Advertisement

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

  • Renee D. Kramer
    Correspondence
    Corresponding author. Renee D. Kramer, Department of Population Health Sciences, Collaborative for Reproductive Equity, University of Wisconsin-Madison, University of Wisconsin-Madison, Madison, WI United States
    Affiliations
    Department of Population Health Sciences, Collaborative for Reproductive Equity, University of Wisconsin-Madison, University of Wisconsin-Madison, Madison, WI United States

    Department of Obstetrics and Gynecology, Department of Gender and Women's Studies, and Collaborative for Reproductive Health Equity, University of Wisconsin-Madison, Madison, WI, United States
    Search for articles by this author
  • Jenny A. Higgins
    Affiliations
    Department of Obstetrics and Gynecology, Department of Gender and Women's Studies, and Collaborative for Reproductive Health Equity, University of Wisconsin-Madison, Madison, WI, United States

    Department of Population Health Sciences, University of Wisconsin-Madison, University of Wisconsin-Madison, Madison, WI, United States
    Search for articles by this author
  • Marguerite E. Burns
    Affiliations
    Department of Population Health Sciences, University of Wisconsin-Madison, University of Wisconsin-Madison, Madison, WI, United States
    Search for articles by this author
  • Lori R. Freedman
    Affiliations
    Department of Obstetrics, Gynecology & Reproductive Sciences, University of California, Oakland, CA, United States
    Search for articles by this author
  • Debra B. Stulberg
    Affiliations
    Department of Family Medicine, University of Chicago, IL, United States
    Search for articles by this author
Open AccessPublished:May 20, 2021DOI:https://doi.org/10.1016/j.contraception.2021.05.007

      ABSTRACT

      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.

      KEYWORDS

      1. Introduction

      Having meaningful agency over childbearing depends on access to reproductive healthcare. However, one-sixth of hospital beds nationally are in Catholic facilities, which prohibit key reproductive health services, including sterilization, reversible contraceptives, certain obstetric treatments, and abortion [
      • Solomon T
      • Uttley L
      • HasBrouck P
      • Jung Y.
      The Growth of Catholic Health Systems.
      ]. The proportion of Catholic hospitals in the U.S. increased 41% from 2001 (11.2%) to 2020 (15.8%) [
      • Solomon T
      • Uttley L
      • HasBrouck P
      • Jung Y.
      The Growth of Catholic Health Systems.
      ]. Further, in some rural areas, a Catholic hospital is the sole community hospital, a federal designation indicating the next-nearest hospital is too distant for community members to access [
      • Solomon T
      • Uttley L
      • HasBrouck P
      • Jung Y.
      The Growth of Catholic Health Systems.
      ]. Care delivery and referrals vary across providers and institutions [
      • Stulberg DB
      • Jackson RA
      • Freedman LR.
      Referrals for services prohibited in Catholic health care facilities: referrals in Catholic healthcare facilities.
      ,
      • Liu Y
      • Hebert LE
      • Hasselbacher LA
      • Stulberg DB.
      “Am I going to be in trouble for what I’m doing?”: providing contraceptive care in religious health care systems.
      ,
      • Guiahi M
      • Teal SB
      • Swartz M
      • Huynh S
      • Schiller G
      • Sheeder J.
      What are women told when requesting family planning services at clinics associated with Catholic hospitals? a mystery caller study of Catholic clinics.
      ,
      • Stulberg DB
      • Hoffman Y
      • Dahlquist IH
      • Freedman LR.
      Tubal ligation in Catholic hospitals: a qualitative study of ob–gyns’ experiences.
      ], and many systems lack transparency about Catholic status and restrictions [
      • Guiahi M
      • Teal SB
      • Swartz M
      • Huynh S
      • Schiller G
      • Sheeder J.
      What are women told when requesting family planning services at clinics associated with Catholic hospitals? a mystery caller study of Catholic clinics.
      ,
      • Takahashi J
      • Cher A
      • Sheeder J
      • Teal S
      • Guiahi M.
      Disclosure of religious identity and health care practices on Catholic hospital websites.
      ].
      The prevalence of being turned away from Catholic healthcare settings without receiving desired reproductive services is unknown, but documenting the effects of Catholic healthcare systems on reproductive health is necessary to help uphold patient autonomy [

      American College of Obstetrics and Gynecologists. Restrictions to Comprehensive Reproductive Health Care 2016.

      ,

      American Public Health Association. Restricted Access to Abortion Violates Human Rights, Precludes Reproductive Justice, and Demands Public Health Intervention 2015.

