Referrals for Services Prohibited In Catholic Health Care Facilities

Assessing the Variability in Interpretation of the Catholic Directives Pertaining to Reproductive Health Services: An Exploratory Qualitative Study of Two Hospitals on the American East Coast

The ethics in Catholic hospitals are guided by the Ethical and Religious Directives for Catholic Health Care Services, which provide direction on many topics, including family planning. Previous research has demonstrated there is variability in the availability of prohibited family planning services at Catholic hospitals. This study aims to research a potential source of variability in interpretation and application of the directives through interviewing ethics committee members. Participants were recruited from two different hospitals on the east coast with a total sample size of eight. Ethics committee members were asked questions regarding their personal approach to ethics, their hospital's approach to ethics, and the permissibility of specific family planning methods at their hospital. Most ethics committee members stated that the Catholic faith and/or directives were important in their hospitals' approach to ethics. Most participants stated that they had instances in which their personal approach to ethics conflicted with their hospital's approach, citing women's health and end-of-life care as common causes of conflict. All but one ethics committee member stated that hormonal contraception was forbidden under the directives; however, many members stated that this was either a gray area or permissible under certain circumstances. Reproductive health issues rarely came before the ethics committee at either site with one participant referring to them as "black and white issues." This research suggests that ethics committee members did not see the directives governing family planning services to be ambiguous. However, given the low frequency in which these issues come to the attention of the ethics committee, it is difficult to determine whether the opinions expressed by our participants contribute to the variability between Catholic hospitals when it comes to reproductive healthcare provision. An interesting topic for future research would be interviewing executives at Catholic hospitals to determine where this variability arises.

Association of Medicaid Reimbursement Policies with Provision of Long-Acting Reversible Contraception in the Postpartum Period, 2012-2018

Background: To address reimbursement challenges associated with long-acting reversible contraception (LARC) in the postpartum period, state Medicaid programs have provided additional payments ("carve-outs"). Implementation has been heterogeneous, with states providing separate payments for the device only, procedure only, or both the device and procedure. Methods: Claims data were drawn from 210,994 deliveries in the United States between 2012 and 2018. Using generalized estimating equations, we assess the relationship between Medicaid carve-out policies and the likelihood of LARC placement at (1) 3 days postpartum, (2) 60 days postpartum, and (3) 1 year postpartum, in Medicaid and commercially insured populations. Results: Among Medicaid beneficiaries, the likelihood of receiving LARC was higher in states with any carve-out, compared with states without carve-outs, at 3 days (adjusted odds ratio [aOR] 1.49 [95% confidence interval: 1.33-1.67], p < 0.001), 60 days (aOR: 1.40 [95% CI: 1.35-1.46], p < 0.001), and 1 year postpartum (aOR: 1.15 [95% CI: 1.11-1.20], p < 0.001). Adjustments were made for geographic region, seasonality, and patient age. Heterogeneity was observed by carve-out type; device carve-outs were consistently associated with greater likelihood of postpartum LARC placement, compared with states with no carve-outs. Similar trends were observed among commercially insured patients. Conclusion: Findings support the effectiveness of Medicaid carve-outs on postpartum LARC provision, particularly for device carve-outs, which were associated with increased postpartum LARC placement at 3 days, 60 days, and 1 year postpartum. This outcome suggests that policies to address cost-related barriers associated with LARC devices may prove most useful in overcoming barriers to immediate postpartum LARC placement, with the overarching aim of promoting reproductive autonomy.

State of Confusion: Ohio's Restrictive Abortion Landscape and the Production of Uncertainty in Reproductive Health Care

This study examines an underexplored source of medical uncertainty: the political context of care. Since 2011, Ohio has passed over 16 abortion-restrictive laws. We know little about how this legislation affects reproductive health care outside of abortion clinics. Drawing on focus groups and interviews with genetic counselors and obstetrician-gynecologists, we examine how abortion legislation impacts their work. We find that interpretation and implementation of legislation is not straightforward and varies by institution and region of the state. An ever-changing legislative landscape combined with uneven implementation of restrictions into policy produces uncertainty in reproductive health care. We also found uncertainty about the legal consequences of abortion in restrictive contexts, with obstetrician-gynecologists reporting greater concerns given their proximity to care provision. We argue that uncertainty can result in stricter interpretations of regulations than necessitated by the law, thereby amplifying the impacts of an already restrictive context for abortion care.

The 'Institutional Lottery': Institutional variation in the processes involved in accessing late abortion in Victoria, Australia

Despite abortion being decriminalised in Victoria, Australia, access remains difficult, especially at later gestations. Institutions (i.e. health services) place restrictions on the availability of late abortions and/or require additional requirements to be satisfied (e.g. Hospital Termination Review Committee approval), as a consequence of local regulation (i.e. policies and processes determined at the institutional level). This paper reports on the results of 27 interviews with Victorian health professionals about late abortion processes and the operation of Termination Review Committees in Victorian health services, which were analysed thematically. The results reveal the operation of an 'institutional lottery' whereby patients' experiences in seeking late abortion services were variable and largely shaped by the institution(s) they found themselves in.

