Research highlights how religiously-affiliated hospitals can restrict reproductive care

Researchers from the University of Chicago’s Center for Interdisciplinary Inquiry and Innovation in Sexual and Reproductive Health (Ci3) and Department of Family Medicine have published a policy brief that highlights key findings about the role of religiously-affiliated hospitals in Cook County, Illinois. The study shows how health care could be affected—particularly for women who may already face barriers as a result of income or racial inequities—given the restrictions religious hospitals can place on access to sexual and reproductive health care services.

In 2016, one in six U.S. acute-care hospital beds was controlled by a Catholic hospital – an increase of 18 percent since 2001. In Illinois, nearly three in 10 (29.5 percent) hospital beds are in Catholic-controlled hospitals. Providers working in Catholic hospitals must follow the Ethical and Religious Directives (ERDs) for Catholic Health Care Services written by the U.S. Conference of Catholic Bishops. These directives prohibit the provision of contraception, abortion, sterilization, and most fertility treatments. Patients who go to Catholic hospitals for childbirth or when experiencing unexpected pregnancy complications have faced harmful denials or delays in care because of the ERDs.

For example, women who want a tubal ligation and need a Cesarean birth have been told they will need to go elsewhere and have a second surgical procedure because tubal ligation is prohibited in their Catholic hospital. Women going through inevitable miscarriages have been told at Catholic hospitals there is no treatment allowed because their fetus still has a heartbeat, even if delaying care would increase the woman’s risk of infection.

Most patients do not seek healthcare with a preference for religious health systems. Rather, people tend to seek care in hospitals covered by their insurance networks. For women enrolled in public insurance programs such as Medicaid, this can mean that networks are determined by managed care plans that limit the providers and hospitals that are covered by the plan. Illinois’ public insurance programs have shifted toward this model. However, under federal guidelines, women enrolled in Medicaid are entitled to receive coverage for comprehensive reproductive and pregnancy-related care, and Illinois now includes Medicaid coverage for abortion care following the passage of legislation in 2016.

The policy brief, titled, “The Role of Religiously-affiliated Hospitals in Reproductive Health Care for Women with Public Insurance in Cook County, Illinois,” presents data from a study designed to better understand the relationship between public insurance enrollment and access to non-religious hospitals within managed care networks.

The study found that:

• 38 percent of all the Cook County hospitals with Labor & Delivery (L&D) departments are Catholic- controlled and 64 percent have a religious affiliation
• In 2018, five of the seven HealthChoice Illinois plans have a greater Catholic hospital saturation than Cook County as a whole (>38 percent Catholic among Cook County L&D hospitals)
• In five of the seven 2018 HealthChoice Illinois plans, 50 percent or more of the Cook County hospitals with L&D departments have some religious affiliation (including Catholic)
• Among female Cook County residents aged 19-44 enrolled in the seven plans between January 2015 and May 2017, 87 percent were in one of the five higher Catholic-saturation plans
• Black and Hispanic/Latino women were significantly more likely to be enrolled in one of the five higher Catholic-saturation plans compared to White women

"The passage of recent Illinois legislation removed restrictions on coverage for abortion care within the state’s public insurance system,” said Lee Hasselbacher, JD, Ci3's Senior Policy Researcher. “So, many women may now be looking within their networks for access to hospital-based abortion care that may be limited based on the religiously-affiliated hospitals within their managed care plan."

To conduct this study, researchers obtained public insurance enrollment data through a freedom of information (FOIA) request to the Illinois Department of Healthcare and Family Services. They then analyzed de-identified data for all female enrollees aged 19-44 in medical assistance programs from January 2015 through May 2017 who lived in Cook County. A list was created of all the hospitals within Cook County that have labor and delivery departments since these hospitals are most likely to provide reproductive health-related care that may face religious restrictions.

To identify Catholic-affiliated hospitals, the team consulted a list maintained by the Catholic Health Association of the United States and searched for specific information on hospital websites and in other published statements by hospital administration sources that a given hospital follows the ERDs. The team relied on hospital websites and other administrative statements to identify Jewish and Christian, non-Catholic hospitals.

“Patients with Medicaid should be able to receive covered family planning services from the qualified provider of their choice; regardless of whether that provider is in or out of their plan’s network,” said Debra Stulberg, MD, associate professor and Director of Research at UChicago’s Department of Family Medicine. "What’s unclear is how often women are aware of and make use of this option, which means many women may only be learning of religious-based restrictions once they arrive at a hospital for care."

The study was supported by the Society of Family Planning Research Fund.