      ]. Further, three features of patients’ experiences must be understood: perceived barriers to care, receipt of referrals, and wait times to obtain care elsewhere. These features likely influence women's future care-seeking behavior but have not been explored quantitatively from the perspective of patients, who bear the consequences of service restrictions. Being unable to obtain a desired contraceptive may have serious consequences for women wishing to prevent childbearing; for women seeking fertility treatment, long delays in accessing interventions may decrease chances of pregnancy.
      To address these gaps, we fielded a probability-based survey of reproductive-aged women in Wisconsin – the state with the highest concentration of Catholic hospitals in the country – to examine how religious restrictions in Catholic hospitals affect patients’ reproductive lives [
      • Solomon T
      • Uttley L
      • HasBrouck P
      • Jung Y.
      The Growth of Catholic Health Systems.
      ]. With four in ten inpatient beds located in Catholic hospitals, Wisconsin residents may be especially likely to have experienced care in these systems firsthand [
      • Solomon T
      • Uttley L
      • HasBrouck P
      • Jung Y.
      The Growth of Catholic Health Systems.
      ]. While Wisconsin has a somewhat higher Catholic population (25%) than the U.S. (20%), research demonstrates that the majority of Catholic women use provider-dependent contraceptive methods [

      Jones RK, Dreweke J. Countering Conventional Wisdom: New Evidence on Religion and Contraceptive Use n.d.:8.

      ,

      Pew Research Center. Religious Landscape Study – Catholics n.d.

      ]. Wisconsin has two rural counties served by Catholic sole community hospitals and has a higher-than-average rural population (25% vs. 19%) [
      • Solomon T
      • Uttley L
      • HasBrouck P
      • Jung Y.
      The Growth of Catholic Health Systems.
      ,

      U.S. Census Bureau. 2011-2015 American Community Survey 5-Year Estimates 2016. https://factfinder.census.gov/faces/tableservices/jsf/pages/productview.xhtml?pid=ACS_15_5YR_CP05&prodType=table (accessed June 16, 2017).

      ]. It is important to include rural-dwelling women, who, due to existing rural-urban disparities in reproductive care access, may experience more significant consequences of being turned away from care [
      • Upadhyay UD
      • Johns NE
      • Meckstroth KR
      • Kerns JL.
      Distance traveled for an abortion and source of care after abortion.
      ,
      • Jerman J
      • Frohwirth L
      • Kavanaugh ML
      • Blades N.
      Barriers to abortion care and their consequences for patients traveling for services: qualitative findings from two states.
      ,
      • Stulberg DB
      • Dude AM
      • Dahlquist I
      • Curlin FA
      Abortion provision among practicing obstetrician–gynecologists.
      ].

      2. Material and methods

      We collaborated with the University of Wisconsin – Madison Survey Center to design and field this mail/web survey. In the screener phase, we sought to identify women between 18−45 years of age by mailing screeners to 8500 random residential addresses in Wisconsin (Table A.1). We sampled women since restricted reproductive services are largely utilized by female-bodied individuals but acknowledge that not all people who use these services identify as women.
      Screeners asked about age and gender and included a $1 pre-incentive; we requested that recipients return the survey using the paid postage regardless of their eligibility. To ensure representation of women in rural areas, including those served by Catholic sole community hospitals, we targeted rural census tracts (Rural-Urban Commuting Area [RUCA] code ≥ 4; n = 2000 screeners sent). The RUCA scheme classifies census tracts by proximity to urban areas using data on where people live and work [

      United States Department of Agriculture Economic Research Service. Documentation: 2010 Rural-Urban Commuting Area (RUCA) Codes 2019. https://www.ers.usda.gov/data-products/rural-urban-commuting-area-codes/documentation/ (accessed September 28, 2019).

      ]. We also targeted the three rural counties where the majority of Medicare beneficiaries obtain inpatient care at a Catholic sole community hospital (Oneida/Vilas/Forest; n = 2000 screeners sent) [

      United States Department of Agriculture Economic Research Service. Documentation: 2010 Rural-Urban Commuting Area (RUCA) Codes 2019. https://www.ers.usda.gov/data-products/rural-urban-commuting-area-codes/documentation/ (accessed September 28, 2019).

      ,

      Uttley L, Khaikin C. Growth of Catholic Hospitals and Health Systems: 2016 Update of the Miscarriage of Medicine Report. New York (NY): The MergerWatch Project; 2016.