Institutional Objection to Voluntary Assisted Dying in Victoria, Australia: An Analysis of Publicly Available Policies

BACKGROUND

Victoria was the first Australian state to legalize voluntary assisted dying (elsewhere known as physician-assisted suicide and euthanasia). Some institutions indicated they would not participate in voluntary assisted dying. The Victorian government issued policy approaches for institutions to consider OBJECTIVE: To describe and analyse publicly available policy documents articulating an institutional objection to voluntary assisted dying in Victoria.

METHODS

Policies were identified using a range of strategies, and those disclosing and discussing the nature of an institutional objection were thematically analysed using the framework method.

RESULTS

The study identified fifteen policies from nine policymakers and developed four themes: (1) extent of refusal to participate in VAD, (2) justification for refusal to provide VAD, (3) responding to requests for VAD, and (4) appeals to state-sanctioned regulatory mechanisms. While institutional objections were stated clearly, there was very little practical detail in most documents to enable patients to effectively navigate objections in practice.

CONCLUSION

This study demonstrates that despite having clear governance pathways developed by centralized bodies (namely, the Victorian government and Catholic Health Australia), many institutions' public-facing policies do not reflect this guidance. Since VAD is contentious, laws governing institutional objection could provide greater clarity and regulatory force than policies alone to better balance the interests of patients and non-participating institutions.

The Impact of 'conscientious objection' on abortion-related outcomes: A synthesis of legal and health evidence

The World Health Organization (WHO) and international human rights bodies have long urged states to take steps to ensure that 'conscientious objection' does not undermine access to abortion in practice. This review uses an established methodology to identify and integrate evidence of the health and human rights impacts of the practice of conscientious objection/refusal. The evidence identified in this review suggests strongly that conscientious objection negatively affects the rights of abortion seekers and has negative implications for the rights of non-objecting health workers. This is exacerbated in situations where an exercise of 'conscience' goes beyond 'opting out' of providing care and extends into seeking to prevent abortion through dissuasion, misinformation, misdirection, delay, and sometimes abuse. The insights from this review suggest that states must take better and further action to centre abortion seekers in the regulation of conscientious objection, and to prevent and ensure accountability for rights-limiting manifestations of conscience that go beyond opting out of direct provision of abortion care in non-emergency settings.

Institutional objection to abortion: A mixed-methods narrative review

Institutional objection (IO) occurs when institutions providing health care claim objector status and refuse to provide legally permissible health services such as abortion. IO may be regulated by sources including law, ethical codes and policies (including State and local/institutional policies). We conducted a mixed-methods narrative review of the empirical evidence exploring IO to abortion provision globally, to inform areas for further research. MEDLINE (Ovid), Embase (Ovid), CINAHL (EBSCO), Global Health (CAB Abstracts), ScienceDirect and Scopus were searched in August 2021 using keywords including 'conscientious objection', 'faith-based organizations', 'religious hospitals' and 'abortion'. Eligible research focused on clinicians' attitudes and experiences of IO to abortion. The 28 studies included in the review were from nine countries: United States (19), Chile (2), Turkey (1), Argentina (1), Australia (1), Colombia (1), Ghana (1), Poland (1) and South Africa (1). The analysis demonstrated that IO was claimed in a range of countries, despite different legislative and policy frameworks. There was strong evidence from the United States that clinicians in religious healthcare institutions were less likely to provide abortions and abortion referrals, and that training of future abortion providers was negatively affected by IO. Qualitative evidence from other countries showed that IO was claimed by secular as well as religious institutions, and individual conscientious objection could be used as a mechanism for imposing IO. Further research is needed to explore whether IO is morally justified, how decisions are made to claim IO, and on what grounds. Finally, appropriate models for regulating IO are needed to ensure the protection of women's access to abortion. Such models could be informed by those used to regulate IO in other contexts, such as voluntary assisted dying.

Short-Interval Pregnancy in the Illinois Medicaid Population Following Delivery in Catholic vs non-Catholic Hospitals

OBJECTIVE

Catholic hospitals restrict access to comprehensive reproductive health services that could impact patient outcomes. We sought to determine whether delivery at a Catholic hospital is associated with shorter pregnancy intervals among patients insured by Medicaid in Illinois.

STUDY DESIGN

We used Illinois Medicaid data files to conduct a retrospective cohort study. We used billing codes to identify deliveries in 2010 and 2011 and classified each by hospital of delivery, maternal age, race/ethnicity, and residential zip code. We calculated the interval from index birth to subsequent conception using an established method, and used Cox proportional hazards regression to compare the rate of subsequent pregnancy between enrollees who delivered in Catholic vs non-Catholic hospitals, adjusting for individual characteristics. We also computed differences in the rates of conception within 6, 12 and 18 month intervals.

