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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
Department of Population Health Sciences, Collaborative for Reproductive Equity, University of Wisconsin-Madison, University of Wisconsin-Madison, Madison, WI United StatesDepartment 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 Obstetrics and Gynecology, Department of Gender and Women's Studies, and Collaborative for Reproductive Health Equity, University of Wisconsin-Madison, Madison, WI, United StatesDepartment of Population Health Sciences, University of Wisconsin-Madison, University of Wisconsin-Madison, Madison, WI, United States
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.
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 [
]. 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 [
What are women told when requesting family planning services at clinics associated with Catholic hospitals? a mystery caller study of Catholic clinics.
What are women told when requesting family planning services at clinics associated with Catholic hospitals? a mystery caller study of Catholic clinics.
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 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 [
]. With four in ten inpatient beds located in Catholic hospitals, Wisconsin residents may be especially likely to have experienced care in these systems firsthand [
]. 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 [
]. 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 [
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 [
]. 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) [
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.
]. 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) [
], 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 [
]. 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 [
]. 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. 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)
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).
Participants could check all that apply, so the total percentage exceeds 100%.
White
619
91.7%
Black
26
3.9%
Hispanic
29
4.3%
American Indian or Alaska Native
15
2.2%
Asian
16
2.4%
Missing
21
3.1%
Educational attainment
<High school degree
19
2.8%
High school
69
10.2%
Some college or associate's degree
211
31.3%
Bachelor's degree
251
37.2%
Advanced degree
124
18.4%
Missing
1
.2%
Confidence in ability to afford unexpected $2000 expense
Not at all confident
198
29.3%
Slightly confident
88
13.0%
Somewhat confident
79
11.7%
Very confident
116
17.2%
Certain
189
28.0%
Missing
5
.7%
Insurance status
Private/Employer/Exchange
558
82.7%
Public
78
11.6%
None/Unsure if covered
39
5.8%
Religion
Catholic
148
21.9%
Not Catholic
514
76.1%
Missing
13
1.9%
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. 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 [
] 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 [
]. 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 [
]. 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 [
]. 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 [
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 [
]. 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 [
]. 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 [
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 [
]. 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.
What are women told when requesting family planning services at clinics associated with Catholic hospitals? a mystery caller study of Catholic clinics.
American Public Health Association. Restricted Access to Abortion Violates Human Rights, Precludes Reproductive Justice, and Demands Public Health Intervention 2015.
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.
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.
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