      ,

      Centers for Medicare and Medicaid Services. Hospital Service Area File –2018. DataCMSGov 2018. https://data.cms.gov/Medicare-Inpatient/Hospital-Service-Area-File-2018/sgw2-6vb4/data (accessed May 25, 2020).

      ]. All hospital beds in these counties – and in their larger health service area – are located in Catholic institutions [

      Wisconsin Area Health Education Centers. Health Service Areas n.d. https://ahec.wisc.edu/resources/health-service-areas/ (accessed August 24, 2020).

      ,

      Catholic Health Association of the United States. Catholic Health Care Directory n.d. https://www.chausa.org/for-members/directories/catholic-health-care-directory.

      ]. In the survey phase, we mailed surveys to eligible screener respondents. We employed best practices to increase survey participation, including offering mail/web response options and cash pre- and post-incentives ($5 and $20, respectively) [
      • Couper MP.
      The future of modes of data collection.
      ,
      • Singer E.
      The use of incentives to reduce nonresponse household surveys.
      ].
      We adapted the survey instrument from a national study on women's awareness of and attitudes toward religious restrictions on reproductive services [
      • Stulberg DB
      • Hoffman Y
      • Dahlquist IH
      • Freedman LR.
      Tubal ligation in Catholic hospitals: a qualitative study of ob–gyns’ experiences.
      ,
      • Freedman LR
      • Stulberg DB.
      Conflicts in care for obstetric complications in Catholic hospitals.
      ,
      • Wascher JM
      • Hebert LE
      • Freedman LR
      • Stulberg DB.
      Do women know whether their hospital is Catholic? results from a national survey.
      ], adding items assessing experiences of being turned away from a Catholic hospital/clinic without receiving desired contraceptive or fertility care. Survey experts at the University of Wisconsin – Madison Survey Center refined our items to ease cognitive processing and maximize continuation [
      • Dillman DA.
      Mail and internet surveys: the tailored design method.
      ,
      • Tourangeau R
      • Rips LJ
      • Rasinski K.
      The Psychology of Survey Response.
      ].
      We first asked respondents, separately by service, whether they had ever wanted to obtain tubal ligation, other birth control, or fertility treatment, but could not. We referred to permanent contraception as “tubal ligation” to use a term that would be most familiar to respondents. If any of these experiences occurred more than once, we prompted respondents to think about the most recent time. The “other birth control” item asked about general method type (intrauterine device [IUD] or implant; birth control pill, patch, or vaginal ring; birth control shot [Depo-Provera©]; or another birth control method [open-ended]). Respondents indicated where the experience took place (hospital/clinic name, city, system). We classified respondents as having been turned away from a Catholic hospital/clinic without receiving desired contraceptive/fertility care if they reported wanting to obtain a service but could not and we identified whether the experience took place at a Catholic facility, per the Catholic Health Association [

      Catholic Health Association of the United States. Catholic Health Care Directory n.d. https://www.chausa.org/for-members/directories/catholic-health-care-directory.

      ]. Because our aim in this study was to understand care denials based on religious restrictions at Catholic facilities, we did not classify the religion (e.g., Protestant, Jewish, secular) of other facilities. After observing the broad range of denial experiences among respondents, we conducted a post hoc exploratory analysis describing denials at non-Catholic facilities. However, we do not draw comparisons between settings as we did not have strong a priori hypotheses and both subsamples were small.
      We assessed perceived barriers to care by asking respondents for the reason(s) they were unable to obtain services. These included payment/insurance barriers; challenges with scheduling/transportation/childcare; that their provider would not provide it because of their health; age; religious policies in their health care system that prohibit it; other policies in their health care system that prohibit it; and that their provider would not provide it and did not give a reason; or gave some other reason (open-ended). We asked respondents whether the provider or someone else working at the hospital/clinic told them somewhere else they could go for the service (“yes,” “no,” or “don't know”).
      We then asked respondents to estimate how long it ultimately took for them to obtain the service (“within a few days,” “1-3 weeks,” “4-6 weeks,” “within months,” “a year or more,” “still have not obtained [service] you want,” “have not obtained [service] because you no longer want it,” or “did not obtain [service] because you became pregnant”). After each set of service-specific questions, respondents could provide written comments.
      To make population-level estimates, we constructed survey weights for sampling design, nonresponse, and population age and education. We conducted chi-squared tests to determine whether prevalence of being turned away varied by rural/urban residence. Among respondents who had been turned away from Catholic healthcare institutions, we examined response distributions about perceived barriers, referrals, and wait time to obtain services. We also conducted chi-squared tests to assess whether wait times differed by service requested. We present descriptive findings on this small subsample unweighted, because it would not be appropriate to apply total population weights to a highly-select subgroup [
      • Levy Paul S.
      • Lemeshow Stanley
      Sampling of Populations Methods and Applications.
      ]. We performed all analyses in Stata 16.0. The Institutional Review Board at the University of Wisconsin – Madison deemed this study exempt from human subjects review.