RESULTS

We identified 96,293 index births and 18,627 subsequent conceptions. Twenty eight percent (26,775) of index births occurred in a Catholic hospital. Women who delivered in a Catholic hospital had a 12% greater risk of conception in the following 18 months (HR 1.12, 95% CI 1.09-1.16) after adjusting for age, race/ethnicity and rural residence. At 18 months, 23.9% of enrollees delivering in a Catholic hospital had become pregnant as compared to 21.2% for enrollees delivering in a non-Catholic hospital (difference of 2.6%, 95% CI 1.8-3.6).

CONCLUSION

Illinois Medicaid enrollees who deliver at Catholic hospitals have an increased risk of short-interval pregnancy. As the market share of Catholic hospitals grows, providers must work with patients to acknowledge and address these potential impacts on reproductive health outcomes and policies must change to promote equitable access.

IMPLICATIONS

Delivery at a Catholic hospital is associated with increased risk of short-interval pregnancy. Further attention from providers, researchers and policy makers alike, is necessary to identify the mechanisms through which these differences manifest such that effective interventions can be developed.

Delivery at Catholic hospitals and postpartum contraception use, five US states, 2015-2018

OBJECTIVES

To evaluate whether the prevalence of postpartum contraceptive use was lower among people who delivered at a Catholic hospital compared to a non-Catholic hospital.

METHODS

We linked 2015-2018 Pregnancy Risk Assessment Monitoring System (PRAMS) survey data from five states to hospital information from the corresponding birth certificate file. People with a live birth self-reported their use of contraception methods on the PRAMS survey at 2-6 months postpartum, which we coded into two dichotomous (yes vs. no) outcomes for use of female sterilization and highly-effective contraception (female/male sterilization, intrauterine device, implant, injectable, oral contraception, patch, or ring). We conducted multilevel log-binomial regression to examine the relationship between birth hospital type and postpartum contraception use adjusting for confounders.

RESULTS

Prevalence of female sterilization for people who delivered at a Catholic hospital was 51% lower than that of their counterparts delivering at a non-Catholic hospital (adjusted prevalence ratio: 0.49; 95% confidence interval: 0.37-0.65).

CONCLUSION

We found lower use of postpartum female sterilization, but no difference in highly effective contraception overall, for people who delivered at a Catholic hospital compared to a non-Catholic hospital.

Willing but unable: Physicians' referral knowledge as barriers to abortion care

Abortion care is a crucial part of reproductive healthcare. Nevertheless, its availability is constrained by numerous forces, including care referrals within the larger healthcare system. Using a unique study of physician faculty across multiple specialties, we examine the factors associated with doctors' ability to refer patients for abortion care among those who were willing to consult in the care of a patient seeking an abortion (N = 674). Even though they were willing to refer a patient for an abortion, half (53%) of the physicians did not know how and whom to make those referrals, though they care for patients who may need them. Those with the least referral knowledge had not been taught abortion care during their medical training and were in earlier stages of their career than those who had more knowledge. This research exposes another obstacle for those seeking an abortion, a barrier that would be overcome with a clear and robust referral system within and across medical specialties.

What you don't know can hurt you: Patient and provider perspectives on postpartum contraceptive care in Illinois Catholic Hospitals

OBJECTIVE

Catholic Religious and Ethical Directives restrict access to contraception; yet offering contraception during a delivery hospitalization facilitates birth spacing and is a convenient option for patients during the postpartum period. We assessed patient and provider experiences with hospital transparency around postpartum contraceptive care in Illinois Catholic Hospitals.

STUDY DESIGN

We interviewed 44 participants with experience in Illinois Catholic Hospitals: 21 patients, and 23 providers, including clinicians, nurses, doulas, and postpartum program staff. We used an open-ended interview approach, with a semistructured guide focused on postpartum contraceptive care. We conducted interviews by phone between November 2019 and June 2020. We audio-recorded interviews, transcribed them verbatim, and coded transcripts in Dedoose. We developed narrative memos for each code, identifying themes and subthemes. We organized these in a matrix for analysis and present here themes regarding hospital transparency that emerged across interviews.

RESULTS

Many patients knew they were delivering in a Catholic hospital; however, few were aware that Catholic policies limited their health care options. Patients expressed a desire for hospitals to be transparent, even "very vocal," about religious restrictions and described consequences of restrictions on patient care. Patients lacked information to make contraceptive decisions, experienced limits on or delays in care, and some lost continuity with trusted providers. Consequences for providers included moral distress in trying to provide care using workarounds such as documenting false medical diagnoses.

CONCLUSIONS

Religious restrictions on postpartum contraception restrict access, cause unnecessary delays in care, and lead to misdiagnosis and marginalization of contraceptive care. Restrictions also cause moral distress to providers who balance career repercussions and professional integrity with patient needs.

IMPLICATIONS

To protect patient autonomy, especially during the vulnerable postpartum period, Catholic hospitals should increase transparency regarding limitations on reproductive health care. Insurers and policy-makers should guarantee that patients have the option to receive care at hospitals without these limitations and facilitate public education about what to expect at Catholic facilities.

