbirth
- Speroff L, et al The postpartum visit: It’s time for a change in order to optimally initiate contraception. Contraception 2008;78:90-98.
- Cronin TJ. Influence of lactation upon ovulation. Lancet 1968;2:422-424.
- Halderman LD, et al. Impact of early postpartum administration of progestin-only hormonal contraceptives compared with nonhormonal contraceptives on short-term breast-feeding patterns. Am J Obstet Gynecol 2002;186:1250-1256.
- [No authors listed]. Access to postpartum sterilization: ACOG Committee Opinion Summary, Number 827. Obstet Gynecol 2021;137:1146-1147.
- Thurman AR, et al. One-year follow-up of women with unfulfilled postpartum sterilization requests. Obstet Gynecol 2010;116:1071-1077.
- Menegay MC, et al. Delivery at Catholic hospitals and postpartum contraception use, five US states, 2015-2018. Perspect Sex Reprod Health 2022;54:5-11.
- Stulberg DB, et al. Tubal ligation in Catholic hospitals: A qualitative study of ob-gyns’ experiences. Contraception 2014;90:422-428.