      3. Results

      Of the 8500 surveys sent, we received completed screeners from 828 eligible respondents and 2173 ineligible respondents, resulting in a screener response rate of 37.6% (Fig. 1). Response rates were somewhat higher among screener recipients living in rural census tracts (39.5%) and rural counties served by sole Catholic hospitals (42.5%) compared to those living in urban tracts (34.7%; both p<.05). Of these 828 eligible screener respondents, 675 (83.4%) responded to the survey and were of eligible age, with no differences by geographic location.
      Fig. 1
      Fig. 1Sampling design, eligibility rates, and response rates for survey sent to Wisconsin mailing addresses, 2019-2020 (N = 8500)
      aUrban census tracts have Rural-Urban Commuting Area (RUCA) codes greater than or equal to 4. Rural census tracts have RUCA codes 1-3. Rural sole hospital counties were rural counties where the majority of Medicare beneficiaries obtain inpatient care at a Catholic sole community hospital (Oneida/Vilas/Forest).
      bScreener response rate calculated using the following formula: (completed eligible screeners) / (total screeners sent – completed ineligible screeners – undeliverable screeners)
      cEligibility rate calculated using the following formula: (completed eligible screeners + completed ineligible screeners) / (total screeners sent – undeliverable screeners)
      Survey response rate calculated using the following formula: (completed eligible surveys) / (total surveys sent – completed ineligible surveys)
      Table 1 presents descriptive statistics of survey respondents in the total sample. The mean age was 33.6 years. Four hundred seventeen (61.7%) resided in urban census tracts; 149 (22.1%) in rural census tracts; and 109 (16.2%) in the three rural counties served by Catholic sole community hospitals. Majorities were White (91.9%), privately-insured (82.7%), and college-educated (55.6%). Twenty-nine percent were “not at all confident” they could afford an unexpected $2000 expense. Eighty-eight percent had ever used a provider-dependent contraceptive method.
      Table 1Demographic and socioeconomic characteristics of Wisconsin women aged 18-45 who completed a state-level survey on religious healthcare, 2019-2020 (N = 675)
      nUnweighted %
      Age (years)
      18-20274.0%
      21-24548.0%
      25-2911116.4%
      30-3415222.5%
      35-3917826.4%
      40-4515322.7%
      Rural/urban residence
      Urban census tracts have Rural-Urban Commuting Area (RUCA) codes greater than or equal to 4. Rural census tracts have RUCA codes 1-3. Rural sole hospital counties were rural counties where the majority of Medicare beneficiaries obtain inpatient care at a Catholic sole community hospital (Oneida/Vilas/Forest).
      Urban census tract41761.8%
      Rural census tract14922.1%
      Rural sole Catholic hospital county10916.1%
      Race/ethnicity
      Participants could check all that apply, so the total percentage exceeds 100%.
      White61991.7%
      Black263.9%
      Hispanic294.3%
      American Indian or Alaska Native152.2%
      Asian162.4%
      Missing213.1%
      Educational attainment
      <High school degree192.8%
      High school6910.2%
      Some college or associate's degree21131.3%
      Bachelor's degree25137.2%
      Advanced degree12418.4%
      Missing1.2%
      Confidence in ability to afford unexpected $2000 expense
      Not at all confident19829.3%
      Slightly confident8813.0%
      Somewhat confident7911.7%
      Very confident11617.2%
      Certain18928.0%
      Missing5.7%
      Insurance status
      Private/Employer/Exchange55882.7%
      Public7811.6%
      None/Unsure if covered395.8%
      Religion
      Catholic14821.9%
      Not Catholic51476.1%
      Missing131.9%
      a Urban census tracts have Rural-Urban Commuting Area (RUCA) codes greater than or equal to 4. Rural census tracts have RUCA codes 1-3. Rural sole hospital counties were rural counties where the majority of Medicare beneficiaries obtain inpatient care at a Catholic sole community hospital (Oneida/Vilas/Forest).
      b Participants could check all that apply, so the total percentage exceeds 100%.