Expectations about availability of contraception and abortion at a hypothetical Catholic hospital: Rural-urban disparities among Wisconsin women

OBJECTIVE

To examine rural-urban differences in reproductive-aged Wisconsin women's expectations for contraceptive and abortion care at a hypothetical Catholic hospital.

STUDY DESIGN

Between October 2019 and April 2020, we fielded a 2-stage, cross-sectional survey to Wisconsin women aged 18 to 45, oversampling rural census tracts and rural counties served by Catholic sole community hospitals. We presented a vignette about a hypothetical Catholic-named hospital; among participants perceiving it as Catholic, we conducted multivariable analyses predicting expectations for contraceptive services (birth control pills, Depo-Provera, intrauterine device or implant, tubal ligation) and abortion in the case of serious fetal indications.

RESULTS

The response rate was 37.6% for the screener and 83.4% for the survey (N = 675). Among respondents (N = 376) perceiving the hospital as Catholic, expecting the full range of contraceptive methods was more common among rural (70.9%) vs urban (46.7%) participants (adjusted odds ratio = 3.99, 95% confidence interval: 1.99-7.99). In adjusted models, odds of expecting each contraceptive method were at least 3 times greater among rural vs urban participants. About one-third expected provision of abortion for serious fetal indications, with no difference by rurality (p > 0.05).

CONCLUSIONS

In Wisconsin, rural women were more likely than urban women to expect a hypothetical Catholic hospital to provide the full range of contraceptive methods as well as each method individually. Disparities were especially large for tubal ligation and long-acting reversible contraceptives-methods that other studies suggest are least-likely to be available in Catholic healthcare settings-which may indicate a mismatch between patients' expectations and service availability.

IMPLICATIONS

Many reproductive-aged Wisconsin women-especially in rural areas-hold misperceptions about availability of reproductive care in Catholic hospitals. Policies mandating greater transparency in service restrictions and interventions enabling patients to make informed decisions about care may help connect patients to the care they need more quickly.

Prevalence and experiences of Wisconsin women turned away from Catholic settings without receiving reproductive care

OBJECTIVE

To estimate prevalence of being turned away from a Catholic healthcare setting without receiving desired reproductive care among Wisconsin women and to document firsthand accounts of these experiences.

STUDY DESIGN

Between October 2019 and April 2020, we fielded a two-stage survey to Wisconsin women aged 18-45, oversampling rural census tracts and rural counties served by Catholic sole community hospitals. We present prevalence of ever being turned away from a Catholic hospital or clinic without receiving desired contraceptive or fertility care and document accounts of referrals, perceived barriers, and wait times to acquire services elsewhere.

RESULTS

The screener response rate was 37.6% (N = 828) and the survey response rate was 83.4% (N = 675). While only 23 (2.0%) of Wisconsin women had ever been turned away from a Catholic hospital or clinic without receiving desired contraceptive or fertility care (95% confidence interval: 1.2%-3.5%), these experiences were more common among women in counties served by Catholic sole community hospitals (n = 9, 8.1% [4.0%-15.6%]) compared to women in other rural census tracts (n = 6, 2.8% [1.3%-6.2%]) and urban census tracts (n = 8, 1.5% [0.7%-3.2%]). Sixteen (69.6%) cited religious restrictions as a barrier to accessing care. Some women - especially those denied tubal ligation - experienced long delays in acquiring time-sensitive care elsewhere.

CONCLUSIONS

About 1-in-12 women in Wisconsin rural counties served by Catholic sole community hospitals reported ever being turned away from a Catholic healthcare setting without receiving desired reproductive care. After tubal ligation denials in Catholic facilities, many women faced long wait times to receive care elsewhere.

IMPLICATIONS

Wisconsin women in rural counties served by Catholic sole community hospitals were about three times more likely than urban women to have ever been turned away from a Catholic facility. As Catholic healthcare expands nationally, it will be increasingly important to better understand how healthcare prohibitions influence patients' lives.

A Review of Research Progress of Pregnancy with Twins with Preeclampsia

Preeclampsia has a significant long-term effect on the health of both mothers and babies. Preeclampsia-related pregnancy complications increase the morbidity and mortality of pregnant women and their fetuses by 5-8%. The recent advancement of assisted reproductive technology, combined with a rise in the number of elderly pregnant women, has resulted in pregnancy incidence with twins. Twins pregnant women have a 2-3 times greater risk of developing preeclampsia than singleton pregnant women, and it happens sooner and progresses faster. It is more severe and may appear in an atypical way. End-organ damage, such as renal failure, stroke, cardiac arrest, pulmonary edema, placental abruption, and cesarean section, are related maternal complications. Fetal growth retardation, stillbirth, and premature delivery with obstetric signs are all fetal complications. According to studies, all multiple pregnancies can take low-dose aspirin (60-150 mg) to minimize the risk of preeclampsia. To improve pregnancy outcomes and reduce the inherent risk of pregnancy with twins, twins should be handled as a high-risk pregnancy and treated differently than singletons. The literature on twin pregnancy with preeclampsia is the subject of this review. It will examine the current state of research on preeclampsia in pregnancy with twins, including the occurrence, diagnosis, and pathophysiological process. Moreover, the effect of pregnancy with twins on the perinatal outcome and pregnancy management of pregnancy with twins, including blood pressure management and preeclampsia prevention and treatment, is examined in this literature review. The goal is to figure out what kind of diagnosis and care you may need.