      3.1 Prevalence of being turned away from Catholic facilities

      Twenty-three respondents – 2.0%, at the population level – had ever been turned away from a Catholic hospital or clinic without receiving desired contraceptive or fertility care (95% confidence interval [CI]: 1.2%-3.5%; Fig. 2). Reports of being turned away from Catholic settings were significantly more common in the three rural counties served by Catholic sole community hospitals (n = 9, 8.1% [4.0%-15.6%]) compared to other rural tracts (n = 6, 2.8% [1.3%-6.2%]) and urban tracts (n = 8, 1.5% [0.7%-3.2%]).
      Fig. 2
      Fig. 2Percentage of Wisconsin women aged 18-45 ever turned away from Catholic hospitals/clinics without receiving desired contraceptive or fertility care, by rural/urban residence,a 2019−2020
      Urban census tracts have Rural-Urban Commuting Area (RUCA) codes greater than or equal to 4. Rural census tracts have RUCA codes 1-3. Rural sole hospital counties were rural counties where the majority of Medicare beneficiaries obtain inpatient care at a Catholic sole community hospital (Oneida/Vilas/Forest).

      3.2 Perceived barriers, referrals, and wait times in Catholic facilities

      Of the 23 respondents who were turned away from Catholic settings, 14 (60.9%) sought tubal ligations; 8 (34.8%), reversible methods; and 1 (4.3%), fertility treatment. When asked why they could not obtain the service, 15 (65.2%) reported their doctor would not provide it based on prohibitive religious policies in their healthcare system. Sixteen (70%) were told of somewhere else to obtain care. Wait times to receive care varied by service requested (p = .03). All eight respondents seeking reversible birth control acquired it within six weeks, but 8 of 14 (57.1%) respondents seeking tubal ligation never obtained it or became pregnant before they could do so.

      3.3 Contexts of experiences of being turned away from Catholic facilities

      Several respondents provided written comments that shed additional light on experiences of being turned away from care. Two respondents who sought tubal ligations instead underwent hysterectomy or Essure. One IUD seeker said she “did not appreciate the inconvenience, plus paying for the visit that was a waste of time,” while another had to wait until she changed jobs because her employer – a Catholic healthcare system – would not cover the cost. Two respondents were able to switch providers after being turned away without receiving birth control or fertility treatment, respectively. After being told that her only options were to wait 1-2 years or pursue adoption, this latter respondent moved to a secular system and was “immediately” referred to a reproductive endocrinologist.

      3.4 Post hoc analyses of experiences being turned away from non-Catholic facilities

      Finally, although the aim of this study was to understand care denials based on the Catholic directives, 38 respondents (5.2%) reported 40 denial experiences in non-Catholic facilities: 20 (50.0%) for reversible contraceptives, 12 (30.0%) for tubal ligation, and 8 (20.0%) for fertility treatment. Respondents received referrals in 9 (22.5%) cases, perceived religious restrictions in four (10.0%) cases, and were still waiting to obtain the desired service in 16 (40.0%) cases.