Interprofessional Abortion Opposition: A National Survey and Qualitative Interviews with Abortion Training Program Directors at U.S. Teaching Hospitals

CONTEXT

Hospital policies and culture affect abortion provision. The prevalence and nature of colleague opposition to abortion and how this opposition limits abortion care in U.S. teaching hospitals have not been investigated.

METHODS

As part of a mixed-methods study, a nationwide survey of residency and site directors at 169 accredited obstetrics-gynecology training programs was conducted in 2015-2016, and 18 in-depth interviews with program directors were conducted in 2014 and 2017. The prevalence and nature of interprofessional opposition were examined using descriptive statistics, and regional differences were investigated using logistic regression. A modified grounded theoretical approach was used to analyze interview data.

RESULTS

Among the 91% of survey respondents who reported that they or their colleagues had wanted or needed to provide abortions in the prior year, 69% faced opposition from colleagues. Most commonly, opposition came from nurses (58%), nursing administration (30%) and anesthesiologists (30%), manifesting as resistance to participating in or cooperating with procedures (51% and 38%, respectively). Fifty-nine percent of respondents had denied care to patients in the prior year because of colleagues' opposition. Respondents in the Midwest and South were more likely than those in the Northeast to deny abortion care to patients because of such opposition (odds ratios, 3.2 and 4.4, respectively). Interviews revealed how participants had to circumvent opposing colleagues, making abortion provision difficult and leading to delays in and, infrequently, denial of abortion care.

CONCLUSIONS

Interprofessional opposition to abortion is widespread in U.S. teaching hospitals. Interventions are needed that prioritize patients' needs while recognizing the challenges hospital colleagues face in their abortion participation decisions.

Restrictions on Reproductive Care at Catholic Hospitals: A Qualitative Study of Patient Experiences and Perspectives

BACKGROUND

Previous studies have shown that many women who would seek care at Catholic hospitals are unaware of the hospital's religious affiliation. Furthermore, women often do not realize that these institutions operate according to religious beliefs that restrict access to certain reproductive services. Our study aimed to gain patient perspectives on experiences seeking reproductive care at religiously affiliated institutions.

METHODS

We conducted a qualitative study using in-depth interviews with 33 women who reported experiences seeking reproductive services at Catholic hospitals. Interview questions focused on women's experiences with religious restrictions, their attitudes towards religious healthcare, and whether and how they think women should be informed of these restrictions. Interviews were thematically analyzed using Dedoose software, applying both a priori concepts such as patient autonomy, informed decision making, and transparency, as well as new concepts that emerged from the data or denoted unanticipated distinctions within codes.

RESULTS

In this paper, we present three findings. First, women value both patient autonomy and hospital religious freedom. Struggling to reconcile these, many blamed themselves for not anticipating religious restrictions. Second, barriers to information prevent women from researching restrictions ahead of time. Third, women would like more information about these restrictions from both doctors and hospitals.

CONCLUSION

Public policy that regulates hospitals should require transparency from hospitals and physicians about religious restrictions on care. Informing the public about religious policies and how they affect reproductive care will allow patients to better anticipate differences and make informed decisions about where to seek care.

"My Hands Are Tied": Abortion Restrictions and Providers' Experiences in Religious and Nonreligious Health Care Systems

CONTEXT

Abortion is generally prohibited in Catholic hospitals, but less is known about abortion restrictions in other religiously affiliated health care facilities. As religiously affiliated health systems expand in the United States, it is important to understand how religious restrictions affect the practices of providers who treat pregnant patients.

METHODS

From September 2016 to May 2018, in-depth interviews were conducted with 31 key informants (clinical providers, ethicists, chaplains and health system administrators) with experience working in secular, Protestant or Catholic health care systems in Illinois. A thematic content approach was used to identify themes related to participants' experiences with abortion policies, the role of ethics committees, the impact on patient care and conflicts with hospital policies.

RESULTS

Few limitations on abortion were reported in secular hospitals, while Catholic hospitals prohibited most abortions, and a Protestant-affiliated system banned abortions deemed "elective." Religiously affiliated hospitals allowed abortions in specific cases, if approved through an ethics consultation. Interpretation of system-wide policies varied by hospital, with some indication that institutional discomfort with abortion influenced policy as much as religious teachings did. Providers constrained by religious restrictions referred or transferred patients desiring abortion, including for pregnancy complications, with those in Protestant hospitals having more latitude to directly refer such patients. As a result of religiously influenced policies, patients could encounter delays, financial obstacles, restrictions on treatment and stigmatization.

CONCLUSIONS

Patients seeking abortion or presenting with pregnancy complications at Catholic and Protestant hospitals may encounter more delays and fewer treatment options than they would at secular hospitals. More research is needed to better understand the implications for women's access to reproductive health care.