      4. Discussion

      This study examines women's prevalence of being turned away from Catholic healthcare institutions without receiving desired contraceptive or fertility care, and to gather women's firsthand accounts of these experiences. Using a random sample of Wisconsin reproductive-aged women, we found that 2% of respondents had ever been turned away from a Catholic hospital or clinic, with this proportion increasing to 8.1%, or one-in-twelve respondents, in rural counties served by Catholic sole community hospitals. The relatively low prevalence of being turned away in the total sample might reflect providers’ use of workarounds [
      • Stulberg DB
      • Jackson RA
      • Freedman LR.
      Referrals for services prohibited in Catholic health care facilities: referrals in Catholic healthcare facilities.
      ,
      • Liu Y
      • Hebert LE
      • Hasselbacher LA
      • Stulberg DB.
      “Am I going to be in trouble for what I’m doing?”: providing contraceptive care in religious health care systems.
      ] or patients’ ability to access services elsewhere. However, the fact that the figure is significantly higher in rural areas with high Catholic healthcare system concentration suggests that patients residing in such areas may be at a distinct disadvantage in accessing the full range of reproductive care.
      This pattern should be viewed in light of the myriad barriers to reproductive care in many rural communities, including greater geographic distance, shortage of obstetric-gynecologic providers, and limited access to abortion care and certain contraceptive methods [
      • Stulberg DB
      • Dude AM
      • Dahlquist I
      • Curlin FA
      Abortion provision among practicing obstetrician–gynecologists.
      ,
      Committee opinion no. 586: Health disparities in rural women..
      ,
      • Heaphy PE
      • Bernard SL.
      Maternal complications of normal deliveries: variation among rural hospitals.
      ]. The number of rural obstetric hospitals nationally decreased by 9% from 2004−2014, but declines were nearly three times greater (25%) in Wisconsin from 2007−2017 [
      • Hung P
      • Henning-Smith CE
      • Casey MM
      • Kozhimannil KB.
      Access to obstetric services in rural counties still declining, with 9 percent losing services, 2004-14.
      ,
      Wisconsin Office of Rural Health
      Obstetric Delivery Services and Workforce in Rural Wisconsin Hospitals.
      ]. This decline, coupled with the high concentration of Catholic healthcare systems in Wisconsin, means that rural patients may be more likely to have few sources for full-spectrum reproductive healthcare services. The overwhelming majority of respondents had ever used a provider-dependent contraceptive method, highlighting the need to ensure that patients can access essential reproductive health services. Though two respondents were able to change hospitals after their experiences at Catholic healthcare facilities, such changes are likely to be infeasible for women with geographic or insurance-related constraints [
      • Drake C
      • Jarlenski M
      • Zhang Y
      • Polsky D.
      Market share of US Catholic hospitals and associated geographic network access to reproductive health services.
      ]. The inability to obtain postpartum contraceptives may have especially acute consequences for patients delivering by cesarean who wish to have a postpartum tubal ligation, who must then assume the unnecessary risk of undergoing an additional surgery [
      • Stulberg DB
      • Hoffman Y
      • Dahlquist IH
      • Freedman LR.
      Tubal ligation in Catholic hospitals: a qualitative study of ob–gyns’ experiences.
      ].
      We also found that a few respondents did not perceive religious policies as a barrier to care, suggesting that the experience of being unable to obtain reproductive care in a Catholic facility does not necessarily confer information about the role of religious restrictions. While most respondents in our study did indicate receiving referrals, many also reported long wait times, suggesting insufficient and delayed connection to time-sensitive services. Many respondents, particularly those seeking tubal ligation, either never obtained the service, turned to a different method than the one they had wanted, or became pregnant during the wait time. Although our subsample of respondents turned away from Catholic facilities was small, findings nevertheless suggest potential long-term consequences for patients’ lives.
      These results are thematically consistent with recent qualitative evidence documenting that some women who had sought postpartum tubal ligations in Catholic hospitals either never received them or experienced an unintended subsequent birth as a result of being unable to obtain care [
      • Wascher JM
      • Stulberg DB
      • Freedman LR.
      Restrictions on reproductive care at Catholic hospitals: a qualitative study of patient experiences and perspectives.
      ]. The idea that barriers to accessing desired postpartum contraceptives can directly impact women's reproductive trajectories is echoed in a large postpartum cohort in Texas, where nearly all unintended pregnancies were conceived by women who had wanted to use a more effective method postpartum, but encountered a barrier to doing so [
      • Potter JE
      • Hubert C
      • Stevenson AJ
      • Hopkins K
      • Aiken ARA
      • White K
      • et al.
      Barriers to postpartum contraception in Texas and pregnancy within 2 years of delivery.
      ]. Our post hoc analyses indicate that many respondents – largely, those seeking reversible contraceptives and fertility treatment – reported being turned away from non-Catholic facilities. Unfortunately, barriers to contraceptive and fertility services are not unique to Catholic facilities, but pervasive throughout the U.S. healthcare system (e.g., Medicaid restrictions on permanent contraception [
      • Borrero S
      • Zite N
      • Potter JE
      • Trussell J.
      Medicaid policy on sterilization – anachronistic or still relevant?.
      ], lack of insurance coverage for fertility treatment [
      • Insogna IG
      • Ginsburg ES.
      Infertility, inequality, and how lack of insurance coverage compromises reproductive autonomy.
      ], contraceptive coverage exemptions for religious employers [
      • Sobel L
      • Salganicoff A
      • Rosenzweig C.
      New regulations broadening employer exemptions to contraceptive coverage.
      ]).
      Strengths of this study include its representation of rural residents and sampling and weighting strategies that allowed for valid population-level inferences. For example, though our sample had higher educational attainment than the target population (e.g., 55% half had a bachelor's degree or higher, compared to 32% statewide; Table A.2), our weighting strategy allowed us to make estimates based on Wisconsin's education distribution. Findings should also be considered in light of study limitations. Though our sample of women turned away is small, a population-based study in a state with a high concentration of Catholic hospitals is a valuable approach to capturing real-life patients perspectives given that it can be difficult to gain access to pursue such research questions within Catholic healthcare systems. Underlying attitudes toward religious healthcare or the passage of time may have influenced reporting. We sought to reduce these possibilities by framing questions about experiences generally and asking respondents to consider their most recent experience. However, in asking about the most recent time, we may have missed earlier encounters and therefore may be undercounting experiences in Catholic settings. Further, a more racially diverse sample may have produced different results, as in Wisconsin, women of color are far more likely than White women to deliver at a Catholic hospital [

      Shepherd K, Franke K, Chiasson MA. Bearing Faith: The Limits of Catholic Health Care for Women of Color. New York, NY: Public Rights Private Conscience Project; n.d.