Market Share of US Catholic Hospitals and Associated Geographic Network Access to Reproductive Health Services

IMPORTANCE

Access to reproductive health services is a public health goal. It is unknown how geographic and health plan network availability of Catholic and non-Catholic hospitals may be associated with access to reproductive health services in the United States.

OBJECTIVE

To characterize the market share of Catholic hospitals in the United States, both overall and within Marketplace health insurance plans' hospital networks.

DESIGN, SETTING, AND PARTICIPANTS

This cross-sectional study of US counties used data on hospitals' Catholic affiliation and discharges, hospital networks in Marketplace health insurance plans, and US Census population data to construct a national, county-level data set. The Catholic hospital market share overall in each county and in Marketplace plans' hospital networks in each county were calculated. The study examined whether the Catholic hospital market share was different within Marketplace networks compared with the counties they served. Data analysis was conducted in May and June 2018.

MAIN OUTCOMES AND MEASURES

The overall Catholic hospital market share was calculated on the basis of the share of discharges in Catholic hospitals in a county compared with all hospital discharges. Overall market share was categorized as minimal (≤2%), low (>2% to ≤20%), high (>20% to ≤70%), or dominant (>70%). The Catholic hospital market share in Marketplace networks was calculated as the share of Catholic hospital discharges in each Marketplace network.

RESULTS

The sample included 4450 hospitals in 3101 counties. Overall, 26.1% of US counties had minimal Catholic hospital market share, 38.6% had low Catholic hospital market share, and 35.3% had high or dominant Catholic hospital market share; 38.7% of US reproductive-aged women resided in counties with high or dominant Catholic hospital market share. Among counties with Catholic hospital market share greater than 2%, the distribution of the median Marketplace network's Catholic hospital market share (median [interquartile range], 4.6% [0%-24.3%]) was lower than overall Catholic hospital market share (median [interquartile range], 18.5% [8.1%-36.5%]). The median Marketplace hospital network had a lower Catholic hospital market share than the county overall in 68.0% of US counties with Catholic hospital market share greater than 2%.

CONCLUSIONS AND RELEVANCE

In this national study, 35.3% of counties had high or dominant Catholic hospital market share serving an estimated 38.7% of US women of reproductive age. Marketplace health insurance plans' hospital networks included a lower share of Catholic hospitals than the counties they serve.

"Am I Going to Be in Trouble for What I'm Doing?": Providing Contraceptive Care in Religious Health Care Systems

CONTEXT

Catholic systems control a growing share of health care in the United States. Because patients seeking contraceptives in Catholic facilities face doctrinal restrictions that may affect access to and quality of care, it is important to understand whether and how providers work within and around institutional policies regarding contraception.

METHODS

In 2016-2018, in-depth interviews were conducted in Illinois with 28 key informants-including providers (obstetrician-gynecologists, other physicians, nurse-midwives) and nonclinical professionals (ethicists, administrators, chaplains)-who had experience in secular, Protestant or Catholic health care systems. Interviews addressed multiple aspects of reproductive care and hospital and system policy. A thematic content approach was used to identify themes related to participants' experiences with and perspectives on contraceptive care.

RESULTS

While respondents working in secular and Protestant systems reported few limitations on contraceptive care, those working in Catholic systems reported multiple barriers. Providers who had worked in Catholic systems described variable institutional policies and enforcement practices, ranging from verbal admonishments to lease agreements prohibiting contraceptive provision in secular clinics on church-owned land. Despite these restrictions, patients' needs motivated many providers to utilize work-arounds; some providers reported having been pressured or directly instructed to document false diagnoses in patients' medical records. Interviewees described how these obstacles burdened patients, especially those with social and financial constraints, and resulted in delayed or lower quality care.

CONCLUSIONS

Providers working in Catholic hospitals are limited in their ability to serve women of reproductive age. Work-arounds intended to circumvent restrictions may inadvertently stigmatize contraception and negatively affect patient care.

Women's Expectation of Receiving Reproductive Health Care at Catholic and Non-Catholic Hospitals

CONTEXT

Catholic hospitals operate under directives that prohibit the provision of contraceptives, sterilization and abortion. Little research has examined women's awareness of these institutions' policies, which affects their ability to make informed decisions about where to seek care.

METHODS

In 2016, some 1,430 women aged 18-45 were recruited from a U.S. probability-based research panel for a survey about hospital care. Respondents were randomized to a hypothetical Catholic or nonreligious hospital group and asked about their expectations for receiving nine specific reproductive services. Multivariable logistic regression analyses were used to evaluate associations between participants' characteristics and their correctly identifying a hospital as Catholic, as well as between characteristics and expecting that birth control pills, tubal ligation or abortion for serious fetal indications would be provided there.