      ]. Finally, there may be differences between screener respondents and nonrespondents that we could not identify.
      In conclusion, our results document some of the lived consequences of religious restrictions: in Wisconsin, one-in-12 women in rural counties served by Catholic sole community hospitals were turned away from Catholic healthcare institutions without receiving desired reproductive services, and women reported long delays in accessing care elsewhere – in some cases leading to more invasive procedures or unintended pregnancy. These findings have important implications beyond Wisconsin: one-third of U.S. reproductive-aged women reside in counties with high-to-dominant Catholic hospital market share [
      • Drake C
      • Jarlenski M
      • Zhang Y
      • Polsky D.
      Market share of US Catholic hospitals and associated geographic network access to reproductive health services.
      ]. Potential mandates for change will be necessary to align healthcare practices with public health principles and patient autonomy. Ultimately, patients should receive client-centered care wherever they seek it, in a manner that does not interfere with their reproductive goals.

      Declaration of Competing Interest

      The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

      Funding

      This work was supported by an anonymous family philanthropic foundation.

      Acknowledgements

      The authors wish to thank the University of Wisconsin Survey Center for their invaluable expertise in sampling design and survey administration.

      Appendix. Supplementary materials

      References

        • Solomon T
        • Uttley L
        • HasBrouck P
        • Jung Y.
        The Growth of Catholic Health Systems.
        Community Catalyst, Boston, MA2020
        • Stulberg DB
        • Jackson RA
        • Freedman LR.
        Referrals for services prohibited in Catholic health care facilities: referrals in Catholic healthcare facilities.
        Perspect Sex Reprod Health. 2016; 48: 111-117
        • Liu Y
        • Hebert LE
        • Hasselbacher LA
        • Stulberg DB.
        “Am I going to be in trouble for what I’m doing?”: providing contraceptive care in religious health care systems.
        Perspect Sex Reprod Health. 2019; 51: 193-199
        • Guiahi M
        • Teal SB
        • Swartz M
        • Huynh S
        • Schiller G
        • Sheeder J.
        What are women told when requesting family planning services at clinics associated with Catholic hospitals? a mystery caller study of Catholic clinics.
        Perspect Sex Reprod Health. 2017; 49: 207-212
        • Stulberg DB
        • Hoffman Y
        • Dahlquist IH
        • Freedman LR.
        Tubal ligation in Catholic hospitals: a qualitative study of ob–gyns’ experiences.
        Contraception. 2014; 90: 422-428
        • Takahashi J
        • Cher A
        • Sheeder J
        • Teal S
        • Guiahi M.
        Disclosure of religious identity and health care practices on Catholic hospital websites.
        JAMA. 2019; 321: 1103
      1. American College of Obstetrics and Gynecologists. Restrictions to Comprehensive Reproductive Health Care 2016.

      2. American Public Health Association. Restricted Access to Abortion Violates Human Rights, Precludes Reproductive Justice, and Demands Public Health Intervention 2015.

      3. Jones RK, Dreweke J. Countering Conventional Wisdom: New Evidence on Religion and Contraceptive Use n.d.:8.

      4. Pew Research Center. Religious Landscape Study – Catholics n.d.

      5. U.S. Census Bureau. 2011-2015 American Community Survey 5-Year Estimates 2016. https://factfinder.census.gov/faces/tableservices/jsf/pages/productview.xhtml?pid=ACS_15_5YR_CP05&prodType=table (accessed June 16, 2017).

        • Upadhyay UD
        • Johns NE
        • Meckstroth KR
        • Kerns JL.
        Distance traveled for an abortion and source of care after abortion.
        Obstetrics Gynecol. 2017; 130: 616-624
        • Jerman J
        • Frohwirth L
        • Kavanaugh ML
        • Blades N.
        Barriers to abortion care and their consequences for patients traveling for services: qualitative findings from two states.
        Perspect Sex Reprod Health. 2017; 49: 95-102
        • Stulberg DB
        • Dude AM
        • Dahlquist I
        • Curlin FA
        Abortion provision among practicing obstetrician–gynecologists.
        Obstetric Gynecol. 2011; 118: 609-614
      6. United States Department of Agriculture Economic Research Service. Documentation: 2010 Rural-Urban Commuting Area (RUCA) Codes 2019. https://www.ers.usda.gov/data-products/rural-urban-commuting-area-codes/documentation/ (accessed September 28, 2019).