RESULTS

Women randomized to the Catholic hospital group were less likely than those randomized to the nonreligious group to expect provision of birth control pills (77% vs. 86%), tubal ligation (70% vs. 78%) or abortion for serious fetal indications (42% vs. 54%). Income level was associated with correctly identifying the Catholic hospital: Compared with individuals with the lowest income, those in three of the four other income groups were more likely to identify the hospital as Catholic (odds ratios, 1.9-2.2). In comparison with women who misidentified the Catholic hospital, those who identified it as Catholic had lower expectations that the hospital would provide birth control pills (0.3), tubal ligation (0.5) or abortion (0.2).

CONCLUSIONS

Many women do not realize the breadth of restrictions on reproductive health care at Catholic hospitals. Without institutional transparency, patient autonomy and health outcomes may be compromised.

SMFM Special Statement: State of the science on multifetal gestations: unique considerations and importance

We sought to review the state of the science for research on multiple gestations. A literature search was performed with the use of PubMed for studies to quantify the representation of multiple gestations for a sample period (2012-2016) that were limited to phase III and IV randomized controlled trials, that were written in English, and that addressed at least 1 of 4 major pregnancy complications: fetal growth restriction or small-for-gestational-age fetus, gestational diabetes mellitus, preeclampsia, and preterm delivery. Of the 226 studies that are included in the analysis, multiple pregnancies were most represented in studies of preterm delivery: 17% of trials recruited both singleton and multiple pregnancies; another 18% of trials recruited only multiple pregnancies. For trials that studied preeclampsia, fetal growth restriction, and gestational diabetes mellitus, 17%, 8%, and 2%, respectively, recruited both singleton and multiple gestations. None of the trials on these 3 topics were limited to women with a multiple pregnancy. Women with a multiple pregnancy are at risk for complications similar to those of women with singleton pregnancies, but their risk is usually higher. Also, the pathophysiologic condition for some complications differs in multiple gestations from those that occur in singleton gestations. Conditions that are unique to multiple pregnancies include excess placenta, placental crowding or inability of the uteroplacental unit to support the normal growth of multiple fetuses, or suboptimal placental implantation sites with an increased risk of abnormal placental location. Other adverse outcomes in multiple gestations are also influenced by twin-specific risk factors, most notably chorionicity. Although twins have been well represented in many studies of preterm birth, these studies have failed to identify adequate predictive tests (short cervical length established over 2 decades ago remains the single best predictor), to establish effective interventions, and to differentiate the underlying pathophysiologic condition of twin preterm birth. Questions about fetal growth also remain. Twin growth deviates from that of singleton gestations starting at approximately 32 weeks of gestation; however, research with long-term follow-up is needed to better distinguish pathologic and physiologic growth deviations, which include growth discordance among pairs (or more). There are virtually no clinical trials that are specific to twins for gestational diabetes mellitus or preeclampsia, and subgroups for multiple pregnancies in existing trials are not large enough to allow definite conclusions. Another important area is the determination of appropriate maternal nutrition or micronutrient supplementation to optimize pregnancy and child health. There are also unique aspects to consider for research design in multiple gestations, such as designation and tracking of the correct fetus prenatally and through delivery. The correct statistical methods must be used to account for correlated data because multiple fetuses share the same mother and intrauterine environment. In summary, multiple gestations often are excluded from research studies, despite a disproportionate contribution to national rates of perinatal morbidity, mortality, and health-care costs. It is important to consider the enrollment of multifetal pregnancies in studies that target mainly women with singleton gestations, even when sample size is inadequate, so that insights that are specific to multiple gestations can be obtained when results of smaller studies are pooled together. The care of pregnant women with multiple gestations presents unique challenges; unfortunately, evidence-based clinical management that includes the diagnosis and treatment of common obstetrics problems are not well-defined for this population.

Society for Maternal-Fetal Medicine (SMFM) Consult Series #48: Immediate postpartum long-acting reversible contraception for women at high risk for medical complications

Reproductive planning is essential for all women and most important for those with complex health conditions or at high risk for complications. Pregnancy planning can allow these high-risk women the opportunity to receive preconception counseling, medication adjustment, and risk assessment related to health conditions that have a direct impact on maternal morbidity and mortality risk. Despite the need for pregnancy planning, medically complex women face barriers to contraceptive use, including systemic barriers, such as underinsurance for women at increased risk for complex medical conditions as well as low uptake of effective postpartum contraception. Providing contraceptive counseling and a full range of contraceptive options, including immediate postpartum long-acting reversible contraception (LARC), is a means of overcoming these barriers. The purpose of this document is to educate all providers, including maternal-fetal medicine subspecialists, about the benefits of postpartum contraception, and to advocate for widespread implementation of immediate postpartum LARC placement programs. The following are Society for Maternal-Fetal Medicine recommendations: we recommend that LARC be offered to women at highest risk for adverse health events as a result of a future pregnancy (GRADE 1B); we recommend that obstetric care providers discuss the availability of immediate postpartum LARC with all pregnant women during prenatal care and consult the U.S. Medical Eligibility Criteria for Contraceptive Use guidelines to determine methods most appropriate for specific medical conditions (GRADE 1C); we recommend that women considering immediate postpartum intrauterine device insertion be counseled that although expulsion rates are higher than with delayed insertion, the benefits appear to outweigh the risk of expulsion, as the long-term continuation rates are higher (GRADE 1C); we recommend that obstetric care providers wishing to utilize immediate postpartum LARC obtain training specific to the immediate postpartum period (BEST PRACTICE); for women who desire and are eligible for LARC, we recommend immediate postpartum placement after a high-risk pregnancy over delayed placement due to overall superior efficacy and cost-effectiveness (GRADE 1B); we recommend that women considering immediate postpartum LARC be encouraged to breastfeed, as current evidence suggests that these methods do not negatively influence lactation (GRADE 1B); for women who desire and are eligible for LARC, we suggest that early postpartum LARC placement be considered when immediate postpartum LARC placement is not feasible (GRADE 2C); and we recommend that contraceptive counseling programs be patient-centered and provided in a shared decision-making framework to avoid coercion (BEST PRACTICE).

Counseling and referrals for women with unplanned pregnancies at publicly funded family planning organizations in Texas

OBJECTIVES

To compare pregnancy options counseling and referral practices at state- and Title X-funded family planning organizations in Texas after enforcement of a policy restricting abortion referrals for providers participating in state-funded programs, which differed from Title X guidelines to provide referrals for services upon request.

STUDY DESIGN

Between November 2014 and February 2015, we conducted in-depth interviews with administrators at publicly funded family planning organizations in Texas about how they integrated primary care and family planning services, including pregnancy options counseling and referrals for unplanned pregnancies. We conducted a thematic analysis of transcripts related to organizations' pregnancy options counseling and referral practices, and compared themes across organizations that did and did not receive Title X funding.

RESULTS

Of the 37 organizations with transcript segments on options counseling and referrals, 15 received Title X and 22 relied on state funding only. All Title X-funded organizations but only nine state-funded organizations reported offering pregnancy options counseling. Respondents at state-only-funded organizations often described directing pregnant women exclusively to prenatal care. Regardless of funding source, most organizations provided women a list of agencies offering abortion, adoption and prenatal care. However, some respondents expressed concern that providing other information about abortion would threaten their state funding. In contrast, respondents indicated staff would make appointments for prenatal care, assist with Medicaid applications and, in some instances, directly connect women with adoption-related services.

CONCLUSIONS

Pregnancy options counseling varied by organizations' funding guidelines. Additionally, abortion referrals were less common than referrals for other pregnancy-related care.

IMPLICATIONS

Programmatic guidelines restricting information on abortion counseling and referrals may adversely affect care for pregnant women at publicly funded family planning organizations.

Provider Conscientious Refusal of Abortion, Obstetrical Emergencies, and Criminal Homicide Law

Catholic doctrine's strict prohibition on abortion can lead clinicians or institutions to conscientiously refuse to provide abortion, although a legal duty to provide abortion would apply to anyone who refused. Conscientious refusals by clinicians to end a pregnancy can constitute murder or reckless homicide under American law if a woman dies as a result of such a refusal. Such refusals are not immunized from criminal liability by the constitutional right to the free exercise of religion or by statutes that confer immunity from criminal homicide prosecution. Core principles of the rule of law require the state to protect the lives of all persons equally and to place the life and health of persons above any the interests of providers have in moral integrity or in respecting the moral status of prenatal humans. In some states criminal liability related to conscientious objection also applies to corporate hospital officials.

What Are Women Told When Requesting Family Planning Services at Clinics Associated with Catholic Hospitals? A Mystery Caller Study

CONTEXT

Catholic Church directives restrict family planning service provision at Catholic health care institutions. It is unclear whether obstetrics and gynecology clinics that are owned by or have business affiliations with Catholic hospitals offer family planning appointments.

METHODS

Mystery callers phoned 144 clinics nationwide that were found on Catholic hospital websites between December 2014 and February 2016, and requested appointments for birth control generally, copper IUD services specifically, tubal ligation and abortion. Chi-square and Fisher's exact tests assessed potential correlates of appointment availability, and multivariable logistic regressions were computed if bivariate testing suggested multiple correlates.

RESULTS

Although 95% of clinics would schedule birth control appointments, smaller proportions would schedule appointments for copper IUDs (68%) or tubal ligation (58%); only 2% would schedule an abortion. Smaller proportions of Catholic-owned than of Catholic-affiliated clinics would schedule appointments for birth control (84% vs. 100%), copper IUDs (4% vs. 97%) and tubal ligation (29% vs. 72%); for birth control and copper IUD services, no other clinic characteristics were related to appointment availability. Multivariable analysis confirmed that tubal ligation appointments were less likely to be offered at Catholic-owned than at Catholic-affiliated clinics (odds ratio. 0.1); location and association with one of the top 10 Catholic health care systems also were significant.

CONCLUSIONS

Adherence to church directives is inconsistent at Catholic-associated clinics. Women visiting such clinics who want highly effective methods may need to rely on less effective methods or delay method uptake while seeking services elsewhere.