      7. Uttley L, Khaikin C. Growth of Catholic Hospitals and Health Systems: 2016 Update of the Miscarriage of Medicine Report. New York (NY): The MergerWatch Project; 2016.

      8. Centers for Medicare and Medicaid Services. Hospital Service Area File –2018. DataCMSGov 2018. https://data.cms.gov/Medicare-Inpatient/Hospital-Service-Area-File-2018/sgw2-6vb4/data (accessed May 25, 2020).

      9. Wisconsin Area Health Education Centers. Health Service Areas n.d. https://ahec.wisc.edu/resources/health-service-areas/ (accessed August 24, 2020).

      10. Catholic Health Association of the United States. Catholic Health Care Directory n.d. https://www.chausa.org/for-members/directories/catholic-health-care-directory.

        • Couper MP.
        The future of modes of data collection.
        Public Opin Q. 2011; 75: 889-908
        • Singer E.
        The use of incentives to reduce nonresponse household surveys.
        Survey Nonresponse. Wiley, New York2002
        • Freedman LR
        • Stulberg DB.
        Conflicts in care for obstetric complications in Catholic hospitals.
        AJOB Primary Res. 2013; 4: 1-10
        • Wascher JM
        • Hebert LE
        • Freedman LR
        • Stulberg DB.
        Do women know whether their hospital is Catholic? results from a national survey.
        Contraception. 2018;
        • Dillman DA.
        Mail and internet surveys: the tailored design method.
        2007 update with new internet, visual, and mixed-mode guide. 2nd ed. Wiley, Hoboken, N.J2007
        • Tourangeau R
        • Rips LJ
        • Rasinski K.
        The Psychology of Survey Response.
        Cambridge University Press, Cambridge2000
        • Levy Paul S.
        • Lemeshow Stanley
        Sampling of Populations Methods and Applications.
        John Wiley & Sons Inc, 2009
      11. Committee opinion no. 586: Health disparities in rural women..
        Obstetric Gynecol. 2014; 123: 384-388
        • Heaphy PE
        • Bernard SL.
        Maternal complications of normal deliveries: variation among rural hospitals.
        J Rural Health. 2000; 16: 139-147
        • Hung P
        • Henning-Smith CE
        • Casey MM
        • Kozhimannil KB.
        Access to obstetric services in rural counties still declining, with 9 percent losing services, 2004-14.
        Health Aff. 2017; 36: 1663-1671
        • Wisconsin Office of Rural Health
        Obstetric Delivery Services and Workforce in Rural Wisconsin Hospitals.
        University of Wisconsin-Madison, 2019
        • Drake C
        • Jarlenski M
        • Zhang Y
        • Polsky D.
        Market share of US Catholic hospitals and associated geographic network access to reproductive health services.
        JAMA Network Open. 2020; 3e1920053
        • Wascher JM
        • Stulberg DB
        • Freedman LR.
        Restrictions on reproductive care at Catholic hospitals: a qualitative study of patient experiences and perspectives.
        AJOB Empirical Bioethic. 2020; 11: 257-267
        • Potter JE
        • Hubert C
        • Stevenson AJ
        • Hopkins K
        • Aiken ARA
        • White K
        • et al.
        Barriers to postpartum contraception in Texas and pregnancy within 2 years of delivery.
        Obstetric Gynecol. 2016; 127: 289-296
        • Borrero S
        • Zite N
        • Potter JE
        • Trussell J.
        Medicaid policy on sterilization – anachronistic or still relevant?.
        N Engl J Med. 2014; 370: 102-104
        • Insogna IG
        • Ginsburg ES.
        Infertility, inequality, and how lack of insurance coverage compromises reproductive autonomy.
        AMA J Ethics. 2018; 20: 1152-1159
        • Sobel L
        • Salganicoff A
        • Rosenzweig C.
        New regulations broadening employer exemptions to contraceptive coverage.
        Impact on Women. 2018;
      12. Shepherd K, Franke K, Chiasson MA. Bearing Faith: The Limits of Catholic Health Care for Women of Color. New York, NY: Public Rights Private Conscience Project; n.d.